J Occup Rehabil DOI 10.1007/s10926-014-9521-x

REVIEW

Healing or Harming? Healthcare Provider Interactions with Injured Workers and Insurers in Workers’ Compensation Systems Elizabeth Kilgour • Agnieszka Kosny Donna McKenzie • Alex Collie



Ó Springer Science+Business Media New York 2014

Abstract Introduction Healthcare providers (HCPs) are influential in the injured worker’s recovery process and fulfil many roles in the delivery of health services. Interactions between HCPs and insurers can also affect injured workers’ engagement in rehabilitation and subsequently their recovery and return to work. Consideration of the injured workers’ perceptions and experiences as consumers of medical and compensation services can provide vital information about the quality, efficacy and impact of such systems. The aim of this systematic review was to identify and synthesize published qualitative research that focused on the interactions between injured workers, HCPs and insurers in workers’ compensation systems in order to identify processes or interactions which impact injured worker recovery. Method A search of six electronic databases for literature published between 1985 and 2012 Electronic supplementary material The online version of this article (doi:10.1007/s10926-014-9521-x) contains supplementary material, which is available to authorized users. E. Kilgour (&)  A. Collie Institute for Safety Compensation and Recovery Research (ISCRR) and Department of Epidemiology and Preventive Medicine, Faculty of Medicine Nursing and Health Science, Monash University, Level 11, 499 St Kilda Rd, Melbourne, VIC 3004, Australia e-mail: [email protected] A. Kosny Monash Centre for Occupational and Environmental Health (MonCOEH) and Department of Epidemiology and Preventive Medicine, Faculty of Medicine Nursing and Health Science, Monash University, 6th Floor, The Alfred Centre 99 Commercial Road, Melbourne, VIC 3004, Australia D. McKenzie Family Violence Unit, Ministry of Social Development, Level 7, Bowen Street, Wellington 6140, New Zealand

revealed 1,006 articles. Screening for relevance identified 27 studies which were assessed for quality against set criteria. A final 13 articles of medium and high quality were retained for data extraction. Results Findings were synthesized using a meta-ethnographic approach. Injured workers reported that HCPs could play both healing and harming roles in their recovery. Supportive patient-centred interaction with HCPs is important for injured workers. Difficult interactions between HCPs and insurers were highlighted in themes of adversarial relations and organisational pressures. Insurer and compensation system processes exerted an influence on the therapeutic relationship. Recommendations to improve relationships included streamlining administrative demands and increasing education and communication between the parties. Conclusion Injured workers with long term complex injuries experience difficulties with healthcare in the workers’ compensation context. Changes in insurer administrative demands and compensation processes could increase HCP participation and job satisfaction. This in turn may improve injured worker recovery. Further research into experiences of distinct healthcare professions with workers’ compensation systems is warranted. Keywords Injured worker  Healthcare provider  Insurer  Workers compensation  Qualitative  Systematic review

Introduction Injured workers involved in compensation systems interact with multiple individuals within medical, compensation, social and employment settings during their rehabilitation. Research suggests that recovery and return to work is

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enhanced when an injured worker has a supportive environment, understanding service providers and a cohesive rehabilitation team [1–6]. Many injured workers recover quickly and return to work; however, those with serious and complex injuries spend much longer in rehabilitation and have more contact with medical and compensation services. Depending on the nature of the injury, workers may have contact with only a few or multiple healthcare providers (HCP). Injured workers who have a mental health claim may see a psychologist or psychiatrist in addition to their general practitioner, whilst those who have physical injuries may also see a range of HCPs including specialist physicians, surgeons, nurses, physiotherapists, occupational therapists and occupational rehabilitation providers. Healthcare providers play a number of critical roles that influence the delivery of healthcare services aimed at improving the injured worker’s health and ability to return to work. In many compensation systems, the primary HCP has a legal role, being responsible for certifying and documenting the work-relatedness of the condition to enable the injured worker to lodge a claim [7] (excluding some jurisdictions, such as the Netherlands, where work-relatedness of the injury is unrelated to income and medical support). The primary HCP may also be required to determine treatment needs and arrange appropriate referrals. In the role of therapist, HCPs may provide measurable, goal-oriented, evidence-based treatments and encourage the injured worker to take an active part in their rehabilitation [8]. Healthcare providers can also be advisors, educating injured workers about health behaviours and treatment options, in addition to reporting to insurers about the injured worker’s progress, ongoing treatment needs and capacity for return to work [8]. Healthcare providers may also act as advocates or mediators, liaising with occupational rehabilitation services as well as the injured worker’s employer to facilitate workplace accommodations to enable a suitable return to work [7]. Separate from the provision of services, HCPs may have an analytical and judgemental role. They may be employed directly by insurers (and on occasions by the injured worker’s legal representative) to provide ‘independent medical assessment’ (and sometimes legal testimony) of injured workers’ treatment requirements and medical status periodically throughout their recovery [9]. The work demands of HCPs who work within compensation systems can be high as they may be required to perform a number of these roles simultaneously to cater for the individual needs of injured workers. The quality of the relationship between the injured worker and the HCP is very important for recovery. Several studies have reported that the attributes and attitudes of the HCP can influence how an injured worker evaluates the

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usefulness of the treatment or service provided [6, 10–14]. Healthcare providers are considered to be more effective if they develop a positive rapport with the injured person and utilise a client-centred approach to treatment [12, 13]. In addition to understanding specific injuries and the recovery process, the HCP’s knowledge of the workers’ compensation system and awareness of the impact of the system on the individual are also important for the injured worker [6, 10, 12]. Injured workers consider HCPs to be unhelpful if they demonstrate a distrustful attitude towards them, or question the legitimacy of their injury or their diagnosis [14]. Healthcare providers who have a poor understanding of the nature of the injured worker’s duties and work demands, or who pressure the injured worker to return to work prematurely and do not communicate clearly with the rehabilitation team are considered as less effective by injured workers [5, 6, 10]. The injured worker’s perception of their interactions with HCPs, and their HCPs collaboration with other stakeholders is an often overlooked factor that can impact return to work outcomes [3]. There is some research suggesting that the interactions between HCPs and injured workers are affected by their involvement in the compensation process. As a consequence of having a compensation claim, injured workers can experience stigma and discrimination [6, 14–16]. Stereotyping by HCPs can be especially damaging for vulnerable injured workers, serving to reinforce illness behaviours and delay recovery [17, 18]. It has also been argued that the multiple roles played by the HCP can interfere negatively with the therapeutic relationship [19– 21]. Clinical opinions regarding diagnoses and treatment requirements may vary depending on the role that the HCP plays within the system [22–25]. Studies have compared assessments of injured workers made by treating HCPs and those made by insurer employed medical examiners. Differences between assessments have been attributed to ideological perspectives about injury (such as the importance of the impact of the injury on the person) and methods used for assessment (such as consultative examinations, radiology findings or file reviews) rather than differing clinical skills of the assessors [22]. Interactions between HCPs and insurers are also very important as this relationship has the potential to influence how the HCP works with the injured worker. Several studies have highlighted the importance of the relationships between HCPs, social insurance agencies and recipients of sickness benefits. It is suggested that these relationships can facilitate or obstruct the claimant’s speed of recovery and return to work by influencing claimants’ access to treatment and engagement in rehabilitation [24, 26–28]. Collaboration between HCPs and insurers can also influence the timeliness and degree of injured workers’ participation in return to work programs [3, 4].

