Tilting at Windmills?

Tilting at Windmills2

 

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.

 

 

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The Power of Social Media

Stipic

 

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.

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Another Elephant? – Lessons from the Comminsure Scandal

CBA Elephant

The ‘Comminisure’ Scandal broke this week putting a media focus on the role of doctors within organisations and the potential for commercial interests to over ride the usual ethics of the medical profession.

For those who didn’t watch 4 Corners here is a link:

Link to 4 Corners – ‘Money for Nothing’

The Conversation on-line news published an incisive article authored by bioethicists in response :

Comminsure scandal reminds us commercial forces are at play in medicine

This article emphasises how doctors involved with insurers can get caught up in the commercial interests of the business with adverse effects on patient care. The authors emphasise how this current scandal demonstrates issues that arise with conflict of interest:

They state:

‘The phrase “conflict of interest” refers to situations in which there is a tension between “primary” values or commitments (interests) and the other “secondary” interests’

The primary value for doctors is that of the medical interests of the patient, described as ‘patient well-being’. Secondary interests can conflict with this primary value. Examples are provided of the potential conflicts that arise with doctors employed by insurance companies, sporting clubs, prisons and refugee camps and for occupational physicians employed by major companies. Does this issue extend to doctors employed in hospitals and government roles?

The key paragraphs in the article are quoted below:

‘Because doctors are so powerful, and because enactment of these powers can have major consequences for vulnerable patients, it is essential doctors always use their skills and authority to act in the patient’s best interests’

and

‘Any relationship that has the potential to get in the way of this primary commitment needs to be navigated with the utmost care. The obligation remains even when doctors work for, or within, an industry that appears to have lost its moral compass’

The Comminsure Scandal brings to the fore another ‘elephant in the room’ in our compensation systems. While the previous ‘elephant’ I referred to in How Big Is the Elephant in the Research Room? is getting smaller with increasing evidence and understanding about the factors that affect outcomes in compensation systems, the hidden conflicts affecting doctors with important roles in our compensation systems has received inadequate attention. It is important that those employed doctors perform a self-analysis, and ask the following questions in relation to potential conflict of interest posed in educational material from the  Australian Institute of Company Directors (AICD):

‘Do I have a conflict of interest?

If you think you might have a conflict of interest, ask yourself these questions:

  • Would someone from outside the company or outside my family think I have a conflict of interest?
  • What would I think if I heard of someone else doing this? Would I think there was a conflict of interest?
  • How would I feel if my actions were printed on the front page of the newspaper?
  • Who could be disadvantaged and who could benefit from my actions?
  • Do I need to get an independent opinion about these issues?’

This scandal has also highlighted issues with excessive use of covert surveillance by insurers as detailed in the Sydney Morning Herald.

Link to SMH Article

SUMMARY

The Comminsure scandal highlights potential issues where doctors are employed by or contracted to organisations that administer or oversee our compensation systems. These factors may contribute to poorer health outcomes in our workers compensation schemes than might otherwise occur if such doctors adhered to fundamental principles i.e. having primary concern for a patient’s or injured worker’s best interest and always using their skills and authority to act in the patient’s best interests.

Perhaps this issue is more important than the conflict that can arise with a doctor’s personal interests to earn a salary, care for their family, maintain a practice and advance their career as can arise in a typical practice setting.

Over to ISCRR to do the research!

 

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WRP Standards at Risk from Red-Tape Reduction

 

Red tape

The Tasmanian Government has embarked on a ‘Red-Tape Reduction’ Review in relation to the state-based Workers Compensation System. The review process is overseen by the WorkSafe Tasmania and the WorkCover Board.

Following a consultation process with the stakeholders the final consultation draft has been released for comment. See link below:

Summary of proposed changes January 2016

A proposal of particular concern is included in Item 3, relating to accreditation of workplace rehabilitation providers (WRP’s).

The proposal is stated as:

‘Remove accreditation of rehabilitation providers only’

This proposal is contrary to the recommendations of the peak professional bodies representing rehabilitation providers and moves the system in a direction opposite to that proposed by the AMA in a recent submission to the WorkCover Board. See link to AMA submission below:

The Medical Voice for Health Outcomes

Doctors have expressed concerns about lack of professionalism and independence by some practitioners who fulfil the rehabilitation provider role on behalf of employers and insurers. Removal of accreditation requirements can only make that worse.

