Paradigm is evolving rapidly – and none too soon.  A data-driven firm known for taking risk on catastrophic claims, Paradigm has strengthened its behavioral health offerings, and added case management, specialty and network services, all intended to make the company one of the major players in workers’ comp medical management.

I’ve tracked Paradigm for more than two decades, watching the company evolve from one stubbornly stuck in a business model that precluded growth to a diversified provider with a broad array of service offerings. In conversations with Paradigm execs several years ago, I wondered why the company wasn’t solving client’s problems, instead focusing narrowly on a highly-selected group of catastrophic claims.

While this made sense from Paradigm’s perspective – it wanted to focus its expertise on a very select type of claim – there was a big problem with this approach.

Namely, Paradigm wasn’t thinking about this from its customers’ perspective. Customers gave Paradigm a big list of claims which Paradigm winnowed down; typically relatively few were actually “accepted” by Paradigm.  The customer had a bunch of problematic claims, but Paradigm wasn’t interested in solving the customer’s problem, it just wanted to cherry-pick claims.

That’s changed.

I caught up with Paradigm Catastrophic Care Management CEO Kevin Turner a couple weeks back to get updated on the company.  Here are my takeaways (Paradigm Outcomes is one of three divisions).

Paradigm is moving down the severity scale, applying the expertise and experience it has gained handling big cat claims to less-complex claims. In so doing, the company is embedding itself deeper and broader into its clients – and growing revenues.

Turner spoke at length about Paradigm’s core asset – the wealth of data the company has amassed over the last three decades – and how that informs the company’s approach to managing cat – and “near-cat” claims (my words, not his).

We also dove into bio-psycho-social issues, including the patient’s “whole family situation” (again, my words) and the critical importance of the family in the recovery process. Marital status and satisfaction, financial stability, relations with children are all key considerations that can impact the recovery process. That just makes sense; if a patient has a difficult home life and kids with issues, it is going to be that much harder to get better.

The company recently launched a home-grown IT application – EDDG – designed to help care managers use the company’s historical data and lessons learned along with bio-psycho-social indicators to manage claims.

Of note, Paradigm is no longer the only company in the cat claims risk taking business. Carisk Partners has gained traction with its Pathways 2 Recovery program, leveraging the company’s deep expertise in behavioral healthcare and workers’ comp experience. Carisk takes risk both on individual claims and for entire portfolios of claims. (disclosure; I work with Carisk)

Where you sit determines what you see; this adage applies to the work comp industry.

For payers, employers, and taxpayers, all is great.  Rates are low and dropping, insurers are enjoying record profits, frequency continues to trend down, medical costs are flat.

The very things that make payers happy have the opposite effect on service companies. For most entities involved in medical management, pharmacy management, investigations, technology, claims systems, Medicare Set-Asides, and litigation defense the drop in frequency and flat medical costs are unwelcome news.

The trickle-down effects of this dichotomy are many and varied.

• There is little-to-no pressure to revise state workers’ comp laws and regulations.
• Insurers are looking to increase their work comp business as it is a big profit maker.
• Claims execs are trying to balance hiring and training new claims adjusters while planning for long-term decreases in claim volume.
• Execs are also extremely careful about investments in new IT projects, as the long-term payoff is also challenged by structural declines in claims.
• The consolidation of service companies continues unabated; IMEs, bill review, specialty networks, PBMs, investigations, case management, cat case management services are all subject to this consolidation.
• Selling services to payers is getting increasingly difficult.  Payers aren’t seeking solutions to major problems; they are reluctant to switch vendors unless there are serious service problems.
• Work comp conferences are struggling due to the structural issues above; the lack of big problems driving intense interest in solutions and an arguably-over-saturated conference market is hurting attendance.

So, what to do?

If you are a service entity, you’ve got to differentiate. You must also deeply understand what individual buyers want, why they want that, what their decision process is, and who else is involved.

Unfortunately many service entities are cutting marketing budgets and pressuring sales staff to deliver deals. While sales targets are important indeed, they must also be realistic.

If you are a payer, I’d echo the last sentence above. Many payers are planning to write more workers’ comp, an obvious impossibility.