Waste-Not Want-Not!

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I hesitate to admit it, but I have been wasting my time and energy, the medical expertise that I possess and other people’s money.

In my practice I undertake one or two medico-legal assessments as an independent doctor each week on workers I have never seen before. There were about 65 of these assessments during 2016 and about 30 so far this year. About 70% of these assessments relate to injured workers being assessed about their entitlements within the Tasmanian Workers Compensation system and a further 20% are motor vehicle accident cases. They cost the person or organisation who requests the assessment just over $2,000 each, on average. In addition, there are nearly as many review assessments of workers I have previously seen.

On that basis, at this practice alone, over $150,000 is paid each year for independent opinions about workers being managed within the local workers compensation and motor accident jurisdictions. These opinions rarely contribute directly to an injured worker getting better, they are used to sort out whether the person belongs in a compensation system or not, whether they are entitled to treatment and the extent of their entitlements. I like to think my recommendations about treatment or the subsequent resolution of liability issues will actually help recovery, although I have no data about that, except the occasional anecdote There is however a significant body of research evidence that confirms that Independent Medical Examination (IME) processes can have negative effects on recovery and return to work, as well as being a source of significant frustration to the doctors providing treatment.

I have analysed the independent assessments undertaken at this practice on claimants within the Tasmanian workers compensation system. On average each claimant has had several IME assessments conducted by other practitioners before they had been seen at this practice.

I recently reviewed a worker for medico-legal purposes and counted up about 25 reports that had been prepared over the 6 year period of his claim, included more than 10 IME assessments, with the balance being formal reports sought from treating practitioners. Perhaps up to $50,000 had been spent on reports in this one case!

On the basis of the above estimates, it seems likely that about $0.5M annually is spent on medico-legal assessments on the workers being assessed at this small practice alone i.e. extrapolation of this practice’s data to include the costs of the assessments already undertaken by other practitioners.

In Tasmania there are about 7,500 workers compensation claims each year. If 5% become “litigated’ and/or complex, that is about 375 cases per year. Some estimates put the number of complex cases at 20%. That would equate to 1,500 claimants annually.

If my own practice experience is typical of litigated/complex claims, that would mean more than $10M is spent Statewide on IME assessments in the workers compensation system. Add to that the legal costs of both the insurers and the workers, surveillance and related administrative costs and the costs to determine liability and entitlements are very significant.

According to WorkCover Tasmania figures, legal and investigation payments (including IME assessments) in the 2015-16 year were nearly $15M (and rising each year). In addition, there are legal and other investigation payments included in the WorkCover figures for lump sum settlement payments. This suggests that legal and other investigation payments might be as much again as the payments for IME’s.

An important function of the WorkCover organisation is to oversee the system. WorkCover is principally funded by a levy on the premiums charged at a rate of about 4% of $150M total premium pool i.e. about $6M. This represents a necessary further overhead expense on our compensation scheme.

Within just the workers compensation system of a small state like Tasmania there is probably more than $20M spent annually to determine eligibility, entitlements and to oversee the system. A large proportion of this activity utilises medical resources.

There is the motor accident insurance system as well with over 2,500 claims a year and $43M paid in claims.

The total paid is likely to be nearly $30M per year between those two schemes on independent medical, legal and investigation costs without any direct benefit in terms of provision of health care and rehabilitation. These processes also have potential to worsen outcomes and further increase costs by driving up treatment costs and prolonging recovery.

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The state health systems are crying out for money to meet the mounting health care costs of a growing and ageing population. For example, there are serious problems with under-staffing and lack of beds at the Royal Hobart Hospital. Better funding for general practice would help keep patients out of hospital, but that will not be enough.

Injured workers and those injured in motor vehicle accidents that choose not to claim and those excluded from compensation systems or don’t recover can end up receiving their treatment through this stretched and under funded health system.

On a national scale the costs of work disability are staggering. Professor Alex Collie from Monash University has estimated that in Australia $25B annually is spent on income support though the various workers compensation and motor accident schemes and the Centrelink Disability Support Pension for people with reduced capacity for work for health reasons.

Real value to the community comes from funding treatment and rehabilitation and improving health and capacity to work. These services add real value, not just sorting out which ‘silo’ a patient is managed within.

The trend in interstate jurisdictions is to limit entitlements for workers compensation, covering only 2 years post-injury. Perhaps it would be better to have clear-cut liability criteria for compensation, e.g. only traumatic injuries and/or time-restricted benefits to reduce the waste of resources on IME, investigation and legal expenses. The resources saved could be utilised to fund return to work services, rehabilitation and health care services to address work disability no matter what is the cause of work incapacity. Some proactive employers already fund rehabilitation and return to work irrespective of causation. They value their workers.

