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 May 12, 2005
Worker's Comp Can Keep Injuries Lingering
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By E.J. Mundell, HealthDay Reporter

TUESDAY, April 5 (HealthDay News) -- It's a familiar story: An employee throws his back out at work, files for worker's compensation, receives a medical diagnosis, and then stays at home with self-reported symptoms that linger for months, or even years.

In most cases, the claims are legitimate, and the affected employee has suffered a disabling, chronic injury.

But a new "meta-analysis" of research from around the world suggests that, in many other instances, financial incentives influence patient outcomes.

In all but one of 211 studies, the presence of worker's comp or similar financial compensation was associated with negligible or much poorer patient outcomes after surgery, according to a study appearing in the April 6 issue of the Journal of the American Medical Association.

"Essentially, the worker is getting paid for being sick, and it's hard for anyone who's being paid to get sick to get well," said Dr. Robert H. Haralson, immediate past president of the American Academy of Disability Evaluating Physicians, and the current executive director for medical affairs at the American Academy of Orthopaedic Surgeons.

According to Haralson, who was not involved in the study, this phenomenon "has been known for years" among orthopedic surgeons treating such common, tough-to-diagnose workplace problems as back pain or carpal tunnel syndrome.

"It's very frustrating" for doctors, he said.

In their study, researchers led by Dr. Ian Harris of Liverpool Hospital, in Liverpool, Australia, combed through data from 211 studies from the United States, Australia, Europe the United Kingdom, and elsewhere.

Across all countries, they found, workers receiving financial compensation for on-the-job injuries were almost four times more likely to have poorer long-term medical outcomes than uncompensated workers.

So, are some injured workers simply exaggerating their symptoms and postponing their recovery?

That's the "64 billion dollar question," Harris said. But he believes most worker's comp recipients with lingering symptoms aren't consciously misrepresenting their misery.

"These patients believe themselves to be worse off, but what causes that belief poses another question," he said.

For example, Harris pointed to a well-studied cultural phenomenon called symptom expectation, whereby "car accident victims in the U.S. and Australia expect to get neck pain after their car accident, and they do."

In contrast, car accident victims in other countries and cultures seem to be not so afflicted with whiplash despite being involved in similar incidents.

Each injured, compensated worker faces various pressures to keep him ill, Harris added. Besides the financial incentive of compensation, endless rounds of medical tests and procedures can help convince injured workers they are, indeed, chronically ill.

Then there are the lawyers.

Studies have shown that, "in terms of medical procedures, disability duration or cost of the case, if a lawyer is involved, it's five times as expensive as if a lawyer is not involved," noted Dr. Edward Bernacki, director of occupational medicine at Johns Hopkins University School of Medicine, and past president of the American College of Occupational and Environmental Medicine.

"There's a few players now in the system -- a lot of attorneys -- that basically see this as a safe haven" to make money, he added.

Harris also believes that many physicians are too aggressive at turning routine workplace injuries into full-blown chronic "syndromes."

With the encouragement of lawyers and the compensation bureacracy, this may help create a system that "allows patients with minor complaints to be pulled into a spiraling process which reinforces and magnifies their symptoms at every turn," he said.

Haralson agreed physicians can do more to change the system.

"The most common problem in these situations is back pain, and there's good evidence that what you ought to do with back pain is head back to work within a couple of days -- even if you continue to have some pain," he said.

Back at work, the injured workers could initially avoid tasks that might exacerbate symptoms. The important thing, according to Haralson, is to keep injured workers from what he called the "disability cascade."

"Look, people enjoy being off work, and many people were doing jobs they didn't much enjoy in the first place," Haralson said.

Once doctors, lawyers and others confirm the idea of illness in the injured worker's mind, "it's just a natural human response to try and avoid that activity," he added.

"It's not that the patient lays awake at night thinking "OK, I'm going to go fool the doctor tomorrow,'" he said. "It's much more complicated, it's more of a natural human phenomenon."

Unfortunately, it's a phenomenon that's costing health-care systems and industries around the world millions of dollars.

Because of improved workplace safety, automation and other factors, "the actual injury rate in the U.S. has been dropping tremendously over the past 30 years," Bernacki said. "However, the cost of an average worker's comp claim is skyrocketing -- the medical portion increases 13 percent a year -- much greater than the medical rate of inflation of about 5 percent."

No one is suggesting that worker's compensation be scrapped, but Bernacki agrees that abuses and inefficiencies exist.

"In some jurisdictions, the worker's comp payment is greater than [the original] salary, and some states have lowered the amount of compensation, to keep it on par with salary replacement," he added. "It's a really tough problem. Quite frankly, the system often overcompensates for individuals that are not sick and undercompensates people who have severe problems."

More information

For the latest on connections between health and workplace productivity, head to the American College of Occupational and Environmental Medicine (www.acoem.org ).

SOURCES: Robert H. Haralson, M.D., executive director, medical affairs, American Academy of Orthopaedic Surgeons, and immediate past president, American Academy of Disability Evaluating Physicians; Edward Bernacki, M.D., M.P.H., director, division of occupational medicine, Johns Hopkins University School of Medicine, Baltimore, and past president, American College of Occupational and Environmental Medicine; Ian Harris, F.R.A.C.S., orthopedic department, Liverpool Hospital, Liverpool, New South Wales, Australia; April 6, 2005, Journal of the American Medical Association

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