Medical Claims Management German Social Health Insurance: Incapacity for work 23.11.2004 Wolfgang Seger

Contents The structure and function of the Medical Service Some economic and epidemiological data about incapacity for work The search for the best point of intervention The search for the best items to screen for clients at high risk for long term Incapacity for Work The organisational structure for intervention Results of Medical Expertise Summary of pathways

The structure and function of the Medical Service

. Hannover Lower Saxony 8 mio inhabitants Population ca 1/10 of Germany

Independancy in our organisation and Sociomedical way of thinking Some facts about the Medical Service Statutory organisation (SGB V) Service to all social health and nursing care insurances Budget: ca. 42. mio € 9,27 € per capita Independancy in our organisation and Sociomedical way of thinking Staff: 500 (full time) 154 medical experts 120 nurses

MDKN Executive Management Board Division Special Operations Division General Manager: Jürgen Vespermann Deputy Manager and Medical Director: Prof. Dr. Wolfgang Seger Division Special Operations Prof. Dr. Wolfgang Seger Controlling Management Support Martin Dutschek Stefan Seidel Division Regional Business Dr. Hubert Krell Central business centers 7 regional Business Centers Central Services Human Res.: Jürgen Mäckeler Inf.Technology: Bernd Nulle Finances: Norbert Krüger Service Center Health Insurance Long Term Care Hannover: Dr. Ute Döbel-Hansen Monika Bettin Annette Franke Braunschweig: Dr. Ulrike Fondahl Gabriele Klindtworth Sabine Eidam Business Group Dental Medicine Rolf Bücken Business Group Consulting Dr. Dietmar Rohland Oldenburg: Dr. Mechthild Hermes Barbara Mainka Detlef Schlickmann Service Center Bianca Wessels Business Group Malpractice Prof. Dr. Rainer Kirchner Sociomed. Expert Group 1 Dr. Sabine Grotkamp Lüneburg: Dr. Christoph Brandau Siegrid Seidel Anke Bahr Göttingen: Dr. Bernd Schlemminger Bärbel Bodenstab Ekkehard Eberding Business Group Hospital Treatment Priv. Doz. Dr. Georg Geißler Business Group External Quality Management Nursing Care Sylvia Theis Osnabrück: Dr. Norbert Jansing Anke Kahtenbrink Manfred Schiermeyer Osnabrück: Dr. Norbert Jansing Anke Kahtenbrink Manfred Schiermeyer Bremen: Dr. Gustav Krimphoff Monika Tietjen Volker Tewes Experts for the Division Special Operations Malpractice, Consulting, Hospital Treatment

Insurances and their associations, ministry of legislative bodies etc. Medical Service Incapacity for Work Consultation Insurances and their associations, ministry of social affairs, legislative bodies etc. Basic Expertise: to solve fundamental questions Individual Expertise

Some economic and epidemiological Data about Incapacity for Work - Is claims management still of importance ? -

1. Quelle: BMGS 2. Aussage: Der Krankenstand hat sich in den letzten 30 Jahren halbiert. 3. Anmerkung: Nach Gründung des MDK (16.10.1989) kontinuierliche Absenkung des Krankenstandes. (Der erste rote Gipfel ist entstanden, weil die MDK-Gutachter Pflege fahren mussten!)

Incapacity for work in different industries / professions 2003 in comparison to 2002 1.Quelle: WIdO 2. Aussage: Rückgang des Krankenstandes in allen Branchen. Die Tabelle ist von unten nach oben zu lesen! Der Vergleich der Krankenstände zwischen der öffentlichen Verwaltung, dem Baugewerbe und der Branche Banken/ Versicherungen verdeutlicht die Bedeutung der Kontextfaktoren. Die medizinischen Faktoren können diese Unterschiede nicht erklären

Economic loss in different industries in Mrd. / Bill. € others 5,3 Producing companies 18,1 Banking, insurances 15,8 Serviceoriented enterprises 15,2 Commerce, hotels, restaurants, traffic 11,5 Building and construction 3,2 Quelle: Statistisches Bundesamt Agriculture, forest, fishery 0,4 2 4 6 8 10 12 14 16 18 20 Mrd / Bn €

Total economic loss due to incapacity for work Quelle: Statistisches Bundesamt Total economic loss due to incapacity for work In 2002 69.500.000.000 € (69,5 Mrd. €)

Quellen: Forschungsergebnisse der Bundesanstalt für Arbeitsschutz und Arbeitsmedizin 1998 Stellungnahme der Bundesregierung,BtDr 15/1783 und 15/2318 Aussage: Langzeit-AU kostet ein Vielfaches der berufsbezogenen Prävention und Rehabilitation, deshalb ist ein frühes und sinnvolles betriebliches Eingliederungsmanagement zu etablieren.

