Medical Claims Management in German Social Health Insurance: Incapacity for work 23.11.2004

1. Medical Claims Management in German Social Health Insurance: Incapacity for work 23.11.2004 Wolfgang Seger

2. The structure and function of the Medical Service Some economic and epidemiological data about incapacity for work The search for the best point of intervention The search for the best items to screen for clients at high risk for long term Incapacity for Work The organisational structure for intervention Results of Medical Expertise Summary of pathways Contents

3. The structure and function of the Medical Service

4. Lower Saxony . Hannover 8 mio inhabitants Population ca 1/10 of Germany

5. Some facts about the Medical Service Statutory organisation (SGB V) Service to all social health and nursing care insurances Budget: ca. 42. mio € 9,27 € per capita Independancy in our organisation and Sociomedical way of thinking Staff: 500 (full time) 154 medical experts 120 nurses

6. Bremen: Dr. Gustav Krimphoff Monika TietjenVolker Tewes Oldenburg: Dr. Mechthild Hermes Barbara Mainka Detlef Schlickmann MDKN Executive Management Board General Manager: Jürgen Vespermann Deputy Manager and Medical Director: Prof. Dr. Wolfgang Seger Division Special Operations Prof. Dr. Wolfgang Seger Controlling Management Support Martin Dutschek Stefan Seidel Division Regional Business Dr. Hubert Krell Central business centers 7 regional Business Centers Central Services Human Res.: Jürgen Mäckeler Inf.Technology: Bernd Nulle Finances: Norbert Krüger Service Center Health Insurance Long Term Care Hannover: Dr. Ute Döbel-Hansen Monika Bettin Annette Franke Braunschweig: Dr. Ulrike Fondahl Gabriele Klindtworth Sabine Eidam Business Group Dental Medicine Rolf Bücken Business Group Consulting Dr. Dietmar Rohland Service Center Bianca Wessels Lüneburg: Dr. Christoph Brandau Siegrid Seidel Anke Bahr Business Group Malpractice Prof. Dr. Rainer Kirchner Sociomed. Expert Group 1 Dr. Sabine Grotkamp Göttingen: Dr. Bernd Schlemminger Bärbel Bodenstab Ekkehard Eberding Osnabrück: Dr. Norbert Jansing Anke Kahtenbrink Manfred Schiermeyer Business Group Hospital Treatment Priv. Doz. Dr. Georg Geißler Business Group External Quality Management Nursing Care Sylvia Theis Osnabrück: Dr. Norbert Jansing Anke Kahtenbrink Manfred Schiermeyer Experts for the Division Special Operations Malpractice, Consulting, Hospital Treatment

7. Medical Service Incapacity for Work Consultation Insurances and their associations, ministry of social affairs, legislative bodies etc. Basic Expertise: to solve fundamental questions Individual Expertise

8. Some economic and epidemiological Data about Incapacity for Work - Is claims management still of importance ? -

10. Incapacity for work in different industries / professions 2003 in comparison to 2002

11. Economic loss in different industries in Mrd. / Bill. € others 5,3 Producing companies 18,1 Banking, insurances 15,8 Serviceoriented enterprises 15,2 Commerce, hotels, restaurants, traffic 11,5 Building and construction 3,2 Agriculture, forest, fishery 0,4 0 2 4 6 8 10 12 14 16 18 20 Mrd / Bn €

13. Total economic loss due to incapacity for work • In 2002 • 69.500.000.000 € • (69,5 Mrd. €)

15. Incapacity for Work: the search for the best point of intervention

16. Up to 1 week Up to 2 weeks 5 4 Up to 3 weeks Up to 4+5 weeks 13 Over 6 weeks 57 21 Distribution of case-related length of incapacity to work in %

17. 60 50 Frequency in percent Duration in percent 40 % 30 20 10 0 - 1 week - 2 weeks - 3 weeks 4.- 6. weeks > 6 weeks Comparison of IW – frequency and IW – duration in percent

