The Frequency and Economic Impact of Musculoskeletal Disorders for California Firefighters

Short abstract

The authors update analyses from a 2010 study on firefighters in California and consider the impacts of the 2013 workers' compensation reforms and the economic shocks of the late 2000s on outcomes for firefighters with musculoskeletal disorders.

Abstract

Musculoskeletal disorders (MSDs) are the most common type of occupational injury or illness suffered by firefighters, so there is considerable interest among policymakers and stakeholders about how best to monitor, prevent, and treat firefighter MSDs. In this study, the authors update analyses from a 2010 RAND study on firefighters in California and consider the impacts of the 2013 workers' compensation reforms and the economic shocks of the late 2000s on outcomes for firefighters with MSDs.

The California Department of Industrial Relations requested that the authors address a wide range of specific research questions on various aspects of firefighters' injury risk and outcomes in the workers' compensation system, from case mix and economic consequences to permanent disability rating and medical treatment patterns. The authors analyzed administrative data from the California workers' compensation system linked to data on earnings for workers injured between 2005 and 2015, with additional analyses to tailor the results to the new reforms. They compare firefighters with three groups of workers in broadly comparable occupations—police, other public-sector workers, and private-sector workers with job demands that resemble firefighting—and supplement the analysis using outside data.

The authors found, among other things, that firefighters continue to face elevated risk of work-related MSDs and that earnings losses for firefighters worsened after the Great Recession of 2008–2009. Their findings will be of interest to policymakers in California and other states and to other audiences concerned with the occupational health and safety of firefighters.

Firefighters play a vital role in protecting the public while facing exceptional hazards to their own health and safety. Smoke inhalation, burns, and traumatic injury are just a few of the serious risks posed by active firefighting. Yet the strenuous physical demands of firefighting can take a less visible toll on the human body, with wear and tear that increases the risk of back injury, joint pain, or other forms of musculoskeletal disorders (MSDs). In fact, MSDs are the most common type of occupational injury or illness suffered by firefighters, so there is considerable interest among policymakers and stakeholders about how best to monitor, prevent, and treat firefighter MSDs.

An earlier RAND Corporation study on MSDs in California firefighters confirmed that firefighters experience MSDs at a significantly elevated rate compared to other workers, even compared to workers in other high-risk jobs (Seabury and McLaren, 2010). Firefighters were more likely than other comparable workers to experience lost time due to an MSD, but the economic consequences of MSDs were, on average, more moderate for firefighters than for workers in similar occupations. MSDs in older firefighters (aged 55 or above at injury) had earnings and employment losses comparable to private-sector workers, however. The report also examined the effect of medical reforms enacted in 2003 and 2004 and found no adverse impact on firefighters.

The 2010 RAND study examined injury dates from 2000 through 2007. Developments since that time call for more current evidence on the frequency, severity, and consequences of firefighter MSDs. The severity of recent wildfire seasons underscores the importance of a healthy firefighting workforce, and awareness of the psychiatric burden borne by public safety workers exposed to traumatic events has grown in recent years. Meanwhile, California undertook a major set of workers' compensation reforms with the enactment, in 2012, of Senate Bill (SB) 863. In addition to medical delivery reforms and other changes, SB 863 modified the permanent disability rating system and benefit levels. Permanent disability benefits were increased, but compensation for secondary or add-on psychiatric impairments was restricted. For injuries occurring in 2013 or later, compensation for add-on psychiatric impairments was allowed only for victims of a violent act or catastrophic injury, raising concern about access to benefits for firefighters who might witness nonviolent traumatic events yet fail to meet the new requirements. Besides these workers' compensation reforms, the economic landscape in California has changed substantially since the previous RAND study. The 2008–2009 Great Recession caused significant economic hardship, and injured and disabled workers appeared to be particularly hard hit; analysis of workers injured between 2005 and 2015 suggests at best a partial recovery in injured workers' labor market outcomes. While declines in postinjury earnings were widespread, the impact on public safety workers has not specifically been examined (Dworsky et al., 2018).

Study Objectives

In this report we update the analyses from the 2010 RAND study and consider the impacts of the 2013 workers' compensation reforms and the economic shocks of the late 2000s on outcomes for firefighters with MSDs. The California Department of Industrial Relations requested that we address a wide range of specific research questions on various aspects of firefighters' injury risk and outcomes in the workers' compensation system, from case mix and economic consequences to permanent disability rating, medical treatment patterns, and the incidence of comorbid psychiatric conditions. We grouped these questions together by topic:

• Characterize recent trends in MSD claim rates and case mix among firefighters.

