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Driving Value in Workers’ Compensation with Evidence-Based Medicine

States that have adopted and enforced Official Disability Guidelines (ODG) are seeing proof of their efficacy for eliminating costs while maintaining quality of care.
By: | April 5, 2018 • 6 min read

Among developed nations, the U.S. falls near the bottom of the rankings in terms of health care efficiency.

“We spend more money, but don’t necessarily see better results,” said Kim Radcliffe, Senior Vice President, Clinical Operations at One Call. “Excessive care and unnecessary diagnostic testing drives up utilization costs without producing real benefit to patients.”

Evidence-based medicine can help flag unnecessary care, delivering better clinical outcomes at a lower cost. For workers’ compensation payers, achieving efficiency is vital to keeping claims costs in check while getting injured workers back to health as quickly as possible.

States that have adopted and enforced Official Disability Guidelines (ODG) — one of the most well-recognized evidence-based guidelines in the industry — offer real world validation that this approach eliminates costs while maintaining quality of care.

Since Texas adopted ODG in 2007, they have reduced lost-time by 34 percent, dropped medical costs by 30 percent, and subsequently decreased workers’ comp insurance premiums by 51 percent.

The Ohio Bureau of Workers’ Compensation also reduced claim duration and medical costs by more than 60 percent within one year of implementing ODG in 2004. In addition, they decreased treatment delays for the top 30 workers’ comp conditions by 77 percent.

Several other states saw notable improvements, including North Dakota, Kansas, Oklahoma and California, since adopting ODG.

“States that do not enforce evidence-based guidelines via a formal utilization review process often have significantly higher utilization and per-unit costs — and often don’t achieve the same level of outcomes as states that utilize a formal program,” Radcliffe said. “There is a lack of consistency in how evidence-based guidelines are enforced among those states with no formal UR rules.”

Employers in states that do not require utilization review or adherence to evidence-based guidelines can still apply the approach and reap its benefits. But it requires working with the right care management partner.

Case Study: Physical Therapy Interventions

Kim Radcliffe, Senior Vice President, Clinical Operations, One Call

Vendors with expertise in both clinical care and workers’ compensation can drive value for their clients by getting involved directly with patient care. One Call leverages its expertise in evidence-based medicine to work at a peer level with clinicians. Evidence-based guidelines provide a roadmap for that process, setting triggers and benchmarks that help steer care down the most efficient path. Doing so not only restores workers back to health faster, but also keeps costs in line for employers.

One injured worker’s recovery journey offers an example.

After surgery for a total knee replacement, the patient received a referral for a high-end in-patient rehabilitation center. That set off one red flag.

“A referral for high-end rehab is a trigger under the guidelines. Such facilities can be very expensive, and aren’t always necessary when a skilled nursing facility is available and can achieve the same results, for a much lower cost,” Radcliffe said.

One Call’s team intervened and got the patient into a skilled nursing facility instead, saving the payer “tens of thousands of dollars.” They worked directly with nursing staff to establish a one-week timeline and monitored his progress throughout. At the end of the week, all agreed he was ready for discharge.

Then came the second red flag.

The treating physician referred the patient for home health physical therapy visits, but guidelines establish that outpatient therapy is preferable whenever possible.

“We moved him straight to outpatient therapy, which not only saved costs, but also shortened his care timeline,” Radcliffe said.

At the end of the prescribed 16 PT visits, the patient received a second referral for more care.

“A second prescription for PT always triggers a review to determine whether or why the first prescription was not enough,” Radcliffe said. After connecting with the treating therapist and reviewing the patient’s progress, they reached a consensus that more care was not warranted.

“Our guidelines dictate treatment only when it is medically necessary and beneficial,” Radcliffe said. “In this case, it was clearly not necessary, and it would not bring the patient any added benefit.”

Ultimately, the patient was able to return to work two to three weeks sooner due to the interventions and redirection of his care, and the payer saved a total of $68,000.

Gaining Provider Trust by Focusing on Patient Needs

Ultimately, enforcing evidence-based guidelines in jurisdictions that have not formally adopted them is impossible without provider buy-in. Establishing open communication channels earns that buy-in and enables faster claims closure without compromising the quality of care. Communication with clinical care providers is critical to applying evidence-based medicine.

Without oversight, some doctors have a tendency to prolong treatment. From a purely clinical perspective the thought is that more care and attention can’t hurt.

That desire to do what is best for the patient is exactly where providers, payers, claims managers, and of course, patients, can find common ground. The key is to establish a collaborative relationship that considers input from the appropriate parties.

“The best way to implement evidence-based medicine in workers’ comp is through direct peer-to-peer calls, rather than formal utilization review. If we see a red flag, we never recommend a change in the care plan until we have attempted to reach the treating provider,” Radcliffe said.

