Is There a Crisis of Confidence in IME Assessments?

Posted on April 27, 2014 by Tasworkdoc

While I personally have had concerns about the ‘quality’ of many IME assessments for some time, I did not realise how widespread the concerns were about the fairness of such assessments until relatively recently.

Injured workers representatives are certainly concerned, both through traditional union representation and the social media networks that have arisen in recent years. Social media sites have been outspoken in their criticism of IME assessments – inferring that almost all such assessments are unfair. WorkCover Victims Diary (based in Victoria) runs a website that has been particularly critical of IME opinions and has resorted to naming and shaming those practitioners who they say are biased.

I am increasingly aware of concerns by treating GP’s and specialists alike. It is acknowledged by most medical practitioners that bias is frequent in IME reports. Many rehabilitation providers will also privately express concerns, yet rarely publicly because their funding is largely controlled by insurers or claims agents.

I have discussed these concerns with insurers. They seem to be the only party without current concerns, apart from some IME assessors themselves. It has been acknowledged to me that in the past insurers could obtain reports to suit their purposes, but they say that the situation is fairer now. 

While it might be tempting to dismiss the concerns of injured workers groups as hysterics, whinging and victim behaviour, I am not so sure. 

Through my own work I come ‘face to face’ with the opinions expressed in IME reports and, at times, the IME assessors themselves. This occurs when I am asked to comment on IME opinions as a treating practitioner or independent assessor. At times I attempt direct dialogue with an IME assessor, although this is rarely ‘allowed’ by the system. I also have the opportunity to critically review IME opinions presented before a court or tribunal in the course of preparation to offer my own opinion and prepare for cross-examination.

I can recall an IME assessor some years ago expressing the opinion that a relatively rare medical condition being claimed as work-related was caused by the use of eye drops. The assessor failed to state that the particular condition is much more likely to be idiopathic i.e. without known cause or due to trauma, rather than due to the small amount of a drug that might be absorbed systemically from eye drops . The assessor confidently stated the eye drops (a non-work related medication) were the cause, without any discussion about other possible causes. This cleared the insurer of any liability. To me it seemed convenient to declare a non-work related cause rather than acknowledge an unknown cause where the insurer might potentially be liable.

The case above illustrates two issues.

1) Privacy principles make analysis of independent opinions difficult

I can’t provide any more details of this case without risking the breach of privacy principles. While such principles are important and necessary, they prevent objective analysis and public discussion about quality and impartiality of independent opinions.

2) Medical obfuscation

The case illustrates that an assessor can wrongly attribute causation that might not be obvious to a non-medical person. The opinion might seem reasonable to the person being assessed or the insurer or claims agent that requested the report. The ‘medical truth’  might only come out if the matter was heard before a formal legal decision-making body. In the majority of such assessments this never occurs, or if it does, it is far too late to influence acceptance of liability for appropriate treatment.

A more common thread in IME assessments is that the workers’ claimed condition is due to underlying/pre-existing degenerative disease, even though there was a clear precipitating injury and no pre-existing symptoms, satisfying the legal definition of causation in most jurisdictions.

Similarly many IME Assessors don’t accept many surgical procedures and other types of intervention as reasonable in the face of contrary opinion from currently-practicing specialists in the field. 

The problems referred to above have significantly dented confidence in the fairness of the current systems to determine liability and reasonable treatment for injured workers. While justice might eventually prevail through our courts system, that process is too slow for most people. Often they have sustained significant damage through psychological stress or delayed treatment before matters are brought before the appropriate court or tribunal.

In a series of blog articles entitled:

IME ASSESSMENTS – THE GOOD, THE BAD & THE UGLY

over the next few weeks, I will analyse these issues in more detail as follows:

1. WHAT IS AN IME ?

2. CURRENT ISSUES WITH IME’S?

3. FIXING THE SYSTEM – ARE THERE ALTERNATIVES TO IME’S?

Look out for my posts.

