After the heavy criticism the case management sector received at the hands of insurers last year, Lynn Rouse looks at the way rehabilitation professionals have responded to the concerns.
This time last year, the rehabilitation industry’s case management fraternity found itself subjected to a bit of a verbal battering. The British Association of Rehabilitation Companies had invited three insurer representatives to a forum to detail their current frustrations in a laudable bid to break down any barriers preventing further uptake and adoption of rehabilitation in the claims process. And the insurers didn’t hold back.
A lack of commercial awareness and disproportionate dealings with injured claimants were central criticisms, resulting in ‘therapy drift’ and inflated costs to insurers. Additional bugbears aired included high turnover of staff, poor management information, a sequential approach to medical and vocational rehabilitation and low levels of innovation.
Stating that he was sharing personal observations, David Fisher, catastrophic and injury claims technical manager at Axa Insurance, said at the time: “My general perception is that rehabilitation overpromises and under-delivers.” In particular, he pointed to the “shifting sands of goals and milestones”, which result in therapy drift. “No one is saying: ‘We can do no more’. If you started to say that you would gain more credibility from the claims handlers that are instructing you day in, day out.”
So, how did rehabilitation professionals respond to these criticisms? Did they regard them as fair comment or too one-dimensional in outlook, ignoring any shortcomings on the insurer front?
“As a case manager it was difficult to sit through but some valid points were made — although the industry didn’t really get a chance to defend itself,” says Deborah Edwards, now head of rehabilitation services at Broadspire Rehabilitation. “You have to understand that case management started from nothing in the UK 10 or so years ago; no one knew what it could do or how much it would cost. It was a hard road to hoe; we had to dig a trench and try to develop fertile ground.”
Changing gears
On further reflection, she adds: “Perhaps the case management industry waited too long and didn’t step up to the mark quickly enough via its organisations like CMS UK or the Vocational Rehabilitation Association. Perhaps it was too focused on fighting to deliver services and, therefore, guilty of not changing gears quickly enough.”
Other commentators are keen to stress that, while they acknowledge these fault-findings to be insurers’ general perceptions, the issues highlighted are by no means endemic. Dr Simon Margolis, chief executive of Premex Group, comments: “While the potential for ‘therapy drift’ clearly exists, I believe the better rehabilitation providers could and should have processes in place that ensure treatment is offered only to the extent there is an ‘evidence-based’ approach and that incremental treatment is only delivered where appropriate, ideally after prior approval from the paying party.
“Often the insurer is relying on the integrity of the rehab provider, and — as in all walks of life and regardless of the industry — there will be some bad apples. But it is unfair to tar the entire sector with the same brush.” If case managers felt a little put upon after the BARC forum, it should be pointed out that insurers do empathise with the challenging role they have to fulfil.
“Case managers have a very difficult job; there are lots of people pulling them one way or the other,” explains Sam Balnaves, rehabilitation team leader at Allianz Insurance. “But it is important to stay client focused, looking at an individual’s personal goals, what you want to achieve and what is realistic.”
She adds: “I do, however, see a lot of process-driven reports with case managers stating their goals and activities rather than ‘this is what we can do for the injured person’. From my perspective, I want to know what they are achieving, not what they are doing and why. For example, is someone now able to ride a bike or drive a car? Case managers must ensure the end goal is always reiterated.
“As regards therapy drift, if you are not continuously pushing towards specific goals this will happen.” Consequently, Ms Balnaves urges case managers to constantly keep ‘smart’ goals at the forefront of their minds: specific, measurable, achievable, realistic and time-specific. “Use objective clinical information markers so that any reader, be they an insurance claims handler or claimant solicitor, can see you are making a difference. And, if something is not working, let stakeholders know and you will gain a lot more credibility with insurers and solicitors.”
For his part, Andrew Pemberton, director at Argent Rehabilitation, adds: “The danger is that we just end up throwing stones at each other and don’t move forward, and I wouldn’t want this issue to turn into a blame game. In reality, providers, insurers and solicitors are all complicit in the success or failure of rehabilitation.”
Carole Chantler, director of clinical services at DWF, points out the blame for therapy drift should not all fall at the feet of case managers: “In respect of ‘knowing when to stop’, communication plays a big part,” she says. “Many providers will say there is poor communication from parties in respect of responding to a request to close a case or fund a therapy. Strategies may have changed between the parties but the providers are not kept in the loop.”
Poor communication
“Perhaps the biggest single problem with regard to therapy drift is that referrers and providers fail in being decisive from the outset,” says Mark Howard, director of rehabilitation and return-to-work at Overland Health. “The problem is exacerbated by poor communication and a lack of evidence-based prognosis and identification of the ‘endgame’, collaborative goal setting.” His colleague, Brian Whelan, head of occupational rehabilitation at Overland Health, adds: “A prognostic report needs to identify the potential of — and barriers affecting — a return to work or function, with a full cost benefit analysis to allow the referrer to make the decision as to whether interventions are to be made.”
In Mr Howard’s view: “We must all push for behaviour change. We need to ensure that the focus is on doing, not talking; being ‘nice’ or ‘protective’ can often worsen the problem.”
This reference to being ‘nice’ echoes one of the other points made at the BARC forum — that the tendency of case managers to herald from the caring professions perhaps exacerbates their reluctance to make the hard commercial decision to stop.
