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FSCO 5 Year Review Strategies for Health care providers. Presentation by Claire Wilkinson Rob Deutschmann (July 15, 2009). Background. 2003 was the last significant change in auto insurance legislation Automatic 5 year review inserted in legislation Intervening years – “tweaking”:

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fsco 5 year review strategies for health care providers

FSCO 5 Year Review Strategies for Health care providers

Presentation by

Claire Wilkinson

Rob Deutschmann

(July 15, 2009)

Presented by Claire Wilkinson and Rob Deutschmann 2009

background
Background
  • 2003 was the last significant change in auto insurance legislation
  • Automatic 5 year review inserted in legislation
  • Intervening years – “tweaking”:
    • Designated Assessment Centres (DACs) to Independent Medical Assessments (IMEs)
    • Treatment provider rates slashed by 1/3
    • Lease company and employer liability limited

Presented by Claire Wilkinson and Rob Deutschmann 2009

fsco report economic political climate
FSCO ReportEconomic / Political climate
  • Loss costs (the costs to provide) for accident benefits saw the largest relative increases during the past five years.
  • Accident benefits rose by 16.3% since 2003 but since 2004, the increase has been 34.6%.

Presented by Claire Wilkinson and Rob Deutschmann 2009

loss ratio measure of performance
Loss RatioMeasure of performance
  • The loss ratio is a fraction where the numerator is the claims paid plus loss reserves and the denominator is the premiums collected.
  • Two types of loss ratios:
    • Accident Benefits; and
    • Bodily Injury claims

Presented by Claire Wilkinson and Rob Deutschmann 2009

loss ratios it s all about the bottom line
Loss ratiosIt’s all about the bottom line
  • The lower the loss ratio, the better for the insurer ($$$)
  • For example, if the claims paid plus reserves is $60 in a year and the premiums collected $80, the loss ratio is 60/80, or 75%.
  • A loss ratio of 75% means an insurer is making a profit. A loss ratio of 90% may represent a loss to the insurer.

Presented by Claire Wilkinson and Rob Deutschmann 2009

accident benefit loss ratio varies among insurers 2008
Accident Benefit loss ratioVaries among insurers - 2008
  • Co-operators - 72%
  • Pilot Insurance - 180%.
  • Average for all Canadian P/C insurers – 125%
  • Bodily injury loss ratio - 69%

Presented by Claire Wilkinson and Rob Deutschmann 2009

statistics according to ibc
Statistics according to IBC
  • No-fault injury claims in Ontario cost much more than similar claims in other provinces.
  • Alberta - $3,000 per claimNew Brunswick - $11,700 per claimOntario - $38,000 per claim

Presented by Claire Wilkinson and Rob Deutschmann 2009

statistics according to ibc1
Statistics according to IBC
  • in Alberta, 40% of sprain and strain claims are still open after 6 months. In Ontario, that figure doubles to 80%.
  • This is part of the IBC attack on treatment providers

Presented by Claire Wilkinson and Rob Deutschmann 2009

here s the scary part according to fsco
Here’s the scary part – according to FSCO
  • Rate increases have not kept pace with rising loss costs and the insurance sector reports significant rate inadequacy in the system.

Presented by Claire Wilkinson and Rob Deutschmann 2009

fsco s bottom line
FSCO’s “bottom line”
  • Declining profitability, significantly lower earnings and loss cost increases will accelerate in 2009 in the absence of structural changes to stabilize costs.
  • Read between the lines – premiums will need to increase if costs are not controlled.

Presented by Claire Wilkinson and Rob Deutschmann 2009

lest we forget insurers have done very well
Lest we forgetInsurers have done very well
  • 2003 to 2007 were record years for insurers
  • Return on Equity:
  • 2003 – 11.9%
  • 2004 – 19.0%
  • 2005 – 16.5%
  • 2006 – 20.1%
  • 2007 – 16.1%
  • 2008 – 7.5%

Presented by Claire Wilkinson and Rob Deutschmann 2009

problems with the insurance debate in ontario
Problems with the insurance debate in Ontario
  • No one knows what the true numbers are
  • Numbers are not shared by the IBC
  • HCAI has not been successful
  • Anecdotal evidence
    • Assessment mills
    • Multiple assessments to overwhelm adjuster
    • Increasing requests for in-home assessments

Presented by Claire Wilkinson and Rob Deutschmann 2009

policy vs politics
Policy vs. Politics
  • It’s all about the politics
  • Nothing strikes fear in the Ontario provincial government more than the risk of increasing

premiums.