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Investigation of the relationships between HCPs and insurers, and the impact of these relationships on injured workers in workers’ compensation systems, is an emerging area of research. It is therefore timely to synthesise findings from existing research that investigates the encounters between these parties in order to gain a more cohesive and comprehensive picture of these important interactions. The experiences and perceptions of injured workers are also important to consider as they are consumers of medical and compensation services who are well placed to provide valuable insights into the functioning of these systems [6, 28–30]. To our knowledge, there has been no other systematic review conducted of qualitative studies that focus on the dynamics and interactions between workers’ compensation personnel, HCPs and injured workers. A number of systematic reviews have considered quantitative or mixed methods studies that investigate effectiveness of interventions for return to work or occupational health and safety (OHS) [31, 32]; work participation and work functioning in particular illness [33]; or treatment interventions for particular injury types [34, 35]; and the influence of compensation on health outcomes [36, 37]. Other systematic reviews have reported on the quality of economic evaluations of workplace based interventions in OHS and the financial merits of disability management interventions [38, 39]. MacEachen et al. [40, 41] conducted two systematic reviews of qualitative literature. The first review [40] examined return to work processes following physical injury and commented on injured worker experiences with workers’ compensation systems in the context of facilitating a return to work, which is a topic not covered in this review. The same review addressed employer contact, but not injured workers’ interaction with HCPs. The second review [41] examined small business’ understanding and implementation of OHS processes. The review focused on employed worker and employer views of OHS issues and did not include other stakeholders such as HCPs or insurers. The purpose of this review was to synthesis qualitative research that addressed injured workers’ perceptions of their interactions with HCP’s and insurers in order to identify processes or interactions which impact injured worker recovery. As the review revealed extensive data, it was deemed necessary to divide the findings into manageable groupings. Injured workers must by necessity interact with insurers to run their claim, and it seemed logical that this larger set of findings be presented separately [42]. For injured workers to receive healthcare services under workers’ compensation the HCP must also interact with insurers, and research suggests that interactions between HCP’s and insurers can also impact injured workers’ recovery [3, 4]. Thus the focus of this paper is to

highlight the experiences of injured workers with HCPs while also exploring the dynamics between HCPs and insurers and the ensuing impact on the injured worker.

Method Focus of Review The review considered studies that addressed injured workers’ experience of their interactions with various parties that were influential in their rehabilitation or recovery. Qualitative studies were chosen to develop a nuanced understanding of these experiences. The main research question was ‘‘What are the interactions between injured workers, health care providers and insurance personnel in workers’ compensation systems?’’ Subsidiary questions included ‘‘What experiences do injured workers have when dealing with insurers or receiving treatment from health care practitioners?’’ and ‘‘What beliefs or impressions do injured workers develop as a result of these interactions?’’ In order to uncover the impact of these relationships, a further question included was ‘‘Are there particular interactions which are more helpful or harmful than others for the injured worker’s recovery process?’’ Search Process A search of electronic literature databases was conducted to identify relevant qualitative peer-reviewed studies published in English from 1985 to 2012. (Refer Online Resource 1 for two database search records). Search terms and key words were adapted for six electronic databases: Medline, Embase, PsychInfo, Sociological Abstracts, Cinahl, and AGIS, to identify articles that were focused on the interactions, regardless of the issue (for example, whether the interaction was about assessments, entitlements, service approval, treatment or return to work), between key parties (injured workers, HCPs, lawyers and insurers) in transport accident and workers’ compensation systems. A search of the bibliographies of short listed studies was subsequently conducted to locate other research that may not have been identified in the initial search. Screening Protocol The consensus of the authors was to exclude studies that included victims of transport accidents, medical negligence or public liability claimants. This allowed the focus to centre upon a single type of compensation system— workers’ compensation systems—a strategy recommended by other researchers [43]. Studies that focused only on

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return to work outcomes were also excluded as a considerable amount of research already exists on this topic, and the aim of this review was to understand the interactions between the parties rather than examine return to work issues. A number of case studies that reported on litigation in workers’ compensation were also excluded as these were written from the lawyers’ perspective rather than in the claimant’s voice. Studies identified from the database and bibliography searches were appraised independently by two reviewers (EK and AC), and inter-rater agreement was above 98 %. A consensus method was used to resolve differences in opinion for six articles. The following inclusion criteria was applied to ensure that the articles were relevant to the review questions; (1) the study applied qualitative methodology, (2) the majority of participants sustained a workrelated injury or disease, (3) the injured worker’s perspective or experience was the major focus of the study, and (4) the study did not exclusively investigate return to work or vocational outcomes. For articles where there was insufficient information, full texts were reviewed, and for seven articles, the authors of the articles were contacted for clarification. Studies that met the inclusion criteria were retained for quality assessment. Quality Assessment A modified version of the quality assessment framework by Spencer et al. [44] was utilized. The evaluative framework is comprised of eighteen appraisal questions, and all have supporting quality indicators that serve to assist the assessor to make an informed judgment about how the output of qualitative reports or journal articles adhere to qualitative principles. The framework takes into account differing theoretical perspectives and focusses on appraising qualitative research based on the quality of design, rigour, credibility and the contribution made to advancing knowledge [44]. MacEachen et al. [40] applied a modified version of the quality assessment framework in a systematic review of qualitative literature on return to work, and consent was obtained to utilise the same quality appraisal and data extraction proforma which were then modified to fit the topic of this review. Questions were reordered and those pertaining to the relevancy of findings from each study to the research question were given priority so that reviewers did not complete a full assessment of studies that had only minimal reference to the review topic. Each question was rated out of five with a higher score being allocated when an article met more of the quality indicators. An overall score was then calculated for the article and levels of quality were assigned as; Very Low (0–15), Low (16–30), Medium

