Tuesday, December 4, 2012

Managing the Managers Who Manage Managed Care

That's not a typo.  That's the challenge of contemporary workers' compensation claims management.  Part of the cynicism and frustration in workers' comp today is driven by the backward incentives and cumbersome statutory constraints of the system.  But another important driver of frustration is the rather complicated managed care infrastructure we've created for ourselves (albeit unintentionally).  As an artifact of the regulatory process in most states, work comp is now rife with the time lines and technicalities of MPNs, UR, BR, PPOs, IMEs, WCJs, ALJs, ADLs, AOE/COE, DOIs, MMIs, and lots of other acronyms that make injured workers and payers alike crazy. 

Commercial and government health plans grapple with some of these constraints, but work comp is a universe all its own when it comes to navigating a claim from start to finish (if, in fact, getting to a proverbial "finish line" is possible).  Others far more experienced than I could probably walk through the detailed history of the development of all of this, but I've simplified it (mostly so I can understand it) to the following: The grand bargain of work comp (a.k.a. the exclusive remedy) is not static.  In fact, it is dynamic and its evolution is marked by legislative and regulatory measures designed to rebalance the bargain when economic realities demand it.

When a state engages in "work comp reform", what that state is essentially doing is "rebalancing the bargain" because the economics of the current system are, in some material way, out of whack.  This is incredibly difficult to do given the micro and macro economic forces at work both within and outside of the work comp system and the special interests that attempt to influence the outcome of the effort.  Sometimes, the bargain tips too far toward the payer/employer... sometimes it tips too far toward the injured worker. 

Regardless of which direction the scale tips, there is no panacea for claims management.  On the other hand, the level of cynicism in work comp is creating blind spots in the claims management process that lead to missed opportunities for positive outcomes.  I find too many assumptions about bad doctors, unmotivated claimants, greedy lawyers, and ineffectual judicial processes.  All of these exist, no doubt.  But opportunities for progress are missed when we assume that engagement and discussion won't move the needle.

Let's engage the participants in the system not in new ways, but rather the old fashioned way.  Let's take the processes, time lines, and technicalities of managed care and call those "Plan B" (they have a place and we need to use those tools when necessary).  And let's develop a "Plan A" that's focused on simply communicating with each other about the best path forward to achieve the clinical and financial outcomes we all want. 

We've forgotten how to talk with each other. 

On Twitter @PRIUM1

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