• Describe the economic consequences of MSDs.

• Estimate the prevalence of psychiatric comorbidities among firefighters with MSDs.

• Estimate the effects of disability rating reforms enacted in SB 863.

• Assess the effect of caps on chiropractic, occupational therapy, and physical medicine visits.

We analyzed administrative data from the California workers' compensation system linked to data on earnings for workers injured between 2005 and 2015, with some additional analyses to tailor the results to the new reforms and to take advantage of data resources that were unavailable previously. Where necessary, or to provide context, we supplement the analysis using outside data from the published literature or national data. As in our earlier study, we identified a comparison group of workers in similar occupations to provide a benchmark for firefighter outcomes and to determine whether any changes over time uniquely affected firefighters or reflected broader systemic changes. We compare firefighters to three groups of workers in broadly comparable occupations: police, other public-sector workers, and private-sector workers with job demands that resemble firefighting (including occupations related to health and safety, transportation, and heavy installation and maintenance). While many of the concerns examined here have relevance throughout the California labor force, the present study is focused narrowly on firefighters with MSDs; broader questions about the consequences of MSDs across the entire labor force or about other health and safety risks faced by firefighters were beyond the scope of our study.

Findings

The following sections of this summary highlight major findings from each of these five chapters.

Firefighters Continue to Face Elevated Risk of Work-Related Musculoskeletal Disorders, Especially Injuries to the Lower Extremities and Trunk

We used data from the California Workers' Compensation Information System to compare the frequency and types of workplace injuries experienced by firefighters to those of workers in other occupations. There are several reasons that we expect injuries to firefighters to differ from those to other workers. Part of that is the intense and demanding nature of the work, which is risky and more likely to result in injury. But firefighters—as well as police officers, other public safety workers, and, to a lesser extent, other public-sector workers more generally—benefit from both special benefits that offer additional compensation for workplace injuries and from additional job security that could make it easier to file injury claims. Thus, we compare the composition of injury claims for firefighters to a range of occupations, including police officers, other public-sector workers, private-sector workers generally, and a group of private-sector occupations specifically chosen because they have a relatively similar set of requirements as firefighters.

As expected, firefighter injury rates are high compared to other workers. Between 2005 and 2017, the firefighter injury rate ranges from just under 200 per 1,000 workers to more than 250 per 1,000. Injury rates for police officers are similar though slightly lower, while the overall rate for all workers ranges from 35 to 50 per 1,000 workers. While the rate of occupational injuries throughout the U.S. labor force has declined steadily, we found no discernable trend for firefighters or police officers. Firefighters also have the highest share of injuries that are musculoskeletal in nature, with 47 percent of injuries involving MSDs compared to 38 percent for police officers, 42 percent for other public-sector workers, 37 percent in our private-sector comparison group with similar job requirements to firefighters, and 42 percent for other private-sector workers. This confirms that MSDs are a particular source of concern for firefighters.

In other analyses, we compare different types and characteristics of firefighter injuries. Firefighters have an elevated risk of MSDs across the full life cycle, with over half of firefighter injuries at ages 40–49 involving MSDs. By comparison, just 39 percent of injuries in our private-sector comparison group involve MSDs. Compared to other occupations, injuries to firefighters are less likely to involve the upper extremities and significantly more likely to involve lower extremities or the trunk. Strains are the modal cause of injury for firefighters; burns are significantly more common among firefighters than other workers but still represent a small share of injuries (6 percent) in comparison to MSDs.

Overall, the injury distribution for firefighters is different than for workers in other jobs, including the private-sector comparison group that was selected because the job demands are similar overall. This is at least suggestive evidence that the differences in types of injury cannot be explained entirely by differences in job demands or physical factors. One possible explanation is that the nature of firefighting influences claim-filing behavior in ways that change the injury mix. This does not necessarily mean increased job security or injury compensation, as we expect these to be similar between firefighters, police officers, and other public employees. However, one hypothesis might be that staffing requirements for firefighters that necessitate their being able to perform all potential duties could lead to higher injury claiming than in occupations where modified work is more readily available. Sorting through the different factors that drive injury composition is ultimately beyond the scope of this study; research on claim-filing behavior across occupations (perhaps including a review of accident reports) would be helpful.

