- Email: [email protected]
The odyssey of occupational injury management
---"
riven between the Scylla and Charybdis of medical and wage losses, employer interest in managing employee injuries
~'~
has traveled from the still waters of
"benign neglect" during the 1960s into uncharted care management territory in the 1990s. Emerging from a period in which employee injury costs were a minor bottom-line concern, workers' compensation has risen to crisis status. Employers ignore this risk only at their peril. TCM 48
May/June1998
Many of us remember that workers' comp originally was designed as a state-mandated, no-fault insurance benefit for employees injured on the job. That approach seemed to work well enough not to draw inordinate attention until the 1970s, when a combination of increased benefits and an apparent erosion of the work ethic drove losses significantly higher. This period also was marked by increased attention from the plaintiff bar.
The Care Management Concept In the i970s and 1980s, employers, through their insurers and claims administrators, tried to meet this challenge by tougher handling of claims and the first systematic application of case management and managed care tools: medical case management and vocational rehabilitation. This variation of the "bad cop, good cop," carrot and stick technique
worked briefly, but ultimately the costs continued to rise. The 1990s saw additional managed care tools applied to workers' comp, including preferred provider organizations, utilization review, and medical bill repricing. Drawn principally from the health care side, these early managed care efforts have resulted in a reported reduction in costs in the mid- to late 1990s. Although these programs produced some positive changes, a more important injury management concept has taken root and begun to flourish by producing significant savings in loss and expense dollars. Practitioners call this concept care management (CM) to distinguish it from earlier case management and managed care efforts. They generally recognize this program as fundamentally different from earlier costcontainment and managed care programs. Unlike those efforts, CM operates nonadversariaily in a fully integrated managed care environment. The goal: to manage the decisions being made by physicians and patients (injured employees) in a noncompetitive manner to ensure optimized medical care and minimum disability.
Controlled Medical Systems To effectively manage those decisions and the outcomes, CM practitioners realized that injured workers need to get immediately into a controlled medical system in which physicians perform in a manner consistent with desired outcomes. If the practitioners waited until they recognized a problem, the case probably was already out of control, care was not optimized, and disability could be protracted. The controlled medical system began by gaining the cooperation of care providers. We know hostility and friction lead to loss of control, poor quality care, and higher costs. To gain cooperation from the medical care providers, the care managers needed to establish a new relationship between CM and medical providers. They needed a partnership based on mutual respect of each other's legitimate interests and abilities. Care providers want referrals, fair and prompt payment of medical bills, and minimum harassment. In return, care managers desire quality care, immediate communication, and an early return-to-work protocol. Both professionals want the patients to remain
The k e y to effective CM rests w i t h the medical care providers" willingness to f o l l o w a set of simple guidelines that determine the e n v i r o n m e n t in which t h e y practice.
compliant and within the managed medical network whenever possible. The key to effective CM rests with the medical care providers' willingness to follow a set of simple guidelines that determine the environment in which they practice. These physician guidelines include such standard practices as seeing injured employees immediately, performing thorough examinations, discussing the findings with the patients, estimating physical capacities, sending the patients back to the place of employment with restrictions (if necessary), and reporting to the care managers on the same day as the injury. Other rules include sparing use of tests and studies, referrals limited to in-network specialists and facilities, and frequent discussions with care managers about cases. Securing the medical care providers' agreement to these guidelines before they are allowed to participate in the network creates a teamwork effort in which the basic rules are clearly understood and accepted before the game begins. In this way the hostility and friction that often accompany workers' comp medical care can be reduced.
Rolesin
ManagementTeam
The care managers' role in working with medical care providers involves "coaching"
the participants to perform at the highest level while following the guidelines. The more closely the providers follow the rules, the higher the level of trust and the better the outcomes will be. This approach also reduces the care managers' and claims handlers' workload. Other participants include injured employees and their employers. In many workers' comp jurisdictions, unlike managed care contracts, injured employees can opt out and choose care providers not in their health plan. This choice places them in an unmanaged care system and usually results in less than optimum care and higher rates of disability if they exercise that option. Although the patients' best interests obviously lie in getting well and returning to employment, that outcome may not always seem dear within a workers' comp system characterized by animosity. Care managers, who are responsible for optimizing care and minimizing disability, cannot afford patient hostility toward care providers, employers, or themselves. Care managers therefore must seek patient cooperation to ensure satisfaction, a relationship that can be accomplished by frequent telephone communication. Employers also play a key role in effective injury management. In a CM system, employers first must get the employees to a network physician at the time of injury. This necessity may involve employee education about injury and the appropriate response. Posting a physician list may help. Second, employers must report the injury by telephone to the care managers to allow them to initiate CM immediately, if necessary. The final employer responsibility in a CM system lies with accepting injured employees back to work when physicians approve the early return-to-work process. We may call this the "just say yes" response. Through temporary alternative duty, light duty, and similar programs, employers must facilitate return to work to minimize disability and maximize the impact of CM.
