RTW and ACC in New Zealand – RTW Matters Analysis

This just in from RTW Matters – Dr Mary Wyatt analyses the New Zealand RTW Monitor results and makes her predictions about whether, in the light of financial pressures and declining RTW rates, NZ  is in for a RTW thaw or a snap freeze.  It’s available only for subscribers, but here’s a brief summary… (oh and subscription isn’t much in financial terms but packs a punch in information terms!)

  • RTW rates are declining in both New Zealand and Australia
  • ACC indicates that this is because of ‘a number of factors, including the ageing population, the increasing complexity of claims, and claims management inefficiencies. The resulting impact has meant that clients are staying on the Scheme longer and costing more.’

As an aside, I wonder how it can be that claims are becoming more complex?  Can someone enlighten me?  Certainly I don’t see this in pain management: people with chronic pain are, almost by definition, complex, and this has not changed on iota in the 20 years I’ve been working in pain mangement.  The only significant changes I’ve seen are that fewer people are attending for pain management with multiple surgeries, and more people are referred slightly earlier than the previous pain duration of 3.5 years.

  • The focus of the Government for ACC is cost containment
  • The ACC has taken the common scheme approach of dealing with financial problems by trying to moving long-term claimants out of the scheme.  Long term claimants are the most costly part of any scheme, and removing them is the most cost-effective ways to deal with cost blowouts.
  • Mary Wyatt points out that one strategy used by ACC to do this is the increasing use of FCE to ‘predict’ whether someone can return to work.  As she says, ‘As a tool to define a person is having a work capacity and therefore no longer being eligible for scheme payments, they may be an effective, however this does not mean they are valid.  Moving people on from the system after a few years is basically declaring a failure of rehabilitation.  If they are capable of returning to the workforce at that point, why haven’t they done so earlier?’

I’d mitigate this last statement by saying that because of legislation, economy and fear, amongst other reasons, people who are ‘fit to work’ in some capacity may not always obtain employment, hence the ‘work testing’ or ‘vocational independence assessment’ that ACC conducts in New Zealand.  The intention of the legislation is not ‘return to work’ but ‘return to work readiness’.  The end of rehabilitation assessment is a slightly different approach from some areas of the world and consists of:

(1) a review of the assessment recommendations that have been made over the course of the claim to establish whether all rehabilitative efforts have been completed

(2) a vocational assessment that details the work options a person may be able to do given ‘education, training and experience’ – without considering functional ability

(3) a medical assessment that reviews the medical status of the person and, in collaboration with the person reviews the various work options to establish whether he or she can sustain ’35 hours or more’ in any of them

For those unfamiliar with New Zealand legislation, there is no ability to litigate for personal physical injury, as ACC provides 24 hour ‘no-fault’ cover forpersonal physical injury for all people whether working or not, funded by levies from employers, employees and various other taxes.  It was first introduced to New Zealand in 1974, and has continued to be a model for many commentators on accident compensation.

It’s difficult to establish why rehabilitation ‘performance’ appears to be less effective than previously.  I can only observe that management of claims is often fragmented, that multiple treatment providers are often involved with quite contradictory aims, that contracts for services to claimants appears very prescriptive and often clumsy, and that case management can be quite different depending on the individual case manager working on a claim.  Perhaps one factor could be the increased use of ‘multidisciplinary’ pain management but using teams of clinicians who rarely meet, may not have any specific education, training or experience in pain management, and who’s membership changes often, and within a programme framework that may be ‘pain management lite’ – or less than the recommended 50 – 100 hours of consolidated input (Main, Sullivan & Watson, 2008).

Back to RTW matters – as a taster, take a look at the free information available, and make your own mind up about its value.

Main, C., Sullivan, M.,  & Watson, P.  (2008). Pain Management: practical applications of the biopsychosocial perspective in clinical and occupational settings. 2nd Ed. Churchill Livingstone, Elsevier, Philadelphia.

Faking and malingering (again!)

One of the most popular posts I’ve written on this blog concerns ‘faking’ or ‘malingering’. I’m curious about this, because even though I have been asked many times whether I have had patients that are ‘faking’, I don’t think about it very often myself. I suppose it is a subject that is dear to the heart of anyone who is concerned about ‘motivation’ – especially where entitlements to payment or other benefits are dependent on the authenticity of the person’s claim to be unable to function.

So, time to unpack the whole topic again I think.

Last time I posted I had trouble finding relevant literature – the main problem being that in academic publications where pain is being discussed, the concept of faking has been superceded by research into areas we can work with clinically. The role of determining whether malingering or faking is not one for clinicians: it properly lives within the realm of private investigators – and even then, findings are up for challenge when a person is observed behaving in one way in one setting and another in a different setting. There are so many things that influence behaviour that it’s simplistic to decide that motivation to intentionally deceive is the primary reason.

If we start with the idea that pain itself is an experience – something we can’t share with each other, in the same way we can’t share whether we see the colour blue in the same way as each other, or the taste of banana! So you and I can’t tell just how much pain any person is in.

What we depend on is behaviour – what the person actually does behaviourally when they experience pain. And you and I know that we do different things in different places even when we experience the same pain! Take the example of stubbing your toe – in your garage you’ll probably swear loudly and jump up and down. In a very quiet church? Well, we probably won’t be able to hear your swearing and your jumping might be replaced with a wince…

In another example: if someone asked you to run 200m, you might take off at a bit of a gallop, but I’ll bet that if you knew there was a large and very angry bull coming after you, you might just move a little faster!

So we know that the social environment influences pain behaviour, and we also know that beliefs about the consequences of action also influence behaviour. We know too that what people understand about the significance of their pain is also a factor that changes behaviour. If you are unaware that the tickling feeling down your leg is actually a large and venomous spider biting you, you may well ignore it, if you think the vaguely tender lump under your armpit is cancer you’ll probably pay good attention to it and ask for a medical opinion. And your reaction to this lump might be even greater if you’ve had a history of cancer in your family.

In the compensation situation, there is no doubt that the security of receiving a weekly payment can be very helpful in the initial stages of recovery from an injury. That security can become problematic when the person is being asked to undertake the relatively risky business of returning to work – What if returning to work fails? What if my pain gets so bad that I can’t keep going? What if I let my employer down?

Some of these very realistic fears can interfere with the readiness for someone to return to work – and yes, compensation means it can easier to remain in status quo than to attempt to return to work. Does this equal malingering? Is the person faking? Or would you and I feel very much the same, and be quite hesitant to risk our health and livelihood too?

Can we as health professionals ‘tell’ whether someone is intentionally faking?

The short answer is no – humans are very poor at telling whether someone is lying. That’s why movies are so successful – even though we know the people are ‘actors’!

Take a look at this clip from You Tube:

And this one:

and the truth?

For another good article on deception – if a bit cognitive – this newly published article review the latest and greatest on the art of detecting deception. It’s just too early to apply this to pain and malingering.

SIP, K., ROEPSTORFF, A., MCGREGOR, W., FRITH, C. (2008). Detecting deception: the scope and limits. Trends in Cognitive Sciences, 12(2), 48-53. DOI: 10.1016/j.tics.2007.11.008