Relationship trouble: The role of health-care providers in complex workers’ compensation claims

The interactions among health-care providers, injured workers and workers’ compensation boards can result in problems that delay the return to work of injured workers with complicated claims, according to a recent analysis by Institute for Work & Health researchers.

Health-care professionals can face challenges in meeting the needs of disabled workers. Some of these challenges arise from the requirements of workers’ compensation systems — particularly when dealing with complex and
long-term claims — and may delay the return to work of injured workers.

These are the findings of an Institute for Work & Health (IWH) analysis of the sometimes complicated relationships among injured workers, health-care providers and workers’ compensation boards. The analysis was led by IWH Scientist Dr. Agnieszka Kosny, a collaborator on a larger IWH study headed by Scientist Dr. Ellen MacEachen.

The larger study examined why injured workers with long-term workers’ compensation claims have problems with return to work (see: www.iwh.on.ca/highlights/toxic-dose). A paper on these newest findings, titled “The role of health-care providers in long-term and complicated worker’s compensation claims,” was published online by the Journal of Occupational Rehabilitation in April (DOI: 10.1007/s10926-011-9307-3).

Begun in 2008, the qualitative study was based on in-depth interviews with injured workers and service providers. This latter group included health-care providers (HCPs) such as general practitioners, occupational health physicians, physiotherapists and chiropractors, along with employees of Ontario’s Workplace Safety and Insurance Board and legal representatives.

Health-care professionals play an important role in workers’ compensation systems. They are relied upon to establish the workrelatedness of injuries, to provide workers’ compensation boards (WCBs) with information about injuries, and to make assessments and recommendations regarding a worker’s ability to return to work.

However, when problems arise in the interactions among HCPs, injured workers and WCBs, the progress of injured workers through the system can become complicated, resulting in delays in their return to work. Kosny and MacEachen examined how and why this happened, and found problems in four main areas.

1. The problem of access

Some injured workers have problems accessing the health care they need. Sometimes it’s because of geography. They may live in areas where family physicians and/or specialists are in short supply. But, according to the paper, it can also be because of their status as compensation claimants.

Some health-care providers are reluctant to provide services to workers’ compensation beneficiaries because they don’t feel they are paid enough when the claims become complex. As well, some health-care providers find the administrative reporting requirements — forms, requests for information and ongoing reports — to be onerous.

These factors can make the health-care provider a little less willing to take on someone with a claim or to think twice before taking on or treating someone who has a complicated claim, says Kosny.

Whether access is difficult because of claimant status or geography, workers may end up in emergency rooms or walk-in clinics to get the health care they need. But, as Kosny points out, these services are not ideal for workers with complicated claims because HCPs in these settings may not be able to provide the detailed medical information and history required by the workers’ compensation system.

2. The problem of communication and understanding

Workers’ compensation boards need detailed and timely health-care information in order to promptly adjudicate a claim. Yet, some HCPs are unfamiliar with workers’ compensation processes and the level of detail required.

This has come up in a number of studies that I have been involved with, says Kosny. A health-care provider may not realize how important it is to give details and very precise information and, if they don’t do that, how that might affect a worker’s claim.

HCPs may not have the clinical information needed for adjudication because they are unable to collect it in the first place, the paper adds. This may be the case when injured workers are uncomfortable about disclosing the details of their condition, are intimidated by the health-care practitioner, fail to disclose problems secondary to the main complaint, and/or have language difficulties.

3. The problem of knowledge

At times, HCPs find it difficult to provide the level of diagnostic and work-relatedness certainty needed by workers’ compensation boards to adjudicate claims, the paper suggests. This is a particular concern for workers with “invisible” injuries such as musculoskeletal disorders and chronic pain, which can be more difficult to diagnose and attribute to work with certainty. These workers can end up getting sent from one health-care practitioner to another as a WCB tries to gather the medical evidence necessary to make a decision.

Compensation system decision-makers prefer diagnostic certainty, and instances of medical uncertainty are not always easily managed, Kosny says. In the case of conflicting medical opinions or diagnostic uncertainty, workers could be launched into a cycle of claim denial and appeals, which may be financially and psychologically devastating.

4. The problem of decision-making ownership and authority

The paper also describes how injured workers and HCPs sometimes find it difficult to determine who is ultimately in charge of the worker’s health and the worker’s claim. This confusion can arise, for example, when disagreements occur between treatment recommendations made by a claimant’s doctor and the recommendations found in clinical management guidelines adopted by workers’ compensation boards.

This puts injured workers “between a rock and a hard place,” Kosny says. Some workers may have to choose between following their doctor’s recommendations or following the recommendations of the workers’ compensation board in order to secure their claim.

Researchers offer some suggestions

Kosny says there are no easy answers to the challenges identified by this analysis. However, the paper did conclude with some suggestions:

  • Find ways to decrease the administrative burden on HCPs working with the workers’ compensation system. For example, re-evaluate the frequency and nature of health-care provider contact required by workers’ compensation boards. It may be that HCPs treating workers with permanent and, potentially, long-term claims do not need to continually report back on minute changes in treatment plans and medication.
  • Continue to educate HCPs and workers on the type and amount of information needed by the workers’ compensation system to process and accept claims without delay.

Source: At Work, Issue 64, Spring 2011: Institute for Work & Health, Toronto