Operation and Outcome In the fully integrated model, CM incorporates an injury-reporting element, managed medical networks, telephonic May/June1998
TCM 49
CM nurses, integrated utilization review, and medical bill review and repricing. All injuries requiring medical care enter the system at the level of management necessary to optimize care and minimize disability. By ensuring the management of all injuries, employers create a higher level of accountability than typically has been experienced in workers' comp programs. Employers can demand that CM provide added value by accurately measuring the impact of that management on the total cost of risk (TCR). For employers, the TCR represents the total dollars spent or incurred for workrelated injuries, including medical losses, wage losses, allocated expenses, case management or managed care expenses, and litigation expenses. These Costs are the dollar loss off the company's bottom line. As such, every dollar stripped from the TCR represents a dollar returned to company profits. Because CM purports to control and manage all aspects of care and disability, employers reasonably may expect to hold care managers accountable for system performance.
are beyond the scope of this article, simply put, employers contrast the TCR for a group of injuries incurred in the year before CM involvement with the TCR for a similar group of claims managed by care managers. Through this comparison, employers can determine whether the care managers have reduced the TCR.
The combination of nonadversarial methods, proactive teamwork, and full accountability make CM a powerful tool for employers concerned with complete injury management.
CM indeed may represent the next major step in the evolution of case management and managed care. The combination of nonadversarial methods, proactive teamwork, and full accountability make CM a powerful tool for employers concerned with complete injury management. For case managers, it represents a growing job market. 0
Peter Nesbi# is vice president of Novaeon in Malvern, Pa., and formerly the owner and president of the Managed Care Alliance.
Employers may readily measure the performance of the care managers by under~ taking a controlled benchmark study. Although the details of this type of study
Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/91089
illmllnml
T he tough, joyous work of rebuilding lives
Multidisciplinary Oncology me Management Conference Sharing Concerns, Finding Solutions
"
" "1 was a major accomplishment er after he suffered a spinal cord Nc accident. own perseverance and treatment at Rehabilitation Center, Ricky put eces of his life back together. ehab is more than a job for us. It's the tough but joyous work of rebuilding lives.
The Inova Rehabilitation Center offers comprehensive inpatient and mtpatient programsfor stroke and for spinal cord, orthopedic, neurological, ardiac and workplace injuries. We serve qonal referralcenterproviding leadership effective, top quality health and !itation services.
B INOVA"REHABILITATION CENTER TCM 50
(800) 5 5 4 - R E H A B
May/June1998
July 31 - August 1, 1998 Philadelphia, PA Join nurses, provider and payor case managers, and social workers at a conference designed to understand the respective roles and responsibilities in caring for individuals with cancer.
Call for a brochure today! O~cology N~.~r"sing Society' {412} 921-7373 customer.service@o~soorg
riven between the Scylla and Charybdis of medical and wage losses, employer interest in managing employee injuries
~'~
has traveled from the still waters of
"benign neglect" during the 1960s into uncharted care management territory in the 1990s. Emerging from a period in which employee injury costs were a minor bottom-line concern, workers' compensation has risen to crisis status. Employers ignore this risk only at their peril. TCM 48
May/June1998
Many of us remember that workers' comp originally was designed as a state-mandated, no-fault insurance benefit for employees injured on the job. That approach seemed to work well enough not to draw inordinate attention until the 1970s, when a combination of increased benefits and an apparent erosion of the work ethic drove losses significantly higher. This period also was marked by increased attention from the plaintiff bar.
The Care Management Concept In the i970s and 1980s, employers, through their insurers and claims administrators, tried to meet this challenge by tougher handling of claims and the first systematic application of case management and managed care tools: medical case management and vocational rehabilitation. This variation of the "bad cop, good cop," carrot and stick technique
worked briefly, but ultimately the costs continued to rise. The 1990s saw additional managed care tools applied to workers' comp, including preferred provider organizations, utilization review, and medical bill repricing. Drawn principally from the health care side, these early managed care efforts have resulted in a reported reduction in costs in the mid- to late 1990s. Although these programs produced some positive changes, a more important injury management concept has taken root and begun to flourish by producing significant savings in loss and expense dollars. Practitioners call this concept care management (CM) to distinguish it from earlier case management and managed care efforts. They generally recognize this program as fundamentally different from earlier costcontainment and managed care programs. Unlike those efforts, CM operates nonadversariaily in a fully integrated managed care environment. The goal: to manage the decisions being made by physicians and patients (injured employees) in a noncompetitive manner to ensure optimized medical care and minimum disability.
