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Psychology Presentation to the Standing Committee on General Government : Auto Insurance Study

Psychology Presentation to the Standing Committee on General Government : Auto Insurance Study. Ontario Psychological Association, Auto Insurance Task Force. No-Fault Accident Benefits. Purpose : to provide timely access to funding for services to reduce impairments and restore functioning.

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Psychology Presentation to the Standing Committee on General Government : Auto Insurance Study

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  1. PsychologyPresentation to the Standing Committee on General Government:Auto Insurance Study Ontario Psychological Association, Auto Insurance Task Force May 6 2013: OPA; amber@kaplanpsychologists.com

  2. No-Fault Accident Benefits • Purpose: to provide timely access to funding for services to reduce impairments and restore functioning. • “impairment” means a loss or abnormality of a psychological, physiological or anatomical structure or function; • Medical benefits: 15. (1)…shall pay for all reasonable and necessary expenses incurred by or on behalf of the insured person as a result of the accident for,(a) medical, surgical, dental, optometric, hospital, nursing, ambulance, audiometric and speech-language pathology services;(b) chiropractic, psychological, occupational therapy and physiotherapy services • Rehabilitation benefits: 16(1) shall pay for all reasonable and necessary expenses incurred by or on behalf of the insured person in undertaking activities and measures described in subsection (3) that are reasonable and necessary for the purpose of reducing or eliminating the effects of any disability resulting from the impairment or to facilitate the person’s reintegration into his or her family, the rest of society and the labour market. May 6 2013: OPA; amber@kaplanpsychologists.com

  3. Psychologists are • Independent, autonomous, regulated health care providers • Trained from bachelor’s to doctoral level in normal and abnormal mental health • Experts in scientific methods applied to health and behaviour • Experts in measurement May 6 2013: OPA; amber@kaplanpsychologists.com

  4. Psychologists • Provide scientific, valid and reliable methods for assessing impairments • Provide cost-effective, empirically-validated, evidence-based treatments • Provide gold standard interventions for depression, anxiety, brain injury, and chronic pain May 6 2013: OPA; amber@kaplanpsychologists.com

  5. Psychologists in Ontario • See patients with traumatic injuries under WSIB, auto insurance, victim services, etc • Are employed in hospital programs for chronic pain, depression, anxiety disorders, schizophrenia, cognitive impairments, and brain injuries • Cannot bill OHIP directly May 6 2013: OPA; amber@kaplanpsychologists.com

  6. So, why fund psychologists under auto insurance? • Car accidents are the single biggest cause of civilian post-traumatic stress and brain injuries • Psychologists provide the most effective treatments for post-traumatic stress • Psychology is the only profession able to measure and diagnose cognitive impairments due to brain injury May 6 2013: OPA; amber@kaplanpsychologists.com

  7. For accident victims, psychologists • Assess and treat post-traumatic stress disorder, depression, chronic pain, and traumatic grief • Assess and rehabilitate brain injuries • Assist in school and work re-entry • Assess and measure disability May 6 2013: OPA; amber@kaplanpsychologists.com

  8. For accident victims, psychologists Tend to be involved with the most seriously injured and vulnerable Work with the high-need victims who have brain injuries and psychological disorders Provide services that are critical for recovery and disability prevention Historically 2-4% in Ontario data May 6 2013: OPA; amber@kaplanpsychologists.com 8

  9. As you know… • Mental health is often misunderstood • Services are often under-funded • Many studies across the country tell this story again and again • Auto is no different May 6 2013: OPA; amber@kaplanpsychologists.com

  10. Need for funding for timely access to psychological services • Imperative for Change: Access to Psychological Services for Canada, March 2013 • The delivery of mental health services in Canada can be characterized as a silent crisis. An increasing demand and need is unmet by provincial and territorial health care systems and private insurers. Instead, attention has continued to focus on politically sensitive areas, such as cardiovascular interventions and joint replacement surgery. Nonetheless, a mental health disorder effects one in five Canadians with an annual societal cost of $50 billion, as reported by the Mental Health Commission of Canada. …. • Despite an awareness of the benefits of evidence-based psychological interventions, there continues to be a severe gap in the ability of patients to receive needed care. • FROM the FSCO website: Increasing Your Liability and Accident Benefits Coverage Medical, Rehabilitation and Attendant Care Benefits: …. Keep in mind that many health care expenses are not covered by OHIP, or only partially covered, including physiotherapy and chiropractic treatment, mobility devices (crutches, wheelchairs), modifications to your home and car that you may require, and other specialized goods and services… May 6 2013: OPA; amber@kaplanpsychologists.com

