The Myth of Predictive Analytics--Really??

by Karen Wolfe

Mark Walls recently posted an article entitled, “The Myth of Predictive Analytics”[1] where he says he has yet to see cost savings from predictive analytics. Such a statement will surely generate a firestorm of comments. This is one of them—and it specifically addresses predictive analytics-informed medical cost management in Workers’ Comp.

The power of predictive analytics to mitigate medical costs is entirely dependent on the operational design of the delivery system. Predictive analytics is the information vehicle that creates knowledge for claims adjusters and others in the medical management process. System design determines how the information gained from predictive analytics is operationalized. How the information is implemented makes all the difference.

Walls goes on to say, “However, the potential for cost savings doesn’t come from the flag, but what you do in response to it. You need to take action and do something differently than you would have done without the flag.”[2] To a point, that’s true. However, the timing and method of delivery and format of the “flag” is critical. The conditions of information delivery that drive cost savings are timeliness, accuracy and efficiency, ease of use, and structured protocols. All are functions of delivery system design.

Timeliness for early intervention
Information must be delivered in the form of alerts as concurrently as possible. The claims rep should receive the information very close to the time of the risk occurrence. To achieve that, the data must be monitored continually with alerts sent immediately. Factors unknown early in the claim can occur at any time throughout the claim. Timely notification activates early intervention, before further damage is done and before the situation becomes more complex. That saves time, money, and leads to better outcomes.

Accuracy and Efficiency
An alert is useful only if it contains all the information the claims rep needs to make an informed decision, to adjust reserves, and to initiate measures that will prevent further medical loss. Predictive analytics is used to calculate and portray projected costs based on history, differentiated costs, and expected time lines. The alert also displays a medical summary of the claim. All the information is portrayed for the claims rep and requires no data look-up and no data entry.

Accuracy and efficiency are cost savers because they are time savers. Even less-experienced claim reps can take accurate steps when all necessary information is provided.

Easy
The information generated by predictive analytics notifies and informs the claims adjuster at the appropriate time without additional effort on the part of the adjuster. The system automatically portrays all pertinent information without need for searching or data entry. At that point, the adjuster can take appropriate and informed action.

Structured protocols
Medical management in Workers’ Comp is traditionally designed and delivered by individuals in the organization in one-off situations. That means processes are inconsistent. Good system design that draws from predictive analytics infuses structure and measurability into the process. Those situations in claims that should be referred to a nurse case manager are tagged in the system by senior management in advance, so they are referred automatically. The claims adjuster is relieved of the problem of when to refer.

The system is designed to make referrals automatically, thereby making them timely and consistent. Pre-determining what kinds of conditions will be referred and to whom, is how the organization sets up standardized medical management protocols. Such consistent, intelligent process management generates measurable results.

Measure results
Cost savings are objectively and accurately measured in a predictive analytics-supported system. On case closure, actual medical costs for the claim are compared to predicted costs based on documented history. Because of predictive analytics and continuous data monitoring, interventions are executed early, making them more effective. Appropriate referrals are made automatically according to protocol rather than intuition. The medical management team collaborates to improve on projected costs.

Documented process
Medical management alert activity on the claim has been documented by the system throughout the course of the claim. Therefore, costs can be appropriately allocated to the claim, the client, or policy-holder including activity detail, thereby creating transparency and trust among constituents. The organization enjoys increased profitability and strategic competitive advantage.

Walls also states, “In the end, good old-fashioned claims handling skills are still the best way to achieve superior outcomes on claims.”[3] However, when the claims handler is supported by a well-designed, predictive analytics-informed intelligent assistant, claims handling the old way is simply obsolete.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation, predictive analytics-informed medical loss management and technical services company. MedMetrics offers intelligent medical management systems that link analytics to operations, thereby making insights actionable and the results measurable. karenwolfe@medmetrics.org

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[1] Walls, M. The Myth of Predictive Analytics. Leaders Speak. WorkCompWire. 9-19-2017. http://www.workcompwire.com/2017/09/mark-walls-the-myth-of-predictive-analytics/

[2] Ibid.

[3] Ibid.

T

A Healthy Disrespect for the Impossible

by Karen Wolfe

When people are extraordinarily successful, examining their characteristics, values, and attitudes can be instructive. The rest of us can learn from them and possibly adopt some of them to advance our own goals. Larry Page, co-founder of Google is an example of one who has achieved exceptional heights. Peering into his thought process can be enlightening.
 

