Medical Aid Principles Policy 25-001 | Effective Date: January 17, 2019

Statements

WorkSafeNB has the legislated authority to determine the necessity, character, and sufficiency of medical aid required to treat an injury by accident under s. 41(1) and 41(3) of the WC Act. The principles in this policy guide WorkSafeNB’s discretion in arranging and paying for this medical aid.

WorkSafeNB is committed to making medical aid decisions that are evidence based. 

Interpretation

  1. The President/C.E.O may delegate authority to the Chief Medical Officer, or other staff as appropriate, to establish standards for care and treatment; purchase, arrange, or provide medical aid; and negotiate the fees it pays for medical aid.
  2. WorkSafeNB is committed to workers receiving care that is timely, appropriate, cost-effective, and evidence based. That commitment is reflected in a framework that WorkSafeNB has adopted for medical aid that ensures injured workers receive:
    • The right care, that is delivered by
    • The right provider, and is obtained at
    • The right cost.

 

Medical Aid Principles

From that framework flow the following principles that guide WorkSafeNB’s medical aid services and decisions:

I. WorkSafeNB is committed to injured and ill workers receiving quality care and services from health care providers that are evidence based.

WorkSafeNB develops, adopts and follows standards for treatment and related services. WorkSafeNB requires that health care delivered to workers be:

    • Evidence based;
    • Appropriate, timely, and cost-effective; and
    • Under the direction of an approved health care practitioner.

 

WorkSafeNB is also committed to the practice of consulting with health care practitioners in the development of plans for the optimum care and rehabilitationof injured workers.

II. WorkSafeNB establishes standards for care and treatment based on evidence.

WorkSafeNB directs the standard for care and treatment provided to injured and ill workers, in accordance with the WC Act, the other principles set out in this policy, and with generally-accepted medical practices. WorkSafeNB develops evidence-based processes and practices related to items which include, but are not limited to:

    • Treatments;
    • Providers; and
    • Prescription drugs, including guidelines for types of drugs prescribed, such as opioids.

 

III. WorkSafeNB promotes the use of guidelines for medical recovery that have been shown, by scientific literature or experience, to be effective in the treatment of injury or occupational disease.

WorkSafeNB manages the care plans proposed by the worker’s health care provider using guidelines that include:

    • Clinical care maps;
    • Disability duration guidelines;
    • Healing times; and
    • Treatment, or clinical practice guidelines.

IV. WorkSafeNB requires scientific evidence of effectiveness of new, non-standard or not generally accepted treatment and tests.

WorkSafeNB is committed to workers receiving quality health care and related services that are evidence based and known to be effective in the rehabilitation of injury and occupational disease. WorkSafeNB does not authorize the administration of treatment or tests to workers until the scientific evidence has been reviewed and the procedure approved. 

V. WorkSafeNB promotes timely access to evidence-based treatment and services.

Prompt access to appropriate, evidence-based treatment and services is important to aid the recovery of injured and ill workers. Significant delays accessing investigations and treatments increase the risk of not returning to work, which has been shown to increase risk of morbidity and early mortality. WorkSafeNB may arrange for workers to receive treatment or services in another location, including out of the province if local sources of services are unavailable or delayed.

VI. WorkSafeNB promotes early and safe return to work as therapy.

Injured and ill workers do not always need to be fully recovered before they benefit from returning to work in some capacity. Evidence shows that early and safe return-to-work programs assist workers to achieve a maximum level of functional ability up to the pre-accident physical job demands.

WorkSafeNB’s rehabilitation goals focus initially on helping workers stay at work during rehabilitation, or safely return to work as early as possible. For more information, see Policy No. 21-400 Rehabilitation.

VII. WorkSafeNB designates specific treatments and tests for prior approval.

WorkSafeNB arranges and pays for the tests and treatments that are evidence based and necessary to treat the workplace injury within generally accepted treatment guidelines.

For treatments or tests in excess of generally accepted treatment guidelines, WorkSafeNB may require a second opinion, or prior authorization of payment.

If prior authorization is not given and WorkSafeNB determines that the tests, treatments and procedures are beyond necessary medical aid, the worker may decide to pursue these treatments, tests or procedures, either at their own expense or through other means. WorkSafeNB does not pay for this treatment.

If evidence demonstrates that these treatments or procedures, not approved by WorkSafeNB, impede recovery as per s. 41(15) of the WC Act, WorkSafeNB applies Policy 21-214 Determining Continued Eligibility for Loss of Earnings Benefits to determine whether loss-of-earnings benefits should cease.

VIII. WorkSafeNB promotes appropriate prescription drug administration.

WorkSafeNB is committed to workers receiving only the appropriate medications, in the appropriate quantities, that evidence indicates are required to effectively treat the injury or occupational disease. In making these determinations, WorkSafeNB uses recognized standards, including the World Health Organization Pain Relief Ladder.

WorkSafeNB may refuse payment for prescriptions which are excessive or inappropriate for the worker, or may cause addiction. In the case where WorkSafeNB determines that an injured or ill worker is addicted to medications received under treatment for the workplace injury, WorkSafeNB will be responsible for costs of addiction treatment. For more information, see Policy 25-012 Medical Aid - Opioids

IX. WorkSafeNB arranges and purchases evidence-based care for workers determined to be necessary medical aid.

WorkSafeNB arranges and purchases the necessary medical aid in the appropriate quantities that evidence indicates are required to effectively treat the injury or occupational disease of a worker.

