Program Showcase: Reducing Progression to STD

Tasha Patterson@Work

Finding a Path Through the Collage of the Leave Universe

Path Through the Leave UniverseBy Dr. Michael Lacroix

Associate Medical Director
Aetna Disability

From the 30,000-foot view, the “leave universe” looks like a collage of employee entitlements that don’t fit together neatly. Aetna found some new patterns in this collage that became the basis for an early intervention pilot program giving employees a large role in finding solutions for needs that result in leaves.

The entitlements collage has the long-established employer-funded benefits of short-term and long-term disability (STD and LTD) and the federal entitlements, including the military and Family and Medical Leave Act (FMLA). But then there are also leaves for a variety of other reasons that may exist in one state, one city, or one employer: leaves for civil air patrol, paternity, school visitations, “snow days,” sabbaticals, etc.

While the collage may appear to be thrown together haphazardly, and with a nod to the human resources (HR) folks that may find it nightmarish to administer, one wonders whether the whole thing may not make more sense from the perspective of the end user, the employee who needs time off. Union members are renowned for their in-depth knowledge of union contracts, and consumers can be astute about using credit cards for different expenses. Is it possible that employees are savvy enough to find an optimal path for themselves through the maze?

For example, an intermittent FMLA leave requiring a fairly large paperwork effort for a relatively small gain — a few hours’ leave in many cases — would make sense if an employee thinks the issue can be fixed pretty quickly. But an STD leave, which could provide for a much longer leave duration and more money, would only make sense if the employee expects to be off work for some time.

Do most employees orchestrate their leaves on this kind of logic? If they do, we should be able to see evidence of progression from intermittent to continuous to STD leaves in cases where the rationale for the leave grows over time, but not so much for cases where the leave can easily be pegged in one category or the other from the outset.

We recently carried out an analysis of 17,000 FMLA requests from 2015. In about half of these cases, we cannot know the basis for the request since, by law, employees do not have to provide that information and indeed our experience is that about half of them do not. In 16% of intermittent leaves, a continuous leave follows next, and 13% ended as STD claims. For those FMLA leaves where a diagnosis was provided, mental health conditions (depression, anxiety, stress) were the most likely to move to continuous, and then into STD, with musculoskeletal conditions (MSK) claims predominating for those over 40. Medically more significant conditions such as cancers, immune disorders, etc., almost always bypassed the intermittent stage altogether and moved straight into STD.

Looking at the intermittent leaves taken for behavioral health and musculoskeletal conditions, while about 14% of these became continuous leaves within 14 calendar days, a third migrated between days 15 and 60, with the remaining half migrating after day 60. This suggests that there may be a kind of incubation period with these leaves when employees try to deal with the problem on their own (and often succeed), but if they have not been successful after two or three weeks, they raise the ante.

We can easily imagine someone trying to deal with increased stress at home or at work by asking the doctor for anxiety medication. Someone may deal with a tendinitis condition by taking ibuprofen and giving the medication a few weeks to have an impact, but then calling for more structured time off if that doesn’t work. After 60 days of this kind of do-it-yourself strategy, those who have not been coping successfully are generally ready to throw in the towel. This suggests that there may be a “sweet spot,” roughly from 15 to 60 days after an intermittent leave request, when employers can intervene to prevent the development of a bigger problem. Note that this incubation period is not wasted: our data indicate that for those claims that ultimately migrate to STD, the STD durations are shorter for both mental and MSK claims if preceded by an intermittent leave.

Intervening at the FMLA stage is potentially tricky because, as noted earlier, employees are entitled by law to those leaves. Offering assistance must be done very carefully. For example, in a pilot currently in progress with intermittent mental health leaves, we call employees to provide them with the information that we have resources that could assist them through their difficult time, and offer them access to these resources. But we never mention the words “Family Medical Leave” or “stay at work.” Nor do we offer any incentive for participation. We only provide information about services which they may or may not wish to use. And we leave it up to them to contact the resources.

About one third of the folks decline any assistance. The large majority, about two-thirds of the employees who were contacted, we described as “engaged” because they took the call and had questions. These people mostly benefited from help in understanding what services they are entitled to, and from a thumbnail education piece (what’s the difference between psychologists, psychiatrists, clinical social workers, etc., and where can you find the specialist who is right for you).

While this may not feel like much of an intervention, and it may feel a bit like walking on eggshells, the financial impact can be profound. After the telephone outreach in the pilot, we did not know the actions taken by the “engaged” members with approved leaves. But we know the outcomes: those who “engaged” (and they were the majority) spent seven fewer days on FML on average than those who declined any assistance. STD durations for those FML claims that did migrate were also much shorter on average (14 days) for members who did “engage.” Note that these data from a pilot need to be confirmed in a larger sample, but they are tantalizing.

Consider that the average duration of an STD musculoskeletal claim is 75 days, and 76 days for a mental health claim (2015 Aetna internal data, unpublished). Consider further that the average daily wage for workers in 2015 was $1841 and that the average daily benefit cost was a further $84 per day.1 For most employers musculoskeletal claims amount to about a third of their STD claims and behavioral claims approximately 10%. Even a small dip in the proportion of claims that migrate from intermittent to continuous, and then to STD, will have a huge impact on the bottom line.


  1. U.S. Department of Labor, Bureau of Labor Statistics, December 2015