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CAMBRIDGE, Mass.-Managed care of workers compensation claimants will undergo a shakeup in the coming decade that will help return the workers comp system to its no-fault roots, an insurer executive predicts.
As more research is published in the next three to five years, "many of what we consider traditional axioms or dogma in workers compensation are going to be replaced," said Bruce G. Sund-quist, chief operating officer of the managed care division of the Chicago-based CNA Insurance Cos.
Mr. Sundquist made his predictions at the recent Workers Compensation Research Institute conference earlier this month in Cambridge, Mass.
Three of the workers comp axioms that he predicts will become outdated in 1997 and 1998 are the cost-effectiveness of discounted medical care,the use of primary care physicians as mere "gatekeepers" and oversight by case managers.
CNA reviewed 10,000 closed claims that in total involved eight types of case managers. Among the claims reviewed, the only effective case managers were nurses with at least five years' experience, and their primary contribution was facilitating an injured employee's return to work.
Another axiom that will be replaced is the perception that claimant fraud is "high" in the workers comp system. He estimates only 3% to 5% of all claims are fraudulent.
"We are going to find that a lot of this stuff never made any difference and in many respects, probably added costs or aggravated what was happening in workers compensation systems," said Mr. Sundquist, a former chemical engineer and loss prevention specialist.
While he did not mention any specific research beyond the CNA claims review, Mr. Sundquist predicted that by the end of next year, more data will be analyzed to measure outcomes. That data will foster "consumerism in health care" and enhance communication among providers, payers and employers, he said. CNA plans to publish parts of its research findings this spring.
The speed of change will increase from 1999 to 2002, Mr. Sundquist predicts.
There will be improved utilization of medical service based on outcomes data as well as performance-based compensation for "right-minded" providers who understand an employer's and insurer's concerns about prompt return to work.
Key stakeholders also will re-evaluate the concept of "compensability," he said. Fighting claims appears to be a waste of money, because although that consumes about 25% of payers' total claims-related costs, fewer than 2% of all claims are successfully denied, he said.
In addition, "there will be movement from the case management model to a new primary care model for health care, in which the primary care provider maintains control of the patient" but refers patients to specialists, as needed.
From 2002 to 2007, the goal will be to establish new standards for workers comp systems, Mr. Sundquist predicts.
That will include "a return to no-fault status (of workers comp) through elimination of adversarial processes," which research has demonstrated to be an inefficient use of resources.
New protocols also will bring significant changes in the treatment regimens in occupational medicine, he said. Employers and employees will become educated consumers of occupational medicine.
Also in the future, there will be easy access to treatment using a quality sports medicine approach by select primary care and specialty providers.
Injured workers will receive more medical care at their job sites, according to Mr. Sundquist. They also will use more computerized kiosk connections to nurses, adjusters and providers.
The future also will bring "collaborative relationships" through data sharing among employers, providers and payers, he said. To facilitate this, workers will get a "smart card" from their employers that providers can use to "charge" workers comp medical treatment. The card will allow treatment data to be collected at the same time.
Also, claims and case managers' roles will be "significantly" changed so their new goals will be communication and problem resolution.
Service organizations must adapt to these changes, because functions that do not add value will be eliminated from workers comp, he said. "Either you are in the game or you will be out of business," Mr. Sundquist said.