Controlled Medical Systems To effectively manage those decisions and the outcomes, CM practitioners realized that injured workers need to get immediately into a controlled medical system in which physicians perform in a manner consistent with desired outcomes. If the practitioners waited until they recognized a problem, the case probably was already out of control, care was not optimized, and disability could be protracted. The controlled medical system began by gaining the cooperation of care providers. We know hostility and friction lead to loss of control, poor quality care, and higher costs. To gain cooperation from the medical care providers, the care managers needed to establish a new relationship between CM and medical providers. They needed a partnership based on mutual respect of each other's legitimate interests and abilities. Care providers want referrals, fair and prompt payment of medical bills, and minimum harassment. In return, care managers desire quality care, immediate communication, and an early return-to-work protocol. Both professionals want the patients to remain
The k e y to effective CM rests w i t h the medical care providers" willingness to f o l l o w a set of simple guidelines that determine the e n v i r o n m e n t in which t h e y practice.
compliant and within the managed medical network whenever possible. The key to effective CM rests with the medical care providers' willingness to follow a set of simple guidelines that determine the environment in which they practice. These physician guidelines include such standard practices as seeing injured employees immediately, performing thorough examinations, discussing the findings with the patients, estimating physical capacities, sending the patients back to the place of employment with restrictions (if necessary), and reporting to the care managers on the same day as the injury. Other rules include sparing use of tests and studies, referrals limited to in-network specialists and facilities, and frequent discussions with care managers about cases. Securing the medical care providers' agreement to these guidelines before they are allowed to participate in the network creates a teamwork effort in which the basic rules are clearly understood and accepted before the game begins. In this way the hostility and friction that often accompany workers' comp medical care can be reduced.
Rolesin
ManagementTeam
The care managers' role in working with medical care providers involves "coaching"
the participants to perform at the highest level while following the guidelines. The more closely the providers follow the rules, the higher the level of trust and the better the outcomes will be. This approach also reduces the care managers' and claims handlers' workload. Other participants include injured employees and their employers. In many workers' comp jurisdictions, unlike managed care contracts, injured employees can opt out and choose care providers not in their health plan. This choice places them in an unmanaged care system and usually results in less than optimum care and higher rates of disability if they exercise that option. Although the patients' best interests obviously lie in getting well and returning to employment, that outcome may not always seem dear within a workers' comp system characterized by animosity. Care managers, who are responsible for optimizing care and minimizing disability, cannot afford patient hostility toward care providers, employers, or themselves. Care managers therefore must seek patient cooperation to ensure satisfaction, a relationship that can be accomplished by frequent telephone communication. Employers also play a key role in effective injury management. In a CM system, employers first must get the employees to a network physician at the time of injury. This necessity may involve employee education about injury and the appropriate response. Posting a physician list may help. Second, employers must report the injury by telephone to the care managers to allow them to initiate CM immediately, if necessary. The final employer responsibility in a CM system lies with accepting injured employees back to work when physicians approve the early return-to-work process. We may call this the "just say yes" response. Through temporary alternative duty, light duty, and similar programs, employers must facilitate return to work to minimize disability and maximize the impact of CM.
Operation and Outcome In the fully integrated model, CM incorporates an injury-reporting element, managed medical networks, telephonic May/June1998
TCM 49
CM nurses, integrated utilization review, and medical bill review and repricing. All injuries requiring medical care enter the system at the level of management necessary to optimize care and minimize disability. By ensuring the management of all injuries, employers create a higher level of accountability than typically has been experienced in workers' comp programs. Employers can demand that CM provide added value by accurately measuring the impact of that management on the total cost of risk (TCR). For employers, the TCR represents the total dollars spent or incurred for workrelated injuries, including medical losses, wage losses, allocated expenses, case management or managed care expenses, and litigation expenses. These Costs are the dollar loss off the company's bottom line. As such, every dollar stripped from the TCR represents a dollar returned to company profits. Because CM purports to control and manage all aspects of care and disability, employers reasonably may expect to hold care managers accountable for system performance.
are beyond the scope of this article, simply put, employers contrast the TCR for a group of injuries incurred in the year before CM involvement with the TCR for a similar group of claims managed by care managers. Through this comparison, employers can determine whether the care managers have reduced the TCR.
The combination of nonadversarial methods, proactive teamwork, and full accountability make CM a powerful tool for employers concerned with complete injury management.
CM indeed may represent the next major step in the evolution of case management and managed care. The combination of nonadversarial methods, proactive teamwork, and full accountability make CM a powerful tool for employers concerned with complete injury management. For case managers, it represents a growing job market. 0
Peter Nesbi# is vice president of Novaeon in Malvern, Pa., and formerly the owner and president of the Managed Care Alliance.
Employers may readily measure the performance of the care managers by under~ taking a controlled benchmark study. Although the details of this type of study
Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/91089
illmllnml
T he tough, joyous work of rebuilding lives
Multidisciplinary Oncology me Management Conference Sharing Concerns, Finding Solutions
"
" "1 was a major accomplishment er after he suffered a spinal cord Nc accident. own perseverance and treatment at Rehabilitation Center, Ricky put eces of his life back together. ehab is more than a job for us. It's the tough but joyous work of rebuilding lives.
The Inova Rehabilitation Center offers comprehensive inpatient and mtpatient programsfor stroke and for spinal cord, orthopedic, neurological, ardiac and workplace injuries. We serve qonal referralcenterproviding leadership effective, top quality health and !itation services.
B INOVA"REHABILITATION CENTER TCM 50
(800) 5 5 4 - R E H A B
May/June1998
July 31 - August 1, 1998 Philadelphia, PA Join nurses, provider and payor case managers, and social workers at a conference designed to understand the respective roles and responsibilities in caring for individuals with cancer.
Call for a brochure today! O~cology N~.~r"sing Society' {412} 921-7373 customer.service@o~soorg