A warehouse worker with a simple back strain waits 3 weeks for physiotherapy approval. An MRI (‘to be thorough’) shows normal age-related changes, described as ‘multilevel degeneration’. 6 months later, the worker is on opioids, avoiding movement and nowhere near work. The original injury healed months ago. What remains is iatrogenic — complications we contributed to.

Most people recover within expected timeframes and their healthcare is appropriate. However, for many workers compensable healthcare inadvertently compounds their difficulties rather than resolving them—with profound consequences for recovery.

The evidence we can no longer ignore

The evidence documenting these patterns exists across randomised trials, cohort studies and scheme data. What's needed is collective recognition of what this means for the people navigating our systems. Consider these key findings:

• Use of scans: A review of multiple high-quality studies show that getting an early MRI for acute low back pain without sound medical reasons leads to 2–4 times higher risk of work disability compared to those who don't receive early imaging. [1–4] 
• Surgery outcomes: Compensable patients have 4 times the odds of poor surgical outcomes than non-compensable cases. Same surgeons, same procedures, notably different results. [5] 
• Opioid prescribing: Many injured workers receive opioids early in their claim (around one-fifth to one-third, depending on the cohort and study). Early high risk opioid prescribing is linked with persistent opioid use and longer claims. [6,7]
• Treatment delays: Treatment delays are common in compensation settings, and longer waits are associated with poorer outcomes, including prolonged disability. Victorian program data and VIWOS highlight the burden and impacts of delays. [8]

These aren't just statistics. Behind each number is someone whose recovery we've complicated, whose confidence we've undermined, whose return to normal life we've delayed. Families under financial stress. Relationships breaking down. Young workers whose careers never recover.

Not everyone. But enough to matter.

Most injured workers receive appropriate care and recover well. Most return to work within expected timeframes. Many GPs and specialists provide excellent, evidence-based treatment despite system pressures.

But for a significant minority — perhaps 20-30% of cases — healthcare becomes part of the problem rather than the solution. These cases consume disproportionate resources, drive scheme costs and represent most of the human suffering in our systems. They are the claims that extend for years, the lives that don’t return to normal, the costs that compound.

How we got here. And why it matters more than ever.

Healthcare in compensation operates under unique pressures. Time-poor GPs manage complex paperwork alongside clinical care. Standard 15-minute consultations must cover assessment, certification, work capacity and compensation requirements. Under this pressure, it's quicker to order a scan than explain why one isn't needed. Easier to prescribe than to discuss non-pharmacological options. Faster to refer than to coordinate recovery.

The system rewards activity over outcomes. We fund procedures, prescriptions and appointments but barely support the time-intensive work of explanation, reassurance and activation.

Fee-for-service arrangements incentivise volume. More scans. More procedures. More prescriptions. More appointments. Each intervention seems reasonable in isolation. Together, they create cascades of harm.

Language compounds the problem. Imaging reports describe ‘degeneration’ and ‘tears’ without age-prevalence context. These words create unnecessary concern. A 45-year-old told their spine shows ‘multilevel degeneration’ hears decay and damage, not normal ageing. They become cautious about movement. Worry increases. Concern drives requests for more opinions, more treatments, anything that might ‘fix’ the damage.

Meanwhile, administrative processes add delays at every step. Approvals stall. Assessments accumulate. Trust erodes between the worker, employer, GP and insurer. Workers report feeling under scrutiny, their pain questioned, their credibility doubted. These experiences influence clinical encounters — more distress, more symptoms, more treatment pursued.

The workplace can become an additional challenge. RTW meetings may feel difficult. Modified duties aren't always available or offered. Supervisors, frustrated by delays, may question the injury's impact. The worker, already anxious and medically focused, interprets every discomfort as evidence they're not ready.

There is a complexity mismatch between the needs of workers’ compensation and the realities of primary care.

Medicine is under unprecedented pressure. GP shortages mean less time per patient. Many experienced GPs now avoid compensation cases entirely, citing poor outcomes and administrative burden. Specialists increasingly opt out. Access narrows precisely when complexity rises.

The human cost in complex cases

Victorian data shows that by year 3 of a claim, depression rates are notably elevated. But we don't need 3 years to see concerning patterns. Within months, we can observe people shifting from someone with a sore back or shoulder to someone who identifies primarily through their injury.

They learn to emphasise their symptoms for assessments. To focus on incapacity for fear of being disbelieved. To avoid movement that might cause setbacks.
Sleep quality declines. Mood deteriorates. Pain becomes increasingly central to daily life.

