How to Leap-frog to the Next Generation of Managed Care

Workers’ Comp medical costs continue to scale, yet managed care programs persist in doing business as usual. Such industry-wide paralysis is hard to explain, especially because realistic answers are available. Managed care initiatives can be powerfully recharged through analytics because the core problems inherent to Workers’ Comp managed care can be addressed using technology. Foremost among the deficits is fragmented data.

Like the weather, data silos are one of those issues everyone talks about but little effort is applied to change. The prevailing attitude is “it is what it is”. Managed care programs (bill review, provider discount networks, medical case management, utilization review, and PBM) individually produce their unique data, but do not consistently share it. The data are so fractured that a unified and current data platform is rarely available for current constructive analysis, new insights, and decision support that could change claim outcomes.

Efforts to integrate data have focused on pulling it all into claims systems, a slow and complex endeavor. But there is a quicker, easier and far less costly way to correct the problem, one that supports an organization’s IT rather than depleting it. The new, more effective strategy is contracting with a specialized Workers’ Comp managed care SaaS partner.

Get a “SaaSy” partner
A cloud-based, web-enabled SaaS (Software as a Service) partner makes it happen—now. Cloud-based means it is Internet-based, with SaaS being the software and other technical tools and services made available from the web. Data are imported from disparate sources for an organization by the SaaS partner, then integrated and analyzed on a concurrent basis. The Internet-based SaaS partner grants all authorized persons in an organization access to secure, analyzed, and re-portrayed data online. Information is integrated across managed care programs and analyses are based on historic and current data from all the relevant sources. And yet, some still resist.

It really does not need to be invented here
Some are still mired in the notion that all initiatives must be created in-house to be of value. This idea could be simply territorial and protective, but it’s time for the old mantra to vanish. IT departments are too overburdened and underfunded to achieve the level of performance available from an specialized SaaS provider. Smart IT leadership will quickly see the value of an expert SaaS managed care partner to relieve them of the burden of retooling managed care.

Create a unified and concurrent data platform
Data is the prerequisite for everything analytical.1 Moreover, data integrated across the enterprise, analyzed, and results made accessible to all the business units involved is critical to improving managed care. Businesses in other industries have proven repeatedly that analytics change outcomes and now those in Workers’ Comp can similarly realize the benefits.

Once the data transfer to the SaaS partner is in place, it can be set to an automatic scheduler for updates. Rather than reviewing graphic presentations of the previous month, quarter or year, the most current data available is analyzed and the information made available to those who need it. Critical information can be accessed on demand and alerts sent to the right person as events in a claim develop. It is the integrated, analyzed data that generates knowledge and results.

Link analytics to operations
The process described here links analytics to operations, making the insights immediately available and actionable. It accelerates current decision support knowledge, making it available to claims adjusters, UR, medical case managers, medical directors, and supervisors. Linking analytics to operations permits and sustains proactive medical cost management.

For instance, current and historic integrated claim data is used to analyze and rate provider performance based on the broad scope of data. Likewise, the SaaS partner develops rules-based electronic monitoring technology to continually search for data combinations in claims that portend high risk or cost. The process of integrating and analyzing data in near-real time by a knowledgeable SaaS partner produces computer-aided, intelligence-guided managed care. The efficiencies and knowledge created through such applied analytics enable communication and timely action, thereby making medical cost management initiatives effective.

Economies of scale reap affordability
A knowledgeable Managed care SaaS partner spreads the cost of development and technical management over multiple clients, thereby significantly reducing the cost for individual organizations. The challenges of system design, development and programming, support and maintenance are all managed by the SaaS partner. And yet, for most organizations the annual cost of partnering with a SaaS provider is far less than hiring one analyst.

Therefore, the question is not why, but when. Who can justify continuing business as usual? “Those who get caught in the past and resist change will be forced deeper into commoditization. Those who can create value through leadership, relationships and creativity will transform the industry and strengthen relationships with their existing and new clients.”2

Note: MedMetrics is an Internet-based SaaS provider experienced in managed care and cost management solutions. You are invited to read other MedMetrics Blogs.


1. Davenport, T. Harris, J., and Morison, R. Analytics at Work, Smarter Decisions, Better Results. Harvard Business School Publishing Corporation. 2010.
2. Friedman, T. The World is Flat. A Brief History of the Twenty-First Century. 2005.