The Guardian 13 December, 2006
NSW workers’ compensation:
A heartless system
Dr Con Costa
National Vice-President, Doctors’ Reform Society
There is a noticeable sharp decline in the number of people requesting a Workers’ Compensation Certificate following injury at work. And, if a claim does go in, doctor and patient are inevitably bombarded with telephone calls, faxes and requests for information or a medical report from the insurer and the "rehabilitation provider". (Rehabilitation organisations are contracted to insurance companies to monitor work injury cases and "assist with work return".)
Most notorious is the "Case Conference". These are insurance company scheduled meetings in the doctor’s office — meetings include the doctor, injured worker, the insurance agent and one or two people from the rehabilitation provider. The doctor’s consulting room has now become so crowded it’s hard to move or breathe — a stifling and uncomfortable atmosphere.
And Case Conferences can go on for over an hour. (Not a good situation for all the sick patients in the doctor’s waiting room who are already stuck with a long wait because of the Howard Government’s GP shortage.) The patient can end up in tears, the doctor exasperated and the insurance and rehabilitation representatives calmly stating they will be back in two weeks to check on whether decisions are followed.
The doctor has no choice but to go along with this process because, when the doctor signs the bottom of the workers’ compensation certificate, the line above states: "I agree to be this worker’s Nominated Treating Doctor and to assist in his/her work return". If the doctor does not submit to the insurance agent’s demands, including Case Conference, (or respond to the mountain of paperwork from insurer and rehabilitation provider), all payments to the injured worker, as well as treatment costs, can be cut off as well as the insurance agent refusal to accept the doctor’s medical certificates.
The situation has now become critical. New workers’ compensation laws are allowing rehabilitation providers and insurance agents to intimidate treating doctors and constantly harass the injured worker. Injured workers are steered towards the company’s doctors at the time of injury, or, where an injured worker insists on seeing their own doctor, insurance agents and "rehabilitation providers" (paid by the insurance agents) try to dictate management of the injured worker to the treating doctor. (It is not well known but the doctor has some rights in the new legislation including the power to change the rehabilitation provider — although few doctors know about these rights and it rarely happens.)
More often than not the doctor just gives up — either complying with these outside forces or simply telling the patient to find another doctor. (Many workers are also not aware that they still have the right to choose their treating doctor — or to change treating doctor where they are not happy with the treatment — but usually too anxious to do so.)
The system gone mad
Recently, a patient came to our Medical Centre because his own doctor was fed up with just such a situation. The doctor didn’t want to be involved anymore because of the harassment. The injured worker had seen two orthopaedic surgeons — both advised arthroscopy on his injured knee. The insurance agent’s retired surgeon (a retired doctor) disagreed, so the insurers were denying liability for the simple surgery. It seems the insurance doctor has more power than three treating doctors — including the two independent orthopaedic surgeons!
Another patient had been seen by a doctor at the airport and told there was "not much wrong" and to go back to work. (She later found out that, without her knowledge or permission, he had also rung the employer immediately after the initial consultation. I found out later he was also under contract to the employers at the airport.) After two or three visits she was unhappy with the doctor’s management ("he didn’t even examine me" was the complaint) and she attended at our medical centre.
After I accepted to take over her care, I was inundated with faxes and paper work and telephone calls and a long period of harassment. The patient’s file became so big it became totally useless and I had to put it in a special filing cabinet. The same doctor at the airport now took up the role of consultant doctor to advise the employer. He continued to be sent copies of all of the medical correspondence by the employer — even though they had all been advised that she was no longer his patient.
My patient was well educated and a feisty personality. She could speak up for herself. But you could only imagine the situation for the thousands of other workers at the airport, many having less English skills and who may be more easily intimidated by the system.
The situation has now gotten to a stage where it can be best described as scandalous and the employers and insurance agents can ride roughshod over the system. Many doctors now do not want to see injured workers because they simply don’t have the time and don’t want all the harassment.
But it does not stop there!!
Employers are now contracting with their own flying squads, officially called Return to Work Coordinators (RTWC) who can go out and visit the injured worker (and their doctor) as soon as the workers’ compensation claim is received — and the RTWCs have wide ranging powers sanctioned by WorkCover. RTWCs (usually very young people just out of university who have a few years training on workforce and no medical background) contact injured worker’s doctors to discuss treatment and return to work plan.
Insurance claims clerks have also been given wider powers and now act as Case Manager and an expanded role including going out to "visit" injured workers and their doctors. (Rehabilitation Providers — who were employed by insurance companies to monitor claims and were originally meant to play an intermediary role between employer and injured worker — now seem to be on the outer and perhaps considered "too independent" and "too slow" by the insurance agents and employers.)
The implications of the further changes to the system were driven home to me last month when I was pressured for almost two hours in front of my patient by a RTWC and insurance Case Manager (neither of whom had any training or background in health care). The purpose of the Case Conference appeared to be: 1) to get the doctor to agree to hand over their patient’s treatment to the insurer — "because they have allied health professionals all under the one roof"; 2) agree to upgrade the work return program at a faster rate — even though it became obvious that the employer really did not have the appropriate duties; 3) comment on two medical specialist reports obtained by the insurance agent and agree to a further meeting with the case manager and RTWC in two weeks time to check on the patients (and my) progress.
So it has come to this: a state Labor government has introduced changes to workers’ compensation which give WorkCover sanctioned power to insurance agents and employers to enter the doctor’s consultation room and dictate management and certification of injured workers, while making Medicare patients second class citizens in the doctor’s waiting room.
I asked the Case Manager how doctors and all the patients in the doctor’s waiting room are going to cope with this new situation? She replied that we would just have to get used to it "because this is the future and she has visited doctors all over Sydney and, to date, doctors have been willing to cooperate."
Medicare or Managed Care
This is not just a bad situation for injured workers and their doctors. It is also what doctors and patients can expect when the insurance companies eventually take over Medicare and gain control of our health system. (Under the US private health system doctors need to ring up the insurance company to get permission before ordering tests or starting treatment and, as with the worker’s compensation system in NSW, the insurance company becomes a constant third party in the doctor-patient consultation. Under US Managed Care you can’t just go to a casualty or emergency centre at a hospital if you feel sick — you have to ring your insurer and they may simply tell you to wait and see a doctor the next day — or direct you to a hospital all the way across town where the insurance company gets a better deal.)
Changes to the IR laws and workers’ compensation and Medicare, are all geared towards the wealthy and vested interests. It has become a sick system. Profits of the insurance companies are booming, the stock market is booming and the private health system (just like the private education system) is awash with money (a lot of it being taxpayers money) while the public system and injured working people are made to starve. We are losing any sense of justice and compassion. The doctor’s role is being demeaned and doctors are at risk of becoming dupes of unscrupulous insurance agents and employers.