Incapacity for Work: the search for the best point of intervention

Distribution of case-related length of incapacity to work in % 57 21 13 4 5 Up to 1 week Up to 2 weeks Up to 3 weeks Up to 4+5 weeks Over 6 weeks Die sozialmedizinisch relevanten AU-Fälle befinden sich in dem rotem und rot-blau gestreiftem Anteil. Die meisten AU-Fälle sind bis zur 3. AU-Woche mit und ohne Krankenkasse / MDK abgeschlossen. Die Gespräche mit den Versicherten zur Prävention der Langzeit-AU führen die Krankenkassen in der 4.- 5. AU- Woche, nur mit dem rot-blauen „Keil“!

Comparison of IW – frequency and IW – duration in percent 10 20 30 40 50 60 % - 1 week - 2 weeks - 3 weeks 4.- 6. weeks > 6 weeks Frequency in percent Duration in percent Gegenüberstellung der Häufigkeit und der Kosten. Die Diskrepanz zwischen Häufigkeit und Kosten in der Gruppe der „über 6 Wochen AU“ ist zu beachten. Die Versichertengespräche durch die Krankenkassen betreffen die Gruppe der „4. bis 6. Woche“, der MDK beschäftigt sich in der Regel mit der letzten blauen Säule.

Point of intervention 6 >8 100 90 80 70 60 50 % of IW-cases 100 100 90 80 IW-cases in % - IW-days in % 70 60 50 Beginning of benefit payment 45 45 40 30 23 20 Quelle: PAULA Untersuchung. Aussage: Eine andere Darstellung der Häufigkeiten als in den Folien 14 und 15. In der 4. und 5. AU-Woche ist der Schnittpunkt der wieder arbeitsfähigen und der wahrscheinlich Langzeit-arbeitsunfähigen gut erkennbar 15 16 9 10 12 10 12 14 10 14 5 7 6 6 Duration of Incapacity for Work in weeks 1 2 3 4 5 6 7 >8

Incapacity for Work: the search for items to screen for clients at high risk for long term Incapacity for Work

Purposes of Screening Identifying claimants at higher risk of long-term incapacity versus those likely to return to work Predicting likely duration of sickness absence and return to work Identifying people who need extra therapeutic or rehabilitation help Identifying those obstacles to coming off benefit and returning to work that may be appropriate for intervention Identifying people likely to respond to (an) intervention versus those likely not to respond Informing a rehabilitation programme or other work-focused intervention Informing the decision-making process and case management

Methods of Screening Actuarial / administrative Identification of risk markers (causal or explanatory significance regarding the outcome or possible intervention), epidemiological and demographic data or in administrative database to produce tables of risk that are simple to use , score, transparent Clinical and psychosocial Predicting likely progress and outcomes (how and why some people develop long-term incapacity and what can be done about it) with strong scientific and statistical foundation

Some facts about clinical and psychosocial predictors Psychosocial factors (`Yellow Flags`) are generally agreed to be stronger predictors of chronic pain and disability than biomedical factors or physical characteristics of work

Displacement of problems in patients during incapacity for work 100% Social / Psycho-social problems,, Internal migration etc.   Medical problem Die Intervention der Krankenkassen (4.-5. AU-Woche Versichertengespräch) ist der subakuten Phase zuzuordnen. Zu verhindern gilt, dass der gelbe Anteil zunimmt. Hinweis: Retrospektive Reha-Studien zeigen, dass ein Beginn der medizinischen Reha drei bzw. fünf Monate nach AU- Beginn kaum einen Reha- Erfolg (Reintegration in die Arbeit) aufweisen! Dieser Prozess der inneren Migration (Ängste vor der Rückkehr zum Arbeitsplatz und Zweifel an eigener Leistungsfähigkeit) kann durch Erhalten des Kontaktes zum Arbeitgeber oder den Arbeitskollegen während der AU verzögert bzw. vermieden werden. Acute period Subacute period Chronic period 2nd. month / 3rd month (evidenced by experience and literature)

