May 6 2013: OPA; [email protected] Psychology Presentation to the Standing Committee on General Government: Auto Insurance Study Ontario Psychological.

May 6 2013: OPA; [email protected]

Psychology Presentation to the Standing Committee on General

Government: Auto Insurance Study

Ontario Psychological Association, Auto Insurance Task Force


No-Fault Accident Benefits Purpose: to provide timely access to funding for services to

reduce impairments and restore functioning. “impairment” means a loss or abnormality of a psychological,

physiological or anatomical structure or function; Medical benefits: 15. (1)…shall pay for all reasonable and

necessary expenses incurred by or on behalf of the insured person as a result of the accident for, (a) medical, surgical, dental, optometric, hospital, nursing, ambulance, audiometric and speech-language pathology services; (b) chiropractic, psychological, occupational therapy and physiotherapy services

Rehabilitation benefits: 16(1) shall pay for all reasonable and necessary expenses incurred by or on behalf of the insured person in undertaking activities and measures described in subsection (3) that are reasonable and necessary for the purpose of reducing or eliminating the effects of any disability resulting from the impairment or to facilitate the person’s reintegration into his or her family, the rest of society and the labour market.


Psychologists are

Independent, autonomous, regulated health care providers

Trained from bachelor’s to doctoral level in normal and abnormal mental health

Experts in scientific methods applied to health and behaviour

Experts in measurement


Psychologists

Provide scientific, valid and reliable methods for assessing impairments

Provide cost-effective, empirically-validated, evidence-based treatments

Provide gold standard interventions for depression, anxiety, brain injury, and chronic pain


Psychologists in Ontario

See patients with traumatic injuries under WSIB, auto insurance, victim services, etc

Are employed in hospital programs for chronic pain, depression, anxiety disorders, schizophrenia, cognitive impairments, and brain injuries

Cannot bill OHIP directly


So, why fund psychologists under auto insurance?

Car accidents are the single biggest cause of civilian post-traumatic stress and brain injuries

Psychologists provide the most effective treatments for post-traumatic stress

Psychology is the only profession able to measure and diagnose cognitive impairments due to brain injury


For accident victims, psychologists

Assess and treat post-traumatic stress disorder, depression, chronic pain, and traumatic grief

Assess and rehabilitate brain injuries Assist in school and work re-entry Assess and measure disability


For accident victims, psychologists

Tend to be involved with the most seriously injured and vulnerable

Work with the high-need victims who have brain injuries and psychological disorders

Provide services that are critical for recovery and disability prevention

Historically 2-4% in Ontario data

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As you know…

Mental health is often misunderstood Services are often under-funded Many studies across the country tell this

story again and again Auto is no different


Need for funding for timely access to psychological services Imperative for Change: Access to Psychological Services for Canada,

March 2013 The delivery of mental health services in Canada can be characterized as a

silent crisis. An increasing demand and need is unmet by provincial and territorial health care systems and private insurers. Instead, attention has continued to focus on politically sensitive areas, such as cardiovascular interventions and joint replacement surgery. Nonetheless, a mental health disorder effects one in five Canadians with an annual societal cost of $50 billion, as reported by the Mental Health Commission of Canada. ….

Despite an awareness of the benefits of evidence-based psychological interventions, there continues to be a severe gap in the ability of patients to receive needed care.

FROM the FSCO website: Increasing Your Liability and Accident Benefits Coverage Medical, Rehabilitation and Attendant Care Benefits: …. Keep in mind that many health care expenses are not covered by OHIP, or only partially covered, including physiotherapy and chiropractic treatment, mobility devices (crutches, wheelchairs), modifications to your home and car that you may require, and other specialized goods and services…


MVA victims with psychological conditions are among the most vulnerable: Psychological disorders and brain

injuries are invisible Easy target for stigma,

misunderstanding, discrimination High rates of disability

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OPA Initiatives

Evidence-based guidelines for assessment and treatment services billable under auto insurance in Ontario. Developed by 20+ psychologists around the province. Published in peer-reviewed journal.


OPA Initiatives

OPA Auto Task Force co-chair on the HCAI Anti-Fraud committee

College of Psychology testing professional identity tracker

Developing joint guidelines for IE assessments and MIG determinations with CAPDA


Thank you for the opportunity

When we presented to the Standing Committee on General Government’s Study of Auto Insurance last May, we presented our members’ concerns that the 2010 reforms were resulting in harm to legitimately injured people with brain injuries and psychological impairments.


Thank you for the opportunity

When we presented to the Standing Committee on Finance and Economic Affairs’ Auto Insurance Study last July, we presented data indicating that the 2010 reforms had resulted in significant improvements in cost-control for the insurance industry.


