Dave North, CEO of Sedgwick CMS was one of the morning panelists. He began with a rather strong statement about workers comp, a statement that was also an indictment of the industry’s complete inability to manage medical – the fact that medical costs have increased 892% over the last 25 years.
North’s presentation reviewed the history of medical management, evolution of managed care, and changes in regulations that have occurred over the last 25 years and then made a few suggestion about hat the comp industry should focus on over the next ten years. North said that despite changes in society, business, and medical care, the types of injuries we see today are similar to the injuries we say 25 years ago.
He made two particularly trenchant observations. First, the unintended consequences of regulations. Specifically, North noted that when the CA pharmacy fee schedule was changed several years ago, it had the unintended consequence of increasing costs – specifically, the repackaging of drugs and dispensing by physicians and clinics at much higher rates due to a loophole in the regulations.
Second, North stated (this is close but probably not word for word) “Discounted networks have underperformed and will someday be regarded as first generation, primitive efforts to address costs.”
Agreed. The question is, when will the industry stop decrying the problem, studying potential solutions and implementing tiny pilots and launch ‘second generation’, outcomes based networks?
Nov
13
A strong change in culture is needed in the worker compensation arena, giving those with medical knowlege the ability to drive the case. Unlike health insurance, the W/C adjuster drives the claim. We need to develop a medical model, where the adjuster becomes a payer of claims and RN’s and MD’s are the drivers of the medical claim, modeling after health insurers with RN case managers and MD’s determining timely authorization of services and best practices. Cost of care is driven higher exponentially by non-medical persons denying, and determining medical treatment pathways.
In regards to the comment above, that IS what is happening in California and the cost still seem to be going up (or so they say). With the inception of a treatment schedule that is presumed correct along with Utilization review, the medical decision making (at least medical necessity piece) has been pulled off the adjusters plate. Not to mention the caps placed on physical medicine (chiro/PT/OT) with the 24 visit cap and the second opinion process for back surgeries that was put into place in 2004.
Working for a UR company in California I find it hard to believe that medical cost have been rising since this legislative reform in 2004, but I think the logical next step is to raise the fee schedule for docs in California. WC can be a treacherous working environment for physicians with all of the reporting, UR, disability, etc. CA is the third lowest paying fee schedule and that needs to change. With that I think we will see many more qualified physicians coming back to WC more willing to jump through some of the hoops that work comp requires.
Best practices need to be based on scientifically reliable data reviewed and applied the individual specifics of each injured-worker’s case by a data-driven medical practitioner. Hope so, Think so medicine as determined by RN’s and Physicians who practice without applying reliable data has contributed to iatrogenic illness and disability that is one of the unmentioned cost drivers in the workers compensation system. Given the medical-legal environment, Evidence-based Guidelines need to be set by the states for all the follow.