Elsevier

Injury

Volume 42, Issue 1, January 2011, Pages 15-24
Injury

Review
Is compensation “bad for health”? A systematic meta-review

https://doi.org/10.1016/j.injury.2009.12.009Get rights and content

Abstract

Objective

There is a common perception that injury compensation has a negative impact on health status, and systematic reviews supporting this thesis have been used to influence policy and practice decisions. This study evaluates the quality of the empirical evidence of a negative correlation between injury compensation and health outcomes, based on systematic reviews involving both verifiable and non-verifiable injuries.

Design

Systematic meta-review (a “review of reviews”).

Data sources

PubMED, CINAHL, EMBASE, PEDro, PsycInfo, EconLit, Lexis, ABI/INFORM, The Cochrane Library, and the AHRQ EPC were searched from the date of their inception to August 2008, and hand searches were conducted.

Review methods

Selection criteria were established a priori. Included systematic reviews examined the impact of compensation on health, involved adults, were published in English and used a range of outcome measures. Two investigators independently applied standard instruments to evaluate the methodological quality of the included reviews. Data on compensation scheme design (i.e., the intervention) and outcome measures were also extracted.

Results

Eleven systematic reviews involving verifiable and non-verifiable injuries met the inclusion criteria. Nine reviews reported an association between compensation and poor health outcomes. All of them were affected by the generally low quality of the primary (observational) research in this field, the heterogeneous nature of compensation laws (schemes) and legal processes for seeking compensation, and the difficulties in measuring compensation in relation to health.

Conclusion

Notwithstanding the limitations of the research in this field, one higher quality review examining a single compensation process and relying on primary studies using health outcome (rather than proxy) measures found strong evidence of no association between litigation and poor health following whiplash, challenging the general belief that legal processes have a negative impact on health status. Moves to alter scheme design and limit access to compensation on the basis that it is “bad for health” are therefore premature, as evidence of such an association is unclear.

Introduction

There is a commonly held view that compensation is bad for health. Indeed, systematic reviews that may lead one to accept this thesis18 have been cited in parliamentary inquiries into compensation law32 and in government-sponsored websites designed to influence the practice of health professionals and insurers.[37], [44] In addition, a series of recent systematic reviews that were conducted under the auspices of the World Health Organization have reinforced this viewpoint.10 Despite the growing application – in policy circles and academe – of the results of these reviews, there is ongoing scientific debate about the relationship between compensation and health outcomes, and systematic reviews of this topic have presented conflicting conclusions.[12], [38]

Curiosity about a possible link between compensation and health outcomes has existed since the 19th Century when cases of “compensation neurosis” and “railway spine”, involving people with objectively unverifiable injuries (i.e., injuries that cannot be verified via objective diagnostic tests) who developed chronic symptoms following seemingly minor accidents, were first identified.47 Theories abound as to why these conditions might occur, and a number of physical, psychological, occupational, cultural, and socio-economic factors have been implicated. Insurance-related factors such as moral hazard have also been proposed,[3], [34] especially in the case of non-verifiable injuries; thus, interest in whether compensation is “bad for health” may also be related to concern about insurance fraud. Alternatively, it may have its roots in the desire to move to a less debilitating and more equitable process for awarding compensation, which until the 20th Century rested solely in the characteristically adversarial common law system. In an effort to provide timely and fair compensation governments in many countries now mandate compulsory insurance products and prescribe the design of motor accident and workers’ compensation schemes in legislation, as most injuries occur on the road and at work. More recently, the relative merits of statutory fault-based and no-fault compensation scheme designs have been debated, with the purported association between compensation and poor health employed to argue for a no-fault approach.32

Uncertainty about the role of compensation and health status also exists in cases where an injury can be verifiably diagnosed through objective means, even though the extent of its effects may still be subject to hidden information. There is interest in whether the process of seeking compensation, or the compensation scheme design, has an impact on health status in the case of both verifiable and non-verifiable injuries, and in the case of the latter, there is particular interest in whether the availability of compensation per se provides an incentive to feign illness for the purposes of financial gain.

While there is apparent interest in linking compensation with poor health status, the evidence for such an association is equivocal, conflicting, and suffering from methodological limitations. The quality of systematic reviews on this topic, which are influential as they are considered the highest level of scientific evidence,[11], [30] is variable.29 This study therefore seeks to determine the validity of the conclusions among systematic reviews that have examined the association between compensation and health status in subjects with verifiable and non-verifiable injuries. Our objective is to consider the quality of the scientific evidence on the thesis that poor health outcomes and the availability of compensation are negatively correlated.

Section snippets

Methods

This study involves a review of systematic reviews.48 A protocol was developed a priori, outlining the search strategy, study selection process, quality assessment methods and method of synthesis.

Study selection and description

The results of the database searches were reviewed against the selection criteria, duplicate citations were removed, and 7% of studies (92/1258) were excluded because they were non-English publications (Fig. 1). Eleven studies, seven qualitative reviews and four meta-analyses, were selected for inclusion in this systematic meta-review. These examined a range of (generally) non-verifiable injuries such as whiplash-associated disorder (WAD),[10], [12], [38] mild traumatic brain injury (MTBI),[6],

Principal findings

Those reviews that performed better in the quality assessment, investigated a single compensation scheme or process, and used health outcome measures that were conceptually close to the latent health state of interest were considered more likely to provide the best quality of evidence about the impact of compensation on health outcomes. One of the reviews which found strong evidence of no association between compensation (derived through litigation) and symptoms or disability following a

Conclusion

There is a common perception that injury compensation has a negative impact on health status among those with verifiable and non-verifiable injuries, and systematic reviews supporting this thesis have been used to influence policy and practice. However, such reviews are of varying quality and present conflicting conclusions.

Systematic reviews that have sought to examine the link between compensation and health outcomes are subject to the inherent methodological weaknesses of observational

Role of the funding source

An unrestricted grant was provided by the Motor Accident Insurance Commission (MAIC) to The University of Queensland for the conduct of this research. MAIC is a statutory body, established under the auspices of the Queensland Treasury, to regulate compulsory third-party (personal injury, auto) markets in Queensland, Australia. MAIC had no role in the study design, in the collection, analysis and interpretation of the data, in the writing of the report, and in the decision to submit this paper

Conflict of interest statement

All authors declare that they have no personal or financial relationships with other people or organizations that could inappropriately influence (bias) their work.

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