Presented by Claire Wilkinson and Rob Deutschmann 2009

ibc and premium increases
IBC and Premium increases
  • Recent news stories – IBC has talked about the need to raise premiums
  • Cause:
    • Investment losses
    • Rising costs in Med and Rehab treatment

Presented by Claire Wilkinson and Rob Deutschmann 2009

the ibc plays on fears of higher premiums
The IBC plays on fears of higher premiums
  • On average, drivers in Ontario pay higher premiums than drivers in all other provinces where auto insurance is sold competitively by private companies – 25% more than in the “private” jurisdiction with the next highest premiums, Alberta.

(IBC submission July 2008)

Presented by Claire Wilkinson and Rob Deutschmann 2009

fsco report
FSCO Report
  • 39 Recommendations
  • There are a few controversial recommendations
  • General theme –

reducing Cost and Complexity

The changes will have the most significant impact on non-CAT seriously injured

Presented by Claire Wilkinson and Rob Deutschmann 2009

health care providers
Health care providers
  • What has changed from your perspective?
  • What should you be aware of and new strategies to apply?
  • How do you continue to be an effective advocate on behalf of your patient?

Presented by Claire Wilkinson and Rob Deutschmann 2009

not quite the same
Not quite the same
  • The catastrophically injured will still have access to a higher level of benefits

BUT there will be G A P S in the system

Presented by Claire Wilkinson and Rob Deutschmann 2009

current catastrophic definitions
Current Catastrophic definitions
  • There is no change AT THIS TIME
  • The “straight forward” definitions:
    • GCS – 9 or less
    • Paraplegia or quadriplpegia
    • Amputation or impairment causing total and permanent loss of use of both arms or an arm and a leg
    • Total loss of vision in both eyes.

Presented by Claire Wilkinson and Rob Deutschmann 2009

the problem areas
The problem areas:
  • The whole person impairment rating of 55% or higher
  • The combining of physical and psychological impairments
  • Marked impairment

Presented by Claire Wilkinson and Rob Deutschmann 2009

why is it a problem
Why is it a problem?
  • The injured person has to wait for assessment:
  • Until health practitioner says persons condition has stabilized; or
  • Two years elapsed since the accident

To determine whether Catastrophically impaired

Presented by Claire Wilkinson and Rob Deutschmann 2009

one big reason it s a problem
One big reason it’s a problem
  • The most controversial change recommended by FSCO . . .

Presented by Claire Wilkinson and Rob Deutschmann 2009

recommendation 22 reducing the med rehab cap
Recommendation #22Reducing the med rehab cap
  • Reduce the cap for medical and rehabilitation benefits for non-catastrophic claims to $25,000.
  • Introduce a $100,000 optional medical and rehabilitation benefit along with the existing $1 million optional benefit.

Presented by Claire Wilkinson and Rob Deutschmann 2009

why did fsco recommend this fsco report
Why did FSCO recommend this?FSCO Report
  • Provide consumers with more choice and would allow them to customize coverage according to their needs.
  • The insurance industry has proposed that a reduced cap of $25,000 would adequately meet the needs of many consumers.
  • Consumers that feel they need a higher level of coverage could be provided the option of purchasing $100,000

Presented by Claire Wilkinson and Rob Deutschmann 2009

consumers will appreciate it fsco report
“Consumers will appreciate it”FSCO Report
  • Considering the rate inadequacy that currently exists in Ontario, consumers will appreciate opportunities to reduce coverage that they may not need and avoid possible premium increases.
    • As an alternative, the cap could be reduced to $50,000 but this would reduce the opportunity for consumers to realize savings.

