This is the first country-wide Swiss study that shows empirical data about the satisfaction of staff of public and private insurance companies with medical appraisals for diverse insurance areas. Thus, this health services research data can provide deeper insight into real world conditions of insurance medicine, which is relevant for decision makers. Overall, staff of public and private insurance companies in Switzerland are satisfied with medical appraisals, but time demand for preparation was judged as too long for every fourth appraisal. Well-grounded and comprehensible conclusions were the single most important factor for high overall satisfaction.
Satisfaction with appraisals for the disability insurance was generally lower compared to appraisals for private insurances. This finding correlates well with the time interval needed for generation of appraisals as measured in our study (mean time interval for disability insurance: 20.8 weeks; for private insurances: 11.6 weeks). Even though appraisals covering questions of disability are often very complex, nearly half a year of mean waiting time for appraisals was judged as too long (dissatisfaction rates: 30% vs. 11%). This has a significant influence on overall satisfaction, as our data have shown.
Interestingly, satisfaction with mono-disciplinary psychiatric appraisals was not relevantly different from satisfaction with other appraisals. This may underline, that even in patients with possibly complex psychiatric problems commissioners are equally satisfied with appraisals, if conclusions are comprehensible and the appraisal task is finished in due time.
Comparison with published data about the satisfaction of staff of Swiss insurances with medical appraisals is limited, as only highly selected appraisals [6] or only legal aspects have been judged in the past [7]. Our study has confirmed some of the findings of the Swiss pilot study about 102 mostly mono-disciplinary appraisals of patients with occupational accidents [4]. Satisfaction had been similarly high for some items (for example, 89% of appraisals with complete response to key questions), but long waiting times for every third appraisal had been criticized, as well. Studies from Scandinavia have also highlighted time consuming waiting times and partly insufficient content of certificates for the social insurance [8] or coordination problems between social insurance officers and assessors [9]. With our quantitative approach, we could confirm central findings of this valuable qualitative data for the Swiss setting.
Our study has some limitations. Firstly, we do not have data to judge the completeness of the number of appraisals for each of the participating insurance companies during the study period. However, considerable efforts have been made to involve key players of the insurances to install an effective internal controlling. Secondly, the coverage of all medical appraisals in the study period was not possible. Some private Swiss insurance companies have not participated in the study or contributed only some few appraisals for organisational reasons. However, we were able to analyse a broad range of appraisals from different insurances areas from all three language regions of Switzerland. We believe that the data are sufficiently representative to display the current situation in Switzerland concerning medical appraisals. Thirdly, the major part of the included appraisals came from the disability insurance. While this reflects the big volume of appraisals for the public, compulsory disability insurance in Switzerland, overall results have to be interpreted cautiously. The results for private insurances are partly different, as shown by the data. Finally, insurance staff may be biased towards higher satisfaction rates, as they were not blinded to the medical professionals who they had invited for appraisal writing. Due to resource limitations, however, multiple checks by additional blinded insurance staff were not possible. Furthermore, blinding was not intended, to ensure data entry by the specific officer/physician, who was familiar with details of the patient case to reliably judge key items, such as coordination issues.
Implications for practice and research
The results of our study should be incorporated into the continuous education programme of physicians, who perform medical appraisals. This can increase their awareness that sound and comprehensible conclusions in the medical appraisal are of outstanding importance. Specifically in court cases this is of relevance, as non-medical legal specialist have to base their decisions on comprehensible medical conclusions [7]. Furthermore, standards of time limits for generation of appraisals should be established. Any time loss due to late appraisals will reduce the probability of early reintegration measures for the patient, if indicated.
A specific sub-project of the MGS-study has assessed the correlation between overall satisfaction of the commissioners and the professional quality of appraisals as judged by trained medical experts [10]. Commissioners were able to identify good appraisals sufficiently well, but had problems to identify low quality appraisals. Thus, the high overall satisfaction of insurance staff with appraisals, as seen in our data, may give an optimistic picture concerning the quality of medical appraisals. Satisfaction research in hospitals has shown, that overall satisfaction rates can be partly misleading [11]. Given these findings, continuous educational measures are also necessary for the staff of insurances. This will enable them to select assessors who provide state of the art appraisals in due time. Nevertheless, assessment of satisfaction from the viewpoint of insurance staff remains important. Some relevant issues can only be judged by the "clients" (i.e. the staff of insurances), such as coordination issues [9] and timeliness.
A follow-up study would contribute valuable information about improvements over time. For example, in the context of current reforms of the Swiss disability law, that promotes reintegration measures to avoid invalidity pensions [12]. Similar studies in the neighbour countries of Switzerland may create useful information to learn from each other. We hypothesize, that conditions in countries such as Germany or Austria may not be long apart.
