And those two often don’t match up very well.

Example.  Work comp insurance companies benefit when medical and indemnity costs are lower than expected.  So, lower medical costs = better “outcome” for the company.

Many – if not most – managed care executives are evaluated in part based on “network penetration” and “discount below fee schedule”.  Thus, the more dollars that flow thru their network, and the deeper the discount those providers give the network, the “better” the executive’s performance is.

Superficially, this makes sense – more care thru lower cost providers equals lower medical cost, which benefits the insurance company.

“Superficially” being the key word.  Here’s the problem with this model.

Insurers contract with PPOs, which in turn 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.

Under a percentage-of-savings arrangement, reducing total medical 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 fact is few carriers, TPAs, or employers have realized that per-bill ‘savings’ is the wrong way to assess a managed care program – or the executive running medical management. 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.

This is by no means the only example out there; I’m quite sure you can come up with more than a couple off the top of your head.

What does this mean for you?

Take the time to understand  – really understand – what success is, and what drives success.  You may be unpleasantly surprised to learn your execs’ motivations are diabolically opposed to your company’s success.

Is it the execs or the IT department?

The workers’ comp, and, for that matter, the entire property and casualty insurance industry, is chronically systems-poor.  While other industries view IT as a strategic asset, continually investing billions in IT, WC/P&C considers IT an expense category to be mined for pennies to add to earnings per share.

We all know how much execs HATE unallocated loss adjustment expenses…

Execs at payers are hamstrung by IT departments that can’t/won’t/aren’t able to implement systems changes. In fairness, IT departments are hamstrung by a lack of strategic vision in many C-suites, which in turn is motivated by financial markets or executive comp plans at mutuals.  Suffice it to say there is plenty of blame to go around – but the result is insurers’ strategy is often greatly limited by IT.

For example, underwriting and distribution. Yes, Google’s initial foray into insurance was short-lived, but that wasn’t because they weren’t selling insurance. In fact profits were good – but “good” by insurance standards, not by tech standards.  Google just couldn’t make the profit levels they are used to.

At some point another tech innovator will figure this out and/or decide a lower profit level is just fine, and then woe betide insurers.

Another example – the medical management world is changing dramatically, and work comp insurers are very hard pressed to adapt. Bundled payments, narrow networks, electronic medical records and vertically integrated delivery systems are here today, and will grow dramatically in importance tomorrow. Flexibility, adaptability, and the ability to move quickly are essential – and equally impossible.  Changing vendors requires IT to design, implement, test and monitor new data feeds to multiple systems and stakeholders.

Conversely, some payers have tied themselves to external vendors who act as consolidators or pipes, thereby greatly reducing the carrier’s IT burden.  In exchange, a LOT of power is transferred to the pipe vendor.  That’s fine if:

1. incentives are aligned over the long term, and
2. the vendor is able and willing to make changes to providers, processes, and feeds as necessary, and
3. there’s transparency.

However, expediency and underinvestment comes at a cost.

CEO T Rex: “Hey, when is that B2B platform scheduled for testing?”

CIO Triceratops: “18 months after I get the money to hire the staff you cut to reduce ULAE…”

The B2B and healthcare delivery market is evolving at a pace akin to that the dinosaurs saw after the meteor hit.  So, here’s a couple of questions you may want to ask yourself.

1. Does your strategy drive your IT, or does your IT drive your strategy?
2. What’s your plan to adapt to the revolutionary changes hitting distribution and medical management?
3. Does your IT department, management, vendors, and infrastructure support that plan?
4. What happens when – not if, but when – a carrier or new entrant builds the infrastructure and capability you can’t or won’t?

In one of his final appearances as President of III, Bob Hartwig PhD dove into the sharing or “gig” economy.

In a futile attempt to keep up with Bob’s frenetic pace, here’s my as-it-happens recording of his main points…

• insurance is evolving to address coverage gaps for those who drive for Uber and Lyft, rent rooms via AirBnB, do work via TaskRabbit or Handy or laundry via Washio.
• lots of variation by state e.g. Uber drivers are employees in CA but not in other states
• smartphone usage is driving this – 50% of all adults worldwide have one – because it costs nothing to pair labor with demand – a revolutionary change
• the tradition of the “good job” is only 135 years old…
• Optimisitic folks think this frees workers from centraiized, often sclerotic  firms, enables workers to get paid more and work where they want when they want
• Pessimistic folks see many jobs disappearing, the end of benefits, no investment in training and an increasingly difficult environment for those with low skills and education.
• 22% of Americans have offered services in the sharing economy, most are male, young, minority, and urban.  All, coincidentally, categories at higher risk for work comp injury.
• 71% of sharers are positive about the experience, AND 58% agree that the industry is exploiting a lack of regulation.
• many “sharing” jobs are subject to automation
  • think Uber drivers – but its going to take a while (I disagree, it’s coming much faster than Hartwig thinks)