“That communication is generally well-received, and it increases the provider’s sense of accountability.”

At the heart of evidence-based medicine is a focus on the needs of the patient.

“Doing the right thing for the patient benefits everyone in the long term,” Radcliffe said. “Our culture at One Call is to take a patient-centric approach and make sure the care plan is one that will get them back to a normal life faster. This approach benefits their employer as well.”

An Expert Partner in Clinical Care

An expansive network of medical providers enables One Call to deliver services on a broad scale across the full spectrum of care. One Call determines a quality provider based on their outcomes and utilization record and directs care to the highest quality providers when possible. A commitment to building relationships and earning the trust of providers also facilitates the review process and making adjustments to treatment plans.

With more than 200 on-staff licensed physical therapists, occupational therapists, certified hand therapists, chiropractors, nurses and dental professionals, One Call’s clinical specialists can engage directly with providers and communicate about clinical issues clearly and effectively.

“A high-level of clinical coordination and in-house clinical expertise is what drives our process,” Radcliffe said. “We focus on what is appropriate and when for a specific injury. Through our Gold Standard Review process, we can identify when an approach isn’t working and use clinical pathways to find a better approach.”

“We can fill in the gap for states that have not formally adopted evidence-based guidelines or utilization review procedures. In states that have, we help them execute it.”

Ultimately, this level of clinical oversight helps to create a consistent level of care for workers’ compensation patients — no matter what jurisdiction they live in.

To learn more about One Call’s services for the workers’ comp industry, visit http://onecallcm.com/.



This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with One Call. The editorial staff of Risk & Insurance had no role in its preparation.

One Call is the nation’s leading provider of specialized solutions to the workers’ compensation industry. One Call’s solutions enable faster, more efficient and more cost-effective claims resolution with a focus on injured workers’ needs across the continuum of care.


Kiss Your Annual Renewal Goodbye; On-Demand Insurance Challenges the Traditional Policy

Gig workers' unique insurance needs drive delivery of on-demand coverage.
By: | September 14, 2018 • 6 min read

The gig economy is growing. Nearly six million Americans, or 3.8 percent of the U.S. workforce, now have “contingent” work arrangements, with a further 10.6 million in categories such as independent contractors, on-call workers or temporary help agency staff and for-contract firms, often with well-known names such as Uber, Lyft and Airbnb.

Scott Walchek, founding chairman and CEO, Trōv

The number of Americans owning a drone is also increasing — one recent survey suggested as much as one in 12 of the population — sparking vigorous debate on how regulation should apply to where and when the devices operate.

Add to this other 21st century societal changes, such as consumers’ appetite for other electronic gadgets and the advent of autonomous vehicles. It’s clear that the cover offered by the annually renewable traditional insurance policy is often not fit for purpose. Helped by the sophistication of insurance technology, the response has been an expanding range of ‘on-demand’ covers.

The term ‘on-demand’ is open to various interpretations. For Scott Walchek, founding chairman and CEO of pioneering on-demand insurance platform Trōv, it’s about “giving people agency over the items they own and enabling them to turn on insurance cover whenever they want for whatever they want — often for just a single item.”


“On-demand represents a whole new behavior and attitude towards insurance, which for years has very much been a case of ‘get it and forget it,’ ” said Walchek.

Trōv’s mobile app enables users to insure just a single item, such as a laptop, whenever they wish and to also select the period of cover required. When ready to buy insurance, they then snap a picture of the sales receipt or product code of the item they want covered.

Welcoming Trōv: A New On-Demand Arrival

While Walchek, who set up Trōv in 2012, stressed it’s a technology company and not an insurance company, it has attracted industry giants such as AXA and Munich Re as partners. Trōv began the U.S. roll-out of its on-demand personal property products this summer by launching in Arizona, having already established itself in Australia and the United Kingdom.

“Australia and the UK were great testing grounds, thanks to their single regulatory authorities,” said Walchek. “Trōv is already approved in 45 states, and we expect to complete the process in all by November.

“On-demand products have a particular appeal to millennials who love the idea of having control via their smart devices and have embraced the concept of an unbundling of experiences: 75 percent of our users are in the 18 to 35 age group.” – Scott Walchek, founding chairman and CEO, Trōv

“On-demand products have a particular appeal to millennials who love the idea of having control via their smart devices and have embraced the concept of an unbundling of experiences: 75 percent of our users are in the 18 to 35 age group,” he added.

“But a mass of tectonic societal shifts is also impacting older generations — on-demand cover fits the new ways in which they work, particularly the ‘untethered’ who aren’t always in the same workplace or using the same device. So we see on-demand going into societal lifestyle changes.”

