BILL 59, Rehabilitation Funding Decision Models. Can we do better?

Author(s): David F. MacDonald

December 1, 2001

Thomson Rogers thanks its readership for participating in the health care professional opinion survey this year. The resulting database of information has been correlated, summarized and presented to Mr. John R. O’Toole, M.P.P., and Parliamentary Assistant to the Minister of Finance.

This Accident Benefit Reporter encloses a conference application and a “Suggestions For Change” submission form, which we invite you to complete and return to Thomson Rogers, to the attention of David MacDonald, for compilation and presentation to Mr. O’Toole at the Riverdale Conference.

The following is a summary of information gleaned from the health care professional opinion survey.

Survey Sample:
122 Health care professionals responded. The professionals were: chiropractors, physicians, speech pathologists, occupational therapists, psychologists, physiotherapists, social workers, rehabilitation counselors, nurses, kinesiologists, and other rehabilitation professionals.

Survey Results:
Survey respondents’ use and familiarity with treatment plan:
Survey Highlights:

  • 94.3% of respondents participated in the preparation of a treatment plan for victims of motor vehicle accidents;
  • 85.2% of respondents have rendered treatment or have provided services pursuant to an approved treatment plan since November 1, 1996.

Effectiveness of Treatment Plan in Facilitating Treatment:

Survey Highlights:

The concerns voiced by the health care professionals in response to the thirty-two questions put to them can be grouped into two categories:

  1. Inappropriate denial of health care professional’s recommendations for treatment; and
  2. Impact upon accident victim of delay in access to medical and rehabilitative needs.

Inappropriate Denial of Health Care Professionals’ Recommendations for Treatment:

Survey Highlights:

  • 58% of survey respondents found that insurers rarely or never contacted the provider to obtain further information about the proposed treatment plan before giving notice that the treatment plan would not be funded.

Impact Upon Accident of Delay in Access to Medical and Rehabilitative Needs:
Survey Highlights:

  • 76% of survey respondents familiar with the treatment plan approval process found that insurer representatives always, usually or sometimes had taken more than fourteen days to issue a decision to approve or deny a treatment plan.
  • 82% of respondents found that the delay in funding treatment plan recommendations always or usually had a negative effect upon the accident victim’s accident-related impairments.

Results of Inappropriate Denials:

  1. Increases burden on public health;
  2. Destabilizes victim’s focus on recovery;
  3. Increases barriers to recovery;
  4. Loss of productivity:
    • for victim;
    • for victim’s employer.
  5. Increases costs to insurer:
    • IRB’s;
    • assessment expenses;
    • transfer payments to OHIP;
    • loss of income claims.
  6. Reduced likelihood of return to function.

Goal to be Achieved Through Changes to Treatment Plan Approval Process:
A treatment approval and delivery model should support the delivery of timely and co-ordinated medical and rehabilitative services and devices with the goal of returning the victim to the maximal level of recovery as quickly as possible.

Fostering a Co-operative Approach:
To reduce approval delays the process must increase dialogue and foster a co-operative approach among the victim, treatment provider and insurer.

Effects of Adversarialism:
The adversarial elements of the current process destabilize the accident victim’s focus on recovery. As one respondent noted “where an adversarial climate develops it can cause psychological impairments which can prolong recovery”.

Recommendations Concerning the D.A.C. Process:

  • D.A.C. members should be members in good standing with their affiliate colleges, and should remain bound to fulfil their ethical responsibilities and best practices in accordance with their College’s Code of Ethics;
  • D.A.C. members should have a duty of care to victims assessed;
  • D.A.C. assessors should be drawn randomly from a pool of certified and qualified specialists on a blind referral basis;
  • make the D.A.C. system transparent:
    • require D.A.C.s to list associated assessors;
    • make them become accredited through the F.S.C.;
    • publish individual D.A.C.s’ rates of approval / denial;
    • provide information about whether D.A.C. assessors have done or continue to do IMEs for insurers.

Recommendations Concerning the Accident Victim’s Need for Early, Coordinated and Sustained Intervention:

  • allow funded treatment to proceed during waiting periods associated with approval of the treatment plan and while a disputed treatment plan is awaiting determination by a D.A.C.;
  • deem an automatic approval of the treatment plan if the insurer has not responded within 7 days;
  • oblige the insurer to attend case conferences and team meetings for the provision and co-ordination of rehabilitation services;
  • prevent the insurer from denying a treatment plan or a portion of a treatment plan unless the insurer:
    • communicates by telephone or in person with the treatment provider recommending services;
    • obtains a written review of the treatment plan by an appropriately qualified health care professional; and
    • provides specific, health care professional-based reasons for rejecting the treatment plan.
  • incorporate a pay pending resolution of dispute system for the first 12 weeks after the accident to a maximum of $4,000.00 for services provided by all health care professionals;
  • provide for automatic approval for services recommended by professionals associated with a treating public hospital required on or for discharge;
  • allow appropriately qualified rehabilitation case managers certified by a college covered by the Health Disciplines Act and/or the Financial Services Commission of Ontario to provide services for non-catastrophic cases where the victim is paediatric, or has sustained multiple trauma or has sustained mild to moderate brain injury.

Recommendations Concerning Catastrophic / Non-catastrophic Designation: Survey respondents recommended as follows:

  • deem injured children to be entitled to the benefits available to those having sustained a catastrophic impairment;
  • change the catastrophic definition to include the impact on functioning and;
  • when there is a permanent impairment, increase the funds available;
  • a formula needs to be developed to assess degrees of loss rather than to dichotomise victims based upon whether they have or have not sustained a catastrophic impairment.

Recommendations Concerning the Form and Content of the Treatment Plan:
Allow health care professionals who have their Masters Degree in Social Work and accredited Speech Pathologists and Occupational Therapists to sign Treatment Plans.

Summary of Key Recommendations and Conclusions:
Delay and adversarial elements are frustrating effective rehabilitation efforts. The solution lies in a limited “pay pending resolution of dispute” approach to rehabilitation which allows members of all Colleges currently regulated by the Health Disciplines Act, M.S.W.s and O.T.s to recommend and receive funding for treatment.

Treatment Plan Recommendations:
A system should be created whereby the assigned adjuster who receives a treatment plan arranges telephone contact with treatment provider unless the insurer automatically agrees to fund the rehabilitation. If, despite this communication, an agreement is not reached, any decision not to fund the treatment plan should be made only after a rehabilitation professional of appropriate qualification reviews the treatment plan, and has a dialogue with the recommending treatment provider and provides a written review of the treatment plan.

“Mandating” a Co-operative Approach to Funding and Providing Treatment:
A new protocol must increase dialogue to promote and increase understanding of:

  • the accident victim’s impairments;
  • the anticipated manner by which the recommendations made by health care professionals will reduce those impairments;

In order to reduce as much as possible the human and economic toll that delayed or denied treatment has upon the victim, the insurer, employers, public health and society.

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