By James A. Schlueter, President, Effective Health Systems
It is often easy to forget that all claims begin with an employee that becomes injured or ill as the result of a workplace accident and requires medical treatment. There was a time not so long ago, when the medical issues were a relatively minor part of the claim, medical issues comprised less than 40% of the workers comp dollar. Managing the claim at that time was a process that focused on effective disability administration. That was a time when the claims’ adjuster was able to control virtually all elements of the claim. Those times are long past however.
It is remarkable that claim frequency has declined by more than fifty-five percent, and yet, medical costs have tripled over the past twenty years. Medical costs now represent sixty-percent of the workers compensation dollar; and the dollars have grown significantly. Not surprisingly, the business of medicine in workers’ compensation has become a highly sophisticated and complex industry. In response, the payer industry has had to develop equally sophisticated strategies and tactics to contain and control the constant and rapid escalation of medical costs. The result has been the growth of a contentious and tangled environment that is complicated by confusing regulations and convoluted business rules.
Systems that previously supported an effective and efficient process no longer support the work requirements of today’s claims management process. Rather than evolving the technologies in response to the complexities of the environment, the industry responded by scaffolding applications onto the old legacy technologies. These concoctions of technologies offer efficient applications, but they have a limited scope and cannot communicate with one another. Subsequently, the systems have become bloated with inefficient and ineffective workflows. The overall claims management process has suffered and it can no longer offer a satisfactory client experience.
Access to detailed information necessary to make informed management decisions tend to be locked within silo technologies. These silos are owned by outside parties that have self-interest to shape the information prior to releasing it. Subsequently, it is almost impossible for managers to get a clear picture of what can be done to reduce operating expenses or identify and manage fraud and misuse. Finally, assuring the company is in compliance with regulatory demands is an administrative nightmare. Faced with years of investments in resources that are now ineffective, creating the needed change appears an impossible challenge.
Very few of the stakeholders in the workers’ compensation process today are satisfied with the state of the industry. The industry seems to be held hostage by functional experts that limit attention to areas that support their particular frame of focus, while ignoring the larger picture. The noise they create serves to distract and redirect the attention of buyers from the key issues at hand. These issues are:
- How do we free the claims professionals from the multitude of routine decisions and tasks, and give them the information they need so they can do what only they can do – recognize patterns, determine a course of action, evaluate the effectiveness of those decisions and adjust to the situation?
- How do we get that sick or injured worker the needed care, at a reasonable cost and in a timely fashion, so they can return to productive work with a minimal disruption of their life?
- How do we ensure that the vendors that deliver quality service and products are rewarded with fair compensation that is paid in a timely fashion, while those that are sub-par can be identified and dealt with effectively?
- How do we do this without recreating the entire system and requiring massive investments in IT and retraining during a period of incredibly tight budgets?
The above issues guided the development of the BaseLine Interactive Technology.
About James A. Schlueter
James A. Schlueter is the Founder and President of Effective Health Systems. He has over 30 years working within the healthcare industry, most of which has been engaged in the workers’ compensation area. He has developed many innovative programs and strategies designed to bring greater management efficiencies and effectiveness to the industry. His primary focus today is on product and business development.
About Effective Health Systems, Inc.
At Effective Health Systems, we do things that help professionals do their jobs better. Our primary offering is a technology we call BaseLine. It is aimed at improving the process of claims management in workers’ compensation.
BaseLine is a Platform as a Service (PaaS) that delivers interoperability between multiple technologies, databases and human workflows. As a web-based service, BaseLine leverages and enhances the value of a client’s existing investments in technologies, people and vendors.
BaseLine communicates with client’s existing systems through a series of interdependent managers that incorporate On-Line Transaction Programing (OLTP) and On-Line Analytics Programing (OLAP) designed to automate, manage and audit complex processes and systems.