Through my work as an occupational physician, I regularly interact with doctors who have a variety of roles in the assessment and management of work-related injuries. Most often I am a member of a team of treating health professionals, but at times as an independent medical examiner, I provide analysis and critique of other doctor’s opinions.
I tend to see patients with injuries that take longer to resolve or require intervention including some who require spinal and other types of surgery. There are more frequently chronic pain patients than in general practice. As an independent medical examiner, I see workers involved in litigation, often having had a prolonged and frustrating period in the workers compensation system.
I have taken a particular interest in other doctor’s views about workers’ compensation issues and have surveyed views of local specialists who interact frequently with the system and participated in discussions with doctors who have concerns about managing patients within compensation systems. While I have not conducted a scientific study of doctors opinions, I can make a number of observations from my perspective.
Doctors have a spectrum of views about workers compensation including some who are cynical about any patient who claims workers’ compensation benefits. Most doctors with a focus on treatment and who interact with the system however are negative about the processes adopted by insurers and the opinions of independent doctors engaged by the insurers.
Doctors have concerns about increasing impositions from claims management practices and legal involvement. Some are reporting difficulty providing care under these constraints and some no longer see workers compensation patients for these reasons.
Doctors have expressed concerns about delays to the provision of appropriate care due to problems with access to consultant medical practitioners and, at times, control over selection of consultant level care by insurers.
Doctors express concerns that there are more requests from insurers to provide reports to justify investigation and treatment expenses. This extends not just to the costs of expensive procedures, but can extend to matters as simple an imaging investigation or the addition of a new medication.
Doctors express concerns that approval for recognised investigation and treatment procedures are often rejected or decisions delayed on the basis of clerical decisions or the opinions of doctors contracted by the insurance industry i.e., from independent medical assessors. There are often significant delays waiting for an insurer to obtain an independent medical opinion to approve a relatively straightforward investigation or treatment procedure.
Doctors are concerned that delays or rejection of funding for recommended treatment can have significant implications for recovery. This has negative consequences for the patient’s psychological health, compounding the risk of a poor outcome.
There are concerns that independent medical assessors at times provide opinions outside their area of expertise, are not up to date in their knowledge of current practice or consider only selected information provided by the insurer. Unnecessary independent medical reviews can lead to confrontation changing the mind-set of the patient to proving their case with detrimental effects on recovery.
Doctor can become overwhelmed by requests from insurers for reports of a medico-legal nature. This can contribute to delays in timely responses from the doctors and reduces their availability to provide treatment and care.
Doctors express concern about reluctance by insurers to fund interventional pain procedures and some surgical procedures.
Doctors are concerned that rehabilitation providers lack independence from the insurers who directly appoint them and fund their services. They sometimes provide advice to the patients, insurers about treatment, or where to seek treatment, outside of their field of expertise. At times rehabilitation providers document an unrealistic ‘return to work’ goal without any understanding of the injury prognosis or discussion with the treating practitioners. This creates wrong expectations for those involved. Unnecessary attendance by the rehabilitation at every doctors appointment can waste time and resources.
Doctors are concerned that insurers often resist funding for retraining and redeployment when it is clear that an injured patient cannot return to their pre-injury work. The focus by insurers is often on return to pre-injury work without recognising when this is not achievable.
Doctors are concerned about unnecessarily confrontational systems to resolve claims where patients reach maximal medical improvement, but are unable to return to their pre-injury work. With the current system insurers can only resolve matters by seeking negative reports from independent doctors to bring matters to settlement. This can be a damaging process psychologically to the worker.
In summary, there are many concerns expressed by doctors about the workers compensation system in Tasmania. Doctors are a key part of the system to provide necessary care for injured workers. Withdrawal from the system by doctors can only degrade the outcomes achieved. The designers of our workers compensation system need to take into account doctor’s views, not just the views of the employers and workers and their representatives.
Insult and Injury 
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One solution to the problems of bias towards the payer by independent medical examiners (IME) is to promote the use of Medical Panels, where experienced and respected clinicians appointed by an independent body make determinations about treatment needs (and other medical matters). Combined with an approach where Independent Opinions are only required in exceptional circumstances i.e. treating doctors’ recommendations are usually followed, the current problems can be avoided.
Another approach, like that adopted in Victoria, is to introduce quality assurance mechanisms for IME’s. I am not sure how well that system is working.
Development of enforceable ‘Codes of Practice’ for IME assessors can also help.
One point that needs to be added to your list of concerns is that compensation insurers are prepared to pay much more for “independent” medical opinions than for the treatment and support of injured workers (apart from the amount paid for surgical and other interventional procedures). It is therefore not surprising that some of our colleagues choose to “follow the money trail” wherever it may lead. That the health care of injured workers tends to become fragmented in this process does not seem to be an issue of concern to them or to third party funders.
Yes, money can be an important factor. I’ll comment in more detail in a forthcoming article about issues with independent medical assessments.
I have touched on this matter in today’s post about the undervaluing of role of the treating doctor, but I will go into more detail when I tackle the more contentious subject of Independent Medical Examiners, a role that I sometimes undertake myself.
Peter I’m not so sure about the Medical Panels. I had a neurosurgeon wish me a miracle at my impairment assessment… my score? 0! As long as the primitive guidelines with Pain chapter removed are in place (amongst other limitations), there is no alternative within the current system. And let’s not forget the money spent on ‘investigation’…. putrid!
There are pros and cons of medical panels – whether they achieve justice depends on the quality of the panelists and the guidelines within which they operate (including impairment assessment guidelines). In most jurisdictions medical panel decisions are binding i.e. cannot be appealed so if they make poor decisions claimants can be in a worse situation. Perhaps a topic to discuss in more detail at some stage, but after I have put together something about IME’s!