Indeed, some participants said they preferred not to treat or to treat only a small number of injured workers because of the loss in salary associated with treating this clientele. The low fees paid by WCBs also seemed to contribute to the stigmatization of injured workers since some participants identified them as patients who do not pay well. The dissatisfaction regarding WCB fees by clinic owners and managers in BC, Ontario and Quebec led to enforcement of certain policies by PT clinics, which are described in greater detail later in this article.
Administrative requirements regarding communication between physiotherapists and WCBs were a major topic of discussion. In all three provinces, WCBs require physiotherapists to complete standardized administrative reports that are sent to the WCB on a predetermined basis. The frequency and format of these communications vary greatly between provinces, and across these differences, a majority of participants explained that current ways of communication do not facilitate the provision of care for injured workers.
For example, several participants from Quebec said they believed their clinical reports completed every 3 weeks were not read by the WCB case managers. While probably a better communication between the case manager and the physio, in terms of progress report, would improve this link. Some suggested that this is the result of WCB case managers being too busy to read all the reports they receive. Several participants said they wished they could communicate with the WCB in a timely fashion and in more flexible ways e.
The lack of clarity about what to communicate to the WCB was also linked to communication policies. Some participants from all three provinces mentioned that they were uncertain what the WCB actually needed to know to adequately manage their cases and that the current forms are not effective for sharing information. Hence, participants mentioned the need for greater clarity in their interactions with WCBs to better respond to communication requirements.
They highlighted policies regarding treatment parameters and choice of professional e. Their influence was experienced as more constraining in private PT clinics compared to those in the public sector. In Ontario and BC, some participants reported that their employer the clinic owner set a maximum number of treatment sessions for the whole block-care or POC model because of financial considerations:.
So there are definitely clinics that are working to the monetary outcome, before the worker outcome. Hence, these participants explained they had no real choice about the number of sessions for these patients. A similar situation was discussed with regard to the length of each session. Other participants explained that after conducting the initial evaluation of a patient, their clinic required them to transfer injured workers to a PT assistant, PT technician or to a group therapy class led by a kinesiologist so that it would be more profitable for their clinic.
This was not the case for patients whose treatment was not covered by the WCB. A participant from Quebec explained:. In BC, one participant said her clinic only pays her on receivables and not on what is actually billed by the clinic.
With the new block-care model, she said she only gets paid around 6 weeks after the end of the treatment block, which creates financial insecurity. This concern was often discussed in relation to younger physiotherapists without an established clientele and who are usually the ones who treat injured workers:.
I am not at the stage where I am going to keep a patient just for the extra pennies it will bring me. Participants working in public clinical settings and those who are paid an annual salary did not express these concerns.
Participants also expressed their satisfaction with regards to their employers when they provided paid time during the week to complete paperwork and make phone calls. Most participants who said they were not provided with time for these tasks in their schedule chose to complete them during patient treatment time:. If my day is fully booked I have no spare time to do that but all these extra additional non-billable caseload management work has to be done before work, after work or in breaks, in my lunch.
So that makes a long work day so I wish my clinic paid me for that [ Participants who seemed dissatisfied with having to treat injured workers often worked in clinical settings that imposed more rules and tacit policies that resulted in treating injured workers differently than other patients. The physiotherapists, leaders and administrators whom we interviewed in BC, Ontario and Quebec identified many of these policies as hindering and limiting the provision of equal and quality care for injured workers.
In the same vein, the establishment of a therapy threshold for PT care within the US Medicare prospective payment system i. In Canada, physicians also reported that their ability to provide treatment they felt their patients required was impaired by the rigidity of WCB policies [ 17 ]. Discussions about ethical standards of practice and their importance in providing care to injured workers have also been recently discussed in the scientific literature [ 38 , 39 ] in an attempt to resolve certain problematic aspects of care.
Ethically, WCBs and PT clinics have fiduciary obligations to implement policies that support fairness and claimant dignity, and that avoid stigmatization and prevent discrimination toward injured workers [ 21 ]. As such, and in line with the commitments WCBs publicly make to provide high quality services [ 40 ] and fair benefits [ 41 , 42 ] to injured workers, they should fulfill these obligations.
Results from this study show that these obligations are far from being completely fulfilled at the moment. Low reimbursement rates for physiotherapists, burdensome treatment requirements and difficulty in communication can contribute to further stigmatization of a clientele that is already dealing with important difficulties: being sick, often not working and supported by a third party payer.
In that regard, several participants expressed being conflicted between what they are told to do and what they believe they should do, and most of them were uncomfortable when they witnessed practices which they viewed as discriminatory or inequitable.
Physiotherapists working with injured workers should have the opportunity to learn about the influence that formal or informal policies can have on their practice, including harmful effects. Fostering the adoption of a critical stance toward current ways of practising seems of utmost important for physiotherapists working with injured workers, but also for all professionals caring for this clientele [ 45 , 46 , 47 ].