Comments and discussion welcome.

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Beware – Risks from use of Independent Doctors for Disability Pensioners

Posted on April 20, 2014 by Tasworkdoc

ABC News 24 recently reported:

“The Federal Government is considering using independent doctors to examine disability pensioners and assess whether they should continue to receive payments.”

While this idea sounds attractive, it is important to consider how systems that currently rely on independent doctors are working.

There is an assumption that such a move will ensure that entitlements are appropriately paid, but there is a potential downside. Not only are there direct costs of such assessments to consider, but issues with diversion of medical resources, the potential for adverse psychological consequences for disability pensioners and associated indirect costs. These problems already occur frequently within the workers compensation system. This should be considered before placing reliance on independent doctors in such a role.

The workers compensation system already relies heavily on independent doctors to determine insurer liability, approve treatment and  decide on capacity to work, yet that approach causes many problems within that system.

Much of the problem with independent doctor’s  opinions stems from the quality of the assessments. The work is generally less demanding and does not involve clinical responsibility, yet is well paid. Specialists approaching retirement or lacking work for a variety of reasons gravitate towards such assessment work. Some doctors who undertake independent assessments do not have the skills or competence to provide accurate opinions. There are also concerns about bias favouring the payer.

Inaccurate or biased opinions provide fodder for lawyers to argue with potential for legal nightmares. This can cause psychological damage to those who become stuck in the system and can be very costly.

Increased demands for independent opinions has the potential to attract more and more doctors without appropriate skills into the field, further exacerbating current problems.

In theory occupational physicians are the appropriate specialty to assess capacity to work. They are trained to assess the impact of the full range of physical and psychological conditions on capacity to work, whereas other specialties might only be able to assess conditions relating to a particular body system and might not have received training in the assessment of psychosocial factors that can compound physical injuries. Occupational physicians are already in short supply. Such a move can only exacerbate that shortage.

WHAT IS NEEDED:

1) Critical analysis of the effectiveness of independent medical assessment systems to achieve desired outcomes and the associated costs, direct and indirect

2) Review potential impact of such a system on medical manpower

3) Develop systems to ensure quality independent medical opinions incorporating:

i) Codes of practice for independent doctors undertaking such assessments requiring them to demonstrate clinical competence and an understanding of what it means to be truly independent

ii) Training and accreditation aligned to the code of practice

iii) A system of audits to establish compliance with the code of practice

 

 

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National Pain Conference in Hobart – Implications for Workers Compensation Systems

Posted on April 17, 2014 by Tasworkdoc

I had the pleasure over the last 3 days to attend the national conference of the Australian Pain Society. Luckily for me it was held in Hobart, just a stone’s throw from my practice on the outskirts of the Hobart CBD – everything is close in Hobart.

I thought it might be useful to provide a summary of what was relevant to my practice as an occupational physician, in particular what information might be helpful to doctors and workers stuck within the worker’s compensation system.

The theme of the conference was ‘Personalised Pain Management – Quest for the Holy Grail’  i.e. what progress has been made in developing strategies that work for individuals to manage persistent/chronic pain. There were keynote speakers from the UK, Canada and USA as well as a variety of renowned Australian experts.

Professor Mogil from Canada presented the Sunderland Lecture on ‘The nature and nurture of pain’  i.e. the influence from both an individual’s genetic makeup and their environment on the genesis of persistent pain. He emphasised the genetic basis for the variability  i.e. different genes affect our susceptibility to the development of persistent pain. Understanding how genes influence pain can help elucidate mechanisms of chronic pain and identify targets to develop new medications and other treatments to control pain. While this holds promise for the future it is a difficult and complex area that at present doesn’t help a clinician, except to the extent that is provides an explanation as to why there are differing responses to injury in individuals.

