CAS
Health and Managed Care
Seminar
October 18, 1999
Charles M. Potok

Late 1980’s, Early 1990’s
•
Deterioration of workers compensation results
•
Increasing assigned risk plan market shares
•
Disastrous residual market loads

1995
Residual Market Loss (NCCI)
Calendar Year
1987
1988
1989
1990
1991
1992
1993
1994
South Carolina
(24,664,367)
(21,648,424)
(56,648,000)
(142,604,000)
14,936,707
34,356,092
23,835,917
21,890,795

Late 1980’s, Early 1990’s
•
Charges of rate suppression
• Accident Year Combined of 125
• Cost Shifting - Accident/Health Workers Comp
• Health Insurance a National Political Issue

Building Blocks of
Accident and Health Managed Care
Utilization
Review
Case
Management
Network
Management

•
Treatment Protocols
•
Nurse MD
•
Quality Medical Care at Lowest Cost
Case
Management

•
Appropriate Treatment
–
Concurrent Review
– Retrospective Review
–
Pre-Admission Certification
•
Medical Bill Review
•
Quality Medical Care At Lowest Cost
Utilization
Review

•
Size of Network
•
Discounts
Network
Management
•
Capitation
•
Keep Out of Office-Prevention
•
Disease Management
•
Immunization-Wellness

Indemnity-Fee For Service
PPO Discounts
HMO Tight

•
Size of Network
•
Discounts
Network
Management
•
Capitation
•
Keep Out of Office-Prevention
•
Disease Management
•
Immunization-Wellness

Building Blocks of
Workers Compensation
Managed Care
Case
Management
Utilization
Review
Network
Management

•
Treatment Protocols
– Different for Workers Compensation
•
Nurse MD, EE, ER
•
Quality Medical Care at Lowest Cost
–
Indemnity Cost early return to work
Case
Management

•
Appropriate Treatment
–
Concurrent Review
– Retrospective Review
–
Pre-Admission Certification
– Starts with First Report of Injury
•
Medical Bill Review
•
Quality Medical Care At Lowest Cost
Utilization
Review

•
Size of Network
•
Discounts
•
Capitation
•
Keep Out of Office-Prevention
– Drug Free Workplace
•
Disease Management
•
Immunization-Wellness = Loss Control
Network
Management

Indemnity-Fee For Service
PPO Discounts
HMO Tight =Occupational
Medicine

•
Size of Network
•
Discounts
•
Capitation
•
Keep Out of Office-Prevention
– Drug Free Workplace
•
Disease Management
•
Immunization-Wellness = Loss Control
Network
Management

Late 1990’s, 2000
Accident & Health Model
•
More Choice
–
Point of Service Options
–
Financial Disincentives
–
Less Primary Care Gatekeepers

Late 1990’s, 2000
Accident & Health Model
•
More Emphasis on Disease Management
•
Better Quality
–
Credentialing
–
Data
•
Less Capitation

Late 1990’s, 2000
Accident & Health Model
• Hospitals, MD’s/Reimbursement Rates
•
Workers Compensation 1998 Accident Year
Combined Ratio 122
•
Health Insurance A National Political Issue

Implications for Workers Compensation
•
More Difficult Case Management
•
More Difficult Utilization Review
•
More Importance on Network

Implications for Workers Compensation
•
24 Hour Coverage Disability Management
•
Internet
Agents/Brokers
Risk Managers
Health Providers
Claimants

Agents/Brokers
•
Rating
•
Issuance
•
Inquiry

Risk Managers
•
First Report of Injury
• EOB’s
•
Loss Control Surveys

Health Providers
•
Medical Bills
–
Hospitals
– MD’s
•
Provider Notes
– Utilization Review

Claimants
•
Content
–
Protocols
– Hospital Process
–
Questions
•
Medical Bill Information
•
Longer Term Case Management
•
7 X 24