Gatekeepers in sickness insurance: a systematic review of the literature on practices of social insurance officers

Abstract

Decisions concerning entitlement to sickness benefits have a substantial impact on the lives of individuals and on society. In most countries, such decisions are made by staff of private or public insurance organisations. The work performed by these professionals is debated, hence more knowledge is needed on this subject. The aim of the present study was to review scientific studies of the practices of social insurance officers (SIOs) published in English, Danish, Norwegian and Swedish. Studies were searched for in literature databases, in reference lists, and through personal contacts. Analyses were made of type of study, areas investigated, research questions, theories used, and the results. Sixteen studies were included. SIOs and several other actors are responsible for applying measures to minimise sick-leave and promote return to work (RTW). The studies focusing on coordination of such measures revealed that SIOs felt unsure about how to handle their contacts with clients and other actors. One study indicated that the SIOs, partly due to lack of time, accepted the recommendations of physicians instead of making their own judgments about granting sickness benefits. While all SIOs must make decisions concerning entitlement to sickness benefits on a daily basis, few of the reviewed studies scrutinised the actual granting of sickness compensation. The studies were also deficient in that they investigated the decision latitude of the SIOs from a very limited perspective, mainly on an individual level and often primarily in relation to colleagues and/or clients rather than to the laws and regulations of the sickness insurance. The concepts and framework in this area of research need to be developed to facilitate elucidation of the interaction between different actors in local spheres, professionals in different disciplines, and between welfare staff and individual citizens.

Swedish social insurance officers' experiences of difficulties in assessing applications for disability pensions – an interview study

“…Söderberg [9] found in her review study of social insurance officers as "gatekeepers" that they sometimes used their decision latitude to prioritize clients who were easier to deal with, e.g. men or non-immigrants, even though this was against the rules.…”

“…But Lipsky also argues that the street-level bureaucrats have an opportunity to find their own way of handling the dilemma to be in-between the clients and the policies in society. As mentioned above, Söderberg [9] also found that social insurance officers used their decision latitude to prioritize. Therefore it is interesting to find that the results indicate that social insurance officers virtually uncritically follow the rules and deliver incomplete memorandums to the Social Insurance Board, rather than taking a more offensive attitude to solve the problem of incomplete and delayed medical certificates.…”

“…These changes in the social insurance system are expected to influence the social insurance officers' experience of dealing with applications for disability pensions. One consequence found, is that the demands on social insurance officers have increased in recent years and their working conditions have deteriorated [7-9]. …”

“…Thus the medical certificates sent to social insurance offices are of great importance. The physician has a major function in completing the extended medical certificate with details of diagnoses and treatment, functional limitations, rehabilitation measures, date of recovery, and, finally, whether or not work capacity is reduced [9]. Earlier studies highlighted that physicians do not receive sufficient knowledge of various working conditions during their training [12-14], and that they find it difficult to keep up with changing social insurance regulations [15].…”

Sickness certificates as a basis for decisions regarding entitlement to sickness insurance benefits

“…Thereafter, a physician's sickness certificate is required. The decisions regarding entitlement to sickness benefits and additional rehabilitation measures are, as in many other welfare states, made by the social insurance officers, largely based on the information provided on sickness certificates regarding disease, functional capacity, and demands at work [4,5]. The sickness certificate is a major instrument for establishing contact and conveying information between two authorities that have a substantial impact on the life and work situation of the patients, as well as on the economic costs to the society [6].…”