Income protection: What's next for rehabilitation?

Let me share with you how I have seen the provision of rehabilitation support evolve in the UK's income protection (IP) market over the past 10 years, and what I believe are the next steps to ensure rehabilitation initiatives meet evidence based standards are cost effective, and are valued by the end consumer.

Early Intervention? Once upon a time…

I remember back in 2010, I was thrilled to work on what was the first telephone-based early intervention (EI) rehabilitation programme for common mental health and musculoskeletal income protection (IP) claims in the UK [i].

The benefits of this innovative claims management approach seemed "obvious", it was a win-win situation for everyone involved: the claimant, the employer, the insurer. The clinical rationale was that by providing the right work-focused rehabilitation support early, we would prevent the escalation of symptoms, and reduce the risk of developing more severe health conditions, that would result in a long-term claim. 

Indeed, as return-to-work outcomes were achieved, the duration of claims were reduced, and for claimants that received support during the deferred period a reduction in claims inception was reported. However, back then, the win-win scenario was a hard concept to sell. Actuaries querying the cost benefit (there was no previous data on outcomes)? Claims managers raising eyebrows at the costs involved, and the industry as a whole querying whether the IP market should be picking up the NHS bill?

Still, the novelty of EI rehabilitation quickly gained interest as a market differentiator in the added-value service space, and more insurers were at least keen to test out pilots in their books. Over the years, we have seen many insurers develop such approach [ii].

Where are we now? An umbrella term for any type of return to health and work support

After 10 years, some of the cost effectiveness concerns are still valid, but we have seen many examples and case studies of positive return-to-work outcomes, reduced claims duration and improved customer satisfaction [iii]/[iv].

In addition, in response to claims trends, there are now specialist rehabilitation services available for conditions such as: cancer, mental health, and musculoskeletal claims, as they remain the top three causes of IP claims [v].

But of course, rehabilitation is not just EI. Many insurers also fund private treatment, physical/psychological, or provide signposting advice. Plus, return-to-work coaching is also available to help the claimant bridge that gap back into employment, addressing issues such as: self-confidence, job search applications, or mediation with the employer. Therefore, the rehabilitation scope is wide.

What is next? Addressing ongoing challenges

We can agree that rehabilitation interventions in IP are helpful, but there are still some challenges that need addressing in order to ensure rehabilitation offerings are cost effective across the IP market, and meet evidence-based standards.

I have compiled a list of recurrent themes that I have come across over the years, based on my interactions with claims managers, claims assessors, rehabilitation providers, insurance clinicians, as well as IP portfolio reviews, individual case reviews, and research related to psychosocial predictors of return to work. I have attempted to provide some suggestions that can help overcome some of those challenges, and I welcome further discussions on how we can ensure we are hitting the mark (!) as an industry as we begin 2020.

Please note, that this is not an exhaustive list, and I have purposely left out the challenges regarding work related stress claims, and future data analytics with use of artificial intelligence for identifying claims patterns, as I felt both topics require a separate review and discussion.  

1. One size does not fit all: Claims colleagues would agree that a similar cause of claim in a similar case, can have completely different outcomes. With cost effectiveness in mind, we must ensure that any type of rehabilitation support is tailored to the individual characteristics of the claim, using a holistic stepped care approach. This means taking into account the specific policy terms and conditions, as well as the claimant's individual set of psychosocial circumstances, beyond the medical diagnosis. Some claimants just need some guidance and signposting, but others require a more intense hand-holding approach, which might involve a set of rehabilitation interventions over a length of time. EI programmes that have a stepped care model at its core are suited to provide tailored care, for example.

2. Identifying the right claims for rehab: Although EI is likely to be the most effective approach, insurers also fund support for short-term or long-term claims. However, the process of identifying return-to-work potential in older claims is complex, and many psychosocial and claims factors need to be considered before funding private support. Outcome data on the effectiveness of such cases is still limited to individual case studies. We need to do more to systematically gather data across the industry. 

