A New Year's Resolution for WC Medical Management

by Karen Wolfe

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