Presented by Claire Wilkinson and Rob Deutschmann 2009

coverage under tort claim fsco report
Coverage under Tort claimFSCO Report
  • Some auto accident claimants would be eligible for compensation beyond the $25,000 by suing an at-fault driver.
  • Those eligible would have to have injuries that exceed the existing “serious and permanent impairment” threshold in the Insurance Act

Presented by Claire Wilkinson and Rob Deutschmann 2009

reducing the med rehab cap
Reducing the med rehab cap
  • Controversial recommendation
  • Alliance of Community Medical & Rehabilitation Providers have actively lobbied primarily on this recommendation
  • No one aware until they are a victim – too late
  • Potential for an increase in cap to $50,000

Presented by Claire Wilkinson and Rob Deutschmann 2009

reducing the med rehab cap1
Reducing the med rehab cap
  • Accident victims suffering from catastrophic injury will not be affected as long as they are deemed Catastrophically impaired immediately
  • Will have access to enhanced medical and rehabilitation benefits and attendant care benefits.

Presented by Claire Wilkinson and Rob Deutschmann 2009

future considerations a third level of coverage
Future considerations:A third level of coverage
  • Some consideration should be given to a more generous level of benefits for group of very seriously injured claimants with serious orthopaedic or brain injury who will not immediately meet the catastrophic test.

Presented by Claire Wilkinson and Rob Deutschmann 2009

even the ibc made a recommendation july 2008
Even the IBC made a recommendation(July 2008)

A. For non-Catastrophic (CAT) claimants, establish the maximum limit for payments for medical/rehabilitation and provider-initiated assessments at $25,000, but retain the $100,000 limit for injured persons admitted to a public hospital for at least two consecutive days in the immediate aftermath of the injury;

Presented by Claire Wilkinson and Rob Deutschmann 2009

so what does this all mean
So what does this all mean
  • Some seriously injured people will fall into the $25,000 to $1million GAP
  • They will use up the AB funds well before 2 year mark
  • They may include:
    • Patient with a GCS of 10 or higher
    • Patient with significant orthopaedic injuries but not complete loss as per CAT defn

Presented by Claire Wilkinson and Rob Deutschmann 2009

what do these victims do
What do these victims do
  • They are facing the prospect of trying to get by with $25,000 for 2 years
  • Future needs will have to be assessed immediately so that strategies can be considered
  • Contact a personal injury lawyer to develop and implement strategies

Presented by Claire Wilkinson and Rob Deutschmann 2009

what should you be looking for
What should you be looking for?
  • Copy of the patient’s insurance policy, or some confirmation, to determine if optional medical coverage was obtained ($100,000 or more)
  • Determine what other medical benefit plans are available – employer; dependant
    • Some lose employment and medical benefits

Presented by Claire Wilkinson and Rob Deutschmann 2009

why a personal injury lawyer
Why a personal injury lawyer?
  • Victims, not at fault, can claim in tort for future medical costs from the at fault party
    • Defining regulation makes access more restricted
  • Often considered later in the process due to the availability of accident benefits but will become important early in process

Presented by Claire Wilkinson and Rob Deutschmann 2009

strategies for medical benefits
Strategies for medical benefits
  • Seek an advance for medical treatment costs from the at fault insurer
  • Tort insurer incentive:
    • the sooner the victim receives treatment,
    • the quicker the recovery
    • the lower the future damages

Presented by Claire Wilkinson and Rob Deutschmann 2009

strategies for medical benefits1
Strategies for medical benefits
  • Guarantee payment to third party provider from tort settlement
    • Cash flow problems for treatment providers
  • Persuade AB insurers to pay for additional treatment if it can bring injured person back to work sooner
    • Insurer can minimize Income Replacement Benefits exposure

Presented by Claire Wilkinson and Rob Deutschmann 2009

advances spent on other priorities
Advances spent on other priorities
  • There are some who say we cannot give the victim these medical funds
  • Medical funds not applied to future medical needs but to household debt
  • Personal injury lawyer could administer the funds
  • Onus on injured person to use funds for treatment – would reflect poorly at trial