What is clear is that the phenomenon of persistent pain has its genesis in ‘neuroplasticity’   i.e. changes at a neuronal and molecular level within the nervous system that result in persisting pain that continues after the original injury has resolved. These changes can occur at the periphery or centrally within the nervous system, at the level of the spinal cord and within the brain itself. The environment of the individual affects these processes and this is where psychological factors and stress are so important.

As a practicing physician my interest is focused on what can be done for an individual patient to assist with recovery and regaining of function following injury and how that translates into action to improve processes at a system level. I was particularly interested in the conference sessions that related to the subgroup of people within the workers compensation system.

The session on the afternoon of the first day entitled ‘Personalised pain management within a multidisciplinary persistent pain program’ was of particular interest. The session included presentations by Professor Michael Nicholas from NSW and Ms Sara Brentnall and Mr Paul Beaton, both from Victoria.

Professor Nicholas emphasised the importance of the patient having their own achievable goals and understanding of the treatment to improve the outcomes. Personalised treatment for chronic pain is vital. His programs include injured workers within compensation systems.

Sara Brentnall presented a perspective from Austin Health in Victoria.  Again in that programme there was emphasis on ‘One Size Doesn’t Fit All’  i.e. individualised programmes. The presentation by Paul Beaton from Eastern Health was the most interesting. Not only was the presentation innovative with amazing graphics, but the programme itself was based on the bio-psycho-social model emphasising the need for multidisciplinary input ‘in collaborative partnerships with those in pain’. The emphasis was on ‘active’ self management with personalised care. ‘The Pain Storm’ concept was presented providing a basis for individuals to understand the factors contributing to their own ‘Pain Storm’ with an integrated array of physical, psychological, medical  and social strategies to put the person with pain in control with the prospect of lasting change in understanding, attitude, skills and environment and more engagement in meaningful life activities.

Interestingly the Victorian programmes referred to above do not include workers compensation patients on the basis that WorkSafe Victoria has a network of practitioners that provide a similar service.

Unfortunately the workers compensation system is a potent factor in taking away an individual’s sense of control and imposing a ‘one size fits all’  approach to the management of persistent pain. It is unsurprising that workers compensation patients have a higher incidence of chronic pain and overall do worse than other types of patients.

The session on ‘Entrapment Neuropathies’  e.g.  carpal tunnel syndrome by Professor Michel Coppieters provided some insights. There is increasing understanding of the changes both at the level of entrapment and centrally within the nervous system from animal models. These changes can explain the variable clinical presentation of these disorders and why they do always present as described in textbooks nor always respond to traditional treatments like decompression surgery. Again this provided insight and understanding about why some conditions are difficult to manage, but little practical guidance on how to achieve better results, except that nerve mobilisation may have a greater role to play.

I did have difficulty accepting some of the conclusions of Professor Chris Maher in his presentation ‘Diagnosis and treatment based classification of back pain’ . I accept that his analysis that the traditional  ‘Red Flags’ used to distinguish serious spine disorders, need revisiting, but I have some difficulty with his conclusion that we are stuck with labelling back pain as ‘non-specific’ on the basis that discal, sacro-iliac and facet joint pain cannot be distinguished clinically or with investigations, including MRI scanning. While it might not be so important to distinguish differing diagnostic entities in a primary care setting in the early stages following injury, I still believe in the specialist management of persistent back pain that it is useful to distinguish these entities while not neglecting management of psycho-social risk factors.

I found a subsequent presentation by Professor Maher very interesting and useful. The presentation ‘What triggers an episode of back pain’  presented new evidence from a study that indicates that not only are the traditional factors in back injury relevant (heavy loads, awkward posture etc) but that being distracted during an activity/task and being fatigued markedly increases the risk of triggering back pain. This makes a great deal of sense to me.

Another matter of interest to patients with CRPS/causalgia/RSD is that the University of NSW  is seeking volunteers with this condition affecting their shoulder/neck/wrist/hand mainly on one side, aged from 18-89 years for MRI studies in Sydney to investigate the role of the brain in CRPS. Interested people could contact Ms Audrey Wang [02] 93991806 or a.wang@neura.edu.au.

