In my blog article at the start of 2016, I outlined a plan for a series of articles about  various ‘insults’ to the achievement of positive health outcomes in compensation systems, in accordance with the theme of this blog.

I also realised that there is also a need to showcase examples of “Best Practice” and I have plans to write about the ‘blessing’ of a positive relationship between an injured worker and their employer, so important to achieving good health outcomes. This article touches on this issue, but it is a subject unto itself.

I did manage to post an article about ‘complexity’ in compensation systems, but at this stage I haven’t made any real progress on writing about the other ‘insults’ – too much else is going on and not enough time!

Distractions This Year to Date

This year there have been various issues I have written about:

• Dr Koh’s whistleblower revelations about CommInsure’s modus operandi;
• Concerns about a proposal to remove accreditation requirements for rehabilitation providers under the Tasmanian Government’s Red-Tape Review;
• Loss of the ‘Beach Study’ that provides factual data about General Practice in Australia. The only study that provides statistics about GP reliance (or lack of it) on doctor’s income from compensation systems; and
• Insights into IME’s from Dr Barry Gilbert

There are also the continuing challenges posed by chronic pain, degenerative and computer-related disorders for our compensation systems.

In this field there is so much happening that is worth sharing. There are my experiences at the ‘Coal-face’ of occupational medicine interacting with injured workers, employers, insurers and other health practitioners, political experiences in the processes to try and make changes to the system from within and developments in understanding of the ‘science’ of this challenging area of medical practice.

I am particularly looking forward to attending ACHRF 2016 in early August. A likely source of inspiration for a further article from me.

Insights from the Tasmanian State Service

A significant proportion of patients under care at my own practice are employees of the Tasmanian State Service. Several recent cases have illustrated the difficulties posed for workers with complicated or prolonged claims due to the structural arrangements in place to manage cases, particularly in the smaller agencies.

While State Service claims are administered by a contracted private organisation (Currently broking firm Jardine Lloyd Thompson), the Agencies themselves make decisions about liability and overall injury management. Each Agency is apparently autonomous in that respect.

Each Agency have their own Injury Management Co-ordinators (IMC).  In the smaller agencies, the same person within the organisation has the responsibility to administer ‘care and concern’ to injured workers, while having an eye to liability and costs of the claim. I am not aware of how each IMC’s performance is formally measured by their employer, but is is apparent that there is (and must be) some focus on claims costs under this management arrangement.

With longer running claims, this conflict for the IMC becomes apparent. Usually the focus on cost containment wins out and even the most caring IMC starts to be seen by the worker as a barrier to their recovery. Unsurprisingly the IMC no longer welcomes contact from the worker and the relationship sours. With a long-term injured worker this relationship is often the only remaining contact with the Agency.

What hope is there for recovery and rehabilitation without any positivity in that relationship?

Treating Doctors – Part of the Team or Outsiders?

As a doctor, and outsider to the formal management system, trying to implement a co-ordinated treatment programme, can be frustrating. On the one hand the treating doctors are supposed to be part of the injury management team but, on the other, doctors are on the outside excluded from information held by the claims managers.

Tasmanian legislation supports transparency and information sharing. The key role of Primary Treating Medical Practitioner (PTMP)  and access by that doctor to the IME opinions obtained to manage the claim (via Section 90 requirements), is contained in the legislation.

However once there are concerns about costs of a claim and/or lack of progress or resolution, legal involvement starts. The legal ‘rules of engagement’ are quite different to those adopted by doctors in medical practice, as discussed in my earlier article.

Reflections on Medical Decision Making

This works against collaboration, information sharing and timeliness of decision making. The objective becomes a reduction or avoidance of liability and associated claims cost.

Currently some lawyers are using technical legal arguments to deny access by PTMP’s to IME reports e.g. on the basis that only an initial IME report has to be released, contrary to the intention and spirit of the legislation to support transparency.

With the State Service there is an obligation to use only state-employed lawyers with the additional restraint of limited resourcing which can add significant delay to the mix of barriers.

Interestingly, in one recent case, after making appropriate enquiries, informal reports from an internal IME adviser were released to me as PTMP, throwing light on the otherwise mysterious behaviour of the Agency in response to a medical management proposal. A small win for common sense.

Unfortunately despite the best intentions of legislators, it seems that common sense and  collaboration can fall victim to over riding demands to follow legal processes to the detriment of health outcomes for those injured at work.

The legal duty of an employer to contain claim expenses does not sit well combined with a role to provide compassion and care, as it does in some State Service IMC roles. These roles need review, combined with acceptance of the principles of transparency and engagement with treating practitioners, to achieve better outcomes.

THE LAW TRUMPS HEALTH – no matter what the guidelines say