It just won’t stop.
Over the last few years, long-suffering TPAs, hammered by the soft insurance market, went from making a few bucks on managed care services to earning most if not all of their profits from commissions on same. Some TPAs provide managed care services themselves, others have preferred partners, and a few are willing to work with any vendor their employer customers bring to the table.
There are good reasons for each model, and I can argue in favor – or against – each of them. But from a broader perspective, there is a bigger issue, one that has been missed in most of the discussion about managed care fee-sharing.
That issue is simple – does the managed care program offered, or enabled, by the TPA actually work? Does it reduce total claims cost? Does it result in fewer extended disabilities?
That’s where the discussion needs to begin. If a TPA doesn’t have managed care expertise, if their executives can’t talk in detail about how their approach addresses total cost, their managed care business model is irrelevant. Unfortunately, there aren’t too many TPAs that have intelligent, effective managed care programs – the original objective has been sublimated to the demand for revenues and profits. Not all TPAs have lost their way (or were never on the right path to begin with); a few are innovating, breaking away from the same old same old discredited model as they search for a true long term solution.
There’s no question many TPAs have expertise in managed care. There’s also no question many risk managers think they know it all, and love to pontificate about their ‘ideal’ model – and force the TPA to implement their brain child, ignoring the TPA’s advice (and then blaming the TPA when the ‘can’t fail’ program fails). But that discussion should start, and end, with the overall goal of the program – lower total claims costs.
Yes it is critically important to know where your workers comp dollars are going. One way to do that is to require the TPA CEO to sign a document (after your attorneys polish the language) stating words to the effect that “We will fully disclose any and all financial transactions involving (TPA) and any and all managed care entities providing services to (employer) and employer’s claimants. This disclosure includes but is not limited to service fees, commissions, implementation fees, RFP and proposal assistance charges, transaction fees, connection fees, membership fees, and any and all other transfer of monies from managed care entities to (TPA).”
That’s a start, the initial requirement that must be met before any substantive discussions can begin. And once that attestation has been signed, step back and ask what the TPA is doing to attack total claims costs.
Because that’s where the big bucks are.
It just won’t stop.