In summary, attending the conference reinforces in my mind, that persistent pain is a difficult ‘beast’. The increasing knowledge about neuroplasticity, particularly the process of  ‘central sensitisation’ and the interplay of genetics, a stressful environment and psychological factors can explain the spectrum of disability seen after work-related injury, but at this stage doesn’t provide a solution for everyone. Injured workers with persistent pain need equitable access to effective multidisciplinary programmes for persistent pain.

It becomes less and less surprising to me that workers compensation systems that take away control, impose additional stresses and fail to recognise the need for individualised treatment programmes contribute to poor outcomes for those with the misfortune to be injured at work. Workers compensation systems need to incorporate processes to stratify people with greater needs into care systems that can adequately deal with those needs without imposing unnecessary additional stressors on them.

 

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Is the role of the treating doctor undervalued ?

Posted on April 10, 2014 by Tasworkdoc

While the amount of time a practitioner spends on a case is not always a measure of their value, it is a measurable input that can be compared to the outcomes achieved in the management of people with work-related injury and illness. The desired outcome depends on the perspective of the observer, but most people would agree that full recovery and ability to return to the workforce in a productive role, at a reasonable cost, is the most important objective where a worker suffers an injury.

In Tasmania WorkCover has placed emphasis on the role of ‘Primary Treating Medical Practitioner‘ or PTMP. This is a legislated role. This is usually the general practitioner chosen by the worker who co-ordinates medical management, liaises with the rehabilitation provider and sometimes directly with the workplace and the insurer. Sometimes a specialist medical practitioner temporarily takes on this role.

A conscientious PTMP will be proactive in co-ordinating the treatment programme by actively engaging with the other treaters, putting forward treatment plans and communicating with the other parties to the management of the worker’s rehabilitation. They will attempt to anticipate and circumvent barriers to treatment and rehabilitation. All this involves the practitioners time, not only in consultations with the worker, but on the telephone and using email, as well as participating in formal meetings and preparing clinical correspondence and reports.

Workers compensation insurers are usually content to fund the PTMP’s time for consultations with the worker, face to face meetings with other parties, visits by the practitioner to the workplace and formal reports, but there is often little recognition of the time involved ‘behind the scenes’ on activities that make the difference between effective treatment from an integrated team and disjointed ineffective management.

On the other hand, doctors engaged for claims management purposes to provide independent medical reports are often paid handsomely with little accountability for what actual input of time and effort goes into their reports and associated activities. There activities often disrupt rather than support or add value to the role of the treating practitioners.

Luckily there are other incentives to doctors to be involved in the actual treatment and management of injured workers i.e. the satisfaction of helping an injured worker recover and the recognition from clinical colleagues of the importance of the role. Without these factors more specialist doctors would gravitate towards independent medical roles, where a good income can be made with little clinical responsibility, little need to keep abreast of current clinical practice and, in same cases, a relatively small input of their time.

I am unsure whether any workers compensation system measures the relative value of doctors involved in treatment/management compared to the value of input from independent doctors. Perhaps some insurers and claims agents have measured the value of independent medical opinions in terms of their own ‘bottom line’!

WorkCover Authorities should consider this issue to determine how to get the best value from our limited medical resources to achieve desirable outcomes for the community as a whole in circumstances where people are unfortunate to be injured or become ill in the course of their work.

 

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Workers Compensation – Quality Health Care or target for Cost Reduction?

Posted on April 7, 2014 by Tasworkdoc

Doctors (and workers too) see a Workers Compensation system as a Health Care system, providing for the needs of those unfortunate to be injured or become ill as a result of their work.

