Having
the long-view perspective offers advantages. Sometimes it also generates
frustration and occasional surprise. One thing we know is that the workers
compensation industry is not given to abrupt change or quick assimilation of
new ideas or technology. Moreover, once a process is in place, bringing about
change is difficult.
Change resistance
Managed Care (medical cost management) is one
of those processes in Workers’ Comp that resists change. While we’ve had
managed care programs in place for twenty-plus years, medical costs continue to
escalate. The confounding thing is business continues as usual, continues the
same services using the same methods, while many hope for different results.
The industry created programs
such as PPO networks, medical case management, utilization review, peer review,
bill review and other initiatives to contain medical costs and produce better claim
outcomes. In doing so, it also built an industry made up of companies and
divisions of companies whose chief focus was medical cost containment. Over the
years, that focus morphed to organizational preservation through revenue
enhancement. Discounting methods and cost saving reporting have been reduced to
simple subterfuge, without evidence of quality medical performance or outcomes.
Starting over
Nonetheless, industry
thinking is beginning to change as the elephants in the room are acknowledged. While it might be
nice, starting over is not an option. The sunk costs are huge. Yet, many medical
cost containment programs in the industry were soundly conceived in the
beginning. The challenge is to realign them to achieve the results originally
intended. Two major initiatives are necessary.
Follow the money (What
else is new?)
Revenue models for
managed care programs must be the first target of change. The consumers of
managed care, the payers, must demand the change. Purchasing decisions are
powerful change agents.
To satisfy the
revenue requirements of managed care organizations as they shift their focus requires
creative thinking and planning. Revenue should be structured to reward desired
behavior and proven outcomes. That will require major process shifting because
the current comfort level is entrenched.
Technology-intensified
managed care
The second step in
revitalizing managed care programs is to reinforce them with intelligent
technology. Over the past twenty plus years, while computer technology has
advanced exponentially, little has made its way to Workers’ Comp. managed care
programs.
Technology offers ample
opportunities to maximize cost savings. They include monitoring historic and
current integrated data to identify and alert professionals of adverse
conditions in claims in real time. Data can be re-presented for business units
to be used as decision support and work-in-progress tools. Analytics can
discern best medical providers to revamp networks and make the information
instantly available to those directing care. Processes can be optimized and
corporate standards enforced. Moreover, predictive models can guide strategic
business decisions.
Making it happen
The first initiative
of change is the more challenging. Changing business rationale carries the risk
of revenue reduction or loss in the transition.
Affordable
Happily, infusing
technology into operations is much easier and affordable. Do-it-yourself
projects can work, but development time and costs can be excessive. However, proven
tools are available to recharge managed care programs and begin realizing
actual medical cost management.
Learn more about
managed care technology “apps” at MedMetrics or contact
karenwolfe@medmetrics.org