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(31–55) High (56–70) Very high (71–85). Refer Appendix for a list of the quality assessment questions. Each of the included articles were read entirely and independently evaluated against the quality appraisal criteria by two researchers (EK and DM). Inter-rater agreement was above 90 % and 25 of the 27 articles were rated within the same level (i.e. very low to very high quality) with only five points difference on the two articles which were not rated in the same quality level. For two of the articles, where consensus was not reached, a third researcher’s (AK) opinion was sought. Only those studies which were rated by a majority of reviewers as medium quality or greater were retained for data extraction. Data Extraction and Synthesis of Findings The researchers involved in quality appraisal (EK, DM and AK) discussed which data to extract from each article. Details that were chosen included research question, theoretical orientation, study methods, sample characteristics and sampling strategy, location and timing of research, analysis methods, reflexivity,1 and relevance of study findings to the review questions. Findings related to interactions between key parties were separated into three categories; interactions between injured workers and insurers, interactions between HCPs and injured workers, and interactions between HCPs and insurers. Synthesis of data was conducted according to interpretivist, meta-ethnographic principles as described by Noblit and Hare [45]. The meta-ethnography method employs multiple stages of analysis and encourages the identification of key concepts and the construction of overarching themes that contrast between and span across the multiple studies. The aim is to develop an interpretation of the combined results from the studies which provides a broader and deeper meaning of the results than can be gleaned from individual studies. Where themes fit logically together, a line of argument can be developed to provide a descriptive explanation of the findings as a whole [45]. Analysis of the findings initially involved the development of first–order concepts where statements and comments in each study relevant to the review question, such as ‘stigma and stereotyping’, were identified. Two reviewers (EK and AK) developed the first–order concepts after examining and discussing an initial three studies. Following meetings between three reviewers (EK, AC and AK) to discuss and identify comparable and contrasting key concepts from the studies, second–order interpretations were developed and organised into meaningful themes. 1

Reflexivity refers to the comments made by the authors of each article on how the context, selection of participants or data collection process affected the results obtained in their study.

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Fig. 1 Flowchart of systematic review of process

Results

Study Characteristics

Search Results

Three of the studies were from Australia, seven were from Canada and one from each of New Zealand, Sweden and the United States. Interviews and focus groups were conducted with over 845 injured workers, and some studies included healthcare providers and/or workers compensation staff and other injured worker representatives. Many of the workers interviewed had serious injuries and longer term claims, and so had greater involvement with the medical and compensation systems than did workers who suffered minor injuries and returned to work easily. Table 1 summarizes the characteristics and quality ratings of the included studies.

The initial search of six electronic databases identified 1,071 studies. Duplicates were removed and the remaining 1,006 studies were assessed for relevance. Studies with titles that were clearly not relevant to the topic were excluded and remaining abstracts were assessed according to the selection protocol. Where relevance of a study was unclear from the abstract, the full text was read. For seven studies where participant characteristics were unclear, the authors were contacted to verify that the injury sustained by participants was work-related. A total of 988 non-relevant studies were excluded. Review of the bibliographies of the 18 retained studies revealed a further 25 potentially relevant studies. These were obtained and then screened for relevance. Both reviewers (EK and AC) considered that an additional nine studies met the selection criteria, and a final 27 studies were retained for quality assessment. Quality assessment of the 27 studies was conducted and 13 studies rated as medium quality or higher were retained for data extraction. Of the 13 retained studies [46–58], nine were rated as medium quality and four were rated as high quality. An overview of the systematic review process is presented in Fig. 1.

Meta-ethnographic Synthesis Results Despite five different countries and ten distinct jurisdictions, injured workers reported similar experiences with HCPs, and similar concerns regarding HCPs’ dealings with insurers were identified. The themes that arose through the synthesis of interactions between HCPs and injured workers and between HCPs and insurers are presented separately. Although injured workers referred frequently to ‘‘doctors’’ or ‘‘specialists’’ and other medical providers, in many

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instances it was not possible to distinguish the exact discipline of healthcare practitioner referred to by the injured worker, and thus the term HCP has been adopted to represent all medical and allied health practitioners. Table 1 lists the various disciplines of HCPs that were mentioned in each study. Healthcare Provider and Injured Worker Interactions Five themes were identified that related to interactions between HCPs and injured workers. These are presented along with the underlying key concepts in Table 2. The issue of Legitimacy Injured workers’ concern about their condition being regarded as legitimate was the most frequent theme to emerge, and was noted in 12 out of the 13 studies [46–53, 55–58]. This included interactions where injured workers described attitudes of disbelief, discrimination or prejudice from HCPs. Stereotypical attitudes were demonstrated by HCPs through statements or actions that indicated their lack of belief in the veracity of injured workers claims [46, 48, 51–53, 55, 56, 58]. Eight of the studies noted that injured workers found HCPs did not believe their reported experience of pain, their claims about the impact of their injuries, or the limitations they described regarding their capacity to perform domestic duties or return to work [46–50, 56–58]. Some injured workers felt HCPs discriminated against them due to race, gender or level of education [46, 48, 55, 56]. Other injured workers noted that HCPs they had consulted prior to their work-related injury became less helpful and less understanding once treatment was requested under the workers’ compensation system [58]. These experiences were demoralising for injured workers who had expected that they would receive professional and respectful treatment from HCPs. The opinion of the HCP was important as it could have a significant influence on the acceptance of a claim or on the injured worker’s continuing eligibility for services and benefits. Pejorative attitudes from HCPs were especially damaging to the therapeutic relationship as injured workers were reliant upon the HCP’s expertise, advice and guidance to manage their treatment and rehabilitation. System Intrusion in the Healthcare Provider-Injured Worker Relationship Provision of healthcare services is a major cost for workers’ compensation systems in most industrialised nations. Thus most compensation systems seek to exert some

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influence over service provision in an effort to manage costs. One positive influence is that being part of the workers’ compensation process can provide low-income workers with access to healthcare services that may be otherwise unaffordable [47]. However, there are a number of deleterious effects of the third party relationship that can also occur. Injured workers reported that some HCPs demonstrated bias against compensable clients [46, 48, 51, 52, 54, 57] and declined to provide services to due to their frustration with compensation system administrative demands and delays with approvals and payment [46, 49, 51, 52, 54]. A frequent observation of injured workers was that HCPs disliked submitting detailed reports to insurers about the injured worker’s treatment, medical status and progress. Administrative requirements could interfere with consultations and influence other medical treatment that injured workers received. Late or inadequate medical reports could result in delays in approvals for surgery, treatment, medications, or obtaining appointments to see a particular medical provider, and even result in the injured worker losing income replacement benefits. In many instances, both HCPs and injured workers were uncomfortable with these multiple, sometimes conflicting, demands of the system upon the HCP [47, 49, 51, 52, 54, 56, 58]. Some injured workers also reported dissatisfaction with the quality of service they received. A common complaint was that HCPs frequently did not communicate well. Injured workers claimed that HCPs did not listen to their concerns, provide adequate explanations or answer queries about health issues. Consultations were frequently hurried, leaving injured workers’ feeling pressured and like an inconvenience to the HCP. Some injured workers reported a lack of needed support, understanding, empathy, or adequate treatment from HCPs [46, 49, 52, 53, 57]. Others commented that they were afraid to confide in or question their HCP, or to request reports required by their insurer from the HCP [52, 53, 57]. Some authors in the reviewed studies argued that the nature of the worker’s injury may have contributed to problematic interactions with HCPs [51, 52, 54, 56]. Injured workers with invisible or complex injuries (such as chronic pain or occupational overuse syndrome) were often long term clients who showed little improvement. These clients were clinically challenging and often required lengthy consultations to address multiple health concerns [48, 50]. Injured workers who had longer term claims could represent a significant administrative load for a busy HCP which prevented the HCP from seeing less demanding clients. Frequently workers’ compensation systems did not provide adequate recompense for extended consultations or the time required to complete detailed reports associated with complex claims [51, 54].

