I recently gave a keynote speech to a group of insurance brokers affiliated with the Institute for Work Comp Professionals; the talk focused on cost drivers in WC, with special emphasis on medical costs.
The part of the talk that generated the most discussion was the section on networks, and specifically how most WC networks have completely failed to reduce medical expenses.
My net is insurers are shooting themselves in the head, with a pistol provided by their managed care departments.
PPOs contract with providers to deliver services at a discount. Most PPOs get paid a percentage of the savings that is delivered by that discount, typically 15 to 22 percent of the savings. So, the more the PPO ‘saves’ the more it makes. On the surface, this sounds good: the system rewards the PPO for saving money and does not pay it when it delivers no savings.
However, a closer look reveals that when the PPO vendors win, the payer loses. The ugly head of the Law of Unintended Consequences emerges again.
At the most basic level, health care costs are driven by a relatively simple equation:
Price per Unit x Number of Units = Total Costs
Under a percentage-of-savings arrangement, reducing total cost is ignored in favor of saving money on unit costs. The PPO gets paid for savings on individual bills. Therefore, the more services that are delivered and the more bills generated, the greater the ‘savings’ and the more money the PPO makes.
The system encourages over utilization because it is in the PPO’s best interest financially to have numerous providers generate lots of bills for lots of services. Also, the providers, squeezed by a per-unit fee schedule that is lower than fee schedule/Usual and Customary Rates (UCR), have a perverse incentive to make up for that discount by performing more services.
The industry has been hit, and hit hard, by the Law of Unintended Consequences. Two of the top managed care “fixes” – fee schedules and PPOs with pricing based on percentage of savings, encourage over-utilization, a major cost driver for workers’ compensation.
It’s no wonder that most PPOs like this model, but why would any of their customers?
The simple answer is that managed care departments at many carriers and third party administrators (TPAs) are evaluated on the basis of their network penetration (the percentage of dollars that flow through a network provider) and network savings (on a per-bill basis).Their internal and external customers have bought into the per-unit discount model, and measure the success of their managed care programs on the dollars and/or bills that flow thru the network, and the savings below fee schedule or UCR delivered by the network.
The fact is few carriers, TPAs, or employers have realized that per-bill ‘savings’ is the wrong way to assess a managed care program. And unless senior management changes their evaluation methodology, their managed care departments will have no incentive to change their program to one that actually does reduce total costs.
After my conversation with a hall full of brokers, my bet is more carriers are going to be getting more questions about this.

Many payers look at ‘medical’ as a line item and nothing more. This myopia, this failure to look deeper, to try to understand what drives medical, is perhaps the most significant shortcoming in the industry.
Many readers will dismiss this criticism, claiming that they are different and smarter, that they know better.
And most will be wrong.
One current example provides compelling evidence of the industry’s ignorance of many things medical. I’ve posted on the pending changes to the Florida fee schedule, namely the move by the Three Member Panel to establish Medicare billed charges as the standard for Usual and Customary for facilities. That’s right, billed charges, not reimbursement. Yet many payers – self insured employers, insurers, and TPAs – are blissfully unaware of the damage this will do.
Here’s why hospital costs are important. According to the WCRI, hospital costs are rapidly accelerating for claims with more than 7 days lost time (which account for 83.5% of all workers’ compensation medical payout).

• Medical payment for NonHospital providers: up 3.8%
• All hospital medical payments: up 7.1%
• Inpatient hospital medical payments: up 12.1%

(Source, Stacy M. Eccelston et. al., The Anatomy of Workers’ Compensation Medical Costs, 6th Edition, 2007, WCRI).
In Florida, where hospital costs are about half of all medical expenses, this is particularly significant. In fact, two studies indicate the Panel’s proposed changes will dramatically increase hospital costs – by over $50 million annually. More troubling, the change will likely have the unintended consequence of shifting the location of care for many patients. With facility reimbursement becoming much more profitable, payers can expect to see many more bills for care delivered in hospitals, outpatient facilities, and ASCs. And they will be paying much more for that care.
Yet payers, in testimony before the Panel, seem to be completely ignorant of the impact of the proposed changes.
Here’s hoping payers wake up from their slumber – and soon. If not, many will have to explain to their clients why they didn’t act to prevent this disaster. Because it is preventable.
(for detailed information on this in the form of an extensive analysis, email infoAThealthstrategyassocDOTcom with Florida Hospital Reimbursement in the subject line)

