By: Melissa McGarry, Director, Product Management and Implementation, Coventry Workers’ Comp Services
Last week we spoke about the benefits of using nurse triage to provide the employee with a roadmap at the point of injury. Providing access to a nurse at a critical point in the process can help employers demonstrate that they want their injured employees to receive timely and appropriate care. This support at the point of injury can help direct them toward a desirable outcome while strengthening the trust between the employee and their employer. While trust between the employee and their employer is critical, trust between the employer and their partners is another topic worthy of discussion.
Broad-based vs. Outcomes-based networks
Traditionally in workers’ comp, broad-based networks have been the standard. The vast majority of employers (either directly or through their TPA or carrier partner) have access to a broad-based PPO network including facilities, professional providers, occupational health clinics and ancillary providers. These networks aim to provide broad access and discounts below fee schedule, with the selection process being a function primarily supported by a network contracting team.
The landscape is changing in search of better outcomes. Many employers are finding that bigger and cheaper is not always better. Interest in networks focused on delivering better outcomes is becoming more prevalent. But, employers and payors must understand the critical differences between these networks in order to make sound business decisions.
Where the differences lie
At the surface, many may think that networks (broad-based or outcomes-based) are built on the same main tenants: providers, specific specialties, discounts and access. While this may hold true in building a broad-based network, when developing a true outcomes-based program, many other factors come into play. An outcomes-based network requires a partnership where expectations are different than what is common in traditional network discussions. When implementing an outcomes-based program, an employer’s focus shifts away from unit-cost reductions in price to life-of-claim improved outcomes. This shift in mentality, from individual transactions to entire claim outcomes, requires an understanding and a dialogue between the employer and partner around what goes into, and can be expected from, implementing an outcomes-based program.
All Kinds of Talent
Population health management, chronic conditions, comorbidities, episodic treatment and others that are often reserved for discussions in a group health landscape have become part of the common work comp vernacular. The increasing complexity of effective work comp injury management requires an expanded group of experts, in addition to the standard network contracting resources, with specialists who ensure that multiple aspects of the claim are incorporated into the program. A dedicated team of work comp analysts, statisticians, medical economists, clinicians (including both physicians and pharmacists), and regulatory experts integrate workers’ comp specific nuances along with concepts not generally regarded in the workers’ comp space. All of this is critical to the design, development and implementation of an outcomes-based program.
Infrastructure & Methodology
The foundation of any outcomes-based network is the provider selection methodology. Three crucial data elements that should be considered when developing an effective outcomes-based network include: 1) an extensive provider population, 2) a statistically reliable threshold of workers’ comp claims for each provider, and 3) a robust data set that includes medical, clinical, and pharmacy transactions, quality review information and indemnity data.
When choosing a partner one must consider whether they have the breadth of provider data with the depth of claim volume required to effectively measure physicians for inclusion in an outcomes-based network. Does their methodology effectively measure claim factors that are important to you? Do you mutually agree to the definition of a favorable claim outcome? Having access to and the ability to utilize this large data cache is a necessary component when developing an outcomes-based network. A partner must have quick and easy access to their own data as well as the ability to incorporate data from outside sources easily and effectively. Finally you need to trust that your network partner has and will continue to invest in technology solutions.
A Never Ending Process
Practice patterns change, new trends become apparent, and more data is always becoming available. The partner who is committed to working with you must engage in ongoing enhancements or refinement to their measures and methodology. Building and supporting an outcomes-based network is a never ending process.
In addition, ensuring that the network delivers the best outcomes possible requires measuring the program’s performance. It takes time for claims to mature and the employer must be willing to trust that, if their employees are accessing outcomes-based providers, they will see positive outcomes. Measuring outcomes too soon will likely result in a constantly moving target. It is essential for claims to mature and close before an employer will be able to truly validate the full impact of their program.
Worth the wait
As long as you have a solid understanding of the performance measurement process, waiting for the results should be well worth it – including lower medical and indemnity costs, treatment and claim durations and reduced disability rates. Bear in mind that not all utilization metrics will necessarily go down, as it can be expected that outcomes-based network providers may manage the claims more aggressively at the front end, but overall, the claim is more likely to resolve favorably.
About Melissa McGarry
Melissa McGarry is director of product implementation for Coventry Workers’ Comp Services. Melissa has more than 25 years of comprehensive industry experience as a provider of healthcare services as well as operations, program development and product management. She holds a Master’s degree in Counselor Education and continues to maintain her licensure as a professional counselor (LPC) in the state of Texas.
About Coventry Workers’ Comp Services
Coventry offers workers’ compensation cost and care management solutions for employers, insurance carriers and third-party administrators. With roots in both clinical and network services, Coventry leverages more than 30 years of industry experience, knowledge and data analytics. The company offers an integrated suite of solutions, powered by technology to enhance network development, clinical integration and operational efficiencies at the client desktop, with a focus on total claims cost.
Coventry WCS is a WorkCompWire Ad Partner.
This is not a paid placement.