2012 ALUCA TurksLegal Scholarship
Winner
Early Intervention for Life and Health Insurance Carly Van Den Akker | Swiss Reinsurance Company
What has been your experience with early intervention in disability and TPD claims? Has rehabilitation and return to work been as successful as many have suggested in the literature? Are some claims more open to early intervention than others? If so, when is it most effective, and what do companies need to do to get the maximum benefits from early intervention? Your answer should review the evidence for and against the effectiveness of early intervention and also discuss the particular problems that may arise in the group claims arena where the company has to work with a trustee or fund administrator to action an early intervention program. Your answer should give practical examples of how these problems can be addressed and overcome.
Introduction In almost every personal injury claim setting around Australia, and in fact globally, the buzz phrase seems to be ‘early intervention’. But what is ‘early intervention’ – is it a concept, a process, an aspiration … or possibly a magic wand to wave to get an outcome on a claim? It is important for insurance companies to understand not only what early intervention (EI) means but to have clear objectives for such intervention as opposed to just going through the motions or ticking a box at claim assessment time. This paper seeks to explore the research in support of EI, and against it, with a focus on what it means within the life insurance sector.
Origins Early intervention programs have been operating effectively in the workers compensation and compulsory third party (CTP) settings since the late 1980’s. Since the concept of EI was embedded in the Australian compensation system, it has continually evolved in line with best practice research:
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Figure 1: The early intervention timeline1
There is now a wealth of evidence to support EI initiatives that focus on retaining the injured or ill at work, or to support return to work (RTW) as soon as safely possible. Occupational rehabilitation providers all sing from the same hymn book with regard to the benefits of early RTW and conversely, the health risks of longer term “worklessness”. Research undertaken by Dr Gordon Waddell and Sir Professor Mansel Aylward found that the impact of worklessness in terms of health risk and life expectancy is “greater than many killer diseases”2. This research goes further to support EI programs leading to timelier RTW and hence reductions in claim durations. Australian research echoes these findings by measuring the chances of returning to work following injury. A study by WorkCover Victoria in 2005 concluded that the likelihood of a person ever returning to work following injury is as low as 35 per cent after an absence of 70 days or more3.
The Concept The first place to start is in defining what ‘early intervention’ means. How do we define ‘early’? In the life disability claims context, ‘early’ is most often when the claim is received on an Assessor’s desk. Typically, this is on the day the waiting period expires or the claim is received from the third party administrator (TPA). Thus best case could be 30 days after the injury or illness first presents but this can stretch out to 90 days or even years from onset of the claimed condition. The Oxford Dictionary states that to ‘intervene’ is to “take part in something so as to prevent or alter a result or course of events”. Therefore in income protection (IP), intervention should focus on preventing claims from exceeding predicted durations or progressing into the increasingly more frequently charted waters of chronic disability. Intervention differs for total and permanent disability (TPD) claims. Here the objective is to make an assessment as to whether a claimant meets the definition of TPD as set out in the policy – so intervention is more aligned with seeking the right information as early as possible in order to make a considered decision to either pay or deny the claim.
Tried and Tested Early intervention programs are not a ‘one size fits all’ approach for claims management. There are some claim types that may be more receptive to EI initiatives than others. Going back to the stated goal of intervention being to prevent claims from exceeding predicted durations, it is widely thought that the crystal ball for anticipated recovery should be more straight forward for
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objective conditions such as muculoskeletal injuries. Here tools such as the Medical Disability Guidelines provide evidence-based timeframes for recovery for many common injuries and illnesses. Despite having the knowledge around when to expect RTW for musculoskeletal injuries, we have all seen enough cases where this expectation is exceeded by months or even years. Consequentially there have been many attempts to implement EI programs to reduce the likelihood of musculoskeletal injuries becoming chronic. In 2008 Dr Michael Nicholas et al conducted a pilot study at Concord Hospital in New South Wales4. A screening approach was implemented using a modified 13-question Orebro Musculoskeletal Pain Questionnaire (OMPQ). Here injured workers had the OMPQ administered within two days of the injury being notified. Based on their OMPQ score, the injured employees received varying degrees of intervention from education and self-directed exercise to hands-on treatment such as physiotherapy and work conditioning for high risk individuals. The intervention groups were then compared to a control group where no intervention was undertaken. The results showed a saving of 25 per cent in claims costs (reduced durations) in the high risk group when compared to the control (no intervention). This is considered strong evidence for EI with a stepped care approach for musculoskeletal injuries and only serves to reinforce that no intervention (control group) can lead to longer term chronic illness. The incidence of mental health-related IP claims is increasing however there are limited studies demonstrating the impact of EI on RTW outcomes for these claimants. One life and health insurer in the United Kingdom is currently running an intervention program designed to assist IP claimants with mild to moderate mental health conditions to stay at work or RTW. This insurer is working together with a rehabilitation provider and an insured client, to implement a stepped care model and apply the principles of EI to mental health conditions. Preliminary results have shown that for mental health claimants referred for intervention after a lag of over six months (average 204 days after onset), the overall RTW/fit for work outcome was 52 per cent. For mental health cases referred within six months (average 80 days after onset), the RTW/fit for work outcome increased to 72 per cent. These research pilots highlight the need to differentiate intervention based not only on the claimed condition, but on triage or screening scores which serve to evaluate the claimant’s attitude to their condition, perceived levels of support, and motivation to RTW. What is evident in these studies is that some level of intervention is more likely to positively influence recovery duration as opposed to taking no action and allowing each claim to take its course.
