APPENDIX
Appendix Table 1 Summary of results from semi-structured interviews
Section Key points
Theory 1 – Income support system role in funding healthcare
− Should work in theory, probably does not in practice
− Fee schedules are too limiting, do not always offer evidence-based care, and when they do practitioners might not adhere to guidelines anyway
− In a private healthcare system, good providers might opt out of care if fee schedules are too low
− Fee schedules could also be used to reduce inequalities between subgroups Theory 2 – Income support
system demands on healthcare providers
− Volume of paperwork required by workers’ compensation systems and a lack of decision-making authority were flagged as disincentives for healthcare providers to engage the system
− This would not affect healthcare quality though Theory 3 – Employer choice
of healthcare provider
− Agreement that this might work in US
− While the theory might hold, the employer is likely to focus on reducing wage replacement time and not healthcare quality
− Employers have little to no say in healthcare in some jurisdictions Theory 4 – Employer
incentives
− Financial incentive could be good, but warned against over-estimating the effect it might have
− Incentives are not based around worker recovery and functional capacity past what is required to return to work
− Experts suggested that functional capacity might not be the right outcome for this theory
− There may be a lack of incentive or motivation for employers to be involved in worker recovery in the UK, as the state handles all wage replacement
− This theory would hold, but there are changes in local legislation that might allow employers to ‘tick the boxes’ until they could remove an injured worker
Theory 5 – Income support system impact on the worker
− All experts agreed with this theory
− Experts suggested that longer wait times and a worker perception that they have to prove their injury is real, or feeling unsupported, questioned, or tested by the system, healthcare provider, or employer, leads to worse functional and recovery outcomes
How do income support systems impact healthcare quality?
− The perception that workers need to prove that they are injured can lead them needing to feel ‘sicker’ and seek more aggressive treatment and diagnostics to prove their pain and have it documented
− Specific characteristics of income support systems, such as the use of Independent Medical Examiners may lead to negative outcomes
How do income support systems impact functional capacity?
− Some disorders might be more ‘credible’ than others; LBP tends to carry more stigma, residual pain issues, and diagnostic uncertainty that can make it frustrating for workers
Other − More benevolent a wage replacement system, the less motivating it is to seek functional improvement
Commented [KJ1]:
Section Key points
− There has been a shift in the US toward lump sum payments to reduce long-term, sometimes indefinite, claim liability
− It was also noted that a substantial volume of workers’ compensation claims in the US may now be
investigated by private investigators, and that it was commonplace for a worker with a low back pain claim to be filmed and this may have a negative impact on functional capacity and recovery
