Thursday, November 8, 2012

UNUM's Chronic Fatigue Syndrome Management Program circa 1995

UNUM's Chronic Fatigue Syndrome Management Program circa 1995


pdf file-

Life Insurance Company
Southern Regional Benefits
Chronic Fatigue Syndrome Management Program

Carolyn L. Jackson M.D.
Revised April 4, 1995


1.0 Executive Summary
1.1 Objective
1.2 Definition
1.3 Evolution
1.4 Risks, Opportunities, & Benefits
1.5 Premise and Approach
1.6 Program Reviews

2.0 Key Roles and Responsibilities
2.1 OSP/RN
2.2 DBS
2.3 Attending Physician
2.4 Claimant
2.5 Employers
2.6 UNUM Rehab
2.7 Social Security Specialist

3.0 Program Plan
4.0 Process Detail
5.0 Pilot

1.0 Executive Summary

1.1 Objective
The objective of the Chronic Fatigue Syndrome Management Program
(CFSMP) is to effectively address the growing number of Chronic
Fatigue Syndrome claims through collaboration with attending
physicians, claimants, employers, and inteinal UNUM groups, thereby
reducing UNUM's financial exposure while simultaneously motivating
claimants to gradually and willingly return to work.

1.2 Definition
The definitions for CFS ase as variable and numerous as its symptoms,
below is one selected definition:
"Chronic fatigue syndrome is a clinically defined condition
characterized by severe disabling fatigue and a combination of
symptoms that prominently features self-reported impairments in
concentration and short term memory, sleep disturbances, and
musculoskeletal pain." (Annals of Internal Medicine, December, 1994;

1.3 Evolution
The etiology of CFS is unknown. It is still being argued whether CFS
is a true physical illness vs an atypical depression. Whatever its
cause, studies indicate that less than 5% of patients who carry this
diagnosis actually have CFS. What, then, do the other 95% of this
group truly have?

Many believe that internal and external environmental factors are
contributing to CFS. Increasing demands are being placed upon
individuals in the workplace. Economic recession, corporate
downsizings, high -tech complexities, the 'do more with less'
philosophy are contributing to great stress for most American workers.
Many professionaIs are struggling in very competitive positions, each
person now doing the work of 1.3 people and bringing much of that work
home. The American Dream is well out of reach for many. These societal
and economic ills have played a key role in the increasing rise of the
diagnosis of CFS, a rise incumbent upon the popularity of this
"medical" diagnosis rather than a "psychiatric" one to explain this

0 can conveniently abbreviate the above statements into a "formula" for CFS:
CFS = Negative External Factors (recession, downsizing, etc.) +
Negative Internal Factors (stress, conflict, failure of coping
mechanisms, etc.) + Entitlement Philosophy = LTD

In six years of managing medical disability claims; 1 have seen a
precipitous rise in the number of CFS claims. Since joining UNUM in
August, 1994, the number of CFS claims refelred into Medical Resources
at SRB has more than doubled. Although CFS claims may represent a
small percentage of the total claim volume, the dollar exposure is
significant. These claims also result in substantial time commitment
by the OSP/RN as well as the DBS group. The increasing level of
frustration generated by their management impacts overall productivity
and effectivity.

1.4 UNUM's Risk and Opportunity
UNUM stands to lose millions if we do not move quickly to address this
increasing problem The subjective nature of CFS leaves us highly
exposed to the self -diagnosis of cIaimants, some of whom take
advantage of doctors and the entire insurance industry. On the other
hand, there are claimants who have legitimate disability related to
CFS. Both groups must be effectively managed. UNUM can position itself
on the leading edge of disability management by developing and
implementing a program to properly manage this most cllallenging area
of LTD claims.

1.5 Premise and Approach
The CFSMP is based on the premise that CFS impacts more than just
LNUM. Employers, attending physicians, and claimants are at risk. Many
attending physicians are having a difficult time managing through the
subjective nature of CFS. Group policyholders (employers) are paying
higher premiums and losing valued employees. Many highly educated and
trained professionals are losing motivation and slipping into
self-imposed oblivion because of CFS.

UNUM Southern Region has developed a program that involves all of the
key groups that are impacted by and that can produce an impact on this
phenomenon. The program intends to develop a collaborative strategy
with all the parties involved to ensure the recovery of the
patientlclaimant, to restore their motivation/incentive, and to effect
their eventual return to full or partial work capacity.

