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?