Page says, “Have a healthy disrespect for the Impossible”. While the statement may not be original with him, it does reflect his world view.

Disrespect the impossible

To conceive and develop the Google concept and then the massive company, its young founders had to have a very healthy disrespect for the impossible. Others besmirched the idea of collecting all the information in the world and then making it available to everyone in the world. Not only was it a bold idea, it was thought by most to be ridiculous and impossible. But Larry Page and Sergey Brin had a very healthy disrespect for the impossible. They made it happen.

The concept of disrespecting the impossible could be entertained by those of us in the Workers’ Compensation industry. True, few of us are likely to reach the pinnacle level of Larry and Sergey, but we can borrow some of their bold thinking to get past the assumptions and barriers that keep us from achieving more.

Everyone agrees Workers’ Compensation as an industry needs a healthy nudge to try new things. The industry is known for its resistance to change. Refer to the article, “Are You an Industry Disruptor? It can be a good thing.”[1] Maybe the way to change the industry, to be an industry disruptor, is to begin with an attitude of disrespecting the impossible.

The impossible in WC

Many people in general, including those in the Workers’ Compensation industry focus on why something cannot be done. Reasons for this notion are many, but probably cultural tradition plays a role. Creativity and inventiveness are not expected or appreciated. Too often, the best way to keep a job in corporations is to keep your head down and avoid being noticed. Spearheading a new idea is risky.

Stonewalling new ideas or doing things differently or adopting new technology in an organization thwarts creative thought and certainly diverts progress. I was once told we have a very good product, but to incorporate it would mean doing things differently in the organization. So the answer is automatically no!

Check assumptions

We all know the old saying about the word ass-u-me. It actually packs some truth. To avoid the trap, check assumptions for veracity. Incorrect assumptions can be highly self-limiting.

Problem-solve

Begin the process of problem-solving with new thinking—disrespect the impossible. What could be done if the perceived barriers did not exist? What could be accomplished if new methods were invented and implemented?

Tenacity

Probably the most important ingredient for achievement in any context is tenacity. It’s easy to quit when the barriers seem daunting. Tenacity combined with a disrespect for the impossible might be the unbeatable formula.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics and technology 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

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[1] http://medmetrics.blogspot.com/2014/12/are-you-industry-disruptor-it-can-be.html
 

Managing Claim Costs Before They Occur

York Risk Services Group reports significant savings and outstanding results in "Managing Claim Costs Before They Occur".

MedMetrics powers the analytics and technology behind York's success.

Read York’s recently published White Paper:

Managing Claim Costs Before They Occur
 

Learn more about MedMetrics.

or contact:
Karen Wolfe, President/CEO
MedMetrics, LLC
Workers’ Compensation Analytics
541-390-1680 (v)
541-388-1422 (f)
karenwolfe@medmetrics.org

 

Repost: You Might Be in the Medical Business Now

By Karen Wolfe

The well-known Workers’ Comp sage, Joe Paduda, published an article today for WorkCompWire entitled, “What Business are You In?” Paduda asserts that leaders in Worker’s Comp industry are misguided regarding what business they are actually in. He says they are in the medical business. The following article was posted by MedMetrics January 8, 2013 and is republished here to underscore Paduda’s point.

In Workers’ Compensation, direct medical costs now amount to 60% of claim costs. For most businesses in most industries, when the bulk of expense dollars shifts significantly, the business process immediately adjusts to target the problem. Not so in Workers’ Comp.

An example is managed care programs in Workers’ Comp having remained essentially unchanged since their inception, now nearly thirty years past. Originally designed to control medical costs (and generate revenue for networks), many managed care programs have fallen short. Some of the original designs were good while others were faulty from the start. That none has evolved, taking advantage of advances in technology, is disheartening.

Retro networks

Most medical provider networks not only have not changed, but have somehow sustained the illusion that they offer value. They report discounts on units of medical services. Shady medical providers respond by ramping up the number of treatment services and the duration of treatment to make up for revenue lost to discounts. Ironically, the result is more discounts reported! No one screams “Foul!” and the elephant in the room smugly sits there.

