New system permits a GP by-pass

By Martin Johnston

When workplace accident compensation is privatised next Thursday, another big change will be that all injury victims get a wide choice of who will treat them.

Doctors will lose their monopoly gatekeeper role and they are not happy about it. They and unionists are worried the profit motive introduces incentives for insurers to reach deals with pliable health workers to treat people cheaply and get them back to work too quickly - claims that are dismissed by the insurance industry.

Currently, only registered medical practitioners can file accident compensation claims. Patients are often referred to other treatment providers - such as physiotherapists - but they have to consult a doctor first.

From July 1, however, all claimants will be able to make their first call to any one of 14 types of health worker: a general practitioner, physiotherapist, chiropractor, nurse, occupational therapist, podiatrist, optometrist, laboratory technician, dentist, audiologist, osteopath, speech therapist, acupuncturist, or counsellor. However, only GPs can let patients have time off work.

"In many workplaces, there are industrial nurses who are fully able to be the first point of call," says a senior Labour Department official. "Rather than having to leave the workplace and go to a GP, this provides flexibility ..."

The department anticipates that private insurers will spend more on treatment and less on earnings compensation and that people will go back to work earlier.

"All the figures suggest that psychologically it's better to be back at work, even on light duties. The longer you stay at home the worse the outcome," the official says.

The fees that doctors can claim from the insurers, set by the Government, will remain at the $26 a consultation they receive now, but the whole range of fees will be reviewed. Most of the other "providers" will be able to claim $19, which is what physiotherapists currently receive for referred visits.

Doctors and physiotherapists warn they might impose surcharges on patients, blaming time-consuming extra form filling required by the work-place insurers, and ACC, which will handle only non-work claims.

ACC officials say that apart from the wider choice of first-contact health workers, claimants will notice little change in the new system. Workers will still be entitled to 80 per cent of their pay while off work.

Employers have to sign up with one of the seven private insurers, or the state-owned @Work Insurance. They have to tell their workers which insurer they have picked and make a copy of the contract available.

With follow-up treatments for non-acute injuries, the insurers have the power to require claimants to get their insurer's prior approval.

That may look like a veto but the Insurance Council says it is not.

"Insurers have the ability to ensure claimants are seeking appropriate treatment," says a council manager, Karlene Davis. "Insurers intend to work collaboratively with treatment providers ... to ensure that injured persons receive prompt, effective treatment that will allow them to achieve sustainable return to work."

But a Medical Association policy manager, Lesley Stockdale, says the private insurers "have not been transparent" on non-acute follow-ups and have failed to state what rules they will apply. Patients may be sent away until they get approval or may end up paying the full price of the consultation.

The association's chairwoman, Dr Pippa MacKay, is concerned that profit-driven private insurers may apply undue pressure on doctors "for other than the patient's best interests."

And she worries that having 14 first-line providers will increase the risk of incorrect diagnosis and treatment. GPs have the best medical overview, she says, denying that she is simply trying to protect doctors' traditional turf.

She cites osteopaths and acupuncturists, saying that unlike doctors they are not subject to medical misadventure claims. The association has also raised concerns over occupational health nurses having to make decisions about whether to refer patients to a GP.

A Nurses Organisation professional nursing adviser, Diana Gunn, says that is a "demeaning comment" as nurses know when they are competent to treat a patient and when to refer on.

Karlene Davis says there are no incentives to return claimants to work before they are ready. Going back too soon will increase re-injury rates and prolong periods of incapacity, and ultimately cost insurers more.

Claimants can expect more treatment and more help in getting back to work, she says. The council expects employers will choose insurers based on their track record in rehabilitation and case management.