Marjorie L. Baldwin

The error of using returns-to-work to measure the outcomes of health care

This article uses data from The Survey of Ontario Workers With Permanent Impairments. the worlds largest survey of injured workers, to show that, as currently used, return-to-work is a misleading measure of the effectiveness of health care. The article discusses examples of two serious limitations on the use of return-to-work to measure the outcomes of health care, where health care refers to all the medical and rehabilitative services provided to a worker following a workplace injury. The first limitation is that return-to-work, like many other outcomes of health care, is influenced by factors that are not directly related to health care. Using a logit model to estimate the determinants of first absences from work after an injury, we find that socioeconomic characteristics, economic incentives, and job characteristics have a significant influence on return-to-work. The second limitation on return-to-work as an outcome measure is that the first return-to-work after an injury, like a hospital discharge, frequently marks the end of only the first of several episodes of work disability caused by the original injury. Using first post-injury returns-to-work as a proxy for recovery, we would assume that 85% of the Ontario workers recovered from their injury when, in fact, 61% had subsequent spells of work disability. We identified four mutually exclusive patterns of post-injury work and work disability. Multinomial logit estimates of the determinants of the patterns show that health care is only one of several influences on return-to-work. The results also demonstrate that if return-to-work is used to measure outcomes, it must be evaluated over a time horizon that permits multiple spells of work disability.

Labor market discrimination against men with disabilities

The 1984 panel of the Survey of Income and Program Participation is used to estimate the extent of labor market discrimination against men with disabilities. Men with disabilities are classified into a group with impairments that are subject to prejudice (handicapped) and a group with impairments that are less subject to prejudice (disabled). Very large differences in employment rates and hourly wages are found between handicapped and nondisabled men. The employment rates and hourly wages of disabled men are slightly lower than those of nondisabled men but substantially higher than those of handicapped men. Using data from the 1972 Social Security Survey of the Disabled as a benchmark, we find that wage differentials between nondisabled and both disabled and handicapped men increased between 1972 and 1984. The employment rate for handicapped men also increased but the 1984 rate was still substantially lower than the rates for nondisabled or disabled men.

Labor Market Discrimination Against Men with Disabilities in the Year of the ADA

The Americans with Disabilities Act (ADA) provides civil rights protections to persons with disabilities, but the debate that preceded passage of the Act was not based on empirical estimates that could be used to measure its performance. This article estimates the extent of wage discrimination against men with disabilities in 1990, providing a reference that can be used to evaluate the impact of the ADA. The results show large productivity–standardized wage differentials between disabled and nondisabled men that are weakly correlated with the strength of prejudice against different impairments. Physical limitations explain part, but not all, of the wage differentials. The results also show that low employment rates are a more serious problem than wage discrimination for workers with disabilities.

Gender Differences in Wage Losses from Impairments: Estimates from the Survey of Income and Program Participation

This article develops a model of the relationships among functional impairments, work disability, employment participation, and wage offers. The model is estimated separately for males and females with data from the 1984 Survey of Income and Program Participation. Using estimates of disability and wage equations, we rank 25 functional impairments by severity of disability, and estimate the wage penalty associated with each impairment. The results show that limitations to mobility and strength are relatively more disabling for males than for females, while the opposite is true for limitations to sensory capacities and appearance.

Back Pain and Work Disability: The Need for a New Paradigm

Using a unique data set of workers’ compensation claims from Ontario, this study analyzes the determinants of first returns to work and subsequent patterns of employment for a sample of workers with back pain and a comparison group of workers with other injuries. The results suggest that the costly and pervasive problem of work-related back claims could be reduced by abandoning the traditional work injury model in favor of a separate paradigm for back pain that reflects its unique characteristics. A change in economic incentives would increase the probability of return to work for back cases, and an expansion of employer-provided job accommodations would increase the probability of stable employment after the first return.

Cost-effectiveness studies of medical and chiropractic care for occupational low back pain ☆: a critical review of the literature

BACKGROUND CONTEXTnBack pain is the single most costly work-related injury. Chiropractors and physicians are the main primary care providers for occupational low back pain (OLBP), but there is no consensus regarding the relative cost-effectiveness of these two modes of care.nnnPURPOSEnTo critically appraise and synthesize recent literature on the cost-effectiveness of medical and chiropractic care for OLBP, and to propose a cost-effectiveness methodology that integrates epidemiologic and economic methods for future studies.nnnSTUDY DESIGNnLiterature review. MEDLINE was searched from 1990 through 1999. Nine articles that met the inclusion criteria were reviewed. The methodological quality of the articles was critically appraised independently by two epidemiologists using standardized review criteria. Two health economists reviewed the studies on cost-effectiveness.nnnRESULTSnThe current literature suggests that chiropractors and physicians provide equally effective care for OLBP but that chiropractic patients are more satisfied with their care. Evidence on the relative costs of medical and chiropractic care is conflicting. Several methodological deficiencies limit the validity of the reviewed studies. No studies combine high-quality cost data with adequate sample sizes and controls for confounding factors.nnnCONCLUSIONnExisting studies fail to clarify whether medical or chiropractic care is more cost effective. We suggest that future studies must combine epidemiologic and economic methods to answer the question adequately.

A Note on Job Mobility Among Workers with Disabilities

This article uses data from the 1990 and 1993 panels of the Survey of Income and Program Participation to analyze relationships between disability status and job mobility. We identify individuals who experienced voluntary or involuntary job separations over a 20-month period and examine the effect of disability status on rates of job change and wage growth following a job change. The results show that disabled workers are more likely to experience involuntary job changes than are nondisabled workers, but there is little difference in the wage effects of job changes by disability status.

The effects of impairments on employment and wages: estimates from the 1984 and 1990 SIPP

Unlike the minority groups covered by civil rights laws in the past, the disabled population is a heterogeneous group. Because of differences in the nature and onset of health conditions, it is important to study the labor market experiences of different impairment groups separately, rather than treating disabled workers as a single group. This article uses data from the 1984 and the 1990 panels of the Survey of Income and Program Participation to analyze trends in the employment and wages of six impairment groups in the years immediately preceding the ADA. The results confirm the diversity of labor market experiences within the disabled population and suggest that policies designed to improve labor market outcomes for workers with disabilities in response to the ADA should be targeted to the different needs of different impairment groups.

The Employment Effects of Wage Discrimination against Black Men

When labor supply curves are upward-sloping, wage discrimination against black men reduces not only their relative wages, but also their relative employment rates. Using data from the 1984 Survey of Income and Program Participation, the authors estimate wage discrimination against black men and, for the first time, quantify the effects of that discrimination on the employment of black and white men. They find that 62% of the difference in offer wages to black and white men, and 67% of the difference in their observed wages, cannot be attributed to differences in productivity. Assuming that the unexplained wage differential is attributable entirely to employer discrimination, then the disincentive effects of wage discrimination reduced the relative employment rate of black men from 89% to 82% of white mens employment rate. Thus, wage discrimination and its employment effects resulted in a substantial transfer of resources from blacks to whites in 1984.

Evidence on the Occupational Segregation of Women With Disabilities

Differences in the occupational segregation of disabled and nondisabled women were investigated. A logit model of occupational choice was estimated with data from the 1984 panel of the Survey of Income and Program Participation (SIPP). The dependent variable in the model equaled 1 if the woman was employed in a predominantly male occupation. Independent variables in the model controlled for workers labor force attachment, health status, and for the demand for labor in predominantly male occupations. The results indicated no significant differences in the occupational segregation of the two groups of women. Disabled women encounter just as much segregation in the labor market as do nondisabled women.