Presented by Claire Wilkinson and Rob Deutschmann 2009

third party lenders
Third party lenders
  • Financial assistance in the form of “bridge loans” to plaintiffs facing financial pressures in advance of the resolution of their legal claims.
  • Flexibility regarding terms
  • Carefully review repayment options, payment priorities and interest rates

Presented by Claire Wilkinson and Rob Deutschmann 2009

other optional benefits housekeeping and caregiver
Other Optional benefits:Housekeeping and Caregiver
  • Recommendation #29
  • Make housekeeping and home maintenance expenses and caregiver benefits optional. Reimbursement for housekeeping and home maintenance expenses and for replacement caregivers needs to reflect actual economic losses.

Presented by Claire Wilkinson and Rob Deutschmann 2009

optional coverage issues
Optional coverage issues
  • FSCO view is that as long as the option is available consumers have access and are protected
  • Optional coverage will not guarantee all have access if the communication / information process is insufficient
  • The role of the Insurance Broker becomes more important

Presented by Claire Wilkinson and Rob Deutschmann 2009

housekeeping and caregiver
Housekeeping and Caregiver
  • FSCO relying on information provided by the IBC
    • “increasing at a significant rate … contributing to rising claim costs”
    • Insurer reports high proportion of payments … although no numbers were provided
    • Anecdotal evidence – receive claims from multiple family members

Presented by Claire Wilkinson and Rob Deutschmann 2009

housekeeping and caregiver1
Housekeeping and Caregiver
  • FSCO is “concerned about growing cost of the benefit”
  • 5 other provinces do not provide caregiver benefit
  • Solution – optional coverage

Presented by Claire Wilkinson and Rob Deutschmann 2009

optional coverage
Optional coverage
  • One approach to address rising costs and utilization is to provide consumers with more choice by converting a number of mandatory benefits to optional benefits.

Presented by Claire Wilkinson and Rob Deutschmann 2009

optional coverage1
Optional coverage
  • This would provide consumers with the ability to customize coverage according to their needs.
  • When do we know what we need.

Presented by Claire Wilkinson and Rob Deutschmann 2009

insurance brokers role
Insurance brokers role
  • Insurance brokers have to step up and educate their clients/customers on the options
  • Mandatory disclosure – sign off sheet
  • Form – outlines the following:
    • all optional coverages outlined
    • Rationale for purchasing coverage
    • Premium associated
    • Client to initial off

Presented by Claire Wilkinson and Rob Deutschmann 2009

broker liability
Broker liability
  • Well established in law that the broker owes a duty to client to advise and review

Presented by Claire Wilkinson and Rob Deutschmann 2009

recommendation 10 cat definition
Recommendation #10CAT definition
  • Further consultation with experts in the field is needed to amend the definition of “catastrophic impairment.”
  • FSCO - The goal for this review should be to ensure that the most seriously injured accident victims are treated fairly.

Presented by Claire Wilkinson and Rob Deutschmann 2009

fsco concerns
FSCO concerns
  • Confusion based on evolving decisions on CAT definition
  • Particularly combining physical and psychological
    • Despite Desbiens and subsequent decisions FSCO unsure whether appropriate to combine
  • Expanded definitions have exposed system to “potential abuse”

Presented by Claire Wilkinson and Rob Deutschmann 2009

fsco concerns1
FSCO concerns
  • FSCO is searching for a “clear and fair” definition of catastrophic impairment

Presented by Claire Wilkinson and Rob Deutschmann 2009

ibc has already started the process
IBC has already started the process
  • The Insurance Bureau of Canada (IBC) approached the Ontario Neurotrauma Foundation to form an expert panel to review the current science and evidence with which to measure and define brain impairment.
  • Evidence Based Classification of Brain Impairment: Application to Catastrophic Impairment Classification

Presented by Claire Wilkinson and Rob Deutschmann 2009

attempting to build a better predictor mousetrap
Attempting to build a better predictor “mousetrap”

Presented by Claire Wilkinson and Rob Deutschmann 2009

attempting to build a better predictor mousetrap1
Attempting to build a better predictor “mousetrap”
  • Discussion of Evidence Based Framework for Identifying Catastrophic Brain Impairment
  • The experts reviewed a large number of assessments that could potentially be used to classify catastrophic brain impairment.
  • Measures identified that do have evidence to support their use in classifying catastrophic brain injury.

