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Rehabilitation: Case management - The ugly duckling

Published 11/09/2008

While most insurers welcome the concept of rehabilitation, its delivery has often met with criticism. Louise Meeson looks at the efficacy and cost benefit of the case management approach adopted by some UK providers, and asks whether this could transform rehabilitation into a model that satisfies all insurers

Although rehabilitation undoubtedly has benefits for claimants and compensators alike, the industry has arguably encountered teething problems. Matthew Beard, director at Medicess, recently claimed the UK rehabilitation industry has “over-sold and under-delivered” and there is “an emerging attitude that engaging rehabilitation only serves to layer cost and elongate claims”. He also warned at the time that unless it became “more self-effacing”, insurers “will turn their back on it” (Post, 21 August 2008, p11).

Although many disagree that insurers are turning away from rehabilitation, few would deny that it has to be deployed appropriately, as it can generate unnecessary costs and the difference between offerings from providers in the market is significant.

David Fisher, injury claims technical manager at Axa Insurance, says: “Rehabilitation is still a developing arena and is frequently misunderstood by insurers and claimant solicitors, but to turn ones back on it would be a big mistake. While there still needs to be a great deal of work on looking at the cost-effectiveness of rehabilitation in respect of various values of claims, there is no doubt that it is here to stay.”

However, he warns that insurers must ensure rehabilitation is used only in appropriate cases, otherwise he says it can add cost and be of little benefit.

David Frost, technical manager for motor and legal services at RSA, adds that rehabilitation “has to be deployed intelligently and only where appropriate”. He explains that RSA, which works with Argent Rehabilitation, has integrated rehabilitation into the claims process so it is deployed early, as he estimates that, where it works, it can reduce claims and settlement times by up to 55%.

What is clear, however, is that rehabilitation is not a one-size-fits-all solution and it does not add value in every case. Mark Baylis, chair of the International Underwriting Association and Association of British Insurers’ rehabilitation working party, says: “There’s no doubt the insurance industry is using more rehabilitation services but there is a big gap between the amount being used in large claims of £250,000 or £500,000 upwards – where insurers tend to see the benefit – and small claims, which attract a more diverse response.”

Rehab effectiveness

He explains that the effectiveness of rehabilitation often depends on how insurers use it. “Some insurers have a one-size-fits-all approach or they don’t train claims handlers in rehabilitation – they may find it doesn’t pay,” he adds.

While some insurers recognise the benefit of rehabilitation, they argue that the quality of services and fees charged by different providers can vary greatly. An Allianz spokeswoman explains: “Allianz is aware that rehabilitation is flavour of the month but unfortunately some rehabilitation and case management companies are driven more by fee income and operational processes than best practice. Consequently, there is a huge gap between the best and worst in the market, with fees escalating from providers at an incredible rate without any demonstrable change in quality.”

She adds that the insurer is committed to the “early implementation and funding of medical and rehabilitation services for claimants on a needs-led and individual basis”, and says Allianz reviews its providers on a regular basis. “To achieve this, we must have close co-operation from claimant lawyers and clinically excellent rehabilitation services, which are increasingly hard to find,” the spokeswoman adds.

Highway Insurance conducted a three-year trial into the effectiveness of rehabilitation, which concluded in April 2006. It found that case-management-led rehabilitation can result in earlier settlement negotiations and increased accuracy on reserving by helping claimants return to pre-accident employment or to consider practical alternatives.

However, Peter Gallagher, claims director at Highway Insurance, says that although the study highlighted the benefits of rehabilitation, it also revealed a “lack of consistency among providers” and resulted in the insurer reducing its panel from six to three.

“What we tend to find is it’s often more focused on the injury and not the person’s needs,” he explains. “We have had cases of people with fairly minor musculo-skeletal injuries where they are sent for an initial needs assessment and the report comes back saying they might need a stair lift. Fitting a £5000 stair lift for an injury that will clear itself up in six months is not practical. On the assessment side, there is more that could be done and the quality of reports needs to be more consistent.”

Jamie McNab, UK portfolio manager for liability at Brit Insurance, adds: “Some companies see an injury and provide as much service as they can for a fee.”

Likewise, Rosie Corless, rehabilitation manager at QBE, says that although the insurer has seen an improvement in the way case managers address claimants’ biopsychosocial needs, the variation in standards between providers needs to be tackled.

Mr Gallagher adds that insurers have not been helped by the Wright v Sullivan case, which suggested that case management take a unilateral, rather than a joint, approach and that this could “potentially elongate the process”.

Looking at the issue from a legal perspective, Andrew Underwood, partner at law firm Keoghs, says it is also important to remember that the compensation system is adversarial, and, while parties may try to work collaboratively, the claimant’s focus will be split between the rehabilitation process and monetary compensation.

