Good Practices in Social Security. Good practice in operation since: Special mention, ISSA Good Practice Award - Europe competition 2016

Transcription

1 Good Practices in Social Security Good practice in operation since: 2008 Weller system: A therapy management model for use by accident insurers A case of the German Social Accident Insurance Institution for the foodstuffs and catering industry, part of the German Social Accident Insurance Special mention, ISSA Good Practice Award - Europe competition 2016 Berufsgenossenschaft Nahrungsmittel und Gastgewerbe Germany Published

2 1 Summary Over 270 million occupational accidents happen each year. These cause high costs and losses in work time. An active therapy management approach is therefore important The Weller system offers a comprehensive model for accident insurer case handlers. The Weller guide contains 170 principal diagnoses with over 450 diagnosis templates ordered by degree of seriousness.? There are standard prognoses for the length of time a person will be unable to work for each injury type This takes account of the type of activity. Any overrun against a target time indicates specificities in the course of a therapy and the need for individual case support. The Weller guide is also used for improved communication between all actors in a therapy process. The Weller system also comprises a central database (UVCD) with details of length of time and cost for closed cases that have been entered by all involved insurers. A good basis for evaluations and improvements. Users in Germany have achieved an average of 25 per cent lower incapacity time with the Weller therapy management system against unmanaged therapy approaches. New developments (since 2015): development of treatment plans for selected diagnoses; Weller system as a sophisticated IT proposal, not requiring great technical efforts, for integration in a variety of user systems (XML data format, web app, web service); integration of Weller into tertiary level courses (bachelor's degree - German Statutory Accident Insurance). Portability: since medical diagnoses form the leading management element, the Weller system has good portability. international; non-occupational accidents. CRITERIA 1 What was the issue/problem/challenge addressed by your good practice? The crucial factor was the considerable number of occupational accidents noted by the Professional Association for Foodstuffs and the Hospitality Industry (Berufsgenossenschaft Nahrungsmittel und Gastgewerbe (BGN)) which has four million insured members. These accidents give rise to high costs, in addition to cash benefits (salary replacement) particulary

3 2 treatment costs. Surveys carried out in Germany indicate that enterprises have to spend on average 500 euros for every day an employee is incapacitated. A reduction in incapacity times after occupational accidents would be of direct benefit to accident insurers and indirectly for enterprises. The BGN's main aim, therefore, is to reduce incapacity times through active management of treatment by case work while at the same time supporting a return to the labour market by the injured person, where possible to the same enterprise, by optimising the rehabilitation process. This requires the development of a suitable expert system to be understood and used by case workers at accident insurers which also improves communication with the doctors providing treatment by virtue of its content and presentation. CRITERIA 2 What were the main objectives and the expected outcomes? Targeted management of treatment after occupational accidents by accident insurers in Germany. Accelerated recovery of the ability to work by persons injured in accidents with support for a successful return to work/the labour market. Cost effects for accident insurers and employers. Increased exchange of experience between accident insurers. Improved communication between all involved: accident insurance case workers, doctors and patients involved in the treatment process. CRITERIA 3 What is the innovative approach/strategy followed to achieve the objectives? Development of a generally recognised and adequate basis for managing treatment: diagnostic keys ("Weller keys"). Reliable incapacity prognoses and treatment proposals for each individual diagnosis based on occupational-medical experience. UVCD: development of a central accident insurance control database (UVCD). This holds all managed closed cases supplied anonymised by users. Costs incurred and periods for each individual case are coded. The UVCD is therefore a basis for evaluations, improvements and benchmarking. Each user receives the costs and time periods for their own cases and the average values for comparable injury profiles.

4 3 1. Caseworker support invoked through flagging of cases exceeding forecast incapacity time (data from the UVCD). 2. Use of UVCD data for internal auditing to reveal any system errors and training requirements and to optimise internal processes. Use of the so-called "fuel gauge approach": the system reports the current status of an individual case with regard to elapsed treatment time and costs incurred to a caseworker set against average values held in the UVCD and presented accordingly - with the indication whether treatment is still "in the green". Creation of a modified "Weller table for medical practitioners" to promote communication between all actors in the treatment process. Development of treatment plans for selected diagnoses to structure treatment more strongly and standardise it more sensibly (standardised cases). Development of the Weller system as a sophisticated IT proposal, not requiring great technical efforts, for integration in a variety of user systems. According to user requirements: 1. In XML data format for integration in user's own system. 2. As web app with corresponding screen masks developed. 3. As web service with provision of the necessary data. CRITERIA 4 Have the resources and inputs been used in an optimal way to achieve the set objectives and the expected outcomes? Please specify what internal or external evaluations of the practice have taken place and what impact/results have been identified/achieved so far. Optimal use of resources through initial system development by two accident insurers with external consulting accident surgical specialists => comparative study by those involved ( ) between Weller-managed and non-managed cases with considerable reductions in incapacity periods in managed cases: overall approximately 25 per cent shorter incapacity periods. Note: For Germany this represents an annual potential saving of approximately one billion euros (for factories only) - with almost two million fewer days work missed after occupational accidents.

5 4 Increase in the number of users as a result of these convincing results ("internal evaluation"): today almost all accident insurers in Germany are Weller system users. Exchange of experience in regular user conferences (every two years) with decisions on system improvement and further development with the participation of various accident insurers. 1. Workshops on special subjects with participants specific to those issues. 2. Weller system management optimisation through the setting up of internal accident medical services tasked with providing ongoing consultation and training for caseworkers. In addition to the "internal evaluation" through the extension of the number of users at national level there is also what might be called an external evaluation - through winning new customers outside the German Statutory Accident Insurance Scheme, particularly private insurers in Germany and Switzerland. Integration of German Statutory Accident Insurance in university courses as well as a pilot project with health insurance bodies in France. Effects/results: 1. Clear reduction in incapacity periods in Weller system managed cases. 2. High level of interest in the use of treatment plans in casework by accident insurers to obtain resources for qualified rehabilitation management. 3. Increase in the number of users through new IT solutions (XML data format, web apps, web service). CRITERIA 5 What lessons have been learned? To what extent would your good practice be appropriate for replication by other social security institutions? The Weller system as the "optimal application" has gained almost nationwide acceptance in the German Statutory Accident Insurance Scheme. Ideas on quality assurance and optimisation as well as system extensions are coming from a growing user group (both statutory and private insurers). Portability: since the leading management element is differentiated medical diagnoses the Weller system can be ported to other sectors:

6 5 International: 1. Modified Weller guidelines for the Swiss Private Accident Insurance Association. Adjustment to Swiss national regulation which recognises a status of partial fitness for work. 2. A pilot project for occupational accidents in France is running with the National Sickness Insurance Fund (CNAM). Non-occupational accidents: 1. The Weller system is being increasingly used by private insurers to manage the treatment process in non-occupational cases better and glean knowledge about possible costs. One frequent application sector is injuries as a result of road traffic accidents. 2. A national and international co-operative venture with health insurance bodies would be conceivable.