ACC announces findings of review of elective surgery decision-making

ACC has released a review of its approach to making decisions on elective surgery, describing the review as a positive step towards establishing a more transparent and effective decision-making process.

Overall, the review found that the majority of clients believed that ACC treated them fairly and their application for surgery was considered by competent ACC staff in a timely manner. It also found that while there was an underlying lack of confidence on the part of key external stakeholders in the robustness and fairness of ACC’s elective surgery decision-making for declined cases, there is also a willingness to work with ACC on solutions.

“We’ve learned from the constructive feedback of ACC staff, clients and the elective surgery sector and now want to act quickly and collaboratively on the Review’s findings,” said ACC General Manager, Claims Management, Denise Cosgrove.

“We share a common goal in ensuring ACC provides quick, accurate and fair decisions on elective surgery for clients in line with its legislation.”

The ACC Review of Elective Surgery Decision-Making was released today (13 May 2011). The review analysed the impact of elective surgery process changes introduced since early 2008. It sought answers to questions about the changes, what impact they have had and how decision making could be improved.

Its recommendations will result in more effective and transparent decisions based on sound clinical evidence and technical advice.

For more detail, see the attached executive summary. The full review is available at www.acc.co.nz/news/index.htm.

ACC Review of Elective Surgery Decision-Making

Executive Summary

Elective surgery is a significant area for ACC with over 50,000 applications for funding received each year at a cost of $234 million in 2009/10. Over the last three years, ACC has phased out auto-approval processes and applied additional resource and medical expertise to ensure only those applications that are appropriate for an accident compensation scheme are approved. While the majority of applications are still approved (78% of decisions made), more surgery cases are being declined, which has led to a high level of interest in ACC’s decision-making.

ACC has completed an internal review of its elective surgery decision-making processes (the Review). The Review was operational in nature and considered ACC’s approach to decision-making, the application of associated legislation and policy, and the role of, and impact on, key stakeholders. This report outlines what was done, the key findings, and the improvements ACC is putting in place as a result.

Overall, the Review found that the majority of clients believed that ACC treated them fairly and their surgery application was considered by competent ACC staff in a timely manner. The Review found that while there is an underlying lack of confidence on the part of key external stakeholders in the robustness and fairness of ACC’s elective surgery decision-making for declined cases, there is also a willingness to work with ACC on solutions.

The Review considered five key aspects of quality elective surgery decision-making and reached the following conclusions.

Cost-effective rehabilitation outcomes – there are necessary and different approaches to elective surgery decision-making within ACC; between determining surgery entitlement on a high volume of claims, and facilitating early return-to-work outcomes. This difference is not well understood and contributes to a perception that ACC is making unfair decisions.

Efficient claims process – the timeliness of approvals is acceptable but it takes too long to decline surgery requests. Current processes do not make the best use of stretched advisory and decision-making capacity. There are opportunities to improve timeliness and outcomes for clients by clarifying information required with the initial surgery request, including surgeons providing better upfront explanations of the causal link between the injury and the condition requiring surgery. ACC resources could also be allocated to decision-making based on surgery type and claim complexity.

Sound clinical evidence and advice – robust clinical evidence is critical to elective surgery decision-making. ACC has built up a body of clinical evidence and expertise but could strengthen the transparency, independence, and currency of clinical evidence and advice applied to decision-making. There are opportunities to clarify roles, target resources, and coordinate the development of clinical evidence for decision-making, including continuing work with the orthopaedic sector on clinical guidelines.

Legally robust decisions – robust decision-making requires the medico-legal framework to be correctly applied to the facts of each individual case. This includes considering whether there is a causal link between the accident, the covered personal injury and the medical condition requiring surgery. There is a lack of understanding by clients, some providers and the general public about ACC’s legislation. Many surgery decisions are complex to make and some are being challenged through the independent review process.

Effective communication and relationships – there is a need for communications to be improved so that clients (and their GP and treating surgeon) are kept better informed of the progress of their request and are provided with clearer explanations as to why requests are declined. The lack of an adequate explanation of the reason for surgery being declined was a major concern for external stakeholders. There is also an opportunity to involve the treating surgeon more in the elective surgery decision-making process, especially before a final decision to decline is made.

Agreed Management Actions

ACC has accepted the findings of the Review and considered, together with key stakeholders, a wide range of suggestions for improvement. More detail on each area for improvement is provided in the relevant section of the report. As a result, ACC has agreed to the following management actions.

Fully utilise elective surgery resource by:

targeting investigation and resource through triage assessment and claims streaming (segmentation by claim complexity)
using all clinical resource and evidence across ACC in a cohesive and consistent manner.

Improve the clinical information provided to ACC by:

agreeing clinical information requirements for all surgery applications based on the complexity of the claim
finalising guidelines to assist surgeons to decide, in conjunction with the client, whether it is appropriate to apply to ACC for surgery funding
requesting information on expected functional improvements within the initial surgery application for selected surgery claims.

Strengthen elective surgery decision-making by:

ensuring adequate technical/legal support to complement clinical advice
instigating an additional review of selected decline decisions prior to confirmation
sharing learning from review and appeal decisions
clarifying the roles of advice-giver and decision-maker.

Improve communication and relationships by:

establishing regular forums with key stakeholders (including GPs, surgeons, and insurers), such as multi-party forums, to share information and progress solutions
working with surgeons and GPs to provide education on ACC’s elective surgery processes and decision-making
ensuring all client communication clearly explains the help available from ACC and outlines the rationale for decisions.