Fall management: Claims, claims and more claims!

This session will address the frequency and severity of claims the senior living industry is experiencing because of resident falls. I'd like to introduce our distinguished guest, WTW's Randy Stimmell, senior living claims expert and client advocate. Welcome, Randy.

RANDY STIMMELL: Thank you very much, Rhonda. It's a pleasure to be here today.

RHONDA DEMENO: Yeah, and I'd like to introduce Austin Elkin, Berkshire Hathaway senior living underwriting specialist. Welcome, Austin.

AUSTIN ELKIN: Hey, Rhonda and Randy. Thanks for having me.

RHONDA DEMENO: And thank you for your time today, Austin. We really appreciate it. In our fall podcast series, we have explored how technology and other more traditional risk management methods, such as rehab and resident wellness program can help reduce the cost of falls.

Today, we're going to pivot a bit. And we're going to discuss the cost of falls, how the underwriting community views fall risk, how they underwrite fall exposures, and how best to optimize your insurance spend and total cost of risk by addressing and publicizing your fall mitigation efforts.

I'm going to start our conversation today with Randy. Can you give us a brief introduction to the WTW's Senior Living Claims Benchmark Study. Could you provide an overview of the study, please?

RANDY STIMMELL: Sure, Rhonda. I'd be glad to. First of all, there's a number of studies out there in the industry with respect to senior living, from actuaries whether they come from the insurance side, or the brokerage side like WTW.

WTW puts on an annual Senior Living Claims Benchmarking Study. And as a matter of fact, we're working on the next edition of that, currently. However, we will be talking about the one that was released in 2022 towards the end of the year.

These benchmarking studies are very helpful to quantify, not only overall loss experience exposure and causal factors for senior living owners and operators, but specific to our topic today falls, it will really focus on falls as being one of the major drivers.

Now a little bit of context behind the WTW Senior Living Claims Benchmarking Study, it's a very, very large study. We believe it's the largest in the industry from the brokerage standpoint. There are over $2.3 billion in incurred loss or reported loss. And those are losses with dollar amounts associated with them.

So, it takes out all the incidents without dollar value. There are over 15,000 claims with incurred loss or reported loss. And the study also contemplates both open and closed claims, included in the study. And open claims are actually developed to ultimate.

We believe that is a helpful way of looking at it. Some studies out there just look at closed claims, but they tend to be a little slow to react to the most current year's trends, and that's where our actuaries help fold it in.

So, the overall goal is to quantify these exposures, especially falls is the number one cost. But in regard to the respondents, it's a cross-section of the senior living, the four main acuities of assisted living, and independent living, skilled, and memory care.

38% of our claimant respondents were assisted living. 34% were independent living. 19% were skilled nursing. And the remaining 9% were memory care. So, it's a good cross-section. And then when we distill these numbers, we distill them into what's called an assisted living equivalent basis.

Each level of acuity has either higher or lower exposure relative to assisted. But most recipients of the study are very, very interested in hearing about an assisted living unit equivalent, and other studies go along those lines.

So, there are three main components and statistics that we take a look at. They would be lost costs; they would be frequency and severity. But let's define those first.

Loss costs are the total dollars per exposure unit in senior living. Exposure unit would be an occupied unit or an occupied bed as the case might be most often termed in skilled nursing. Frequency would be the number of claims, and we take a look at that per 1,000 exposures.

So again, we look at loss costs per exposure unit, per bed or unit. And then frequency since it's a lower number, we look at it per 1,000. And then severity would be the average severity or average cost per claim type.

The overall loss cost that came out in our 2022 study was 650 per exposure unit, or per bed or occupied unit. It's trending at 4% per annum. And it has been over the most recent past, frequency per 1,000 exposures is 4.64 per 1,000 units. And that's been trending at a 1/2 a percent per year. And severity is at 140,000, and that's been trending at 3.5% per year, which is in line.

Now those are the overall numbers. But let's take a look at falls. Now falls represent approximately a third of the total claim costs for the industry. And when you look at costs, there's two components that go into it, frequency, or the number of claims, and severity, which is the average cost per claim.

Now what's interesting in falls, and what really drives that cost is the frequency. Approximately one third of the claims that occur that have dollars associated with them are false claims. But what's interesting when you look at the average severity, falls tend to be one of the lower costs per average severity.

