Ontario auto insurers pool injury data

Mystery of rising costs may be unlocked

TORONTO, Feb. 3 /CNW/ -

Anyone treating injuries from Ontario vehicle collisions must now send reports and bills to auto insurers via the new Health Claims for Auto Insurance system. Data on injuries and treatments is to be analysed, with patients' identities protected.

By James Daw

Some 4,700 clinics and lone practitioners have been ready and waiting to treat injuries caused by vehicle collisions in Ontario, at an ever-increasing cost.

Yet no one has had a way to sum up the millions of pieces of paper they would send to 127 different insurers. No one could even say how more than 60,000 persons a year were injured, how they were treated or how soon they recovered.

Tuesday (February 1) marked a potential milestone for change, however.

A single, paperless and secure system became the mandatory way for clinics and practitioners to pass their patients' information, treatment proposals and invoices to insurers.

The primary goal of the new Health Claims for Auto Insurance system, or HCAI for short, was to improve efficiency. But it will also provide a source of data that could be analysed to improve care, provide explanations and, maybe, control costs.

All Ontario drivers are required to buy a minimum level of accident benefits to pay for treatment of injuries, assistive devices and income support, regardless of fault. The cost of claims for these benefits doubled in Ontario in five years to $3.8 billion by 2009, taking up 39 per cent of total auto premiums. Yet the precise reasons for cost increases of this magnitude remained a mystery.

"Auto insurance is the single largest payer of out-patient rehabilitation services…including physiotherapy, chiropractic, occupational and psychological therapy, (which are services) not generally available through public healthcare system," notes one physiotherapist and researcher.

"Until now, there was no standard data collection required," says Viivi Riis, who worked with consultants and employees of the Insurance Bureau of Canada to develop HCAI under the watchful eye of provincial insurance and privacy commissioners.

An earlier version of HCAI launched in 2007 did not prove up to the task. But the redesigned system handled 1.3 million standard forms in 2010 as it was ramped up toward full capacity this month. It weathered a dramatic surge of activity in August before the province imposed a $3,500 cap on spending for most minor injuries.

Riis notes that any initial analysis of HCAI data will only be able to compare the age, gender, postal district and insurer of those injured, the nature of injuries, the number and types of therapists and treatments delivered, how often, for how long and at what cost.  (No information that would permit the identification of individual injured persons may pass into the database.)   

Later, says Riis, the standard forms may be refined. Practitioners may be asked to describe any pre-existing conditions, physical limitations and treatment goals using numbered codes instead of sentences the can only be examined one at a time.

Pierre Côté, a scientist in the Division of Health Care and Outcomes Research at the Toronto Western Research Institute, foresees the potential to track compliance with treatment guidelines, to monitor patterns of care and possibly to develop a tool to predict how long it will take an injured person to recover in Ontario.

"To achieve these goals, they will have to make sure they are getting high-quality data," he warns.

Independent researchers could potentially ask the ministries of health and labour to assist in cross-referencing anonymous data on auto insurance, workers compensation and public healthcare. "I have done this in Saskatchewan," he said.

It might then be possible to explore questions such as whether there are differences in the healthcare experience and health outcomes of patients in the different healthcare funding streams.

There will be limits to what can be achieved, says Côté. "Using administrative data will not have the richness of a clinical dataset in terms of measuring pain intensity, functional limitations or other things…like levels of depression and health-related quality of life."

Peter Stymiest, chief operating officer of the LifeMark Health chain of private clinics, expects the efficiency of the new system will free up administrative staff for customer service and education.

"We don't expect dramatic cost savings," says Stymiest, whose company offers physiotherapy and other treatments through 38 clinics in Ontario, plus others across Canada. He holds out some hope that analysis of HCAI data will lead to better care.

"The value is really the ability to analyse (treatment) outcome information, the clinical interventions that will lead to determining best practices in Ontario," he said in an interview. "We'll have an Ontario solution to handling common injuries like whiplash…information that is related to our system and the way that we work.

"I think that will be a huge value (to know) what interventions are working, what timelines are reasonable, what outcomes are expected," he added. "I think we will find a lot of people are getting good care at a reasonable cost. At the same time, we are going to see what the exceptions are, and where there are issues."

LifeMark clinics are among the 117 in Ontario accredited by CARF Canada, part of the Tucson-based Commission on Accreditation of Rehabilitation Facilities, which compares clinics with internationally recognized organizational and program standards. Stymiest says various insurers have chosen LifeMark clinics as preferred care providers.

But insurers have raised serious doubts about other clinic operators, and several Toronto-area clinics are being sued for allegedly submitting fraudulent claims for assessment and treatment.

Christopher Kiah, president of Allstate Insurance Co. of Canada, says every jurisdiction in North America where auto insurers pay for significant medical benefits on a no-fault basis tends to see rising costs, fraud and abuse.

He expects insurers will gradually recoup their investment in substantial cost of developing the HCAI system through efficiency gains. The added benefit, he says, would come from collecting data that might highlight adverse trends and potential abuse in the system.

James Daw is a journalist and researcher at the Insurance Bureau of Canada.

James Daw is an award-winning journalist and Certified Financial Planner who worked for 34 years as a reporter and columnist with the Toronto Star. He has joined the Insurance Bureau of Canada with the mandate to continue researching and writing about issues and trends of importance to consumers and businesses in Canada.

SOURCE INSURANCE BUREAU OF CANADA

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Mark Klein at 416-362-2031 ext. 4387

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