Valuable new research on how the distinct workers’ compensation systems in Quebec and Ontario affect doctors in their various roles was presented to a packed room at the Spring 2015 session of the Bancroft Institute Discussion and Policy series held last week at the University of Toronto.
Authors Katherine Lippel (Faculty of Law, University of Toronto), Joan Eakin (Dalla Lana School of Public Health, University of Toronto), Linn Holness (St Michael’s Hospital; Dept. of Medicine, University of Toronto), Dana Howse (Dalla Lana School of Public Health, University of Toronto) provided a variety of perspectives on “How Characteristics of Workers’ Compensation Systems Affect Doctors: A Comparative Study of Québec and Ontario.”
The study originated from RAACWI research pointing to different responses of injured workers in Ontario and those in Quebec towards doctors, raising the question of what in the system could explain this difference. Researchers used both quantitative data from an analysis of the literature (and its context), and qualitative data from a series of interviews and focus groups with physicians.
Thursday’s presentation focused mainly on the aspect of the study related to doctors’ gatekeeping role in opening or closing the pathway to benefits and access to health care. Although in both provinces the compensation board has the last word on causation or work-relatedness and entitlement, one key difference is in the weight given to the role of the treating doctor. Whereas Ontario physicians often reported feeling their opinions are ignored by the WSIB, Quebec law since 1985 has made the treating doctor’s opinion binding on the Board (CSST) in regard not only to diagnosis and treatment, but also evaluation of permanent impairment, functional limitations, and maximum medical recovery. While this has the advantage of giving the injured worker faster access to healthcare, challenges to this medical opinion, by Board, employer or worker, require a formal appeal or contestation process in Quebec (unlike in Ontario) with potentially costly third-party medical opinions.
In discussing their findings, the researchers emphasized the need for a good understanding of the specific compensation system in its broader context (“jurisdiction matters”) and an awareness that doctors are not a monolithic entity, nor do they always play an equivalent role in the Ontario and Quebec systems. Their position, profession and function (treating doctor, specialist, “independent medical expert” (IME), insurers’ or employer doctor, Board doctor…) may affect diagnosis and their own experiences and response to involvement with workers’ compensation. Another key factor raised was the role of money operating differently upon doctors’ experiences; for example, provincial differences in billing and funding may provide incentives or disincentives for accepting workers’ compensation cases, or an “industry of contestation” provide a lucrative income for the expert writing evaluations.
The researchers also brought a sociological understanding to the “social location” occupied by the treating doctor in relation to workers’ compensation and their highly charged role (socially, politically and emotionally). Among common concerns discussed by doctors: complying with prevailing societal notions of protecting the public purse, tensions between a gatekeeping role and physician-patient relationship; dealing with an overly bureaucratic claims process while receiving little feedback; impact of the requirement for “objective medical evidence” on unnecessary testing.
The presentation addressed not only how physicians view the system but also how injured workers see doctors and the importance of the evaluative report. Injured workers Will Noiles and Daniela Ruiz added input from their personal experiences.
Appreciative feedback and commentary on the research study was provided by panelists Catherine Fenech (ONIWG), David Chezzi (CUPE national WSIB representative; OHCOW Chair), Laura Lunansky (IWC) and Mortimer Mamelak (Dept. of Psychiatry, University of Toronto). Issues raised included worker right to see the report of the IME, inappropriate demands for access to the doctor’s clinical notes and their potential (mis)interpretation. Dr Mamelak noted, in reference to workers’ compensation economics, that poverty (compounded by the stress of poverty) is today’s most serious disease. The morning session concluded with a lively open discussion between the audience and researchers on the study’s findings.