1 Understanding independent medical assessments a multijurisdictional analysis Agnieszka Kosny (Institute for Work & Health), Amy Allen (Department of Epidemiology & Preventive Medicine, Monash University), Alex Collie (Institute for Safety, Compensation and Recovery Research) Acknowledgement: Funding provided by Accident Compensation Commission (ACC - New Zealand)
2 What is an independent medical assessment? A. Panel of medical experts sees an injured worker, evaluates his/her medical condition and provides feedback to the WCB. B. HCP internal to the board reviews a claim file and provides advice for claim management purposes C. A specialist determines an injured worker level of impairment after MMR has been reached D. The worker s HCP, along with a team selected by the WCB provides an assessment about why a workers recovery is stalled.
3 According to our study participants...all the above!
4 Introduction Most workers compensation boards carry out some form of IMAs evidence-based, objective measurements of disability provide expert advice on eligibility for cover and entitlements determine the level of disability and/or impairment Research has pointed to dissatisfaction with the IMA process Injured workers: biased, un-therapeutic, painful, inconvenient, with a view to cutting benefits HCPs: administratively burdensome, time consuming, legalistic Much of the research on IMAs comes from the USA difficult to generalize to other settings
5 Methods The purpose of this study was to understand why and how compensation bodies in a variety of jurisdictions use medical assessments When are the assessments done and by whom? What models of procurement are used? How is quality assessed? (including quality and timeliness of reports) Key challenges and best practices ACC funded the study issues they identified in their system: Variable quality in reporting and timeliness A public perception that clients had limited choice in assessors Due to limited choice - assessments viewed as favourable to ACC
6 Methods Examined selected workers compensation boards in Australia, New Zealand and Canada (n=14) Review of publically available policy/info/procedures Interviews with senior policy makers/service providers about IMAs in their jurisdiction Sample selected to maximize variation by region, size (and based on availability/willingness)
7 Role Time in Role WCB or insurer North America or Australia/NZ 1. Director of Health Care Services 6 years WCB North America 2. Senior Clinician/Senior Medical Advisor 4 years WCB/Insurer Australia/NZ 3. Manager of Health Care Services 6 years WCB North America 4. Chief Medical Officer/Director of Clinical Services 5 years WCB North America 5. Chief Nursing Officer/Director of Professional Practices 6. Physician Advisor, Integrated Disability Management/Chief Occupational Health 5 years WCB North America 19 years Insurer North America 7. Senior Coordinator, Medical Assessment Tribunal 3 years Insurer Australia/NZ 8. Workers Compensation Manager 6 months Insurer Australia/NZ 9. Manager, Vocational and Pain Services 3 Years WCB Australia/NZ 10. Assistant Director 12 years WCB Australia/NZ 11. Relationship manager, Medical and Hospital 1 year WCB Australia/NZ 12. Physician Manager 6 years WCB North America 13. Manager, Legislation and Scheme Information 2 years WCB Australia/NZ 14. Manager, Independent Medical Exams 2 years WCB Australia/NZ
8 Caveats IMA means different things in different jurisdictions e.g. medical panels, external medical exams, internal claim file reviews Difficult to answer certain questions (e.g. How many MAs done per year?) [answers: unknown, ,000] Interview information sometimes conflicted with written documents Some IMA options were theoretically available but rarely used (e.g medical panels) Participants did not always have information on all types of IMAs performed focussed on most common Do not identify jurisdictions by name to preserve anonymity of participants
9 Four key reasons for doing IMAs Failure to progress Claim not progressing as expected; unexpected recovery and RTW delays, treatment to working. (MH claims as a matter of course) Permanent impairment Determine impairment after MMR is reached, IW assessed and assigned disability rating Medical disputes (often in-house) IMAs when there are differences in medical opinion, review treatment paths or experimental therapies Determining liability or cutting payments work-relatedness of injury, decreasing or ceasing payments, IMAs form of evidence in court cases Other reasons: review of IW surveillance footage, determining fitness for work, RTW planning and voc rehab assessment, fresh medical opinion
10 Different approaches to IMA Internal - IMAs are carried out in house. HCPs based at the WCB to provide services as needed. External- IMAs carried by medical-legal clinics, by HCPs who have an on-going relationship with WCB or on an ad-hoc/as needed basis Collaborative IMAs include HCPs from various disciplines, on-going contact, discussion and info sharing about outcome and process Individualistic IMA done by one HCP (not treating HCP), based on exam, little contact with other HCPs or info sharing with IW In-person IW undergoes physical exam, HCP is sent file/info summarized by case manager Paper-based- claim file review based on questions posed by case manager, IW not necessarily informed the process is taking place
11 Results - Across jurisdictions All jurisdictions engaged in some form of IMA Some North American WCBs moving away from traditional IMA (oneon-one assessment by specialist outside of the WCB). Whole person model of assessment carried out by multidisciplinary teams, input from worker, treating HCP, detailed reporting In house medical teams decreases need for traditional IMAs Staged approach to IMA: in-house HCP consulted (claim file review), if more info needed, HCP would see the IW for an exam or IW referred for assessment in the community. Medical panel reviews - reviews of last resort.
