Insult and Injury

In a comment about Tilting at Windmills, Richard Gilley made the following statement:

“The total Tasmanian workers compensation medical benefit spend for 2014/15 was $43 million. HIC payments to Tasmanian GPs (NRAs) in 2014/15 were $130 million i.e. not counting private consultations or over the rebate fees, up to 33% of GP payments were workers compensation related.”

To me a suggestion that workers compensation made up to 33% of a doctor’s income seemed grossly inaccurate, based on discussions with GP colleagues.

I attended a meeting of ANZSOM tonight, for a presentation entitled “Occupational Medicine in Tasmania’ from Dr Mark Spearpoint. Dr Spearpoint referred to data from “the Beach Study” (Bettering the Evaluation and Care of Health) from the Family Medicine Research Centre.

The report from 2013-14 includes the following table:

This table indicates that only 1.7% of GP encounters were claimed as workers compensation.

The study also provided the following detail about work-related attendances at GP practices. This showed that 2.4 per 100 of GP encounters related to work-related problems, but this rate did not mean that all these encounters were funded through workers compensation.

I also talked to a well-respected general practitioner in a ‘somewhat’ occupationally focussed practice and he analysed his billings which indicated that less than 7% of billing income relates to workers compensation.

The calculation method used by Richard Gilley to suggest a third of doctor’s income come from compensation payments is seriously flawed, probably because use of the medical benefit spend of $43 million in the Tasmanian workers compensation scheme as the numerator in his calculation includes many other types of payments not just payments to doctors. His denominator of $130 million is probably also an underestimate as it does not take into account income from consultations not funded by HIC.

I hope however to get comments from the data experts at WorkCover Tasmania.

Although as an occupational physician I agree with Richard that GP’s could do better with greater emphasis on better management of workers compensation cases, the reality is that workers compensation is considerably less than 10% of an average GP’s work and there is likely to be a lot more focus on non-work related chronic disease management i.e. diabetes and hypertension.

CONCLUSION

Richard’s data is probably wrong by an order of magnitude. There needs to be alternative means to get GP’s interested other than by suggesting a significant proportion of their income is from compensation systems, which it is not.

In response to my recent article commenting on the ComminInsure scandal there was a feisty response from Richard Gilley on LinkedIn – in the  Group Workers Compensation Australia.

The thrust of his comment was to point out the conflict between a GP’s need to earn a living and their often-stated primary goal of provision of patient care. The non-medical commentator pointed out that most GP’s charge fees for services rendered and suggested (having recently completed an environmental medicine course and the knowledge that it can take upwards of half an hour to take a comprehensive patient history) that GP’s spend insufficient time dealing with work injury matters and that it is ‘simply a matter of finances’. Further Richard suggested that when a compensation payer makes an arrangement with a care provider an important relationship develops with power by the payer over the payee and this issue is magnified when the care provider is an employee of the payer. The suggested solution was that all GP’s be salaried by the government, but suggested that doctors would strongly object.

In response to another comment by Rosemary McKenzie-Ferguson who runs a support service for injured workers in Adelaide, Richard suggested that to raise concerns about the matters referred to in the article was ’tilting at windmills’ presumably referring to the insurers (or perhaps the whole system) as Don Quixote’s windmills i.e. an imagined issue.

When I flagged the need for a considered response to his comments, Richard suggested that I relate my response ‘as a GP’ not as an occupational physician. This is difficult for me as I have not worked in General Practice for 30 years when the current issues did not exist (or I had not experienced them), but I can make observations about modern-day general practice based on discussions with GP colleagues.

Firstly, I would say that GP’s and some Medical Specialists and people involved in supporting injured workers see a side of our compensation systems, not seen first hand by most of the other participants. Referring to my own experience, I remain surprised about the sheer numbers of people who attend my practice who appear to have been unnecessarily ‘damaged’ by the system. In a small state like Tasmania, you might think the numbers would be small, but I usually see 2 or 3 people each week for IME assessments and I would say that the majority of those have suffered some unnecessary harm from the system. In addition, amongst those patients referred by their GP’s due to complexity there is a high rate of unnecessary damage. Recently adverse events affecting patients I am treating became so common that I have implemented ‘Adverse Event Reporting’ in my practice. Since this policy was implemented on 01 March, I have completed about 6 reports of significant adverse events that have complicated recovery. Some events relate to the management of the claim and some to medical and rehabilitation management. These are not minor events, but include significant clinical setbacks causing total incapacity for work, additional need for medical or psychological input and, in one, case psychiatric hospital admission. These reports are being circulated to WorkCover to help build a picture of what is happening at the coal face.

It might be useful for other participants to spend a day (or even a week) in a medical practice or an Injured Worker’s Support Facility to understand the reality of our current compensation systems.

I think I do have some understanding of the insurer’s and employer’s perspective. I have worked in a management role with a large employer (Health & Safety Manager for Hydro Tasmania), more recently than I have worked in general practice and much more recently I have had a role as adviser to an insurer. My knowledge of general practice comes from day-to-day interaction with GP’s who refer to my practice, in addition to interaction with GP’s through my role with the AMA’s Workers Compensation Reform Committee and more recently with the RACGP.