The bad guys

Industry research tells us less than 4% of the doctors generate over 70% of the costs. Moreover, it is easy to figure out who those people are by analyzing the data, so what keeps organizations from steering away from them? Individuals in the 4% bracket should be identified and claimants directed away from them. Better yet, stop referring to them just because they are in the network (and generating those bogus discounts).

Medical management is complicated

Many payers feel powerless in managing medical costs. Claims adjusters and Workers’ Comp managers may know a lot about work injuries, but they cannot be expected to create system change. Rather than trying to manage doctors, they should simply avoid the bad ones. Even in states where directing care is not allowed, intelligence about provider performance and claim outcomes is useful to inform decisions by claims adjusters, nurse case managers, and injured workers.

Monitor the data

A crescendo of concern about Opioid use and abuse has emerged recently. It’s not the drugs themselves that escalate costs, but the collateral damage they inflict on injured workers. Dependence, addiction, and pain confusion prevent, delay, and complicate recovery. Monitoring the data in real time to discover abuse in the form of repetitive prescriptions can be very effective. Most complex claims develop over time and would be more easily resolved and costs avoided when discovered in earlier stages.

Predictive modeling

Predicting the claims that are likely to become complex is an excellent initiative. Still, monitoring all claims electronically, concurrently, and continuously may be a more practical approach. For instance, an alert is sent when a second or third Opioid bill appears in a claim. Now is the time to intervene, whether the claim was predicted to be costly or not.

Even when a claim is tagged using predictive modeling, the only logical procedure is to monitor that claim from the beginning and intervene as conditions warrant. By the same token, concurrent data monitoring can trigger an alert when something suspicious arises in a claim. All claims can be monitored electronically rather than the few singled out through predictive modeling. It’s a powerful medical management tool and nothing slips between the cracks.

Technology-intensified medical management

Tackling the medical part of the business can be complex and difficult, especially for people not specifically trained in it. However, applying analytics and delivering information appropriately through technology tools is powerful. Deliver the right information to the right person at the right time so that early intervention will impact claim conditions, events, and medical costs more effectively. Well-designed technology will find problems early and inform the appropriate persons, thereby linking analytics to operations and significantly impacting results.

You are in the medical business

Workers’ Comp leaders should recognize they can’t avoid addressing the medical portion of claims. They are are actually in the medical business. It’s time to get serious and implement the expert methodologies available to actualize intended managed care initiatives. Continuing business as usual guarantees continuing high costs and substandard results. Ultimately, it could jeopardize the business itself.

Many organizations do not have the resources to develop the kind of tools briefly described here. Instead, they can purchase them from a third party Workers’ Comp managed care technology company. It is doable, affordable, and effective. Even small organizations can partake in the benefits.

Karen Wolfe is president of MedMetrics which applies analytics and technology to maximize medical management initiatives. Visit MedMetrics to learn about MedMetrics Provider Performance Suite and other “power apps” that link analytics to operations, thereby making them actionable.  For questions, contact karenwolfe@medmetrics.org

 

 

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How to Optimize the Nurse Case Management Advantage

A White Paper by Karen Wolfe

Traditionally in Workers’ Comp, nurse case management (NCM) services have been widely espoused, yet often misunderstood and underutilized. The reasons for underutilization are many, including claim ownership tension between NCM’s and claims adjusters. More significantly, is NCM difficulty in defining its work and measuring its value. The issue is not lost on the nurses themselves.

Last to computerize

Medical case management is last and least to computerize. NCM typically cannot attract adequate funding to create appropriate systems. When a process is poorly understood, designing a proper software system is impossible. Too often, computerization for NCM is confined to adding nurse notes to the claim system. Notes cannot be calculated or analyzed and outcomes cannot be measured based on nursing initiatives.

Recognized NCM value

Nevertheless, at long last, NCM value is now being recognized. American Airlines recently reported they are adding NCM’s to their medical management staff and will refer all lost time claims to them. They cite a pilot project where nurse interventions were documented and measured, proving their value in getting injured workers back to work. Additional NCM recognition has been published, as well.

