Background
Introduction
The Dutch social security system for work disability assessment
Disability assessments by insurance physicians
Research questions
Methods
Study design and procedure
Study population
Outcome measures for disability assessments
Client characteristic | Class | |
---|---|---|
Gender | ||
(background) | Man(= 1)(ref) | 44.4% |
Woman (= 2) | 55.6% | |
Age | ||
(background) | 15-24 years | 2.6% |
25-34 years | 19.3% | |
35-44 years | 36.1% | |
45-54 years | 32.4% | |
≥ 55 years | 9.6% | |
Mean (sd) median age (years) | 42.5 (9.1) 43.0 | |
Statutory regime | ||
(background) | WAO (= 1) (ref) | 26.8% |
HERBO (= 2) | 47.5% | |
WIA (= 3) | 25.7% | |
Sector of Occupation | ||
(background) | Agriculture/Fishery/Foods (= 1) | 4.4% |
Construction (= 2) | 6.3% | |
Industry (= 3) | 9.1% | |
Retail/Wholesale (= 4) | 9.4% | |
Transport (= 5) | 3.3% | |
Financial Services(= 6) | 6.1% | |
Employment Agencies (= 7) | 5.5% | |
Health and Care(= 8) | 14.1% | |
Education(= 9) | 3.0% | |
Other Governmental (= 10) | 4.8% | |
Other company/profession (= 11) (ref) | 34.2% | |
Diagnosis | ||
(background) | Cardiovascular (= 1)(ref) | 5.1% |
Musculoskeletal (= 2) | 32.2% | |
Mental (= 3) | 34.3% | |
Other(= 4) | 28.5% | |
Objectification of Complaints | ||
(background) | Yes (= 0) (ref) | 48.1% |
No (= 1) | 51.9% | |
No Sustainable Capacities Left Extended | ||
(outcome measure) | No (= 0) (ref) | 65.0% |
Yes (= 1) | 35.0% | |
Maximum Work Disability Class | ||
(outcome measure) | < 80% (= 0) (ref) | 57.2% |
80 - 100% (= 1) | 42.8% |
Client characteristic | Class | |
---|---|---|
Standard Earnings per month | ||
(background) | € 0 - € 917 (= 1) | 10.1% |
€ 918 - € 1127 (= 2) | 22.4% | |
€ 1128 - € 1535 (= 3) | 35.3% | |
€ 1535 - € 2069 (= 4) | 22.5% | |
(€ 2070 - highest (= 5) | 9.7% | |
Mean (sd) median score (scale 1..5) | 3.0 (1.1) 3.0 | |
Standard Working Hours per week | ||
(background) | ≤ 20 hours (= 1) | 13.1% |
21 thru 32 hours (= 2) | 21.5% | |
32 thru 38 hours (= 3) | 44.0% | |
39 thru 40 hours (= 4) | 16.6% | |
> 40 hours (= 5) | 4.8% | |
Mean (sd) median score (scale = 1..5) | 2.8 (1.0) 3.0 | |
Education Level | ||
(background) | Grade 1(= 1) | 4.4% |
Grade 2 (= 2) | 23.1% | |
Grade 3(= 3) | 31.8% | |
Grade 4 and 5 (= 4) | 30.1% | |
Grade 6 and 7(= 5) | 10.6% | |
Mean (sd) median score (scale 1..5) | 3.2 (1.0) 3.0 | |
Mental Incapacities | ||
(background) | Not or Slightly (= 0) (ref) | 85.6% |
Moderate (= 1) | 7.5% | |
Rather strong or Strong (= 2) | 6.8% | |
Physical Incapacities | ||
(background) | Not or Slightly (= 0) (ref) | 84.6% |
Moderate (= 1) | 5.6% | |
Rather strong or Strong (= 2) | 9.8% | |
Autonomous Incapacities | ||
(background) | Not or Slightly (= 0) (ref) | 92.3% |
Moderate (= 1) | 3.5% | |
Rather strong or Strong (= 2) | 4.2% | |
Functional Incapacity Score | ||
(outcome measure) | (Nearly) none incapacities (= 0) | 69.9% |
Score (1) | 11.1% | |
Score (2) | 13.1% | |
Score (3) | 2.8% | |
Score (4) | 2.7% | |
Score (5) | 0.2% | |
Maximum severe incapacities (= 6) | 0.1% | |
Mean (sd) median score (scale 0..6) | 0.6 (1.0) 0.0 |
Client background variables
Insurance physician variables
Background variables | ||
---|---|---|
Gender | Man | 58.8% |
Woman | 41.2% | |
Age | 30-45 years | 23.6% |
46-50 years | 27.7% | |
51-55 years | 25.0% | |
≥ 56 years | 23.7% | |
