A Crisis of Trust
Trust in the medical system has long been a fragile commodity in workers’ compensation. Unlike private healthcare, where patients select their providers and develop long-term relationships with physicians, injured workers often find themselves assigned to doctors they do not know and may not trust. This lack of choice, combined with the perception that medical providers serve the interests of employers and insurers rather than the patient, creates an environment of skepticism.
The COVID-19 pandemic accelerated a broader decline in trust in medical institutions across America. Public skepticism of health agencies, vaccines, and government mandates helped fuel a crisis of confidence that has further eroded trust in medical professionals. This loss of trust extends beyond general healthcare and is deeply relevant to the workers’ compensation system, where trust was already a scarce resource.
A recent article in The Economist (January 28, 2025) highlighted how COVID-19 deepened institutional distrust, particularly in medical and public health authorities. The study noted that trust in science, government, and healthcare institutions fell sharply, with partisan divides exacerbating the problem. These trends mirror the challenges faced in workers’ compensation, where trust in medical professionals was already low, and skepticism of medical decision-making continues to hinder effective claims resolution.
Pre-Existing Trust Deficit in Workers’ Compensation
The workers’ compensation medical system has long been plagued by a pre-existing trust deficit, with concerns about fairness, transparency, and quality of care at its core. This deficit is influenced by several key factors, including:
- Perceived Conflicts of Interest: Injured workers often believe doctors are more aligned with employers and insurance companies than patient well-being. The requirement for treating physicians to comply with utilization review processes further fosters suspicion.
- Lack of Choice in Medical Providers: Unlike in traditional healthcare, where patients can choose their provider, many workers’ compensation systems restrict provider selection, reinforcing the perception that treatment decisions are made for cost containment rather than care quality. However, this varies by state. Some states, such as New York and Washington, do not allow the employer to make any recommendations on the treating physician. Others permit a mix, where the employee can pre-select a treating physician before an injury occurs, and some states allow the employer full authority to assign a provider. Understanding these nuances is critical when discussing provider trust in the system. Studies have shown that doctors experienced in treating work-related injuries achieve better outcomes than those with less experience in this area.
- Inconsistent Medical Outcomes: The variability in medical evaluations, particularly in Independent Medical Examinations (IMEs) and Qualified Medical Evaluations (QMEs), makes injured workers distrust medical findings and recommendations.
- Delays in Treatment Approval: Workers’ compensation systems often involve bureaucratic delays in approving necessary treatments, leading to frustration and distrust among injured workers.
- Skepticism of Early Return-to-Work Programs: Many believe doctors in the workers’ compensation system return injured employees to work too early, exposing them to further injury. Kinesiophobia (an unrealistic fear of re-injury) helps drive this skepticism. However, studies have consistently shown that structured early return-to-work programs, including light or modified duty, reduce disability durations and lower the risk of permanent residual impairments. The disconnect between perception and evidence exacerbates the trust gap between unions, employers, and medical providers.
- More Treatment is Better: In today’s world, most people believe that “more is better.” This is a closely held belief with medical care. The reality of medical care is that more is not always better. This is one reason that California put in evidence-based treatment guidelines. When doctors want to treat more than evidence-based treatment guidelines and then complain to the injured worker about the lack of approvals, it furthers the distrust of the workers’ compensation system.
COVID-19 and the Acceleration of Medical Distrust
The COVID-19 pandemic further eroded confidence in medical professionals in several key ways:
- Inconsistent and Conflicting Medical Guidance: Just as shifting public health recommendations during COVID created public skepticism, frequent discrepancies between treating physicians, IMEs, and insurance medical reviews exacerbate distrust in workers’ compensation.
- Politicization of Medical Advice: The pandemic made trust in medical professionals a politically charged issue. Trust in treating physicians versus employer-selected medical evaluators in workers’ compensation often aligns with a worker-versus-employer mentality.
