The one year anniversary of the September 2010 changes to the Statutory Accident Benefits Schedule is here. This seems like an appropriate time to consider how the changes have affected the Ontario Auto Insurance Industry. Today we focus on examining the impact of the Minor Injury Guideline. In order to obtain the viewpoint of the Ontario Insurers, we spoke with Viivi Riis, Senior Health Analyst with the Insurance Bureau of Canada. Riis was kind enough to provide us with her perspective on the effect of the MIG.
Brief Background on the SABS Changes
The September 2010 changes were developed by the Financial Services Commission of Ontario (FSCO) in a bid to stem the increasing costs and complexity of the auto insurance system. The Auto Insurance Industry has been losing money at an incredible rate with no relief in sight. Much like a sick patient on a television medical show, an ongoing downward spiral seems to be a foregone conclusion without an impressively dramatic intervention. Unfortunately, unlike television shows that are resolved in 60 minute episodes, the SABS requires far more work and a dedicated commitment from all involved parties in order to effect a cure.
For those of you wondering what started the whole fiasco, David Gambrill, Editor of Canadian Underwriter Magazine, summed up the Auto Insurance Industry’s previous situation perfectly when he stated: “Ontario’s Auto Insurance Industry is ill…(t)he system is too complex, nobody understands or wants to fill out the paperwork, there are too many health professionals; assessments for minor injuries, most of the insurers’ money is propping up the system (including cottage industries for assessment) rather than going to the claimants, the system disproportionately caters to minor injury claimants, etc. etc.” (Canadian Underwriter, Ontario’s Ailing Auto Industry, 2009, 05, 01). With these multiple issues to address, the FSCO was faced with the momentous task of addressing all of the largesse and complex issues while finding logical, efficient solutions. This is not the easiest task when you consider the number of different businesses that interact with the Ontario Insurance industry. There are no clear answers or easy solutions.
In March of 2009, the Superintendent of Financial Services presented a report to the Minister of Finance giving 39 recommendations on reforming the SABS. The report is available for review on the FSCO website. The 39 recommendations echoed the sentiments of all the key stakeholders, who were given the opportunity to voice their concerns during the consultation phase, that the current SABS was far too complex and needed to be simplified and clarified.
The recommendations were adopted and the SABS changes came into effect on September 1, 2010. Although many in the Auto Insurance Industry were hoping that the changes would be a clean sweep and immediately remedy the issues, one year later, the FSCO’s strategy appears to have resulted in more of a transformative effort. It will take more time to know the ultimate effect of streamlining the old model, reducing coverage and adding caps.
The MIG: Present and Future
The MIG replaced the PAF Guideline and was developed in consultation with insurance industry stakeholders, healthcare professionals and legal representatives. According to the FSCO, the MIG is not a permanent answer to the auto industry’s woes and should only be seen as an interim measure, “with the expectation that it will be replaced in the future with a more comprehensive Guideline that will prescribe evidence-based treatment as identified by the Neck Pain Task Force and other expert Authorities.” (FSCO Bulletin 10/10).
The next step is the Minor Injury Treatment Protocol (MITP). In its “Statement of Priorities and Strategic Direction” (June 2011), the FSCO indicated that the MITP is “an initiative to develop a treatment protocol for minor injuries that reflects the current scientific and medical literature. This project began in 2010 and will be completed in 2014. A consultant will oversee the work to provide FSCO with an evidence-based treatment protocol, clinical prediction rules to identify patients at risk of becoming chronic, and a marketing strategy for educating the public and health providers on the new protocol.”
The FSCO shared more information about the MITP in its “Auto Insurance e-Newsletter (May 2011 edition): “The MITP will be used by insurers and health care providers when treating minor injuries resulting from automobile accidents. It will include clinical prediction rules to screen for patients who may be at higher risk for developing chronic pain and disability. In addition, it will focus on treatment outcomes and provide health care providers with numerous milestones that could be used to measure progress. FSCO will use the MITP to ultimately develop a Guideline, which will be issued by the Superintendent. The MITP project will also include a plan for the education and marketing of the new protocol.” It appears that the MIG, in its current state, is with us until at least 2014.
The FSCO created the Minor Injury Guideline (MIG) to accompany the SABS changes. The MIG is intended to provide a solid directive for the identification, treatment and management of minor injuries. The MIG is a perfect example of the overall intention of the changes and the associated challenges: The MIG requires a fundamental change in the way that insurers, health professionals and insurance partners approach their cases.