Mean (sd) median age (years) | 50.7 (7.0) 50.4 | |
Career as Insurance Physician* | 0-10 years | 24.1% |
11-15 years | 25.6% | |
16-20 years | 26.2% | |
≥ 21 years | 24.1% | |
Mean (sd) median career (years) | 16.0 (7.7) 16.5 | |
Former Curative Physician | No (= 0) | 84.4% |
Yes (= 1) | 15.6% | |
Specialist in Insurance Medicine | No (= 0) | 13.6% |
Yes (= 1) | 86.4% | |
Standard working hours per week | < 25 hours (= 1) | 18.1% |
25-32 hours (= 2) | 23.1% | |
> 32 hours (= 3) | 58.8% | |
Most clients from WIA | No (= 0) | 64.3% |
Yes (= 1) | 35.7% | |
Most clients from WAO | No (= 0) | 70.4% |
Yes (= 1) | 29.6% | |
Most clients from WAJONG | No (= 0) | 86.9.% |
Yes (= 1) | 13.1% | |
Average number of assessments per week | 1-5 | 23.1% |
6-15 | 29.7% | |
16-22 | 25.6% | |
23-28 | 21.6% | |
Mean (sd) median assessments (number) | 14.0 (8.4) 15.0 | |
ASE variables** | ||
Attitude | Mean (sd) median | 0.0 (1.0) 0.0 |
Social Norm | Mean (sd) median | 0.0 (1.0) 0.0 |
self-Efficacy | Mean (sd) median | 17.6 (3.2) 18.0 |
Barriers | Mean (sd) median | 0.0 (1.0) 0.0 |
Knowledge | Mean (sd) median | 0.0 (1.0) 0.0 |
Intention | Mean (sd) median | 0.0 (1.0) 0.0 |
Behaviour: process | Mean (sd) median | 0.0 (1.0) 0.0 |
Behaviour: assessment | Mean (sd) median | 0.0 (1.0) 0.0 |
-
Attitude: the insurance physician has a more positive attitude towards the profession of insurance physician, the quality of one's work, the professional staff, and the (Dutch) social insurance system;
-
Social Norm: the insurance physician performed more autonomously, less influenced or uninfluenced by the social environment (colleagues, organization, society);
-
Self-Efficacy: the insurance physician has more confidence in his/her own ability to control the interaction with the client during the assessment interview;
-
Barriers: the insurance physician experiences more barriers arising from work pressure, emotional workload, less scope for decision-making, higher levels of burnout, poorer cooperation in the office, less incentives from management and relatively more 'difficult' clients;
-
Knowledge: the insurance physician has sufficient information about the medical status of the client and about the rehabilitation efforts of the employer and the client;
-
Intention: the insurance physician attaches more importance to: the promotion of recovery, resumption of work, self-reflection and re-integration, the relevance of capability, illness, disorders and handicaps in the assessment and, most of all, proper checks for the consistency of information on the daily activities and home situation of the client. To some extent this paints the professional attitude that one would expect from an insurance physician;
-
Behaviour concerning the assessment process (Behaviour: process): the insurance physician has more confidence in his/her own vision of the job. A higher score suggests an insurance physician who is eager, takes control and is prepared to strike a compromise with the client;
-
Behaviour concerning the assessment content (Behaviour: assessment): the insurance physician adheres more to rules and professional standards. A higher score is typical of an insurance physician who sticks to the guidelines, does not consider the specific situation of the client, thinks as he goes along, but still believes that he engages with the client.
