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					A perfect partnership: improving the financials and delivering better client outcomes
Liz Cairns, Manager, National Serious Injury Service, ACC Dr Maree Dyson, Strategic and Technical Consultant Darryl Frank, Actuary, PricewaterhouseCoopers

November 2008

Introducing ACC’s serious injury clients
Liz Cairns, Manager, National Serious Injury Service

ACC - unique in the world
– No fault – Everyone in NZ including workers, non-workers, & tourists – Any kind of personal injury caused by an accident (including assault, medical mishap, mental injury) – Funded by everyone through direct levies (workers, employers, car owners) and taxation

ACC’s serious injury clients
• Injury causes
– Predominantly motor vehicle

• Permanently disabled after an accident
– Brain injuries – Spinal cord injuries – Other e.g. severe burns, multiple amputations

• ACC fund life long care and support

ACC’s serious injury clients
Other 5% Severe brain injury 19%

Spinal cord injury 42%

Moderate brain injury 34%

ACC’s serious injury clients
• ACC receives 1.5 million + claims per year • 250 – 300 are serious injury claims • Currently ACC has 4,172 serious injury clients • Size of the serious injury client base will continue growing for another 20-25 years

ACC’s serious injury clients
• Currently 4,172 clients with a serious injury:
– 390 are children 0-16 years 17 are aged 90+ years – Average age at injury = 28 years Average age now = 41 years – 74% male 26% female

Serious injury - actuarial perspective
Darryl Frank, Actuary, PricewaterhouseCoopers

Context – overall ACC Scheme
Payment type Social rehabilitation (serious) Social rehabilitation (non-serious) Weekly compensation Medical/ hospital Other TOTAL Annual payments $m 226 182 948 694 223 2,274 Liabilities 5,131 868 5,290 2,150 1,595 15,033 Multiplier 22.7 4.8 5.6 3.1 7.2 6.6

• Ratio of liabilities to annual payments:
– About 7 for ACC Scheme as a whole – About 23 for serious injury social rehabilitation costs

Context – overall ACC Scheme
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Annual payments Liabilities Serious injury claims All other claims

• Serious injury claims are about 10% of payments and over 30% of liabilities

Average cost per person
Incomplete, $0.42m Paraplegic, $0.84m Comparable, $0.48m Severe TBI, $2.03m

Low-level tetra, $2.05m

Moderate TBI, $0.79m

High-level tetra, $3.00m

• Over the person’s lifetime, , ACC will fund an average of $1.2m of social rehabilitation (excludes treatment and weekly compensation)

Number of $1million + claims
Distribution of claim liabilities
35% 30% 25% 20% 15% 10% 5% 0% $0 - 100k $100k 500k $500k 1m $1 - 3m $3 - 5m $5 - 10m $10m+

• Nearly half of all claims have liabilities of more than $1m, this represents over 80% total of serious injury liabilities.

A liability overview
Incomplete, $239.88m Paraplegic, $526.96m Comparable, $119.80m Severe TBI, $1,604.21m

Low-level tetra, $417.09m

High-level tetra, $931.66m Moderate TBI, $1,231.24m

• If ACC stopped business today…
– $5.1 billion is needed to fund social rehabilitation for existing seriously injured clients to the end of their lives

Modelling challenges
• In any scheme these benefits are the most challenging to model…..
– Short payment history relative to the volume of future payments – Changes in provision of care and expectations of claimants, families and care providers – Changes in broader supply and demand for attendant care and like services – Changes in claims management approaches

• Challenge is greater in ACC….
– Uncertainty relating to care provided by families – Past management of claims not “optimal”. Difficult to assess ACC portfolio relative to “best practice”

Modelling approach
• Due to small number of claims, and variability in cost per claim, serious injury claims are modelled individually • Takes into account
– – – – Age Duration since injury Injury Type (eg high level TBI, paraplegic etc) Current payments

• Allow for mortality (higher than population mortality) • Growth in average cost per claim is the greatest challenge……

Modelling of liabilities
Past and projected cost per claim
160,000 140,000 Average cost per claim 120,000 100,000 80,000 60,000 40,000 20,000 0
20 17 20 09 20 01 20 03 20 11 20 19 20 21 20 13 20 05 20 07 20 15 20 23 20 25

Payment year

• Past growth in average cost could lead has been Continuation of past trends per claim to significant liability increases significant
– each additional 1% p.a. growth in cost/claim adds about $700m

New NSIS has similarities with TAC
• • • • Dedicated staff managing serious injury claims Focus on liability impact of decision making Focus also on client outcomes, not just cost More objective assessment approach (using measures such as FIM) • Improved data capture • Alternatives to Attendant Care
These should result in greater consistency of decisionmaking, leading to more predictable payment increases

TAC experience
TAC changed claims management approach about 8 years ago Recent ACC experience similar to TAC’s prior to change
TAC growth rate in attendant care costs for catastrophically injured clients (delay years 4+)
25% 20% 15% 10% 5% 0% -5% -10% -15% -20% Service Year ended September 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
New Division established

