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© Copyright 1998 Maclean Hunter Publishing Ltd. The following article first appeared in the April 1998
edition of BENEFITS CANADA magazine.
One-stop assessment shopping
A growing number of insurance companies are looking to independent assessment clinics as a way of
controlling the cost of disability payouts
By Diana Swift
With his crisp military bearing and exquisitely twirled mustachios, Dr. Harvey Lewis looks as if, in
another life, he might have led the charge of the Light Brigade. But since 1989, the former urologist has
been leading another sort of charge: against what he sees as the out-of-control payouts in employee
disability and auto-accident health benefits.
Lewis, founder and medical director of Toronto's Riverfront Medical Evaluations, is on the leading edge of
a Canadian growth industry: medical clinics increasingly dedicated to one-stop multidisciplinary
assessments of disabled employees and accident victims. These evaluations are often supported by
computerized machine measurements of an individual's functional capacity and ability to return to the
demands of the workplace he or she has just left.
"Controlling disability payouts is becoming a priority for insurance companies and their claims handlers
and that's true for employers as well. Workforce health benefits are a skyrocketing item in their corporate
budgets," says Lewis, who while practising occupational medicine in the U.S. saw a pressing need for solid,
nonpartisan medical assessments that would stand up in court if need be.
A BRISK BUSINESS
For centres like Lewis's Riverfront--which provides an umbrella service of evaluations in fields from
neurology and psychiatry to ophthalmology, rheumatology and orthopedics--the main clients are insurance
companies and plaintiffs' lawyers. And these clients are providing a brisk business. "We've had near
exponential growth to the point where we're doing several thousand evaluations a year," says Lewis.
Riverfront maintains an operation in London, Ont., and is negotiating with insurers in other parts of
southwestern Ontario and Ottawa to open facilities there, says recently appointed chief executive officer
Lindon Rees, adding that the group has also added a multidisciplinary mental health services section.
Although Riverfront is dedicated to independent assessment and doesn't provide actual treatment, some
active treatment clinics are also tapping into the evaluative trend. Toronto's King's Health Centre does
multidisciplinary independent medical evaluations (IMEs) and functional capacity testing on kinesiologic
machines, as does Medical Clinics Inc., which runs The Doctor's Office chain.
Some organizations offer no medical services but act as referral networks only, such as Waterloo,
Ont.-based CompreMed Canada, a firm of "process consultants in medical-network solutions" that walks its
corporate and insurance-industry clients through the labyrinth of IMEs. CompreMed's marketing director Eric
Hubbard says clients are increasingly turning to IMEs, and his firm is planning to add outcome measurements
to the data it collects on frequency of use and cost.
CAUTIOUS OPTIMISM
While generally applauding the IME trend, consultants have some reservations. "These evaluations are
wonderful when you really need them, but they are too expensive to be used routinely," says Drew Sousa, a
disability management consultant at Watson Wyatt Worldwide in Toronto. "So the employer has to have a set
of criteria to decide which individuals need to be assessed in this way."
Sousa believes the information chain should start with the ongoing caregiver, usually the family doctor.
"But if you have an unresponsive physician and employee, or are not getting the answers you need, then you
should consider going to independent multidisciplinary evaluation."
Though far from cheap, these assessments can translate into substantial savings since they are aimed at
determining true eligibility and ultimately at getting the employee back to work, into optimal treatment or
a more suitable job. "If you look at our block of business," says Doug Smeall, assistant vice-president of
managed health and disability care at Sun Life Assurance Company of Canada in Toronto, "you're looking at
an average life reserve value of future disability benefits of $70,000--or closer to $90,000 for the
younger, higher-paid individuals going to these multidisciplinary clinics."
Compare those figures with a $2,000 assessment (Riverfront says a typical simple IME costs $600) and maybe
a six- to eight-week treatment program that may run you $10,000. The up-front outlay is substantial but the
alternative could be a $90,000 release back to the client. "It's the old thing--you can pay me now or pay
me later," says Smeall, who wholeheartedly supports the IME trend.
But Dr. Paul Tepperman, senior vice-president of corporate health services at the King's Health Centre,
says that unless candidates are carefully selected, the IME and functional ability analysis requested by a
third party can just as often support as challenge the claim.
While Smeall concedes some rehab programs could cost much less--$3,000 for the evaluation plus some
low-grade exercise and cognitive therapy--he says that a key ingredient in an employee's successful rehab
is whether there's a job to go back to. Smeall spends a lot of his time these days persuading employers
with salary continuance programs to let the carrier get involved early in managing cases that are
candidates for LTD--and boosting the odds of successful treatment by keeping the employee's job open.
"These cases shouldn't be allowed to go on for six months or it gets very iffy," he says.
BREAKING OUT THE COST
According to Smeall, carriers are also trying to convince employers that the costs of evaluations and
rehab--traditionally buried in the policy-holder's premiums--now need to be unbundled. While five years ago
there wasn't much demand for these evaluations, the nature of disease states has changed, he says, adding
that people are coming in with self-reported symptoms, such as chronic fatigue and environmental illnesses,
where a diagnosis is made by ruling out a lot of other conditions that fall under different specialties.
