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The MedMetrics blog provides comments and insights regarding the world of Workers’ Compensation, principally, issues that are medically-related. The blog offers viewpoints regarding issues affecting the industry written by persons who have long experience in the industry. Our intent is to offer additional fabric, perspective, and hopefully, inspiration to our readers.

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Thursday, May 23, 2013

WC Medical Cost Control Made Simple and Affordable Through Technology

A White Paper
by Karen Wolfe

Everyone talks about it, but few are taking significant steps to effectively control medical costs in Workers’ Comp. Solutions are available that can significantly impact medical costs, but too few are implementing them. Moreover, the solutions are easy and affordable, leaving payers with the question, “How can continuing business as usual be justified”?

Technology as a cost management tool
The elements of success are already in place. Every payer organization, has data and an IT (Information Technology) department, either internally or through a third party (TPA). Now they need to advance beyond gathering, storing, and reporting data, to developing new capabilities through technology. The objective is to design technology applications that significantly impact claim costs.

Plain data
In its raw form, the data is not very useful. But when it is subjected to analysis and re-presented to business units in a simple and meaningful way, it delivers valuable claim management intelligence. For example, data can be evaluated through analytics to measure medical provider performance.

Transform data
Medical provider files in claims, bill review, and network systems contain the provider’s name, address, and other demographic information. However, the provider record alone cannot divulge the provider’s impact on claims, including cost, return to work, referral patterns, and other critical factors. But when data from bill review, claims level, utilization review, and pharmacy systems are integrated around a medical provider, the resulting information is exponential.

Measure medical provider performance
Medical provider data integrated across systems offers a platform for powerful analysis. Comparing providers of similar medical specialties treating similar injuries will reveal best patterns of medical care. Analyzing frequency of return to work, indemnity costs, legal involvement, and other factors associated with providers in the data will bring best providers for Workers’ Comp to surface and expose the poor performers and abusers. Workers’ Comp industry research shows avoiding the poorly performing providers results in measureable cost savings every time.

Electronic claims monitoring
Additionally, when data is electronically monitored on a continuous and concurrent basis, it can prompt and guide adjusters and medical managers to take timely and appropriate action. An example is electronically monitoring the data for medical doctors’ prescribing behaviors. Automatic alerts of excessive Opioid prescriptions are sent to appropriate persons who initiate damage control. Lives and dollars are saved.

Computer-intensified medical management
Computer-intensified medical cost management through rules-based data monitoring can be applied to scores of conditions and events in claims that portend risk and cost. Using technology to monitor all claims continuously can even preclude elaborate and expensive methods such as predictive modeling. Claims identified as risky through predictive modeling must be monitored going forward. However, monitoring all claims electronically through specifically designed technology insures that no risky claims are missed, including those identified or not identified through predictive modeling. Electronic data monitoring is the more comprehensive, yet affordable solution.

Maintaining status-quo
The IT tasks required to maintain claims systems and properly handle data are considerable. Therefore, additional IT tasks are not viewed favorably. At the same time, business units compete for IT time and are hesitant to request additional IT resources. Therefore, a simple solution that could save millions may be disregarded to avoid internal disruption. Change avoidance guarantees business as usual with no impact on medical costs.

Outsource for repurposed technology
Often the most propitious way to repurpose technology for Workers’ Comp medical cost control is to outsource to Workers’ Comp managed care and technology specialists. To build systems internally that will achieve significant medical cost control can be a daunting and lengthy task. Knowledgeable business unit personnel must translate strategies to IT personnel for design and development. IT personnel must be dedicated to the project and continuing process. Outsourcing is more practical.

Outsourcing extends IT
IT’s role in outsourcing is to transmit data elements in a secure file from each source system. Data integration and mapping is provided by the outsourced company, freeing IT from the burden. Updates to the data are set automatically so IT involvement is minimized. Outsourcing positions IT to oversee the technology project, while extending its capabilities with significantly less time and cost.

Outsourcing medical cost management through outsourced technology is simpler, quicker, and much less costly than developing new medical cost management technology internally. Outsourcing technology to target medical costs through analytics and data monitoring is very affordable and offers favorable and timely cost benefits results. Doing nothing cannot be justified.

Karen Wolfe is the President and CEO of MedMetrics®, LLC, an online Workers’ Compensation analytics company. MedMetrics links analytics to operations to make them actionable for medical cost control.