Presented by Claire Wilkinson and Rob Deutschmann 2009

attempting to build a better predictor mousetrap2
Attempting to build a better predictor “mousetrap”
  • The final set of assessments that were felt to have sufficient evidence for use were:

1. Glasgow Coma Scale (GCS)

2. Age

3. Computed Tomography (CT) Scan in those with GCS < than 9

4. Somatosensory Evoked Potentials (SEPs)

5. Duration of Post Traumatic Amnesia (possibly measured by the Galveston Orientation and Amnesia Test (GOAT))

6. Disability Rating Scale (DRS)

Presented by Claire Wilkinson and Rob Deutschmann 2009

which way is fsco trending on cat assessments
Which way is FSCO trending on CAT assessments?
  • Could reduce the number of people deemed catastrophic
  • Some involved with the Neurotrauma team working on the report argue otherwise
    • More people will be covered
    • More certainty and fewer disputes
  • More complication

Presented by Claire Wilkinson and Rob Deutschmann 2009

where should they go with the cat determination
Where should they go with the CAT determination?
  • If you want to help the most seriously injured then:
  • Simplify the assessment model – DON’T make it more complicated
    • More CAT variations adds complication
  • Expand the number of seriously injured that qualify as CAT and focus on NEED

Presented by Claire Wilkinson and Rob Deutschmann 2009

recommendation 17 catastrophic assessors
Recommendation #17Catastrophic Assessors
  • Restrict the ability to conduct catastrophic impairment assessments to practitioners with appropriate training and experience.

Presented by Claire Wilkinson and Rob Deutschmann 2009

cost of catastrophic assessments
Cost of Catastrophic assessments
  • One insurer provided FSCO with examples of insurer examinations to determine catastrophic impairment that ranged in cost from $15,000 to $43,000
  • The Toronto Transit Commission reports assessments often cost between $20,000 and $30,000 and involve a multidisciplinary team of experts

Presented by Claire Wilkinson and Rob Deutschmann 2009

cost of assessments
Cost of Assessments
  • FSCO questions why so much is being spent on catastrophic impairment assessments
  • FSCO – “insurers insist on lengthy medical-legal reports in response to requests for catastrophic impairment determinations that have little merit. This type of security comes at a very high price. “

Presented by Claire Wilkinson and Rob Deutschmann 2009

cost of assessments fsco report
Cost of AssessmentsFSCO Report
  • The WSIB conducts an analogous assessment
  • The assessment is also based on the AMA Guides, but based on the 3rd edition
  • In the WSIB system, assessors are predominantly physicians who are trained on the use of the Guides.

Presented by Claire Wilkinson and Rob Deutschmann 2009

the problem with inadequate assessments
The problem with inadequate assessments
  • Inaccurate ratings,
  • More FSCO disputes
    • Mediations and arbitrations
  • Additional assessments
  • all adding more costs and uncertainty to the system.

Presented by Claire Wilkinson and Rob Deutschmann 2009

who will do cat assessments fsco report
Who will do CAT assessments?FSCO Report
  • WSIB assessors – who are predominantly specially trained physicians – are paid a substantially lower flat fee which covers time spent with the injured worker, reviewing documentation, and preparing a report.

Presented by Claire Wilkinson and Rob Deutschmann 2009

capping assessment costs
Capping Assessment costs
  • Recommendation #12:
  • The fee for completing forms including any assessment required to complete the form should be capped at $200. The cost of all other assessments should be capped at $2,000

Presented by Claire Wilkinson and Rob Deutschmann 2009

capping assessment costs1
Capping Assessment costs
  • Recommendation #18:
  • The costs of insurer examinations should be capped at $2,000.00
  • FSCO - providing “balance” in reducing assessments under s.24 and IMEs under s.42
    • Would be interesting to know the costs attributed under each section