The Tasmanian Association of Vocational Rehabilitation Providers has commented as follows:

Proposed Removal of WRP Accreditation letter Feb 2016

At present organisations, rather than individuals, are accredited in Tasmania if they provide any of the following services:

  •   initial workplace rehabilitation assessment 
  •  assessment of the functional capacity of a worker 
  •  workplace assessment 
  •  job analysis 
  •  advice concerning job modification 
  •  rehabilitation counselling 
  •  vocational assessment 
  •  advice or assistance in relation to job seeking 
  •  advice or assistance in arranging vocation re-education or retraining. 

See link to details of current accreditation requirement:

Workplace_rehabilitation_services

The AMA has suggested that accreditation for WRP’s should be at the individual level, not organisational level and include practitioners who operate independently to organise rehabilitation programmes and offer ‘case management’ services, not just the services currently defined. A WRP has an important role in support and facilitation of RTW and done poorly can have significant adverse consequences for the case outcome.

Injury Management Co-ordinators (IMC’s) as defined under Tasmanian Legislation, have a role in developing Injury Management Plans, but they now commonly work in a similar role to that of a rehabilitation provider, without a requirement for appropriate qualifications or accreditation.

Many IMC’s and some WRP’s do not have qualifications registrable with AHPRA and there is clearly a need for professional standards and accreditation.

SUMMARY

The proposal to remove WRP accreditation is regressive and has the potential to worsen outcomes for those injured at work and in need of professional rehabilitation assistance. Accreditation requirements, particularly for practitioners without existing AHPRA registration, need to be extended rather than relaxed.

 

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Towards Simplicity – Complex Case Management by Doctors

Simplicity

This article follows on from my recent article about complexity in workers compensation systems that refers to the concept of ‘complex case management’ by experienced medical practitioners.

Article: ‘The Insult of Complexity’

Reducing Complexity for Injured Workers

The AMA in Tasmania, through its workers compensation reform committee has put forward a proposal that builds on the concept of defining roles for doctors within our workers compensation systems with a proposed role of ‘Complex Medical Case Manager’.
Definition of this role, along with the development of processes to identify poor prognosis cases early, is a key plank in the reforms proposed by the AMA to improve health outcomes for injured workers.

Link to AMA Submission – ‘The Medical Voice for Health Outcomes’

I do have a vested interest in the concept of ‘complex case management’. In effect, this is what I do when an injured worker is referred to my practice by their general practitioner for ongoing management of their injury. A proactive role by a doctor co-ordinating medical management with a strong focus on recovery and rehabilitation can overcome some of the barriers to recovery inherent in our compensation systems by reducing complexity for the injured worker.
Managing a complex case takes interest, motivation, knowledge of processes and resources and experience along with a significant time commitment if it to be done well. It is important to achieve the right balance between promoting self-management by the worker while providing support and understanding. This is the ‘art’ of ‘complex case management’.
Sometimes taking on this role requires a willingness to undertake activities not usually undertaken by a doctor e.g. participating in meetings and conferences in a variety of locations and formats, visiting workplaces and talking to key people in the worker’s work and home life. The role  requires skills in communication, co-ordination of the diverse group of practitioners involved in treatment, development of a consensus treatment plan and communicating that plan clearly to both the worker and the funding organisation.
A proactive doctor advocating a rational and co-ordinated management plan is sometimes welcomed by the insurer and employer, but at other times a co-ordinated approach by the treatment team is seen as a threat to control of the claim by the insurer or claims agent. There can be a fine line between acting as an advocate for an appropriate medical treatment and rehabilitation programme and becoming enmeshed in legal issues.
In my own practice to allow sufficient time to undertake this role, I set aside each Thursday free of clinic appointments to have the time to consider proactive case management, make telephone or email contact and prepare formal written communications with various key people involved. This cannot be done effectively while consulting. Managing a complex case cannot be done effectively at review consultations, even with relatively frequent appointments. Rarely these days can you contact another health professional, rehabilitation provider or insurance claims officer with a single telephone call. My day free of clinic appointments ensures I have the time to put together co-ordinated plans and communicate those plans to the relevant parties and my accessibility for returned telephone calls.  ‘Telephone Tag’ is usually the name of the ‘game’, although email, fax and text communication plays a part too.
To me, detail is important in managing a case. Some might call it obsessional behaviour. The extra effort in making a telephone call to the worker or sorting out an apparent discrepancy between treater opinions can mean the difference between trust and distrust by the worker with their management programme, changing the focus from progress to stagnation.
I have kept records of the actual amount of time spent on managing complex cases that illustrate how a doctor’s time is spent in a proactive co-ordination role on complex cases.
I recently analysed my time spent on 5 complex cases over the last year or two. These include two cases managed by self-insurers, a case managed by a private insurer, a case managed by the Tasmanian State Service Compensation Scheme and one Comcare case. Each person was referred by their general practitioner for ongoing management of their work-related injury at my practice.
The time spent on these cases totalled 166 hours with 78 hours (i.e. less than 50%) of that time spent in face to face consultations with the worker and/or meetings with the rehabilitation providers assigned to the case.
The balance of time (88 hours in total) was spent as follows:
16%                        Telephone discussions with patient
15%                        Telephone discussions and email communication with other key people
7%                          Correspondence to other treaters
6%                          Correspondence & formal reports to non-treaters
4%                          Workplace visits
4%                          Other meetings
In another complex case not included in the analysis above there was a need to visit a dysfunctional workplace within a secure work environment where security arrangements meant multiple contacts with workplace and rehabilitation personnel to be able to gain first hand knowledge critical to understanding the dynamics affecting recovery. In this case there has been the need to interact with a rehabilitation provider, mediator, injury management co-ordinator and no less than 4 workplace people in addition to the usual number of treating health professionals including general practitioner, physiotherapist, psychologist and other medical specialists. In this case less than 25% of my time on this case has been in face to face consultations with the worker.

