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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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Tuesday, February 21, 2017

Proof of Value for Workers' Comp Medical Management

by Karen Wolfe

Everyone knows the bulk of Workers’ Comp costs now are medical. Claims reps and nurse case managers handle injured workers and their medical costs with utmost care. Anecdotally, their work saves time and money. The problem is that concrete evidence of their value has been elusive—until now.

How can costs avoided and time saved be measured? It’s like pulling invisible rabbits from a magician’s hat. It should be awe-inspiring, but what really happened? Quantifying what did not happen is usually impossible. However, quantifying and measuring savings is completely feasible when a different approach using predictive analytics is used.

The real magic
The Workers’ Comp industry does not readily embrace change or innovation. That is changing as pressure increases to become more efficient to sustain profitability as resources shrink. The best approach to meeting this challenge is incorporating advanced technical strategies such as predictive analytics that are designed to support and streamline the business process and make workers smarter. The collateral benefit is being able to objectively measure and report savings.

Solution design
The solution is to extensively analyze the organization’s historic data using predictive analytics and deliver the insights in the form of actionable information to all the stakeholders including claims reps, medical managers, and other decision-makers. Just a few steps are needed including data analysis, data monitoring, informing and integrating the efforts of stakeholders, and then measuring the savings. The first and most critical initiative is analyzing historic data using predictive analytics methodologies.

Predictive analytics
Analyzing historic data utilizes predictive analytics methodologies. Deeply analyze the organization’s data to identify cost drivers, actions taken, and outcomes. Organizations differ in their client bases so the kind of injuries they experience varies.

Organizations are also unique because they develop distinctive internal and cultural processes regarding claims handling and medical management. Therefore, an organization’s data is the most meaningful data in understanding future costs. Because of the differentiating factors, using others’ data, regardless of how large the database, can mislead.

Monitor the data
Situations and conditions found in the past are likely to recur. Once the risks are identified in historic data, they can be searched programmatically in current data through continuous data monitoring. When problematic situations occur in the data, appropriate responses and interventions are mobilized immediately. The insights are delivered to medical management stakeholders, including claims reps, medical case managers, senior management, and others as appropriate. The knowledge delivered is structured to assist them in decision support and coordinating efforts.

Deliver insights
Risk information in claims is delivered concurrently to stakeholders so they can make early and sound decisions, then initiate appropriate action. Importantly, all medical management participants receive similar information so initiatives are coordinated and integrated, thereby implementing strong, multi-disciplinary approaches.

When risk conditions in claims are identified in this manner it means reserves in that claim need attention as well.  When events and conditions in claims change indicating a need for more intense medical management, reserving should also be addressed. Based on predictive analytics, the probable ultimate medical costs are projected and portrayed for claims reps, thereby providing key knowledge to support appropriate action.

Coordination impact
Data monitoring identifies claims with risk conditions concurrently and informs the stakeholders immediately. Intervention efforts are coordinated between claims reps, medical case managers, and others, providing broad-based, integrated initiatives leading to improved results. Savings are gained through proactive, coordinated intervention by professionals who are offered key information for decision support making them accurate, efficient, and effective.

Measure savings
When claims are closed, objective savings are measured by comparing projected performance based on predictive analytics with what was accomplished through proactive, integrated initiatives across all medical management participants. The calculations are quantifiable and objective.

The simplest and most rewarding approach is to outsource this process to a knowledgeable medical analytics company. Internal processes need not change, but professionals and business processes are made more accurate and efficient—a win for the organization, its employees, and its clients.

Technology is far less expensive than people. When it is designed to assist professional workers by making them more accurate and efficient, the return on investment is profound.

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


Tuesday, February 7, 2017

Will Watson Replace Workers' Comp Professionals?

by Karen Wolfe

A recent post in LinkedIn noted the Japanese firm, Fukokui Mutual Life Insurance has replaced more than thirty office workers with artificial intelligence.[1] The Artificial Intelligence (AI) replacement in this case is the famed IBM Watson. Watson, or one of its doubles, is in fact impacting nearly all industries in multiple ways. Eliminating workers is the paramount goal. But could Watson replace workers in Workers’ Comp?

AI has been around for decades but now with advanced technology, it has fully caught on and its applications are widely varied. AI is what drives driverless vehicles and operates machinery sans human involvement. Short of that and more practically, AI machine technology is used to enhance worker productivity, accuracy, and efficiency. Importantly, AI should never reach Workers’ Comp if more pragmatic, technology-based strategies are implemented now.

Wake-up call
Replacing Workers’ Comp professionals with Watson or its double is not feasible at this point or hopefully, ever. The possibility of replacement by the likes of Watson should not panic anyone in the Workers’ Comp industry, at least not now. Yet, it is a wake-up call to the industry.

Watson in WC
Imagine injured workers navigating the Workers’ Comp system without claims adjusters and medical case managers. Picture Watson managing claims. It could make payments without difficulty, and even review the bills effectively. Watson could also determine which claims are the most challenging and refer them to medical case management.

Stop there!

Watson as case manager
Envisioning Watson as medical case manager is a real stretch. Human interaction is central to medical case management effectiveness. Likewise, Watson delivering claim management services without dialogue with the claimant would be spotty and unpleasant at best. Accuracy and efficiency under Watson management could be nearly perfect, but claim adjusting relies heavily on human interaction. Injured workers managed by Watson would feel victimized in a heartless system. The only recourse would be to litigate. Watson might have trouble with that.

While replacing professionals with technology like Watson is going too far, it should prompt Workers’ Comp payers to actively engage current technology to improve processes and outcomes—just to keep up. Clearly, the momentum in every industry is more technology in order to gain efficiency and Workers’ Comp cannot afford to lag behind. To stay in the game, technology designed to assist workers with task-relevant knowledge and decision support that makes them more accurate, more efficient, and, yes, smarter is crucial.

Dodging Watson
Watson will replace health insurance industry administrative workers fairly easily. Essentially, bills are paid if they match the benefit plan and the treating doctor is in the PPO. However, the Workers’ Comp industry is very different from general health and much more complex. The question is how can the Workers’ comp industry optimize efficiency and productivity without discarding its professionals and alienating injured workers? The answer is to apply currently available predictive analytics technology to make WC professionals smarter, more accurate, and highly efficient. Of course, that also spells profitability for the organization.

Knowledge assistance
Apply predictive analytics to understand historic data and the cost drivers inherent in it. Monitor the data continuously to identify risk conditions as they occur. Create apps that inform claims reps of conditions and events in claims that need attention in real time so action is early and proactive.
Assist claims reps by providing information for decision support such as the probable ultimate medical reserve amount for a claim. Time and effort is saved, while accuracy and efficiency is gained. Rather than laboring with decisions such as adjusting reserves, a timely and accurate projection is presented, thereby optimizing efficiency.
Similarly, relevant information should be available for medical case managers so they can avoid searching for claim information and status. Timely alerts and shared information promote collaboration and integration of efforts between claims and case management decision-makers in the organization. Watson is thwarted.

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