Rather than making a huge overhaul of the entire system, little steps such as the introduction of the MIG are essential to turn the system around and begin to rectify the areas that have become hot spots for wasteful and non-innovative processes. In its current capacity, the MIG should help eliminate some of the barriers to early treatment of minor injuries while actively promoting those treatments and therapies that favour early return to work and normal routines for Claimants. According to Riis, the expected long term goal in the use of “the MIG by health professionals is to deliver the type of care that is shown in health care literature to be effective. We hope to see a lower incidence of disability in the sprain/strain/WAD population. Recovery and return to function for injured persons is a positive outcome for the Claimant, insurer and provider.”
Can the MIG Ameliorate the Situation?
The IBC is conducting surveys on utilization of the MIG and associated costs, but the results will not be available until the fall. While we don’t have any advance information on the findings from the surveys, we can look at a key factor of the MIG that reflects the intent of the changes to the SABS.
One of the primary issues that the MIG focuses on is the early identification and management of psycho-social risk factors. When treatment options focus only on the injury and not on how the injury affects the Claimant’s life as whole, interventions and proactive therapies aren’t applied in time to identify and prevent other issues from becoming obstacles to recovery. Viivi Riis and the IBC have found that “there are a number of barriers, in Ontario, to the return-to-work process, many of which have nothing to do with the injury itself.” In the past, treatment has centered on the injury without taking into account the potential for psycho-social issues such as fear avoidance or catastrophizing behaviours that may have a tendency to prolong disabilities. When it comes to applying the MIG in order to stave off this issue, Riis believes that while it isn’t “the insurers’ role to identify these risks, (that) health businesses should engage their insurance partners to discuss how such issues can be addressed…by treatment providers already engaged with the Claimant.” Therefore, working more closely with the Claimant, gathering information on all aspects of their lifestyle and proactively addressing their needs will help the Insurance Industry keep costs down and avoid increasing the length of time that the Claimant will be unable to engage in their regular routine. According to Riis, “Early disability (and return to work) management is possible in the MIG, and I think there is room for innovation by health care businesses in this regard.”
Rather than change the SABS completely, it is necessary to change the way that insurers and providers work with it. This can be seen in the way that the MIG now requires insurers, health care providers and insurance partners to focus on all the elements that will affect the Claimant’s return-to-work options. Riis believes the evidence over the past year will show that “the challenge will be to actually achieve the desired outcome (successful return to function) as opposed to exhausting a patient’s benefit dollars on vocation interventions that try but don’t achieve the outcome.” When the focus is not on giving as many treatments as possible in order to max out the Claimant’s options but instead to provide the treatments and interventions that best help return them to their regular function, there will be more meaningful and individualized care.
A Paradigm Shift: Focus on Function
As difficult as it is to exact meaningful change in business best practices on a day to day basis, it becomes even more daunting when you try to overhaul an entire, complex system. While giving a presentation titled “Minor Injury Guideline- What’s Happening?” Viivi Riis said that “acceptance of the SABS recommended changes requires a paradigm shift”. This stance is further exemplified in the administration of the MIG, where not only must health care providers change their focus from maximum medical recovery; they will also need to reassess their standard response to the management of strain and sprain injuries.
For example, Riis and the IBC have found that when it comes to the treatment of strains and sprains the “evidence…overwhelmingly suggests that a return to usual activities and advice in that regard is beneficial to health outcomes… (t)here is new evidence on how to manage sprain, strain and WAD injuries and acute pain. Some of that evidence raises questions about traditional physical treatment approaches that are still widely used. Based on what our members tell me, early treatment continues to be focused on physical treatment while disability management occurs as an afterthought or after MIG resources have been exhausted by physical treatment approaches. Too many Claimants with sprain and strain injuries are still advised by health care providers to avoid activities in part or completely, with no explanation of why this advice is necessary.”
The MIG removes the ability of the treatment provider to maintain an arms’ length relationship with the Claimant. Providers must be more involved in the case management side of the equation and see the treatment model on the whole rather than focusing solely on the injury. The take home message would appear to be: focus on function and early return to work and normal routines, rather than on maximum medical recovery.
The changes have only been in effect for one year and as Viiivi Riis said: “(i)n the absence of data, it is impossible to know if the reforms are achieving their intended effect. Insurers report various experiences.” Nevertheless, once the Insurance Industry and all health care providers have embraced the MIG and the spirit of the new SABS, we will witness an evolution: innovation resulting from fresh new solutions.