Workers Compensation however is different to most other types of health care system. The system provides funding for treatment costs as well as the income of the claimant (or at least a significant percentage where there are ‘step-down’ provisions). This drives the imperative to achieve return to work so that the employer can resume responsibility for wages costs. Usually the wages cost  to an insurer is far higher than the medical and rehabilitation costs.

Insurers, the financial organisations that underwrite or administer workers compensation systems, see things differently to doctors and workers. A person lodging a claim is seen in terms of the ‘estimate‘ associated with that claim i.e. the amount of money that needs to be notionally set aside to cover the cost of that claim. The estimate is also used to calculate premiums for future insurance periods. Each claim is seen to have the potential to affect the ‘bottom line’ of the insurer’s business with the imperative that claims be ‘managed’ to reduce costs and ensure the ongoing viability of the financial organisation, its ability to make a profit and provide a return to its shareholders. An important strategy is to close off claims to save costs associated with administration and eliminate liability.

Governments of all persuasions have expressed an objective of reducing the costs of Workers Compensation, with the inference that such costs are an excessive overhead cost to business.

Traditionally insurers have relied on claims management processes, particularly investigations, to establish or refute liability, and the associated legal processes to control their costs.  Only recently have other more health-orientated processes, such as the use of rehabilitation providers, been adopted, but usually still within a legal framework, centred around reduction of liability.

Our justice system works on the principle of opposing arguments where a legal authority makes a decision about which one is more likely to be correct. The defendant and plaintiff have to prove their case. Each side with their legal team seeks evidence to back their version of events and a win or lose outcome is obtained. There is benefit seen in a swift resolution.

Our health care systems work differently. Injuries and diseases are diagnosed and treated or managed. There is a hierarchy of doctors with varying degrees of expertise in the particular condition.  Often multi-disciplinary teams  provide the breadth and depth of knowledge to consider all facets of a particular condition. Decision making is usually by consensus between the practitioners involved. Within the medical and allied health fields there usually exists a shared understanding of who has the most expertise and whose opinions should be given the most weight. Long-term health conditions, such as chronic pain, and associated psychological illness require ongoing management and often require a change to employment that is more suitable.

Insurers see claims within a legal model most of the time. They are the defendant seeking evidence that the claimant’s (the plaintiff) claim for funds for treatment or income maintenance is invalid. To prove that they need evidence:

1)The claimant doesn’t have the condition claimed

2) If they have the claimed condition, they are not liable  i.e. it isn’t work-related

3) If 1) or 2) can’t be proved then the condition has resolved or some other cause has supervened

Insurers are looking for a win/lose outcome and the financial certainty of closing off the claim.

Arguably the health care of people in the work force is an important aspect of maintaining Australia’s economic prosperity. It shouldn’t be a ‘race to the bottom’  to provide the cheapest system of workers’ compensation at the cost of the standard of care provided to workers. We need a quality system that supports recovery and rehabilitation, provides value for the money spent but doesn’t damage people further in the process.

Can the current approach adequately provide for the health needs of those injured at work? My experience is that it cannot, particularly those workers with long-term health  problems arising from a work-injury. Often the system contributes to that ill-health.

In my next article, ‘Medico-legal Assessment – Where  the Legal and Medical Worlds collide’, I will extend these concepts in a discussion about the difficulties associated with a system where liability for medical treatment and rehabilitation is determined by an insurer on the basis of Independent Medical Reports.

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Double Whammy for Insurers from Tasmanian Impairment Guidelines

Posted on April 2, 2014 by Tasworkdoc

The WorkCover Tasmania Guidelines to Impairment Assessment that modify the American AMA  (4th Edition) Guides are used to assess impairment of Tasmanian workers.

Without going into some more fundamental issues about the use of impairment assessment systems (such as the validity of any system that attempts to quantify injury in percentage terms or the reasons for exclusion of pain as a separately assessable impairment), there are two areas of current concern about the Tasmanian Guides.
Perhaps the issue of greatest concern is the effect that a spinal impairment rating can have on an insurer’s willingness to approve spinal surgery procedures.

