Workers’ compensation systems vary greatly in their medical assessment practices

Although most workers’ compensation boards set out procedures for independent assessments by medical professionals as part of the administration and management of work-related injury claims, how these assessments are carried out varies greatly.

In a study of 14 jurisdictions in Canada, Australia and New Zealand, Institute for Work & Health (IWH) Scientist Dr. Agnieszka Kosny, along with colleagues at Monash University in Australia, found considerable differences in how workers’ compensation boards (WCBs) use assessments, recruit and retain medical assessors, and perform quality control. The range of practices is rather surprising, she notes, given that WCBs are fairly similar in function and purpose.

Nevertheless, Kosny found some common challenges across the jurisdictions, and she believes their differences could point to ways to overcome them—if they shared their experiences.

Because the jurisdictions are so different in the way they use independent medical assessments, they could learn a lot from each other, says Kosny. Depending on their context and their needs, they could potentially learn ways to do medical assessments that are less intrusive or less costly, for example. But my impression is the different jurisdictions currently don’t talk much to each other about these issues.

Kosny shared the results of her study on independent medical assessments (IMAs) at a plenary hosted by the Institute earlier this year. A slidecast of that presentation is now available at: www.iwh.on.ca/plenaries/2015-jan-13.

Public perception a common concern

The purpose of Kosny’s study was to understand the role and function of IMAs across a number of different systems. IMAs generally involve health-care professionals providing their opinions on injured workers’ levels of disability or impairment, independent of the opinions of workers’ treating health-care providers.

The organization that funded the study, the Accident Compensation Corporation (ACC) in New Zealand, had identified a number of issues with IMAs in its own system, Kosny says. It wanted to understand how other compensation boards dealt with similar issues.

To undertake her study, Kosny reviewed publicly available material on IMAs in each jurisdiction and interviewed a senior health-care or policy advisor in each of the 14 participating boards (the boards are not named to protect the anonymity of those interviewed).

Kosny’s study gave rise to a number of key findings:

The term means different things in different jurisdictions. In some, IMAs are done in-house by health professionals who are independent from the treating physician. In others, they are collaborative assessments in which health-care providers from different disciplines hold ongoing discussions about cases. In some boards, the term is used for paper-based reviews of claims, a process which may take place without the injured worker knowing.

WCBs use independent medical assessments for four main purposes. These are: to explore reasons for unexpected delays in recovery and return to work; to make a permanent impairment determination; to help resolve medical disputes (e.g. about treatment paths or experimental therapies); and to determine liability or to establish grounds for reductions in benefits.

A disjuncture exists between publicly available information on IMAs and how they are actually carried out. There are differences between the information publicly available on IMAs (e.g. on websites) and how IMAs are carried out in practice, as described by the study participants. This could be quite confusing to injured workers, when they find information on how the process is supposed to unfold and then experience something different, Kosny notes.

The challenges faced by WCBs cluster around common themes. Many boards struggle with recruiting medical professionals to act as assessors, as the administrative burden involved can be high. The scarcity of assessors is a particular concern in rural and remote areas; it often means workers making compensation claims have to travel long distances to be assessed. As well, jurisdictions with too few assessors sometimes find higher levels of mistrust among workers, who perceive that the assessors on the roster are biased in favour of the boards.

Recruitment issues also play into a second challenge faced by many boards, which is that of quality assurance. This is a common challenge, says Kosny. When there are too few assessors, it can be more difficult for WCBs to institute quality assurance practices. Many of the boards in the study do not monitor quality systematically, according to Kosny. Even when rigorous processes are in place, such as the case at two boards in the study, the focus of the reviews is on the quality of the report, not on the quality of the medical opinion.

Although small, Kosny’s study suggests a need for further research into medical assessments. Medical assessments are important to individual workers, so questions about the professionals who are recruited as assessors, how their work is monitored and how injured workers experience different types of IMAs are very important, she says. Yet there is little research on these topics.

Source: At Work, Issue 80, Spring 2015: Institute for Work & Health, Toronto

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