Such an approach also has the potential to reduce the toxic effects of compensation systems,  improve health outcomes and save money, but there would be many challenges in such a change for the current stakeholders and various vested interests.

I will expand on potential new approaches in my next blog article.

FOOD FOR THOUGHT!

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Debate about Workers Compensation – Moves to Mid-Winter Hobart!

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At the time of the winter solstice Hobart is an exciting place thanks to David Walsh’s MONA with the DARK MOFO and Winter Feast Events. There are challenging events like the nude swim in the River Derwent and entertainment and art events that attract people from all over the globe.

This year there will also be a stimulating series of events relating to the normally dry subject of Compensation Systems and Rehabilitation / Return to Work.

The local professional association of rehabilitation providers, the Tasmanian Association of Vocational Rehabilitation Providers (TAVRP) has organised a Symposium – “The Dark Side of Rehab” with a quality line-up of speakers:

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Here is the Programme

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VISIT THE TAVRP WEBSITE OR HOBART TICKETS TO REGISTER

In association with that event, there will be a number of other events including a Pre Symposium Seminar organised by Hobart Occupational Medicine with Professor Alex Collie presenting a summary of research about compensation health and Post- symposium workshops including a session from the WorkCover Guy, Mark Stipic about overcoming ambivalence  by employers to RTW.

There will also be Injured Worker’s Forum about the need for additional support and representation for injured workers run by Rosemary McKenzie Ferguson from the SA-based Work Injured Resource Connection. Here is the Programme.

HOBART IS THE PLACE TO BE MID-WINTER, WHETHER YOU ARE A LOVER OF QUIRKY ART EVENTS, PRACTITIONER OF THE DARK ARTS OR DEDICATED HEALTH OR INSURANCE PROFESSIONAL INTERESTED IN PARTICIPATING IN THE DEBATE ABOUT COMPENSATION SYSTEMS AND HEALTH. HAVE A LOOK AROUND OUR GREAT STATE – IN ITS WINTER GLORY!

More information about these events will be posted soon.

I look forward to meeting you in Hobart.

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Choosing Wisely – Request for comments

I have become aware that the option of making comments on this article is no longer available.

Choosing Wisely was published recently and I was expecting some feedback from small business on this matter.

You can now comment below.

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Choosing Wisely – Workers Compensation Insurance for Small Business

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Let’s forget momentarily about the effect of compensation systems on health outcomes. Rather, lets consider the position of a small employer taking out workers compensation insurance in Tasmania i.e. a small business perspective. There is a requirement for such insurance, but how does the business make a choice between the various licensed insurers?

Usually small business use a broking firm or agent to advise them about insurance matters, but how much can your broker tell you?

Some employers, I hope most, would want an insurer that helps them look after their injured workers, not just the cheapest possible premium to meet their obligation to comply with the law.

MY PERSONAL “LEAGUE TABLES”

As a doctor working in the field, I am aware of the different approaches by the various insurers but, apart from insurance premium information, there is no other readily available information to help a small business choose their insurer, unless they have experience with claims to judge for themselves.

I have my own “League Table” of the various insurers based on my experience in dealing with those insurers as a doctor looking after injured workers. Interestingly my own table is quite similar to the ratings of other doctors who work in similar roles and the workplace rehabilitation providers who are prepared to share their own personal views on this subject.

I also have experience from discussions with insurers about communication protocols between my practice and those insurers. There is a wide divergence between insurers about how they are prepared to communicate with doctors. To me, this reflects on the willingness of the insurer to engage and participate in a team process to assist recovery and return to work. Some insurers behave in a way which suggests that believe they should have ultimate control over all aspects of management of the case, including which practitioners provide treatment, the scope of practitioner treatment and management of the worker’s rehabilitation. While the insurers in Tasmania can ultimately be financially responsible for associated costs, I believe there needs to be cooperation and respect for the role of others in the process, whose responsibility is to the welfare of their patients.

