Medical management top concern for comp sector: Study

Medical management ranked as a top concern among workers comp insiders in focus groups aimed at improving claims outcomes across the board, according to the results of a survey released Tuesday.

For its annual benchmarking study, Chicago-based Rising Medical Solutions used data from six year’s worth of surveys, totaling 1,800 respondents, and conducted focus groups using those topics with the input from more than 40 industry professionals weighing in on ways to improve the state of the workers comp system, according to the study.

The 2018 focus group participants included a national cross section of self-insured employers, national and regional insurers, state funds, third-party administrators, brokerages and industry consultancies. Participants were segmented into two focus groups — claims leaders and clinicians or managed care leaders — to allow researchers to identify commonalities in the groups’ medical management priorities and approaches, and expose gaps that may need to be bridged to improve outcomes, according to a statement by Rising, a national firm that provides medical cost containment and medical care management services to the workers compensation.

Researchers then narrowed the top issues participants ranked as critical in managing comp systems and claims nationwide. In addition to medical management, the study lists other topics that warrant attention to assist with better claims outcomes, including:

• Medical severity due to macroeconomic and social factors, such as the aging workforce, the opioid epidemic, mental health, obesity, and diabetes, having a significant impact on claims;
• The deployment of nurse case management, return-to-work services, and nurse/claims triage as the top three medical management programs most critical to claim outcomes;
• Quality and provider outcomes;
• And the integration of advocacy-based claims models, or what is known as employee-centric customer service claims model that focuses on employee engagement during the injury recovery process, removes adversarial obstacles, makes access to benefits simple, builds trust, and holds the organization accountable to metrics that go beyond cost containment.

“Five years of data shows the claims community ideologically agrees on what’s most critical to successful claims resolution,” Rachel Fikes, vice president and study program director at Rising Medical Solutions, said in a statement. “However, the data does not show that medical performance management is a critical industry priority in practice… It’s important that we don’t become desensitized to the persistent medical challenges that have become the new norm. We must continue to pursue and deploy viable strategies on the frontlines.”