Are Doctors Pulling Back?

Complexity of compensation systems affects doctors too. A recently published study sheds some light on the phenomenon of increasing reluctance by doctors to get involved in treating patients within compensation systems. More and more doctors are being put off by the complexity of dealing with workers compensation as discussed in the following article. Surveys have shown that as many as 50% of general practitioners are now reluctant to get involved in the management of patients within complex compensation systems. In addition, some specialists simply refuse to see workers compensation cases.

There are already some legislative provisions about the role of doctors in managing work-related injury. For example, Tasmanian workers compensation legislation sets out the role of the Primary Treating Medical Practitioner (PTMP) as follows:
Screen Shot 2016-01-30 at 6.46.47 AM
The key item relevant to this topic is (d) above – the role of co-ordinator of medical treatment, usually undertaken by the worker’s general practitioner. The impact of this legislative requirement is difficult to determine, but I believe it is very useful for this to be set out as a guide to an important role in a compensation system.

Solutions

A solution to these problems involves reducing complexity for injured workers and their doctors to improve health outcomes and overcome the problems associated with doctors withdrawing provision of services within compensation systems.
An agreed ‘Best Practice’ approach to managing work related injury between the various stakeholders is the key. Mechanisms to facilitate streaming of injured workers into different management pathways according to their injury and prognosis should be developed. This approach would encourage early assessment and intervention to address risk factors for a poor prognosis, especially recognised psychosocial issues, and provision of medical and rehabilitation resources commensurate with the needs of each individual case.
General practitioners have a fundamentally important role in such early intervention. There needs to be a mechanism to provide education and support for doctors who want to be involved in managing patients in compensation systems, in addition to mechanisms for doctors to ethically make alternative care arrangements in circumstances where they do not have the time, knowledge, experience or interest to provide necessary care.
WorkCover Tasmania is trialling a Medical Mentoring & Advisory Service (MAMS), provided by experienced general practitioners to guide doctors in the management of their work-injured patients. It will be interesting to assess the impact of this support initiative for general practitioners.
There should also be agreed processes to assist doctors to identify cases of work-related injury where additional resources are likely to be required that might be beyond the scope of the average time-poor general practitioner. This involves the development of screening tools to identify poor-prognosis cases early and providing alternative management pathways for referral to doctors who have the interest and skills to work proactively within compensation systems. Such a model would be consistent with usual medical referral models, maintaining the patient’s right to choice of treating doctor.

Is Legislative Support Needed to Implement a Complex Case Management Model?

The most important aspect of implementing an effective Complex Case Management Model will be consultation and agreement between the various stakeholders, particularly the insurers who administer claims and provide funding and the doctors that provide and co-ordinate treatment.
The agreed principles do need to have a legal basis either through legislative amendment or adoption of a legally enforceable ‘Code of Practice’ that defines:
  • The various relevant management roles for doctors and insurers
  • Important review and decision points in case management
  • Alternative management pathways
In cases where there is dispute and disagreement, which is not uncommon in a compensation setting, agreed best practice needs to be supported by the legal system to ensure that all stakeholders abide by the rules.

How Would Complex Case Management Work in Practice?