- Concerns About Financial Incentives: The skepticism developed around pharmaceutical companies and vaccine mandates mirrors injured workers’ concerns about doctors making return-to-work decisions based on financial incentives rather than medical necessity.
The Impact on Workers’ Compensation Medical-Legal Outcomes
The increasing mistrust in medical professionals affects workers’ compensation in several ways:
- Resistance to Medical Recommendations: Injured workers are more likely to question prescribed treatment plans, seek additional opinions, or outright reject medical advice, believing the system is working against them.
- Increased Litigation and Delayed Recovery: Skepticism of treating physicians and IMEs leads to more legal disputes, legal fights over who may provide treatment, extended disability durations, and higher costs for employers and insurers. Significant delays in return to work can impact the ability of the worker to return to any work. Loss of a job is both an economic and physical disaster for the injured worker.
- Reduced Compliance with Return-to-Work Plans: Just as vaccine hesitancy became widespread due to mistrust in medical institutions, injured workers may be less likely to comply with return-to-work plans recommended by workers’ compensation doctors.
The Unique Role of Compensability in Medical Trust
One key difference between workers’ compensation and general healthcare is the requirement for compensability determinations. Unlike group health insurance, which focuses on medical treatment, workers’ compensation requires a finding that the injury is work-related. Workers’ compensation also involves determination of the ability to return to work and in what capacity.
- Why It Matters: Injured workers often see compensability disputes as a sign that the system is trying to deny their care rather than assess whether the injury is truly work-related. This perception fuels distrust.
- Impact on Trust: When medical determinations are intertwined with legal and financial considerations, injured workers may view their treating doctors skeptically, believing that economic interests, rather than patient well-being, drive decisions.
- Solution: Greater transparency in explaining compensability determinations can help workers understand why care is approved or denied, reducing feelings of injustice.
Addressing Kinesiophobia and Trust in Medical Care
Another major factor affecting trust in the workers’ compensation system is kinesiophobia, or the fear of pain associated with movement, or fear of re-injury, which can significantly impact recovery. Research has shown that injured workers who fear re-injury are more likely to resist return-to-work programs, prolonging disability durations, and increasing skepticism of medical recommendations.
Engaging Injured Workers with Coaching or a Nurse Case Manager
A successful approach to overcoming skepticism and resistance is engaging the injured worker with a dedicated coach or a nurse case manager who can help navigate the treatment process.
- Personalized Guidance: A coach acts as a bridge between the injured worker and the medical system, explaining treatment plans, clarifying expectations, and addressing concerns in real time. I call this “translating doctor to English.”
- Advocacy and Support: The coach provides reassurance, ensures workers understand their rights and responsibilities, and helps them adhere to prescribed treatments.
- Engagement and Compliance: Workers who feel supported are more likely to follow through with medical appointments, physical therapy, and return-to-work plans, leading to better recovery outcomes.
- Early Issue Resolution: A coach can identify barriers to recovery—whether medical, psychological, or logistical—before they escalate into more significant problems that delay the return to work.
- Trust Reinforcement: By having a reliable point of contact who prioritizes their well-being, injured workers develop greater trust in the system and are less likely to perceive adversarial intentions.
Conclusion
It is in the worker’s best interest to receive quality medical care. It is also in the employer’s best interest to provide quality and timely care because this is the ideal formula to obtain optimum results with the lowest cost of the claim. Quality, timely care is the magic formula to optimize medical outcomes and reduce claims costs.
Trust in medical institutions has eroded across all healthcare sectors, and workers’ compensation is no exception. The existing trust deficit in workers’ compensation, compounded by the pandemic’s lasting effects, has led to increased skepticism of medical evaluations, prolonged litigation, and poorer outcomes for injured workers. By implementing transparency measures, standardizing medical decision-making, and enhancing patient engagement through coaching, the workers’ compensation industry can begin to rebuild trust and improve outcomes in the system.
