The role of health-care providers in complicated claims

In brief

  • Problematic interactions among health-care providers, injured workers and workers’ compensation boards may delay the return to work of injured workers with complicated claims.
  • Problems can arise in four domains: access to care, conflicting or imperfect medical knowledge, limited understanding of workers’ compensation system requirements and confusion about decision-making authority.
  • These problems can result in frustration, financial difficulties and mental health problems for injured workers.
  • Open lines of communication among all parties is the goal.

Why was this analysis done?

Health-care providers (HCPs) play a central role in workers’ compensation systems. They help determine if injuries are related to work, provide information to workers’ compensation boards (WCBs) about the nature and extent of injuries, and assess and make recommendations about workers’ return-to-work capabilities. However, when problems occur among the health-care system, injured workers and WCBs, it can delay the return to work of injured workers with complex claims. This analysis explains why and how this happens.

How was this analysis done?

This analysis builds on a larger Institute for Work & Health study that examined why injured workers with long-term workers’ compensation claims have problems with return to work (see www.iwh.on.ca/highlights/toxic-dose). The qualitative study was based on 34 interviews with injured workers who had long-term and complicated claims, 14 peer helpers and 21 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.

What did the researchers find?

The researchers identified four domains related to injured workers’ experiences of the health-care system that played key roles in complicating and prolonging compensation claims:

  • access (e.g. problems among injured workers accessing the health care needed, often due to geography or their status as injured workers);
  • communication and understanding (e.g. health-care providers being unfamiliar with the need of WCBs for timely and detailed information in order to adjudicate claims);
  • knowledge (e.g. health-care providers being unable to provide the level of diagnostic and work-relatedness certainty preferred by WCBs in order to adjudicate claims, especially when dealing with “invisible” injuries such as musculoskeletal disorders and chronic pain); and
  • decision-making ownership (e.g. confusion among the parties about who has ultimate decision-making authority with respect to workers’ health).

These problems resulted in frustration, financial difficulties and mental health problems for injured workers.

The researchers provided some recommendations to improve the ways that injured workers’ health-care needs are being met and to facilitate a supportive relationship between compensation boards and HCPs. For one, they emphasized the need for more communication among all compensation system parties.

What are some strengths and weaknesses of the study?

Strengths of this study include the synergy between accounts of injured workers and service providers, and among participants across the study locations. Weaknesses include the focus on one jurisdiction (Ontario) and the limitation of the number of injured workers studied.

Publication Information

Title: 

The role of health care providers in long term and complicated workers' compensation claims

Author(s): 

Kosny A, MacEachen E, Ferrier S, Chambers L

Journal: 

Journal of Occupational Rehabilitation. 2011; [DOI 10.1007/s10926-011-9307-3]