impact of claims management, treatment, and rehabilitation on recovery and return to...
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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
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
Why should insurers listen?
• Learn how research can be used to:
– Identify what’s proven to work andwhere there’s slim evidence thatsomething works as intended
– Avoid wasting money re-inventingthe wheel
– Get things done faster
– Get a better return on investment
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
NZ’s Accident CompensationScheme
• 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
NZ’s accident compensation scheme
Client mix
DisabilityLong termShort term
Rehabilitation & recovery Lifetime support
Back strainMultiple injuriesPersistent pain
Sprains & strains
Cuts & bruisesBroken bones
Traumatic brain injurySpinal cord injury
Multiple amputationsSevere burns
Claim volumes
Claim volumesAnnual claim cost = $2.1 billion
Outstanding claims liability =$20.4 billion
27% cost15% liability
51% cost33% liability
22% cost52% liability
Short termclaims
Medium & longterm claims
Disabilityclaims
Data as at 30 Jun 2011
, costs, & liabilities
Spinal cordinjury38%
Severe & moderate traumatic brain injury
58%
Other5%
Injuries involved in disability claims
Data as at 30 Jun 2011
Case studyAchieving better independence & participation
outcomes for clients
Achieving sustainable growthin costs & liabilities
Situation 30 June 2007
Liability blow-outIsolation & dependence
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%
Brain injury 56% 35% 9%
Human assistance
Income replacementResidential care
Equipment
Hospital/ rehab
Housing & vehicles
Specialist services
Assessments
Teacher aide
Other
Drivers of cost growth
Single biggest driver of cost & liability growth
StrategyIdentifying the problem
Selecting solutions
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 One size fitsall
DiffuseaccountabilityNo alternativesManaging the
service gateway
Selecting solutions
• Clear vision of wherewe needed to get to:1. Stabilise growth in costs to
a sustainable rate2. Improve client outcomes:
increase participation
2003 2004 2005 2006 2007 2008 2009 2010
Cost per claim
Sustainable growth rate
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
ImplementationPerson-centred planningEvidence-based practice
Alternatives to attendant careClient segmentation & case management specialisation
Outcomes focusPerformance reporting
Person-centred planning in action
Where will these supports come from ?
What supports are needed ?
Community Employer
Family ACC
Client Other funders
School
1. Home/living2. Work/education
3. Leisure /recreation4. Community access
Participatorygoals
Treatment Rehabilitation
Person-centred planning
Maximise independence & participation
Linked to evidence-based practice
Assessment Alternatives to attendant care
Case management Reporting
Assessment
• Best in class, objective assessment tools & methods
Alternatives to attendant care
• Short-term, outcome-focused services:
– Supported Living
– Supported Employment
– Youth transition
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
Case management specialisation
• In-house specialists
• Disability experience
• Located in clients’ communities local knowledge
• Reflected in case loads
• Competency based
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
Outcomes focus
• Information for clients
– Emphasis on livingan everyday life
– Focus on clients’goals, not “entitlements”
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
} Impact on costs
Efficiency and effectiveness reporting
Performance reporting model
INPUTSClients:
Demographic & complexity indicators
Finance:Infrastructure
Services to clients
OUTPUTSWhat is provided:
E.g. episodes of service, hours of service,
exceptional responses, plans completed
OUTCOMESImpact on client’s lives:
To person-centred objectives
Evidenced by evidence-based measures
Processes Compliance audits,
satisfaction surveys, dispute
rates, etc
Putting it all together…
ResultsClient goal achievement
Employment participationActuarial release
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
CostOutcomes
Role of ResearchPast
PresentFuture
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
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
Present continued…
• Development of decision guides:– Consultation with expert clinicians
adapted 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 content
development for Fact Sheets– Client focus groups guided content
of DVDs– Client interviews & advisory group
provided accessibility solutions forwebsite
Present continued…
• Selection of outcome measures:– Similar selection criteria to selection
of assessment tools
– Linked to client objectives & used to monitor client goal achievement
– Used for supplier performance feedback
• Client satisfaction– Independent research measures
client satisfaction with service delivery
– Used to drive operational tactics &service quality improvements
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
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?
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?
Conclusions
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
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
We have partnered with…
• Our in-house researchers
• Best practice treatment & rehabilitation practitioners
• Academics & health researchers - locally & internationally
• Market researchers
Research is a tool
• It will be used by insurersas long as it..
– Continues to be useful
– Remains practical
Questions?
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