A Consistent Repeatable Measure!
Over Medicalization of Claims
There has been much discussion in the claims profession concerning the “over medicalization of claims” in disability and in workers comp insurance over the years.
What do we mean by this?
Well, in the medical profession, a bio medical model is followed, a patient has a medical condition, a treatment is applied, and the patient will recover, hopefully.
In the claims world, great importance is placed on the doctor’s report (the attending physicians statement) which tells us what is wrong and what the prognosis is for the condition improving.
So, you may have noticed that claims are referred to as a “Mental Health claim” or as a “Musculoskeletal claim” or as a “Laceration claim”…?
Claims are bucketed by the medical diagnosis.
Every claim has a condition, sometimes 2 or more, there is a treatment, and the medical guidelines tell us how long the claim should last for… Often this approach works, particularly in a straightforward injury or an illness with a known cause.
Yet we all know that this is just half the story, and often the situation is much more complex. The fact is that:
“The length of duration of a claim has little to do with the speed of healing of the illness or injury!” The mindset of the claimant is the other half of the equation.
Why do we manage claims with an over emphasis on the medical?
Maybe because it’s easy to understand the bio medical model … Diagnosis + Treatment = Recovery and Return to Work
However, there are many other factors that can influence the recovery process.
The Psychosocial View
What if we were to take a more holistic view of the ‘individual’ behind the claim? Let’s look at some of the psychosocial factors which influence their return to work.
What type of personality do they have?
What else is going on in this person’s world?
How is work going?
What’s going on at home?
How’s their financial situation?
We know that individual motivation, drive, and expectations have a huge part to play in returning to work. So does that person’s mental state, including psychological symptoms and diagnoses.
These psychosocial factors can play as big-a-part in return to work as the medical diagnosis – sometimes bigger.
This is why we refer to the Bio-psychosocial Model.
The difficulty has been in how to measure these factors, there is no ICD 10 code for “I hate my boss” or “I’m worried about getting hurt.”
Previously this type of information may have been obtained in a telephone interview with the claimant, and entered into the file as case notes. An experienced case manager over a 45-minute call can root out what’s going on, but what if they are not experienced, or they miss something.
The claimant is unlikely to say… “well it’s not really my bad back, it’s that my boss keeps shouting at me for no reason, I hate my job, I’m worried I’m going to get fired, I’m anxious and depressed!”
So, now we have a disability claim for a lower back sprain where, if there had been a more supportive work environment, there would perhaps have been no claim at all?
The Medical Guidelines might tell us that a lower back sprain is 7 to 21 days depending on the occupation…. But what if they also “hate their boss”?
A Consistent Repeatable Scale
For the last 5 years TCL has been collecting Psychosocial data using a number of Questionnaires, which are completed by the claimants. The objective is to understand more about these factors, and what effect they have on the ultimate duration of the claim.
We now have a validated scale that provides a consistent and repeatable measurement of these factors. By asking certain questions at the very start of a claim, we can determine the influence of these psychosocial factors on the likely duration of the claim.
Case managers can now be equipped with more precise insights on the driving factors and proactively assist the claimant in seeking more targeted and timely treatment. Thus returning people to work quicker, and significantly shortening claim duration.
We now have a reliable way of understanding the ‘whole person’, not just the medical diagnosis.
In the next few weeks, The Claim Lab will lift-the-covers on our discoveries, from the perspective of a clinical psychologist, and claims management.
From Clinical Psychology perspective “Bio Medical vs Bio-Psychosocial, and why is this so important in recovery.”
From Claim Management perspective “How do we add this to our claims management process?” (in an easy understandable way)….
If you want to discuss what this in more detail, please contact us at email@example.com.