Impact of claims management, treatment, and rehabilitation on recovery and return to independence

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Impact of claims management, treatment, and
rehabilitation on recovery and return to
independence

• Liz Cairns, Manager Serious Injury Service, ACC,
  NZ

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Making research part of your DNA

• Case study of how to get better client outcomes
  at the same time controlling costs liabilities
• How research was applied continues to be used
  to inform strategic and tactical decision-making

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Why should insurers listen?

• Learn how research can be used to
• Identify whats proven to work andwhere theres
  slim evidence thatsomething works as intended
• Avoid wasting money re-inventingthe wheel
• Get things done faster
• Get a better return on investment

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Why should researchers listen?

• Learn how
• You can make a difference
• To be part of the solution, notjust describing
  the problems
• Leverage your intellectual capitalby partnering
  with insurers

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NZs Accident Compensation Scheme
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NZs accident compensation scheme

• No fault
• Covers everyone in NZ including workers,
  non-workers, tourists
• Any kind of personal injury caused by an
  accident (including assault, medical mishap,
  mental injury)
• Funded through insurance premiums (workers,
  employers, car owners), fuel taxes, and
  government appropriations

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Client mix
Rehabilitation recovery
Lifetime support
Disability
Long term
Short term
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Claim volumes
, costs, liabilities
Annual claim cost 2.1 billion Outstanding
claims liability 20.4 billion
Claim volumes
Short termclaims
Medium long term claims
Disabilityclaims
Data as at 30 Jun 2011
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Injuries involved in disability claims
Data as at 30 Jun 2011
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Situation 30 June 2007

• Accelerating rate of growth in average cost per
  disability claim
• 4.2 in 2005
• 5.8 in 2006
• 14.3 in 2007

Low participation rates in community activities
employment Best Typical NZ Spinal 80 40 18 Br
ain injury 56 35 9
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Drivers of cost growth
Single biggest driver of cost liability growth
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Problem diagnosis

• Generalist case management
• Over-reliance on attendant care
• No understanding of liability
• Poor accountability for liabilityor performance
• Assessment practices
• Assessors suppliers driving our business

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Selecting solutions

• Clear vision of wherewe needed to get to
• Stabilise growth in costs to a sustainable rate
• Improve client outcomesincrease participation

Sustainable growth rate
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Selecting solutions

• Strategy was a road map of what we needed to do
  to get there
• Disability model/philosophy
• Evidence-based approach to
• Assessments
• Decision-making about human assistance packages
• Service outcomes
• Specialist case management
• Alternatives to attendant care
• Deliver claims liability knowledge liability
  driver understanding

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Person-centred planning in action

• Treatment ?
• Rehabilitation ?

Participatory goals

1. Home/living
2. Work/education
3. Leisure /recreation
4. Community access

What supports are needed ?
Where will these supports come from ?
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Linked to evidence-based practice
Maximise independence participation
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Assessment

• Best in class, objective assessment tools
  methods

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Alternatives to attendant care

• Short-term, outcome-focused services
• Supported Living
• Supported Employment
• Youth transition

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Alternatives to attendant care

• Short-term, outcome-focused services
• Supported Living
• Supported Employment
• Youth transition
• Equipment solutions
• Smoke alarms sprinkler systems
• Personal alarms
• Short-rise lifts

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Case management specialisation

• In-house specialists
• Disability experience
• Located in clients communities? local knowledge
• Reflected in case loads
• Competency based

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Claim liability knowledge

• Historically, this knowledge was limited to those
  concerned with funding pricing for premiums
• Now integrating liability into decision-making
  about sustainable levels of support service

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Outcomes focus

• Information for clients
• Emphasis on livingan everyday life
• Focus on clientsgoals, not entitlements

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Outcomes focus

• Purchasing disability support services
• Services already existed in disability sector,
  but not previously accessed by ACC
• ACC a relatively small player but regarded as
  cash rich ? purchase for outcomes
• Interventions must achieve an outcome
• Evidence of need for intervention
• Episode-based funding
• Episode tied to a client goal
• Standardised outcome measures

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Performance reporting model
INPUTS Clients Demographic complexity
indicators Finance Infrastructure Services to
clients
OUTPUTS What is provided E.g. episodes of
service, hours of service, exceptional responses,
plans completed
OUTCOMES Impact on clients lives To
person-centred objectives Evidenced by
evidence-based measures
Efficiency and effectiveness reporting
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Putting it all together
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Results

• Achieved a delicate balance
• 820 million contribution to actuarial release
• 61 of clients achieving or exceeding their
  self-directed goals
• 22 in part-time or fulltimepaid work

Cost
Outcomes
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Past

• Problem identification
• Statistics on cost liability drivers
• File reviews to determine impact differentcase
  management models
• International comparisons on use of human
  assistance (attendant care)
• Evidence base for efficacy of interventions,
  such as
• Supervision to manage problem behaviours
• Music therapy
• Client and staff forums

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Present

• Selection of solutions
• Selection of assessment tools
• Selection criteria was they had to
  beinternationally researched, valid reliable,
  easy to administer
• Service development
• Literature search on behavioural interventions
  led to creation ofBehaviour Support Service
• Online surveys of suppliers staffinformed
  strategic development of existing Disability
  Support Services

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Present continued

• Development of decision guides
• Consultation with expert cliniciansadapted NSW
  spinal cord injury guidelines for NZ environment
• Statistical modelling of FIM data attendant
  care hours led to development of predictive
  model
• Development of communications
• Client advisory group aided contentdevelopment
  for Fact Sheets
• Client focus groups guided contentof DVDs
• Client interviews advisory groupprovided
  accessibility solutions forwebsite

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Present continued

• Selection of outcome measures
• Similar selection criteria to selectionof
  assessment tools
• Linked to client objectives used to monitor
  client goal achievement
• Used for supplier performance feedback
• Client satisfaction
• Independent research measuresclient satisfaction
  with service delivery
• Used to drive operational tactics service
  quality improvements

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Present continued

• Rapid response
• Evaluation of business-critical services
• TBI and Spinal Strategies being informed at the
  outset by evidence and best theory
• Development of decision support resources for
  spinal cord injury management in the community
• Development of relationships with international
  practitioners in applied research

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Future

• Horizon scanning
• Relevance of new technologies
• Do they help clients to achieve their
  objectives?
• Do they give the insurer an acceptable return on
  investment?
• Advances in medical treatment
• Is there enough good-quality evidence of their
  widespread effectiveness?
• Should the insurer be an earlyadopter or fast
  follower?

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Future

• Responding to developing issues
• Health status of people with disabilities
• Existing co-morbidities
• Impact of aging
• Skilled labour shortages in the disabilitysector
• Current workforce is aging
• Where will replacements for the current
  workforce come from?

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Conclusions
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Research helped us

• Define the problems we faced identify the root
  causes we needed to concentrate on
• Select solutions faster, without needing to
  re-invent the wheel
• Achieve consistency in decision-making

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We are using research to

• Measure our progress
• Manage our suppliers performance
• Effectively communicate with our clients
  stakeholders
• Develop better interventions
• Improve the quality of our services
• Keep abreast of new technologies, medical
  advances, future challenges

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We have partnered with

• Our in-house researchers
• Best practice treatment rehabilitation
  practitioners
• Academics health researchers - locally
  internationally
• Market researchers

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Research is a tool

• It will be used by insurersas long as it..
• Continues to be useful
• Remains practical

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Questions?