Facts for the selection of items Best selection of individual predictors and the construction and scoring of screening tools are time-dependent (It is not possible to predict long-term outcomes with any accuracy using clinical and psychosocial variables in the early days of sickness, this only becomes possible by about 3-6 weeks)

The window for screening

Facts for the selection of items Best selection of individual predictors and the construction and scoring of screening tools are outcome-specific and intervention-specific (the risk of long-term incapacity, and hence prediction and screening, are partly dependent on the success rate of the intervention and the probability of response)

Some facts about clinical and psychosocial predictors The accuracy of prediction varies with all of the above. The best specificity and sensitivity achieved in clinical and psychosocial screening is of the order of 80-90 %, and more generally about 70-80 %

Clinical and psychosocial predictors

Sociodemographic predictors

Recommendation for screening by literature:

Suggestion for Socio-demographic screening (Waddell, Burton and Main)

Suggestion for Psychosocial Screening (Waddel et al)

Literature: screening in the context of long-term incapacity … is possible and potentially valuable in a social security context `Administrative`Screening based on socio-demographic resk markers and `Individual`Screening focusing on clinical and psychosocial factors can be combined into a logical and practical sequence in the screening process … can achive about 70-80 % sensitivity and / or specificity

Timing and Accuracy of Screening Practical problem to define the onset of illness, of disability or of incapacity The development of long-term incapacity involves biopsychosocial changes and may influence further progress and constitute obstacles to coming off benefit and returning to work At different times in the course of incapacity, screening faces very different statistical tasks On day 1 screening has to identify the 1-2 % of individuals who will go on long-term incapacity from amongst 98-99% with relatively simple problems, most of whom are likely to return to work quite rapidly, irrespective of any intervention After 26 weeks of sickness absence most will have variable, complex mixtures of biopsychosocial problems, an the task would be to distinguish the 40% likely to continue on long-term incapacity from those who might return to work.

Necessary informations for the screening: Items of Incapacity for Work how often and how long Items of Social Conditions Working condition, employer, family Severe diseases in case history cancer, accident, hospital or rehabilitation, claim for pension benefits, Psychotherapy etc. Medical findings Analysis of records Questinnaire to the therapist Questionnaire to the client: Information about workplace and medical reports Current diagnosis Informationsbeschaffung läuft über die Krankenkasse an den MDK, oder aber wir besorgen uns die Infos über den Versicherten oder den Leistungserbringer oder Sozialleistungsträger direkt selbst: Vorberatungsbogen der AOK und BEK und Versichertenanschreiben/MDK. Nach SFB folgt die Begutachtung: Folien mit MDK Gutachten (Kasuistiken). Dann folgt die Beurteilung

Incapacity for Work: the organisational structure for intervention

„ABBA 2004″ The ABBA is a guideline, which was developped in cooperation between health insurances, medical service and the federal associations of insurances. It is a guideline in accordance with the relevant legislation (Social Law Code No. 5) . It is liable to the health care insurances as well as to its medical services.

Screening by health insurance Group 1 Non striking Group 2 striking (Selection criteria)

Grouping till day 21 Non striking group 1 striking group 2 Duration of IW ? Date of beginning IW ? Diagnoses ? Certifiying doctor ? Social case history ? Utilisation of other benefits ? striking group 2

there is no need for action Group 1 On principle there is no need for action up to day 28 ! Die Krankenkassenmitarbeiter sind zu ermutigen selbst die Plausibilität der Arbeitsunfähigkeit zu beurteilen. In der Regel können nach dem Telefonat etwa 30-60 % der Fälle von der Krankenkasse selbst gemanagt werden