In my own practice we have introduced Adverse Event Reporting. Over the last 12 months we have flagged about one adverse event each month. Of the 11 events, 6 occurred with the State Service Scheme, 2 with Allianz Insurance and a single event for Comcare, GIO Insurance and a self-insurer. Most interestingly, the category of event that predominated were issues relating to management of the claim (5 occurrences) compared to 4 occurrences relating primarily to the workplace and the remaining 2 occurrences relating to rehabilitation issues and medical complications. The consequences of the events ranged from minor setbacks to the workers mental health through to significant periods of incapacity for work and even extended psychiatric hospital admission. Luckily there were no suicides in this small group. While the numbers are small and the sample from this practice is probably significantly biased, it does provide a glimpse into the operation of workers compensation systems in Tasmania.

If such reporting was adopted more widely, useful information would be available to all scheme participants.

WIRO PUBLISHING COMPLAINTS

In New South Wales, the Workers Compensation Independent Review Office (WIRO), now publishes a range of information in their regular WIRO Solutions Brief, including a breakdown of complaints by Insurer. The table below from December 2016 illustrates the type of information publicly available in New South Wales.

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NSW WC Data Dec 2016 – Source WIRO Solutions Bulletin February 2017

LIFE INSURANCE COMPANIES PUBLISHING DISPUTE & REJECTION RATES

In the wake of public concerns about the Life Insurance industry, the Australian Securities and Investment Commission (ASIC) prepared a report in late 2016, Life insurance claims: An industry review that detailed declined claim rates and claim outcome rates for a range of insurance products.

The most marked variation in rates between insurers occurred with Total and Permanent Disability (TPD) claims as illustrated by the table below.

screen-shot-2017-02-12-at-8-03-18-pmCOMPETITION PRINCIPLES

An important market principle is that consumers, in this case employers, can make an informed choice about how they support their workers who are injured in the course of their work. It should not simply be a choice based on price, but take into account the employer’s approach to human resource management.

At present only limited information is publicly available about the approaches taken by various insurers to managing claims from injured workers. The cheapest premium might save money up front, but consideration also needs to be to the less obvious and long term costs associated with an aggressive approach by their insurer in disputing claims or complicating access to medical and rehabilitation management.

CONCLUSIONS

WorkCover Tasmania publishes data about scheme performance. In the Scheme Review to 30 June 2016, there is separate analysis of data for the Tasmanian State Service, Self-Insurers and Private Licensed Insurers, but it would help employers, especially small employers without the experience of previous claims, to make an informed choice if scheme performance data was broken down further, separating out the private insurers. The insurers provide the data, so I wouldn’t expect that to be too difficult. It is already occurring in other jurisdictions.

Introduction of new measures of actual health outcomes and adverse events could also be considered, again broken down by insurer.

Perhaps Worker Assist could provide some data as well?

The measures would help small business CHOOSE WISELY in relation to important aspects of human resource management, the health and wellbeing of their employees injured at work.

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Tendentious – What Does that Mean?

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@Bafflegab1 on Twitter describes himself:

‘Long-time critic of Ontario auto insurers; their defence lawyers; and their hired gun medico-legal assessors. Also critical of plaintiff bar lethargy.’

In a recent tweet, he referred to a judgement in the Canadian Superior Court of Justice from 2004 that I had not previously seen.

The judgement is of interest in that it considers the issue of an IME organisation that sought damages from The Canadian Broadcasting Corporation (CBC) in relation to a programme “Prove it if You Can” broadcast by CBC that had been derogatory about the conduct of the IME organisation – AssessMed.

Justice Paul Rivard ruled that the assertions made in the programme were objectively fair and there was no spite, ill will, any direct or ulterior motive on the part of the CBC by broadcasting the programme.  He states:

“I have already indicated that the comments in the program were based on true facts. The defendants honestly believed in the truth of the comments. The comments were based on facts upon which a person could honestly hold the opinions expressed. In such circumstances, I conclude the comments were objectively fair”

The judge calculated damages that might apply if his judgement was later found to be in error, however this ruling was that no damages were payable on the basis that CBC had made fair comment.

This brings me to the word ‘tendentious’, a word I had no knowledge of before reading this  judgement.

According to the Cambridge Dictionary this means:

“(of speech or writing) expressing or supporting a particular opinion that many other people disagree with”

Justice Rivard used the term tendentious in the context of describing the approach of Dr Richman, the director and Chief Medical Officer of AssessMed. Dr Richman had prepared an article “Manufacturing Disability” which to Justice Rivard revealed a clear and strong view held by Dr Richman that the majority of claimants studied at AssessMed wilfully misrepresented their situation, and that they did so often with assistance of their health care providers. His judgement includes the following:

‘While Dr. Richman’s opinions find some support in medical literature, they are considered too skeptical by others. Dr. Richman’s research in this area was based on discussions with assessors at AssessMed but not on any empirical or validated study. In my view, it reflected a tendentious approach to assessments, which subjected AssessMed to being viewed as partial to insurers.’

