Workers' Compensation Medical Care: Status Quo No Longer Working
Historically over the past 2-3 decades, group health plans--unlike workers' compensation organizations--have created and utilized medical analytics and other advanced tools and strategies to reduce unnecessary care, identify waste and fraud, improve patient care and outcomes, and enhance the efficiency of healthcare delivery and financing. Now, workers' compensation carriers are beginning to begin to think more like group health plans, and overcoming complex hurdles to do so, according to Joel Hoffman, senior vice president of Eden Prairie, Minn., based Ingenix Consulting, a leading provider of health information, technology and consulting services.
"The world of worker's compensation has evolved over the years and one thing has become very clear: the status quo is no longer good enough nor working well, for both employers or injured workers," says Hoffman, noting that here are many tools and ideas that worker' compensation organizations can borrow from the health plan world that can help injured workers experience a faster and sustained return to work and, at the same time, help avoid unnecessary expenditures in the process.
After all, health care is health care. For example, a person who suffers a back injury working in the yard should not be treated any differently than someone lifting a heavy load on the job, assuming the same physiological nature of the injury, says Hoffman. Yet, that "treatment gap" has been common across the country in workers' compensation, mainly due to the patchwork of laws and regulations that govern workers' compensation, the feeling of entitlement of the injured worker, and past industry practices of expediting the return to work at any cost. The same would also hold true for medical care connected to other property and casualty claims, such as automotive or general liability.
Hoffman, who manages Ingenix's Financial Advisory and Actuarial Services practice, says firms like Ingenix can help workers' comp leverage health plan best practices for much improved injured worker outcomes and employer liability management.
"Firms like ours are partnering with participants in the property and casualty marketplace to deploy advanced medical analytics to help drive their business objectives," says Hoffman, who has more than 25 years' consulting experience in health insurance and managed care. By taking a close look at the entire medical side of a comp claim, Hoffman says his team can quickly understand the forces driving any "outlier" experience and identify the optimal care paths. Next, he says, it's critical to establish the necessary corrective actions by leveraging both the specific diagnostic tools Ingenix has developed, as well as industry-leading practices obtained from Ingenix Consultant's years of experience advising health care payers and provider organizations.
"Joel and his team help health plans and managed care organizations assess and diagnose performance issues, implement necessary corrective action measures, and put in place the requisite infrastructure and tools to maintain desired performance levels," says Steve Suter, general manager, Property and Casualty at Ingenix, adding that those efforts led to successful turnarounds, growth, sales, partnerships and acquisitions for Ingenix's health care clients.
"That knowledge and experience is clearly translating well to our property and casualty clients," Suter adds. "The P&C payers in particular are not realizing loss costs savings they had hoped to achieve via new claim system implementations, so Joel's team is helping them utilize their data to improve their management of medical costs."
Hoffman adds that while there clearly are tools and techniques that can be ported from health plan management to workers' compensation and other P&C lines, it also takes the right expertise to implement them.
"The fundamental tools are certainly the same," he says. "But the determination of what caused that trend and the increased spending, what the right care path is, and overall, why workers' compensation experience moves the way it does is not easy to do without the right expertise. Our partnering with workers' compensation experts from our clients and within Ingenix has proved invaluable in applying health benefit management techniques to produce the improved results we are seeing in managing workers' compensation risk."
Ingenix has offered its P&C clients cost containment tools such as bill review, PPO network access, e-billing, Bill Review, EDI, data benchmarking, reporting and electronic payments and statements for years, Suter explains, but customized medical analytics can help take a good cost containment P&C strategy to the next level.
Some of Ingenix's strategies and techniques include:
-- Managing the injured worker by understanding the best and most efficient care pathways to treat the injured worker
-- Managing the providers of care by identifying providers or networks of providers that consistently produce the best outcomes for injured workers
-- Managing the risk for workers' compensation carriers and other benefit management vendors in the space by better understanding the risks of an injured workers' case and the associated liabilities, and when and how to intervene in a case
-- Merging in health benefits data--richer from a clinical perspective--with workers' comp data to improve outcomes and create predictive models to facilitate better outcomes
For so long, Hoffman concluded, the health plan side and the workers' compensation side were considered apples and oranges, yet there is much crossover and opportunity. Bringing knowledge and experience from the health plan side to the workers' compensation market can help an industry that is hungry for answers to increase employee productivity and reduce costs. Workers' Comp can question the status quo and implement new, proven ideas and tactics to sustain an injured workers' return to work--without sacrificing quality of care--workers' compensation's ultimate goal.
To learn more, contact Ingenix at email@example.com or call 800 765 6619. You can also visit us online at http://www.ingenix.com.
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September 29, 2010
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