Healthcare professionals should thus move from a circumscribed focus on patient treatment to become more attentive to the policy processes that shape their behaviours [ 48 ]. This awareness and reflexivity could help them advocate for changes to rules and policies at different levels.
Findings from our study also demonstrate that considerable work is needed to improve PT care for injured workers.
Some concrete solutions can be envisioned. Following the concept of clinical governance [ 49 ], it seems important that stakeholders involved in the process of care for injured workers, including physiotherapists, administrators or managers, insurers and politicians aim toward better integrating services for this clientele.
Policies found at the clinical level in this study were often established in reaction to problematic WCB state level policies. Policies at the WCB level are currently developed in political contexts, by politicised actors. According to participants, this process does not always involve stakeholders who have good knowledge of clinical realities in physiotherapy.
Policies that are detached from the clinical context have the potential to be regarded as less relevant and overly restrictive by health professionals [ 49 ]. Insuring that a variety of stakeholders with knowledge of the work disability field, including patient representatives, physiotherapists and work disability researchers, are able to inform the development or refinement of WCB policies regarding PT care might help address current challenges reported by the participants.
Long-term collaborations between PT associations and WCBs could also be initiated so that specific challenges could be better understood by both parties and concrete solutions, adapted to the policy context of each province, developed and implemented.
These policies thus push physiotherapists to account for realities of the workplace, a factor that has been shown to play a determining role in the return to work process after an injury [ 50 ] but has yet to be widely implemented in PT care [ 8 ]. Although these guidelines as for any practice guideline should not be used without clinical judgement and are mostly generic, they nonetheless provide up-to-date guidance on modalities that have been proven to be effective as well as those that are ineffective for certain types of injuries and are supported by a clear policy at the WCB level.
In addition, the Ontario WCB requires physiotherapists to use functional outcome measures adapted to each POC to evaluate the improvement of injured workers. Indeed, it has been shown that insurance providers can promote the use of best practices [ 51 ].
These initiatives are all good starting points in order to facilitate the alignment between best clinical requirements and policy measures at the organizational and state levels. As such, a promising area where clinical practice should meet state level mechanisms and policies relates to the need for feedback for healthcare professionals and clinics regarding the care they provide. Indeed, health professionals and health organisations need to receive feedback on their performance so they can evaluate their practices [ 52 ] and motivate them to improve.
BC WCB has recently implemented a policy to provide personalized feedback to each PT service provider by means of a confidential online report card. To our knowledge, Ontario and Quebec WCBs have no specific feedback or performance evaluation systems. The BC system should be studied and, if proven effective, its uptake should be encouraged more broadly.
Furthermore, this could also be applied to other healthcare provider services for injured workers. Over the course of the interviews, we observed that several participants were hesitant or refrained from discussing certain topics, despite being reassured regarding the steps that the research team would take to preserve their anonymity. Since the physiotherapy community of leaders and administrators with regards to injured workers in Canada is small, and because some potential participants expressed concern that they could be identified based on their demographic information, we did not collect these details.
Therefore, we are unable to present this information in the paper. PT care for compensated workers appears to be a sensitive and even politicised topic, especially for participants who hold management or leadership positions. Consequently, it is possible that some important information may not have been shared during the collection of data, which might limit the reach of our investigation of this phenomenon. Further, the web of systemic features involved in the provision of care for injured workers is complex and our study may have only revealed certain aspects that affected the participants.
This study corroborates the importance of recognizing that patient care is largely influenced by the organizational dynamics of healthcare institutions and compensation structures rather than upon individual professionalism [ 53 ].
New studies could thus aim to further explore and understand the influence of inter-organisational interactions on the provision of PT care for injured workers, using the concept of clinical governance, for example [ 49 ]. Future studies could also use the frameworks of business and organizational ethics to investigate how administrators from WCBs and PT clinics could foster a strong ethics cultures in their organizations and insure that specific policies and procedures allow espoused values to be proactively incorporated on a day-to-day basis [ 53 ].
Other studies could also aim to quantify the impact of certain macro and meso-level policies on outcomes of care for patients and professional satisfaction. Follow-up projects could then target and modify problematic policies in order to aim for greater equity and improved care for injured workers. Our results show these policies can alter the provision of equitable and quality care.
At the WCB level, clinical and administrative requirements regarding treatments interventions, end points for treatment, reimbursement rates and ways of communicating can create challenges for physiotherapists and affect patient care. Provincial WCBs should acknowledge the influence their policies can have on the provision of PT care. PT clinics are for-profit entities. Nonetheless, they provide important health services and need to ensure that equitable and quality care is provided to all their clients.
Clinic owners and managers should implement policies that promote equity, and critically appraise whether their policies could lead to a lower standard of care for injured workers. Physiotherapists working in the occupational health field in each province could advocate for policies that could reduce challenges encountered while treating injured workers.