For their families, it means financial pressure, role reversals and children witnessing a parent's decline. Relationships fracture under the strain. Adolescents in these households show higher rates of distress. The ripple effects extend far beyond the original injury.

This is the pattern we see in complex cases. Not through malice or incompetence, but through systems and processes that can compound rather than resolve the challenges of injury.

Why this series matters now

For decades, we've discussed these problems informally. We've shared experiences, expressed concern and then moved on to other priorities. But the challenges are intensifying. The pressures on the medical workforce are growing. Administrative complexity is increasing. Digital systems that promised efficiency often add layers of process without improving outcomes.

And the evidence base has matured. We can now quantify what's happening and measure the impact. We can trace the pathways from an unnecessary scan to prolonged disability, from early opioid to long-term dependence, from delayed approval to chronic pain.

This introductory article kicks off a fortnightly series on RTWMatters.org produced in partnership between RTWMatters and It Pays to Care. Each article will examine a specific aspect of how healthcare delivery can inadvertently complicate recovery in workers' compensation.

It will explore these topics:

• How imaging creates disability where none existed.
• Why opioid prescribing patterns in compensation predict poor outcomes.
• How administrative delays become clinical complications.
• What happens when young workers enter these pathways.
• Why assessment processes become barriers to recovery.
• How workplace interactions amplify or resolve medical messages.
• The role of health literacy in recovery trajectories.
• How lack of trust shapes clinical decisions and defensive practice.

Other topics will emerge to respond to the evolving discussion and feedback from the sector.

The conversation we need to have

This is not about blame. Every player in the system — clinicians, insurers, regulators, employers, rehabilitation providers — operates under constraints and competing pressures. We're all trying to help. Yet collectively, the ecosystem can produce unintended harm for vulnerable workers.

The opportunity is real, but only if we examine these patterns together. Some problems lie in healthcare, some in claims management, some in bureaucracy, and many at the intersection of work injury schemes and healthcare delivery.

We need scheme managers asking hard questions about approval processes. Clinicians examining their role in perpetuating cascades. Employers understanding how workplace interactions affect clinical outcomes. Regulators considering how policy drives practice.

Most importantly, we need to move beyond acknowledging problems to actively addressing them. The human and financial costs are too high to continue with business as usual.

What happens next

This topic series will inform presentations at 2 key conferences: WorkCover WA in September and the Personal Injury Education Foundation conference in Sydney in October.

We're not proposing solutions. Before we can act effectively, we need to see these patterns clearly and acknowledge their impact. We need these issues to be visible, discussed and recognised as priorities that require collective attention. Only with that foundation can we build the coordinated response these challenges demand.

The question isn't whether healthcare in workers' compensation can cause harm. The evidence is clear. The human and financial costs are documented. Behind the statistics are real people whose recovery has been harmed by systems designed to help them and our collective inability to address known problems.

The question is whether we'll continue to accept these outcomes or use what we know to create genuine change.

The next article will examine how early imaging drives disability in workers' compensation, with evidence from randomised trials and cohort studies showing consistent patterns of harm.

References

1. Graves JM, Fulton Kehoe D, Jarvik JG, Franklin GM. Early imaging for acute low back pain: impact on one year outcomes. Spine (Phila Pa 1976). 2012;37(18):1617 1627.
2. Webster BS, Bauer AZ, Choi Y, Cifuentes M, Pransky GS. Iatrogenic consequences of early MRI in acute, work related, disabling low back pain. Spine (Phila Pa 1976). 2013;38(22):1939 1946.
3. Shraim M, Al Omari B, Elgamal B. Association between early MRI and length of disability in acute low back pain: a systematic review. BMC Musculoskelet Disord. 2021;22:983.
4. Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low back pain: systematic review and meta analysis. Lancet. 2009;373(9662):463 472.
5. Harris IA, Mulford J, Solomon M, van Gelder J, Young J. Association between compensation status and outcome after surgery: a meta analysis. JAMA. 2005;293(13):1644 1652.
6. Berecki Gisolf J, Collie A, McClure RJ. Prescription opioids for occupational injury: results from workers’ compensation claims records. Pain Med. 2014;15(9):1549 1557.
7. Tefera YG, Gray SE, Nielsen S, Di Donato MF, Collie A. Early high risk opioid prescribing and persistent opioid use in Australian workers with workers’ compensation claims for back and neck musculoskeletal disorders or injuries: a retrospective cohort study. CNS Drugs. 2025;39(5):499 512.
8. Collie A, Lane TJ, Hassani Mahmooei B, et al. Victorian Injured Worker Outcomes Study Part 1: Health, Work and System Experiences. Melbourne: Monash University/ISCRR; 2019.