The recent article in the ARCHIVES entitled "Occupational Injury and Illness in the United States" by Leigh et al¹ is quite accurate in assessing the costs of occupational injuries and illnesses. It also emphasizes the paucity of public attention that is given to this problem despite the tremendous drain that occupational injury and illness places on our societal and economic resources. However, I was surprised to find that the article completely omitted any reference to the inefficiencies, waste, and not infrequent fraud that are inherent in the present system of workers' compensation.

When the workers' compensation statutes were first promulgated, they were based on the legal principle of "exclusive remedy." According to this principle, an injured employee would agree not to sue the employer because of a work-related injury, and in return, the injured employee would receive total reimbursement for any and all medical costs incurred, as well as full or partial wages during the period the employee was unable to work. If the disability, either partial or total, was permanent, the employee would receive indemnity payments indefinitely unless a lump-sum settlement was agreed on by the employer and the employee. It had been anticipated that such workers' compensation laws would provide fair and equitable protection for both the injured employee and his or her employer. Unfortunately, this has not proved to be the case. While society is desperately attempting to control the costs of non–occupational injury and illness by different stratagems, such as health maintenance organizations and regulated fees under Medicare and Medicaid, the costs of occupational injury continue to increase progressively. There are several reasons why this has occurred. Workers' compensation costs often bear no relationship to the actual severity of the injury or illness. Instead, it becomes an adversarial contest between the injured employee and his or her employer. Medical considerations are often sidetracked, and psychological, social, and economic considerations become the determining factors. The prolongation of "disability," based largely on symptoms but often with scant objective findings, is the result of "perverse incentive." Job dissatisfaction, disputes with supervisors, and domestic problems, combined with the availability of workers' compensation benefits and other disability benefits, all conspire to prolong the period of "disability" and to delay return to work. A second large factor in the escalating costs of workers' compensation is the absence of any well-defined standards of care. The medical care of the injured employees is often provided by practitioners with little or no expertise in occupational medicine, with little or no concern for the productivity and economic costs of prolonged disability, and with the knowledge that all the medical costs are defrayed by the employers or their insurance carriers indefinitely. There is no incentive to contain costs by limiting the number of visits and diagnostic tests. Since the attending physician legally controls the length of disability and the time the employee can and should return to work, the motivation of both the employee and the physician are paramount considerations. Collusion between employee and physician conspire to increase costs and to prolong disability.