I have learnt a new word and am also aware of a judicial opinion rejecting a claim for damages by an IME assessment firm in Canada against Canada’s national broadcaster after it aired a programme that supported the notion that IME assessors can be biased in their dealings with motor vehicle accident claimants..

Are there any parallels in Australia?

Here is a link to the judgement for those interested:

https://www.canlii.org/en/on/onsc/doc/2004/2004canlii28479/2004canlii28479.html?

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Injured Worker Support and Representation in Tasmania – Do we need more?

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In the early days of this site I wrote an article about Injured Worker Support Websites where I asked for comments about the best approach to provide such support. There was a lot of negativity about the WorkCover Victim website at that time. Here is an excerpt from what I considered to be a balanced comment about my article:

“I don’t think websites run by injured workers who are entrenched in their own sick roles or victim roles themselves, will ever be healthy or empowering to other injured workers; its like leaving the lunatics to run the asylum and wondering why no one is getting any better. However, these seem to be the very people who tend to set up these websites and Facebook groups.

Without an appropriately skilled person facilitating or moderating these support websites and focusing its members on positive mind-sets and positive skill building, they devolve into an orgy of victimhood, toxic behaviours and one big pity-party.”

The best known active professional support sites include the New South Wales based Injured Workers Support Network co-ordinated by Rowan Kernebone and in South Australia, Rosemary McKenzie-Ferguson runs the Work Injured Resource Connection which provides, as well as information, more practical help through their ‘Bags of Love’ programme and has set up a Deceased Workers Memorial Forest in commemoration of lives lost due to the work place .

More recently the Injured Workers Group of Victoria has set up a site operated by injured workers (I understand with Rowan’s assistance).

In Tasmania, there is a service for injured workers, Worker Assist, with a focus on providing legal advice to injured workers and assistance with navigating the system, but no independent injured worker support site similar to those in NSW or South Australia. I understand, despite efforts to raise awareness about Worker Assist, that this service remains relatively underutilised.

Worker Assist’s website lists the following services:

“Worker Assist provides assistance, information and advice to injured Tasmanian workers in the following areas:

  • Workers Compensation Claims under the Tasmanian scheme
  • Return to Work and Rehabilitation following a workplace injury
  • Claims under the Asbestos Related Diseases Compensation Fund”

Worker Assist is primarily Government Funded and supported by Unions Tasmania, although I understand ongoing funding for the service is not secure in the long-term.

I recently had a call from a person enquiring about whether I knew anyone who could provide support to an injured worker about to attend an IME assessment with a doctor with a somewhat contentious reputation. The injured worker was not a patient of this practice, but I did my best to put them in touch with a person who I thought might be able to help and advised about the services available through Worker Assist.

I see a lot of injured workers struggling to come to grips with the confusion and loss of control inherent in workers compensation. Many need more than legal advice to help them take control and avoid becoming increasingly frustrated and downhearted.

Judging by the queries I receive from my own patients and now enquiries from other quarters, I believe there would be value in Tasmania dedicating additional resources to injured worker support. I wonder about the value of an Injured Worker Support Service to complement the valuable service provided by Worker Assist i.e. not only advice about legal matters and the operation of the system, but to provide more practical support and positive interaction with other workers who share a similar predicament.

Another issue I have encountered is who, or what organisation, can effectively represent injured workers at a system level? Traditionally the union movement has undertaken that role, but with decreasing rates of union membership throughout the workforce and  a primary union concern about industrial conditions over health issues, (with some exceptions for specific health risks, such as asbestos), perhaps there is a role for a dedicated organisation representing the interests of injured workers, separate from industrial organisations, at least to complement union representation.

For a service to meet the needs of injured workers, I believe it needs to be primarily run on behalf of injured workers by an ‘….appropriately skilled person facilitating or moderating…’ independent of any organisation with a vested interest using sound principles of support that enhances self-reliance and control to avoid becoming enmeshed in conspiracy theories about workers compensation and adoption of a victim mentality.

What type of model would work best in Tasmania? I am not sure, but I like the idea of a website with useful factual information and worker stories, in combination with more practical help, including providing direct support for injured workers by accompanying then to difficult interactions, education and information meetings, and providing a forum for positive interaction between injured workers.