In July 2012,

We also presented data from reputable psychology treatment clinics outside the Toronto area that indicated approvals for recommended assessment and treatment services had decreased significantly since the 2010 reforms.


Data from reputable clinics in Hamilton – Burlington

April 2010 April 2012Approved 100% 63.41%Denied 0 21.95%Partial Approval 0 14.63%

May 2010 May 2012Approved 88.23% 48.71%Denied 11.76% 33.33%Partial Approval 0 15.38%

June 2010 June 2012Approved 100% 40%Denied 0 13.33%Partial Approval 0 0

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Data from reputable clinics in Hamilton – Burlington

Pre-Sept 1, 2010 (N = 780 OCF-18s)

2008 2009 To Aug 31/10 Total pre-change

Full Approval 72% 67% 77% 72% (n = 562)

Partial Approval 3% 5% 2% 3% (n = 24)

Total Approved 75% 71% 79% 75% (n = 586)

Denied 25% 29% 21% 25% (n = 196)

Post-Sept 1, 2010 (N = 680 OCF-18s)

After Sept 1/10 2011 2012 Total post-change

Full Approval 55% 61% 52% 59% (N = 398)

Partial Approval 10% 7% 6% 7% (N = 48)

Total Approved 71% 68% 58% 66% (N = 446)

Denied 29% 32% 42% 34% (N = 231)18


As a result, in July 2012, we reported concern about potential Increased disputes, transaction costs Increased disability Increased tort/ BI costs More mediations and arbitrations Increased costs to public systems

(OHIP, CPP, etc.)


As a result, in July 2012 we reported concern about potential

Increased barriers, lack of timely rehab More assessments without treatment Increased patient frustration, cynicism Delays without resolving disputes More problems for injured victims


In August 2012,

We were especially pleased to present to the Anti-Fraud Task Force

We told them that OPA has advocated for specific measures to target, investigate, and prosecute fraud for many years, and that

Many of the Task Force’s recommendations are consistent with those we have recommended.


In August 2012, we recommended to the Task Force Assessing successes achieved before

enacting more costly and intrusive measures requiring additional regulation.

Ensuring patient privacy and due process in investigations.

Including OPA and CAPDA in future discussions and planning.


Today

We’re happy to have the chance to follow up with you today to provide an update on the current trends in assessment and treatment for rehabilitation (not disability) by psychologists in the province.


What now?

AB Claims costs are down Fraud initiatives are in effect next month Approvals for reputable assessment

and treatment services are down What are the effects of 2010 reforms on

insurance examinations? What is happening with minor injuries?


And, the big question:

What does this mean for patients?


What is happening with IEs?

Polled members we knew to be active in the auto insurance sector and whose practices we knew to be reputable.

We received replies from Burlington, Hamilton, London, Barrie, Downsview, Thornhill, and downtown Toronto.

All report IE referrals to their practices down 50-90% since 2010.


Most report reviewing fewer excessive applications

Burlington: Indicates fewer but, “we never really saw all that many over-the-top applications before. The large majority seemed to be reasonable, at least in our neck of the woods”.

London: “Never did see any”. Barrie: “To be honest, I never saw very

many bad applications to begin with”.


Most report reviewing fewer excessive applications

Thornhill: Estimates 80% reduction. Indicates, “Before it was ridiculous. Most of the assessment companies with bad applications have disappeared…”

Downsview: Approximately 50% reduction in bad applications.


So, IE referrals seem to be down

And, bad applications seem to be down But, all respondents also indicated that

they’re being asked more questions in each referral, especially in the GTA

Burlington, Barrie, London: maximum 8-15 questions per referral

Downsview, Thornhill, Toronto: maximum 20-32 questions per referral


They are being asked to answer more questions for lower fees

Burlington: …with the cap, we were essentially forced into flat-fee agreements with the IE vendors we work with

Barrie: …with the cap, I have to limit my time. I do now sometimes put in hours that I cannot bill, in order to do an adequate job.

Downsview: …some files we review are as high as 4000 pages and we can’t bill for the review.


We also heard reports of concerns about off-loading London Health Sciences: Since I also do work

in an MoHLTC hospital clinic, we see MANY former AISI funded patients on our waitlists who have been cut off (or never left the MIG) and they are waiting over a year to be seen by OT, SLP, SW, psychology...

As the insurance-funded service menu shrinks, the hospital waitlists grow, and the ER visits increase.