Introduction of Lifetime Support

TAC: pre-New division TAC: Lifetime Support established

TAC: new Division for severely injured clients ACC "lagged"

Serious injury - strategy
Dr Maree Dyson, Strategic and Technical Consultant

Situation 30 June 2007

Accelerating rate of growth in average cost per serious injury claim: • 4.2% • 5.8% • 14.3% in 2005 in 2006 in 2007

Low participation rates in community activities & employment: Best SCI 80% TBI 56% Typical 40% 35% NZ 18% 9%

Liability blow-out

Isolation & dependence

Strategy
• Simple objectives:
– Stabilise growth rate to sustainable rate – Improve client outcomes

Sustainable Sustainable growth rate growth rate

Cost per claim 2003 2004 2005 2006 2007 2008 2009 2010

Strategic approach

Targeted our clients Knowing attendant Managing the Increased Specialist case & alternatives care management service gateway accountability

Knowing our clients

Service-based planning

Person-centred planning

Managing the gateway
• Assessment:
– Not routine – In response to change in needs and/or circumstances only – Evidence based assessment tools • incorporating FIM & FAM, OBS, Lawton’s IADL measures – Decision-making tools

• Outcomes:
– Use of objective outcome measures (AusTOMs) – Closing the ‘service loop’

Targeted Attendant Care
FIM+FAM Lawton’s IADL Attendant Care Guidelines for SCI

Human assistance

High medical support needs Overt Behaviour Scale (OBS) Exceptional responses

Technological alternatives to attendant care

Life alternatives to attendant care

Facilitating alternatives to attendant care
• New disability support services:
– Supported Living • Focus on independence & participation goals – Supported Employment • Focus on finding & maintaining open, paid employment – 2009, Transition from School to Work • Focus on the 16+ group

Increasing accountability
Inputs Outputs Outcomes

Client demographics and complexity indicators (e.g injury profile, age, disability) ACC reporting: – Client complexity – Service utilisation – Costs – ACC decisions – Outcomes

Various (e.g. ACC decisions, number of episodes of intervention, costs, hours of service, service duration)

Actual impact on clients’ lives (e.g. employment participation, goal achievement, increased participation, stability) Provider monitoring: – Client complexity – Costs – Outputs – Outcomes

Reports

Efficiency and effectiveness reporting & purchasing

Benchmarking
• Can we bring some benchmarks to the use of Attendant Care to:
– Assist staff decision making – Provide more information to stakeholders – Improve actuarial modelling

• SCI Guidelines • Functional Independence Measure (FIM)

Improving information, decisions & modelling
FIM™ is an 18-item instrument
• Covering areas such as mobility, transfers, communication • FIM™ is directly relevant to the need Item scores range from 1 (indicating complete dependence) to 7 (complete independence) attendant care, but…

for

• Scores of 5 or less indicate the person needs human assistance to complete the task

Can the FIM™ to predict attendant care hours?

What is acceptable variance explanation in service modelling?
• Serious injury profile:
– SCI 19% variance – 7% for TBI

• Case mix relies on a ~ 15% variance explanation in LOS • FIM-FRGs explain ~ 31% of the variance in length of stay in inpatient rehabilitation • US VA Hospital Based Home Care (HBHC) model explains 20% of the cost variance • Nursing home Resource Utilization Groups (RUGs) ~45% of the variance in patient contact time

Yes ….
• ~47% of the variance in attendant care hours can be explained by a FIM based model • Strong result in human services modelling • Unexplained variance
– FIM does not profile challenging behaviours – Ceiling effects – Other

Is ageing a risk?
Traumatic brain injury
• People injured over the age of 40 tend to have poorer outcomes than people injured at an earlier age • Limited international longitudinal data • Is dementia a risk? • Stability in support needs likely:
– Traumatic Brain Injury Model Systems (TBIMS) data – ACC data

Is ageing a risk?
Spinal cord injury
• Extensive international longitudinal data • Increasing needs more likely if:
– Paraplegic – Injured under 15 years of age – Injured over 50 years of age – Now over 50 and > 15 years post accident

This is our risk

• High utilisation and median hours of Attendant Care • Key strategy
– Using a standardised measure (ICAP) that describes the difference between chronological age and developmental age

Serious injury - delivery and results
Liz Cairns Manager, National Serious Injury Service

Structure
National Service Senior National Service Senior Manager Support Manager Support
Coordinator Coordinator Support needs yet to be established or changing

Service Delivery Service Delivery Manager Manager
Area Team Area Team Area Team Manager Area Team Manager

Support needs wellestablished and stable

Area Team Area Team Manager Manager

Area Team Area Team Manager Manager

Manager Manager
Midlands

Area Team Area Team Manager Manager

Area Team Area Team Manager Manager

Auckland Support Auckland Support North Coordinator South Coordinator

Service Southern Central Service Coordinator Coordinator

Structure
• Key elements of this structure:
– Client segmentation into active management versus stable needs – Job roles differentiated to meet needs of different client segments (active management versus stable needs) – Case loads matched to the requirements of each role, so staff have time to do the job required – Mentoring role (Senior Support Coordinator) to support development of specialist skills & knowledge – Locate staff close to communities where clients reside, so they develop knowledge of local community services & supports