So, what's driving the loss cost is the sheer volume or the number of claims that go into it.

RHONDA DEMENO: That's very informative. Can you make any comparisons between the loss cost per bed for falls as compared to skin pressure ulcers or medical management?

RANDY STIMMELL: That's a very good question, Rhonda. And let me address that. We take a look at a number of different causal factors based on accident descriptions that are provided to us from the claims data.

We're certainly focusing on falls today. But as one would expect, choking, elopement, medical management, and wounds, and ulcers, are really the highest severity in the industry. Choking at 300,000 per claim, elopement at 262,500, medical management at 240,000, and wounds and ulcers at 230,000.

Now falls, on the other hand, is close to the average of the overall study, or 160,000 with the average of the overall study being 140,000. So, it's a relatively less costly claim, but the driver is the frequency, or the number of claims, which are most prevalent in the senior living industry.

RHONDA DEMENO: So, with those claims, as a client advocate, what are some of the mitigation techniques that you would recommend?

RANDY STIMMELL: Well, certainly, clinical risk management resources are critical to address this exposure to understand it and to put recommendations in place. And clinical risk management could reside within the client organization or respondent organization. But other resources like WTW and insurers can provide these clinical resources to help address it.

There are also a number of partner vendors that are in the industry space that can do fall prediction, and fall assessment, and all sorts of other products to help address this exposure.

RHONDA DEMENO: Yes, and we did have an opportunity to talk to some other providers. And I hope today's audience will definitely tap into the entire series because you'll see some of those mitigation tactics. Now I'm going to turn over our questions to Austin.

Austin, whenever underwriters are looking at fall risk, how do the underwriters review fall risk for communities?

AUSTIN ELKIN: Well, as Randy mentioned right, falls are responsible. They're the number one driver of claim frequency in this business, right?

And when you add up the total dollar amount spent on falls, it's far and away the majority of the money that insurers are spending when a loss happens via their retention or deductible, and then, of course, you know, what their carriers end up spending when they're defending and settling a claim.

So, it's really the number one exposure that we're trying to underwrite to. It's what drives all the loss in this business, and therefore, the premium in this business. And so, it's critically important to understand that fall risk.

Obviously, depending on the type of facility that we're looking at, the fall risk and our insureds, and therefore, an insurer's exposure to that fall risk is going to vary.

From our perspective, I'd say a couple of things, right, in terms of what we're looking for. Number one, especially nowadays, right, the senior living industry has come a really long way from where it was, say, 10, 20 years ago in terms of understanding their risks and exposures, and trying to mitigate those, and address those.

So, I'd say by and large, it's probably assumed that there's some sort of fall management protocol at any facility that a carrier is going to be looking at. But highlighting specific items that you're doing, and certainly think new protocols or techniques that you're utilizing is critically important.

Really, the number one thing that a carrier is going to look at is your loss experience, right? And to some extent, as much information as you may or may not provide on what your actual policies and procedures are relative to falls, the loss experience is really what's going to win the day, and drive home, and you know, resonate with your underwriters the most.

If you present a lot of robust policies and procedures relative to falls, but you're having a lot of fall claims, and the circumstances of those claims would show up in your loss descriptions, indicate that residents are experiencing repeated falls that result in injury, maybe in death.

You know, it's going to be obvious that either, for whatever reason, those efforts to mitigate those falls aren't bearing fruit, or it's really not changing the loss experience in any material way. And at the end of the day, that's what carriers are going to be looking at the most.

So, I think a couple things you can do is as much as you can communicate in a general sense, what you're doing to address and mitigate falls, I think, expectation setting with families and residents is critically important. Staff training is critically important. And certainly, if you're starting to utilize new technologies to try to address this, you mentioned, and Randy alluded to new technologies.

And it sounds like in this podcast series, you're going to speak to some of those. That's a new thing that's kind of hit the market within just the past couple of years. And I think-- I'm a personal believer that it has real power to change the falls landscape in this industry. So, I think highlighting that to your carriers and telling them sort of the cutting-edge things you're doing will certainly help.

And then anything that you've implemented that's new, especially in response to fall issues, especially fall claim issues that you've had in the past, is critically important, right?

