By: Shelley Boyce, CEO, MedRisk
Workers’ Compensation managed care has come a long way since its emergence in the mid-1990’s. When it first arrived on the scene, managed workers’ comp looked a lot like group health – big generalist discounted networks – with discounts below state fee schedules instead of discounts below billed charges.
As the industry matured, specialty networks evolved, looking at distinct and unique areas of the total medical spend – crafting workers’ compensation specific protocols, formularies and guidelines to ensure that injured workers got the right care at the right time with the best outcomes.
Now, tough economic times and plateauing managed care savings are driving carriers to push for more and more in-network penetration. And the most effective way to increase penetration is to increase the size of the network.
But the truth is that the road to that big number is often obtained by robbing Peter to pay Paul – moving generalist dollars into specialty dollars. And specialty networks are subleasing big lists of any willing providers from generalist networks to swell their ranks. The challenge is how to grow your specialty network without losing the very thing that made specialty networks a good strategy – the right providers, the right management, the right outcome.
Specialty networks emerged in the workers’ compensation space because the needs of the injured worker were different from the needs of the group health insured. In workers’ compensation, time really is money. Return to functionality, return-to-work are the key objectives. Discounts at the unit level are nice, but they are not going to get the worker back onto the plant floor. So, as we move to optimum specialty network penetration, how do we keep from diluting the value?
There are a couple of things that we need to focus on.
The first thing we need to do is enroll the payer community in sharing information proactively and concurrently. Many companies are pursuing data analytics as part of their business operations, and this is a great first step. Retrospectively evaluating what happened is critical in evaluating effectiveness. But it is only as good as the information you have, and that information is decentralized at best in the managed care world.
Many in the managed care world never know if the patients they are managing ever go back to work, unless someone conducts a special study. How much more effective would treating clinicians be if they all knew what other services were being provided to their patients? How much more effective would we all be if we knew, in real time, that we had supported a sustained return-to-work? We need to work together to clinically manage our patients – to receive the best care and the best outcome.
The second thing we need to work on is effectively managing our growing networks. We need to continue to expect networks to identify and execute on the special needs of their respective specialties – using the best protocols, the best practices, the specialty guidelines that differentiated them from the generalist networks in the first place. The best networks are the ones that use these tools to train their growing network members to do the right things at the right time. Don’t trade patient outcomes for in-network penetration. Expect both.
That’s what I think.
About Shelley L. Boyce
Shelley Boyce is founder and chief executive officer of MedRisk, Inc. – the nation’s leading provider of physical medicine management services for the workers’ compensation industry.
Along with overseeing all aspects of MedRisk’s strategic growth and business development initiatives, Ms. Boyce serves on the board of directors of the Workers’ Compensation Research Institute (WCRI) and is a member and former chair of WCRI’s Core Funders Group.
Ms. Boyce is also involved in a number of initiatives that support business and educational development. She is on the University of Virginia (UVA) School of Nursing Advisory Board, is a member of UVA’s National Committee on University Resources (NCOUR) and 2011 Jefferson Scholars Selection Committee. Ms. Boyce is also on the board of the Children’s Scholarship Fund Philadelphia and is Chair of the Board of Advisors for the Wharton School of Business Entrepreneurial Program.
Ms. Boyce holds a Bachelor’s Degree in Nursing from the University of Virginia and a Master of Business Administration from the Wharton School of Business at the University of Pennsylvania.
About MedRisk
Founded in 1994 and based in King of Prussia, Pa., MedRisk, Inc. is one of the fastest growing companies in the Greater Philadelphia area, according to Deloitte’s “Technology Fast 50” and Philadelphia SmartCEO magazine’s “Future 50” award. The company provides physical medicine management services to the workers’ compensation industry. MedRisk has leveraged its technological expertise and evidence-based research to provide a growing list of products and services to its client community including data analytics, specialty network services and utilization review services. MedRisk’s programs deliver savings and operational efficiencies that are significantly greater than traditional programs. Customers include insurance carriers, self-insured employers, third-party administrators, state funds, general managed care companies, case management companies, claims adjusters and physical medicine providers. To make a referral or for more information, visit www.medrisknet.com or call 800-225-9675.