Putting ‘Life’ back into Life Research has brought us to the realization that medical management (treatment-based care) in isolation typically does not equate to recovery and RTW. Evidence-based practice supports the
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adoption of a biopsychosocial (BPS) approach to claims management and the earlier these BPS factors are identified, the better the prospects are for overcoming them. Effective claims management therefore needs to focus on putting ‘life’ back into life insurance. There are several tools available to assist Assessors and Rehabilitation Consultants to identify BPS factors. Screening questionnaires such as the OMPQ, DASS (Depression, Anxiety and Stress Scale) and the FactorWEB are available online and can be administered by non-allied health personnel. The focus of these tools is to drill down on factors outside the injury/illness diagnosis (red or medical flags) that may be impacting recovery and RTW:
Figure 2: The flags model5
Early intervention programs should seek to identify these warning flags to recovery and RTW through early screening and action-planning to ensure these indicators do not become long term obstacles. The recent addition of ‘pink’ flags or positive attributes such as strong motivation levels, emotional resilience, high job satisfaction and commitment should be harnessed by Assessors as enabling drivers to claims resolution.
Overcoming Obstacles When considering the implementation of EI initiatives within the life market, there is often more doubt than confidence. High on the list of objections are rationale for why EI works in workers compensation settings but not in life: (i) (ii)
The immediate notification timeframe for an injury/illness and hence the ideal backdrop for true ‘early’ implementation of strategies to assist claims management. The insurer’s capacity to fund reasonably necessary medical treatment. Claimants
(iii)
therefore have access to appropriate treatment in the acute stage of their injury where most evidence supports the efficacy of treatment. The governing legislation that binds all employers to participate in the injury management and RTW process through regular contact with key stakeholders, and by making all attempts, as far as reasonably practicable, to accommodate injured employees on light duties.
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Although some limitations apply in the management of IP claims, there is still scope to influence claims durations through EI programs. Tackling the first hurdle of intervening early despite the waiting period or notification delay may be the most challenging in the life setting – and particularly for group claims where the insurer is required to work with the trustee or fund administrator. In these portfolios, it is crucial for the insurer to seek permission to contact members directly to facilitate early information gathering and identification of potential barriers for RTW. Traditionally, life insurance has been much of a paper-based management system where claims are notified in writing and much of the management happens through reliance on written information. Insurers now are starting to realize the benefits of speaking directly to the member when the claim is notified (through channels such as tele-collect) – not only to quickly obtain information missing from the claim form, but also as a means of judging the member’s attitude to their injury or illness and their perceptions around recovery and RTW. Being able to pick up the phone and speak with members is often a daunting prospect for Assessors however the benefits stretch far beyond information gathering. Speaking with the member is a great opportunity to educate about the claims process, to undertake BPS screening and to build rapport and trust … a recipe for effective claims management. How can we use the waiting period more effectively for group claims? Here Assessors have the opportunity to develop collaborative working relationships with the group scheme and the employer organisations. Often the employer contact is within the Human Resources department and may also be the designated RTW Coordinator. Some life insurers are now solidifying processes to obtain long term absence data from their insured group employers on a regular basis in order to preempt the lodgment of IP claims when paid sick leave is exhausted. This is just the first step in what has the potential to be a proactive approach to reducing new IP claims or at a minimum, reducing some claims durations through preservation of the employer-employee relationship. This strategy may be more suitably termed ‘early engagement’ and wherever possible should involve the group scheme. Life insurers have an opportunity to: 1.
Promote the health benefits of work with insured employers and encourage the extension of their in-house injury management program (offering suitable duties and graduated RTW) beyond their obligations to workers compensation claimants. This RTW-focused program could be universal, setting the expectation to all employees, that a safe and durable RTW is everyone’s top priority – this may go some way towards addressing obstacle 3 (the lack of governing legislation for RTW in life insurance).
The health promotion piece should extend to targeting the knowledge and beliefs of workplace representatives regarding conditions such as cancer – studies have shown that it is often the perceptions of the employer that delay RTW rather than the employee.
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Facilitate early contact with employees eligible to lodge an IP claim by obtaining consent. This may allow the insurer to offer early rehabilitation services and to start the dialogue around the claim process and expectations for RTW.
3.
Engage in onsite case conferencing and familiarisation with the workplace. Successful RTW requires the buy-in of all key parties and Assessors/Rehabilitation Consultants who are familiar with the nature of the duties and work environment find they are able to better relate to claimants when negotiating RTW plans.
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Educate on how protracted claims durations can lead to inflation in group salary continuance policy prices.
Challenging the second opposition regarding the inability to fund treatment involves education around the failures of the medical model as outlined previously. Furthermore, in many instances, claims are received well beyond the physiological recovery time for the injury or illness. We need to adopt a BPS approach to claims management and sell the therapeutic benefits of work as therapy: “for most individuals, working improves general health and wellbeing and reduces psychological distress�6. The inability to fund Medicare-listed treatment should force claims staff to think outside the box for other options that could be considered under the rehabilitation benefit. Here we are not limited to just funding rehabilitation programs. Alternatives such as work-related activity programs, online cognitive behavioural therapy (CBT) programs and business coaching are just a few options available.
The Path to Divine Intervention
Engaging the key stakeholders early: - -
In group schemes, this could be obtaining long term absence data, gaining consent to contact the members directly from the fund administrator, promoting the health benefits of work, duties familiarisation and expanding organisational injury management programs to ALL injuries and illnesses whether work-related or not. In retail schemes, early claims submission should be encouraged with Advisors. Early contact with the member, their treating health professional and employer should be about building rapport and setting expectation for RTW/ resolution.
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Intervening early: - - - -
Screen or triage new claims to identify those at risk of long term absence. Recognise the BPS factors that might be influencing recovery and RTW – including the positive pink flags! Consider stepped-care models of intervention based on risk category. For claimants at higher risk of long term disability, consider early referral for treatment / rehabilitation options with an element of CBT to influence positive behavior change. Utilise scores from the screening tools with the member’s General Practitioner as evidence for the need for treatment referral (for example – high DASS scores could flag referral for a Mental Health Care Plan). Provide hands-on training for Assessors to enhance confidence to call members and health practitioners. Share success stories and embrace positive outcomes. Realise the RTW goal from the outset. If the member is unlikely to RTW in their own occupation and their employer cannot support alternatives, or if the member is terminated – early referral for vocational rehabilitation is essential. Remember that successful RTW outcomes are more likely where referral occurs within the first 12 months.
The message is clear: proactive intervention at the earliest possible stage is more effectivethan taking no action or simply reacting to incoming mail. The EI approach the insurer adopts needs to be multifaceted, endorsed at all levels and focused on putting ‘life’ back into life insurance.
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References Adapted from: Wyatt, M. Power to the employee and employer – what the research says. Melbourne. Resworks; 2010 1
Waddell G., & Aylward M. The scientific and conceptual basis of incapacity benefits. London. The Stationery Office; 2005 2
Johnson D, Fry T. Factors Affecting Return to Work after Injury: A study for the Victorian WorkCover Authority. Melbourne. Melbourne Institute of Applied Economic and Social Research; 2002Financial Standard – BT Life Fast Tracks Claims 3
Nicholas, Pearce, McGarity, Linton, Peat. Early intervention in high risk individuals injured at work. Concord Repatriation General Hospital; 2008 4
Shae-Mills S. Pre-claim intervention of long duration workers’ compensation claims. Curtin Health Innovation Research Centre, Western Australia; 2009 5
Australasian Faculty of Occupational & Environmental Medicine (AFOEM). Australian Consensus Statement on the Health Benefits of Work, Sydney; 2011 6
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