18. Point of intervention % of IW-cases 100 100 90 80 • IW-cases in % • - IW-days in % 70 60 50 Beginning of benefit payment 45 45 40 30 23 20 15 16 9 10 12 12 10 14 10 14 5 7 6 6 Duration of Incapacity for Work in weeks 0 0 1 2 3 4 5 6 7 >8

19. Incapacity for Work: the search for items to screen for clients at high risk for long term Incapacity for Work

20. Identifying claimants at higher risk of long-term incapacity versus those likely to return to work Predicting likely duration of sickness absence and return to work Identifying people who need extra therapeutic or rehabilitation help Identifying those obstacles to coming off benefit and returning to work that may be appropriate for intervention Identifying people likely to respond to (an) intervention versus those likely not to respond Informing a rehabilitation programme or other work-focused intervention Informing the decision-making process and case management Purposes of Screening

21. Actuarial / administrative Identification of risk markers (causal or explanatory significance regarding the outcome or possible intervention), epidemiological and demographic data or in administrative database to produce tables of risk that are simple to use , score, transparent Clinical and psychosocial Predicting likely progress and outcomes (how and why some people develop long-term incapacity and what can be done about it) with strong scientific and statistical foundation Methods of Screening

22. Psychosocial factors (`Yellow Flags`) are generally agreed to be stronger predictors of chronic pain and disability than biomedical factors or physical characteristics of work Some facts about clinical and psychosocial predictors

23. 100% Displacement of problems in patients during incapacity for work Social / Psycho-social problems,, Internal migration etc. Medical problem Chronic period 2nd. month / 3rd month Acuteperiod Subacute period (evidenced by experience and literature)

24. Best selection of individual predictors and the construction and scoring of screening tools are time-dependent (It is not possible to predict long-term outcomes with any accuracy using clinical and psychosocial variables in the early days of sickness, this only becomes possible by about 3-6 weeks) Facts for the selection of items

25. The window for screening

26. Best selection of individual predictors and the construction and scoring of screening tools are outcome-specific and intervention-specific (the risk of long-term incapacity, and hence prediction and screening, are partly dependent on the success rate of the intervention and the probability of response) Facts for the selection of items

27. The accuracy of prediction varies with all of the above. The best specificity and sensitivity achieved in clinical and psychosocial screening is of the order of 80-90 %, and more generally about 70-80 % Some facts about clinical and psychosocial predictors

28. Clinical and psychosocial predictors

29. Sociodemographic predictors

30. Recommendation for screening by literature:

31. Suggestion for Socio-demographic screening (Waddell, Burton and Main)

32. Suggestion for Psychosocial Screening (Waddel et al)

33. … is possible and potentially valuable in a social security context `Administrative`Screening based on socio-demographic resk markers and `Individual`Screening focusing on clinical and psychosocial factors can be combined into a logical and practical sequence in the screening process … can achive about 70-80 % sensitivity and / or specificity Literature: screening in the context of long-term incapacity

34. Timing: Practical problem to define the onset of illness, of disability or of incapacity The development of long-term incapacity involves biopsychosocial changes and may influence further progress and constitute obstacles to coming off benefit and returning to work At different times in the course of incapacity, screening faces very different statistical tasks On day 1 screening has to identify the 1-2 % of individuals who will go on long-term incapacity from amongst 98-99% with relatively simple problems, most of whom are likely to return to work quite rapidly, irrespective of any intervention After 26 weeks of sickness absence most will have variable, complex mixtures of biopsychosocial problems, an the task would be to distinguish the 40% likely to continue on long-term incapacity from those who might return to work. Timing and Accuracy of Screening

35. Items of Incapacity for Work how often and how long Items of Social Conditions Working condition, employer, family Severe diseases in case history cancer, accident, hospital or rehabilitation, claim for pension benefits, Psychotherapy etc. Medical findings Analysis of records Questinnaire to the therapist Questionnaire to the client: Information about workplace and medical reports Current diagnosis Necessary informations for the screening:

36. Incapacity for Work: the organisational structure for intervention

37. „ABBA 2004″ • The ABBA is a guideline, which was developped in cooperation between health insurances, medical service and the federal associations of insurances. • It is a guideline in accordance with the relevant legislation (Social Law Code No. 5) . • It is liable to the health care insurances as well as to its medical services.