The right time for intervention 45 23 5 12 100 10 20 30 40 50 60 70 80 90 1 2 3 4 6 7 >8 % der AU-Fälle AU Fälle in % - AU Tage in % Beginn: Krankengeldbezug Quelle: PAULA Untersuchung. Aussage: Eine andere Darstellung der Häufigkeiten als in den Folien 14 und 15. In der 4. und 5. AU-Woche ist der Schnittpunkt der wieder arbeitsfähigen und der wahrscheinlich Langzeit-arbeitsunfähigen gut erkennbar 15 16 9 10 12 14 10 14 7 6 6 Dauer der Arbeitsunfähigkeit in Wochen

Group 1 After day 28: Reassure the correct diagnosis which is leading to incapacity for work Seek a dialogue with the client up to day 35 in respect to his work- place Prove the possibility for a stepwise reintegration if further clarifying is necessary take sociomedical case consultation (SCC) into consideration Be aware of the right time for the right intervention (catalogues for normal disease courses and length of therapy, teaching of decision managers etc.) Die Krankenkassenmitarbeiter sind zu ermutigen selbst die Plausibilität der Arbeitsunfähigkeit zu beurteilen. In der Regel können nach dem Telefonat etwa 30-60 % der Fälle von der Krankenkasse selbst gemanagt werden

Completion of material for SCC, Defining the right order / Group 1 Completion of material for SCC, Defining the right order / commission, Fixing the date Presentation to SCC* Submission day 28 Dialogue with client till day 35 IW* plausible IW* terminated * Sociomedical Case Consultation ** Incapacity for work

Preselection for group Sum of IW-days per year higher than average? Reference is the statistical average in industry / profession / health insurance and length of reconvalescence

Incapacity to work in reference to the disease groups (IW Cases and IW Length)

Grouping for preselection (HI) High frequency of IW in respect to age (IW-carreer)? Interruption of benefits in case history? Repeated IW due to the same disease? Recent case history more than 3 months? „Personal pattern of duration of IW″ recognizable? Pattern without relation to diagnosis: constant duration per IW-case, seasonal pattern when comparing the years, frequent involvement of Fridays and Mondays Informations extracted from the dialogue with the client (standardised !) Intended date of revival of work, intended date of contact with the unemployment insurance? If appropriate: documentation of backgrounds for the Medical Service. Comparison of workplace requirements with mentioned impaiments and handicaps (specifications of workpalce and its environment necessary) Fragen, die sich die Fallmanager bei der Krankenkasse stellen müssen.

Result of preseclection Presentation to Sociomedical Case Consultation (SCC) necessary? If yes, than: Compilation of relevant and usable informations and definition of decisive questions for the SCC

Compilation of data (1) Family name, first name, date of birth, address, incl. telephone- no. Last relevant occupation, duration of last employment, employer Similar occupations ( if employment is terminated during IW for unskilled and semi-skilled clients) If unemployed: date of submission for commission through insurance for unemployment Beginning of IW, Termination of sick pay by employer or sickness benefits by insurance Diagnosis leading to IW / ICD-10 Doctor certifying IW ( name, specialisation, tel., address) Duration or IW-times and diagnoses of IW during 3-5 years

Compilation of data (2) Sum of IW-days per year during 3-5 years Utilisation data about medical benefits for rehabilitation / participation State of process for eventual claims for rehabilitation, participation or pension Data about hospital teatments during 3 years Medical findings of medical specialists and non medical therapist, medical reports of in- and out-patient treatments (negative) social context factors Occupational diseases / accidents (with connexion to IW) Benefits of pension funds, kind of benefits GdB / MdE etc. (degree of handicaps or disabilities recognized by other social or statutory institutions)

Examples for questions arising in health insurance Incapacity in doubt (health insurance decision maker) / securing recovery (prospective duration of IW ?/ assessment of short or long term personal capability performance !) Incapacity in doubt (employer) Impending, emerging or irreversible incapacity for employment or occupational disability § 51 SGB V (Medical Rehabilitation / rehabilitation for occupational participation) Link with preceding IW-times (the same disease?) Other links with IW (stepwise occupational reintegration / referral to unemployment insurance)

Medical Service: Sociomedical Case Health insurance : Screening and preselection Gr.1 Gr.2 Hinweis: Bei dieser Folie, in der PowerPoint-Version 2002, kann durch einen zweiten Maus-Klick eine Animation eingeschaltet werden: „die Bescheinigungen fliegen durch den Trichter“. Medical Service: Sociomedical Case Consultation