Wooing Baby Boomers

In addition to its backing for Trōv, across the Atlantic, AXA has partnered with Insurtech start-up By Miles, launching a pay-as-you-go car insurance policy in the UK. The product is promoted as low-cost car insurance for drivers who travel no more than 140 miles per week, or 7,000 miles annually.

“Due to the growing need for these products, companies such as Marmalade — cover for learner drivers — and Cuvva — cover for part-time drivers — have also increased in popularity, and we expect to see more enter the market in the near future,” said AXA UK’s head of telematics, Katy Simpson.

Simpson confirmed that the new products’ initial appeal is to younger motorists, who are more regular users of new technology, while older drivers are warier about sharing too much personal information. However, she expects this to change as on-demand products become more prevalent.

“Looking at mileage-based insurance, such as By Miles specifically, it’s actually older generations who are most likely to save money, as the use of their vehicles tends to decline. Our job is therefore to not only create more customer-centric products but also highlight their benefits to everyone.”

Another Insurtech ready to partner with long-established names is New York-based Slice Labs, which in the UK is working with Legal & General to enter the homeshare insurance market, recently announcing that XL Catlin will use its insurance cloud services platform to create the world’s first on-demand cyber insurance solution.

“For our cyber product, we were looking for a partner on the fintech side, which dovetailed perfectly with what Slice was trying to do,” said John Coletti, head of XL Catlin’s cyber insurance team.

“The premise of selling cyber insurance to small businesses needs a platform such as that provided by Slice — we can get to customers in a discrete, seamless manner, and the partnership offers potential to open up other products.”

Slice Labs’ CEO Tim Attia added: “You can roll up on-demand cover in many different areas, ranging from contract workers to vacation rentals.

“The next leap forward will be provided by the new economy, which will create a range of new risks for on-demand insurance to respond to. McKinsey forecasts that by 2025, ecosystems will account for 30 percent of global premium revenue.


“When you’re a start-up, you can innovate and question long-held assumptions, but you don’t have the scale that an insurer can provide,” said Attia. “Our platform works well in getting new products out to the market and is scalable.”

Slice Labs is now reviewing the emerging markets, which aren’t hampered by “old, outdated infrastructures,” and plans to test the water via a hackathon in southeast Asia.

Collaboration Vs Competition

Insurtech-insurer collaborations suggest that the industry noted the banking sector’s experience, which names the tech disruptors before deciding partnerships, made greater sense commercially.

“It’s an interesting correlation,” said Slice’s managing director for marketing, Emily Kosick.

“I believe the trend worth calling out is that the window for insurers to innovate is much shorter, thanks to the banking sector’s efforts to offer omni-channel banking, incorporating mobile devices and, more recently, intelligent assistants like Alexa for personal banking.

“Banks have bought into the value of these technology partnerships but had the benefit of consumer expectations changing slowly with them. This compares to insurers who are in an ever-increasing on-demand world where the risk is high for laggards to be left behind.”

As with fintechs in banking, Insurtechs initially focused on the retail segment, with 75 percent of business in personal lines and the remainder in the commercial segment.

“Banks have bought into the value of these technology partnerships but had the benefit of consumer expectations changing slowly with them. This compares to insurers who are in an ever-increasing on-demand world where the risk is high for laggards to be left behind.” — Emily Kosick, managing director, marketing, Slice

Those proportions may be set to change, with innovations such as digital commercial insurance brokerage Embroker’s recent launch of the first digital D&O liability insurance policy, designed for venture capital-backed tech start-ups and reinsured by Munich Re.

Embroker said coverage that formerly took weeks to obtain is now available instantly.

“We focus on three main issues in developing new digital business — what is the customer’s pain point, what is the expense ratio and does it lend itself to algorithmic underwriting?” said CEO Matt Miller. “Workers’ compensation is another obvious class of insurance that can benefit from this approach.”

Jason Griswold, co-founder and chief operating officer of Insurtech REIN, highlighted further opportunities: “I’d add a third category to personal and business lines and that’s business-to-business-to-consumer. It’s there we see the biggest opportunities for partnering with major ecosystems generating large numbers of insureds and also big volumes of data.”

For now, insurers are accommodating Insurtech disruption. Will that change?


“Insurtechs have focused on products that regulators can understand easily and for which there is clear existing legislation, with consumer protection and insurer solvency the two issues of paramount importance,” noted Shawn Hanson, litigation partner at law firm Akin Gump.

“In time, we could see the disruptors partner with reinsurers rather than primary carriers. Another possibility is the likes of Amazon, Alphabet, Facebook and Apple, with their massive balance sheets, deciding to link up with a reinsurer,” he said.

“You can imagine one of them finding a good Insurtech and buying it, much as Amazon’s purchase of Whole Foods gave it entry into the retail sector.” &

Graham Buck is a UK-based writer and has contributed to Risk & Insurance® since 1998. He can be reached at riskletters.com.