Workplace injuries are a major cause of disability and death. The workers' compensation system was developed to provide compensation to workers for work-related injuries and illnesses. Workers' compensation laws delegate that employers assume most of the costs related to work-related illnesses and injuries, regardless of fault. In the United States, each state mandates its own system for compensation. Federal employees are covered by federal workers' compensation laws. The following are the basic benefits that are included in the compensation systems of all states:
- Income replacement for temporary total disability
- Dependent support for employee death
- Payment for medical, hospital, and death benefits.
Income replacement is usually at a reduced rate as determined by the state, often based on a percentage of the employee's average weekly wage when the worker has a disability or is not accommodated at work with restrictions. The employee may have a waiting period before payments begin. Income benefits can be based upon a percentage of impairment resulting from the injury or illness or a schedule related to a specific loss, such as the loss of a limb.
Issues of Concern
Usually, workers' compensation is a no-fault system. When providing workers' compensation benefits, the employer is usually immune from further legal action. Each state usually defines compensability, but in general, the benefits are limited to accidents, injuries, and illnesses "which arise out of and in the course of employment." All states recognize responsibilities for work-related illnesses. Identifying work-related illnesses can be complex and multifactorial due to the onset from exposure to onset of illness/symptoms, insidious onset, and multiple causation issues. Workers' compensation is a legal system rather than a medical system. Courts within a territory interpret the workers' compensation language and issues, and usually, compensation is administered by the state commission or board level.
The provider must be adept at gathering occupational health and exposure history. The history may include all jobs held, exposures, symptoms, symptoms among co-workers, nonwork exposures, tobacco smoke exposure, lead exposure, water supply, diet, pets, and home cleaning products. The treating physician may be asked to identify work-relatedness by the insurance adjuster, employer, or case manager, so the non-occupationally health-trained physician, either specialist or general practitioner, may refer/request an occupational and environmental health boarded physician address work-related questions. Another common question asked by adjusters, employers, and case managers is the concept of maximum medical improvement or maximum medical recovery in which the treating physician opines the employee has recovered from the injury at a level at which the provider states no further treatment will significantly change the outcome of the medical condition. Often disagreements occur regarding the degree of disability, readiness to return to work, and if the condition is work-related.
Many states utilize managed care concepts, fee schedules, and/or treatment guidelines to monitor the usage of medical treatment for usual and customary charges. State statute determines the choice of medical care. Some states allow the employer to control care via a provider panel, while others allow the employee free choice of providers. The employer has the right to have the employee examined by a physician of their choice, which may be referred to as an independent medical examination in which a non-treating physician evaluates the employee and provides an opinion regarding:
- General health condition
- Work status
- Recommendations for physical abilities
- Length of time to be unable to work
- Recommendation for current and future treatment
- Relationship of the condition to work and if the condition was aggravated or developed due to conditions at work, and estimation of maximum medical improvement.
The employee that is unable to work or is not accommodated due to restrictions is provided with disability payments which are categorized as:
- Temporary total disability (TTD): the employee is unable to return to any continuous gainful employment due to an occupational illness or injury.
- Temporary partial disability (TPD): the employee is still under medical treatment for the work injury or illness but can return to work which has restrictions, or he/she is working at a lower-paying position than the pre-injury position
- Permanent total disability (PTD): this is paid when the employee has a condition in which is permanent and completely incapacitates the employee, so the employee is not able ever to perform gainful employment for the rest of their life.
- Permanent partial disability (PPD): this condition results in the loss of body parts or lasting impairment that is estimated to be unlikely to improve, and there is a potential decrease in wage-earning ability.
Most states have statutes to provide income based upon specific losses (e.g., a limb, eye) or disfigurement. Employees receive income benefits based on a percentage of impairment resulting from injury or illness, which may be temporary or permanent. Usually, pain and suffering issues are not part of the worker's compensation system awards. All states have a statute of limitations for filing worker's compensation claims, which can be related to filing within a time frame after the accident or learning of the diagnosis or when the disease becomes symptomatic.
Injury cases that demonstrate barriers to recovery and rehabilitation include:
- Prolonged treatment
- Development of complex injury conditions after initial injury
- longer-than-expected recovery exceeding disability guidelines
- Prolonged disability from a minor type injury
- Multiple treating physicians, therapists, other practitioners
- Lack of incentive (usually financial or psychosocial) to comply with medical treatment and return to work.
Occupational diseases can be difficult to identify as work-related, as a disease can have multiple causes, and it can be difficult to determine which specific factors "caused" the disease. In some instances, occupational diseases do not develop until years after exposure. Some occupational injuries occur as a result of extended exposure to a hazard. Examples of cumulative disorders include hearing loss, carpal tunnel syndrome, and chronic low back pain. For cases in which multiple causes are present, occupational and personal health, the legal standard is to review the preponderance of the evidence to determine work-relatedness or not. The preponderance of the evidence means that it is more likely than not that the illness was caused by, aggravated by, or hastened by workplace exposure.
Enhancing Healthcare Team Outcomes
Healthcare providers across the entire interprofessional team need to at least be familiar with the workers' compensation system, both from a financial as well as a clinical point of view. This necessity runs across clinicians, specialists, mid-level practitioners, nurses, pharmacists, physical and occupational therapists. The need to return the patient to work while ensuring that their recovery is sufficient to do so, balanced against the needs for potential employment modifications, must always be in view.