Accordingly, WorkSafeNB is committed to being proactive in validating an injured or ill worker’s diagnosis upon which to base medical and rehabilitation planning.

WorkSafeNB may refuse to approve payment for treatments that are in excess of generally accepted treatment guidelines and/or fail to produce evidence of functional improvement. In such situations, WorkSafeNB explores alternate rehabilitation options.

X. WorkSafeNB requires workers to actively participate in rehabilitation plans, assessments, treatments and services.

Subsection 41(15) of the WC Act provides authority for WorkSafeNB to reduce or suspend loss-of-earnings benefits whenever an injured or ill worker does not attend and participate in medical examinations, treatments, and/or rehabilitation programs. For more information, see Policy 21-214 Determining Continued Eligibility for Loss of Earnings Benefits.

XI. WorkSafeNB only recognizes providers that have been authorized to deliver health care services.

WorkSafeNB may approve providers that have been licensed or accredited to deliver health care services in the province by provincial or national licensing agencies. If such agencies do not exist for a particular health care provider, WorkSafeNB may approve these health care providers on an individual basis

XII. WorkSafeNB supports injured workers in their initial choice of approved health care provider.

Injured workers have the right to choose their health care provider from among those who are licensed or approved by WorkSafeNB.

WorkSafeNB may limit the number of visits to health care providers and the number of health care providers visited to what is reasonable for the injured worker’s compensable condition.

WorkSafeNB also has the authority to change a worker’s healthcare provider if recovery is slower than anticipated or if other barriers to recovery are apparent.

When authorizing appointments with approved health care providers, WorkSafeNB considers such factors as the condition of the worker, waiting times, and distance to be travelled for the appointment or treatment. All decisions concerning choice of health care providers are subject to a test of reasonableness, and must be consistent with the principles of right care, right provider and right cost.

XIII. WorkSafeNB supports optimum care and rehabilitation of injured and ill workers.

In certain circumstances, workers may have reason to require a change of health care provider. WorkSafeNB may authorize the request, or may initiate referral of an injured worker to another health care provider in the event that recovery is not progressing or staff have concerns about a proposed treatment plan.

When authorizing payment for subsequent opinions, WorkSafeNB considers the condition of the worker, the impact of waiting times, and distance to be travelled. All decisions concerning choice of health care providers are subject to a test of reasonableness, must be evidence based, and must be consistent with the principles of right care, right provider and right cost.

XIV. WorkSafeNB pays for prescription drugs at the generic drug rate, where equivalents exist.

WorkSafeNB ensures the best price for prescription drugs by using a generic brand whenever possible. WorkSafeNB further manages drug costs by using a prescription drug formulary. WorkSafeNB may make an exception for a prescription drug in the event that the treating physician provides reasons for specific drug requirements.

XV. WorkSafeNB establishes the fees it pays for health care and related services, by negotiating with individuals or health care provider groups or by adopting health care provider fee schedules, as appropriate.

WorkSafeNB negotiates fees with:

    • Medical practitioners;
    • Chiropractors;
    • Physiotherapists; and
    • Any other health care providers, as required.

WorkSafeNB pays fees according to the current rate schedules as established by the following health care providers and facilities:

    • Hospitals;
    • Dental practitioners and denturists;
    • Optometrists;
    • Nursing and home health care services;
    • WorkSafeNB’s Rehabilitation Centre; and
    • Any other health care providers and services, as required.

 

Workers’ Compensation Act (RSNB 1973, c W-13)

1

38.2(7), 38.11(16)

40(2), 41, 43, 47

85(4), 85(5) and 85(7)

Case Law

Creighton v. WHSCC 2009 NBCA 73

The Court upheld the denial of several treatments because their effectiveness was not supported by the principles of evidence-based medicine. It further reiterated WorkSafeNB’s authority to determine the necessity, character and sufficiency of the medical aid to be provided. 

Care map - a tool for the management of care processes that incorporates milestones to trigger interventions, according to best practices (Canadian Medical Association).. 

Clinical practice guidelines - systematically developed statements to help health care providers and clients make decisions about appropriate health care for specific clinical circumstances (Canadian Council on Health Services Accreditation).

Disability duration guidelines - the time frame within which 75% of injured or ill persons return to work for specified job demands for a specific condition.

Formulary - a list of pre-approved prescription drugs and other medical or surgical supplies generally approved by WorkSafeNB as effective for treating a compensable injury or disease.

Healing time - the average length of time that patients generally require to heal or recover from specific injuries or conditions.

Health care provider - practitioner or facility, either within or outside the province, which delivers health care and related services.

Medical aid - includes medical, surgical and dental aid, hospital and skilled nursing services, services of a registered chiropractor within his legal jurisdiction, artificial members and apparatus including the repair and replacement thereof, transportation, clothing allowances with respect to damage caused to clothing as a result of the use of an artificial apparatus or as a result of any accident, and such other treatment, services or attendance as are necessary as a result of any injury (WC Act).

Medical aid also includes primary physiotherapy, work recovery, work conditioning, and gradual/transitional return to work initiatives.

Medical Practitioner - means a person duly registered under the laws of the Province as authorized to practice medicine in the Province, and includes a medical officer of Her Majesty’s armed forces serving in the Province (WC Act).

Nurse - means a person who is registered under the laws of the Province as authorized to practice as a nurse (WC Act).

Nurse practitioner - means a person who is registered under the laws of the Province as authorized to practice as a nurse practitioner (WC Act).

Practitioner - one who has met the professional and legal requirements necessary to provide health care and related services.

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