Who’s offering what?
The "Fifth Annual Milliman & Robertson Survey of HMOs: Integrated Disability Management and Managed Workers’ Compensation Strategies and Products" report found that of health maintenance organizations offering managed workers’ compensation and integrated disability management services:
• 75% provide clients with a toll-free number to expedite claims reporting from employees, employers, and providers.
• 25% offer clients early intervention to flag potential lost-time or high-cost claims.
• 75% offer clients telephonic and on-site case management services for lost-time claims.
• 50% offer clients utilization review services to monitor treatment protocols and medical service use.
• 63% offer clients rehabilitation services and return-to-work programs.
• 25% offer prescription drug programs.
• 13% offer durable medical equipment for disabled employees.
One reason few HMOs have turned a profit on their managed workers’ comp and integrated disability is that they offer selected services and fail to implement a full managed workers’ compensation model, says report co-author William L. Granahan, CIC, LIA, CMC, a senior consultant and practice manager with Milliman & Robertson’s Boston office. "Done correctly, this model does work. However, if you don’t put the model with all of its components together carefully, then it doesn’t work."
He says that model includes:
Loss control and safety programs. "This includes wellness programs and health screening. It doesn’t sound much like workers’ compensation, but it’s an excellent first step in creating employer and employee awareness about health issues," he explains. "It goes far beyond the usual safety program, like making sure there are no banana peels on the floor, and includes things like cholesterol screening." First report of injury. "Many HMOs have trouble with this piece. There has to be a state-of-the-art information system for reporting injuries in the first 24 to 48 hours," he says. "The problem is these systems are expensive. HMOs can lease systems or partner with someone who has one. It should be able to manage all information associated with the claim." Medical management. HMOs should set up preferred provider organizations (PPOs) of occupationally trained physicians, Granahan notes. "We’ve consulted with hospital systems who put PPOs together that included gynecologists and gastroenterologists. This network has to be one composed of physicians that know musculoskeletal injuries, which make up the majority of workers’ comp claims." Case management. HMOs must have nurse case managers who begin to manage workers’ comp claims the minute they become lost-time claims, he says. "A case manager must be assigned to every lost-time case, even if the claim is only going to be managed telephonically. That case manager is the liaison between the employee, employer, and provider, holding everything together." Return-to-work program. This should be coordinated by the case manager, he says. Outcomes measures. "Many HMOs fail to deliver on the measurement piece. When you offer employers a service, those employers want to know how much you will decrease their overall claims."
Gathering outcomes data
Granahan admits that many HMOs lack adequate claims data to do an accurate outcomes study. "We’re working on a benchmarking study right now, and we’re hoping to prove that medical and case management reduced overall claims costs," he says. Granahan and his colleagues are comparing the total cost of workers’ comp claims in a retail food company with a managed workers’ comp model to a retail food company without a managed workers’ comp model. The two have the same parent company and similar demographics.
"Most of the data captured on workers’ comp claims over the years have been financial data. We can look at the cost of the claim, but we’re not sure we can look at what type of treatment was provided," he notes. "We do hope we can compare back injury claims in one company to back injury claims in the other and find that the claims in the company with the managed workers’ compensation model were two months shorter and somewhat less expensive."
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