Oskar Mittag, Hanna Kampling, Christina ReeseMedical Center – University of FreiburgInstitut for Quality Management and Social Medicine

Workshop „European practices to support those with partial work capacity and rehabilitation“43th National Rehabilitation Conference, Helsinki, Finland, 9.3.2015

Return to work practices in the Netherlands and in Germany

Acknowledgement

Dr. Monique Broekhuizen (Dutch Society of Insurance Medicine)

Dr. Wout de Boer (asim; Basel)

Jim Faas, Mr. (Nederlandse Vereniging voor Verzekeringsgeneeskunde; NVVG)

Henning Groskreutz (University of Kassel)

Dr. Bettina Hesse (German Statutory Pension Fund; DRV)

Dr. Jeannette Hoevers (Dutch Social Security Agency; UWV)

Dr. André Weel (Netherlands Society of Occupational Medicine; NVAB)

Prof. Dr. Felix Welti (University of Kassel)

Oene Zwittink (Dutch Society of Labour Assessors; UWV)

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Our team of experts

Why is this issue important at all, …

In Germany many people of working age rely on disability benefits astheir main source of income

Disabilty pension inflow accounts for more than 20 percent of all pensions (not including survivor´s benefits etc.)

Average age at entry into disabilty pension is 50 years

Almost half of those claiming disability pension have receivedunemployment or other social benefits before

More than 40 percent have not had any rehabilitation treatment duringthe last five years before entering disability schemes

Policy reforms during the past two decades have not yielded substantial effects as to reducing disabilty benefit inflow …

The German situation

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… and why did we look at the Netherlands for a comparison?

In the 1980s and 1990s, disability benefit rates in the Netherlands wereamong the highest in the world

Between 1994 and 2006 a series of policy reforms have taken placewhich led to a complete overhaul of the system

Basic principles of the reforms were active return to work strategies, increased employer responsibility, and strong incentives for all players

As a result of these measures the inflow into the disability scheme was reduced by 60 percent …

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Looking at differences …

Some basic statistics

NL DE FIArea 42,000 km2 357,000 km2 339,000 km2

Population 16.8 m 80.8 m 5.4 mDensity 405 / km2 226 / km2 16 / km2

GDP (per capita) 35,900 € 33,300 € 35,600 €Unemployment rate(2010 – 2012)1 4.7 % 6.1 % 7,9 %Disability benefits

inflow (% pop.) stock (% pop.)

0.3 %2

3.8 %20.2 %3

2.1 %3??

Economic integration of the handicapped4

% GDP% unemployment% total spending

2,1 %324 %18 %

0,1 %103 %

5 %

1,8 %250 %12 %

The Netherlands, Germany, and Finland

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1 OECD, 2014 2 van Sonsbeek & Gradus, 2011 3 DRV, 2014, 4 OECD, 2010

Major reform steps in Germany

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Year Policy reforms

2001 Disabiltiy pension allowances linked to working ability(< 6 h / < 3 h per day)

2004 Internal Occupational Reintegration Programm (BEM; § 84 Abs. 2 SGB IX)

2007 Retirement age extended to 67 years (gradually)2014 New disability pensions slightly raised („Rentenpaket“)

Major reform steps in the Netherlands

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Year Policy reforms

1994 Sick leave benefits from employer extended to 6 weeks(WetTZ)

1996 Sick leave benefits extended to 52 weeks (WULBZ)1998 Experience-rating of employer´s disabilty insurance premiums

2002 Joint responsibilty of employer and employee for return to workprocess with strict protocol („Gatekeeper law“)

2004 Stricter assessment criteria for disability benefits; sick leavebenefits extended to 104 weeks (WVLBZ)

2006 Disability benefits according to loss of earning capacity (WIA)

2004-09 Large-scale reassessment of disability beneficiaries(ca. 350,000 cases)

Spirit of the Dutch policy reforms …

“Sick and partly disabled employees are expected to do their utmost to return to the labour-market. In turn, these employees can expect to be given the chance to participate in the work process and to get the chance to develop themselves in it. Consequently, the government expects employers to provide these chances. All parties concerned – employees, employers, insurance companies and the UWV – have to exert their strength to promote durable participation of sick and partly disabled employees in the work process. They should give reintegration a maximum chance of succeeding. At the end of the period of wage payment employer and employee together draw up a reintegration report. There they set forth the activities undertaken in order to reach resumption of work. The summary has to convince the benefit agency that employer and employee have done everything possible for reintegration.”

