2015—a whole
new year. Will it be back to the old routine or to a new resolve for Workers’
Compensation medical management?
Same old…
Managed
care programs in Workers’ Compensation have been in place for over twenty-five
years. Among them are provider discount networks, bill review, medical case
management, utilization review, and peer review. They all continue to operate
pretty much as they always have, yet medical costs continue to increase.
Lackluster results
With adherence
to traditional managed care methods, the medical portion of claim costs
continues to increase. Not all can be attributed to inflation or the medical
system in the US. Logic says change is needed in medical management methods. We
need to implement new and different initiatives to actually make a difference.
Keep the baby
This is
not to say the old methods can or should be discarded. To discard them would be
to eviscerate the medical management system, definitely a risky and costly move.
Instead, traditional programs should be enhanced and supercharged using new methods.
They need to be improved, accompanied by honest evaluation of their contributed
value.
Supercharge medical management
Happily,
new options are available for tackling the old issues of claim complexity and
cost. Appropriately applied technology methods can put managed care programs
ahead of trouble and make it easier to resolve problems at less cost.
While technology
has advanced exponentially in the past twenty-five years, few of its advantages
have made their way to Workers’ Compensation. However, with minimal effort and
cost, the gains can be amazingly substantial. Some enhancements to current
processes include the following.
Value-driven provider networks
Poorly
performing medical providers are guaranteed to increase costs and generate
substandard outcomes, a fact proven repeatedly through industry research. Yet,
little attention is paid to selecting quality medical providers. Nevertheless,
providers can be vetted by analyzing the data. The evidence of performance is
there.
Providers
associated with poor outcomes, high cost, and even fraud can be identified by
scrutinizing the data. The next step is obvious—when they are found, don’t use
them. Avoid directing injured workers to the costly providers even when a
discount is promised.
In states
where directing care is not possible, the list of suggested providers should
not include the bad ones. Additionally, the best practice list should be
updated continually to insure continued performance.
Save 20-30%!
By
choosing best-in-class medical providers based on the analytics means 20-30% or
more savings in overall claim costs measured in reduced medical costs,
indemnity costs, and overall claim costs. The numbers are impossible to ignore.
Electronic data monitoring
Integrating
and monitoring claims data can also produce equally powerful results. Integrating
the data means combining claims data from the multiple silos that typically
house it. Monitoring means electronically monitoring the data using a
specialized rules-based system and alerting the appropriate person when certain
conditions occur.
Electronic
data monitoring carries the advantage of early intervention into troublesome or
threatening claims. It also adds structure to existing adjustor and medical
case management processes.
Structure delivers efficiency and efficiency
generates cost savings both administratively and in medical cost control. Moreover,
structure allows definitive and accountable analysis of savings.
Proof of value
Service organizations,
particularly medical case managers, have long had the challenge of measuring
and reporting their value. Too often individuals, not the organization, determine
when to respond and what to do.
However,
when the response is consistent for similar conditions, measures of value are possible.
Continuous data monitoring allows a tally of the number of times the same or
similar conditions occur in claims and calculates savings benefits of their documented
responses. That leads to choosing the most effective responses to specific
conditions, thereby continuously improving the process.
A New Year’s Resolution
Rather than
returning this January to the old routines, resolve to update and upgrade
medical management using the new and more powerful applications available.Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics and services company. MedMetrics analyzes the data and offers online apps that super-charge medical management by linking analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org
