Re: Catastrophic Impairment Project Expert Panel Report Public Consultation

Transcription

1 May 11, 2011 Mr. Willie Handler Senior Policy Analyst Auto Insurance Policy Unit Financial Services Commissioner of Ontario 5160 Yonge Street P.O. Box 85 Toronto, Ontario M2N 6L9 Re: Catastrophic Impairment Project Expert Panel Report Public Consultation Dear Mr. Handler: On behalf of the Coalition Representing Health Professionals in Automobile Insurance Reform, we are pleased to submit general comments and recommendations, which we trust will assist in reviewing the catastrophic definitions. The Coalition is strongly supportive of this collaborative process with stakeholders to improve, in this case, access to benefits to the most seriously injured. At the outset, however, the Coalition is concerned that there is no data to support this endeavour. The Coalition strongly encourages FSCO to obtain historical data from insurance companies to better understand if there is a problem with the current CAT impairment definition and, if so, where. As well, FSCO may well consider adding the OCF-19 to the HCAI system to ensure that this information is tracked in future. We have recommended that where the expert panel has provided specific changes to the present definition, each professional association whose members are actively involved in determination and/or treating patients that are catastrophically impaired, should provide individual submissions to ensure that scientific and evidence-based information specific to each area of expertise be provided to the panel. 1. Definition We have reviewed, in your report, the definition under Section 4. The expert panel stated that a catastrophic impairment is an extremely serious impairment or a combination of impairments that is expected to be permanent and which severely impacts an individual s ability to function independently. When the notion of catastrophic was introduced in 1996, there was a different benefit structure: $100,000 plus cost of assessments (in 1996 dollars) for persons who were seriously injured but would not meet the catastrophic threshold. Since the implementation of auto insurance reforms in September 2010, we note that the gap of medical benefits between catastrophic and non-catastrophic has widened. With the reduction to $50,000 1 Coalition Response to Report on CAT Impairment

2 including cost of assessments for non-catastrophic injuries, we must ensure that the new catastrophic threshold will provide sufficient funding for persons who are seriously injured. Further, it was the opinion of the panel that catastrophic impairment is not a medical entity; rather it is a legal entity, which defines a point along the medical spectrum of impairment of severity. The Coalition has concerns that the expert panel, in reviewing the definitions, has looked at it purely from a scientific basis. Therefore, in order to determine a new or modified criterion, a review of the case law and arbitration decisions that occurred since the CAT determination criteria was introduced in 1996 should be reviewed and considered with both legal consultants and arbitrators such that the new definitions do not create the sort of contention that has historically occurred. The Coalition cautions the government against rushing this process. We encourage the government to take the time required for the panel and other consultants to undertake a methodical and thorough investigation of these newly proposed tools, criterion and definitions before making a significant change to the SABS. This process may require, for example, a focus group whereby we walk actual patients through the definitions to ensure that we are not creating unintentional barriers. FSCO expects that the future MIG expert panel may require two years or longer to complete its investigations. We have to expect that the CAT definitions, which affect persons with far more serious injuries than minor injuries, may require the same period of time. 2. Paediatric Definitions The catastrophic expert panel has identified and recommended that an expert paediatric working group be convened to address the issues of paediatric determination. The panel was of the conclusion, given the complexity in issues and time constraints, that they were not adequately able to address the issue of paediatrics. As a paediatric population is a vulnerable population and their needs are extensive, it is a strong recommendation of the Coalition that this expert panel for the paediatric population be a priority and that the working group be convened to address this issue as soon as possible. We would also recommend that the working group include both scientists as well as clinicians working in the field. The team should include a multidisciplinary group of health care professionals to ensure continuity of feedback and care options for paediatric patients. 3. Interim Catastrophic Impairment The Coalition is in support of the recommendations that there be an interim catastrophic determination status so that insured individuals have access to rehabilitation services that are necessary to improve their health and minimize their chances of achieving a final impairment level that is less than catastrophic. As the present definition indicates that the insured may need to wait up to 2 years before determination occurs, the establishment of interim criteria is one that the Coalition supports. The specific criteria to attain interim status, however, must be reviewed. We agree that inpatient admission to an acute care facility (e.g., hospital or Emergency Room) may 2 Coalition Response to Report on CAT Impairment