3. Rehabilitation providers' understanding of IP: It is key that rehabilitation companies have a clear understanding of the IP policy terms and conditions. The challenge is that there are many IP product variations in the market, old policies and new versions of IP. For example: switching definitions, variations in deferred periods, own occupation, suited role, activities of daily living, target market, etc. The insurance jargon can be very confusing for rehabilitation providers and for the claimants themselves. Clear communication is therefore key to ensure providers are absolutely clear as to what the rehabilitation goal is! 

4. The claims assessor role: In an age where technology is driving human interactions, there is a need for human contact. The claims assessor is in a key position to drive behaviour change in claimants, and guide them through the journey back to health and work. The use of soft skills that enable true rapport and trust with the claimant not just enhances their customer journey, but can creates sort of "contract" in the rehabilitation journey. I believe telephone interactions, where possible, should be the best way to gather key claims information with a particular focus on psychosocial risk factors for long-term claims. We need to continue to work on developing claims assessors communication skills, so they are equipped to deal with challenging conversations, whilst also focusing on a proactive claims management plan.  Claims teams also need to have up to date knowledge of different types of rehabilitation interventions for their claims book.

5. Sometimes rehabilitation doesn't work: Yes, this can be the elephant in the room! In some instances rehabilitation might not be successful, or might not be appropriate. There are many reasons as to why this may be the case (worsening of health condition, psychosocial changes, etc), but the important message is that we must know when and how to stop. Both claims assessor and provider need to work closely to end support in a therapeutic manner. The information gathered however, might be helpful in seeking alternative claims management options aligned with the insurer's claims philosophy, if the claim is likely to remain medically valid in the long term. 

6. The health risk landscape: The causes of claims are usually reported as a single condition in the industry, but it is increasingly common to see that claimants present with one or more health conditions at the time of claim. This trend is in line with lifestyle driven health conditions that we see today, and that are likely to continue in the future. For example: obesity is associated with other long-term health conditions such as diabetes, heart disease, hypertension and mental ill health. It also underpins the development of common musculoskeletal conditions such as back pain [vi]. As an industry we need to be prepared to implement return-to-work support claims strategies that use a holistic approach. Equally rehabilitation providers need to be multi-skilled in dealing with co-morbid conditions.

Mental health wellbeing is highly topical at present. Years ago, the World Health Organisation (WHO) predicted that by the year 2020 depression will be the leading cause of disability worldwide. This has now become true according to the latest WHO statistics of December 2019 [vii]. 

I believe that collaboration across industries can help drive meaningful change to aid employees' mental health wellbeing. The group income protection (GIP) market, for example, lends itself to work closely with employers in the prevention of sickness absence initiatives. There is now raised awareness on the links between employee wellbeing, job satisfaction and sickness absence. We should encourage discussions to promote the implementation of wellbeing initiatives at work, that focus on relationships, work demands, and work-life balance, which are harder to implement as they involve training and culture change.

Best practice framework

We are doing the right thing and we have come a long way in the last 10 years. Successful individual case stories have highlighted the powerful added value service that rehabilitation provides in an industry where the public perception of insurers is still dominated by the negative press (of unpaid claims). 

As IP products continue to evolve into more meaningful cover, that is not limited to just financial support, as an industry, we need to achieve a consensus of a best practice framework; to ensure the provision of rehabilitation programmes is underpinned by evidence-based approaches; it is tailored to the IP industry and is further adapted to the insurers' specific product design and target market.

A holistic claims management approach that truly understands the claimant's health difficulties and its functional impact on work will enable insurers put in place the right type of rehabilitation.

Monica Garcia is a health and wellbeing insurance consultant

References

1. Swiss Re. Early Intervention for IP Claims (2013). Cited in: Telephonic Support to facilitate return to work: what works, how and when. Department for Work and Pensions, page 37. (2013).Telephonic support to facilitate return to work: what works, how, and when? (RR853)
2. Protection Guru, Higgs, A.Return to work rehab: Who offers it and how? (2019)
3. Seven families (2014).http://7families.co.uk
4. Swiss Re DI Claims success, holistic approach enables "more moments like this" (2016)DI Claims Success.
5. Association of British Insurers (ABI) UK Insurance and Long-Term Savings The state of the market 2019
6. Black, D (2016) An independent review into the impact on employment outcomes of drug or alcohol addiction, and obesity.
7. World Health Organisation,Depression (2019).