No. 40: Do private clinics or expedited fees reduce wait- or return-to-work times for injured workers following knee surgery?

Koehoorn M, McLeod CB, Fan J, McGrail K, Barer M, Côté P, Hogg-Johnson S. Do private clinics or expedited fees reduce wait- or return-to-work times for injured workers following knee surgery? Healthcare Policy August 2011;7(1):55-67.


Workers' Compensation programs are designed to protect employees from the financial hardships associated with work-related injuries and occupational diseases. Workers' Compensation programs are funded by employers, not by government. When workers are injured on the job, their health care services are often paid through these designated funds.

Some workers' compensation systems in Canada pay additional surgical fee supplements to expedite care, believing these measures will reduce surgery wait times, decrease total disability time, improve return-to-work outcomes, and reduce disability costs.

In 1996, British Columbia’s “WorkSafeBC” began paying private clinics for surgeries arising from work-related musculoskeletal injuries. This was followed in 2001 by WorkSafeBC paying for expedited surgical care to improve disability-related outcomes, including shortening return-to-work times.

In 2004, for example, WorkSafeBC (the workers' compensation system in British Columbia) paid almost 375% more ($3,222) for expedited knee surgery performed in a private clinic than for a non-expedited knee procedure in a public hospital ($859) (both fees represent the aggregation of facility, surgical, and anaesthetists' fees).

Methods and limitations

This study examined the effect of expediting surgeries for workers undergoing knee surgery (meniscectomy) by comparing wait times and return-to-work outcomes of expedited and non-expedited surgeries, in both public and private facilities. Waiting was defined as the time from the last surgical consult to the surgery data.

The sample included 1,380 insured injured workers who underwent a WorkSafeBC-funded knee meniscectomy/repair in a day procedure between January 2001 and December 2005, of which 238 were public hospital non-expedited procedures, 568 public hospital expedited procedures, and 574 private clinic expedited procedures. 

The three study groups, defined by expedited status and surgical setting, were not statistically different for baseline characteristics of age at time of surgery, wage at time of injury, percentage of women, or occupation (95% confidence intervals for all estimates overlapped across the three study groups).

Findings and analysis

The median surgery wait time for expedited surgeries was 22 calendar days in public hospitals as compared to 24 calendar days in private clinic. For non-expedited surgeries in public hospitals, the wait time was 37 calendar days.

The median time to return to work following surgery in public hospitals was 58 calendar days for non-expedited care, as compared to 60 calendar days for expedited care. For expedited surgery in private clinics the median return to work time was 66 days, or approximately one work week longer in private clinics.

The total disability duration (i.e. time from last surgical consult prior to surgery, to first return to work) for expedited care was 91 days in public hospital and 101 days in private clinic, or 10 days longer in private clinics.


Expedited fees were effective in reducing wait time for knee surgery in both public not-for-profit and private for-profit facilities. However, paying for expedited care in private for-profit surgical clinics does not result in shorter wait times or faster return-to-work times than expedited care in public not-for profit hospitals.

Logically, paying expedited fees to private for-profit facilities to reduce waiting times would only seem worthwhile if the return to work outcomes were better, not worse. Given the extra fees associated with expedited surgery, the marginal “value for money” of performing these expedited surgeries in private for-profit clinics is not evident.

One aspect not examined in this paper is the interactive effect, if any, of expediting surgeries for injured workers on wait times for other patients in the public system. If the limited supply of orthopedic surgeons is preferentially allocated to expedited injured workers treated in for-profit clinics, are those surgeons less available to Canadians not injured on the job? If these arrangements disadvantage Canadians who rely on the public health care system, then this would undermine the core value of universality enshrined in the Canada Health Act.


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