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Medical expenses continue to press upward with scant evidence that the health-care system is delivering better outcomes. The median time of injury disability increased between 1995 and 2003 from five to seven days, or 40 percent. The managed-care initiatives of the 1990s appear largely to have broken down. At least, that is the perception of many--including senior claims executives, case managers and enlightened providers.

Insurers pressing forward to reverse these trends run into some formidable barriers. One such barrier is the entrenched position of internal staffs and external vendors to continue the practices of the past, however questionable they have proven in controlling costs. Another barrier is the autonomy of the injured worker and the doctor. They cannot be taken for granted.

Thus it could be that innovative practices by insurers, and no amount of utilization review, bill review, preferred-provider organization credentialing or any other effort to manage medicine, can really influence to a significant extent the costs and quality of care. Five such practices do exist in the marketplace currently, though they are not widely applied. They could stem rising medical costs while improving the quality of care for work injuries.

A close examination of these strategies not only draws out their nuances, but reveals alternative approaches as evidenced by the current practices of several dozen insurers, third-party administrators, employers, managed-care firms and medical providers. It also helps to receive feedback from four executives working in three of the largest workers' compensation insurers, who have shared their thoughts on these five innovations.

THE RUNDOWN ON THE RX

The first of the five practices that can reduce costs and improve treatment--and these are in no particular order--is to aggressively highlight a network of clinics and doctor offices that give initial care to injured workers.

Our executives liked this idea, which some insurers have implemented though most have not.

One executive wrote in an e-mail, "Current studies revealed a 58 percent savings driving in to occupational-health providers versus emergency rooms and family physicians."

The second prescription for better medical care is to build premium-quality specialty-provider networks.

On this topic, another of the executives wrote, "We have been trying to measure quality doctors since the late 1990s; it appears we can tell the great 5 percent and bad 5 percent. Premium-quality networks are a nice ideal but are hard to define. You also have to ensure access to care."

Third, to bring health care back to health, insurers should seriously invest in medical catastrophe management.

"This is great," said one of the executives. "What have we learned from Katrina and CAT management that we can apply to medical care? We currently do this."

Coming in fourth is the practice of innovation in chronic-pain management. About 15 percent to 20 percent of long-term workers' comp claims heading to Social Security Disability Insurance and Medicare coverage are chronic-pain complaints with ongoing use of drugs.

So estimates Jean Feldman at Choice Medical Management in Tampa, Fla., whose team examined the medical histories of hundreds of claims as part of Medicare planning. The team found many instances where pain management was not utilized on time.

Said one executive, "We often have staff--nurses and adjusters--with little guidance on the type of program most appropriate to intervene for certain types of pain."

At fifth is the workers' comp prescription of staying attentive to the medical-only claim that may evolve into something more serious.

"I like it. We currently do this," one executive wrote.

On the whole supportive of this five-part prescription plan, our executives seasoned their comments with strong doses of caution, even skepticism, that from planting these practices, one can harvest their fruits in the foreseeable future.

One executive wrote about the cost of mistakes from innovation: "Misuse of resource can be as bad as no resource, and goals will never be achieved."

Another commented ruefully, "In the (midst) of an exhaustive process of selecting our new network providers, we found, disturbingly, is that there is no company out there that has any substantive analytics around outcomes. It remains a discounting game, and you know, that is not always the answer."

SALVE NO. 1

Time out to naysaying! Let's instead focus on one common thread to all five of these practices--the self-confidence, not usually found in insurers, that demonstrates that one can successfully communicate and collaborate with doctors, not just hold them at arm's length. One cannot get more fundamental than this: Communicate with doctors more productively.

Joseph Fortuna, a physician working for the Troy, Mich.-based auto-parts manufacturer Delphi, gives advice on how to talk with a patient's doctor. He says that in more than 30 percent of claims, there is no direct communication between the doctor and the insurer. Claims strategy is decided upon with zero consultation with the treating doctor.

To ensure a reasonable discussion, on the other hand, and bring to the phone a doctor who can issue a release for work, Fortuna advises talking to the right person. Then fax them the job description. Suggest specific work restrictions. In the course of all this, use the name of the patient's employer if at all possible. The provider will be much more responsive to an employer's need than he will be to an insurer's need.

And ask the right question, Fortuna says.

Wrong question: "Can Mr. Y return to work?"

Right question: "Did you tell Mr. Y to stay out of work?"

Wrong question: "When can Mr. Y return to work?"

Right question: "Can Mr. Y return to work on Monday?"

Wrong question: "What are the restrictions?"

Right question: "Can Mr. Y return to work with a thirty-pound lifting restriction?"

As for call frequency, Fortuna's rule of thumb as a work-site occupational-medicine physician is to make more than three calls during five working days. He recommends using the following escalating pattern of messages when trying to directly reach the provider:

Day one: "Please ask Dr. X to call Dr. Y concerning patient Z."

Day three: "I am Dr. Y, an occupational-medicine physician in city A. I need to speak with Dr. X concerning patient Z's work restrictions. I have a signed medical-information release from patient Z. I need to speak to Dr. X by (day six) so that patient Z's benefits may not be interrupted."

Day five: "This is Dr. Y. I am still trying to reach Dr. X about patient Z. I left messages on (day one) and (day three), but have not received a call back. Please ask Dr. X to call me by (day six)."

Opening a clear and productive channel of communication with doctors is just one of the strategies that some workers' comp insurers are applying to heal themselves and the system.

Stay tuned for the next article and an in-depth look at the two practices that involve provider networks.

Three insurers, in Washington state, Louisiana and Massachusetts, are committed to tightening up collaboration among employers, initial care providers and insurers, and a widening number of insurers are using specialized-provider networks to zero in on quality of care and to get reimbursement. The target providers here are physical therapists, orthopedists, physiatrists and neurologists.

PETER ROUSMANIERE, a Vermont-based consultant and writer, is the workers' comp columnist for Risk & Insurance®.

December 1, 2005

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