Sweden

New Zealand

Jaye and Fitzgerald [50]

Victoria

Australia

Toronto

Canada

Hubertsson et al. [49]

Cromie et al. [48]

Cacciacarro and Kirsh [47]

Canada

Beardwood et al. [46]

Toronto

Jurisdiction (country, provence or state)

Study author/s and date published (citation reference)

4

3

23



3

11

Male

20

11

6

1

6

Female

Gender (number)

15

6

4

17

Sample size (number)

20-60

33–63

20–40

40–69

40?

Age in years

Clerical workers, librarians, bank and post office workers, university students, butchers, labourers, cleaners, and wool handlers

Employment status noted as; 8 employed, 3 selfemployed, 3 unemployed, 1 student

Physiotherapists

1 retired, 3 unemployed

Not specified; Injured workers ‘worked in a range of sectors’ and ‘approximately one half were union members’’

Occupation/s

Table 1 Summary of study characteristics, including quality rating and type of health provider

Occupational overuse syndrome (OOS)

Rheumatic disease (2) Back or neck problems: slipped disk or lumbago (6) Fibromyalgia (2) Stroke (2)

Rheumatoid arthritis (3)

Upper limb, neck or low back

3 males had backrelated injuries, 1 female had RSI injury

‘More than 50 % had a back injury, and upper extremity injuries were also common’

Injury type/s

Interview

Interview

Interview

Interview

Interview

Method of data collection

Injured workers encounters with employers, health professionals and the Accident Compensation Commission

Injured workers perception of their contact with the Social Insurance Agency and healthcare system, and obstructing or facilitating factors for their recovery and return to work

The experience of physical therapists who made a WorkCover claim

Identification of mental health consequences of work injury and the barriers and enablers of positive mental health for injured workers

Injured workers perceptions of the impediments created by the medical, compensation, and rehabilitation systems

Focus of research

Doctor (G.P.), occupational therapist, medical specialist, rheumatologist, orthopaedic surgeon

Doctor, social worker, physician

Physiotherapist, specialist general physician, rheumatologist, neurologist psychiatrist, medical examiners

Doctor, occupational therapist

Doctor (family), physiotherapist, chiropractor, psychiatrist, respirologist, physician

Type of health care provider discussed in studya

Medium

Medium

Medium

Medium

High

Quality rating

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MacEachen et al. [54]

b

MacEachen et al. [53]

Canada Ontario

One Canadian province

Canada

Canada Quebec, Ontario, British Columbia

Lippel [52]

b

Canada11 sites in Ontario

Jurisdiction (country, provence or state)

Kosny et al. [51]

b

Study author/s and date published (citation reference)

Table 1 continued

34 injured workers (IW) plus 14 Peer Helpers (PH) and 21 Service Providers

69;

37

85 plus 1 group of 25 injured workers and 5 groups of injured worker representatives

34 injured workers and 14 peer helpers and service providers

48;

Sample size (number)

26 IW ? PH

23

52 %

26

Male

22 IW ? PH

14

48 %

22

Female

Gender (number)

Average age 50 yrs. at time of interview and 40 yrs. at time of injury.

30–69

not specified

40 average

Age in years

Service providers included various health care practitioners, legal advisors, human resources personnel, and workers’ compensation staff

Clerical (3) Construction e.g., installers, carpenters (4) Health care e.g., health care aides, nurses (6) Machine operators, assemblers, and maintenance mechanics (15) Service e.g., mail carrier, library technician, hydro worker (6) Truck drivers (3)

Injured worker occupations were described as broad but not specified; Representatives of injured workers included not for profit community advocates, lawyers, union reps, and staff of office of the worker advisor

Service providers’ included; health care providers, professional and paralegal, injured worker reps, workers comp decision makers, and return-to-work coordinators

Injured workers included; trades, transport and equipment operators, manufacturing, service and health care work

Occupation/s

More than half of the workers had back or soft tissue injuries. Others had fractures, head injuries, amputations, crushes and one had a respiratory illness

Back pain/hurt back (12) Soft tissue injuries (9) Fractures/limb injury (6) Crushing injuries (4) Head injuries (2) Respiratory disorders/asbestosis (2) Cancer (1)

Back injuries, upper extremity disorders, various other musculo-skeletal disorders, burns, fractures, head injuries, respiratory disease, poisoning by neuro-toxic substances, loss of an eye and 4 mental health claims including posttraumatic stress disorder

Back injuries, soft tissue, fractures, crushes, head injuries, amputation, cancer, respiratory problems

Injury type/s

Interview

Interview

85 Interviews 6 Focus Groups

Interview

Method of data collection

Understanding systemic, processrelated problems affecting injured workers who had failed to return to work as expected

How injured worker peer support groups perform both positive and negative Return-towork functions at the individual and policy level

The experience of injured workers and identification of specific steps in the compensation process and specific actors in the system that had a positive or negative impact on that experience

Interactions between injured workers, the Workers’ Compensation Boards, and health care systems that may complicate and extend workers compensation claims, and the underlying mechanisms

Focus of research

Doctor, physician, physiotherapist, chiropractor, psychiatrist occupational health physician

Doctor (G.P.) specialist physician, psychiatrist, neuropsychologist, pain specialist, occupational therapist, physiotherapist, psychologist

Doctor, treating physician, physiotherapy, osteopathy, pain clinics, acupuncture, nurses, specialist physician, psychologist, psychiatrist, rehabilitation counsellor, occupational therapist

Doctor (family), specialist, physician, surgeon, chiropractor, occupational health physician, board doctor

Type of health care provider discussed in studya

High

Medium

High

High

Quality rating

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Jurisdiction (country, provence or state)

Canada Province not specified

Australia New South Wales

Australia South Australia

Study author/s and date published (citation reference)

Murray [55]

Reid et al. [56]

RobertsYates [57]

Table 1 continued

85

52

26

Sample size (number)

48



24

Male

37

52

2

Female

Gender (number)

25–65

40?