§ 3.1 Work and Income according to Labour Capacity (WIA) law (2006)

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(cited from: de Boer, 2010, p. 9)

Spirit of the Dutch policy reforms …

“Sick and partly disabled employees are expected to do their utmost to return to the labour-market. In turn, these employees can expect to be given the chance to participate in the work process and to get the chance to develop themselves in it. Consequently, the government expects employers to provide these chances. All parties concerned – employees, employers, insurance companies and the UWV – have to exert their strength to promote durable participation of sick and partly disabled employees in the work process. They should give reintegration a maximum chance of succeeding. At the end of the period of wage payment employer and employee together draw up a reintegration report. There they set forth the activities undertaken in order to reach resumption of work. The summary has to convince the benefit agency that employer and employee have done everything possible for reintegration.”

§ 3.1 Work and Income according to Labour Capacity (WIA) law

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(cited from: de Boer, 2010, p. 9)

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Sick leavebenefits …

Overview of the main policy differences

Germany The Netherlands- Employer 6 weeks (100%) - Health insurance ≤ 72 weeks (70%)

Employer 104 (+ 52) weeks(1st y 100%; 2nd y ≥ 70%)

- Reintegration Programm (BEM)- Health insurance (§ 51 SGB V) - „Rehab before pension“ (§ 9 SGB VI)

„Gatekeeper protocol“ (fixed time structure for return to work effortsincluding mandatory “milestones“)

Little incentives for return to work(e.g. financial obligation of employer; loss of income if new job pays less)

Strong incentives for all actors(e.g. experience-rating of premiums; compensation for loss of income)

Benefits depending on working ability(> 6h / 3-6h, / < 3h per day)

Benefits according to loss of earningcapacity (< 35% / 35-80% / > 80%)

Work vs. leisure accident Causation makes no differenceDisability „pension“ („Rente“) Disability „benefit“ („uitkering“)

Germany vs. the Netherlands

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Return to workstrategies …

Overview of the main policy differences

Germany The Netherlands- Employer 6 weeks (100%) - Health insurance ≤ 72 weeks (70%)

Employer 104 (+ 52) weeks(1st y 100%; 2nd y ≥ 70%)

- Reintegration Programm (BEM)- Health insurance (§ 51 SGB V) - „Rehab before pension“ (§ 9 SGB VI)

„Gatekeeper protocol“ (fixed time structure for return to work effortsincluding mandatory “milestones“)

Little incentives for return to work(e.g. financial obligation of employer; loss of income if new job pays less)

Strong incentives for all actors(e.g. experience-rating of premiums; compensation for loss of income)

Benefits depending on working ability(> 6h / 3-6h, / < 3h per day)

Benefits according to loss of earningcapacity (< 35% / 35-80% / > 80%)

Work vs. leisure accident Causation makes no differenceDisability „pension“ („Rente“) Disability „benefit“ („uitkering“)

Germany vs. the Netherlands

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Process requirements during the first two years

Week Measures / tasks Players

1 Worker reports ill (no certificate needed for up to 6 weeks); employerinforms Arbodienst or company doctor; sick leave benefits (100%)

worker, employer

6After consulting the worker occupational physician providesproblem analysis including advice about resumption of work; employer starts reintegration-file

Occupationalphysician, employer

8 Vocational rehabilitation plan is prepared (evaluation about every6 weeks mandatory); case management assignement

worker, employer

46-52 First year evaluation to the UWV (Employee Insurance Agency) including plans for the second year

worker, employer

53 … Employer can provide job in another company („Tweede spoor“ ) worker, employer

87-91 After consulting the worker the employer produces re-integration report; during week 91 the employee applies for disability benefits

worker, employer

91-104 On the basis of the re-integration report UWV decides if theemployer has to pay sick leave for another 52 weeks (ca. 12%!) UWV

105 … Disability benefits if loss of earning capacity > 35 % (WIA); routine reassessments during the first five years UWV

„Gatekeeper protocol“

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Toolbox of return to work interventiones

Counseling, job coaching, family counseling

Stepwise reintegration

Adaption of work situation (e.g. working hours, lifting assistent)

Medical rehabilitation (e.g. cardiac, neurological)

Behavior therapy, stress management, relaxation training

Physiotherapy, back therapy training, physical excercises

Medication, vaccinations, hyposensitization

Continuing education, specific trainings (e.g. computer training, jobapplication training, public speaking)