We also heard reports of concerns about off-loading Hamilton Health Sciences and

Burlington: …our program is working on an REB to look at quantifying this change since 2010. There is definitely the sense that there is greater waitlist pressure since the funding changes and the reduced IE approvals. This includes to mental health services at St. Joe’s and Joe Brant.


Our current impressions:

Excessive applications that were driving up costs appear to have been primarily in the GTA and appear to have decreased.

IEs outside the GTA didn’t see these to begin with, so they’re not seeing any fewer of them.

Significantly increased cost-pressures


What does this mean for patients? May be off-loading to public services

that are already under-resourced More people accessing our fractured

public mental health care system. Unable to handle these increases Resulting in increased wait times


What is happening with IE companies? Psychologists are being asked to do

more for less They are reporting that there used to be

more competition in the IE marketplace. As a result, it was easier to say no to

any given company if there were unreasonable expectations.


What is happening with IE companies?

Consolidation of IE companies has resulted in downward pressures on assessors regarding:

the costs of their own assessments; and The costs of plans for services they review As a result, IEs are facing new economic

pressures and micromanaging the costs of proposed assessments and treatment plans.


What does this mean for patients?

Many approved plans are trimmed.


What is happening with the minor injury cap? Seems to be effective gate-keeping,

containing many accident victims appropriately.

The challenge is how to identify those who are appropriately in and out.

In general, insurers are requiring an IE to determine whether or not there is a psychological disorder due to the MVA that requires treatment.


What does this mean for patients? This adds demand on the patient and cost to

the system. People with soft-tissue injuries and

psychological disorders have to go through an extra step in order to document that disorder before they can access appropriate assessment and treatment.

Creates an extra obstacle and intrusive burden for people who are already suffering.


What does this mean for patients? E.g., if physician diagnoses and refers

specifically for assessment and treatment of PTSD and our screening shows strong indicators of this, does it really make sense to ask the patient to disclose all of their traumatic memories and experiences to someone who is never going to see them again?


Is there a better way?

If a psychologist follows the OPA Guidelines and does a thorough screening, this should result in a strong application that could be approved without requiring IE.

In fact, if the screening is done properly, the IE should approve it (and in our experience, usually does).



Does it make sense for the system to have this additional cost?

The treating psychologist still has to engage the patient him/herself in order to initiate treatment.

Is it possible to collaborate with insurers to streamline process for the patients and save cost to the system?



Insurer in-house psychological consultant or IE paper review as a first screen?

Some may be obviously not minor injuries and therefore approved.

Only send on those that are questionable to in-person assessment?


While it is true that fraud had reached level intolerable levels in auto and other sectors There now is a system-wide focus on

accident victims and rehab providers as being fraudulent or too costly.

Focus on cost-cutting and anti-fraud creates atmosphere where everyone is hypervigilant.

More presumption of looking for fraud. No assessments that are perceived to be

neutral. Increased level of distrust, suspicion.


What does this mean for patients? This creates the dual burden on patients of

both the presumption of fraud and the micromanaging of costs.

Has an impact on care: shorter plans, more time between them, partial approvals.

Means less proper, effective momentum toward improvement; increases treatment costs and transaction costs.


What does this mean for patients? More partial approvals, shorter plans,

even for complicated patients Subsequent plans are more likely to be

sent for IEs More frequent IEs During full course of treatment over

several plans, more IEs, more disruptions than before 2010.


What does this mean for patients? Result can be choppy, watered-down

care. Presumption of fraud, too much cost,

and seeking unneeded service is shaping the environment from the beginning for treatment providers, adjusters, and IEs, all of which ends up affecting the patient’s care.


MVA victims with psychological conditions are among the most vulnerable: While we know they generate high costs

to payor systems We hate to see this small percentage of

vulnerable injured people injured further by a system that pre-judges them to be fakes and liars, and continually questions their need for more care.


Currently, We are hoping for more sophisticated and

targeted approaches to fraud. We are in support of many of the new

proposed anti-fraud measures because they look like they’re going to be more targeted.

We hope to be involved in the implementation process, for example regarding licensing of health facilities.

We anticipate that these will provide increased cost-savings and reduce the overall atmosphere of distrust.


Thank you for the opportunity to meet with you

We will provide more specific details in our written submission and would welcome the opportunity to address any questions.

Reply to Dr. Amber Smith, 905 5295131 [email protected]

May 6 2013: OPA; [email protected] Psychology Presentation to the Standing Committee on General Government: Auto Insurance Study Ontario Psychological.

Documents

brain injury slide

brain injuries psychologists

measurement slide

different slide

psychological disorders

psychological interventions

chronic pain slide

measure disability slide