Doctors (and workers too) see a Workers Compensation system as a Health Care system, providing for the needs of those unfortunate to be injured or become ill as a result of their work.
Workers Compensation however is different to most other types of health care system. The system provides funding for treatment costs as well as the income of the claimant (or at least a significant percentage where there are ‘step-down’ provisions). This drives the imperative to achieve return to work so that the employer can resume responsibility for wages costs. Usually the wages cost to an insurer is far higher than the medical and rehabilitation costs.
Insurers, the financial organisations that underwrite or administer workers compensation systems, see things differently to doctors and workers. A person lodging a claim is seen in terms of the ‘estimate‘ associated with that claim i.e. the amount of money that needs to be notionally set aside to cover the cost of that claim. The estimate is also used to calculate premiums for future insurance periods. Each claim is seen to have the potential to affect the ‘bottom line’ of the insurer’s business with the imperative that claims be ‘managed’ to reduce costs and ensure the ongoing viability of the financial organisation, its ability to make a profit and provide a return to its shareholders. An important strategy is to close off claims to save costs associated with administration and eliminate liability.
Governments of all persuasions have expressed an objective of reducing the costs of Workers Compensation, with the inference that such costs are an excessive overhead cost to business.
Traditionally insurers have relied on claims management processes, particularly investigations, to establish or refute liability, and the associated legal processes to control their costs. Only recently have other more health-orientated processes, such as the use of rehabilitation providers, been adopted, but usually still within a legal framework, centred around reduction of liability.
Our justice system works on the principle of opposing arguments where a legal authority makes a decision about which one is more likely to be correct. The defendant and plaintiff have to prove their case. Each side with their legal team seeks evidence to back their version of events and a win or lose outcome is obtained. There is benefit seen in a swift resolution.
Our health care systems work differently. Injuries and diseases are diagnosed and treated or managed. There is a hierarchy of doctors with varying degrees of expertise in the particular condition. Often multi-disciplinary teams provide the breadth and depth of knowledge to consider all facets of a particular condition. Decision making is usually by consensus between the practitioners involved. Within the medical and allied health fields there usually exists a shared understanding of who has the most expertise and whose opinions should be given the most weight. Long-term health conditions, such as chronic pain, and associated psychological illness require ongoing management and often require a change to employment that is more suitable.
Insurers see claims within a legal model most of the time. They are the defendant seeking evidence that the claimant’s (the plaintiff) claim for funds for treatment or income maintenance is invalid. To prove that they need evidence:
1)The claimant doesn’t have the condition claimed
2) If they have the claimed condition, they are not liable i.e. it isn’t work-related
3) If 1) or 2) can’t be proved then the condition has resolved or some other cause has supervened
Insurers are looking for a win/lose outcome and the financial certainty of closing off the claim.
Arguably the health care of people in the work force is an important aspect of maintaining Australia’s economic prosperity. It shouldn’t be a ‘race to the bottom’ to provide the cheapest system of workers’ compensation at the cost of the standard of care provided to workers. We need a quality system that supports recovery and rehabilitation, provides value for the money spent but doesn’t damage people further in the process.
Can the current approach adequately provide for the health needs of those injured at work? My experience is that it cannot, particularly those workers with long-term health problems arising from a work-injury. Often the system contributes to that ill-health.
In my next article, ‘Medico-legal Assessment – Where the Legal and Medical Worlds collide’, I will extend these concepts in a discussion about the difficulties associated with a system where liability for medical treatment and rehabilitation is determined by an insurer on the basis of Independent Medical Reports.
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