Analysis
Model specifications
Intra-Class Correlations
Results
Non-response
Descriptives of the outcome measures
Outcome measures | NSCE | FIS0 | FIS123 | FIS456 | MWDC |
---|---|---|---|---|---|
Across insurance physicians | |||||
Mean | 35.1 | 69.6 | 27.3 | 4.1 | 42.9 |
median | 34.1 | 72.0 | 25.9 | 2.0 | 42.9 |
minimum | 8.6 | 22.4 | 4.8 | 0.5 | 10.5 |
maximum | 83.3 | 95.2 | 61.2 | 19.3 | 86.1 |
standard deviation | 11.9 | 11.0 | 9.0 | 3.0 | 9.8 |
variation coefficient | 0.34 | 0.16 | 0.33 | 0.75 | 0.23 |
Across offices
| |||||
Mean | 34.7 | 68.6 | 28.1 | 3.3 | 43.9 |
median | 33.3 | 68.5 | 28.3 | 3.2 | 42.7 |
minimum | 18.2 | 44.6 | 20.7 | 0.9 | 35.1 |
maximum | 49.9 | 78.3 | 47.3 | 8.8 | 53.0 |
standard deviation | 8.3 | 6.7 | 5.1 | 2.0 | 4.4 |
variation coefficient | 0.24 | 0.10 | 0.18 | 0.60 | 0.10 |
Multilevel analyses
Fixed | Random | ||||
---|---|---|---|---|---|
IP | Office | ||||
OR | 95% CI | p | p | p | |
Client (CL)
| |||||
Constant | 0.647 | 0.531-0.789 | **** | **** | *** |
Gender_CL (female) | 1.340 | 1.276-1.408 | **** | **** | |
Age_CL/10 | 1.036 | 1.012-1.061 | *** | **** | |
Statutory regime HERBO (yes) | 1.009 | 0.927-1.098 | NS | **** | |
Statutory regime WIA (yes) | 1.169 | 1.070-1.277 | **** | **** | |
Agriculture/Fishery/Foods (yes) | 1.035 | 0.931-1.150 | NS | ||
Construction (yes) | 0.834 | 0.739-0.942 | *** | ||
Industry (yes) | 0.965 | 0.888-1.047 | NS | ||
Retail/Wholesale (yes) | 1.197 | 1.105-1.297 | **** | ||
Transport (yes) | 0.842 | 0.753-0.942 | *** | ||
Financial Services (yes) | 1.139 | 1.045-1.241 | *** | ||
Employment Agencies (yes) | 1.215 | 1.108-1.333 | **** | ||
Health and Care (yes) | 1.121 | 1.030-1.219 | *** | ||
Education (yes) | 1.154 | 1.008-1.321 | ** | ||
Other Governmental (yes) | 1.287 | 1.157-1.430 | **** | ||
Musculoskeletal diseases (yes) | 0.264 | 0.243-0.288 | **** | **** | |
Mental diseases (yes) | 1.632 | 1.480-1.800 | **** | **** | |
Other diseases (yes) | 1.276 | 1.189-1.370 | **** | ||
Objectification of Complaints (yes) | 0.342 | 0.318-0.368 | **** | **** | |
Insurance Physician (IP)
| |||||
Attitude | 0.950 | 0.896-1.008 | * | NA |
Fixed | Random | ||||
---|---|---|---|---|---|
IP | Office | ||||
OR | 95% CI | p | p | p | |
Client (CL)
| |||||
Constant | 0.338 | 0.274-0.417 | **** | **** | |
Gender_CL (female) | 1.046 | 1.008-1.086 | ** | **** | |
Age_CL/10 | 1.156 | 1.130-1.183 | **** | **** | |
Statutory regime HERBO (yes) | 1.968 | 1.809-2.141 | **** | **** | |
Statutory regime WIA (yes) | 1.511 | 1.381-1.654 | **** | **** | |
Agriculture/Fishery/Foods (yes) | 0.998 | 0.935-1.065 | NS | ||
Construction (yes) | 0.862 | 0.797-0.933 | **** | ||
Industry (yes) | 0.893 | 0.849-0.940 | **** | ||
Retail/Wholesale (yes) | 0.941 | 0.892-0.992 | ** | ||
Transport (yes) | 0.810 | 0.750-0.874 | **** | ||
Financial Services (yes) | 0.924 | 0.871-0.980 | *** | ||
Employment Agencies (yes) | 0.900 | 0.851-0.953 | **** | ||
Health and Care (yes) | 0.969 | 0.914-1.028 | NS | ||
Education (yes) | 1.068 | 0.965-1.183 | NS | ||