Health education (e.g. smoking cessation)

Examples from NVAB guidelines (nvab.artsennet.nl/Richtlijenen.htm)

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Rehabilitation centers / clinicsNL ca. 26 centers / 14 clinic departments1

DE > 1,400 clinics / centers1 Lewerenz & Köhler (2010)

Process requirements during the first two years

Week Measures / tasks Players

1 Worker reports ill (no certificate needed for up to 6 weeks); employerinforms Arbodienst or company doctor; sick leave benefits (100%)

worker, employer

6After consulting the worker occupational physician providesproblem analysis including advice about resumption of work; employer starts reintegration-file

Occupationalphysician, employer

8 Vocational rehabilitation plan is prepared (evaluation about every6 weeks mandatory); case management assignement

worker, employer

46-52 First year evaluation to the UWV (Employee Insurance Agency) including plans for the second year

worker, employer

53 … Employer can provide job in another company („Tweede spoor“ ) worker, employer

87-91 After consulting the worker the employer produces re-integration report; during week 91 the employee applies for disability benefits

worker, employer

91-104 On the basis of the re-integration report UWV decides if theemployer has to pay sick leave for another 52 weeks (ca. 12%!) UWV

105 … Disability benefits if loss of earning capacity > 35 % (WIA); routine reassessments during the first five years UWV

„Gatekeeper protocol“

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Incentives …

Overview of the main policy differences

Germany The Netherlands- Employer 6 weeks (100%) - Health insurance ≤ 72 weeks (70%)

Employer 104 (+ 52) weeks(1st y 100%; 2nd y ≥ 70%)

- Reintegration Programm (BEM)- Health insurance (§ 51 SGB V) - „Rehab before pension“ (§ 9 SGB VI)

„Gatekeeper protocol“ (fixed time structure for return to work effortsincluding mandatory “milestones“)

Little incentives for return to work(e.g. financial obligation of employer; loss of income if new job pays less)

Strong incentives for all actors(e.g. experience-rating of premiums; compensation for loss of income)

Benefits depending on working ability(> 6h / 3-6h, / < 3h per day)

Benefits according to loss of earningcapacity (< 35% / 35-80% / > 80%)

Work vs. leisure accident Causation makes no differenceDisability „pension“ („Rente“) Disability „benefit“ („uitkering“)

Germany vs. the Netherlands

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Jane Doe; 56 years; cleaning woman in a hospital(gross wage 1,800 €); loss of earning capacity 50% / working ability < 6h

6 weeks … 72 weeks …

1,800 1,260

Situation in Germany …

1,800 … > 1,260

… and in the Netherlands104 weeks …

What happens if she gets a job that pays 900 € …• In Germany: She loses her sick-pay• In the Netherlands: no change (but employer is

somewhat relieved from sick-pay)

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Disabilitybenefits…

Overview of the main policy differences

Germany The Netherlands- Employer 6 weeks (100%) - Health insurance ≤ 72 weeks (70%)

Employer 104 (+ 52) weeks(1st y 100%; 2nd y ≥ 70%)

- Reintegration Programm (BEM)- Health insurance (§ 51 SGB V) - „Rehab before pension“ (§ 9 SGB VI)

„Gatekeeper protocol“ (fixed time structure for return to work effortsincluding mandatory “milestones“)

Little incentives for return to work(e.g. financial obligation of employer; loss of income if new job pays less)

Strong incentives for all actors(e.g. experience-rating of premiums; compensation for loss of income)

Benefits depending on working ability(> 6h / 3-6h, / < 3h per day)

Benefits according to loss of earningcapacity (< 35% / 35-80% / > 80%)

Work vs. leisure accident Causation makes no differenceDisability „pension“ („Rente“) Disability „benefit“ („uitkering“)

Germany vs. the Netherlands

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How is the loss of earning capacity determined?

Definition Remaining earning capacity is the wage which a person can earn by doing work thathe or she is capable of doing despite the illness.

AssessmentMedical assessment (insurance physician) and assessment by a job expert

Based on the re-integration report, information from the Arbodienst and thetreating physicians, and face to face assessment (ca. 3 h)

Key assessment tool is the Functional Ability List (FML) with 70 items includingwork related tasks as well as activities of daily living

The FML profile is compared to a data base of ca. 7,500 jobs, and the averageearning of feasable jobs is compared to the claimant´s past earnings.

ConsequencesIf the loss of earning capacity is more than 35 percent the claimant will receivedisability benefits (and the employer´s disabilty insurance premiums will go up forthe next 10 years). .