So that your cares can sit there, look at your claims that you've had in the past, and say, OK, they told us that after these things happened, right, they implemented some new procedure, and hopefully we can draw that line in the sand. And then as we look at your risk this year and in the coming years, we see that loss experience start to change.

RHONDA DEMENO: Well, thank you for that. That was a very good overview. So, do you see acuity creep as one of the factors? Do underwriters even consider? Do they even go there talking about the correct placement of the residents?

Do they look at that information like an admission, process? Or do they look at anything in regard to ensuring that the residents are in the correct level of care setting?

AUSTIN ELKIN: Yeah. I think that's definitely something that every underwriter is trying to get their hands around. In terms of how that review specifically happens, it's going to vary by company.

Some companies do have internal risk managers who can review actual fall policies and procedures, and maybe opine on how they think, how effective they think those are. Now again, your loss experience will be the final arbiter of how that's going, and how an insurance company is going to view you as a risk.

You know, but looking at acuity creep, I mean, the things that are going to stand out to an underwriter, right, is if you see on a loss run loss descriptions that show upwards of 5, 10, 20 falls for the same resident, it's going to stand out that there was probably a point where that resident was no longer appropriate for the care setting, especially if we're talking about senior living, right?

Maybe they should have moved on to skilled nursing at that point. They'd become largely immobile and need more assistance throughout the day. And so that's something that we'll definitely see.

I'd say not necessarily related directly to falls, but one that really stands out a lot is if an underwriter is looking at a senior living risk, and they see skin breakdown or pressure ulcer claims on there, that's going to be an immediate red flag that you've got some placement issues, and some maybe resident assessment issues. And you've got some acuity creep coming into your building.

Circumstantially, you may have a resident who went out for surgery, did a short rehab, and has now come back to their home, which is your facility, and they're receiving some home care to button up the final stages of their recovery, and that may include maybe a low stage pressure ulcer that they're kind of getting rid of.

But generally speaking, seeing that at all in an assisted living facility is always a little concerning. And if you see any pattern of that, and certainly anything any pressure ulcers that are probably beyond the stage one, certainly if you get up into higher stages of pressure ulcers and unstageable ones, that's going to be a major red flag that you've got, like I said, acuity creep and placement issues within your building.

And it's probably going to have you viewed unfavorably as a risk.

RHONDA DEMENO: Gotcha. Now I know all providers are always concerned about the bottom line and pricing. Do fall risk mitigation practices change the premiums that senior living organizations are being charged?

AUSTIN ELKIN: Yeah. That's a great question. That's, I think, Rhonda, you hit it on the head right. That is the thing that is certainly in the context of the insurance discussion is always top of mind, right? What is my premium? How much am I paying? Let's also not forget, right, that the premium is just one component of it.

If you have a loss issues, you're probably going to end up being forced to have higher retentions, which is money that the insured has to pay directly out of their pocket. So not only will they have higher premiums, they'll have higher retention. So, their total cost of risk is going up.

But you know, like I said, falls are the number one driver of claims in this space. So, communicating what you're doing from a fall mitigation standpoint is critically important. I can't say that the communication of what you're doing to implement that is going to have at least in the first year. Let's say, that you're presenting it, a direct impact on your premium.

You know, I'd say if an underwriter is looking at your risk, and you honestly told them, yeah, we have no fall mitigation policies and procedures, that will probably directly impact your premium in a negative way, especially if they see that there is an issue on your loss runs.

But really, what carriers have to see to really try to move the needle in a material way on your premium is going to be a change in your loss experience. So, I think you might see small credits given or a few dollars shaved off if you're implementing a new policy and procedure, or a new technology.

And certainly, I think if a carrier is a big believer in or partnering with some of these third-party vendors, then there might be a small credit there. But really, what's going to move the needle on your premium is being able to implement these techniques, and then show that they're actually working relative to your claims experience.

So that's why I always say definitely, it's worth highlighting to your carriers. When you're implementing something new and keeping note of when that went into place, right? And I would remind them of it every year because the reality is if you tell me that your renewal in two months, again, it's not going to have an immediate impact on your premium, or at least not a material one.