With the latest editions of the Guides (Version 2 & 3) fusion or disc replacement surgery is considered to meet the criteria for ‘multilevel structural compromise”. This automatically is rated as DRE category IV or V. This is 20% and 25% Whole Person Impairment (WPI) respectively in the lumbar spine and 25% and 35% WPI in the cervical spine. In the absence of surgical intervention most spine injuries are rated at 5% or 10% WPI and only the most severe injuries with associated spinal cord damage are rated above that level.

Under Tasmanian workers compensation legislation there is a threshold for access to Common Law. Workers with injuries rated at 20% WPI (previously 30%) and above have access to common law damages. Insurers considering a recommendation to fund spinal fusion or disc replacement surgery are faced with the potential ‘double whammy’ of the not insignificant costs of the surgery and the prospect of a higher impairment rating opening the door for the worker to common law entitlements and higher lump sum payments for permanent impairment. In addition, there are often concerns that the surgery may not have a positive outcome in terms of getting the worker back to work. Understandably insurers hesitate to fund spinal surgery.

My concern as a doctor managing work injuries is that the current impairment guidelines for assessment of spinal impairment can create a barrier to appropriate surgical intervention in some cases. The solution lies in a review of spinal impairment criteria, that recognises the effects of fusion and disc replacement on the structural integrity of the spine, but does not equate a more functional spine post operatively to an impairment category higher than that of a dysfunctional spine prior to surgery. This might require both a review of spinal impairment ratings for spinal conditions associated with disabling pain who have not had such surgery and spinal conditions where surgery has been undertaken. The important issue is that WPI ratings per se should not act as a disincentive to insurers to approve necessary spinal procedures. Spinal surgery should only be considered on the medical merits of the proposed procedure.

The other issue of concern is the assessment of impairment associated with Complex Regional Pain Syndrome (CRPS), previously known as Reflex Sympathetic Dystrophy (RSD). The WorkCover Guides have strict criteria before a worker can be assessed using the specific methodology for assessing impairment associated with CRPS. The diagnostic criteria in the guides are not based on the internationally accepted diagnostic criteria for CRPS. Only severe cases of CRPS meet the criteria. The most common scenario is that the clinical diagnosis of CRPS is clear, often agreed by both the treating practitioners and independent assessors, yet the prescribed methodology for assessing the disorder cannot be used. This is a situation where the Guidelines do not align with current clinical practice. This results in artificially low impairment ratings for a disorder which can result in a permanent disorder with a very high level of disability. The solution here is clear, the diagnostic criteria for CRPS included in the impairment guidelines should be brought into line with current clinical practice.

While I am not as familiar with the WorkCover Impairment Guidelines in other states (Victoria does not have statutory guidelines, only AMA4), I suspect the same issues might arise there too.

 

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Perspective – What do doctor’s think about Workers Compensation?

Posted on March 28, 2014 by Tasworkdoc

Through my work as an occupational physician, I regularly interact with doctors who have a variety of roles in the assessment and management of work-related injuries. Most often I am a member of a team of treating health professionals, but at times as an independent medical examiner, I provide analysis and critique of other doctor’s opinions.

I tend to see patients with injuries that take longer to resolve or require intervention including some who require spinal and other types of surgery. There are more frequently chronic pain patients than in general practice. As an independent medical examiner, I see workers involved in litigation, often having had a prolonged and frustrating period in the workers compensation system.

I have taken a particular interest in other doctor’s views about workers’ compensation issues and have surveyed views of local specialists who interact frequently with the system and participated in discussions with doctors who have concerns about managing patients within compensation systems. While I have not conducted a scientific study of  doctors opinions, I can make a number of observations from my perspective.

Doctors have a spectrum of views about workers compensation including some who are cynical about any patient who claims workers’ compensation benefits. Most doctors with a focus on treatment and who interact with the system however are negative about the processes adopted by insurers and the opinions of independent doctors engaged by the insurers.

