Special Report: Carpal tunnel screening
Carpal tunnel screening may save money but poses huge legal risks
Employers may love the idea, but you must know the downside
Screening employees for existing carpal tunnel syndrome (CTS) or the potential to develop it is an idea that is catching on among employers seeking to cut the costs of repetitive strain injuries. But there are potential problems that must be considered before you offer this service. The screening may save employers a lot of money but only if they can avoid the lawsuits that might be filed when screening leads to a job refusal.
In addition, there is significant debate over the value of nerve conduction studies, the method used to detect carpal tunnel syndrome and predict who might develop it in the future. Even if there were no legal worries associated with the testing, some critics say the studies simply do not work. (For more on the effectiveness debate, see story, p. 139.) The test involves using electronic instruments to track nerve impulses in the hands and wrists.
A leading proponent of carpal tunnel screening is Ronald C. Bingham, MD, president of IPS Physician Services, an occupational health provider in Jackson, TN.
Bingham offers a service called "Wrist-Watch" to local employers, using nerve conduction studies to test workers for existing CTS or a predisposition to developing it when exposed to repetitive motion on the job. Nerve conduction studies often are used to confirm CTS after a patient reports symptoms, but Bingham’s service is more aggressive. It uses the technique to screen new employees.
"Our Wrist-Watch program uses this same method of evaluation proactively, after the hire is made before employment begins," Bingham explains in marketing material to local employers. "It incorporates the most effective strategies for any illness or injury: early detection and prevention. By using state-of-the-art technology, Wrist-Watch will substantially reduce the suffering and costs associated with CTS."
The right way to use study results
Interestingly, Bingham is an outspoken critic of how nerve conduction studies are used by many occupational health providers. He recommends the service as a useful screening tool but only if provided in the right way.
"This test routinely is poorly done by technicians and physicians coast to coast. This is a test that is easy to do poorly," Bingham explains to OHM readers. "There is a right and wrong way to do the test and a right and wrong way for employers to use the results. I believe in it, but there are a lot of people promoting this who don’t fully understand the limitations."
Bingham explains there are three general ways that employers can use the results of nerve conduction studies:
1. Study results are used only as a baseline just as you would use the results of an employee’s first hearing test.
That method, the most conservative approach to using the nerve conduction studies, can be effective in eliminating costs associated with previously existing conditions.
"I get a lot of calls from employers who ask how this woman can have CTS when she’s only worked there for three days," Bingham says. "Employers are being punished for slow nerves that were there already. We can debate whether slow nerves are clinically associated with CTS, but the fact is that the courts will award payment, and the slow nerve test results will prompt surgery and disability and all the costs that come along with them. Employers pay dearly for that slowing once it is discovered post hire."
2. Test results serve as a placement tool.
If the test shows the worker has a pre-existing problem with his hands, Bingham says it only makes sense to steer that worker away from a job that is hard on the hands. That is possible in most work situations, he says, though you may have to dissuade employers from the idea that they have no appropriate alternatives.
"Employers often want to say that all their jobs are highly wrist and hand intensive," Bingham says. "In fact, it usually is a small number, even in an industry like meat packing that is considered high risk for CTS. It concerns me when employers want to categorically dismiss all people with nerve abnormality. That’s not right."
3. The job offer is rescinded when the nerve conduction study shows CTS or a predisposition.
The Americans with Disabilities Act (ADA) requires such testing be done only after a conditional job offer, and then the ADA requires that a reasonable accommodation be made if possible. Rescinding a job offer based on exam results showing no current symptoms but a tendency to develop CTS is very risky, according to an ADA official. (See p. 144 for an exclusive report on how nerve conduction studies might violate the ADA.)
Bingham says some of his clients will rescind the job offer when a nerve abnormality is discovered, but he is less comfortable with that action than with using the results as a baseline or a placement tool. He leaves it to the employer to make sure the worker is treated fairly and no laws are broken, but he feels obligated to educate the employer fully about what the test does and does not indicate. He tells them that no medical test is perfect and that there is no certainty that a worker with slow nerves actually will develop CTS.
"Unfortunately, a lot of employers embark on this without a full understanding and run the risk of making major errors," he says. "They are potentially setting themselves up for lots of legal problems when they make decisions based on inaccurate information."
The idea of screening out CTS holds great appeal for employers. At DeVilbiss Air Power Co. in Jackson, TN, repetitive strain injuries used to make up a significant portion of all workers’ compensation, disability, and overall occupational health costs. The company manufactures air compressors, and while it apparently suffered no more repetitive strain injuries than would be expected in such a manufacturing operation, safety officials were looking for any way to reduce the cost to the company and the impact on employees.
In 1993, Bingham offered his screening services to the company and Claude Kelly, director of human resources, decided to try the screening. After a year, Kelly was convinced the screening worked.
"We saw a drop in overall workers’ compensation costs after a year, and there was no doubt that part of that drop is attributable to the screening program," Kelly says. "It’s hard to say just how much the screening is responsible for the drop, but we don’t have any doubt that it cut our costs by eliminating a lot of carpal tunnel that we would have had otherwise."
The company’s overall costs for workers’ compensation were $325,000 in 1993 and $18,000 in 1996.
Kelly says other improvements helped cut the costs, but he says the carpal tunnel screening is responsible for a large portion because a single carpal tunnel case can be expensive, especially if surgery is required. The screening is no more expensive than sending an employee for a physical, he notes.
"It’s not an expensive service when you compare it to the cost of a carpal tunnel case," he says. "If we save just one carpal tunnel case, we’ve more than recovered the cost of screening employees for six months or a year."
Kelly says the screening is a positive move for both the company and the employee. The company saves dollars by avoiding the carpal tunnel injury, and the employee is spared by not being put into a position that promotes or exacerbates the injury. In most of the cases in which any problem is noted, the screening suggests the employee has a tendency to develop CTS, rather than indicating an existing problem.
When that happens, DeVilbiss avoids putting that employee in a position that would expose him or her to repetitive strain. So far, the company has not had to deny a person a job as a result of the screening, but Kelly says that is a possibility.
"If we were near full employment and the only position open is one that would involve a lot of repetitive motion, we wouldn’t want to put that person in the position and know that it would cause an injury," Kelly says. "That would be regrettable, but it wouldn’t be right for the employee if we knew that position would lead to a serious problem after some time."
Kelly admits that denying a position as a result of the screening will be a more ticklish situation than simply steering the person toward a less risky job within the company.
So far, DeVilbiss has heard little protest from employees who are screened, but Kelly says he would not be surprised if someone charged discrimination upon being denied a position.
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