When that's really going to start to bear fruit is probably a year or two down the road. Because keep in mind, you're looking retrospectively at losses. And so, you really kind of going back a couple of years to see what the experience was.

And if it's two years down the road that you implemented something, and you're not reminding your carrier of it, right, and they can see a change in your loss experience, they may say that's just a coincidence, right? They had a good year and maybe we'll see this stuff pick back up. So, let's stay cautious on it.

So, I think the more you can sort of drive home and make connections and correlations between the actions that you're doing on the risk management side and the clinical side, and how that's driving outcomes on the claims side, I think is critically important to help optimize your insurance program.

RHONDA DEMENO: So how do operators go about getting credit for their fall mitigation efforts?

AUSTIN ELKIN: Well, I mean, you know, it's I'd say it's pretty simple in terms of really just making sure that you're communicating that info and putting together a good submission. I know that in the day to day of running a facility, obviously, your residents are your first priority as they always should be, right?

And I know it's tough to peel away and devote some time to putting together your insurance submission. But at the end of the day, right, it's a line item on your financials, something that you have to pay for.

And it ultimately can contribute to helping deliver quality care because you can pay less on your premiums, you can invest more in your facility. You can invest more in resident care. You can provide a better product to your residents. You know, so I mean, really, trying to take the time to provide your broker or your insurance agent with that information to pass along to the carriers is critically important.

Your submission is sort of your time to shine to put your best foot forward. In some cases, it may be the only thing that a carrier gets to see or understand about your organization. The step beyond that, which I would recommend every company do if they can is meet with your underwriters.

Take the time to sit down in a meeting with them, whether that's in person, or over the phone, or over Teams or Zoom, a video call, and explain your story. Tell your story, right? Nobody can tell your story better than you can. Nice to have your broker or your insurance representative do their best to tell your story, but really, you're living it, right? You feel it. You're invested in the organization.

So, nobody can tell that better than you. And really, establishing a relationship and trust with the insurance marketplace and with your carriers is critically important. I mean, I think it sometimes just gets down to as simple as people want to do business with people that they like and people that they trust, right?

And if it's just words on a page, I don't know that person, right? I don't know what they're about. I can't get a feel for who they are. So, I would say number one, make sure you're really investing the time in a quality insurance submission, pass along as much information as you can. Like I said earlier, highlight changes that you've made, especially in response to adverse events.

Don't shy away from that at all. Maybe there's some reluctance from insureds to highlight when something went wrong. But really, that's your opportunity. I mean, we're going to see it on your loss run, right? And so that's your opportunity to tell us, hey, yeah, we can admit that something went wrong, and here's what we're doing about it.

If you're putting your head in the sand about that, that's how an underwriter is going to feel that you run your operation, that you're ignoring your problems. And obviously, that's not going to make for a good risk. So, you're going to be less attractive for it.

So again, I put together a really quality submission, and try to tell your story directly to your underwriters and establish those relationships. And I think that'll ultimately, hopefully, yield a better insurance renewal for you.

RHONDA DEMENO: Very similar to risk management in many ways as far as really full transparency. Disclose us something negatively impacted your loss run. But then tell the story of what you've put in place to really mitigate and improve upon any issues that may be trending. And in this case, today we're talking about falls.

So, one question I have too, Austin, is how can carriers help support insureds fall mitigation efforts? Can the carriers help support these mitigation efforts?

AUSTIN ELKIN: Yeah, I mean, absolutely. I hope so, right? I mean, at the end of the day, I think we're all in this together. An operator and their carriers’ fortunes are inextricably linked, you know, when they join up together to be a policyholder and an insurer, right? The actions of that operator, their risks are then transferred over to the balance sheet of the insurance carrier.

And so, I think carriers should have a vested interest in trying to help their insureds improve their operations, improve their quality. And therefore, improve their outcomes.

That comes in various forms, depending again on who the carrier is. Like I mentioned, some carriers have in-house risk management resources. They're able to send out to an insurer to do an assessment of a facility, and make some recommendations, or maybe be on call.

Some carriers may provide sort of a risk management budget or stipend that an insurer can use to maybe hire a consultant, or on education materials, or maybe even on technology, like some of the things that we see coming out now. And in some cases, the amount of that support, whether it be an actual risk management consultant or funds that are provided is going to vary.