46–61

Age in years

Process workers, machine operators, an IT technician, truck drivers, nursing assistants, cooks, cleaners, veterinary nurse, nursery assistants and retail sales assistants. electrical technicians, security/ surveillance officers, a project officer, a trade’s assistant, labourers, child carers, officer manager, clerks, fork lift drivers, concrete finishers, waiters, meat factory hands, nurses, boilermakers, a bread room hand, welders, fitter/ turners, metal polishers and a weaver

Telephonists (28) Chicken Process Plant workers (24)

In-shore (15) and deep–sea (15) fishharvesters

Occupation/s

Back (26), neck (6), shoulder (18), arm (6), elbow (6), hand (3), wrist (4), finger including amputations (4), knee (5), foot (5), (3) multiple injuries, stress and depression (7)

Repetitive Strain Injury (RSI)

Not specified

Injury type/s

Interview

Interview

Interview

Method of data collection

Injured workers’ viewpoints of claims/injury management by the insuring agents, employers, vocational and medical providers

The interaction of women with RSI and the medicolegal system and the effects it had on the course of their illnesses

The perceptions of inshore and deep-sea fish harvesters’ experience of the workers’ compensation system

Focus of research

Doctor (g.p.), specialist physician psychologist

Doctor (family, company), specialist physician, neurologist, rheumatologist, chiropractor, orthopaedic surgeon, physiotherapist, occupational therapist, social worker, psychologist, psychiatrist

Doctor

Type of health care provider discussed in studya

Medium

Medium

Medium

Quality rating

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Claims managers often contested the HCP’s recommendations for treatment or medications. This frustrated HCPs, who felt this was a disregard of their professional training and expertise [46, 50–52, 54]. The disconnect between the HCP’s recommendations and the insurer’s approval left the worker in an unenviable position of having two ‘masters’ who disagreed; if the injured worker did not follow the HCP’s recommendation, they may be considered an uncooperative or resistant patient, and could further frustrate the HCP [46, 48, 51]. If the injured worker went against the insurer’s directive they were at risk of losing benefits. Injured workers who were already on lower incomes were unlikely to be able to afford treatments that were not approved [46, 47]. This conundrum created additional anxiety and financial pressure to the stress of injury.

Similarities and differences in injured workers experience of the workers’ compensation systems and medical care systems in Florida and Wisconsin Interview

Doctor

Focus of research Method of data collection

Type of health care provider discussed in studya

Quality rating

Medium

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Designation of the type of healthcare provider is as described in each study

Author A. Kosny was not involved in the selection, relevance screening, quality assessment or appraisal of these studies b

a

50 % 50 % USA Florida and Wisconsin Strunin and Boden 2004 [58]

Florida (204) many were Hispanic and/or nonWhite Wisconsin (198) almost all White and nonHispanic

Female Male

Jurisdiction (country, provence or state) Study author/s and date published (citation reference)

Table 1 continued

Sample size (number)

Gender (number)

Age in years

Not specified. Both state samples were stratified by age and gender, and the distribution of these character-istics was virtually identical

Occupation/s

Not specified – but 1/3 in each state had worked in pre-injury job for less than 1 year at time of injury

Injury type/s

All the workers suffered back injuries in 1990

Non-therapeutic Encounters Injured workers may be referred by the insurer to an independent medical expert for the purpose of assessing the status and work-relatedness of their injury. Medical examinations can be conducted when the claim is first lodged, or during rehabilitation to assess the injured worker’s recovery progress, or to determine degree of impairment once the injured worker is medically stable [9, 59]. The insurer makes a judgement about the injured worker’s eligibility for income benefits or medical services based on the report from the medical expert [23, 25]. In some systems, the injured worker does not automatically receive a copy of the independent medical examination report, but must request a copy of the report from the insurer [9]. The injured worker has little control over the independent medical examination process which has no therapeutic role in the injured worker’s recovery [60]. In several of the reviewed studies, injured workers reported experiencing the medical assessment process as hostile and accusatory and questioned the independence of the examiners who they felt demonstrated judgemental, damning and biased attitudes [46, 48, 50, 55, 56, 58]. Injured workers also noted a difference in medical opinion between insurer-employed medical assessors, and their own treating practitioners [47, 48, 50, 56, 58]. Some injured workers described the ‘independent medical examination’ experience as one which could be painful and stressful, both physically and emotionally. Medical assessments were frequently problematic; on occasions the medical investigation was superficial, at other times it caused the worker to experience pain or flare-ups of their injury [46, 48–52, 56, 57]. In eight of the studies [46, 48–52, 56, 57], injured workers reported that they had to attend multiple medical examinations. Other injured workers stated that when they

Diagnosis and treatment difficulties

Non-therapeutic encounters

System intrusion on HCP-IW relationship

Legitimacy

Themes

x

x

Time delays—for approvals and appointments

IW not receiving needed support

x x

IW seeking effective treatment

medical uncertainty and injury complexity

X

X

x

X

x

Discrimination by examiner

x

x x

x

x

X

x

x

X

x

x

X

Cromie et al. [48]

IME process hostile and accusatory

x

X

x

x

X

x

X

Cacciacarro and Kirsh [47]

IME reports incorrect

HCP and IME conflicting opinions

x

X

x

Cost and geographic access to HCP

Multiple examinations

x

IW being viewed as uncooperative or resistant

IW afraid to confide in/ question HCP

x

HCP bias against workers compensation claimants

X

x

Not being believed by HCP

HCP role conflictprovider/reporter/ decision-maker

x

X

Beardwood et al. [46]

References

Stigma and stereotyping by HCP

Key concepts

x

X

x

x

x

X

x

X

Hubertsson et al. [49]

x

x

X

x

x

x

x

X

x

X

Jaye and Fitzgerald [50]

Table 2 Health care provider and injured worker interactions—themes and key concepts

x

x

X

x

X

x

x

x

x

x

X

x

X

Kosny et al. [51]

x

X

x

x

x

x

x

X

x

X

Lippel et al. [52]

x

X

x

x

X

x

X

MacEachen et al. [53]

x

x

x

X

MacEachen et al. [54]

x

X

x

X

Murray [55]

x

x

X

x

x

x

x

x

X

x

X

x

x

X

Reid et al. [56]

x

X

x

x

X

x

x

x

X

x

X

Roberts – Yates [57]

x

x

X

x

X

x

x

X

Strunin and Boden [58]

5

6

8

4

4

4

5

8

11

3

3

3

5

5

6

7

11

8

8

12

Totals

J Occup Rehabil

123

123

2

5

x

x x

X X X

x

The capital ‘X’ refers to the number of articles that are included in the theme, whilst the lowercase ‘x’ refers to the articles that are included in the key concepts

x HCP validated workrelatedness and IW concerns

HCP healthcare provider, IW injured worker, IME independant medical examination

X

x x

X

Respect and understanding by HCP Therapeutic encounters

Beardwood et al. [46]

Key concepts Themes

Table 2 continued

References

Cacciacarro and Kirsh [47]

Cromie et al. [48]

Hubertsson et al. [49]

Jaye and Fitzgerald [50]

Kosny et al. [51]

Lippel et al. [52]

MacEachen et al. [53]

MacEachen et al. [54]

Murray [55]

Reid et al. [56]

Roberts – Yates [57]

Strunin and Boden [58]