Christopher Flatt, Workers’ Compensation Center of Excellence Leader for Marsh Inc., in an article written for WorkCompWire (http://www.workcompwire.com/) stated, “One option that employers should consider as part of an integrated approach to controlling workers’ compensation costs is formalized nurse case management.Taking actions to drive down medical expenses is an essential component to controlling workers’ compensation costs.”[1]

Formalized NCM process

While Mr. Flatt does not define “formalized” nurse case management, he goes on to say, “Nurse case management is considered a “best practice” in helping to direct treatment, manage medical costs, and reduce disability durations, by providing appropriate care and returning employees to work more quickly. Shorter claim durations and returning injured employees back to work have a direct correlation in reducing workers’ compensation costs”.[2] These are certainly the preferred outcomes, but how does the NCM program achieve them? What are the action steps? How is the process documented and measured for effectiveness? Importantly, how are the NCM initiatives standardized across the organization?

Part of the reason NCM is misunderstood is the lack of a formalized process. The services are delivered by individuals responding to a situation as presented to them or as they perceive it.

Referral criteria

Mr. Flatt continues with some concrete suggestions such as deciding what type of claims should automatically be assigned to the NCM and at what points for existing claims. He suggests predictive analytics can be used to make these decisions. However, a formalized and optimized NCM process can be made far simpler and less costly.

Industry research and individual wisdom

Industry research and wisdom gained through individual and organizational experience can supply the indicators for referral to NCM. For instance, one approach is leveraging the America Airlines experience and set the standard that all lost time claims are referred to NCM.

Another example is research shows comorbidities increase claim duration and cost. These cases should also be referred to NCM for oversight. Yet another example is inappropriate medical providers profoundly increase costs. NCM’s should have efficient electronic tools to direct care to the best in class providers.

The list of valid criteria for referral to NCM is potentially extensive.  Nevertheless, the question should be, how can these conditions be identified in claims as they occur and referred to NCM accurately and consistently?

Computer-aided medical management

As a long-ago nurse and a long time medical systems designer and developer, I believe the answer lies in appropriate computerized system design. To be effective, three components are necessary:

1.      Formalized Criteria for referral

Create electronic profiles containing combinations of data elements found in claims that represent the conditions for referral to NCM’s. For instance, when comorbidity ICD-9’s (diabetes, heart disease, obesity) are found in claims, an automatic referral is sent to NCM. This formalizes and enforces the processes consistently.

2.      Technology Powered

Continuously monitor historic and current integrated claim data. The integrated data should contain five years of history and be sourced from clams, bill review, and pharmacy (PBM).

3.      Referral Alert

The system automatically notifies the NCM when the conditions in a claim match that in a profile. This occurs at the beginning or any point during the claim because the data is continuously updated and monitored electronically in context with the criteria.

The process is simple, yet powerful. Moreover, using a computer-intensified medical management power tool offers even more to the process. All referrals to NCM, the reason for referral, and to whom they were sent is documented by the system, thereby creating a formalized audit trail. Organizational procedures or action steps can accompany the referrals, further formalizing and standardizing the process.

Measuring cost savings

When the system documents the process automatically, individual claim savings can be measured. For instance, directing care to a best practice provider, thereby avoiding a low scoring provider, is a cost savings guarantee. Industry research is used as a basis for estimating cost savings in each instance and since it is a computerized system, cumulative savings reports can be produced on demand to quantify the process.

Analytics inspired, technology powered Medical Management

The NCM advantage can be formalized and optimized with technology. Learn more about MedMetrics WC Medical Intelligence Profiles with Alerts and its other medical management power tools or contact KarenWolfe@medmetrics.org for further information.

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[1] http://www.workcompwire.com/2013/01/christopher-flatt-the-case-for-formalized-nurse-case-management/?utm_source=WCR+Daily+1%2F22%2F13+-+A+New+Leader+Speaks%21&utm_campaign=WCR&utm_medium=email

 

[2] Ibid.

Two Steps to Recharge WC Managed Care

By Karen Wolfe

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

 

 

 

 

 

How to Make WC Managed Care Effective, Affordable, and Accountable

By Karen Wolfe

In a recent blog, Joe Paduda posed the question “Managed care in work comp: worth the cost?”[1] He continued, "Are we wasting hundreds of millions on ineffective programs, or are these programs holding costs well below what they otherwise would be?" 

Frankly, that this question is asked, whether we are wasting hundreds of millions on ineffective managed care programs, reveals a lot by itself. Why have managed care processes and outcomes not been measured for effectiveness continuously throughout their history? Managed care programs have been applied to Workers’ Compensation for twenty-five years, yet the question of whether they are effective is only now being asked? The fact is, managed care effectiveness is largely unknown because the appropriate technology has not been properly applied to manage, measure and monitor the processes.