Findings from this study could also serve as a catalyst to further explore and understand the way state level and organizational policies could be developed to be better aligned so they could in turn facilitate the use of best practices and promote ethical and quality care for injured workers across the country.
PT technicians are healthcare professionals who are included under the category of PT professionals. See Table 1 for more information. See Table 1 for more information about the block of care model in British Columbia. PT services covered in the Canadian Health Act mainly refer to hospital-associated care such as inpatient hospital PT, PT services provided by community service centers often observing strict criteria and usually accessible following an inpatient hospital stay and PT provided in outpatient hospital departments often accessible to patients who underwent a surgery or who have been referred through a special hospital program.
Nuckols TK, et al. Evaluating medical treatment guideline sets for injured workers in California. Also available in print form. Goldfarb CA. J Hand Surg. Article Google Scholar. Waddell G, Burton AK. Occupational health guidelines for the management of low back pain at work: evidence review. Occup Med. Garg RK, et al. J Pain. Article PubMed Google Scholar. Standiford Helm I. Pain Physician. PubMed Google Scholar.
Shaw L, et al. Knowledge brokering with injured workers: Perspectives of injured worker groups and health care professionals. Lugtenberg M, et al. Addressing occupational factors in the management of low back pain: implications for physical therapist practice. Phys Ther. Johnston V, Shaw WS. Helping workers help themselves: empowering physiotherapy clients to manage musculoskeletal problems at work.
Phys Ther Rev. Lowe A, et al. Disability management of injured workers: a best practices resource guide for physical therapists. ISBN Pollard H, de Luca K. A descriptive report of management strategies used by chiropractors, as reviewed by a single independent chiropractic consultant in the Australian workers compensation system.
Chiropr Osteopat. Gross DP, et al. Development of a computer-based clinical decision support tool for selecting appropriate rehabilitation interventions for injured workers. J Occup Rehabil. Cote P, et al. Chiropractors and return-to-work: the experiences of three Canadian focus groups. J Manip Physiol Ther. Hudon A, et al. The debt to equity ratio also provides information on the capital structure of a business, the extent to which a firm's capital is financed through debt.
This ratio is relevant for all industries. This is a solvency ratio indicating a firm's ability to pay its long-term debts, the amount of debt outstanding in relation to the amount of capital. The lower the ratio, the more solvent the business is.
Net fixed assets represent long-term investment, so this percentage indicates relative capital investment structure. It indicates the profitability of a business, relating the total business revenue to the amount of investment committed to earning that income. This ratio provides an indication of the economic productivity of capital. This percentage indicates the profitability of a business, relating the business income to the amount of investment committed to earning that income.
This percentage is also known as "return on investment" or "return on equity. This percentage, also known as "return on total investment," is a relative measure of profitability and represents the rate of return earned on the investment of total assets by a business. The higher the percentage, the better profitability is. This percentage represents the total of cash and other resources that are expected to be realized in cash, or sold or consumed within one year or the normal operating cycle of the business, whichever is longer.
This percentage represents all claims against debtors arising from the sale of goods and services and any other miscellaneous claims with respect to non-trade transaction. It excludes loan receivables and some receivables from related parties. This percentage represents tangible assets held for sale in the ordinary course of business, or goods in the process of production for such sale, or materials to be consumed in the production of goods and services for sale. It excludes assets held for rental purposes.
This percentage represents all current assets not accounted for in accounts receivable and closing inventory. This percentage represents tangible or intangible property held by businesses for use in the production or supply of goods and services or for rental to others in the regular operations of the business. It excludes those assets intended for sale.
Examples of such items are plant, equipment, patents, goodwill, etc. Valuation of net fixed assets is the recorded net value of accumulated depreciation, amortization and depletion.
This figure represents the average value of all resources controlled by an enterprise as a result of past transactions or events from which future economic benefits may be obtained. This percentage represents obligations that are expected to be paid within one year, or within the normal operating cycle, whichever is longer.
Current liabilities are generally paid out of current assets or through creation of other current liabilities.
Examples of such liabilities include accounts payable, customer advances, etc. This percentage represents all current loans and notes payable to Canadian chartered banks and foreign bank subsidiaries, with the exception of loans from a foreign bank, loans secured by real estate mortgages, bankers acceptances, bank mortgages and the current portion of long-term bank loans.
This percentage represents obligations that are not reasonably expected to be liquidated within the normal operating cycle of the business but, instead, are payable at some date beyond that time. It includes obligations such as long-term bank loans and notes payable to Canadian chartered banks and foreign subsidiaries, with the exception of loans secured by real estate mortgages, loans from foreign banks and bank mortgages and other long-term liabilities. This percentage represents the obligations of an enterprise arising from past transactions or events, the settlements of which may result in the transfer of assets, provision of services or other yielding of economic benefits in the future.
This percentage represents the net worth of businesses and includes elements such as the value of common and preferred shares, as well as earned, contributed and other surpluses. This figure must match total assets to ensure a balance sheet is properly balanced.
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