Impact of claims management,
treatment, and rehabilitation on
recovery and return to independence
Liz Cairns, Manager Serious Injury Service,
ACC, NZ
Making research part of your DNA
• Case study of how to get better client
outcomes at the same time controlling
costs & liabilities
• How research was applied & continues
to be used to inform strategic and
tactical decision-making
Why should insurers listen?
• Learn how research can be
used to:
– Identify what’s proven to work and
where there’s slim evidence that
something works as intended
– Avoid wasting money re-inventing
the wheel
– Get things done faster
– Get a better return on investment
Why should researchers listen?
• Learn how :
– You can make a difference
– To be part of the solution, not
just describing the problems
– Leverage your intellectual capital
by partnering with insurers
NZ’s Accident Compensation
Scheme
NZ’s accident compensation scheme
• No fault
• Covers everyone in NZ including
workers, non-workers, & tourists
• Any kind of personal injury caused
by an accident (including assault,
medical mishap, mental injury)
• Funded through insurance premiums
(workers, employers, car owners),
fuel taxes, and
government appropriations
Client mix
Rehabilitation & recovery
Short term
Sprains &
strains
Cuts & bruises
Broken bones
Lifetime support
Long term
Disability
Back strain
Multiple injuries
Persistent pain
Traumatic brain injury
Spinal cord injury
Multiple amputations
Severe burns
Claim volumes , costs, & liabilities
Annual claim cost = $2.1 billion
Outstanding claims liability =$20.4 billion
Claim
volumes
Data as at 30 Jun 2011
27% cost
15% liability
51% cost
33% liability
22% cost
52% liability
Short term
claims
Medium & long
term claims
Disability
claims
Injuries involved in disability
claims
Severe &
moderate
traumatic
brain injury
58%
Spinal cord
injury
38%
Other
5%
Data as at 30 Jun 2011
Case study
Achieving better independence & participation
outcomes for clients
Achieving sustainable growth
in costs & liabilities
Situation 30 June 2007
Low participation rates in community
activities & employment:
Accelerating rate of growth in average
cost per disability claim:
Best
Typical
NZ
• 4.2%
in 2005
Spinal
80%
40%
18%
• 5.8%
in 2006
Brain injury
56%
35%
9%
• 14.3%
in 2007
Isolation & dependence
Liability blow-out
Drivers of cost growth
Residential care
Income replacement
Equipment
Hospital/ rehab
Housing & vehicles
Single biggest
driver of cost &
liability growth
Human assistance
Specialist services
Assessments
Teacher aide
Other
Strategy
Identifying the problem
Selecting solutions
Problem diagnosis
• Generalist case management
• Over-reliance on attendant care
• No understanding of liability
• Poor accountability for liability
or performance
• Assessment practices
• Assessors & suppliers driving our business
Managing
One
size the
fits
Diffuse
No
alternatives
service
gateway
all
accountability
Selecting solutions
• Clear vision of where
we needed to get to:
1. Stabilise growth in costs to
a sustainable rate
2. Improve client outcomes:
increase participation
Sustainable
growth rate
Cost per claim
2003 2004 2005 2006 2007 2008 2009 2010
Selecting solutions
• Strategy was a road map of
what we needed to do to get there:
– Disability model/philosophy
– Evidence-based approach to:
• Assessments
• Decision-making about human assistance
packages
• Service outcomes
– Specialist case management
– Alternatives to attendant care
– Deliver claims liability knowledge & liability driver
understanding
Implementation
Person-centred planning
Evidence-based practice
Alternatives to attendant care
Client segmentation & case management specialisation
Outcomes focus
Performance reporting
Person-centred planning in action
 Treatment 
 Rehabilitation 
Participatory
goals
1. Home/living
2. Work/education
3. Leisure /recreation
4. Community access
What supports
are needed ?
Client
Family
Other
funders
Where will these
supports come from ?
