Workers’ Compensation Issues of Concern, Clinical
Significance and Enhancing Healthcare Team Outcomes

Introduction

Work-related injuries are a significant cause of disability and death. Therefore, the Workers’ Compensation system compensates employees for workplace injuries and illnesses. As a result, laws require the responsibility of employers to cover most of the expenses related to the injury or illness, regardless of fault.

Each state in the United States enforces its own compensation system. Federal Workers’ Compensation laws cover federal employees. All states mandate the following primary benefits within a compensation system.

• Lost wage replacement for temporary total disability.

   

• Support for an employee’s dependents in the event of death.

   

• Monetary compensation for medical, hospital, and death benefits.

However, monetary compensation is reduced, typically a percentage of an employee’s average weekly wage at the time of disability or limited to work restrictions, depending on each state. In addition, employees usually have a waiting period before monetary payments begin. An impairment percentage due to the injury or illness, a scheduled loss determines the income benefits, such as losing a limb.

Issues of Concern

Workers’ Compensation is typically a no-fault system, and the employer is immune from further legal action. However, workplace accidents, injuries, and illnesses restrict benefits, as determined by each state’s compensability. In addition, all states identify work-related illness responsibilities.

Examining workplace illnesses may become complex and multifactorial regarding exposure onset to the appearance of symptoms, insidious onset, and multiple causation issues. Therefore, Workers’ Compensation is a legal system, not a medical system. The courts within the system specify the language and issues and administer benefits through the state board commission.

The Workers’ Compensation provider must identify occupational health and exposure history, including positions, exposures, employee and coworker symptoms, non-work exposures, tobacco smoke, lead exposure, water supply, diet, pets, and home cleaning agents. The insurance adjuster, employer, or case manager may define work-relatedness as requested by the non-occupationally health-treating physician, either specialist or general practitioner, to address workplace questions.

In addition, the concept of maximum medical improvement or maximum medical recovery may need identification for the physician to determine the greatest employee recovery where no further treatment would significantly improve the medical outcome. Finally, common disagreements may arise regarding the disability degree, readiness to return to work, and if the condition occurred in the workplace.

Managed care concepts, fee schedules, or treatment guidelines may monitor medical treatment usage and customary charges. As a result, state statute identifies the choice of medical treatment. However, some states utilize a provider panel to control care, while some provide a free choice of providers.

The employer can choose a provider, possibly referred to as an independent medical examination of a non-treating physician, examines the employee, and decides on the following:

• General health condition

   

• Work status

   

• Physical abilities recommendations

   

• Length of work absence

   

• Current and future treatment recommendations

   

• Work condition relationship, either aggravated or developed to work conditions, and maximum medical improvement estimation

An employee unable to work or unaccommodated with restrictions will receive a category for disability payments following:

• Temporary total disability (TTD): An employee can not return to any continuous work due to a workplace injury or illness.

   

• Temporary partial disability (TPD): An employee continues to receive medical treatment for a workplace injury or illness but may return with restrictions or work in a lower-paying position than the pre-injury position.

   

• Permanent total disability (PTD): A permanent and entirely incapacitating condition causes paid leave because the employee may never perform work responsibilities.

   

• Permanent partial disability (PPD): An employee loses body parts, or the condition is unlikely to improve, causing a possible decreased wage-earning ability.

State statutes identify an employee’s income based on specific losses or disfigurement, such as conditions affecting the limb or eye. However, a percentage of injury or illness impairment determines monetary benefits, either temporary or permanent.

The Workers’ Compensation system typically does not include awards for pain and suffering. In addition, states will have a statute of limitations to file a Workers’ Compensation claim, filing within a specified timeframe, such as the time after the accident, learning of the diagnosis, or when symptoms appear.

Recovery and rehabilitation injury barriers include cases such as:

• Prolonged treatment

   

• Complex injury conditions develop after the initial injury

   

• A longer recovery that exceeds disability guidelines

   

• A minor type of injury that develops a prolonged disability

   

• Multiple treating physicians, therapists, and other practitioners

   

• Comorbidities

   

• Absent incentives, either financial or psychosocial, for medical compliance and returning to work

Clinical Significance

Occupational diseases with multiple causes may become challenging to identify and determine specific causes. For example, some occupational diseases may not develop for years after exposure or occur due to extended hazard exposure. In addition, cumulative disorders include hearing loss, carpal tunnel syndrome, and chronic back pain.

The legal standard consists of a review of evidence preponderance to determine work-relatedness when multiple causes are present. An evidence preponderance review determines that workplace exposure likely caused or aggravated the illness.

Enhancing Healthcare Team Outcomes

Interprofessional healthcare members must financially and clinically acknowledge the Workers’ Compensation system, including specialists, mid-level practitioners, nurses, pharmacists, and physical and occupational therapists. In addition, the healthcare team must balance the employment modifications and ensure sufficient recovery.