Assessment for WIA-benefits (week 91 - 104)

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For comparison: How is the remaining workingability assessed in Germany?

The crucial criterion (working ability in termsof hours per day) is not well defined. Assessors develop their own standards. Assessments differ widely.

(cf. Dickmann & Brooks, 2007)

Jane Doe; 56 years; cleaning woman in a hospital(gross wage 1,800 €); loss of earning capacity 50% / working ability < 6h

6 weeks … 72 weeks …

1,800 1,260 ….

Situation in Germany …

1,800 … > 1,260

… and in the Netherlands104 weeks …

Jane Doe; 56 years; cleaning woman in a hospital(gross wage 1,800 €); loss of earning capacity 50% / working ability < 6h

6 weeks … 72 weeks … disability pension … … retirement

1,800 1,260 385 – 770 ….

Situation in Germany …

1,800 … > 1,260 630 1.086

… and in the Netherlands104 weeks … disability benefits … … retirement

What happens if she gets a job that pays 900 € …• In Germany: disability pension cut down by 1/4 • In the Netherlands: no cutback on disability benefit

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Work vs. homeaccident …

Overview of the main policy differences

Germany The Netherlands- Employer 6 weeks (100%) - Health insurance ≤ 72 weeks (70%)

Employer 104 (+ 52) weeks(1st y 100%; 2nd y ≥ 70%)

- Reintegration Programm (BEM)- Health insurance (§ 51 SGB V) - „Rehab before pension“ (§ 9 SGB VI)

„Gatekeeper protocol“ (fixed time structure for return to work effortsincluding mandatory “milestones“)

Little incentives for return to work(e.g. financial obligation of employer; loss of income if new job pays less)

Strong incentives for all actors(e.g. experience-rating of premiums; compensation for loss of income)

Benefits depending on working ability(> 6h / 3-6h, / < 3h per day)

Benefits according to loss of earningcapacity (< 35% / 35-80% / > 80%)

Work vs. leisure accident Causation makes no differenceDisability „pension“ („Rente“) Disability „benefit“ („uitkering“)

Germany vs. the Netherlands

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Joe Doe; 32 years; roofing worker (gross wage 2.400 €); severe traumatic brain injury; loss of earning capacity / working ability: 100 % / < 3h

6 weeks … 72 weeks … disability pension … … retirement

2,400 1,680 860 …..

Situation in Germany

2,400 1,920 1,600 ….

2,400 … > 1,680 1,800 1.086

… and in the Netherlands104 weeks … disability benefits … … retirement

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„Pension“ vs. „benefit“ …

Overview of the main policy differences

Germany The Netherlands- Employer 6 weeks (100%) - Health insurance ≤ 72 weeks (70%)

Employer 104 (+ 52) weeks(1st y 100%; 2nd y ≥ 70%)

- Reintegration Programm (BEM)- Health insurance (§ 51 SGB V) - „Rehab before pension“ (§ 9 SGB VI)

„Gatekeeper protocol“ (fixed time structure for return to work effortsincluding mandatory “milestones“)

Little incentives for return to work(e.g. financial obligation of employer; loss of income if new job pays less)

Strong incentives for all actors(e.g. experience-rating of premiums; compensation for loss of income)

Benefits depending on working ability(> 6h / 3-6h, / < 3h per day)

Benefits according to loss of earningcapacity (< 35% / 35-80% / > 80%)

Work vs. leisure accident Causation makes no differenceDisability „pension“ („Rente“) Disability „benefit“ („uitkering“)

Germany vs. the Netherlands

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„eläke“ „tuki“

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Outcomes …

Effects of the policy reforms in the NetherlandsDisability benefit inflow / stock 1968-2010 (van Sonsbeek & Gradus, 2011, S. 7)

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„Gatekeeper law“

Disabilty pension inflow in Germany 1993 – 2011

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1993 …. 2000 2011

Old age pensions

Disability pensions

Policy reform (1.1.2001)Pension inflow 1993 – 2011 (DRV, 2012)

Take home messagesWhat is it that we can learn from the Netherlands?

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Reintegration into work should start early …

… and include active case management

Fixed schedule with mandatory „milestones“

Few players with well defined responsibilities

Effective incentives and sanctions

Flexible return to work interventions („toolbox“)

(Disabilty benefits should be seperate from old age pension)

Thank you very much… paljon kiitoksia!