12 Results Across jurisdictions Disjuncture between publically available info on IMAs and what happened on the ground E.g. information about medical panels on website yet according to participants these were virtually never used - Confusing for IWs? Huge variation in practices and approaches E.g. Recruitment and training: informally, by word of mouth, at conferences (no training) versus formal tender to be on a roster of eligible assessors E.g. payment for reports: some assessors salaried employees of WCB, some payed per report, some per time spent, formal payment structure versus pay whatever assessor demands
13 Results across jurisdictions The social, health care and legislative context is important E.g. Process of IMA more adversarial/less collaborative in jurisdictions where workers have access to common law as part of the workers compensation process Also may drive # of IMAs being conducted (requested by lawyer and insurer)
14 Key issues and challenges Recruitment Difficulty attracting and keeping qualified HCPs Administratively cumbersome process setting up appointments, moving documents and reports back and forth, payment Some jurisdictions required specific qualifications and training (e.g. whole person impairment assessment) limited pool Particularly challenging in remote/rural areas When there are only a few available HCPs bias or the perception of bias Use of semi/retired HCP perception that WCB was not using HCP with most up-to-date skills or knowledge
15 Key challenges Quality assurance Timeliness of reporting and quality of reports Long delays in receiving reports, incomplete information, jargon etc. not useful for case manager In some jurisdictions no formal review or feedback process We talk with our feet Difficult to penalize HCP for poor reporting in jurisdictions where recruitment was an issue One Australian jurisdiction had very rigorous process of QA Peer reviewers from the same specialty reviewed de-identified reports and scored them If score lower than a predetermined level reviewer was given feedback (follow up 3 m later) Note: QA focussed on quality of reporting not quality of medical opinion
16 Key issues and challenges Client perception Bias, mistrust - view that process serves interest of employer/insurer aim to cut benefits Confusion about the process Little preparation for what to expect (assessment not therapeutic) Limited or no feedback from assessors Misconceptions about outcomes (e.g. payout) Repeated IMAs particularly onerous
17 Best Practices Internal medical consultants not every matter needs to be sent out for external independent medical review Quick referrals related to medical matters Greater control over quality In-house medical staff can help case managers make well-informed decisions; Medical staff can learn from case managers Less burdensome for the worker? (decreases travel etc) Incentives for medical assessors how can WCBs attract and retain assessors? provide training opportunities, high monetary reimbursements, decrease admin burden Use of organizations like e-reports to help with the administrative management of appointments/reports
18 Best Practices Quality assurance Systematic review of reports Feedback to assessors Payment structures to reward timely, complete reporting Public input Feedback from stakeholders could make the appointment of HCPs as assessors more balanced & transparent Collaborative assessments - by tapping various sources of information and including treating HCP and IW, the process becomes more collaborative Not simply passing judgement but rather solving the puzzle of why recovery has stalled Understanding is enhanced = RTW success, high satisfaction rates
19 Best Practices Preparing workers Different types of assessments, conflicting information IW should know what to expect One person or panel, what sort of exam, who is on the panel, what is the purpose of the exam, will they be told the result, etc. Will not receive medical advice or treatment Permanent impairment assessment IW should have realistic expectations about the likely outcome of the assessment One Australian jurisdiction contacted each worker who was going to have an IMA, explained the process to them. Also developed a video that workers could watch.
20 Best practices Decrease burden of IMAs on IWs Limit number of IMAs Decrease travel as much as possible use of technologies such as tele-health may be an option in rural/remote locations IMAs may be viewed in more favourable light if they result in tangible benefits for the worker - e.g. Collaborative assessments - e.g. Referral to speciality services
21 Future research areas How do IWs perceive different types of MAs? What could help improve their experiences? From the assessors perspective, what could facilitate their engagement with WCB and IWs undergoing assessment? An examination of forms, templates and guidelines used for various types of assessments how can reporting be improved? Should medical evidence provided by IMAs be evaluated? (not just report quality)? New models of providing MAs should be explored collaborative models and new technologies/information management systems can they make the process less burdensome?
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