Don’t Blame Me

By Jim McVeagh 10/02/2011


I see that ACC has now decided that the increase in surgery refusals is nothing to do with their belligerent campaign to kick every long-standing injury off their books, but it is all the fault of the specialists.

Some surgeons are putting through claims they know won’t be approved by ACC, its board chairman John Judge says.

ACC bosses were quizzed during a parliamentary committee hearing today about why the decline rate for claims had increased.

What a load of nonsense! Firstly, it is not the job of specialists to veto patient’s requests for ACC funding. The doctor is supposed to advocate for his/her patient not block their claim. Secondly, the specialist certainly knows a great deal more than the claims assessor about the patient. Whilst there may be the odd doctor who tries to “game” the system, the vast majority are sending in claims that they think are genuine. Thus, the statement below by the CEO of ACC, Jan White, is also dubious.

“We are not challenging their clinical decision making, we would never challenge that…we do not intrude on that, but they are not experts on understanding the legislation or the limitation of what is funded under ACC.”

Actually, you are challenging the specialists’ decision making and the smoke screen about doctors not “understanding the legislation” is just that – a smoke screen. For the vast majority of claims the only relevant question is “is this an accidental injury?” and the answer is usually straightforward. Though there are quirks in the legislation (sunburn, for instance, is not considered an accidental injury – go figure), the quirks are either well known by specialists (and GPs) or they are rare and obscure. Inappropriate referral is certainly not the real reason why declines of service have more than tripled (11% in 2005; 20% 2010 – but the total number of claims has doubled so the absolute number of refusals is nearly 4 times higher)

No, the real reason why claim refusal is so much higher is not the specialists’ inability, but the magic word – degeneration. The new army of claim deniers assessors have latched on to this word and decline virtually all claims where there is any evidence of degenerative changes. To all intents this probably excludes most people over thirty and many under this age with long-standing injuries, particularly for orthopaedic claims – the vast bulk of ACC work.

If you seriously injure your knee at age 7, it is likely that, by your 20th birthday, you will already have significant degenerative changes. If you then re-injure the knee, it is perfectly possible, particularly if the claim is complex, that ACC will deny the claim on the grounds that the problem is degenerative. This is despite the degeneration being secondary to the original injury and NOT due to “normal wear and tear”

If you are a 60 year old woman who falls and injures her shoulder, the chances are substantial that ACC will deny any claim on the grounds that you have degenerative changes in your shoulder. This is certainly true. However, ACC do not appear to appreciate that those degenerative changes were causing little or no problem prior to the accident. Though the traumatic damage is probably worse because of the degeneration, there would be no damage, had there not been an injury. ACC often deny claims because the injury was minor but the damage is severe (and therefore “degenerative”). They do not seem to appreciate that tissue becomes more fragile with age and apparently minor trauma can severely compromise previously functional ligaments and tendons.

This keenness to deny claims on spurious degenerative grounds actually stems from a much more central problem (coupled with National’s keenness to reduce the burgeoning ACC budget)

The deeper problem, particularly for those who do not have health insurance, is false compartmentalisation of health funding. Should you tear your shoulder’s rotator cuff, someone is going to have to fix it. That someone is the government, regardless of whether ACC say yes or not. The only difference is that ACC have no real finite budget – they are funded for accidents and are obliged to cough up when one is injured. The elective orthopaedic system is substantially curtailed by its funding budget and responds to increasing demand by increasing waiting times, rather than the number of operation it funds. The ultimate result of these savings in ACC are extended misery and a strained elective operation system in which one waits interminably.

For those who do have health insurance, the whole claim denial process at ACC seriously retards making a similar claim against your health insurer. Those of us who can afford our own insurance would be vastly better off were we not forced to take the wholly inadequate government ACC policy.

This latter problem can be fixed by allowing other insurance companies to compete freely with ACC in all areas. The other can only be fixed by decompartmentalising health funding. It terms of ACC, this would most likely involve a loosening of the current criteria that is causing so many claim denials and, in order to compensate for increased cost, change the long-term claim criteria. It this case, I would give serious thought to monetarising all claims above 6 months (lump compensation at an agreed rate) to remove ACC’s long-term liabilities. That multi-billion dollar “gap” would disappear and ACC could then act as a kind of relief valve on the elective surgery system.

Until then, specialists will continue to send patients to Uncle Scrooge to have their claims denied. And no amount of blame-calling will change that.

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