Price for patients of no-cost compensation
A significant proportion of non-compensable medical consultations are bulk billed, that is the government pays the whole cost of the consultation.
However, most doctors charge patients more than the government has agreed to rebate. Medicare pays the bulk of the bill, with the patient chipping in a co-payment. This may be a small amount, such as five dollars, or a more significant amount, depending on the individual doctor and the level of specialisation.
Not so with workers’ compensation, where the bills for medical and other health consultations typically bypass the patient. The invoice for the consultation is generally sent either to the employer, or directly to the insurer.
Thinking about how this might affect rehabilitation outcomes, I’m reminded of an interesting shift that occurred in Victoria in the late eighties.
In 1986, the Victorian government changed the rules relating to compensation payments for car accidents, making the patient responsible for the first $400 or so of medical expenses.
At the time I was working as a GP. Patients would have a car accident, develop a sore neck, and someone would suggest they should go to the doctor for a check-up. Caring health professionals, me included, would then try to do something for the patient. A sore neck would become a diagnosis of whiplash, and since that diagnosis required treatment, we would send them off for physiotherapy.
When the rules changed, and patients became responsible for initial treatment costs, whiplash claims in Victoria dropped by 90%. (Claims for whiplash have remained much the same in other states.) People stopped coming to the doctor as they had to pay, and they quickly judged it was not needed. If they did go to the doctor and were referred to physio, they may not have gone at all, or they may have gone a few times. Few people went enough to reach the threshold of $400.
Was this a change for the better, or worse?
We know that whiplash problems will abate with time whether the patient has treatment or not. The best approach is to let the patient know this will occur and encourage them to remain active and do normal activities.
Once people start having treatment, there is a more formal focus on the condition. People are often advised to restrict activity, and the whole life cycle of observing a problem, treating a problem, and an increased focus on the problem begins. In turn, this can perpetuate the problem.
What lessons can the workers’ compensation system learn from Victoria’s experiences? Should compensation patients pay a component of the medical costs?
The obvious downside to such an approach is that the patient may be on a low income, and the costs can mount up.
However, there are significant upsides.
If we all had free milk there would no doubt be a greater amount of milk going to waste in our fridges. If you're not paying for something, it's common and normal human nature that less care is taken with the item.
If patients have to dip into their pocket, even for a small amount such as $2.50, they start to assess the value of what they’re getting for there money. If they are responsible for some of the costs of treatment, they may begin asking important questions. Is it making a difference? How long will it continue? Should something else be done?
I believe that over-treatment would be less likely to occur.
Patients would place more value on the treatment, and are more likely to be active participants in treatment recommendations.
As a consequence they would be less likely to be a passive recipient of the system, and more likely to follow through on recommendations.
And in turn, they may well achieve better outcomes.
Published 31 October, 2010