I’m at the annual meeting of the Institute of WorkComp Professionals in Asheville, NC today. A very impressive group; what is notable is these folks actually do ‘get it’; they do understand that workers comp is not just a spreadsheet game, a price war, a contest to see who can squeeze the carrier the most.
These agents understand that the value they must deliver is to develop and implement long term programs, programs that attack cost drivers, that reduce injuries and speed return to work.
And those programs, and the results they provide, can’t be done on the cheap.

I had a chance to spend more time with the Medcor folks this morning at RIMS, and liked what I saw. They’ve been doing the combo first report of injury (or most of it)/nurse triage/network direction work for ten years now, and some of their nurses (all calls are answered by nurses) have logged over 5000 calls.
Because they don’t have any stake in any network, they don’t worry about increasing network penetration (a wholly misguided metric used to evaluate managed care plans) per se, but rather focus on getting claimants to the right doc. They do have the ability to send patients to specific docs based on the type of injury – but (here’s a shocker) most of their customers are not yet sophisticated enough to be able to identify those ‘right’ docs.
The value? Avoided ER admissions and reduced claim frequency.
Not an earth-changing business, but one with a lot of potential – even more if the employer is somewhat sophisticated.

Medicare Set Asides were a hot business for a couple of years with NuQuest HealthAdvocates and Gould and Lamb dominating the industry. Then Coventry entered the market thru its priority services sub, quickly moving up to the fourth spot. Coventry stumbled with its guarantee recently, losing a couple of clients (namely AIG and Macy’s).
Today the MSA business is growing but not nearly as fast as in 2006. The big jumps in volume in the sector are pretty much over; while most vendors are seeing some increases in volume, the double-digit growth of the past looks to be gone.
There are still new entrants but the show floor isn’t nearly as crowded with erstwhile MSA vendors as it was last year.
What’s next? Depends on the Feds and adoption rates in other lines of business. Expect to see MSAs become more prevalent in other P&C lines especially GL and other liability lines.

AIG is no longer using Coventry for MSAs.
AIG was quite displeased when Coventry raised prices for networks and other services. AIG has long been a loyal First Health/Coventry customer, and was one of their larger MSA customers.
The defection, and other business losses has led to a reported 60% drop in revenue for Coventry’s Priority Services unit (they handle the MSAs (Medicare Set-Asides); sources indicate Q1 2008 MSA revenue is down almost $3 million from Q12007.
Priority Services has had other problems, namely issues related to its ‘guarantee’ that CMS would accept its recommendations for Medicare Set-Aside amounts. I don’t have the details, but it appears that Coventry has not been able to deliver on what has been its key marketing message – the guarantee. Apparently this is in large part due to CMS’ unfamiliarity with state workers comp fee schedules.
The drop off in business reportedly has led to layoffs at Coventry’s Priority Services division.
The business decline comes on the heels of a Federal subpoena issued to Coventry demanding they cease any and all destruction of records related to their MSA business dating back at least three years. The subpoena has made its way to all PS employees, and may well be tied to a complaint from a couple years back alleging that PS inappropriately used Coventry’s online access to Medicare eligibility data.
The net is this – Coventry has been very aggressively working to maximize WC revenues, to sell all its services to all its customers by bundling, offering what amounts to bulk purchase deals, and in some cases requiring customers to agree to significant price increases. When you are a monopoly in one critical area (workers comp networks) you have some pretty strong leverage.
The problem arises in other areas, where Coventry does not have a monopoly, and customers, angered by their heavy-handed tactics, vote with their feet and move their business elsewhere. The workers comp buyer is tough, does not like to be hemmed into a corner, can be loyal but only if s/he believes s/he is being treated fairly, and has a long memory.
Coventry may be forgetting that their priorities must be aligned with their customers’ if they are to prosper over the long term.