But if nothing else, I think it'll help offset some of those costs and some of those efforts. But I think really you can make as many recommendations as you want, but you know, what wins the day is just doing these things day in and day out, right? Residents are in these facilities, it's their homes. They're there, you know? I'm going to say almost every hour of every day.

And so, you've got to consistently be applying those principles every day because it just takes a second for something to go wrong. Now obviously, falls are a reality of the senior living business. That's why by and large, residents are coming to these facilities.

And so that's why I'd also say that setting expectations and communicating with the family is critically important, but there's a lot of carrier resources out there that I think are available to insureds. And if you don't have them, ask, right?

I mean, sometimes it's just as simple as that. I think when it gets down to an insurance renewal, sometimes there's so much focus on the dollars and the premium that in that negotiation process of trying to whittle that down as far as possible.

Maybe a carrier who would otherwise provide a risk management stipend, they have to peel it out in order to try to achieve some premium savings that you're being asked for. And I think while that may yield some short-term benefits, I think in the long term, it's probably a little shortsighted, right?

I think it's not something-- falls isn't something you're going to solve overnight. And so, I think you really have to invest in it, year in year out, day in day out to really change the long-term trends of yourself as an organization, and certainly, of the rest of the industry.

RHONDA DEMENO: So, you talked about trends, and Randy talked about benchmarking. There's several different benchmark claim studies. Do the carriers look at those benchmark studies?

AUSTIN ELKIN: Yeah, absolutely. I mean, we're all pretty aware of them when they come out. And we circulate them internally within our organization for sure. And you know, anyone that becomes available, we try to pick it up and digest it.

The findings of those studies have some variability. But by and large, they all say the same things, right? They all tell you that falls is the number one driver of claims in this space from just a total dollar standpoint, certainly from a frequency standpoint, as Randy highlighted.

On an individual claim basis from a severity standpoint, they're not the largest ticket item. But because they happen so often, those dollars add up. And some studies will say that falls are maybe responsible for something like 30% or 40% of claims, and some say upwards of 70%.

I'd probably argue if you look at a fall and what that can ultimately lead to, I'd say in some way, falls are either directly or indirectly responsible for probably 80% or 90% of the claims out there, right?

Because it may not be the fall in that injury or if there even was an acute injury from it that leads to the claim, but it may slowly change the outlook of that resident, result in some change in condition, you know, then require some change in their medication, perhaps, that-- or maybe you sent them out.

You thought they had a fall, and you sent them out to the ER. They go to the ER. There's change in their medication, and then that resident comes back, and your facility doesn't implement that change. And then you've got a medical management claim there.

RHONDA DEMENO: That's a very good point. I'm going to pivot the conversation to Randy. Randy, our study, the WTW Senior Living Claim Benchmark Study, was one of the largest studies that-- I heard you mention that in the industry. Those folks that are joining in our podcast today, how can they access their report if they haven't seen the report?

RANDY STIMMELL: Oh, sure. They could just go to the WTW website, which is WTWco, C-O, .com. There's a search function or search line up above. And you can just type in Senior Living Benchmarking Study or Claims Benchmarking Study. And you'll see the annual studies that we've done, as well as a number of other thought leadership that we've put out.

One thing also about the study that was touched upon during this podcast is that it does report on the statistics, the numbers involved behind it. But it also provides some very good information on, for example, with respect to falls.

10 rules for effective falls management is a little call out box in there, and managing falls fewer incidents lead to lower costs. That'll give you some basic information, but then there's also an opportunity that you can dive further into our senior living website to get additional information.

And certainly, we would always welcome you reaching out to us. And we'll provide whatever support that we can.

RHONDA DEMENO: The other thing I would like to point out too is we really are open to having other senior living providers participate in our study. If they would like to participate in the study, and even if we don't broker their insurance, how could they participate in the study?

RANDY STIMMELL: Oh, that's a great question and point, Rhonda. Every respondent to the study is their data is completely on an anonymous basis. It's all rolled up into overall totals.

If they would like to participate in the study, we would welcome their data and make it even more robust than probably what's considered the largest broker provided benchmarking study. They could reach out to me directly, or really anybody on the WTW team.

