Does access to compensation have an impact on recovery outcomes after injury?

To the Editor: A recent article by O’Donnell and colleagues1 claimed contradictory results to a previous study which found that compensation was associated with worse health and return-to-work outcomes after injury.2 Their findings were similar to those of the previous study until they excluded a group of non-compensable patients because they had accessed private health insurance. The authors argued that “private health insurance was similar to other compensation agencies in that patients in this group had their health care costs met”. Using this argument, all patients would be compensable, as Australia has a universal health care system in which all Australians have their health care costs met. There is no precedent in the literature for such an exclusion. Compensation bodies provide additional payments beyond health costs, including payment for pain and suffering and income replacement. They also involve patients in a complex process with many features thought to influence outcomes (eg, the adversarial nature of making compensation claims and delays in receiving payments). We believe that the exclusion of private patients from the non-compensable group in the study by O’Donnell et al was incorrect and reduced the already small study sample, limiting the capacity to identify differences across groups.

Furthermore, O’Donnell and colleagues found that compensable patients had higher anxiety levels at 24 months, until a supplementary analysis showed that, after controlling for stressful interactions with compensation agencies, compensation itself became non-significant. Surely stressful interactions are one of the mechanisms by which any compensation effect might be mediated. To say that an association is not significant once the mechanism of the effect is allowed for is akin to stating that smoking is not carcinogenic once the carcinogens are allowed for. O’Donnell and colleagues appear to be stating that simple access to compensation is not harmful, with which we agree, but fail to consider the complexities of compensation involvement.

Both studies1,2 share a common limitation — that of comparing victims of transport-related injury with victims of other injury types. A recent study confirmed compensation and lawyer involvement as predictors of worse outcomes in a study of compensable and non-compensable transport-related trauma.3 A true understanding of the effect of compensation requires comparison of patients of comparable injury circumstances (eg, road trauma) and different compensation systems. Studies are clearly needed to establish a better understanding of the complexities of compensation delivery and the impact on outcomes. O’Donnell and colleagues’ conclusions have the potential to mislead compensation authorities and other stakeholders who should be focused on addressing this issue.