Doctors have concerns about increasing impositions from claims management practices and legal involvement. Some are reporting difficulty providing care under these constraints and some no longer see workers compensation patients for these reasons.

Doctors have expressed concerns about delays to the provision of appropriate care due to problems with access to consultant medical practitioners and, at times, control over selection of consultant level care by insurers.

Doctors express concerns that there are more requests from insurers to provide reports to justify investigation and treatment expenses. This extends not just to the costs of expensive procedures, but can extend to matters as simple an imaging investigation or the addition of a new medication.

Doctors express concerns that approval for recognised investigation and treatment procedures are often rejected or decisions delayed on the basis of clerical decisions or the opinions of doctors contracted by the insurance industry i.e., from independent medical assessors. There are often significant delays waiting for an insurer to obtain an independent medical opinion to approve a relatively straightforward investigation or treatment procedure.

Doctors are concerned that delays or rejection of funding for recommended treatment can have significant implications for recovery. This has negative consequences for the patient’s psychological health, compounding the risk of a poor outcome.

 There are concerns that independent medical assessors at times provide opinions outside their area of expertise, are not up to date in their knowledge of current practice or consider only selected information provided by the insurer. Unnecessary independent medical reviews can lead to confrontation changing the mind-set of the patient to proving their case with detrimental effects on recovery.

Doctor can become overwhelmed by requests from insurers for reports of a medico-legal nature. This can contribute to delays in timely responses from the doctors and reduces their availability to provide treatment and care.

Doctors express concern about reluctance by insurers to fund interventional pain procedures and some surgical procedures.

Doctors are concerned that rehabilitation providers lack independence from the insurers who directly appoint them and fund their services. They sometimes provide advice to the patients, insurers about treatment, or where to seek treatment, outside of their field of expertise. At times rehabilitation providers document an unrealistic ‘return to work’ goal without any understanding of the injury prognosis or discussion with the treating practitioners. This creates wrong expectations for those involved. Unnecessary attendance by the rehabilitation at every doctors appointment can waste time and resources.

Doctors are concerned that insurers often resist funding for retraining and redeployment when it is clear that an injured patient cannot return to their pre-injury work. The focus by insurers is often on return to pre-injury work without recognising when this is not achievable.

Doctors are concerned about unnecessarily confrontational systems  to resolve claims where patients reach maximal medical improvement, but are unable to return to their pre-injury work. With the current system insurers can only resolve matters by seeking negative reports from independent doctors to bring matters to settlement. This can be a damaging process psychologically to the worker.

In summary, there are many concerns expressed by doctors about the workers compensation system in Tasmania. Doctors are a key part of the system to provide necessary care for injured workers. Withdrawal from the system by doctors can only degrade the outcomes achieved. The designers of our workers compensation system need to take into account doctor’s views, not just the views of the employers and workers and their representatives.

 

 

 

 

 

 

 

 

 

 

 

 

 

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Why Insult and Injury?

Posted on March 27, 2014 by Tasworkdoc

As a young doctor working as the Health & Safety Manager with Hydro Tasmania (then the Hydro-Electric Commission), I had experience of main stream media. I was asked by management to participate in an interview with the Mercury newspaper about some of the good work we were doing with Health Promotion Programmes for the workforce. I dutifully discussed with the journalist who came to interview me the programmes we were organising to help employees improve their lifestyle, including alcohol and drug programmes.

The following Sunday morning I was awaken by a call from my boss, the HR manager, drawing my attention to the headline on the Sunday Tasmanian. The headline, the exact wording of which I can’t remember, stated that the Hydro was full of hopeless drunks. This was at a time that the West Coast construction schemes were winding down and the redundant workers were trying to find alternative employment. Understandably the unions were outraged about this slur on their members. My penance was that I had to travel around the state meeting and apologising to workers about my revelations to the media.