Due to the program complexjty and newness, a pilot approach will be
used, approaching one CSF physician at a time to make him/her aware of
this collaborative strategy and the ways in which it can enhance their
management of the CFS patient. As this pilot progresses, from one CFS
physician to another, best practices will be identified, developed and
implemented utilizing the philosophy and spirit of Continuous

1.6 Program Reviews
Ongoing program reviews will be held periodically to facilitate
strategic management, information sharing, continuous improvement and
total involvement. Attending CFS physicians, UNUM management,
employers, and other key contributors will be invited to attend. Guest
speakers will be brought in to enhance the value of the program
reviews. DBS's will have the opportunity to pose questions and
highlight concerns to help with the overall program. The program
reviews will be held at the SRB office in Atlanta.

2.0 Roles and Responsibilities
Although the following groups are responsible for many activities, the
roles and responsibilities listed are only those relevant to the
support of the CFSMP.

2.1 On Site Physician/Registered Nurse (OSP/RN)
-Early intervention in all CSF claims
-Establishment of an on-going partnership with the attending physician
-Timely collaboration with the DBSs in setting claim direction
-Identification of opportunities for claim resolution
-Ongoing identification and implementation of best practices for
claims management

3.2 Disability Benefits Specialist (DBS)
-Manage these files more aggressively and in a proactive rather than a
reactive fashion
-Identify opportunities to implement early intervention as soon as
possible by having them identified by the policyholder during the STD
-develop improved claims management skills
-work more closely and more frequently with the claimant and the
attending physician
-Frequently update medical information from the claimant and the
attending physician
-Identify opportunities to capitalize on any improvement in the
claimant's functionality or significant change in his/her medical

2.3 Attending Physicians
-Support realistic therapeutic regiment, recovery time and return to work goals
-Work with UNUM OSP/RN to establish interim recovery objectives for
returning to work
-Cooperate and collaborate with UNUM OSP/RN in helping claimant to
overcome disability and return to work
-Collaborate with UNUJM OSP/RN to determine the appropl-iate juncture
to evaluate claimant's medical statuslfunctional capacity via IME,
FDE, neuropsychiatric testing, etc.
-Open and objective discussion on interpretation of results of these evaluations
-Support plan to gradually increase claimant's functionality, using
graded exercise programs, work conditioning programs and psychotherapy
when and where appropriate
-Work with UNUM rehabilitation services or an outside vendor in an
effort to retuin the patient/claimant back to maximum functionality
with or without symptoms

2.4 Claimant
-Increase motivation to return to work
-Work with attending physician to establish and meet recoveiy goals
-Work with UNUM rehab and be open to recommendations
-Cooperate with effo~tso f graded increase in functionality

2.5 Employers
-Hold claimant's job open for as long as possible
Work with UNUM rehab to modify job or work schedule for early return to work

2.6 UNUM Rehab
-Clarify the job function of claimants
-Work with cmployers to modify jobs where appropriate
-Perform transferable skills analysis when indicated
-Provide direct and indirect vocational counseling
-Coordinate Work Incentive Benefit program

2.7 Social Security Specialist
Assist the OSP/RN and/or DBS determine SSDI feasibility when appropriate
-Work with the claimant when SSDI is feasible

3.0 Program Plan

3.1 Understand and define the problern
3.2 Establisli Guidelines for Managing the Problem
3.3 Idenify Key Players and Stakeholders
3.4 Gain Support and Buy-in from Key Players & Stakeholders
3.5 Finalize Operational Process
3.6 Pilot Implementation
3.7 Pilot Evaluation and Feedback
3.8 Implement Continuous Improvement steps
3.90 Implementation with sequential physicians
3.91 Evaluation, Feedback, Enhancements through On-going Program Reviews
3.92 Eventually expand this project to be used in all "subjective" claims

4.0 Chronic Fatigue Syndrome
Process Detail

3.1 Claim received

3.2 DBA/DBS marks up the claim arid begins initial claim work-up. This
step includes a detailed call to the claimant ( addendum A),
discussion with employer ( addendum B ), and a letter to the attending
physician (see addendum C) requesting the claimant's medical records
(to include all office notes, consult notes and diagnostic tests).

4.1 Claim is referred to the OSP/RN for the initial medical review.
This step includes a call to the attending physician to establish a
paitnering relationship and to set expectations and return to work
goals. Recovery goals for the claimant are agreed upon by the UNUM
OSP/RN and the attending physician.

4.4 Joint claim review by both the DBS and UNUM medical. All pertinent
information and data are shared at this point, enabling the DBS to
make and informed decision about the next step in management of the

4.5 DBS decision to accept or deny claim.

3.6 If DBS accepts claim, then the ongoing CFS claim management
process is initialized.
(steps 4.7 through 4.9)

4.7 DBS establishes a claim review schedule, whlch should be at least
evely three months, or sooner if there is a change in the claimant's
functionality or medical status.

