Please Note: Although the following cases are based on real occurrences, information that may identify individuals associated with these cases have been changed in order to protect confidentiality.
May 19, 2016: Case 4: 35-year-old female with repetitive strain injury associated with data entry, computer and keyboard work. Taken off work due to pain and functional disability. She was treated by her doctor and a therapist for over 12 months and continued to struggle with work related tasks and could not stay at work. One year after initial treatment began, she was finally referred to a chiropractor. After only four weeks of treatment by her chiropractor she was symptom-free and back to her regular activities and is not currently missing any work.
Research consistently shows that when an evidence based approach is applied to the treatment of patients, the outcomes are better and cost is significantly reduced. (http://www.ncbi.nlm.nih.gov/pubmed/20889389) In this case, evidence based care would have put this patient in a chiropractor’s office directly after their injury or at least after a short course (3-4 weeks) of other therapies that may have been effective for this injury had not been successful. Instead, this patient and their employer were negatively affected for over a year due to the mismanagement of the claim and the refusal of WHSCC to embrace research based approaches that ensure that injured workers receive the best possible care in a timely manner.
Should WHSCC be held accountable to manage claims in the most effective and cost effective manner in order to save employers money and reduce lost productivity? Can health providers work effectively in a system where the necessity and character of care is determined by a business model rather than an evidence based health care model? How many Injured workers suffer at the hands of this outdated model of care every year? What is the annual cost to employers of this mismanagement?
May 18, 2016: Case 3: Injured worker presented to their chiropractor on May 18, 2016 for care related to an ongoing issue as the result of a work related injury. In the absence of written approval, the chiropractor has been instructed by WHSCC case manager that they must complete a lengthy form outlining the need for care despite the fact that this had been previously well established for this patient. The chiropractor was informed that they would not be reimbursed by WHSCC for the completion of this form and that they could not recover the cost associated with completing this form from the injured worker. Care could not be guaranteed to be approved until the case manager reviewed the information on the requested form causing further delays in care. In the absence of a commitment from WHSCC to reimburse the chiropractor for the reasonable cost of completing this form, as is done for other health care providers, and to guarantee approval of care in a timely manner, the chiropractor was unable to take time away from patient care in a busy clinic to complete this form. The injured worker is now told by WHSCC that she cannot access care because there is no approval.
What happens to this injured worker now that they cannot access their necessary care? Should the chiropractor treat if the patient is willing and able to cover costs associated with treatment? What are the ethical considerations when a chiropractor determines that care is necessary but WHSCC tells the chiropractor that, in the absence of approval, they cannot treat?
May 17, 2016 Case 2: In March 2016 patient presented to their chiropractor with RE-Occurance of a previous injury. Pt had chose their chiropractor as their primary health care provider for this case as the chiropractor had successfully resolved similar issues for them in the past. As the Primary Provider, the chiropractor should be the health care provider that primarily directs necessary care in relation to the injury.
As with all RE-Occurance of Injury it usually takes a week or 2 to render a decision from WHSCC. Under these circumstances, especially because the patient required immediate attention to reduce pain and remain at work, the pt had agreed that should WHSCC decide the case is not legitmate, the pt will cover the costs. Otherwise the patient would have had to stop work due to pain while awaiting approval. The pt had extensive treatment over 2 months which helped them remain at work. As the patient’s cost associated with care was continuing to rise, and still no correspondence from WHSCC with approval, the patient decided to end care at that time despite the fact that the condition was not fully resolved. Several weeks later the patient’s symptoms intensified once again and because there was still no decision from WHSCC (2 MONTHS LATER), The patient consulted their MD who referred the patient for a different form of treatment by another health professional . This care was approved 1 week later!!! and yet her initial claim that should have initiated the claim process, completed by the chiropractor, was still not approved.
2 weeks later the patient reappeared in the chiropractors office as the treatment recommended by their MD was not as effective as the care that had been administered by the patients chiropractor. After the patient explained the current situation to the chiropractor, a call was made to WHSCC and the chiropractor was informed that there was an over site on this claim and no one had looked at it until now. The chiropractor was informed that the claim would be approved only on a go forward basis, leaving this pt to pay the bill for care received up to this point. The chiropractor rebutted this statement by saying ” you just admitted WHSCC made a mistake and it is a legitimate claim, so why should this patient have to pay. The case manager advised that they would consult their superiors on this matter.
The next day the chiropractor received notification that the past treatment would still not be covered leaving the patient to pay for the costs associated with an injury that was confirmed to be in relation to a work related cause. The patient decided to appeal the decision by WHSCC to not pay for this care. After considerable effort this patient was informed that the cost of the previous care would be covered.
Was this case managed in a manner that promoted the best possible care of the injured worker? Were there unnecessary barriers that may have impacted this patient’s well being both physically and mentality? In a system that is supposed to be there to protect injured workers how can this continue to happen?
May 16, 2016- Case 1: 25 yr old patient awaiting approval of care since report sent by chiropractor 9 weeks ago. Patient has been under care previously and managed well when receiving treatment. Continuation of chiropractic treatment for management of pain and disability has also been recommended by medical specialist. Chiropractor informed that WHSCC will require another form to be completed and patient will have to wait for this to be reviewed for approval as initial form submission is now outdated. Should the chiropractor treat as they know is required or allow administrative delays at WHSCC to impact the health of this injured worker? Who is responsible to pay for care received? Is this patient still considered an injured worker in the absence of approved payment by WHSCC? Too many unanswered questions. Patient still waits for approval and suffers.