Presented by Claire Wilkinson and Rob Deutschmann 2009

fsco s view of assessments
FSCO’s view of assessments
  • Assessment costs are getting out of control and have to be reined in.
  • FSCO does not want to regulate the provision of third party medical examinations.
  • FSCO would participate in a process involving health care associations to develop standards

Presented by Claire Wilkinson and Rob Deutschmann 2009

what is the basis for this view
What is the basis for this view?
  • FSCO does not have it’s own figures
  • Reliance on IBC information
  • Use of anecdotal evidence:
    • “Assessment mills”
    • Multiple assessment requests to overwhelm adjusters
    • Assessments requested without consent of insured
    • Illegal payments for referrals

Presented by Claire Wilkinson and Rob Deutschmann 2009

the cap on assessments and imes
The cap on assessments and IMEs
  • $2,000 cap on assessments will not cover the cost
    • CAT assessments
    • Psychological / neuropsychological
  • Would the $2,000.00 cap apply per assessment
    • Multi disciplinary assessments

Presented by Claire Wilkinson and Rob Deutschmann 2009

strategy moving forward
Strategy moving forward
  • Issue - current AB assessors will reduce or discontinue CAT assessments
  • A third party source will have to fund assessment costs
    • Third party lenders
    • Personal injury lawyers
  • Clarify the per assessment concept

Presented by Claire Wilkinson and Rob Deutschmann 2009

recommendation 14 in home assessments
Recommendation #14In-home Assessments
  • Availability of in-home assessments should be limited to seriously injured claimants
  • Evaluate their need for attendant care services and home modifications.

Presented by Claire Wilkinson and Rob Deutschmann 2009

in home assessments fsco report
In-home AssessmentsFSCO Report
  • Existing industry data does not separate out assessments conducted in the claimant’s home.
  • There is sufficient anecdotal information to support the suggestion that they have become a growing source of costs.

Presented by Claire Wilkinson and Rob Deutschmann 2009

in home assessments fsco report1
In-home AssessmentsFSCO Report
  • The WSIB conducts similar assessments but they are limited to their most seriously injured clients.
  • FSCO – “there is nothing unique about auto accident victims when it comes to assessment needs”.

Presented by Claire Wilkinson and Rob Deutschmann 2009

in home assessments fsco report2
In-home AssessmentsFSCO Report
  • Expensive and limited health care resources are being tied up by health care providers travelling to clients.
  • Therefore, most assessments should be conducted in a clinical setting.

Presented by Claire Wilkinson and Rob Deutschmann 2009

in home assessments issues to consider
In-home AssessmentsIssues to consider
  • Recommendation based on IBC reports
  • Uses WSIB analogy
  • Who is “seriously injured”
  • Not a defined term under the SABs
  • How do you replicate home setting in clinical setting
  • Will add uncertainty to the process
  • Delay access to assessment and treatment

Presented by Claire Wilkinson and Rob Deutschmann 2009

future concern fsco reliance on wsib model
Future Concern:FSCO reliance on WSIB model
  • Numerous references to WSIB throughout the FSCO report
  • #35 – training adjusters
    • FSCO looked at how WSIB structured claim adjudication
  • #30 – Harmonizing auto and workplace insurance systems
  • #26 – Fees
    • Reduction in 2003 intended to bring fees in line with WSIB fees

Presented by Claire Wilkinson and Rob Deutschmann 2009

recommendation 25 payment for past attendant care
Recommendation #25Payment for past Attendant Care
  • The attendant care benefit should continue to compensate claimants for incurred expenses.
  • Looking at payments for past attendant care

Presented by Claire Wilkinson and Rob Deutschmann 2009

past attendant care
Past Attendant Care
  • McMichael case
  • Generally where 24/7 care required
  • Insured did not have to show that expenses were actually incurred but that they were reasonable and necessary
  • Insurers could receive windfall by denying and delaying benefit

Presented by Claire Wilkinson and Rob Deutschmann 2009

past attendant care1
Past Attendant Care
  • FSCO trying to balance interests by recommending payment if insurer is shown to be unreasonably denying
  • Uncertainty when interpreting “unreasonable” conduct
  • Insurer’s tinkering to fill a “loophole”