3 be appropriate criteria for interim identification, however, in-patient rehabilitation may not be appropriate. 4. In-Patient Rehabilitation Services In multiple areas, the CAT panel recommended utilizing in-patient rehabilitation as a measure to determine catastrophic impairment including: 2a -paraplegia or tetraplegia: in-patient spinal cord rehabilitation in a public rehabilitation hospital 2 (b) - severe impairment of ambulatory mobility : a period of in-patient rehabilitation in a public rehabilitation facility 2 (d) traumatic brain injuries; interim catastrophic impairment status: admission to a program of in-patient neurological rehabilitation at a recognized neurological rehabilitation centre 2(d) traumatic brain injuries (not interim); moderate disability level (MD-) after one year due to documented brain impairment provided that the determination has been preceded by a period of in-patient neurological services in a recognized rehabilitation centre. The criterion of in-patient rehab services has many practical implications which may unintentionally block access to an appropriate level of medical benefits. These include access and capacity, the level of complexity of the candidate who is in the in-patient program, changes in Ministry of Health criterion and the Ontario economy, and appropriate diagnosis. According to the information received from the Acquired Brain Injury dataset that draws ABIspecific data for existing Canadian Institute of Health Information, a total of 76,993 episodes of care were reported in Ontario for the fiscal years 2003 to The Toronto ABI Network reports that there are only 109 ABI in-patient rehab beds across the province. There are issues which have been identified by the ABI Network indicating that there is a growing trend of acute care providers discharging people directly for home care while they either wait for a bed and/or begin therapy in the community. We understand that the criteria of in-patient rehabilitation have been used by the Expert Panel as a way to avoid unnecessary claims and we can appreciate this. The Coalition, however, recommends that alternative criteria be used: change in-patient rehabilitation to admission to an acute care hospital or Emergency Room. This, in our opinion, would still satisfy the screening requirement, yet ensure that all those that meet the CAT definition threshold are not faced with an unintentional barrier or, conversely, place undue stress on the public system to make referrals to inpatient rehabilitation. 3 Coalition Response to Report on CAT Impairment

4 5. Combining Physical and Psychological Impairment According to the report, the panel did not have resources to conduct a comprehensive review of the literature to determine whether there were valid and reliable methods of combining physical and psychological impairments. The panel recommended that an expert panel of clinicians and scientists systematically develop a review of the literature to determine a valid and reliable methodology available to rate and combine physical and psychological impairments. In reviewing the definition of impairment as identified in the SABS, the SABS states, an impairment as means a loss or abnormality of psychological, physiological or anatomical structure or function. An individual that has had both psychological and physiological or anatomical change in structure or function leading to an impairment needs to be evaluated in both domains. The panel has identified that the appropriate rating and percentage allocation has been one of concern, yet there are means of combining physical and mental impairments. Under the psychiatric impairment, the expert panel has identified a GAF score as a measure of determining catastrophic level of impairment. It may be useful to have the initial consensus team review the GAF score using other jurisdictions to determine a percentage of impairment rating consistent with a GAF score for a certain level of objectivity. This has been considered and has previously been used in other jurisdictions including the Workplace Safety and Insurance Board of Ontario (WSIB). The WSIB rates psychological conditions using the Mental and Behavioural Disorders Rating Scale, which combines elements of the American Medical Association's Guides to the Evaluation of Permanent Impairment, 3rd edition (revised), (the AMA Guides) with the WSIB's Psychotraumatic and Behavioural Disorders Rating Schedule. This method utilizes, the AMA Guides in the following manner: 1. Class 1, No impairment (0%) - no impairment noted 2. Class 2, Mild impairment (5-15%) - impairment levels compatible with most useful function 3. Class 3, Moderate impairment (20-45%) - impairment levels compatible with some but not all useful function 4. Class 4, Marked impairment (50-90%) - impairment levels significantly impede useful function 5. Class 5, Extreme impairment (95%) The California System has a GAF to WPI conversion table (State of California, 2005; appended) that can also be considered as a method to determine an appropriate rating. The RAND Institute (2005) conducted an extensive and well-designed empirical study that showed these ratings underestimate mental and behavioral impairment by 40% compared with other impairment classes in the Guides. 4 Coalition Response to Report on CAT Impairment

5 CONCLUSIONS Overall, we congratulate the Financial Services Commission for taking a scientific approach to reviewing the definition of catastrophic impairment, however, we recommend that this be combined with the legal context under which this definition is applied. As with any scientific review of the data there will be gaps in what the evidence shows; as well, the evidence will change over time as new science emerges. At this time, the Coalition recommends that the additional work, as recommended by the Panel, should be pursued; this process cannot be rushed as it impacts the most seriously injured, a group which the government has committed to protecting. As well, the Panel should review the multi-stakeholder submissions which will have valuable information and research (as specifically requested by FSCO) which may not have been available to the team during their initial investigations. The area of Catastrophic Determination has become a critical component of automobile insurance policy and any changes to the definition should be well researched and have appropriate consensus from all stakeholders. If you have any specific questions or would require further clarification, please feel free to contact us directly. Respectfully Submitted, Moez Rajwani Coalition Representing Health Professionals in Automobile Insurance Reform 5 Coalition Response to Report on CAT Impairment