A professionally run organisation could also act as a lobby group to ensure that the perspective of injured workers is factored in at a system level, through interactions with Government and WorkCover and other representative organisations, such as the TCCI, Unions Tasmania, Insurer Representative Groups and groups representing medical, legal and rehabilitation providers.

I expect Worker Assist and Unions Tasmania might be able to provide some insights into the unmet needs of injured workers from their interactions with injured workers.

It would be useful to obtain comments from Worker Assist, Unions Tasmania and interstate Injured Worker Support Site coordinators and any people in Tasmania who might have an interest in such matters.

I look forward to comments.

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THE GREAT DIVIDE – a sorry tale of lost teamwork!

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The Great Divide!

 

Firstly, let me say welcome to a few new followers to my blog following the release of Mark Stipic’s podcast of a second interview with me on RTW Nation about engagement with general practitioners.Thank you Mark.

Here is a link in case you missed it: http://rtwnation.com/34

Peter Sutczak introduced me to the ‘modern’ concept of vocational rehabilitation in the 1980’s. He used posters, similar to the one below, to get across the Teamwork Concept necessary to achieve the desired outcome – recovery and return to work.

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The concept was that everyone paddled together (up shit creek, if necessary) to achieve the goal that was best for the individual worker, their employer and society as a whole.

How that all seems to have changed (or perhaps was never achieved).

The two sides of the fence!

The Tasmanian Association of Vocational Rehabilitation Providers (TAVRP) has recently advertised its intention to run a symposium in June 2017 to coincide with Dark MOFO and Tasmania’s Mid-Winter Feast. The title is an ominous “The Dark Side of Rehab – A look at the more complex and controversial aspects of occupational rehabilitation”. I don’t know the details of the programme yet, but I expect it will  be interesting.

While TAVRP  is aligned with the peak national rehabilitation organisations ASORC and ARPA, there is another group, supported by WorkCover  Tasmania  called the Injury Management coordinators Association.

Tasmanian legislation makes provision for the role of Injury Management Co-ordinator and once a person has completed a short course they can be accredited in this role and work as independent provider coordinating rehabilitation without the more rigorous accreditation required by organisations to provide the schedule of rehabilitation services defined by legislation.

There appears to be a divide within the world of vocational rehabilitation

Perhaps the same division occurs amongst employers, those that will go the extra mile to support their employees with injury or illness and those who focus seems to be more on workers compensation as a cost of business to be contained. There is probably a third group of employers, those that haven’t even considered the issue!

I am aware of other dichotomies in the world of workers compensation. In the legal world there are plaintiff and defendant lawyers, and that applies very strongly to lawyers who operate in the world of workers compensation. Interestingly, I have heard plaintiff lawyers use the term moving to the “Dark Side” when referring to the world of defendant Law. Perhaps defendant lawyers use the same term for the world of plaintiff law. I am sure the legal profession can enlighten me on this point.

Plaintiff and Defendant Doctors?

Recently an occupational physician colleague asked me why I didn’t immediately object to being labelled a “plaintiff” doctor in discussion at a recent educational meeting about the role of surveillance (another murky issue) in occupational medicine . I answered that I didn’t agree with the label, but am now so used to the categorisation of doctors either on one side or other of the fence (and similar categorisation of every other “player’ in workers compensation) that I hardly notice such labelling any more.

John Quintner, in a recent comment on my recent blog article about an opinion piece from AFOEM President, Dr Peter Connaughton stated as follows in relation to the roles taken by occupational physicians, perhaps referring to the “Dark Side” of occupational medicine.

‘However, many became willing pawns in the adversarial arena, often being on the side of third-party insurers. ‘

It is clear that increasingly doctors who operate in the workers compensation space are being categorised as well, as either plaintiff or defendent doctors. How sad!

Adversarialism as a concept

As illustrated by the diagram below from Culture of Peace Activist, Peter Newton-Evans , adversarialism can become a vicious cycle:

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Adversarialism in Workers Compensation

It is becoming clear that over the years there has been a move towards adversarialism in workers compensation, almost certainly to the detriment of health outcomes for injured workers. There are now teams of people whose focus is either on the objective of cost reduction or on achieving health outcomes, but rarely both.

How do we overcome these artificial boundaries and achieve better outcomes all round? Each side of the fence needs to reach out and understand the other’s perspective and try to regain a shared focus on achieving the best outcome for the injured worker. If that goal can be achieved, I expect that costs can be contained.

LET’S GET BACK TO TEAMWORK – USING THE EVIDENCE BASE TO GUIDE US ABOUT WHAT WORKS!

 

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