Analytics backed by technology

Stated simply, analytics can determine what processes are most effective and technology can be leveraged to direct the managed care focus to the claims, events, and conditions in most need of attention. That creates efficiency. The managed care focus should be on claims that contain elements that are known to portend trouble, thereby avoiding frivolous activity and extraneous cost.

Inform the process

To ensure managed care methods are effective and to power the processes, both technology and analytics must be applied. Work-in-process electronic software tools must be developed and implemented to translate analytics to action.  Electronic tools specifically designed for Workers’ compensation managed care will inform the process, improve the outcome, and measure its effectiveness. Using technology to continuously monitor historic and current claim data will exact a more perfect result.

How to recharge managed care
Specific essentials are needed to recharge managed care effectiveness and establish its accountability. All are necessary and all are based on technology and analytics that build on existing resources:

1. Build a unified historic and current data platform
2. Monitor the integrated data continuously
3. Analyze the data to discover problematic conditions in claims
4. Link the analytics to operations with software “apps”

1.      Build a unified and current data platform
The data must be comprehensive, sourced from multiple data silos. Those include bill review data, PBM (Pharmacy Benefit Management) data, and claims system level data. The data must be integrated at the claim level and updated continuously for comprehensive analysis. These basic technological tasks create the platform for performance.

2.      Monitor the integrated data continuously

The unified, concurrent, and continuously updated data platform must be electronically monitored continuously. The crux of computer-aided medical management is maximizing claim monitoring using the technology. Relying on manual monitoring of current and historic data in claims to distinguish those that need attention is not practical or even possible.

Moreover, monitoring current claims data in context with claims history is a technological function that searches for conditions and elements in claims that portend risk and cost. Manual monitoring by even experienced persons cannot begin to approach this goal.

3.      Analyze the data to discover problematic conditions

Rules-based and knowledge-based algorithms built into the underlying software will identify actual or potentially problematic claims. Electronic data monitoring is used to uncover events, diagnoses, and data combinations that are of concern.

Reveal hidden threats

For instance, a diagnosis of diabetes might be documented on a bill by a treating physician on the fourth or fifth visit. Such a comorbidity buried in the data might easily go unnoticed without computer-aided medical management. Yet, technology will uncover it every time.

Identify poor providers

Another example of analytics used to uncover risk is evaluating physician performance. A physician who keeps claimants off work without sound rationale or a blatantly fraudulent doctor who is treating the claimant are both predictive of higher cost outcomes. Yet, when the physician is on the approved panel, no one takes notice. A smart software system will alert appropriate persons apprising them that a low ranking physician is treating the claimant—as it is occurring.

The same smart system will single out best-in-class medical providers so that claimants can be directed to them from the start.

4.      Link the analytics to operations using software “apps”

Analytics must be logically linked to operations. No advantage is gained by performing analytics and letting them languish somewhere in graphic form. Analytics must be made actionable.

When the results of analytics are translated into software tools and alerts for claims adjusters, medical case managers and others, the information can be acted upon before much of the damage is done. Medical provider networks can be converted to quality networks. Claims cannot deteriorate without notice.

Software multiplies intelligence

Bill Gates said software is the multiplier of human creativity and performance. Software makes people do what they do best even better. Managed care programs can be intelligently revitalized by applying technology and analytics to the process, thereby gaining efficiency, accuracy, and accountability.

Paduda concludes: “Paying over a hundred million dollars for network access without clear and convincing proof that they are improving outcomes is not smart.” Also, “Using case management and UR indiscriminately across all providers in all cases is a waste of money and counter-productive.” He is absolutely correct. But it need not be that way. Affordable solutions are available now.

What it takes

A logical and efficient merger of technology and analytics is the only feasible way to resolve the issues in managed care. Automated processes coupled with intelligent analytics will produce the desired results along with the necessary proof of value. Happily, building the system internally, a costly and time-consuming effort, is not necessary.

A knowledgeable managed care analytics outsource will implement the advantages without the hassle, time, or cost of builidng these functions internally. In fact, managed care power apps can be added to the managed care initiatives of any size organization for less than the cost of a part time analyst!