A possible approach to the medical management of injured workers has been developed by the AMA in Tasmania. There are defined alternative pathways, including a pathway for ‘Complex Cases’ where the worker’s general practitioner (perhaps supported by information from the insurer or employer) makes an assessment of prognosis early on in the course of a claim. Poor prognosis cases can be streamed into an alternate management pathway on referral by the general practitioner to another doctor with recognised skills as a ‘Complex Medical Case Manager’ (CMCM).
The role of a CMCM is to act as a trusted guide within the system with primary responsibility for the best health and rehabilitation outcome for the patient, translating sometimes conflicting messages into a coherent and understandable one to save the worker from the confusion and distress associated with uncertainty and allow focus on recovery and rehabilitation.
Most CMCM’s will be general practitioners who have an interest in working within compensation systems and have demonstrated an understanding of the role and the capacity to work to undertake this type of work. Medical specialists could also take on this role in some circumstances, particularly occupational or rehabilitation physicians.
While a Workplace Rehabilitation Provider (WRP) can assist this process in many cases, there is greater value from a trusting doctor/patient relationship in complex cases where there is potential for confusion about the primary role of a WRP. A knowledgeable and experienced doctor is best placed to achieve the best outcome in complex cases.
The flowchart below illustrates how the process might work and the various roles and review points involved.

Link to: Complex Case Management Model FlowChart

An important component of the model will be a simple screening tool that can be used by the general practitioner to identify a potential poor prognosis. For example, this might involve assessment of factors that suggest that the worker will be off work or require workplace restrictions for a month or more.
Another important component of the model will be a role description for the CMCM perhaps expanding on the existing legislative definition of the role of PTMP detailed above. The role description would emphasise the proactive nature of the role in co-ordination of treatment and facilitation of rehabilitation and return to work in conjunction with the workplace rehabilitation provider.

SUMMARY

The development of the concept of Complex Case Management with definition of related roles and alternative management pathways has the potential to address some of the barriers to recovery for injury by simplifying interactions between injured workers and compensation systems while providing a mechanism to address concerns about doctors withdrawing their services from these systems.

 

Peter Sharman 04 February 2016

Statement of Roles and Interests by Author

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Information for IME Assessors and Expert Witnesses

Supreme Court Tasmania

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

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The Insult of Complexity

Dr Jason Thompson

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:

Screen Shot 2015-12-31 at 6.02.52 pm

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

 

 

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What to expect in 2016

2016 plans

Over the coming 12 months, I hope to continue publishing material on Insult & Injury’ relevant to the improvement in design of our workers compensation systems.

It is an exciting time in this field with increasing recognition of modifiable factors that affect health outcomes in our compensation systems.

In particular, ISCRR is providing relevant and practical evidence-based information that politicians, bureaucrats and insurance companies involved in scheme design can take on board to improve outcomes. I hope the medical profession and union movement also ‘buy in’ to these issues and push for change.

My focus over the coming 12 months will be on commentary on what I have termed the Seven ‘Deadly’ Insults in compensation systems, updates on important relevant research findings, analysis of how we measure the performance of our compensation systems and other topical matters that arise throughout the 12 month period.

My first blog article for the year, to be published soon, discusses the insult of ‘complexity’ as a important factor at both individual and system level that is potentially modifiable to improve outcomes. This subject was recently presented at the ISCRR Research Forum in Melbourne by Dr Jason Thompson.

The other six ‘deadly’ insults are:

  • attitudes
  • conflict
  • interference
  • ignorance
  • lack of evidence
  • money

I hope to cover those subjects in more detail throughout the year.

I am interested in feedback about other topics readers might be interested to have covered.

HAPPY NEW YEAR & INFORMATIVE READING!

Peter Sharman – Hobart

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ISCRR Research Forum – Does Injury Compensation Cause Harm?

 

iscrr-logo

The Institute for Safety, Compensation and Recovery Research (ISCRR) is conducting a forum in early December in Melbourne to discuss this important subject.

See my earlier post on this subject – “Are Our Compensation Systems an Occupational Hazard”

https://insultandinjury.org/2015/01/22/are-our-compensation-systems-an-occupational-hazard/

Here is a link to the information about the ISCRR forum.

http://www.iscrr.com.au/news/events/does-injury-compensation-cause-harm-forum-2015.html

I urge you to attend.

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The Myth of Workers Compensation Fraud

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Alex Collie, CEO of the Institute for Safety, Compensation and Recovery Research (ISCRR) in Victoria recently flagged this article on Twitter as worthy of reading.

Although the article refers to rates of fraud in the United States, where there the perception is that people are very litigious, the commentary suggests that the true incidence of blatant fraud in probably quite low.

Most people I speak to in Australia who have some knowledge of this subject agree the situation is the same in Australia.

Here is a link to the article:

The Myth Of Workers’ Compensation Fraud – NAIDW My Blog Application

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