I learnt from that episode, not only to be careful with media, but that for something to be newsworthy, it needs to be ‘sexy’.

As a practitioner in private medical practice, I wanted to contribute to debate from my experience of the problems with the workers compensation system. Not only to raise issues, but to put forward solutions. That is difficult as a solo practitioner.

A few years ago I made a concerted effort to get a ‘Letter to the Editor’ published in the Mercury newspaper. After some persistence including discussions with a journalist insider, I managed to get a letter published. I was disappointed with the response. A few diehards contacted me direct, but nothing much else happened. I must however thank the Mercury  for the heading they used to publish my letter ‘Adding Insult to Injury”, as I have adapted that name as the title of this blog.

I took to providing feedback to WorkCover Tasmania direct and have found that satisfying and at times rewarding, but not the same as reaching a wider audience about the issues.

Recently I have participated in discussions with AMA Tasmania about the problems with the workers compensation system in Tasmania. There are certainly widespread concerns by doctors about how the system operates and the AMA issued a press release just prior to the recent Tasmanian election. While a small article appeared in the back pages of the Mercury it didn’t receive much publicity at all. I was told by several people in the industry that the issue isn’t ‘sexy enough’  to rate much coverage.

Despite this it is clear to me that this is an important issue, particularly for those that have the misfortune to be injured at work and those trying to help them recover.

The literature is clear that people whose injuries are managed within a compensation system have worse outcomes, but why? Insurers would have you believe it is all because of fraud, secondary gain or that injured workers don’t want to get better. In reality it is more complex. Certainly there are issues about ‘taking responsibility’  for one’s own recovery that can be lacking within a compensation system, but there are many other factors that affect the outcome. Important issues include stigmatisation of workers who put in claims and lack of access to appropriate treatment. The system often unreasonably questions a person’s genuineness, creating a response to prove there has been injury. The system of claims management remains adversarial. Responses include the development of secondary psychological illness which can be more disabling than the original injury. These issues can have dramatic effects on injured workers, i.e. Adding Insult to Injury.

My view is that in a properly designed compensation system the outcomes can be virtually the same as outcomes for the same injuries managed outside a compensation system.

In this blog Insult and Injury, I hope to provide constructive comments to the politicians and bureaucrats that design our systems to help reduce the extent of that insult from the system. I have given up writing to the Main Stream Media. I have accepted that this issue does not sell newspapers.

See my brief video clip where I explain this http://vimeo.com/105348272

See also my latest post  – Let me Explain!

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About Tasworkdoc and an overview of compensation systems in Tasmania

Posted on March 13, 2014 by Tasworkdoc

I am occupational physician, Dr Peter Sharman. I work in a private medical practice in Hobart, Tasmania – the southernmost state of Australia.

In my practice I see workers referred by their general practitioners with various types of work-related injuries. These are mostly musculoskeletal injuries, both of traumatic and gradual onset as well as various associated psychological disorders. With interaction with patients for treatment and providing advice about rehabilitation, I have the opportunity, first-hand, to observe interactions between individual patients and complex compensation systems. I interact with other doctors who undertake similar work. I also conduct independent medical assessments, including impairment assessments for musculoskeletal injuries and asbestos-related disease compensation.

In Tasmania the state-based workers compensation system is overseen by WorkCover Tasmania, but private insurance companies carry the liability. These companies insure businesses and manage their injury claims in return for an experience-based premium paid directly by the business. There is also a compensation system for people injured in motor vehicle accidents, the Motor Accident Insurance Board (MAIB). Some workers in Tasmania are covered for workers compensation by Comcare, the federal government body set up to provide compensation for employees of federal agencies, like the Tax Office and Centrelink. Some larger national employers also use the Comcare compensation model.

I hope to contribute to improvements in these systems by making constructive comments based on first hand experience as both a treating practitioner and independent medical assessor. Any opinions expressed are my own.

Look out for further contributions.

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