Presented by Claire Wilkinson and Rob Deutschmann 2009

recommendation 33 future care reports
Recommendation #33Future Care reports
  • The cost of future care cost reports should not be an expense recoverable under the SABS
  • Continuing with the theme of reducing assessment costs

Presented by Claire Wilkinson and Rob Deutschmann 2009

future care reports
Future Care reports
  • Insurers dispute payment of reports as they do not deal with an “incurred expense”
  • Insurers would like to see CCAC standards applied to recommendations
  • FSCO does not consider these reports covered by the SABs

Presented by Claire Wilkinson and Rob Deutschmann 2009

future care reports options
Future Care reportsOptions
  • Accepted that they are necessary for CAT cases
  • Issue is whether the insured is seriously injured to require any significant future care needs
  • Will become a negotiated item with AB adjuster wishing to settle file
  • Can be covered where insured has a tort claim

Presented by Claire Wilkinson and Rob Deutschmann 2009

role of the family doctor
Role of the family doctor
  • Recommendations #15 and #21 have been focused on the role of the family doctor in auto insurance claims
  • Attempting to control cost of assessments
  • Attempting to better coordinate rehabilation

Presented by Claire Wilkinson and Rob Deutschmann 2009

recommendation 15 assessments
Recommendation #15Assessments
  • Consider having assessment requests completed only after a referral is made by the health professional primarily responsible for the claimant’s rehabilitation (in most cases a family physician).
  • Assessment requests would continue to be submitted by providers following a referral

Presented by Claire Wilkinson and Rob Deutschmann 2009

involvement of family doctor fsco report
Involvement of family doctorFSCO Report
  • Current problem:
  • Any regulated health professional or social worker is able to submit a request for an assessment and the insurer must respond.
  • Insurer cannot deny the request until an insurer examination has been conducted.
  • Insurer must incur costs in response to even the most questionable assessment requests

Presented by Claire Wilkinson and Rob Deutschmann 2009

involvement of family doctor fsco report1
Involvement of family doctorFSCO Report
  • Why is the Ontario auto insurance system so different than other systems?
  • FSCO has concluded that one area where Ontario differs is in how treatment is managed.
  • The Ontario system appears to lead to multiple and duplicative assessments and fragmented treatment

Presented by Claire Wilkinson and Rob Deutschmann 2009

involvement of family doctor fsco report2
Involvement of family doctorFSCO report
  • In approximately half of Canadian jurisdictions, physicians direct assessments and treatment. In Saskatchewan claimants are asked to designate a primary practitioner who can be a physician, chiropractor or physiotherapist

Presented by Claire Wilkinson and Rob Deutschmann 2009

involvement of the family doctor fsco report
Involvement of the family doctorFSCO report
  • In Ontario there are 24 professions that are authorized to conduct an assessment
  • expansion in the number of regulated health professions may create even more cost pressures on the auto insurance system when implemented such that they begin to conduct assessments

Presented by Claire Wilkinson and Rob Deutschmann 2009

involvement of the family doctor fsco conclusion
Involvement of the family doctorFSCO conclusion
  • A single professional responsible for rehabilitation can fully and accurately respond to questions from the claimant and adjuster concerning the appropriateness of the proposed assessments and treatment

Presented by Claire Wilkinson and Rob Deutschmann 2009

involvement of the family doctor fsco conclusion1
Involvement of the family doctorFSCO conclusion
  • The increased involvement of physicians is not expected to impact on the doctor shortage in Ontario.
  • Claimants with more serious injuries already see their family doctors following an accident.
  • The proposed changes will not significantly increase the number of doctor visits and will benefit claimants by keeping their family doctors better informed on their progress

Presented by Claire Wilkinson and Rob Deutschmann 2009

recommendation 21 access to treatment
Recommendation #21Access to treatment
  • Consider having treatment plans completed only after a referral is made by a health professional primarily responsible for the claimant’s rehabilitation (in most cases a family physician)
  • Treatment plans would continue to be submitted by providers following a referral.