  11. MVA victims with psychological conditions are among the most vulnerable: Psychological disorders and brain injuries are invisible Easy target for stigma, misunderstanding, discrimination High rates of disability May 6 2013: OPA; amber@kaplanpsychologists.com 11

  12. OPA Initiatives • Evidence-based guidelines for assessment and treatment services billable under auto insurance in Ontario. Developed by 20+ psychologists around the province. Published in peer-reviewed journal. May 6 2013: OPA; amber@kaplanpsychologists.com

  13. OPAInitiatives • OPA Auto Task Force co-chair on the HCAI Anti-Fraud committee • College of Psychology testing professional identity tracker • Developing joint guidelines for IE assessments and MIG determinations with CAPDA May 6 2013: OPA; amber@kaplanpsychologists.com

  14. Thank you for the opportunity • When we presented to the Standing Committee on General Government’s Study of Auto Insurance last May, we presented our members’ concerns that the 2010 reforms were resulting in harm to legitimately injured people with brain injuries and psychological impairments. May 6 2013: OPA; amber@kaplanpsychologists.com

  15. Thank you for the opportunity • When we presented to the Standing Committee on Finance and Economic Affairs’ Auto Insurance Study last July, we presented data indicating that the 2010 reforms had resulted in significant improvements in cost-control for the insurance industry. May 6 2013: OPA; amber@kaplanpsychologists.com

  16. In July 2012, • We also presented data from reputable psychology treatment clinics outside the Toronto area that indicated approvals for recommended assessment and treatment services had decreased significantly since the 2010 reforms. May 6 2013: OPA; amber@kaplanpsychologists.com

  17. Data from reputable clinics in Hamilton – Burlington April 2010 April 2012 Approved 100% 63.41% Denied 0 21.95% Partial Approval 0 14.63% May 2010 May 2012 Approved 88.23% 48.71% Denied 11.76% 33.33% Partial Approval 0 15.38% June 2010 June 2012 Approved 100% 40% Denied 0 13.33% Partial Approval 0 0 May 6 2013: OPA; amber@kaplanpsychologists.com 17

  18. Data from reputable clinics in Hamilton – Burlington Pre-Sept 1, 2010 (N = 780 OCF-18s) 2008 2009 To Aug 31/10 Total pre-change Full Approval 72% 67% 77% 72% (n = 562) Partial Approval 3% 5% 2% 3% (n = 24) Total Approved 75% 71% 79% 75% (n = 586) Denied 25% 29% 21% 25% (n = 196) Post-Sept 1, 2010 (N = 680 OCF-18s) After Sept 1/10 2011 2012 Total post-change Full Approval 55% 61% 52% 59% (N = 398) Partial Approval 10% 7% 6% 7% (N = 48) Total Approved 71% 68% 58% 66% (N = 446) Denied 29% 32% 42% 34% (N = 231) May 6 2013: OPA; amber@kaplanpsychologists.com 18

  19. As a result, in July 2012, we reported concern about potential • Increased disputes, transaction costs • Increased disability • Increased tort/ BI costs • More mediations and arbitrations • Increased costs to public systems (OHIP, CPP, etc.) May 6 2013: OPA; amber@kaplanpsychologists.com

  20. As a result, in July 2012 we reported concern about potential • Increased barriers, lack of timely rehab • More assessments without treatment • Increased patient frustration, cynicism • Delays without resolving disputes • More problems for injured victims May 6 2013: OPA; amber@kaplanpsychologists.com

  21. In August 2012, • We were especially pleased to present to the Anti-Fraud Task Force • We told them that OPA has advocated for specific measures to target, investigate, and prosecute fraud for many years, and that • Many of the Task Force’s recommendations are consistent with those we have recommended. May 6 2013: OPA; amber@kaplanpsychologists.com

  22. In August 2012, we recommended to the Task Force • Assessing successes achieved before enacting more costly and intrusive measures requiring additional regulation. • Ensuring patient privacy and due process in investigations. • Including OPA and CAPDA in future discussions and planning. May 6 2013: OPA; amber@kaplanpsychologists.com