The first point to make is that the issues about potential conflict between  the need to make a living and the goals you seek to achieve at work are common to everyone in our society. Doctors are not unique in that regard.

I was talking on the weekend to another doctor originally from the UK with an interest in medical ethics. He pointed out that the tradition of the UK medical fraternity is of independence from authority and a focus on a patient’s best interests.. A German colleague had apparently pointed out to him that it was unlikely that the UK medical fraternity would have got involved in the type of atrocities committed by doctors in Nazi Germany due to differing traditions. The ethics of Australian doctors are still probably largely based on those traditions from the UK.

Ethical Australian doctors do put patient care as their priority, but this is not to say that there are not financial imperatives that might drive the way that is undertaken. I too have reservations about some aspects of fee for service, enshrined in our systems, most notably our Medicare System which carries over into the AMA Fee schedule. The system dictates use of defined ‘item numbers’ that describe particular procedures and consultation activities, mainly those activities undertaken ‘face to face’ with a patient. This system can drive unhelpful practices. If a doctor can earn more per hour through multiple short appointments, when a single longer appointment to properly consider a complex issue would be better, then the billing system is counterproductive. If there is no item number for telephone contacts, meetings, prolonged consultations to take a proper history or other valuable activity then those activities might be neglected to the detriment of good outcomes. There might be an argument that doctors should just change an hourly rate for their services, like lawyers do. But that would introduce a whole new set of issues, for the payers I expect, and an opportunity for the very small proportion of unscrupulous doctors.

In my view, the issues of doctors doing the bidding of an insurer are not in the same league as the issues that drive doctors behaviour in a private practice. Most doctors still want to achieve the best health outcome for their patients, although the system might not support the best way to achieve those goals at present.

The suggestion that the average GP providing treatment is at risk of becoming beholden to  a workers compensation insurer is a nonsense, especially in an underwritten state like Tasmania, where there are multiple private insurers. For the average GP treating work injuries is a tiny fraction of their workload. Drivers other than relationships with insurers are far more influential. A risk might arise in a practice that develops a preferred provider arrangement to provide treatment services for a large employer, but the most significant risks arise with direct contractual or employment arrangements between doctors and those organisations that carry liability, particularly when the doctors involved only do that type of work as highlighted the CommInsure scandal.

I agree there needs to be a review of remuneration arrangements for doctors providing both treatment and IME opinions, but I doubt anyone is going to support a change to a model where all GP’s are salaried by Government.

I don’t think we are ‘Tilting at Windmills’. There is increasing evidence, becoming increasingly apparent  from ISCRR and other research, about the hazards associated with compensation systems. The windmills, or should I say the mist-shrouded giants, are real – the entrenched negative attitudes towards injured workers within the system and the short-sighted financial drivers within an insurance-based system that actually increase the costs in the long run from work-related ill-health and injury. That cost is ultimately borne by the whole community – measured in suffering, lost productivity and cost-shifting to our social security system for those who end up on the scrap-heap.

I thank Richard for his candid comments and look forward to his response.

I only ‘met’ Mark Stipic “The WorkCover Guy” quite recently and I am still to meet him close up in the real world. We were apparently both present at the December 2015 ISCRR Forum in Melbourne, but I didn’t know about him then.

Earlier this year Mark and I connected on Twitter and two weeks ago he interviewed me for a Podcast for his RTW Nation Series. His interview with me is the eighth he has done. In the interview I was able to explain some of the background to my ‘activism’ on Social Media, how I have applied hazard management principles learnt in my training as an occupational physician to risks from compensation systems, as well as explain the approach I take to managing cases referred by general practitioners, so-called ‘complex cases’ as outlined in my previous blog article ‘Towards Simplicity – Complex Case Management by Doctors’.

In addition, I had the opportunity to put out there some new concepts such as ‘Adverse Event Reporting’ by doctors in compensation systems and even answering the ‘magic wand’ question i.e. with a magic wand what would you change about the current system. You can be the judge of whether it is of value by listening to the podcast. Here is a link:

RTW Nation Podcast Episode 8 – Peter Sharman about Complex Case Management

What is different about Mark’s approach is that he is trying to make workers compensation subjects engaging and interesting. He has done multiple (100, I understand) video clips to answer commonly asked questions in his field.

Social Media provides a powerful tool for engagement and discussion between practitioners and other stakeholders who are geographically separated and might not otherwise interact. New ideas can follow this interaction providing impetus for positive change, based on the evidence and experience in the real world.

Keep up the good work Mark.

Readers of this blog might be interested to read the following article on my practice website about new Tasmanian requirements for IME assessment and giving expert evidence in court.

See link below:

Article

Dr Jason Thompson

At the recent ISCRR Research Forum held in Melbourne, Dr Jason Thompson gave an informative presentation that resonated with my experience as an occupational physician providing care for people within compensation systems.