5

Totals

J Occup Rehabil

obtained medical assessment reports, they found independent medical examiners had made spurious statements about causal relationships between the injury and the injured workers’ body shapes or weight, or how injury provided a ‘secondary gain’ via the avoidance of domestic, marital or maternal roles [46, 48, 56]. In other reports, examiners had drawn conclusions that were outside the independent medical examiner’s area of expertise, for example where physicians stated that injuries were psychologically-based but the ‘expert’ had no training in psychology [48, 50, 56, 57]. In some instances, injured workers left the compensation system rather than attend further medical assessments due to these negative experiences [48]. On occasions, injured workers had to travel considerable distances for medical assessment by an insurer-employed medical expert, and then found they waited lengthy periods in uncomfortable waiting rooms [50, 51, 56]. Lengthy travel and waiting times could result in the injured worker presenting for assessment in greater pain and with a less cooperative attitude which further fuelled the independent medical examiner’s view that the injured worker may be overstating the impact of the injury or was malingering. Injured workers were suspicious of insurer motives, and suspected that cost-containment reasoning was behind sending them to out of town medical experts [50]. Diagnosis and Treatment Difficulties A consequence of having multiple examinations was that the worker often received multiple opinions as to the cause or appropriate treatment for their injury. Obtaining a clear diagnosis was important for several reasons. For the worker, a clear diagnosis prevented worry and anxiety and allowed them to focus on treatment and adjust more quickly to their injury and return to work. A straightforward diagnosis also enabled the insurer to make an expedient judgement about the injured worker’s eligibility for benefits and facilitated quicker approval of surgery and treatments. A clear diagnosis assisted the multiple health care providers that could be involved in an injured worker’s rehabilitation to determine appropriate treatments, and provide consistent advice about recovery and estimates of capacity to return to work. Six of the studies [46, 50, 51, 53, 56, 57] reported that injured workers resorted to their own networks, using word-of-mouth recommendations from other injured workers or unions, in order to find HCPs that could provide a clear diagnosis and effective treatment, or to obtain medical reports to refute the diagnoses given by insureremployed medical assessors. However, this did not always serve to simplify their situation. Injured workers received conflicting medical opinions as healthcare practitioners

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were uncertain about the diagnosis, or doctors stuck to their medical opinions regardless of the symptoms workers reported, even if the symptoms were in direct contradiction with their diagnosis [46, 48, 50, 51, 56]. Injured workers who were desperate to recover and return to their pre-injury life sometimes tolerated inappropriate treatments that were painful, could exacerbate their injuries, or proved to be ineffective [46, 51, 56]. Therapeutic Encounters In contrast to the difficult interactions between injured workers and HCPs that were described in previous themes, injured workers reported positive and helpful relationships with HCPs in five of the reviewed studies [47, 49, 52, 56, 57]. Positive interactions were characterised by HCPs who demonstrated respect for the injured worker and their individual needs, or offered help and guidance in negotiating the system [47, 49, 52, 56, 57]. Although reported less frequently, injured workers placed great emphasis on the support provided by HCPs. Injured workers described feelings of relief when HCPs validated the work-relatedness of their injury, or gave reassurance and normalised their concerns [47, 56]. Healthcare Provider and Insurer Interactions The relationship between HCPs and workers’ compensation insurers was addressed in ten of the reviewed studies [46, 48, 50–55, 57, 58]. As well as canvassing injured workers’ opinions, three studies included peer helpers and/or service providers, legal representatives and workers’ compensation staff [51, 52, 54]. This dynamic was worthy of consideration as the consequences of these interactions influenced not only how the injured worker related to both parties, but also the services that that the injured worker received. Three main themes associated with the interactions between HCPs and insurers were identified and are illustrated in Table 3. Two of the themes revolve around the relationship between HCPs and insurers and the organizational demands placed on HCPs by insurers. The third theme relates to possible ways of improving relations between HCPs and insurers. The issues identified below refer to the concerns of HCPs who provide services to workers’ compensation clients and do not reflect the experiences of HCPs who act as independent medical examiners or medical experts employed directly by the insurer organisations. Adversarial Relations The theme of adversarial relations occurred across nine of the studies [46, 50–55, 57, 58]. The major cause, reported

in seven of the studies [46, 51, 53–55, 57, 58] was that HCPs disliked providing services within the workers’ compensation system, because their professional expertise and treatment advice for injured workers was often ignored by claims managers. In some cases, claims managers challenged the professional opinions of the HCPs by sending injured workers to other medical assessors to obtain reports to contest diagnoses or treatment recommendations [46, 50–52, 54]. Healthcare providers were further frustrated by claims managers who were not medically trained yet ignored professional recommendations, and advised injured workers to return to work too early [46, 51, 53, 58], or directed the medical treatment of the injured worker by refusing prescribed medications if they were not on approved lists. Denials or delays [52, 54] could render the HCP’s treatment less effective and lead to injury chronicity—something that could have potentially been avoided had appropriate treatment been approved earlier. In response, some HCPs became exasperated with the workers’ compensation system and cooperation between insurers and HCPs suffered [51, 54, 57, 58]. Organisational Pressures Healthcare practitioners were frustrated by insurers’ lack of understanding concerning the pressures of their work. Healthcare providers understood that insurers needed information to determine the injured worker’s status and treatment requirements. However, claims managers seemed to have an unrealistic expectation that HCPs were readily available to discuss cases or complete detailed reports without adequate recompense for their time [46, 50, 51, 53, 54, 57]. Administrative requests conflicted with other competing clinical demands that HCPs faced, and so could result in tardy or inadequately completed forms and reports [46, 51, 54, 57]. Some of the studies noted that insurers paid lower fees for HCPs to provide services to injured workers and for some practitioners this meant 50 % lower fees [51] than they could command when treating non-compensable clients. Cessation of funding for services [58] at short notice by insurers showed little regard for HCP’s treatment plans and were further disincentive to provide services to compensable patients. Four of the studies noted that HCPs lacked knowledge about how the workers’ compensation system functioned and of the expectations of insurers [48, 50, 51, 54]. The lack of knowledge of legislation and insurer requirements translated into uncertainty for HCPs about their role. It was sometimes unclear to HCPs if their role was to be a therapist, patient advocate, assessor, or decision-maker. Healthcare practitioners also struggled with administrative

123

123

Review of remuneration and simplification of admin demands

Communication and education

low fees or nil recompense for services x

X

x

HCP not completing forms accurately or promptly

HCP lack of knowledge of system or INS expectations

x

HCP find admin demands onerous

X

x

INS contest HCP opinions

Lack of co-operation btw HCP and INS

x

X

Beardwood et al. [46]

References

INS ignore HCP expertise and treatment recommendations

Key concepts Cacciacarro and Kirsh [47]

x

X

x

X

Cromie et al. [48]

Hubertsson et al. [49]

x

x

X

x

X

Jaye and Fitzgerald [50]

x

x

X

x

x

x

x

X

x

x

x

X

Kosny et al. [51]

x

X

Lippel et al. [52]

x

X

x

X

MacEachen et al. [53]

x

x

X

x

x

x

x

X

x

x

x

X

MacEachen et al. [54]

The capital ‘X’ refers to the number of articles that are included in the theme, whilst the lowercase ‘x’ refers to the articles that are included in the key concepts

HCP healthcare provider, IW injured worker, IME independant medical examination

Improving relations btw HCP and IP

Organisational pressures

Adversarial relations

Themes

Table 3 Health care provider and insurer interactions—themes and key concepts

x

X

Murray [55]

Reid et al. [56]

x

X

x

x

X

x

x

X

Roberts –Yates [57]

x

X

x

x

X

Strunin and Boden [58]

2

5

5

3

4

4

6

8

4

5

7

9

Totals

J Occup Rehabil

J Occup Rehabil

aspects of practice, being unclear about what and how much information was required to adequately document injury details and complete medical reports [46, 51, 54, 57].