  23. Today • We’re happy to have the chance to follow up with you today to provide an update on the current trends in assessment and treatment for rehabilitation (not disability) by psychologists in the province. May 6 2013: OPA; amber@kaplanpsychologists.com

  24. What now? • AB Claims costs are down • Fraud initiatives are in effect next month • Approvals for reputable assessment and treatment services are down • What are the effects of 2010 reforms on insurance examinations? • What is happening with minor injuries? May 6 2013: OPA; amber@kaplanpsychologists.com

  25. And, the big question: What does this mean for patients? May 6 2013: OPA; amber@kaplanpsychologists.com

  26. What is happening with IEs? • Polled members we knew to be active in the auto insurance sector and whose practices we knew to be reputable. • We received replies from Burlington, Hamilton, London, Barrie, Downsview, Thornhill, and downtown Toronto. • All report IE referrals to their practices down 50-90% since 2010. May 6 2013: OPA; amber@kaplanpsychologists.com

  27. Most report reviewing fewer excessive applications • Burlington: Indicates fewer but, “we never really saw all that many over-the-top applications before.  The large majority seemed to be reasonable, at least in our neck of the woods”. • London: “Never did see any”. • Barrie: “To be honest, I never saw very many bad applications to begin with”. May 6 2013: OPA; amber@kaplanpsychologists.com

  28. Most report reviewing fewer excessive applications • Thornhill: Estimates 80% reduction. Indicates, “Before it was ridiculous. Most of the assessment companies with bad applications have disappeared…” • Downsview: Approximately 50% reduction in bad applications. May 6 2013: OPA; amber@kaplanpsychologists.com

  29. So, IE referrals seem to be down • And, bad applications seem to be down • But, all respondents also indicated that they’re being asked more questions in each referral, especially in the GTA • Burlington, Barrie, London: maximum 8-15 questions per referral • Downsview, Thornhill, Toronto: maximum 20-32 questions per referral May 6 2013: OPA; amber@kaplanpsychologists.com

  30. They are being asked to answer more questions for lower fees • Burlington: …with the cap, we were essentially forced into flat-fee agreements with the IE vendors we work with • Barrie: …with the cap, I have to limit my time. I do now sometimes put in hours that I cannot bill, in order to do an adequate job. • Downsview: …some files we review are as high as 4000 pages and we can’t bill for the review. May 6 2013: OPA; amber@kaplanpsychologists.com

  31. We also heard reports of concerns about off-loading • London Health Sciences: Since I also do work in an MoHLTC hospital clinic, we see MANY former AISI funded patients on our waitlists who have been cut off (or never left the MIG) and they are waiting over a year to be seen by OT, SLP, SW, psychology... • As the insurance-funded service menu shrinks, the hospital waitlists grow, and the ER visits increase. May 6 2013: OPA; amber@kaplanpsychologists.com

  32. We also heard reports of concerns about off-loading • Hamilton Health Sciences and Burlington: …our program is working on an REB to look at quantifying this change since 2010. There is definitely the sense that there is greater waitlist pressure since the funding changes and the reduced IE approvals. This includes to mental health services at St. Joe’s and Joe Brant. May 6 2013: OPA; amber@kaplanpsychologists.com

  33. Our current impressions: • Excessive applications that were driving up costs appear to have been primarily in the GTA and appear to have decreased. • IEs outside the GTA didn’t see these to begin with, so they’re not seeing any fewer of them. • Significantly increased cost-pressures May 6 2013: OPA; amber@kaplanpsychologists.com

  34. What does this mean for patients? • May be off-loading to public services that are already under-resourced • More people accessing our fractured public mental health care system. • Unable to handle these increases • Resulting in increased wait times May 6 2013: OPA; amber@kaplanpsychologists.com

  35. What is happening with IE companies? • Psychologists are being asked to do more for less • They are reporting that there used to be more competition in the IE marketplace. • As a result, it was easier to say no to any given company if there were unreasonable expectations. May 6 2013: OPA; amber@kaplanpsychologists.com

  36. What is happening with IE companies? • Consolidation of IE companies has resulted in downward pressures on assessors regarding: • the costs of their own assessments; and • The costs of plans for services they review • As a result, IEs are facing new economic pressures and micromanaging the costs of proposed assessments and treatment plans. May 6 2013: OPA; amber@kaplanpsychologists.com

