Using programs of care to achieve better health outcomes

Insurance Bureau of Canada
March 12/2004

Mandating the use of evidence-based Programs of Care will mean that insurers, health providers, claimants and the court system will have similar expectations for the type and cost of reasonable and necessary treatment for common accident-related injuries.

Definition:
A Program of Care specifies the appropriate type and timing of healthcare interventions for a specific category of injury or disease. The prime candidate for this treatment is soft tissue injury, but as well conditions such as post traumatic stress disorder, mild traumatic brain injury, or moderate to severe brain injury where the incidence of the condition is fairly high, may also be brought into a Program of Care.

A Program of Care is based upon best practices and the most up to date scientific evidence regarding recovery patterns and effective clinical intervention. It aims to bring both quality and consistency to healthcare delivery and is intended to augment existing clinical guidelines and good clinical judgment.

The Ontario Program of Care for whiplash injuries, the Pre-Approved Frameworks (PAF) for Whiplash Associated Disorder (WAD), Grades I and II, conditions, also offers administrative savings to insurers and providers insofar as the insurer does not require prior approval in order to pay for the PAF services.

The Alberta Workers’ Compensation Board has created a made-in-Alberta solution by several Continuum of Care Models (CCM) for the following injuries:

  • Soft tissue injuries including whiplash
  • Mild to Moderate brain injuries
  • Moderate to Severe brain injuries
  • Cumulative Trauma
  • Consultative on-set physiological injuries
  • Acute on-set physiological injuriesBenefits of the Program of Care approach:
  • Assures evidence-based care – puts a break on over-utilization of health services, while providing appropriate care;
  • Reduces the incidence of treatments that are either ineffective or counter-productive to early recovery;
  • Provides for early rehabilitation intervention to reduce chronicity;
  • Provides certainty for patients and providers;
  • Produces administrative savings to insurers and providers;
  • Retains health professional’s ability to make clinical judgments based on needs of individual patient;
  • Through a commitment to constant evaluation and re-evaluation, the program can be improved over time – resulting in quicker and fuller recoveries.The elements of a Program of Care are typically as follows:
  • The maximum number of treatments allowable;
  • Types of treatment that will be paid for;
  • Duration of treatment;
  • Service expectations with respect to access, cycle times, reporting;
  • Expected health outcomes;
  • Expected provider participation in performance monitoring and outcome evaluation;
  • Reimbursement (which is typically based on the program, as distinct from the fee-for-service system which incents over-treatment).Process involved in developing a Program of Care:
  • Requires collaboration among experts and clinicians as well as the payers – which is a necessary pre-requisite for the parties ultimately having confidence in the care program;
  • Review of the relevant literature and best practices for the condition under consideration;
  • Development of a background paper and preliminary program of care;
  • Validation of the preliminary program with stakeholders;
  • Pilot the care model to demonstrate its effectiveness and broaden buy-in;
  • Roll-out the Program of Care.Conclusion:
  • Regardless of who the payer is, there are never enough resources to finance unlimited health services;
  • In the auto insurance sector as in all others, health care costs must be contained if the cost of insurance is to remain affordable;
  • At the same time, people who are injured in MVAs have to be able to expect that they will have the health care resources they need for recovery;
  • Evidence-based Programs of Care are an effective means for meeting both of these imperatives.
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