Earnings Losses for Firefighters Worsened After the Great Recession of 2008–2009, yet the Economic Consequences of Musculoskeletal Disorders for Firefighters Remain Less Severe than for Workers in Similar Occupations

We also examined postinjury earnings and employment for firefighters, using methods developed in previous RAND studies to compare injured worker outcomes to a control group of similar workers without an injury. In the second year after injury, injured firefighters earned 95 percent of what they would have earned in the absence of the injury. As in our 2010 study, firefighters with MSDs appear to have less severe economic consequences from their injuries than do workers in similar occupations. Postinjury earnings in the second year after injury were sharply lower in comparable occupations: 88 percent for police, 85 percent for other public-sector workers, and 87 percent for private-sector workers. These differences in earnings are mirrored closely by differences in the proportion of injured workers who continue to work for the employer where the injury occurred, or the at-injury employer. In most occupations, employment at the at-injury employer is well below the overall employment rate, indicating that injury can lead to increased job separations or career changes even for workers who remain employed. For firefighters, in contrast, at-injury employment two years after injury is 95 percent of the level that would have been expected in the absence of injury—very close to the overall level of employment (at any employer). This is an unusual pattern of postinjury outcomes, both because at-injury employment is nearly as high as overall employment and because it is much higher than observed in comparison occupations. Fire departments appear to do better than other employers—even public-sector employers—at retaining injured workers.

Turning to trends in outcomes over time, we find that labor market outcomes for firefighters declined following the Great Recession of 2008–2009. This decline in outcomes was not unique to firefighters: we also saw worsening postinjury outcomes for similar occupations, a pattern consistent with previous RAND research showing widespread impacts of the Great Recession throughout the workers' compensation system. That said, it is surprising to see this decline in outcomes among firefighters because we would have expected the exceptionally high postinjury job retention among firefighters and their status as critical public safety personnel to have protected them from the slack labor market conditions facing private-sector workers. These trends in systemwide outcomes have not yet been adequately explained.¹

Disability Evaluation Unit Ratings and Statutory Permanent Disability Benefits Rose for Firefighters After Senate Bill 863 Implementation

Based on their standard ratings, firefighters with permanently disabling musculoskeletal disorders who were rated at the California Disability Evaluation Unit (DEU) appeared to have similar impairment severity to police and other comparison occupations with the same type of rating. Firefighters had slightly higher final ratings than comparable occupations prior to SB 863, however. Firefighters have relatively high occupational adjustments, and their slightly older age at injury may also result in more favorable adjustments under the current disability rating schedule. Other aspects of the rating process, such as the frequency with which apportionment is recommended and the use of alternative rating procedures, were not dramatically different between firefighters and other occupations.

Implementation of SB 863 was followed by higher final ratings for firefighters with musculoskeletal disorders who received summary ratings (typically performed for workers without legal representation at the request of a workers' compensation judge). It is somewhat surprising, however, that the average final rating did not increase on consult ratings (performed at the request of a party to the case, typically when the worker has legal representation). The only provision of SB 863 that would tend to reduce ratings was the elimination of psychiatric add-on impairments, and we saw that psychiatric impairments were rated in fewer than 1 in 100 MSD cases for firefighters prior to SB 863. Our results hint at an alternative mechanism that may have operated independently of SB 863, which was an increase in the frequency of apportionment to nonoccupational cause. We did not have a sufficient sample size of firefighters with consult ratings to examine differences between occupations, but similar changes in the frequency of apportionment on consult ratings were apparent across most occupations examined.

These findings suggest that increased apportionment among consult ratings may have offset some of the rating increases anticipated under SB 863. However, a broader analysis of occupations not included in this study (and less comparable to firefighters) would be needed to produce informative estimates about the frequency of apportionment. More systematic validation of apportionment information in DEU ratings data—which was well beyond the scope of this study—is needed to confirm these suggestive findings. DEU ratings data for consult ratings do not contain reliable information about how apportionment affects ratings (such as the percent apportioned by impairment or the rating before apportionment), so we cannot attribute the differences in SB 863 impacts between consult and summary ratings to apportionment without further investigation. Notwithstanding the somewhat muted benefit increases that we observed on consult ratings, statutory benefits were substantially higher across all occupations and rating types examined thanks to the increase in the weekly maximum implemented under SB 863.