Presented by Claire Wilkinson and Rob Deutschmann 2009

physicians initiate treatment request fsco report
Physicians initiate treatment requestFSCO report
  • Concern about the expansion of the definition of regulated health professions
  • Expanding health practitioner status will increase complexity and diffuse accountability
  • 7 of 10 provinces – physicians only may certify need for treatment

Presented by Claire Wilkinson and Rob Deutschmann 2009

physicians initiate treatment request fsco report1
Physicians initiate treatment requestFSCO Report
  • No single health professional actually overseeing a patient’s rehabilitation
    • Left to the AB adjuster.
  • Directing patient to appropriate treatment providers
  • The insured would see the health professional before subsequent treatment plans
  • PAFs would continue

Presented by Claire Wilkinson and Rob Deutschmann 2009

physicians initiate treatment request fsco report2
Physicians initiate treatment requestFSCO Report
  • Eliminate the potential for conflict in existing delivery model - health professional not connected to treatment facility
  • Family physicians directing their patients to appropriate health care providers and services
  • Ontarians without family doctors will use walk-in clinics / ambulatory care

Presented by Claire Wilkinson and Rob Deutschmann 2009

potential issues with 15 and 21
Potential issues with #15 and #21
  • Delays to see a family doctor
    • Delay in treatment
  • Shortage of family doctors in Ontario
    • Increase use of walk in clinics / emergency
    • Flexibility needed for those without a family doctor
  • PAF may have to be expanded
    • Recommendation #23
  • Not supported by the OMA

Presented by Claire Wilkinson and Rob Deutschmann 2009

use of family doctor
Use of family doctor
  • The forms and reporting process will have to be simplified
  • Reporting to physicians – inundated with paperwork and reports
  • Treatment providers will have to educate physicians on the SABs process
  • Treatment providers will have to interact more with family physicians

Presented by Claire Wilkinson and Rob Deutschmann 2009

recommendation 31 tort law suit changes
Recommendation #31Tort (law suit)changes
  • Reducing the deductibles (from $30,000) to $20,000 and (from $15,000) to $10,000
    • 2003 increase was excessive
  • Eliminating the deductibles for fatality claims,
    • Ex. Grandparent dies leaving a spouse, 3 children and 10 grandchildren
    • Total deductible - $245,000

Presented by Claire Wilkinson and Rob Deutschmann 2009

recommendation 31 tort law suit changes1
Recommendation #31Tort (law suit)changes
  • Revoking the definition of serious and permanent impairment
    • Provide clarity
  • A closed claim study would assist in determining the impact of further tort changes being considered.
    • Only jurisdiction with both a deductible and threshold

Presented by Claire Wilkinson and Rob Deutschmann 2009

recommendation 35 better trained adjusters
Recommendation #35Better trained adjusters
  • Insurance claims departments need to better focus on the needs of claimants with serious injuries.
  • The IBC, Insurance Institute of Ontario and the Ontario Insurance Adjusters Association should work together to train adjusters on the needs of claimants with serious injuries to reduce exposure to potential allegations of unfair and deceptive acts or practices.

Presented by Claire Wilkinson and Rob Deutschmann 2009

39 recommendations what will happen next
39 RecommendationsWhat will happen next?
  • Announcement has been pushed back to the end of August
  • Minister not bound by the FSCO recommendations.
  • Expect most of the package to be adopted with some modifications – focus on the med rehab cap

Presented by Claire Wilkinson and Rob Deutschmann 2009

future reviews s 289 insurance act
Future Reviewss.289, Insurance Act
  • At least once every two years, the Minister shall table a report in respect of the adequacy of statutory accident benefits and setting out changes made to the SABs since the last report and changes that are proposed to the SABs at the time of the report
  • Last report was end of 2008

Presented by Claire Wilkinson and Rob Deutschmann 2009

future review
Future review
  • This is in addition to the 5 year review
  • Review the July 2008 IBC submission
  • The IBC will continue to propose significant cuts to Accident Benefits
    • ie. Housekeeping – limiting entitlement to 2 weeks for least serious injuries
    • Not payable to family members where no economic loss incurred

Presented by Claire Wilkinson and Rob Deutschmann 2009