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

1. Impact of claims management, treatment, and rehabilitation on recovery and return to independence Liz Cairns, Manager Serious Injury Service, ACC, NZ

2. 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

3. 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

4. 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

5. NZ’s Accident Compensation Scheme

6. 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

7. Client mix Sprains & strains Cuts & bruises Broken bones Back strain Multiple injuries Persistent pain Traumatic brain injury Spinal cord injury Multiple amputations Severe burns Rehabilitation & recovery Lifetime support Short term Long term Disability

8. 27% cost15% liability 51% cost33% liability 22% cost52% liability 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

9. Injuries involved in disability claims Spinal cord injury 38% Severe & moderate traumatic brain injury 58% Other 5% Data as at 30 Jun 2011

10. Case study Achieving better independence & participation outcomes for clients Achieving sustainable growth in costs & liabilities

11. Situation 30 June 2007 Liability blow-out Isolation & dependence Low participation rates in community activities & employment: Best Typical NZ Spinal 80% 40% 18% Brain injury 56% 35% 9% • Accelerating rate of growth in average cost per disability claim: • 4.2% in 2005 • 5.8% in 2006 • 14.3% in 2007

12. Drivers of cost growth Single biggest driver of cost & liability growth

13. Strategy Identifying the problem Selecting solutions

14. Managing theservice gateway Diffuseaccountability One size fitsall No alternatives 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

15. Cost per claim 2003 2004 2005 2006 2007 2008 2009 2010 Selecting solutions • Clear vision of wherewe needed to get to: • Stabilise growth in costs to a sustainable rate • Improve client outcomes:increase participation Sustainable growth rate

16. 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

17. Implementation Person-centred planning Evidence-based practice Alternatives to attendant care Client segmentation & case management specialisation Outcomes focus Performance reporting

18. Client Other funders Family ACC Community Employer School Person-centred planning in action • Treatment  • Rehabilitation  Participatory goals • Home/living • Work/education • Leisure /recreation • Community access What supports are needed ? Where will these supports come from ?

19. Linked to evidence-based practice Person-centred planning Alternatives to attendant care Case management Assessment Reporting Maximise independence & participation

20. Assessment Best in class, objective assessment tools & methods

21. Alternatives to attendant care Short-term, outcome-focused services: Supported Living Supported Employment Youth transition

22. 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

23. Case management specialisation In-house specialists Disability experience Located in clients’ communities local knowledge Reflected in case loads Competency based

24. 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

25. Outcomes focus Information for clients Emphasis on livingan everyday life Focus on clients’goals, not “entitlements”

26. 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

27. Performance reporting model Processes Compliance audits, satisfaction surveys, dispute rates, etc OUTCOMES Impact on client’s lives: To person-centred objectives Evidenced by evidence-based measures 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 Efficiency and effectiveness reporting

28. Putting it all together…

29. Results Client goal achievement Employment participation Actuarial release

30. 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

31. Role of Research Past Present Future

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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?

38. 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?

39. Conclusions

40. 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

41. 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

42. We have partnered with… • Our in-house researchers • Best practice treatment & rehabilitation practitioners • Academics & health researchers - locally & internationally • Market researchers

43. Research is a tool • It will be used by insurersas long as it.. • Continues to be useful • Remains practical

44. Questions?