Firefighters with Musculoskeletal Disorders Rarely Receive Treatment or Permanent Disability Benefits for Post-Traumatic Stress Disorder or Other Psychiatric Conditions

We examined diagnosis codes on medical services and prescriptions billed to workers' compensation to identify MSD injuries with comorbid psychiatric conditions. These data indicate that firefighters and police have similar rates of psychiatric comorbidities, but incidence rates for public safety workers are substantially lower than rates observed among other public-sector workers or comparable private-sector workers. We do find evidence that psychiatric comorbidities are associated with worse labor market outcomes compared to MSDs without such comorbidities. This finding was anticipated given previous evidence on earnings losses for workers with permanent disability due to psychiatric impairments (Dworsky et al., 2016). We do not, however, find strong evidence that the incremental losses associated with psychiatric comorbidities vary across occupations.

Taken together, these findings do not provide evidence that post-traumatic stress disorder (PTSD) or other psychiatric comorbidities are a more serious concern for firefighters than for workers in other similar occupations. Two important limitations of this work need to be added, however. First, we rely on medical claims to identify psychiatric disorders, and we observe only medical care provided through the workers' compensation system. Because public-sector workers are likely to have access to high-quality health insurance outside of workers' compensation, we cannot rule out the possibility that workers are seeking treatment for psychiatric conditions outside the workers' compensation system, either through group health or without any reimbursement from insurance at all. A second and more troubling caveat is that mental health stigma could also lead to the patterns observed in these data. Stigma is widely recognized as a barrier to diagnosis and treatment of PTSD and mental disorders more generally among public safety workers, but the scope of this study did not encompass measurement of firefighter mental health independently of care provided through workers' compensation.

We Did Not Find Evidence That Treatment Caps on Chiropractors, Occupational Therapy, and Physical Medicine Had a Substantial Impact on Most Workers

The workers' compensation system is designed to provide injured workers with necessary medical care. There is concern among stakeholders that some policies used to control costs have interfered with workers' ability to access needed care, however. SB 228, enacted in 2003, sought to control medical spending growth through a number of policy levers, including the establishment of treatment caps on chiropractic and physical medicine. Evidence remains limited on the impacts of the SB 228 treatment caps on patterns of care or worker outcomes, so the Commission on Health and Safety and Workers' Compensation requested that we study this issue. We ask what proportion of workers with and without MSDs have sufficiently high utilization of the capped services to potentially be affected by the caps and whether we see a larger-than-expected number of workers stopping treatment when they reach the cap. We do not find clear evidence that the SB 228 treatment caps pose a particularly strong barrier to the receipt of the types of care subject to the caps. We note that, without a comparison group not subject to the treatment caps, it is not possible to credibly evaluate the impacts of the treatment caps on patient outcomes. However, the lack of evidence that workers are substantially constrained by the treatment caps suggests that other, more harmful consequences of the treatment caps may not be a major concern.

Policy Implications and Priorities for Future Research

For firefighters, as for other groups of injured workers, the weak recovery of labor market outcomes from the Great Recession is worrisome. The findings of this report, as with other analyses for broader groups of workers, highlight the need to understand how and why the Great Recession had such lasting effects on postinjury outcomes.

Our analysis of disability ratings indicated that SB 863 has been effective in raising final ratings and statutory benefits for both firefighters and for comparable groups of workers. The rating changes and the increase in the statutory maximum in SB 863 appear to have been particularly favorable for firefighters, likely due to the high proportion of firefighters who earn above the pre–SB 863 maximum weekly wage and due to the prevalence of knee impairments, which received the second-largest possible increase in final ratings from changes to the formula used to calculate ratings. We did, however, notice an uptick in the frequency with which apportionment was recommended on consult ratings. While this trend was not notably different for firefighters than for other comparable occupations, it would be valuable to investigate changes in apportionment frequency more carefully and to collect additional data capable of illuminating the impacts of apportionment on ratings since SB 863 took effect. This may require substantial additional data collection beyond DEU, but clearer evidence on the role that apportionment plays in the disability rating system would likely be welcomed by policymakers and stakeholders.

Finally, while we are concerned about the impact of mental health stigma on our analysis of PTSD and psychiatric comorbidities, somewhat different methods and additional data collection are necessary to understand the implications of our findings that these public safety workers are far less likely to receive treatment for psychiatric conditions in the workers' compensation system. Data from the workers' compensation system also cannot speak to the incidence of PTSD or mental distress among workers who do not file claims for a workplace injury. The potential for stigma suggests a need to go beyond claims data and use complementary approaches to assess firefighters' and police officers' mental health, potentially including surveys or analyses of group health claims.