  37. What does this mean for patients? • Many approved plans are trimmed. May 6 2013: OPA; amber@kaplanpsychologists.com

  38. What is happening with the minor injury cap? • Seems to be effective gate-keeping, containing many accident victims appropriately. • The challenge is how to identify those who are appropriately in and out. • In general, insurers are requiring an IE to determine whether or not there is a psychological disorder due to the MVA that requires treatment. May 6 2013: OPA; amber@kaplanpsychologists.com

  39. What does this mean for patients? • This adds demand on the patient and cost to the system. • People with soft-tissue injuries and psychological disorders have to go through an extra step in order to document that disorder before they can access appropriate assessment and treatment. • Creates an extra obstacle and intrusive burden for people who are already suffering. May 6 2013: OPA; amber@kaplanpsychologists.com

  40. What does this mean for patients? • E.g., if physician diagnoses and refers specifically for assessment and treatment of PTSD and our screening shows strong indicators of this, does it really make sense to ask the patient to disclose all of their traumatic memories and experiences to someone who is never going to see them again? May 6 2013: OPA; amber@kaplanpsychologists.com

  41. Is there a better way? • If a psychologist follows the OPA Guidelines and does a thorough screening, this should result in a strong application that could be approved without requiring IE. • In fact, if the screening is done properly, the IE should approve it (and in our experience, usually does). May 6 2013: OPA; amber@kaplanpsychologists.com

  42. Is there a better way? • Does it make sense for the system to have this additional cost? • The treating psychologist still has to engage the patient him/herself in order to initiate treatment.  • Is it possible to collaborate with insurers to streamline process for the patients and save cost to the system? May 6 2013: OPA; amber@kaplanpsychologists.com

  43. Is there a better way? • Insurer in-house psychological consultant or IE paper review as a first screen? • Some may be obviously not minor injuries and therefore approved. • Only send on those that are questionable to in-person assessment? May 6 2013: OPA; amber@kaplanpsychologists.com

  44. While it is true that fraud had reached level intolerable levels in auto and other sectors • There now is a system-wide focus on accident victims and rehab providers as being fraudulent or too costly. • Focus on cost-cutting and anti-fraud creates atmosphere where everyone is hypervigilant. • More presumption of looking for fraud. • No assessments that are perceived to be neutral. • Increased level of distrust, suspicion. May 6 2013: OPA; amber@kaplanpsychologists.com

  45. What does this mean for patients? • This creates the dual burden on patients of both the presumption of fraud and the micromanaging of costs. • Has an impact on care: shorter plans, more time between them, partial approvals. • Means less proper, effective momentum toward improvement; increases treatment costs and transaction costs. May 6 2013: OPA; amber@kaplanpsychologists.com

  46. What does this mean for patients? • More partial approvals, shorter plans, even for complicated patients • Subsequent plans are more likely to be sent for IEs • More frequent IEs • During full course of treatment over several plans, more IEs, more disruptions than before 2010. May 6 2013: OPA; amber@kaplanpsychologists.com

  47. What does this mean for patients? • Result can be choppy, watered-down care. • Presumption of fraud, too much cost, and seeking unneeded service is shaping the environment from the beginning for treatment providers, adjusters, and IEs, all of which ends up affecting the patient’s care. May 6 2013: OPA; amber@kaplanpsychologists.com

  48. MVA victims with psychological conditions are among the most vulnerable: • While we know they generate high costs to payor systems • We hate to see this small percentage of vulnerable injured people injured further by a system that pre-judges them to be fakes and liars, and continually questions their need for more care. May 6 2013: OPA; amber@kaplanpsychologists.com

  49. Currently, • We are hoping for more sophisticated and targeted approaches to fraud. • We are in support of many of the new proposed anti-fraud measures because they look like they’re going to be more targeted. • We hope to be involved in the implementation process, for example regarding licensing of health facilities. • We anticipate that these will provide increased cost-savings and reduce the overall atmosphere of distrust. May 6 2013: OPA; amber@kaplanpsychologists.com

  50. Thank you for the opportunity to meet with you We will provide more specific details in our written submission and would welcome the opportunity to address any questions. Reply to Dr. Amber Smith, 905 5295131 amber@kaplanpsychologists.com May 6 2013: OPA; amber@kaplanpsychologists.com

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