Bruce Singleton: Using Networks for More Than Just Discounts

By: Bruce Singleton, Vice President of Network Products
Coventry Workers’ Compensation Services

Accessing a workers’ compensation network has become an integral part of virtually every risk management program. While adjusters, nurses and others usually attempt to channel to network providers when permitted by law, many times the goal seems to be focused on obtaining a retrospective discount for services rather than prospectively selecting the provider who is most capable of managing the injured worker’s condition.

As we know, beyond discounts, there is value in knowing the provider licensures are in good standing, they meet credentialing standards, and they treat occupationally-injured or ill patients. It sure beats having to search the telephone book or better yet ‘googling’ to find one. But what about scheduling services with a provider based on their overall claim outcomes? Over the past several years, outcomes-based programs have emerged, initially for large employers, in various forms, using numerous methodologies to identify the providers believed to meet the designated outcomes targets. To be most effective and reliable, however, these methodologies must be based on sound data and should also employ nationally-accepted guidelines for measurement.

Data is key…
The cache of data necessary for statistically-reliable measurements is often underestimated. The amount of data available in developing outcomes programs is the single most limiting factor in the reliability and scope of the programs. For example, nationally-accepted guidelines, as well as common sense, suggest that a provider must have treated a reasonable minimum number of injuries (in the evaluation period) for us to rely on that data as a predictor of their overall results. It would not, for example, be appropriate to rely on measurements for a provider who has treated three low back injuries in three years. When the sample size, by nature of injury, is factored in, organizations soon realize that many point-of-entry providers cannot be effectively measured based on a single employer or payor’s data. The limitations become even more obvious when measuring specialists who only treat a fraction of the injuries as compared with point-of-entry providers. Data is the key to a successful program…whether you have enough, and the right type, will determine whether the program can deliver any results.

Analytic competency is critical…
Organizations typically have analytical resources to develop basic provider measurements, but the sophistication of those measurements depends on the depth of workers’ compensation knowledge and statistical methods of the analytic team. Using the appropriate statistical methods that fit the pattern of the data is critical to relying on the results. In addition, following nationally-recognized guidelines for measuring providers is almost always overlooked in organizations’ methodologies, but outcomes-based programs will need to consider these if they expect longevity. These guidelines suggest, for example, that it is not appropriate to only measure costs but that cost measurements must be accompanied by quality measurements. In addition, organizations are guided to include all stakeholder groups in the development of their programs, including providers, customers and even patients to the extent that it is reasonable to do so. While data may be the single most limiting factor in an effective outcomes initiative, serious consideration of these broader programmatic decisions establishes a complete program.

Beyond discounts to outcomes
Organizations that access a large data store, including medical, pharmacy and indemnity data, and that consider all aspects of a comprehensive provider measurement program, can provide payors with a more refined tool that is more likely to deliver incrementally successful outcomes over time. While traditional workers’ compensation networks will continue to be utilized, this is the starting point of getting more out of what you already have. Payors may then develop provider-specific claim intervention strategies with lower administrative burden, which target improved outcomes with lower overall costs.

About Bruce Singleton
Bruce Singleton is the Vice President of Network Products for Coventry Workers’ Comp Services. With more than 20 years of experience in health care, including over 12 years in the workers’ compensation area, Bruce’s experience spans financial, operations, acquisition and product areas. He is currently responsible for the product strategies for Coventry’s workers’ compensation and auto networks, which includes state-regulated products, network access products and outcomes-based network products.

Prior to its acquisition by Coventry, Bruce worked for Concentra Network Services, where he served in various leadership roles in operations and product strategies, and worked extensively with regulators, operations and customers to define and implement regulated network products in California and Texas. Prior to Concentra, Bruce worked for Monarch Dental Corporation, Electronic Data Systems and Arthur Andersen, LLP.

About Coventry
Coventry Workers’ Comp Services, a division of Coventry Health Care, Inc. (NYSE: CVH), is the leading provider of cost and care management solutions for property and casualty insurance carriers, (workers’ compensation and auto insurers), third-party administrators and self-insured employers. We design best-in-class products and services to help our partners restore the health and productivity of injured workers and insureds as quickly and as cost effectively as possible. We accomplish this by developing and maintaining consultative, trusting partnerships with our clients and stakeholders, built on a foundation of innovative and customized solutions that support the claims management process.