38. Group 1 Non striking Group 2 striking (Selection criteria) Screening by health insurance

39. Non striking group 1 Grouping till day 21 Duration of IW ? Date of beginning IW ? Diagnoses ? Certifiying doctor ? Social case history ? Utilisation of other benefits ? striking group 2

40. On principle there is no need for action up to day 28 ! Group 1

41. % derAU-Fälle 100 100 90 80 70 60 50 45 45 40 30 23 20 12 10 5 0 0 1 2 3 4 5 6 7 >8 The right time for intervention • AU Fälle in % • - AU Tage in % Beginn: Krankengeldbezug 15 16 9 10 12 14 10 14 7 6 6 Dauer der Arbeitsunfähigkeit in Wochen

42. After day 28: Reassure the correct diagnosis which is leading to incapacity for work Seek a dialogue with the client up to day 35 in respect to his work- place Prove the possibility for a stepwise reintegration if further clarifying is necessary take sociomedical case consultation (SCC) into consideration Be aware of the right time for the right intervention (catalogues for normal disease courses and length of therapy, teaching of decision managers etc.) Group 1

43. Group 1 Completion of materialfor SCC, Defining theright order / commission, Fixing the date Presentation to SCC* Submission day 28 Dialogue with client till day 35 IW* plausible IW* terminated * Sociomedical Case Consultation ** Incapacity for work

44. Sum of IW-days per year higher than average? Reference is the statistical average in industry / profession / health insurance and length of reconvalescence Preselection for group

45. Incapacity to work in reference to the disease groups (IW Cases and IW Length)

46. High frequency of IW in respect to age (IW-carreer)? Interruption of benefits in case history? Repeated IW due to the same disease? Recent case history more than 3 months? „Personal pattern of duration of IW″ recognizable? Pattern without relation to diagnosis: constant duration per IW-case, seasonal pattern when comparing the years, frequent involvement of Fridays and Mondays Informations extracted from the dialogue with the client (standardised !) Intended date of revival of work, intended date of contact with the unemployment insurance? If appropriate: documentation of backgrounds for the Medical Service. Comparison of workplace requirements with mentioned impaiments and handicaps (specifications of workpalce and its environment necessary) Grouping for preselection (HI)

47. Presentation to Sociomedical Case Consultation (SCC) necessary? If yes, than: Compilation of relevant and usable informations and definition of decisive questions for the SCC Result of preseclection

48. Family name, first name, date of birth, address, incl. telephone- no. Last relevant occupation, duration of last employment, employer Similar occupations ( if employment is terminated during IW for unskilled and semi-skilled clients) If unemployed: date of submission for commission through insurance for unemployment Beginning of IW, Termination of sick pay by employer or sickness benefits by insurance Diagnosis leading to IW / ICD-10 Doctor certifying IW ( name, specialisation, tel., address) Duration or IW-times and diagnoses of IW during 3-5 years Compilation of data (1)

49. Sum of IW-days per year during 3-5 years Utilisation data about medical benefits for rehabilitation / participation State of process for eventual claims for rehabilitation, participation or pension Data about hospital teatments during 3 years Medical findings of medical specialists and non medical therapist, medical reports of in- and out-patient treatments (negative) social context factors Occupational diseases / accidents (with connexion to IW) Benefits of pension funds, kind of benefits GdB / MdE etc. (degree of handicaps or disabilities recognized by other social or statutory institutions) Compilation of data (2)

50. Incapacity in doubt (health insurance decision maker) / securing recovery (prospective duration of IW ?/ assessment of short or long term personal capability performance !) Incapacity in doubt (employer) Impending, emerging or irreversible incapacity for employment or occupational disability § 51 SGB V(Medical Rehabilitation / rehabilitation for occupational participation) Link with preceding IW-times(the same disease?) Other links with IW(stepwise occupational reintegration / referral to unemployment insurance) Examples for questions arising in health insurance