“These conflicting aims create a difficult environment into which rehabilitation case managers have to tread carefully,” he says. “A challenge for the industry on both sides of the divide is to explore how clinical case managers can work more effectively for the benefit of the claimant, not the process. At the top of the agenda should be the right to gain direct access to the case manager; to prompt access to the core non-privileged case manager records; and hold the case manager to account for their actions during the process.”

Adversarial approach

He adds that unless insurer access to case managers and the rehabilitation process is improved, “an increasingly adversarial approach to rehabilitation may result”.

It is hoped that the voluntary standards currently being drafted by the UK Rehabilitation Council will help benchmark rehabilitation practices, with Mr Baylis saying it should “help people chose the right provider in the first place and ensure the contract delivers”.

Meanwhile, Deborah Edwards, rehabilitation services director at Argent Rehabilitation, also welcomes the move, and says there is a need for “some sort of accreditation for the delivery of rehabilitation services”.

However, on the whole, insurers seem to be embracing rehabilitation as they can see its efficacy and cost-benefit when deployed in appropriate cases. After trialling it for several years, Brit Insurance is rolling out rehabilitation to all its employers’ liability policyholders this autumn.

“If someone has to wait six months for an operation on the NHS but we can get surgery sorted privately in two weeks, then this speeds up the claim, helps the injured person get back to work and ensures premiums are kept down. The only danger is if you are spending money where there is no added value. All rehabilitation must be subject to a cost-benefit analysis,” Mr McNab says.

He admits that rehabilitation has suffered some “growing pains” and, at times, has been “slightly off the mark” but says that on the whole it is working and offers great benefits.

Most insurers also appear to back the case-management model, as opposed to a more medical doctor-led approach, as the preferred option of delivery. Mr Gallagher points out that as rehabilitation involves treating the person as a whole, not just the injury, a massive medical input is not always required.

Dr Nicholas Kendall, a member of the HCML medical advisory board, also supports the view that doctors should not be in charge of the process, and says this “outdated view” is “contrary to both historical experience and current evidence”. He adds that clinicians “do not generally constrain the amount or duration of healthcare and have a tendency to overlook important functional outcomes”.

Unnecessary suffering

He claims: “This has led to over-servicing and provision of unnecessary interventions, in addition to delays in return to work in all the most common types of health problems, whether due to injury or disease. The result has been spiralling cost burden, both direct and indirect, and unnecessary disability and suffering.”

Similarly, Nancy Hempstead, head of healthcare for Europe, the Middle East and Africa at Crawford and Company, is not convinced that the medical model is the correct approach. Although the NHS focuses on getting people well enough to be discharged, she says it is not necessarily focused on getting people ready to return work.

“I don’t think the medical model is the right way,” Ms Hempstead explains. “If you have a good clinician that has broad-based experience they should have the ability to talk to a client and determine what needs to be done.”

Helen Spillards, managing director at Independent Case Management Consultancy, comments: “Usually when a case manager is instructed, the injured person has already been seen on the NHS by a doctor and their recovery is being hindered due to waiting lists, so funding for private treatment can accelerate their care and recovery.

“There is no doubt doctors play an essential part in the rehabilitation process. However, if a person is already under the care of a consultant on the NHS, to ensure continuity of care and to keep costs to a minimum, the case manager needs to utilise the services that have been made available on the NHS rather than duplicating them and adding unnecessary expense. If the case manager is experienced and the rehabilitation is implemented properly, the entire process should – at worst – be cost-neutral to the insurer.”

Ms Spillards reiterates the opinion that doctors are “trained to focus on the physical and anatomical aspects of a person, rather than giving the holistic approach other medical professionals or a multidisciplinary team are trained to do”. She says if the medical model was implemented across the board, costs for insurers would escalate out of control and return to work would become a “pipe dream”.

Ms Edwards adds that case managers “are the safety net that keeps everyone focused on the goal of ensuring the claimant has increased functionality, recovers well and returns to work as quickly as possible”, while Mr Frost describes them as objective “project managers” that help move the process along.

So, while it appears that the rehabilitation industry still has work to do, most insurers seem to be reaping the benefits to some extent. Perhaps more collaborative working between all parties involved in the personal injury process is the key to its future success.

NHS CASE STUDY David Frost, technical manager for motor and legal services at RSA, says: “We dealt with an individual who suffered a knee injury. He was mobile and could drive, but couldn’t work. In terms of the NHS, he was a low priority but, in terms of our case manager, he was a high priority as he was prevented from re-entering the workplace.

“The NHS timetable for surgery fell within the time frame the case manager had set. However, the case manager, looking at the process holistically, had identified that the individual had been scheduled for a number of interventions that had been cancelled at late notice. The case manager had, therefore, already arranged private intervention as a backup if the surgery was cancelled. About 24 hours before, the NHS cancelled the procedure as it was a low priority but we were able to offer him private surgery instead, as the arrangements had already been made.”

This article has been reprinted with permission of the Claims Standards Council

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