And they can connect with me. And we can go from there. And I can help them with data parameters that we're looking for to augment our study even further. And maybe I'll just make a quick plug on that.

RHONDA DEMENO: Please do. Yes.

RANDY STIMMELL: In any study, statistical study that you're doing, right? It has value when you have a higher number of data points, right? And so, the more information that we could put into any one of these studies makes it more valuable to everybody, and all stakeholders involved, right?

And I think it just helps everybody in the industry understand what we're all dealing with and understand-- again, if you're looking at it from an operator's perspective and trying to benchmark yourself against it, how are you actually performing. And the better the data is the more informed opinion you can make of that.

RHONDA DEMENO: I agree. And thanks Austin for adding that content. Very important. And I think informative to our audience. Randy, do you have any final comments. We're about-- running out of time. Do you have any final comments on how WTW works with carriers on fall claims, or any key takeaways from our discussion today?

RANDY STIMMELL: Yeah. Thanks, Rhonda. Austin provided some great information earlier as far as setting the stage, and the submission, and the direct underwriter visits, and relationship, and everything else.

And really, what we do and need to do, as WTW Senior Living, is to really empower our clients, first of all, recommend best practices to them, help them implement them, and help them to showcase them. And then as far as our job is to make sure that we get all the relevant information that Austin can take a look at, and really showcase what their capabilities are.

And to Austin's point earlier, sometimes bad things happen to very good operators. But Austin and others would like to hear an explanation of lessons learned from that, and why it's not going to happen again if it does.

And then there's also the burden of doubt is if it didn't occur before, but you've seen it from other industry participants, could it happen to you in the future? So, there's always those considerations. But really to empower our clients to implement the very best practices and to showcase those best practices because it's going to lead to a lower total cost of risk to them going forward.

RHONDA DEMENO: Austin, do you have any key takeaways that you'd like to address today?

AUSTIN ELKIN: I think we've covered a lot in this podcast. And I think the thing is, right, falls is like we talked about such a huge burden on the industry. We can talk about it for years on end in terms of what needs to be done to try to address it and mitigate it.

But I think we've highlighted just-- and sort of scratched the surface on a couple items to maybe help mitigate falls. And I know we get into more of that in this podcast series in terms of some of those specific actual techniques. But in terms of engaging with your carrier, I would just reiterate, right, putting your best foot forward, communicating, and having that relationship.

And one thing that we really didn't get into a ton on this podcast, but I'm sure you are and others, and in future ones is in terms of a claim, it's just as important, if not more to have that relationship and communication with your resident and with their family, right? And so, communication is key.

RHONDA DEMENO: Absolutely. Setting those expectations up front is so important and reviewing them on a routine basis with the resident and family members, that can really help with managing any events that occur, especially falls.

That about takes us to the max time today, but we really want to thank everyone for attending this podcast. We do encourage all listeners to listen in to all of the episodes on fall management and our podcast series to get a comprehensive review of the importance of sound fall management programs.

This series focused on the importance of keeping residents safe and on their feet. We address the trends of fall claims today. We will be discussing artificial intelligence, monitoring. And we'll also talk about the importance of disclosure and the series.

Fall management and mitigation should be top of mind for all operators in senior living, whether skilled, assisted living, independent living, or memory care. The rising number of deaths in fall claims must be addressed through sound fall management programming and fall risk screening to address resident specific risk factors.

I know we've addressed many important concepts today. So, thank you, Randy, for taking the time out to have this very important discussion.

RANDY STIMMELL: Thank you, Rhonda and Austin. I really enjoyed this discussion today. Thanks for allowing me to participate.

RHONDA DEMENO: And thank you very much, Austin. We appreciate your time today and your contribution.

AUSTIN ELKIN: Of course. Thank you very much, and you know, thank you for everything that you do to highlight this important topic and support the industry.

RHONDA DEMENO: To review or obtain any information about our guest today, please go to our podcast page to learn more about these experts on fall mitigation and on insurance implications.

We would encourage all of you to check out their bios to learn more information about both Randy and Austin. This concludes our third episode of our fall management series. We hope you'll join us for the entire series to gain valuable information on fall management and safety foundations. And thank you all for joining our podcast today.

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