Wednesday, May 8, 2013

Technology in Workers’ Comp—It’s Not Just for Documenting Anymore

by Karen Wolfe

Sweeping changes underway
Multiple articles have been published recently warning of sweeping changes impacting the Workers’ Comp industry. In an article entitled, Take Time for Technology, Steve Penman, COO at Sedgwick states, “Workers’ compensation is a data intensive system and it remains a challenge for virtually all employers. Increasing regulations, rising medical costs, and the uncertainty posed by healthcare reform continue to make this a formidable issue on all fronts. Technology is having a profound influence on the way organizations are managing their workers’ compensation programs.”[1] Yet, many organizations continue to do business as usual rather than embrace technology to understand and effectively manage through the quickly evolving business scene.

Beyond storage headaches
Payers in Workers’ Comp have long used computer technology to manage bill payments and document actions or events associated with claims. The result after many years of computerization is the vast quantity of data. However, little has been done in the industry to leverage that data to make it a viable decision support tool rather than just a storage headache. Little has been done to convert the data into a working tool that can impact claim process and outcomes.

Obama Care impact
In another recent article, Is your workers’ compensation technology platform readyfor healthcare reform? Mike Allen asks, “Is your workers’ compensation technology platform ready for healthcare reform?”[2] Allen offers a litany of initiatives taking place before our eyes in general healthcare.  He continues, “No doubt there are many opportunities to leverage the technologies implemented as part of new American medical model to improve treatment of injured workers.  What steps are you taking to make this happen?”

In yet another article entitled, Affordable Care Act of 2010 - Workers' Compensation Community, Take Heed![3] Todd Brown, EK Health's Director of Bill Review, states “The Affordable Care Act of 2010 in section 10109 gave authority to the Secretary of HEW to periodically review and determine whether or not Property and Casualty including workers’ compensation insurance should be brought up under the HIPAA umbrella. The act requires that the consideration for inclusion of Property and Causality under HIPAA be reviewed every three years.” In other words, Workers’ Comp payers may be quickly swept into the Obama Care technology surge at any time.

The warnings are well-founded and clear. To manage change, the use of technology is increasingly important for the Workers’ Comp industry. Unfortunately, the industry is already significantly behind others. The Affordable Care Act (Obama Care) is driving the rush to technology in general healthcare and it will significantly impact Workers’ Comp whether or not it is formally included in the Act. Moreover, the greatest challenge to Workers’ Comp payers is not gathering more data. It is changing the way technology is applied to the data to make it a powerful tool.

New uses for technology
The use of technology must move beyond traditional computerized documentation and reporting. To their credit, some Workers’ Comp organizations have successfully applied predictive modeling techniques to the data to derive important knowledge about potential risk. But intelligence must be linked to operations through technology to make it actionable.

Integrated platforms
The major thrust in general healthcare technology in response to Obama Care is to significantly improve quality of medical care while controlling costs.  Platforms that integrate patients’ medical records from hospitals, laboratories, doctors’ offices, and ancillary providers are in place or well underway.

In Workers’ Comp, integrating the data from all sources associated with a claim is crucial. Bill review, claims, pharmacy, medical case management, and utilization review systems should be integrated at the claim level to gain the total picture of the claim at any point. In other words, documentation must continue, it must improve in accuracy, and the information must be integrated across the claim.

Decision support
Workers’ Comp data must also be re-presented to the business units for real time decision support. Claims and medical professionals should be able to access current comprehensive claim information to make decisions about best doctors and other factors pertinent to quality and cost management.

Data made a working tool
Additionally, the data in Workers’ Comp must be translated to make it a work-in-progress tool. The integrated data from all sources in Workers’ Comp should be monitored continually and concurrently using technology to identify conditions in claims that portend risk and cost. Monitoring historic and current claim data continuously and applying rules for alerts and interventions will improve quality of care and outcomes while automatically documenting the process. Such is the nature of the new technology.

Integrated claim data is monitored electronically to uncover conditions identified in predictive modeling, industry research, and gleaned from the wisdom of experienced professionals. When such conditions in a claim are identified, technology is used to automatically notify the appropriate person to intervene. Early, knowledgeable intervention avoids complexity and results in quality and improved outcomes while costs are controlled.

Better late…?
The technology imperative is urgent and clear for Workers’ Comp. “Better late than never” does not apply because the impact in underway. Never is not an option!

Ms. Wolfe is president and CEO of MedMetrics® that offers technology and analytics designed to strengthen medical and cost management methods in Workers’ Comp. MedMetrics' suite of technical services and online power apps offer payers, managed care service providers and provider networks a quick and affordable path to cutting edge technology that recharges managed care. For questions, contact karenwolfe@medmetrics.org

[1] Penman, S. Take Time for Technology.  WorkCompWire  May 6, 2013 http://www.workcompwire.com/2013/05/steve-penman-take-time-for-technology/
[2] http://michaelgallen.wordpress.com/2013/05/07/is-your-workers-compensation-technology-platform-ready-for-healthcare-reform/