16 months on…
• National service specialising in serious injury
– 100 Support/Service Coordinators handling 4,200 serious injury cases – Five regional Area Team Managers
Central

Northland & North Auckland South Auckland & Waikato Midlands

– National & regional KPIs specific to serious injury: • Liability • Client outcomes • Quality

Southern

Knowing our clients

Hours per week Recommended in ACC Spinal Guidelines Current situation CASE 1: Tetraplegic CASE 2: Tetraplegic CASE 3: Paraplegic CASE 4: Paraplegic 168.0 58.0 114.0 0.0 28.5 - 91.5 98.5 - 105.5 0.5 - 14.5 0.5 - 10.0

Knowing our clients

Hours per week Recommended in ACC Spinal Guidelines Current situation CASE 1: Tetraplegic CASE 2: Tetraplegic CASE 3: Paraplegic CASE 4: Paraplegic 168.0 58.0 114.0 0.0 28.5 - 91.5 98.5 - 105.5 0.5 - 14.5 0.5 - 10.0

Knowing our clients

Hours per week Recommended in ACC Spinal Guidelines Current situation CASE 1: Tetraplegic CASE 2: Tetraplegic CASE 3: Paraplegic CASE 4: Paraplegic 168.0 58.0 114.0 0.0 28.5 - 91.5 98.5 - 105.5 0.5 - 14.5 0.5 - 10.0

Managing the service gateway
• Pilot results
Support Needs Assessment service trial Oct – Dec 2007
Existing clients (102) • • 96 attendant care costs held stable 6 attendant care costs reduced by 440 hours per week, saving: – $5380 per week – $270,00 per year – $5.5m liability • New clients (20) Newly-injured clients have on average 20 hours less attendant care compared to newlyinjured from this time last year

– $4.7m not added to liability

Technological alternatives to attendant care
• Assessor advised increasing attendant care hours to enable a 70 year old client to access their community
– Increase in attendant care hours – Liability impact 21.0 hours $134,000

• Alternative response
Stair lift so client can get out of house & access the community themselves $57,000

• Reduction in ACC • Reduction in ACC Scheme liability Scheme liability

$77,000 $77,000 over life of the claim over life of the claim

Facilitating alternatives to attendant care
• Supported Living
– 11 service providers nationwide – 123 clients receiving service – Outcomes → reduced attendant care & increasing participation

• Supported Employment trial (one site)
– 40% of referred long term unemployed clients now in paid employment (6 spinal & 9 brain injury)

• Community participation though Individual Planning
– Hemi case study

Financial results Q1
• Total costs: 4% lower than expected for the quarter
– Assessment costs $300k less than same period last year – Housing modifications: $1.5m less than same period last year – Vehicles: $2.8m less than same period last year – Attendant care see next slide….

Financial results Q1
– Attendant care
Median attendant care hours per week Baseline: 31 Mar 08 27.0 28.0 17.0 17.0 17.0 30 Sep 08 28.0 25.0 17.0 16.0 17.0

Age group 0-14 years 15-24 years 25-44 years 45-64 years 65+ years

% of clients 8.4 13.2 37.3 32.5 8.7

% using attendant care 54.0% 38.9% 33.8% 34.3% 44.0%

Case study: “Hemi”
• • • • History: 43 year old male with severe brain injury 5 years post-injury Currently living with wife & 3 children on family land in rural South Auckland • 118 hours of attendant care per week
– Includes 87 hours for “supervision” – Hemi socially isolated & not engaged with his local community – Partner struggling with being Mum to 3 kids & being Hemi’s full-time carer

Case study: “Hemi”
• Independence:
– “Supervision” replaced with personal alarm for emergencies

• Involved at local marae
– Carving – Kapa haka – Hemi & his partner get some time out from each other while he’s at the marae

Case study: “Hemi”
• Result - stabilised cost growth:
– Reduction in attendant care hours (supervision) – Personal alarm - $42,000 per year +>$1,000 per year

Net annual • •Reduction insavings • Reduction in ACC ACC for NZ taxpayers Scheme liability Scheme liability

$0.820 million $0.820 year - $41,000 permillion over life of the claim over life of the claim

Strategic objectives
• Stabilise liabilities growth rate • Improve client outcomes

Sustainable Sustainable growth rate growth rate

Cost per claim 2003 2004 2005 2006 2007 2008 2009 2010

…supporting participation …living life !
Rebuilding independence…

A perfect partnership: improving the financials and delivering better client outcomes Questions?
Liz Cairns, Manager, National Serious Injury Service, ACC Dr Maree Dyson, Strategic and Technical Consultant Darryl Frank, Actuary, PricewaterhouseCoopers


				
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