Dr Thompson explained how complexity increases almost exponentially with the number of potential interactions in a system. He provided the example that doubling the number of issues that a worker confronts within a system from 6 to 12 leads to 5 times as much potential complexity. Studies have shown that complexity is maximal between 7 and 9 weeks after a claim. Dr Thompson’s slide below illustrates the impact:

Dr Thompson explained that while there is potential for harm from complex compensation systems, there is an opportunity with simplification in the design of our compensation systems. Reducing the number of potential interactions within the system by 50%, can potentially reduce complexity by 80%.

Patient Feedback

Often I get the most useful feedback from a patient when they are discharged to their general practitioner at the stage when I have no more to offer them, hopefully when they are well on the road to recovery and return to work. At that stage they have insight and perspective from their recent ‘journey’.

The outstanding feature of this feedback is the value placed by that person on the involvement of a professional who understands the system and is ‘on their side’ in an unfamiliar, confusing and adversarial system. Medical expertise is assumed.

A practitioner who can actively communicate with the various parties involved, explain the various agendas of the ‘players’ and make sense for them about what is happening in the context of their particular injury and employment situation helps enormously. There is value in simplification!

Satisfaction for Doctors Too!

Doctors gain considerable satisfaction saving lives in medical emergencies, but satisfaction results from helping patients in many other settings too. I have been told that consistent, calm and knowledgeable support and guidance from a doctor in the context of the uncertainty of workers compensation can save lives too by preventing self harm, although it is difficult to prove. I have no doubt care that counteracts the negative influence of complexity does reduce morbidity and enhance recovery.

Preliminary research suggests as many as 50% of doctors are reluctant to get involved in managing patients within compensation systems. A management approach that improves doctor’s satisfaction cannot go astray.

The Impact of Complexity

The number of potential interactions for injured workers with any more than a minor injury can be mind boggling. It is routine for patients in compensation systems to have interactions with multiple health practitioners (general practitioners, specialists, psychologists, physiotherapists and other allied health practitioners), workplace rehabilitation providers, claims/case managers, in addition their immediate workplace supervisor, HR personnel and their work colleagues. In Tasmania, there are legislated roles for Injury Management Co-ordinators too. In most cases of long-term injury you can add independent doctors and lawyers to the list.

In a recent complex case of work-related musculoskeletal disease complicated by difficulties with return to work due to workplace issues, I counted 17 people who had been closely involved including the worker’s general practitioner, medical specialists x3 (surgeon, occupational physician and medical acupuncturist), allied health practitioners x2 (psychologist and physiotherapist), workplace line managers x 3, workplace HR manager, workplace colleagues x 3, workplace rehabilitation providers x 2, in addition to claims personnel, union representative & mediator.Although the case is well down the track at least 13 of those are still actively involved. The complexity affects not only the injured worker, but the other people involved. As a doctor involved in care I have had direct interactions with most of the 17 people above. Interactions cause complexity and substantially increase the requirements of time and commitment by everyone involved, not to mention the associated costs.

Injured workers often flounder in these complex systems due to confusing or conflicting medical or rehabilitation advice from the array of people involved. Uncertainty from this confusion magnifies feelings of guilt and self-doubt already inherent within compensation systems due to entrenched negative attitudes from many of the ‘players’. Those injured workers already psychologically vulnerable or lacking resources to cope  are likely to suffer additional negative psychological consequences on top of those that arise from the pain and disability from their physical injury. In this setting chronic pain, depression and poor functional outcomes are much more likely.

The negative impact of independent medical examinations (IME’s), in particular, is becoming increasingly recognised. This is not just from the confusion generated by conflicting medical opinions and delays with approvals for treatment, but from the psychological impact of perceived procedural unfairness.

A recent study of psychologists interviewed about the impact on their clients from IME assessments has highlighted the impact of this complexity. A significant proportion of psychologist’s time is spent debriefing their clients after IME assessments!

Reducing Complexity Through Complex Case Management

While our compensation systems usually recognise and value investigations, medical treatment and procedures, and early return to work interventions, the value of a single point of support, understanding, guidance, certification and proactive co-ordination of multidisciplinary management in the complex systems now in place, is undervalued.

Concerns are raised about general practice costs and over servicing by general practitioners and other doctors who are the key providers of the services that support injured workers and co-ordinate complex cases. In some states there are legislative provisions that provide a disincentive for GP’s to spend time with injured workers. In NSW, for example, there is a prohibition on the use of time-based AMA consultation item numbers.

While in most cases the appropriate level of support and clarity can be provided by an enthusiastic general practitioner, with increasing levels of complexity, in combination with a vulnerable worker, the average general practitioner will not have the time, experience or skills to interact in a proactive manner with all the players and provide the necessary simplification.

I will expand on the concept of complex case management by doctors and how to identify those injured workers who might benefit from streaming into such an alternative management pathway in my forthcoming blog articles.

COMPLEX CASE MANAGEMENT undertaken by skilled and experienced doctors is a potential simplification mechanism for those at risk of harm from the complexity of compensation systems. There is enough evidence of potential benefit to conduct trials and develop the concept further in combination with early intervention strategies.

Peter Sharman