Bob Rabbitts, president of the Bodily Injury Claims Management Association, and technical claims manager for Allianz, comments: “Human nature dictates that rehab providers, and the medical profession generally, are trained to be sympathetic. So realistic goal-setting and being honest when cases aren’t working must continue to be addressed. However, case managers should also look carefully at new instructions, and sometimes decline, if they suspect rehabilitation may not work. They should not allow business targets to get in the way.”
Some rehabilitation providers have tackled this issue head on — simultaneously seeking to address the understandable concerns insurers have regarding the historically high staff turnover in case management. As Ms Balnaves explains: “Firms are trying to combat this; we have seen positive moves and it has to be on the agenda. If you end up with three consecutive case managers on a complex injury, and I have seen that on more than one occasion, you lose so much credibility — especially with the claimant solicitor. They will close doors to you as a result.”
Corpore is one firm that took staffing concerns on board, introducing a training scheme back in 2007, as Leanne Potts, operations manager in its health management & injury response service, explains. “The predominant employment of people from the caring professions carries a risk. But that was a fundamental reason for developing our training programme: to address the fact many employees join us from the NHS and need to then apply their caring skills in a commercial setting.
“It is a very different mindset and one that individuals have to get their heads around. But it was also in response to the fact we were employing a high number of foreign nationals and insurers were becoming critical of high staff turnover. We wanted to underline the fact we are in this for the long haul.” The training programme’s results have since seen success on multiple fronts.
A lack of transparency on clinical decision-making and governance can lead to misunderstandings according to Tony Urwin, sales & marketing director at Medicals Direct Healthcare. “In today’s world, with real-time access to specific case data, innovation needs to focus on systems that will in turn help make the process transparent. However, this is a price-sensitive market and the cost of developing these systems will always be a consideration.”
Mr Pemberton takes up the issue about price sensitivity to suggest the ways in which rehabilitation services are purchased can dictate the way they are delivered — and not always to positive effect: “Some of the points made about commerciality were fair comment but insurers, as purchasers, haven’t done a lot to stimulate change for the better.
“For example, pushing fixed price services onto rehabilitation providers in an attempt to cost contain and limit exposure does not necessarily drive the right quality of behaviour. Say, for argument’s sake, you know you will only get paid £750 for a case but feel that is not enough to provide the right and most appropriate type of intervention. Isn’t there a risk of providers cutting back on what they are willing to do?”
Despite insurers flagging up their concerns at the BARC forum last year — at the direct request of the organisation it should be stated — they also recognise that the training and expertise of their own staff can hinder the process. “One of the reasons issues may occasionally crop up is the lack of extensive experience among claims handlers when dealing with rehabilitation services,” concedes Carol O’Donnell, technical casualty consultant at Ecclesiastical. “Each case needs to be carefully assessed and it is really up to the individual claims handler to direct what treatment is authorised and which treatments need to be withdrawn if no results are being achieved.
“Of course, claims handlers are not rehabilitiation experts and rely on the service provider for direction and guidance in making such decisions. That’s why it is really important we have a strong partnership with providers, so we learn to trust and understand their advice, as we would with any other service provider.”
In terms of avoiding the risk of therapy drift, Ms O’Donnell explains that neither of its current service providers operates a policy of recommending blocks of therapy, preferring to have a limited number of sessions and feedback, enabling an assessment of the value of treatment at an early stage an on an ongoing basis. “Treatment must be personal to the symptoms of the individual claimant — a ‘sheep dip’ approach is wholly unproductive for either party.”
Holding regular case clinics with providers also helps, she says, for both new and ongoing cases. “This allows us to be proactive by sharing best practice and raise any issues we may have with the service provided at the earliest opportunity.”
Looking to the future
In terms of best advice for case managers going forward, Ms Balnaves suggests: “From a case manager’s point of view, I would argue you have to be prepared to challenge. This can be difficult and that challenge may have to be aimed at the insurer, the claimant solicitor or the treating team. This is a difficult skill to master but case managers need to be assertive. They must be prepared to say when they don’t agree with what is happening. This is a skill that gives case managers real credibility because insurers — or solicitors — can then feel confident they know exactly what they are talking about.”
Insurers also need to fully link rehabilitation into the claims process and undergo a cultural mindshift of their own, suggests Mr Pemberton. “Low-value claims aren’t settled on the outcome of any rehabilitation, they are settled on the medico-legal report. So, in a sense, it doesn’t matter how good or bad a service you provide; the impact of rehabilitation is not visible to the claims handler as a cost benefit; all they see is a bill.
“Until rehabilitation matters to the value of the claim, especially at the fast-track end, insurers will continue to argue it is not cost effective,” he says. “Claims handlers are also often told they ‘have to do’ rehabilitation for certain injuries and that is a bad place for the industry to be. We need claims handlers to want to undertake rehab because they know it adds value — and the same goes for claimant solicitors.”
His closing call is for insurers to carry out robust, scientific cost-benefit research, using a control group of cases with a structured study design. Only then can the cost-benefit case debate move from hearsay to evidence.
“No one has really done this research in a robust way and that is why the debate rages on, because there is no categoric evidence. As long as we are dealing with unscientific data, insurers will continue to have doubts over the cost benefit of rehab.”
Case study — how training can have a tangible impact
Corpore’s Building the Foundations training programme has demonstrated the following benefits:
• Decreased annual staff turnover by 72%
• More than doubled the number of British case management staff to 77%
• Supported physiotherapists to successfully pass external clinical audit’s using their continuing professional development as evidence
• Improved productivity by 33%
• Reduced the average duration of desktop vocational rehabilitation cases to 10 weeks.
Medico-Legal News Source: PostOnline
