1. “Reconciling Limited Resources with Unlimited Expectations” California Research Colloquium on Workers’ Compensation Medical Benefit Delivery and Return-to-Work May 1 & 2, 2003 Chris Mardesich, JD, MPH RAND Universal Care

2. “Reconciling Limited Resources with Unlimited Expectations” Rising costs of health care : Cost shifting Desire for high quality care Medical Technology Aging population Etc.

3. “Reconciling Limited Resources with Unlimited Expectations” Presumption: Resources cannot meet expectations. Key Question: How competently can a Managed Care System of health care delivery in a Workers’ Compensation context meet or balance the expectations of the key stakeholders?

4. “Reconciling Limited Resources with Unlimited Expectations” Whose Expectations? Key Stakeholders (in no particular order): Compensably Injured Workers Employers/Premium Payors Health Service Providers Workers’ Compensation Carriers Shared/Similar Expectations of Stakeholders Dissimilar and Contrary Expectations

5. “Reconciling Limited Resources with Unlimited Expectations” Do the various models of Managed Care Organizations (MCOs) meet key stakeholder expectations differently? HMO Staff, Group, Network, IPA, Mixed (choice of worker, provider, etc.) PPO POS? Spectrum of Expectations: Increasing Expectations = Increasing Cost (Resources)

6. “Reconciling Limited Resources with Unlimited Expectations” Basic Principles of MCOs Category 1 Principles - Similar in Workers’ Comp and Non-Workers’ Comp MCOs: Integration of Financing/Delivery of Care Provider Selection Provider Reimbursement Provider Credentialing Dispute Resolution

7. “Reconciling Limited Resources with Unlimited Expectations” Basic Principles of MCOs: Category 2 Principles - Key concepts in Managed Care Workers’ Compensation: Certification Requirements AB 749 Deeming Utilization Management Utilization Review, Case Mgmt, Peer Review URAC, etc. Quality Management Wide variety of quality services designed to ensure that services meet a recognized standard of care NCQA, etc.

8. “Reconciling Limited Resources with Unlimited Expectations” Can a managed care system help reconcile limited resources with unlimited expectations? Reconcile: Accountability and Improvement Accountability Data driven – managed care (UM, QM, etc.) is data driven Presumption will continue Balance stakeholder expectations (some shared/some divergent) Limited number studies note lower of costs (resource efficiency) Further Study Needed Improvement/Opportunity for Reconciliation Less anecdotal/more empirical Outcome studies