Medical decisionmaking – who is in control?

When a clinical neurologist went public last year over dealings with the Nova Scotia WCB (CBC News Oct. 10, 2014) that she termed “appallingly disturbing”, she raised an issue that often confronts injured workers, leaving them “between a rock and a hard place”: either accept treatment recommended by Board-appointed doctors (who may not even have seen them first-hand) rather than the treatment recommended by their own physician, or have their benefits cut. A recent report in RankandFile.ca looked medical rehabilitation and health benefits for Ontario’s injured workers, with WSIB funds for doctor-recommended treatment being cut and those for Board-run assessment centres increased. “…The IWAJ [Injured Workers Action for Justice] claim that these assessment centres are known for predicting early recoveries and can facilitate the denial of claims, as well as a premature return to work….”

The use of “expected recovery times“, rather than assessment of the patient and his/her “actual and medically supported recovery” (Toronto Star, Feb. 4, 2015), is an issue of concern addressed in responses to the Board’s new draft policies on pre-existing conditions. As the IWC Backgrounder notes, “This denies injured workers compensation on the basis of an individualized assessment of their disability, a principle affirmed by the leading Supreme Court of Canada decision in Martin & Laseur ([2003] 2. S.C.R. 504 – the chronic pain case ).”

Just who is in charge of medical care and decision-making was one of the topics addressed in studies by the Institute for Work & Health and Australia’s Centre for Occupational and Environmental Health, and discussed at a recent Bancroft Institute meeting (see list of further reading below). South of the border, alarm has been raised over the mandated use of “evidence-based guidelines” for treatment and return to work. While not challenging the value of evidence-based clinical guidelines, a presentation to the American Academy of Orthopaedic Surgeons noted the issue is who writes them (many US states use the “Official Disability Guidelines” written by the private, insurance-funded Work Loss Data Institute or “ACOEM Practice Guidelines”) and how they are implemented:

No longer does the doctor have the presumption of being correct and the insurance company has to prove otherwise,” he said. “Now the guidelines are assumed to be correct and the doctor has to prove it otherwise.” ( Workers compensation system under attack: do treatment guidelines threaten the patient-physician relationship?” AAOS Now, Jan. 2014)

And among the destructive workers’ compensation developments outlined in the National Economic and Social Rights Initiative (NESRI) Oct. 2014 report – increasing employer control over workers’ medical treatment, more conditions excluded from coverage (and deemed due to pre-existing conditions, age… )

Further reading: