Pains, Claims and Automobiles

New programs like Aviva Canada’s Premiere Healthcare aim to transform how injury claims are managed. Using an evidence-based treatment model, Aviva says its program marks a radical shift in the relationship between customer, insurer and health provider. Will it work?

Despite a growing body of medical evidence on the proper treatment of soft tissue injuries, most insurance companies have not substantially changed how they handle these claims. The outcome has been predictable, and frustrating. This includes overworked accident benefits adjusters, adversarial relationships between insurers and health providers, a corresponding slew of regulatory – and often bureaucratic – requirements and, most importantly, delays or obstacles for customers.

In short, many say the system is broken and needs to be fixed. Such “fixes” may involve legislative initiatives, such as caps on pain and suffering awards (in Atlantic Canada and Alberta) or pre-approved frameworks for the treatment of certain injuries (in Ontario).

But some insurance companies are taking matters into their own hands and are changing the whole method of claims handling. One such example is Aviva Canada’s Premiere Healthcare program, which was launched in October. Designed to cut through many of the administrative processes and delays associated with soft tissue injuries, the program provides treatment to customers immediately after a collision. Customers can choose to go to one of seven pre-approved rehabilitation networks – including 169 clinics in Ontario – within guaranteed timelines.

“All of the evidence around soft tissue injuries suggests that there should be a continuum of care model, which starts right at the onset of the injury,” Greg Somerville, executive vice president, reinsurance and claims for Aviva Canada, says. “We built a model and changed our entire operation to ensure that the injured person gets into our health program as soon as we find out about it. It is undeniable that early intervention has a positive impact on recovery rate.”

Soft tissue injuries – which typically involve whiplash, strains, sprains and bruises to muscles, tendons and ligaments – are not a minor irritant. The Insurance Bureau of Canada (IBC) estimates 80% of insurance claims following car accidents result from soft tissue injuries. Insurers in Canada spend about $4 billion annually to help people recover from these injuries. What frustrates insurance companies is that this money does not seem to make people better faster.

“The real conundrum is that we have known for some time the type of treatment that will make a difference and yet, for whatever reason,we are having trouble putting this knowledge into action,” Dr. Sally Nikolaj, president of Nikolaj Consulting Inc., says. “I really think what is missing is the execution. How do you take the literature and make it come alive? A big part of the answer is that the insurer has to play a role.”

An internationally known consultant on the implementation of injury treatment models, Nikola helped Aviva set up the Premiere program but she first started to develop soft tissue care models while working with the Alberta Workers Compensation Board in the ’90s. These models reflect the latest, evidence-based medical research to ensure that the care and treatment provided are appropriate and occur at the right time. They are essentially “road maps,” based on typical recovery patterns and best practices in health care. And they are ideally supported by evaluation systems that measure what Nikolaj refers to as the critical “trilogy” – duration of disability, claimant satisfaction and health costs.

The results for the Alberta WCB showed a dramatic improvement. Before the soft tissue care model was introduced, roughly 9% of Alberta’s workers with sprain and strain injuries were receiving some type of compensation benefit 18 weeks after they were injured. After the model was introduced, this figure dropped to about 3%.

Nikolaj says the Socit de L’assurance Automobile du Qubec (SAAQ) introduced a similar pilot of the soft tissue care model in 2001. The finding of that pilot showed a significant decline in the proportion of claims reaching 18 weeks of duration – down from 50% to 21%. SAAQ actuaries estimated the cost savings would be about $30 million per year. In 2002, SAAQ approved a province-wide rollout of the soft tissue care model.

The IBC conducted an Ontario Whiplash Pilot project from 2003 to 2004. Five insurers, including Aviva, used Nikolaj’s model for claimants in Mississauga and Brampton and compared the results to control groups. The results of that pilot project are just now available. Barb Sulzenko-Laurie, director of health and policy issues with the IBC, says the data shows a marked improvement in claimant satisfaction and duration of disability. Of the 50% of claimants who responded to the pilot project survey, 87% said they were highly or very satisfied.

“We compared the duration of disability and the health care costs of the pilot project to control groups, and it was a very favorable comparison,” Sulzenko-Laurie says and adds that the pilot results are currently being reviewed by an external evaluator.

The Ontario Whiplash Pilot was a springboard to the development of the Premiere Healthcare model, but there are some important differences. “Ease and speed of access to qualified healthcare providers for customers, and less administration for both customers and clinics – through streamlined services and independent third-party evaluation of all claims – set Premiere Healthcare apart,” Somerville says.

EXPEDITING CARE

To change the process, customers who report their claims through Aviva claims care centres are now asked questions about their health status and also given the option to speak to a claims specialist. This “warm transfer” allows the company to make contact with claimants as soon as possible and refer them immediately to an appropriate Premiere health care facility. Customers who report an injury are scheduled into an appointment within 24 hours.

“The research has shown that a soft tissue injury continuum of care is more effective than not having a continuum of care,” Dr. David Corey, an active memeber of the Premiere Healthcare program and president of the Health Recovery Group, says. “So let’s use what we know works, let’s make sure people get early, effective treatment when they need it.”

“You could have the best health care providers who are delivering evidencebased care, but if you can’t develop theprocesses to send the appropriate claimants to them, it won’t make a difference,” Nikolaj says. “I am pleased that Aviva seems to have figured this out.”

“Most insurers are of the opinion that if they make a recommendation to a claimant, it will be seen as a negative,” Brenda Rusnak, CEO of ACTIVE Health Management, says. Her firm is part of the Premiere network. “Aviva has proven that theory completely wrong,” she says. “We are seeing that claimants like the fact that Aviva is taking that extra step and helping them access the care they need.”

The Premiere program is not just focusing on claimants, but other “points of entry” into the injury management system as well, such as family physicians.

FILE SHARING

Once the claimant is identified, there is a corresponding responsibility on the health care provider network to provide timely service.”We had to say to the health providers, ‘If we get the front end right, identify the people who need this help, you have to accommodate them immediately,'” Nikolaj says. “There cannot be a queue.”

Aviva’s Premiere Healthcare program is also unique in that Aviva’s advisor and the health provider share authority over the claim file. “We essentially moved the decision-making over treatment and rehabilitation decisions from the insurer side to the health care side,” Gordon Rasbach, vice president of Healthcare Services for Aviva, says. “Healthcare providers now adjudicate the amount of treatment and type of
treatment required, not the advisor.”

In addition, health care providers in the new model are doing their part to streamline the paper-intensive process of making an accident benefits claim. Health clinics in the Premiere network will help claimants complete the lengthy application forms. Absent the Premiere network, this process is, “without a doubt, the greatest source of customer complaint,” Rasbach says.

A change to the claims adjudication policy puts more control in the hands of treatment providers. But there is accountability, as well. As Nikolaj notes: “Some would say, ‘Well, the pendulum has swung and we may start to see over-treatment.’ And there is a risk of that. My personal feeling is that I would rather have that risk than the possibility of treatment being delayed. If the injured person doesnt need any treatment, then Aviva has to trust the providers will send the person on their way. This approach is based upon the belief that providers will do the right thing.”

Rusnak says the Premiere program allows health providers to work as “trusted partners” to the insurance industry. “So many times we have been forced to jump through hoops – to treat in accordance with a fee schedule and legislation – as opposed to giving patients what they need,” she says. “And that is what we have to get back to – a system that fits in with how health providers actually assess, make prognoses and treat patients.”

Another critical aspect of the Premiere Healthcare program is an ongoing evaluation process, including monthly intervals of monitoring outcomes. Rasbach notes there will be a two-year learning period for the collection of data and experience on both the insurance and health care sides of the equation.

“Aviva is now into the health care performance evaluation business,” Rasbach says. “We have not previously needed this competency as an insurer, so we have hired a significant amount of former clinic owners and former health practitioners on staff to fulfill this need.”

“I particularly like the performance accountability issue, because it is the first time that there has really been an independent monitoring of meaningful outcomes for the treatments that health care providers are doing,” Corey says. “You have to look at the bigger picture. Did people recover? Did their symptoms improve? Did they return to work and regular activity? This is a systematic way of measuring those meaningful outcomes.”

ACCREDITATION PROCESS

To select its network of health care providers, Aviva relies on a commitment to an accreditation process known as CARF, the Commission on Accreditation of Rehabilitation Facilities. This internationally recognized standards organization has accredited more than 38,000 clinics and services in the U.S., Canada and Europe.

Rasbach says accreditation and evaluation are necessary building blocks to any kind of insurer health care network. “My fear is that there are going to be insurers who will set up preferred networks in the traditional sense, but now will be dealing with flesh and bones, not fenders and glass,” he says. “And they are going to leave themselves wide open if they dont incorporate some kind of third party accreditation or evaluation piece. If they don’t get this part right, they may find themselves legally at risk. “

The Ontario Trial Lawyers Association has already sent a letter to provincial regulators arguing that these kinds of programs could put health-care providers in a conflict of interest. In early October, association directors Richard Halpern, Patrick Brown and Charles Gluckstein warned that “the health care provider is being called upon to balance responsibility to the patient with responsibility to the organization managing the care, resulting in a tension that will be difficult to resolve.”

REBUILDING TRUST

Looking ahead, Aviva plans to expand the Premiere Healthcare program from Ontario into Atlantic Canada and Alberta in “the very near future,” Rasbach says. It will expand not only geographically, but also to include other forms of claimant injuries. “We are already looking into programs of care for pain disorders and fractures,” he notes.

Underlying the entire Premiere Healthcare program is the rebuilding of trust between insurers and health care providers. “That may sound like motherhood, but when we got down to the desk level of the average claims adjuster, we found out that many of them had longstanding animosity towards health care providers,” Nikolaj says. “They felt for years they were being taken advantage of, and that their whole job revolved around fighting with providers.”

Parts of the system have been set up more to control disputes as opposed to doing what is best thing for the patient, Corey adds. “Instead of managing injuries, we have been managing disputes, and I have thought for years that was the wrong focus.”

Rasbach says health care providers and insurers “needed to start with a clean slate.” And while the Premiere Healthcare program is only three months old, expectations are high. Rasbach would not release participation levels to date, but he says the number of claimants participating in the program has exceeded expectations.

Many will be watching if it meets its goals. The big question with the program in the coming months: will it actually work?

“Aviva has got the first part right,” Nikolaj says. “They are getting claimants in. Now we will have to see if it is making a difference.”

Nikolaj says too many insurance companies have built the whole disability management piece on cost containment. “You can offer cheap health care but if the quality is not there or if your clients are dissatisfied, the whole thing will fall apart,” she says. “Aviva has really bought into the philosophy that if claimants get quality health care as fast as possible, and you focus on outcomes, they will return to their pre-accident lifestyle as quickly as possible.”