CHRONIC FATIGUE SYNDROME MANAGEMENT PROGRAM
UNUM’s “CFS Management Plan”, 4th April 1995
Contents
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, clamants, employers, and internal 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 are 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 musculosketal pain."(Annals of Internal Medicine, December, 1994; 121:953959)
   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`36 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 arc 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 professionals 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 disorder.

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

In six years of managing medical disability claims, I have seen a precipitous rise in the number of CFS claims. Since joining UNUM in August, 1994, the number of CFS caims referred 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 resort 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-diagnoses of claimants, 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 challenging area of LTD claims.
   1.5 Premise and Approach:
The CFSMP is based on the premise that CFS impacts more than just UNUM. 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 patient/claimant, to restore their motivation/incentive, and to effect their eventual return to full or partial work capacity.
Due to the program complexity 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, deve-loped and implemented utilizing the philosophy and spirit of Continuous Improvement.
   1.6 Program Reviews
On-going 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 I 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 is setting claim direction
•Identification of opportunities for claim resolution
•On-going identification and implementation of best practices for claims management
   2.1 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 period
•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 status
   2.3 Attending Physicians
•Support realistic therapeutic regimen recovery time and return to work goals
•Work with UNUM OSPIRN to establish interim recovery objectives for returning to work
•Cooperate and collaborate with UNUM OSPIRN in helping claimant to overcome disability and return to work
•Collaborate with UNUM OSP/RN to determine the appropriate Juncture to evaluate claimant's medical status/functional capacity via IME, FCE, 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 return 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 recovery goals
•Work with UNUM rehab and be open to recommendations
•Cooperate with efforts of 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 employers 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 OSPIRN and/or DBS determine SSDI feasibility when appropriate
•Work with the claimant when SSDI (Social Security Disability) is feasible
3.0 Program Plan
   3.1 Understand and define the problem
   3.2 Establish Guidelines for Managing the Problem
   3.3 Identify 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
   3.9 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
   4.1 Claim received
   4.2 DBA/DBS marks up the claim and 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).
   4.3 Claim is referred to the OSP/RN for the initial medical diagnosis. This step includes a call to the attending physician to establish a partnering 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 an informed decision about the next step in management of the claim.
   4.5 DBS decision to accept or deny claim.
   4.6 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, which should be at least every 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 performed 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 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 performed by OSPIRN and should include the following:
-Discussion with the attending physician to review claimant's progress and 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 or other groups that can help the claimant increase functionality.
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 chosen.
Dr. Salvato, a widely-known CSF 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, ground breaking visit are as follows:

Objectives of the Visit:
The first 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 patient/clairnant 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 may 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 which UNUM could contribute to and enhance the management of the CFS patient/claimant
•In particular, she was very interested in the OSP/RN partnering concept and the many ways that our Rehab services could impact the patient's functional/vocational outcome
•She was surprised to know that we had a social security specialist to help with S SDI applications (aiding her patients with SSDI application 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 CSF 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 would channel CSF claims from other UNUM offices through the SRB OSPIRN or Rehab specialist
•Overall, she expressed an enthusiasm about working with UNUM and encouraged us to speak with some of her peers about a similar arrangement

Update on Atlanta CFS Pilot July 25, 1995

Background
• 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: Susan Steele/ Anne Dinsmore role}

Key Premise:CFS impacts MORE than Just UNUM
CFSMP
• 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
WHO? WHAT?
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
WHO? WHAT?
Claimant:
Increase motivation to RTW -cooperate on efforts for graded increase in functionality EmployersHold claimants job open for as long as possible. Modify job or work schedule to allow early RTW (Retirement)
Rehab:
Clarify the job function of claimants; work with ERs to modify jobs when indicated

CHRONIC FATIGUE SYNDROME CURRENT THINKING AT UNUM
Diagnosis: 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:
Eliminate all other conditions before giving CFS diagnosis

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