Posttraumatic Stress in California's Workers' Compensation System

A Study of Mental Health Presumptions for Firefighters and Peace Officers Under Senate Bill 542

by Denise D. Quigley, Michael Dworsky, Nabeel Qureshi, J. Scott Ashwood, Kelsey O'Hollaren, Lisa S. Meredith

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Research Questions

  1. How prevalent are mental health conditions and suicidality among firefighters and peace officers, and how does their prevalence vary across occupations?
  2. What processes are involved in firefighters' and peace officers' filing of workers' compensation claims?
  3. How are PTSD and other mental health claims handled in the workers' compensation system?
  4. How will SB 542 affect fire and police department stakeholders and the workers' compensation system in relation to mental health care for exposure to trauma at work and claims?
  5. How will the bill affect costs to state and local government?

In 2019, California enacted Senate Bill (SB) 542, which created a rebuttable presumption that posttraumatic stress disorder (PTSD) in firefighters and peace officers is a work-related injury and thus compensable under workers' compensation.

California has long used presumptions to facilitate workers' compensation claims for many other occupational health conditions in first responders, including cancer, heart trouble, and hernia. SB 542 is intended to encourage care-seeking among first responders and reduce the stigma associated with filing a workers' compensation claim for a mental health condition. The presumption is in effect for injuries occurring between January 1, 2020, and December 31, 2024.

The authors of this report evaluate the prevalence of mental health conditions and illnesses among firefighters and peace officers and discuss the implications that this evidence has for policy regarding presumptions established by SB 542. Using a mixed-methods approach, the authors also investigate the frequency of workers' compensation claims involving PTSD, how often these claims are denied, and how first responders experiencing PTSD access mental health care. First responders' mental health and experiences in the workers' compensation system are compared with those of workers in other trauma-exposed occupations. Claims involving PTSD are compared with claims involving other health conditions — such as cancer, heart trouble, and hernias — that are also presumed to be work-related in first responders under California law. The report also contains estimates of the costs to state and local government that might result from presumptive coverage of PTSD in the workers' compensation system, and the authors also discuss stakeholder perspectives on SB 542.

Key Findings

  • Mental distress and suicidality are not more prevalent among California's first responders than among workers in other occupations who are exposed to trauma on the job.
  • Claims filed by firefighters and peace officers are more likely to involve PTSD than are claims by the average worker in California but are also denied more often.
  • First responders' PTSD claims are denied more often than claims for other conditions (e.g., cancer or heart trouble) with a presumption of being work-related.
  • Although it is often feasible to prove that a mental health condition is job-related, there are barriers that contribute to potentially avoidable claim denials.
  • Firefighters and peace officers also face barriers to care-seeking — primarily, mental health stigma, fear of professional consequences, and lack of access to culturally competent mental health providers who understand the realities and exceptional demands of their work.
  • Nearly all workers interviewed filed workers' compensation claims for mental health conditions, but almost none received PTSD care paid for by workers' compensation; rather, nearly all paid for care out-of-pocket, sometimes causing severe financial strain.
  • Without SB 542, first responders' workers' compensation claims involving PTSD would cost state and local governments an average of $20 million per year in benefit costs. Under SB 542, costs for claims involving PTSD may increase substantially. Costs under SB 542 are highly uncertain, however, and could range from $48 million to $347 million per year.
  • A retroactive presumption covering PTSD with 2017–2019 injury dates might cost $79 million, although these costs are also highly uncertain.

Recommendations

  • Revisit the questions discussed in this report closer to the expiration of the SB 542 presumption, perhaps in 2023. A retrospective evaluation could provide clearer evidence on care-seeking patterns, claims denial rates, and claims costs with the presumption in place.
  • Conduct a qualitative investigation to examine whether SB 542 succeeded in reducing mental health stigma or promoting other changes in department culture.
  • Scope an ex post evaluation to measure the effects of first responder turnover, training, and early retirement and to quantify their implications for the net costs of SB 542.
  • Gather more information about what details and evidence are requested by claims administrators and examine claim denials resulting from disconnects in mental health provider documentation.
  • Further examine the availability of culturally competent mental health providers and explore ways to provide first responders with a wider choice of providers, care, and treatment.
  • Start building an evidence base for better-integrated systems that help to deliver and finance mental health care for first responders with work-related trauma exposure.
  • Instead of making piecemeal improvements to employee assistance programs, employer-sponsored insurance, or workers' compensation programs, investigate the costs and benefits of alternative models used in some police departments for delivering mental health care through direct care provision.
  • Consult policymakers, departments, labor unions, and providers to find avenues for improving and accelerating first responder access to mental health treatment.
  • Consider the mental health effects of occupational trauma exposures and working conditions across a much wider set of occupations and industries.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Background and Overview of Study

  • Chapter Three

    Posttraumatic Stress, PTSD, and Suicide Among First Responders

  • Chapter Four

    PTSD in California's Workers' Compensation System

  • Chapter Five

    Proving the Job-Relatedness of Mental Health Claims

  • Chapter Six

    Access to Mental Health Care for First Responders

  • Chapter Seven

    Costs of PTSD Claims and Potential Cost Impacts of SB 542

  • Chapter Eight

    Stakeholder Perspectives on SB 542 and Areas to Improve

  • Chapter Nine

    Policy Recommendations and Future Research Priorities

  • Appendix A

    Question-by-Question Summary of Findings

  • Appendix B

    Additional Information on Qualitative Methods

  • Appendix C

    Additional Information and Supplementary Results on Quantitative Analyses

  • Appendix D

    Comparison Occupations and O*Net Work Context Measures

Research conducted by

The research described in this report was prepared for the the California Commission on Health and Safety and Workers' Compensation (CHSWC) in the Department of Industrial Relations (DIR) and conducted by the Community Health and Environmental Policy Program within RAND Social and Economic Well-Being.

This report is part of the RAND Corporation Research report series. RAND reports present research findings and objective analysis that address the challenges facing the public and private sectors. All RAND reports undergo rigorous peer review to ensure high standards for research quality and objectivity.

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.