Other Governmental (yes) | 1.135 | 1.062-1.214 | **** | ||
Musculoskeletal diseases (yes) | 0.697 | 0.644-0.754 | **** | **** | |
Mental diseases (yes) | 1.772 | 1.629-1.928 | **** | **** | |
Other diseases (yes) | 0.899 | 0.832-0.970 | *** | **** | |
Objectification of Complaints (yes) | 0.560 | 0.530-0.591 | **** | **** | |
Standard Earnings | 0.880 | 0.863-0.897 | **** | **** | |
Standard Working Hours | 0.978 | 0.961-0.996 | ** | ||
Education level | 0.956 | 0.941-0.971 | **** | **** | |
Insurance Physician (IP)
| |||||
Years Career as IP | 1.009 | 1.003-1.015 | *** | NA |
Fixed | Random | ||||
---|---|---|---|---|---|
IP | Office | ||||
OR | 95% CI | p | p | p | |
Client (CL)
| |||||
Constant | 2.832 | 1.004-7.987 | ** | *** | |
Gender_CL (female) | 0.918 | 0.870-0.967 | *** | ||
Age_CL/10 | 0.978 | 0.801-1.196 | NS | ** | |
Legal regime HERBO (yes) | 0.945 | 0.858-1.040 | NS | **** | |
Statutory regime HERBO (yes) | 0.610 | 0.540-0.688 | **** | **** | |
Statutory regime WIA (yes) | 1.134 | 0.995-1.293 | * | ||
Construction (yes) | 0.845 | 0.732-0.974 | ** | ||
Industry (yes) | 0.882 | 0.795-0.979 | ** | ||
Retail/Wholesale (yes) | 0.967 | 0.875-1.068 | NS | ||
Transport (yes) | 0.772 | 0.670-0.889 | **** | ||
Financial Services (yes) | 0.919 | 0.817-1.034 | NS | ||
Employment Agencies (yes) | 1.084 | 0.968-1.215 | NS | ||
Health and Care (yes) | 0.920 | 0.826-1.025 | NS | ||
Education (yes) | 0.854 | 0.701-1.041 | NS | ||
Other Governmental (yes) | 0.805 | 0.698-0.929 | *** | ||
Musculoskeletal diseases (yes) | 0.594 | 0.537-0.656 | **** | ** | |
Mental diseases (yes) | 1.134 | 1.008-1.276 | ** | *** | |
Other diseases (yes) | 1.122 | 1.017-1.237 | ** | ||
Objectification of Complaints (yes) | 0.615 | 0.577-0.656 | **** | *** | |
Mental Incapacities moderate (yes) | 5.496 | 4.944-6.109 | **** | **** | |
Mental Incapacities strong (yes) | 13.929 | 12.144-15.978 | **** | **** | |
Physical Incapacities moderate (yes) | 5.960 | 5.446-6.522 | **** | ** | |
Physical Incapacities strong (yes) | 21.520 | 19.898-23.275 | **** | ||
Autonomous Incapacities moderate (yes) | 2.472 | 2.181-2.802 | **** | ||
Autonomous Incapacities strong (yes) | 4.730 | 4.173-5.363 | **** | ** | |
Standard Earnings | 0.828 | 0.805-0.851 | **** | ||
Standard Working Hours | 0.959 | 0.937-0.982 | **** | ||
Education level | 0.777 | 0.753-0.802 | **** | **** | |
Insurance Physician (IP)
| |||||
Age_IP/10 | 0.819 | 0.673-0.996 | ** | NA | |
Age_IP*Age_CL/100 | 1.039 | 0.999-1.080 | * | NA | |
Former Curative Physician (yes) | 1.150 | 1.003-1.319 | ** | NA | |
Self-efficacy | 0.988 | 0.975-1.002 | * | NA | |
Knowledge | 1.057 | 1.006-1.110 | ** | NA | |
Behaviour: assessment | 1.070 | 1.017-1.126 | *** | NA |
Dependent variables | NSCE (n = 83755) | FIS (n = 64190) | MWDC (n = 64190) |
---|---|---|---|
ICC IP-level | 7.1% | 11.8% | 6.5% |
ICC Office-level | 1.6% | 0.0% | 0.0% |
R2 total model | 19.1% | 18.5% | 37.2% |
Contribution in R2 by client variables* | 10.4% | 6.7% | 30.7% |