Although the cost of evaluations are still built into the premiums on smaller accounts, that's not the case
for larger clients. "There's nothing in the premium rate structure to support a $2,000 multidisciplinary
assessment claim, so we're charging that back to the policy-holder on larger accounts," says Smeall.
In his view, these vague new complaints are best handled in cross-specialty clinics. "They just don't lend
themselves to the silo effect where we look at the person one specialty at a time. We're looking for a
whole-person report. We like different assessors to interview the claimant and then 'team back,' giving us
the whole-body picture."
And one-stop clinics also confer benefits on the disabled person, says Bonnie Geldoff, rehab and
early-intervention supervisor at The Co-Operators in Regina. "Instead of being shuttled around town from
specialist to specialist, they only go to one office. And the team discussion and reporting approach makes
it easier for claims handlers."
The Co-Operators uses such evaluation centres in cities that have them, but, says Geldoff, the majority of
centres in Saskatchewan are still geared toward rehabilitation and physical medicine, not the formidable
assortment of on-premises specialty assessments offered by the new breed.
MIND AND BODY
The interdisciplinary, whole-body picture of the employee so valued by Smeall often includes a strong
psychological component. Quite apart from the person's back pain or arthritis being exacerbated by an
undiagnosed depression or other psychiatric disorder, the very prospect of compensation can twist the
all-too-human claimant's attitude.
"You take a man who gets a concussion playing amateur soccer on the weekend," says Toronto psychiatrist Dr.
Monte Bail, a specialist in medicolegal evaluations. "He has a headache, he takes it easy for a couple of
weeks and then he's back to playing soccer. But if he gets a medically identical concussion at work or in
an auto accident where there's compensation involved, he's off on disability."
Similarly, a single mother with two small children who pays an arm and a leg for overnight babysitting
while she works the midnight shift may overtly state her willingness to return to work but covertly have
strong reasons not to. "These are issues of secondary gain that a multidisciplinary assessment can help
sort out," says Smeall.
Despite the trend to interdisciplinary IMEs, the mainstay of medical assessment remains the family
physician-at-large. But the long-standing doctor-patient relationships these clinicians form can get in the
way of objectivity. "The family doctor wants to believe the patient is telling the truth and wants to help
him and his family but sometimes doing something to help isn't actually helping very much. For instance,
continually prescribing narcotics to relieve pain may end up contributing to a chronic pain disorder," says
Bail.
Recognizing this very problem, the Canadian Medical Association last spring issued a policy statement
urging doctors to do more about getting sick and disabled workers into optimal rehab and back on the job.
It recommended doctors support early communication with the employer and the use of cross-specialty teams
to facilitate return to work.
And while some claimants may balk at undergoing IMEs and functional capacity analyses, they really have no
choice. "It's usually a condition of the policy that the carrier can request such an evaluation," says Bill
Heinkel, director of group life and disability benefits for Great-West Life Assurance Co. in Winnipeg.
"This is typically asked for at the start of a claim when the nature of the illness or the claimant's
eligibility isn't clear."
NOT FOR THE FAINT OF HEART
A full-scale work-up at a place like Riverfront is no light undertaking. Apart from time spent with perhaps
several medical specialists, the complementary functional capacity evaluation can take the better part of a
day.
The process begins with the arrival of the apprehensive claimant, who fills out a comprehensive
questionnaire on his or her work, medical situation and discomfort level. Staff members conduct a thorough
intake interview and may scrutinize a video documenting the claimant's range of motion.
Thoroughly pre-profiled, the candidate moves to the machines. Riverfront uses the ERGOS (rhymes with "here
goes") Work Simulator. "We take a baseline discomfort level and note any changes in discomfort and any
inconsistencies of performance as the claimant works on the machine," says chief kinesiologist Lori
Attwood.
This process usually helps put claimants at ease as they strut their stuff on the simulators, which combine
mechanical testing with software-driven electronic measurement in a protocol that mimics the requisites of
most job functions defined by the Canadian Classification and Dictionary of Occupations. The areas
measured include strength, flexibility, endurance and range of motion.
AN HONEST APPROACH
But often it's a case of determining the status of an honest person who has truly come to believe he's more
disabled than he actually is. Says Riverfront kinesiologist Craig McCleary: "These tests protect people who
have legitimate claims and help direct people who aren't perhaps being as honest as they should be about
their claim. They help clarify a confusing situation. They help draw a line."
The functional testing aims to give objective, reproducible and, hopefully, legally admissible data that
can back up the clinical IME. It also helps determine the work capacity of a returning employee and may
include such guidelines as: "No raising right arm above the shoulder level" or "No rapid changes from
sitting to standing position."
Like Wyatt's Sousa, the King's Centre's Tepperman believes the key to making good use of IMEs and
functional capacity analyses is judicious selection of candidates. And this, he says, may require the input
of an expert benefits consultant. "It's a waste of money to use these services on cases where there's no
possibility of resolution, where the disability is established and should not be challenged. It's like any
product--if you don't know how to use it, you're not going to get the results you expect."
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