Improving Relations Between Healthcare Providers and Insurers Almost half the review studies generated suggestions as to how the working relationship between HCPs and insurers could be improved. These ideas fell into two broad categories. First, it was suggested that improvements could be achieved through increasing the communication between the parties by improving education about the system and respective roles [46, 48, 51, 54, 57]. A number of the studies proposed that a helpful step would be to have more regular communication between the parties with a focus on increasing dialogue about compensation system requirements in relation to insurers’ decision-making processes, especially for complex claims. Other recommendations were for insurers to elaborate, to HCPs and injured workers, the type and amount of information required [51] and highlight how important detailed accurate reports were in the decision-making process [54]. Secondly, it was suggested that by improving remuneration and simplifying administrative demands HCPs would be more likely to engage proactively with the workers’ compensation system [51, 54]. It was recommended that HCPs should receive payments equal to fees they obtained for services to non-compensable patients. Rather than depend on the goodwill of HCPs, insurers should provide appropriate remuneration for them to be involved in case discussions. A further suggestion that would effectively reduce administrative demands (and thus reduce service costs) was for HCPs to provide reports less frequently for longer term and medically stable clients [51].

Discussion Medical and rehabilitation services are essential for injured workers, and HCPs can have considerable impact on an injured worker’s recovery as they are involved throughout the process. The roles that HCPs perform in compensation systems are numerous and complex, with competing demands made on them from both injured workers and insurers. Perhaps unwittingly, HCPs can play both a healing and harming role in injured workers’ recovery. In the studies in this review, HCPs functioned as ‘healers’ when providing respectful patient-centred therapy; demonstrating interest and understanding, providing explanations

for injured workers’ health concerns and validating the work-relatedness of the injury. Provision of guidance on injury management strategies, and practical support from HCPs to assist injured workers to negotiate the compensation system and expedite treatment, were important therapeutic components. The review findings support existing studies that suggest these characteristics are important attributes of HCPs that positively influence an injured worker’s recovery and return to work [24, 27, 61, 62]. Studies of HCP-patient relationships in non-compensable settings have also highlighted the importance of patientcentred approaches and the therapeutic relationship. Whilst it is recognised that research in non-compensable settings provides little insight into the influence of workers’ compensation insurers’ presence on HCP behaviour, such studies may provide a context that assists with interpretation of the present findings. Supportive and empowering relationships have been linked with positive experiences of rehabilitation for clients with non-work-related health issues [63]. A systematic review of studies regarding physician-patient communication in primary health care settings found that verbal behaviours of physicians including; patient-centred behaviour, empathy, courtesy, friendliness, reassurance and support, explanation giving, and positive reinforcement of patient actions, were linked with patient satisfaction, compliance, comprehension and perception of a good interpersonal relationship. Participatory decision-making was considered vital, as patients who were involved in this process had better health outcomes [64]. It is equally important to understand the challenging and unsatisfactory interactions that may occur between HCPs and injured workers, as research suggests that negative encounters can have a detrimental influence on the health and wellbeing of the injured person [65]. In this review, injured workers reported occasions where HCPs also functioned in a harming role. Injured workers described instances where HCPs provided poor service by ignoring their concerns or queries and rushing consultations, or failing to submit necessary medical reports in a timely fashion. These negative interactions could have long lasting consequences. Injured workers could lose entitlements for medical and rehabilitation services or income benefits, creating financial difficulties for their entire family [66] and adding stress and anxiety to physical illness [42]. Healthcare providers may develop negative attitudes towards patients who fail to improve or to whom they can provide little help and assistance [67]. Distrust and lack of belief from a HCP is damaging as it feeds the individual’s sense of injustice and feeling of having been wronged [65]. This can compound the psychological stress that injured workers endure as a result of the stereotyping and suspicion that they face from insurers and other sections of the community [17, 42, 66].

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Perhaps the clearest example from this review of how HCPs can act in a harming role is through the ‘independent medical examination’ process. Injured workers in the review studies described difficult, distrusting and unhelpful interactions with HCPs during sometimes painful medical examinations. Examinations requested by the insurer and conducted by an insurer-employed medical expert are a type of interaction that has no therapeutic intent and where the HCP has no healing role [16]. The medical expert can influence whether or not a claim is accepted, or can deny or confirm that the injured worker has an ‘injury or illness’ which affords the injured worker a socially acceptable ‘sick role’ [16–18]. As injured workers are particularly vulnerable during the independent medical assessment process, the iatrogenic potential of the process is worthy of consideration by medical examiners who conduct the examinations [17, 18, 23], as well as by insurers who receive and implement medical report recommendations. Insurers also intrude in the therapeutic relationship between injured workers and treating HCPs, by requesting independent medical assessments to evaluate the recovery progress of the injured worker. Such assessments seem to challenge both the injured worker and the healthcare practitioner [60]. The underlying assumption seems to be that insurers consider that injured workers are fraudulent or malingering [18, 42] and healthcare practitioners collude with them by reporting the exaggerated symptoms in order to provide more services [60]. As a result of multiple assessments, the injured worker’s vulnerability can be exacerbated [18] and the healthcare practitioner may become frustrated and less cooperative with the insurer. Contradictory opinions from insurer employed medical experts could cast doubt on the adequacy of the treating HCPs approach and thus undermine the injured worker’s confidence in their therapist. The therapeutic relationship can become tainted and the recovery progress of the injured worker may be stalled. Interactions between insurers and HCPs are important as they can influence the willingness of healthcare practitioners to engage with compensable systems. Healthcare providers’ disillusionment with organisational aspects of the compensation system (lower fees, payment delays, high administrative demands, interference in treatment, and contesting medical opinions) meant that some HCPs refused to see compensation claimants at all. Having fewer HCP’s who were willing to work in compensable systems could mean injured workers may be required to travel further to access providers who have less expertise and experience with treating work-related injuries. Injured workers who consult inexperienced HCPs may find that necessary documentation is not adequately completed and lose entitlements to income or medical benefits as a result. A reduction in the availability of skilled and experienced