Sociomedical Case Consultation Central step for the processing of each order / commission to the Medical Service for a Medical Expertise to assess the capability for work (The location of the health insurance determines the proper Medical Service)

Goals for individual consultation Reduction of insurance sickness benefits Avoidance of long term incapacity for work stepwise reintegration Recommendation of medical and occupational rehabilitation / participation Supply with auxiliary devices Adaptation of workplace etc. Unter berufsbezogener medizinischer Reha versteht man folgendes: Bezogen auf die berufliche Anforderung werden die Beeinträchtigungen bzw. Defizite erfasst. Die medizinische Rehabilitation richtet sich ähnlich wie beim Leistungssport nach den individuellen Anforderungen. Besonders trainiert werden diejenigen Organe / Organsysteme, die besonders beruflich gefordert (beansprucht) werden: Weg von Vermeidung, hin zur Aktivität. Zunehmend werden diese Therapieformen in Form von ambulanten medizinischen bzw. stationären Rehabilitationen angeboten. Die Rentenversicherer übernehmen die Kosten, sofern die EF gefährdet oder gemindert ist. Ist das nicht der Fall, so kann der Krankenkasse die Kostenübernahme zur Vermeidung von Langzeit- AU (Vielfaches der Kosten von Prävention bzw. Rehabilitation, siehe auch Kommentar der Folie 6) empfohlen werden.

with postal information in office of medical service Feed back procedures with postal information MDK- Questionnaire to the client Variation of SCC MDK Telephoning the contracting doctor MDK Telefonat mit Vertragsarzt MDK Telephoning the client Vers.-Gespräch MDK Dialogue with client in office of medical service Short examination

Three sociomedically relevant potential subgroups: Medical Service categorises Group 2 by Group 1 Group 2 Three sociomedically relevant potential subgroups: 1. Incapacity for work (doubts / potential misuse of benefits) 2. Potential long-time cases (psychosocial problems) 3. Rehabilitation/Participation (med. severe disease) If necessary precision of the relevant and decisive question Hinweis: Bei dieser Folie, in der PowerPoint-Version 2002, kann durch einen zweiten Maus-Klick eine Animation eingeschaltet werden: „die Bescheinigungen fliegen durch den Trichter“.

Differentiation in Group 2 . Suspected misuse of benefits from Incapacity for Work or medically not justifiable IW typ. doubts of health insurance if benefits from unemployment insurance are terminated ... the undifferentiated back pain II. Suspected psychosocial superposition with long term effect typ. loss of employment in critical age ... reaktive depression and multimorbidity II. Impending, emerging or irreversible incapacity for employment or occupational disability (medical problem) Qualified occupation ... tumor disease with residues

Results of SCC IW plausible procedure to follow IW not plausible Info from SCC written to contracting doctor by med. expert Written to contracting doctor by case manager Initiation of expertise In centre of own medical service for file examination or personal assessment Forwarding to (with open result) Medical Service where client is living. Further information to case manager

Informationen to case manager Request for a written factual medical report Impulse for a dialogue with the client Requesting other information / evidence

Medical Service: Way of expertise (IW) Expertise by file examination Expertise by personal dialogue with client without assessment (regional) Expertise by personal investigation / assessment related to symptoms comprehensive Case conference (regional)

Goal of expertises of the Medical Service The assessment of the Medical Service of the health insurances does not necessarily cover the entire capacity of performance (Questions are differing to other Social Insurances like unemployment, pension, occupational accidents) Assessment of Incapacity for work in relation to the profile of the real workplace, not the employment of the labour market in general

Assessment for health insurance Course of insurance benefit / membership IW Iw Aufgabe des Sozialmediziners im MDK ist es, bei wesentlich geminderter Leistungsfähigkeit durch die aktuelle zur Arbeitsunfähigkeit führenden Krankheit ein Leistungsbild (LB) zu erstellen. Egal, ob die Krankenkasse danach gefragt hat oder nicht. Beauftragt die Krankenkasse den MDK mit Erstellung eines Leistungsbildes während der Heilungsphase (zeitlich begrenzte Rekonvaleszenz), so ist ein LB nicht zu erstellen! Die Krankenkasse ist aber darauf hinzuweisen, dass nach bestimmter Zeit mit Wiederherstellung des Leistungsvermögens, wie vor der aktuellen Arbeitsunfähigkeit, zu rechnen ist. Es ist verwaltungstechnisch für die Krankenkasse einfacher, die Arbeitsunfähigkeit zu beenden, als jemanden zu verweisen (2 BSG Grundsatzurteile zur Verweisbarkeit!) Assessment of long term capacity for work (positive / negative) Assessment of short and middle term capacity for work