Learn more about MedMetrics or for discussion, contact KarenWolfe@MedMetrics.org

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[1] http://www.joepaduda.com/archives/002361.html

Cost Control Discovered at the Intersection of Technology and Managed Care

By Karen Wolfe

Costs continue to rise
Regardless of the myriad of interventions directed at containing claim costs in Workers’ Compensation, costs continue to increase. Now that the medical portion of claim costs amounts to sixty percent or more, the fact must be acknowledge that traditional managed care initiatives are inadequate. Moreover, new medical costs seem to be appearing from unfamiliar places, leaving no apparent recourse. Costs are finding new avenues of expression in the form of drug costs, complex medical procedures, and exponential costs due to comorbidities.

What now?
It seems everything that can be done, has been done. Managed care programs including provider networks, bill review, utilization review, peer review, and medical case management are conceptually well-founded. Still, outcomes are disappointing. What more can be done?

Starting over is absolutely not an option. Disbanding current managed care programs and creating new ones is completely impractical. Sunk costs of existing programs are huge, and building new ones is not feasible or affordable. Besides, managed care programs in Workers’ Compensation are well-founded conceptually, and based on solid principals. They just need to function more effectively.

Managed care is tired
Managed care programs in Workers’ Compensation are tired. Like much of our country’s infrastructure, they have not been revitalized over the years of their existence. They operate today just like they did twenty years ago. Specifically, most managed care programs have not taken advantage of the exponential advances in technology during their tenure.

Same tenure—different results
Think about it. As recently as twenty years ago (1991 seems like yesterday) Microsoft’s Disk Operating System (DOS) was the predominant operating system for personal computers. PC’s were large, expensive, and scarce in companies. Local area networks were just emerging and required hard-wiring to connect, servers, PC’s and printers. The Internet was not yet available for general use. Significantly, this was also the time of Workers’ Comp managed care ascendency. Yet, it would be some time before managed care programs were even computerized.

Computerization in managed care is relatively recent and the uptake has been laboriously slow. At the same time, evolution in technology has been explosive. Reluctant technology upgrades in managed care have been dedicated to hardware and operating software at a pace consistent with Microsoft operating system advances. Little has been done in managed care to exploit technology to actually benefit outcomes.

In contrast, PC’s (350 million were sold in 2010!), cell phones, and smart phones have proliferated. It is estimated 4.6 billion cell phones are in use worldwide. They are enabled with text messaging, web browsers and cameras, as well as by wireless connectivity in place of landlines to reach remote communities, as well as by new social networks that enable collaboration on more and more devices. As recently as 2005, Facebook was a start-up phenomenon, Twitter was still a sound, the cloud was something in the sky, and 3G was a parking space.1 The flood of technology and its applications has serious and exciting implications for Workers’ Comp managed care.

Differentiate through technology
Underscoring the point, Joel Cawley, the vice president for strategy at IBM is quoted as saying, “Two things will differentiate companies, countries, and individuals from one another. One is analytics. Once everyone is connected, prosperity will depend on how well you or your company can analyze and apply all the data pouring through these networks to optimize your ability to provide better…(services).”2

The Workers’ Compensation industry must of necessity step up to the challenge because continuing to do business as usual is ever more unconscionable in light of claim cost escalation and deteriorating outcomes. Workers’ Comp organizations, whether they are insurers, third party payers, self-insured employers, or service providers to the industry, must leverage technology to improve their services and control costs. To do otherwise is derelict.

Move to the intersection of technology and managed care
Analyze the data to gain insight into best practices and procedures and who is providing them. Leverage the data to find best in class doctors and other providers. Enable current data to inform adjusters and medical case managers of claims containing potentially calamitous conditions. Let technology notify appropriate persons of approaching key benchmarks and other pivotal conditions. Most importantly, act on the findings of analytics.

Drive the results of analytics to operations to mobilize appropriate action to intervene in time to prevent further damage. Make analytics and technology work-in-progress tools that lead people to informed decisions and to taking action early enough to contain costs. Most importantly, embrace technology to ramp-up, revitalize, and recharge managed care programs. Use analytics backed by technology to take charge of outcomes. Move to the intersection of technology and managed care.

Learn how MedMetrics will move you to the intersection of technology and managed care, thereby gaining more control of costs and outcomes.

1 Friedman, T., Mandelbaum, M. That Used to Be Us: How America Fell Behind in the World It Invented and How We Can Come Back. Farrar, Straus and Giroux. 2011.
2 Ibid.