Community
Employer
School
ACC
Linked to evidence-based practice
Person-centred planning
Maximise independence & participation
Assessment
Alternatives to
attendant care
Case
management
Reporting
Assessment
• Best in class, objective assessment tools & methods
Alternatives to attendant care
• Short-term, outcomefocused services:
– Supported Living
– Supported Employment
– Youth transition
Alternatives to attendant care
• Short-term, outcomefocused services:
– Supported Living
– Supported Employment
– Youth transition
• Equipment solutions:
– Smoke alarms & sprinkler systems
– Personal alarms
– Short-rise lifts
Case management specialisation
• In-house specialists
• Disability experience
• Located in clients’ communities
 local knowledge
• Reflected in case loads
• Competency based
Claim liability knowledge
• Historically, this knowledge
was limited to those
concerned with funding &
pricing for premiums
• Now integrating liability into
decision-making about
sustainable levels of support &
service
Outcomes focus
• Information for clients
– Emphasis on living
an everyday life
– Focus on clients’
goals, not “entitlements”
Outcomes focus
• Purchasing disability support services
– Services already existed in disability sector, but not previously
accessed by ACC
– ACC a relatively small player but regarded as
cash rich  purchase for outcomes
• Interventions must achieve an outcome
– Evidence of need for intervention
– Episode-based funding
– Episode tied to a client goal
– Standardised outcome measures

Impact on costs
Performance reporting model
INPUTS
OUTPUTS
Clients:
Demographic &
complexity indicators
Finance:
Infrastructure
Services to clients
What is provided:
E.g. episodes of service,
hours of service,
exceptional responses,
plans completed
Processes
OUTCOMES
Impact on client’s lives:
To person-centred
objectives
Evidenced by evidencebased measures
Compliance
audits,
satisfaction
surveys, dispute
rates, etc
Efficiency and effectiveness reporting
Putting it all together…
Results
Client goal achievement
Employment participation
Actuarial release
Results
• Achieved a delicate balance
– $820 million contribution to
actuarial release
– 61% of clients achieving or
exceeding their self-directed
goals
– 22% in part-time or fulltime
paid work
Cost
Outcomes
Role of Research
Past
Present
Future
Past
• Problem identification:
– Statistics on cost & liability drivers
– File reviews to determine impact different
case management models
– International comparisons on use of
human assistance (attendant care)
– Evidence base for efficacy of interventions,
such as:
• Supervision to manage problem
behaviours
• Music therapy
– Client and staff forums
Present
• Selection of solutions:
– Selection of assessment tools:
• Selection criteria was they had to be
internationally researched, valid &
reliable, easy to administer
– Service development:
• Literature search on behavioural
interventions led to creation of
Behaviour Support Service
• Online surveys of suppliers & staff
informed strategic development of
existing Disability Support Services
Present continued…
• Development of decision guides:
– Consultation with expert clinicians
adapted NSW spinal cord injury
guidelines for NZ environment
– Statistical modelling of FIM data &
attendant care hours led to
development of predictive model
• Development of communications
– Client advisory group aided content
development for Fact Sheets
– Client focus groups guided content
of DVDs
– Client interviews & advisory group
provided accessibility solutions for
website
Present continued…
• Selection of outcome measures:
– Similar selection criteria to selection
of assessment tools
– Linked to client objectives & used
to monitor client goal achievement
– Used for supplier performance
feedback
• Client satisfaction
– Independent research measures
client satisfaction with service delivery
– Used to drive operational tactics &
service quality improvements
Present continued…
• Rapid response
• Evaluation of business-critical services
• TBI and Spinal Strategies being informed at the outset by
evidence and ‘best theory’
• Development of decision support resources for spinal cord injury
management in the community
• Development of relationships with international practitioners in
applied research
Future
• Horizon scanning
– Relevance of new technologies
• Do they help clients to
achieve their objectives?
• Do they give the insurer an
acceptable return on investment?
– Advances in medical treatment
• Is there enough good-quality
evidence of their widespread
effectiveness?
• Should the insurer be an early
adopter or fast follower?
Future
• Responding to developing issues
– Health status of people with disabilities
• Existing co-morbidities
• Impact of aging
– Skilled labour shortages in the disability
sector
• Current workforce is aging
• Where will replacements for the
current workforce come from?
Conclusions
Research helped us…
• Define the problems we faced & identify the root
causes we needed to concentrate on
• Select solutions faster, without needing to re-invent the
wheel
• Achieve consistency in decision-making
We are using research to…
• Measure our progress
• Manage our suppliers’ performance
• Effectively communicate with our clients & stakeholders
• Develop better interventions
• Improve the quality of our services
• Keep abreast of new technologies, medical advances, &
future challenges
We have partnered with…
• Our in-house researchers
• Best practice treatment & rehabilitation practitioners
• Academics & health researchers - locally &
internationally
• Market researchers
Research is a tool
• It will be used by insurers
as long as it..
– Continues to be useful
– Remains practical
Questions?