Requirements to the Medical Services (approved) doctor: medically and socially correct and competent objective, fair and impartial avoiding to interfere with the running treatment to the advice / expertise legible and concise consistent and complete in accordance with the relevant legislation and current guidelines

Medical expertise by assessment Recommended time period to invite the client for assessment Not later than 2-3 weeks after SCC Processing of contradiction / second expertise within 5 days

Standardised documentation list of results of medical expertise: From the medical view … … no longer incapable for work (within the following 14 days) ... incapable for work for a defined time period ... irreversibly incapable for work … documentation of a comprehensive long term time assessment of capability for work in general (eg. with the recommendation of transfer to pension fund) … other statement

Expertise of Medical Service Information to health insurance Expertise File examination of personal assessment Information to the contracting doctor

Claims Management of Incapacity for work: Results

Sociomedical Case Consultations and their occasions Number of Case Consultations Final decisions by Case Consultation Incapacity for work 230.860 165.626 In-patient benefits (hospital) 96.866 78.398 Out-patient benefits (contracting therapists) 97.591 89.977 Unconventional remedies or medication 7.235 5.586 Preventive measures or rehabilitation 154.425 134.967 Therapeutic appliances 46.471 35.118 Dental medicine 281 89 Therapeutic malpractice 1.797 1.128 Other Cases 36.205 31.784 Sum 671.731 542.673

Incapacity for work: Expertises and their occasion in 2003, Lower Saxony Occasions Number of Expertises First Expertise Second and third expertise   Securing the success of treatment / doubtful incapacity for work (insurance) 28.282 21.157 5.653 Doubtful Incapicity for work (employer) 2.111 2.069 35 Impulse for Rehabilitation 4.987 3.869 1.067 Connexion with preceding IW-Time 26 18 7 Referring to unemployment insurance 939 878 56

Incapacity for work: instruments for expertise Occasions Number Of expertises File Analysis Personal assess- ment in office Personal assess-ment in home Securing the success of treat-ment / doubtful incapacity for work (insurance) 28.282 3.519 24.733 30 Doubtful incapacity for work (employer) 2.111 126 1.985 Impulse for rehabilitation 4.987 1.050 3.930 7 Connexion with preceding IW-Time 26 16 10 Referring to unemployment insurance 939 624 310 5

Incapacity for work: results Occasions Number of first expertise Start to work Still unable to Work for a defined period Unable to work in the long run Securing the success of treat-ment / doubtful incapacity for work (insurance) 21.157 3.754 15.929 1.474 Doubtful incapacity for work (employer) 2.069 849 1.198 22 claim for rehabilitation 3.869 246 2.858 765 Sum 27.991 4.892 20.188 2.333

Claims Management of Incapacity for work: Pathways

Common responsibility Case Manager health insurance Medical Service SCC Preselection of case Analysis of documents Compilation of data Questionnaire Investigations Putting decisive questions Impulse for subse- quent procedures Answering decisive questions Besonders hervorzuheben ist die gemeinsame Verantwortung der Krankenkasse und des MDK für das SFB-Einzelfallergebnis. Common responsibility for the results

Group 2 ? SCC Doubtful incapacity (employer) Evaluation by medically doubtfull informations Group 2 ? SCC Doubtful incapacity (employer) Evaluation by case manager No SCC Medically clear informations

Differences between the contracting doctor and the doctor of Medical Service Renewed submission SCC SCC New aspects? IW plausible? Benefit decision of health insurance yes no Objection Contracting doctor Die SFB soll gemeinsam (Krankenkasse und MDK) durchgeführt werden. Das führt zu Lerneffekten auf beiden Seiten und zu effizienten Ergebnissen in der SFB (Ressourcen!). Confirmation of IW Personal assessment

Ende Thank You