Medical treatment decisions and workcover

workcover-medical-treatment-denied

Let’s just imagine that we are a doctor or specialist and that we’ve accepted to treat an injured worker.Who is really making the medical/surgical decisions about our injured workers? Shouldn’t the workcover insurers at least share the liability or at least bear the responsibility of their own actions or lack thereof?

Medical treatment decisions and workcover

from the point of view of an orthopaedic surgeon

The patient I am seeing is a 30-something lady who has been quite badly injured to her shoulder at her workplace. She (the injured worker) was clearly in pain and was physically unable to take her top off (and to put it back on) as she was unable to lift her shoulder / arm high enough. Her husband helped her with dressing and undressing, both here at the consultation and at home.

I am an experienced upper limb surgeon and believed the injured worker had a full tear of at least one (perhaps 2) tendons of her rotator cuff. In my opinion she would require timely surgery in order to repair the rotator cuff. From clinical experience she would need an MRI to confirm the [location and extent] of the tears.

In an ideal world, this injured worker’s medical/surgical treatment would rapidly progress and the injured worker would be operated quickly in order for the best success and to lessen or cease her suffering. Rotator cuff tears are notoriously painful. However when a patient is on ‘workcover’, his or her medical/surgical treatment is rapidly halted because of the way workcover insurers ‘operate’.

The medical treatment I prescribed / recommended was abruptly halted when the injured worker’s insurance company deemed the MRI as not ‘reasonable’ or ‘medically necessary’…

We all know that workcover insurers have trained their staff – such as case managers- to adhere to certain clinical guidelines and pathways with the major goal of ‘controlling costs’ and maximising the insurance company’s profit. Unfortunately, the reality is that most of these so called workcover case managers do not possess any medical or health care training. Most only possess a high school diploma and have no knowledge whatsoever about the human body, let alone any medical knowledge.

Mindful of the above, I took the next step together with the injured worker and appealed to medical reason, the workcover insurer’s case manager, the ‘independent medical examiner’ and the ‘in house medical advisor’.

The workcover insurance companies tend to call these peer-to-peer discussions, at least those conducted with an in-house medical advisor or some IME – because, in theory, we are supposedly equally “educated”.

Over the past few years I have often tried to ‘reason’ with these medical advisors (as well as case managers) to attempt to see the medical decision from my point of view, that of an experienced and specialists upper limb surgeon.

Sadly, there has never been any sort of reasoning in this “peer-to-peer” discussions. According to the workcover insurer’s own “clinical guides” the injured worker must try 6 weeks of physio first…and fail badly.

In my opinion these 6 weeks of ‘physio’ on a fully torn rotator cuff equals sheer torture and unnecessary torture for a  patient (injured worker) who is not even able to lift her shoulder enough to dress herself, brush her teeth or wash her hair with her dominant arm and hand.

The injured worker’s, as well as my own pleas fell on deaf ears and in the end, the workcover insurer case manager explained that he was “not denying care” and that the injured worker was free to pay for the MRI out-of-pocket.

Needless to say, the injured worker was currently unable to work and certainly did not have extra money to pay for such an expensive MRI test.

Ironically, the faster the injured worker would receive treatment, the sooner she would be back to work and off weekly payments.

If we disregard compassion and true medical care and go with workcover insurance company guidelines (ie cost containment), this does not make sense either.

Over time, leaving this injured worker untreated will cost more in terms of disability, pain medications, doctors visits, spouse’s time lost to work to take care of her needs and many more.

So, who made the medical decision here?

As an orthopaedic surgeon, my medical decision was to have the injured worker undertake a MRI to confirm the diagnosis and then to go on and be treated as soon as possible (surgery). My decision and recommendation to the injured worker’s insurance company was based on the injured worker’s history and from my physical examination as well as my past experience treating similar injuries.

The decision here was made by the workcover insurer (I would guess the in-house medical advisor at best) based on some obscure insurance company guides to control costs without ever speaking to the injured worker or examining the injured worker.

Yet, I am the one responsible for that decision. The insurance company is pretty much held free from any liability. The workcover insurance company’s medical advisor (or some IME) is essentially free to make these decisions every day with no oversight like doctors and specialists must face in the trenches .

I ask again, who is really making the medical decisions about our injured workers? Shouldn’t the workcover insurers at least share the liability or at least bear the responsibility of their own actions, like the rest of us do?

Another good read is our article “the doctor and the workers compensation patient

[Dictated by WCV and manually transcribed on her behalf]



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3 Responses to “Medical treatment decisions and workcover”

  1. What the Ortho surgeaon needs to do is “tell” them in writing what is required and why and then “tell them” it would be “medically negligent” to deny the MRI/surgery etc. The medical practitioner can be help medically negligent if they do not appropriately diagnose and treat an injury/condition, so they need to “legally pass the buck” and have the WorkCover Agent or Advisors prove beyond reasonable doubt how they can clinically justif their decision to deny treatment and make them do it using their own Clinical Framework, reseacrh and evidence from suitably qualified and experienced medical professionals. Anything less is medical negligence!

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  2. Corruption in black and white. At least there is one decent doctor prepared to take the time to question the system – and speak the truth.

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  3. I had a rotator cuff injury, SLAP tear and other ligament issues to shoulder. My orthopaedic surgeon specifically insisted that I made sure I did not forget to bring my MRI scans to the hospital on surgery day as it was crucial to have in order to use as what he described as a ‘road map’. Without the MRI scans the key hole surgery would have not been as successful. If a surgeon requests an MRI then get one. It’s like a cruel case manager saying you don’t need a scalpel because the cut can be made with a bread and butter knife.

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