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HCP’s could effectively serve as an impediment to recovery for injured workers. Studies that considered the job satisfaction of physicians in non-compensable settings found that less administrative demands, higher job autonomy and enhanced social supports were predictors of greater satisfaction [68, 69]. It was suggested that administrative changes that give physicians more control over how they work and provide better social support would most likely improve physician morale and performance [69]. Other similar studies in non-compensable settings that have investigated the influence of physicians’ job satisfaction on patient outcomes in general practice noted the importance of physicians’ job satisfaction and lower work stress in promoting patients’ psychological well-being [70]. How clinicians feel about their work can influence whether patients carry out instructions and physicians’ job satisfaction is linked with patient actions that are critical to the management of their chronic diseases [70]. Thus it is probable that HCPs dissatisfaction with compensation systems will have implications for recovery and return to work outcomes for injured workers. This review demonstrates that interactions between injured workers, HCPs and insurers are complex and interrelated. The third party relationship with insurer as funder of medical services, by definition necessitates some influence over the provision and evaluation of those services. It is the methods used by insurers to facilitate such services, and the corresponding impact on HCPs and injured workers that require further consideration. Strengths and Limitations Strengths of this review included the systematic selection of the review studies by researchers who together had extensive knowledge of international workers’ compensation systems, delivery of healthcare services to injured workers, and qualitative research. Analysis of the interactions between HCPs and injured workers separately from those between HCPs and insurers, allowed for clearer presentation of the findings. In turn, this enabled a line of argument to emerge about how actions of the insurer influence the provision of healthcare services and can influence the therapeutic relationship, contributing to significant psychosocial consequences for the injured worker. A cautious approach to generalization of these findings to other nations and jurisdictions may be warranted as limited studies from Europe (one jurisdiction), the United States (two jurisdictions), three out of seven Australian jurisdictions, and four of the possible 13 provincial jurisdictions from Canada were represented in the review. Injured workers and HCP’s experiences in Asian countries have not been considered and could reveal other cultural factors which are important mediators within workers’

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compensation systems. Also, as all reviewers read English, only articles published in English were included in the review. A further limitation of this review is that it was not possible to differentiate between the various medical and allied health disciplines, except when injured workers clearly referred to an insurer-employed independent medical examiner or company doctor versus a treating HCP. Injured workers may have been more satisfied with their HCPs than this review suggests as it is not possible to ascertain if injured workers were asked directly about positive experiences with HCPs since not all reviewed studies included the questions asked in participant interviews. Likewise, only a few of the review studies included interviews with HCPs and workers compensation staff, and as a result many observations about HCPs and insurer interactions stem from peer helpers, legal advisers and injured workers. Accordingly, further information about the interactions between these parties could be obtained from research with specific groups of HCPs. For example, it would be interesting to identify whether there were differing experiences for physiotherapists, or occupational therapists or psychologists in their interactions with workers’ compensation insurers or with injured workers. The influence of these interactions on job satisfaction amongst different HCP groups could also be examined. Different HCP groups may also have varied opinions regarding initiatives to improve relations between key parties in compensation systems. Such information may allow for better methods of service provision tailored to the needs of specific injury groups.

Conclusion This review demonstrates that in many instances, injured workers with long-term complex injuries experience difficulties when receiving health services in the context of workers’ compensation systems. Findings in this review support existing research that indicates that supportive patient-centred interaction with HCPs is important for injured workers’ recovery. Healthcare providers experience problematic interactions with insurers, and injured workers bear the brunt of HCPs’ frustrations as some HCPs offer poorer quality service or refuse to treat compensable clients as a result. In the review studies, independent medical examinations were a source of contention for both injured workers and HCPs and likely exert an influence on the therapeutic relationship. Studies in non-compensable settings have demonstrated the importance of patient-centred care and physician job satisfaction for psychological wellbeing and improved treatment adherence and health

outcomes for patients. It is likely that the same factors could influence injured workers recovery. It would be in the interests of compensation authorities to address ways to improve interactions between insurers and HCPs and review regulations that govern this relationship. Reduction of organisational pressures and improving communications between insurers and service providers could result in increased job satisfaction for HCPs and ensure that providers are more amenable to operating in compensation systems. Benefits from improved HCP participation and job satisfaction is more than likely to have a corresponding positive influence on injured workers’ recovery and return to work. Acknowledgments The project was funded by WorkSafe Victoria, the Transport Accident Commission and Monash University, Victoria, Australia. The authors wish to thank Dr. E MacEachen for the use of quality appraisal and data extraction proforma previously developed for a systematic review of qualitative literature on return to work. The project No FS-M-11-029 was funded by WorkSafe Victoria and the Transport Accident Commission, (TAC) Victoria, Australia. ISCRR is a joint initiative of TAC, WorkSafe Victoria and Monash University.

Appendix Quality Assessment Questions The questions from the quality assessment framework developed by Spencer [44] and modified by MacEachen [40] were reordered to fit the focus of the review. Each question was rated out of five using the suggested underlying quality guidelines. Questions 1 and 2 were regarded as important screening indicators. If reviewers did not score the first two questions at 2 or above, the assessment was not continued as it was evident that the article was not of sufficient relevance to be included in the review. 1.

2.

3. 4. 5. 6. 7. 8.

How has knowledge/understanding of interactions between key parties in workers’ compensation systems been extended by the research? Scope for drawing wider inference about interactions between key parties in workers’ compensation systems—how well is this explained? How well does the study address the original aims and purpose? How credible are the findings? How defensible is the research design? How well defended is the sample design/target selection of cases? Sample composition/case inclusion—how well is coverage described? How well was the data collection carried out?

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9. 10. 11. 12. 13. 14. 15. 16. 17.

How adequately has the research process been documented? How well was the approach to/formulation of the analysis conveyed? Contexts of data sources—how well are they retained/ portrayed? How well has diversity of perspective and content been explored? How well has detail, depth and richness of data been conveyed? How clear are the links between data, interpretation and conclusions? How clear and coherent is the reporting? How clear are the assumptions/theoretical perspectives/values that shaped form and output of the study? What evidence is there of attention to ethical issues?

The question excluded in this modified version was ‘‘How clear is the basis of evaluative appraisal?’’ which applies only to evaluation research. Rating Calculation Guidelines Each of the quality assessment questions were rated out of five and scores were then totalled to achieve the overall rating of the article. An overall score was calculated for the article and levels of quality were assigned as; Very low (0–15), Low (16–30), Medium (31–55) High (56–70) Very high (71–85). The questions included in each section, and the possible maximum scores for each section are listed below;

Question

Category

1–4

Findings

20

5–7

Design and sample

15

8–9

Data collection

10

10–13 14

Analysis Auditability

20 5

15

Reporting

5

16

Reflexivity and neutrality

5

17

Ethics Total score

Rated score

Maximum score

5 85

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Healing or harming? Healthcare provider interactions with injured workers and insurers in workers' compensation systems.

Healthcare providers (HCPs) are influential in the injured worker's recovery process and fulfil many roles in the delivery of health services. Interac...
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