4.8 At each sequential review, the first level of the review is
pelformed by the DBS and should include the following:
-Review of office notes
-Review of all diagnostic tests
-Review of referrals to other physicians
-Telephone discussion with the claimant to assess changes in functionality
-Telephone call to employer to assess job status ( Is there still a
position open? Has the person been terminated?)
-An RBR visit early in the process is encouraged to give us an
accurate assessment/objectification of the claimant's condition

4.9 At each sequential review, the second level of the review is
pelformed by OSP/RN and should include the following:
-Discussion with the attending physician to review claimant's progress
against recovery goals.
-Strategizing with the attending physician to get or keep the claimant
on track for recovery.
-A determination of the need for diagnostic tests that evaluate
physical and cognitive functionality
-discussion of need for specialty consult or IME
-A determination of the need to involve UNUM rehab, psychotherapists,
employers and other groups that can help the claimant increase

5.0 Pilot Strategy
Due to the complexity and newness of the program the CFSMP utilizes a
pilot strategy. To help "sell" the program on a large scale, a track
record of wins must be established.

A list of attending physicians who handle CFS cases frequently seen by
the Southern Regional Benefits office has been compiled. From that
list, the attending physician with the highest volume of claims was

Dr. Salvato, a widely-known CFS physician in Houston, Texas was
carefully approached, first by telephone, which led to a scheduled
visit to her office and lab. Highlights of that initial,
groundbreaking visit are as follows:

Objectives of the Visit:
-This fist objective was to get into her office and get past the
presumed initial barriers.
-The second objective was to give her a clear picture of how we can
work together for the mutual benefit of the patienuclaimant resulting
in a successful outcome for all involved, i.e., a win-win situation.
-There was a strong effort to avoid the development of an adversarial
relationship, and to smooth over any existing rough edges between her
office and UNUM-SRB.
-Convince her to "buy-in" to the collaborative approach

Results of the visit to Dr Salvato's office:
-Dr. Salvato now has a much clearer picture of ways in whlch UNUM
could contribute to and enhance the management of the CFS
-In particular, she was very interested in the OSPIRN partnering
concept and the many ways that our Rehab services could impact the
patient's functional/vocational outcome
-She was surprised to how that we had a social security specialist to
help with SSDI applications (aiding her patients with SSDI
applications has been a Problem area for her)
-She was also not aware of and was very interested in our WIB program
-She was enthusiastic in a collaborative approach to evaluating
functional capacity and working together on an incremental return to
work (She expressed past difficulty in getting employers to accept
modified work schedules/duties)
-Specifically, we arranged that all UNUM files that involved her CST
patient's would be channeled through the OSP or the Rehab specialist
for discussions with her. A specific time and date would be
pre-arranged for these discussions on an ongoing basis
-We could channel CFSF claims from other UNUM offices through the SRB
OSP/RN or Rehab specialist
-Overall, she expressed an enthusiasm about working with LNUM and
encouraged us to speak with some of her peers about a similar

Update on Atlanta CFS Pilot
July 25, 1995

Chronic Fatigue Syndrome Management Program (CFSMP)
Key participants:
Dr Carolyn Jackson and Sally Fowler
(Southern Regional Benefits)
Dr Don Abbott (Portland) and UNUM medical staff
(Unknown role): Susan Steele/Anne Dinsmore

Key Premise: CFS Impacts MORE than Just UNUM

Paying Higher Premiums
Losing Valued Employees

Difficulty With Subjectivity of CFS

Highly educated professionals slipping into self-imposed oblivion!

Approach one CFS physician at a time and make him/her aware of our
collaborative strategy

As this pilot progresses, from one CFS physician to another, best
practices will be identified, developed, and implemented.

Roles and Responsibilities


On-Site Physician Early intervention on all CFS claims
Establish partnership with AP

DBS Manage CFS files more aggressively,
proactively, and more frequently.
Identify/notify during STD period

Attending Physician Support realistic therapeutic regimen,
recovery time and RTW goals

Everyone Partnership/collaboration on
establishing, monitoring and meeting RTW goals

Roles and Responsibilities


Claimant Increase motivation to RTW -- cooperate
on efforts for graded increase in functionality

Employers Hold claimants job open for as long as
possible -- modify job or work schedule to allow early RTW

UNUM Rehab Clarify the job function of claimants; work
with ERs to modify jobs when indicated


- Neurosis with a new banner

Claimant Profile
- Professional working women ages 30-50
- Susceptible to doctor's power of suggestion
- Self-reports symptoms
- Longer claim duration
- Difficult return to work (recovery claims)

Condition Profile
- Burnout: loss of concentration, memory, sleep
- Sensitive immune system
- CFS is symptom, not cause
- Cause involves other psychological, psychosomatic issues
- Often linked to soft tissue conditions

Treatment Protocol
- Eliminated all other conditions before giving CFS diagnosis

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