2014 NWCDC

Ask and You Receive

Communication and transparency rule when it comes to managed care programs.
By: | November 21, 2014

When consultant Barry Bloom of The bdb Group looked at his co-presenters on a panel on modeling managed care, he knew two things for sure. One, they operate in perhaps the toughest state in the country, and two, they may be among the best in the business.

Joining Bloom on the panel, presented at the 2014 National Workers’ Compensation and Disability Management Conference & Expo in Las Vegas, were John Smolk, principal manager, workers’ compensation, for Southern California Edison and John Riggs, manager of workers’ compensation for Disneyland.

In their workers’ compensation risk management, both Disney and Southern California Edison are large self-insured programs that care for thousands of employees.

Smolk and Riggs also share other characteristics. Both firmly believe in the importance of transparency in managing every aspect of their programs, from pharmacy benefits to medical providers and from claims adjustment to utilization review.

Whether a program is big or small, bundled or unbundled, transparency rules, the two said.

“I am big on transparency,” Riggs said.

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“Transparency creates awareness,” Smolk seconded. “You need to make sure transparency is paramount.”

It’s an emerging theme in workers’ compensation risk management that you have to know who you are, what your philosophy is, and then be forceful and clear in communicating that to your employees and your risk management vendors and partners.

“It’s important that your program is well understood,” Riggs said.

In the complex world of medical management, that translates to being outspoken about what you expect from your service partners.

“If you don’t ask, you don’t get,” Riggs said.

Workers’ compensation risk managers also struggle with the concept of return on investment and its balance with quality of care.

Riggs, Smolk and Bloom cautioned that those who look for the lowest price in their medical services are not going to get the best quality of care; it’s just not going to happen.

“It’s not out there,” Bloom said.

What is practical and possible is achieving a balance between cost and quality of care — and here comes that word transparency again — creating medical provider networks, and where possible under state law, pharmacy benefit networks in which the goal of achieving that balance is ingrained.

It takes a lot of resources and energy to create a workers’ compensation program that knows what it is philosophically and communicates that philosophy.

Whether it’s the fees charged by the doctor or the sweat equity a risk manager has to put in to get great results, and ultimately lower costs, it’s not an easy road.

“There is a tremendous amount of effort that each one of us has to put into their programs,” Riggs said.

Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]

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The R&I Editorial Team can be reached at [email protected]