1. CAS Health and Managed Care Seminar October 18, 1999 Charles M. Potok

3. Late 1980’s, Early 1990’s Deterioration of workers compensation results Increasing assigned risk plan market shares Disastrous residual market loads

4. Residual Market Loss (NCCI)

5. Late 1980’s, Early 1990’s Charges of rate suppression Accident Year Combined of 125 Cost Shifting - Accident/Health Workers Comp Health Insurance a National Political Issue

6. Utilization Review Network Management Building Blocks of Accident and Health Managed Care Case Management

7. Treatment Protocols Nurse MD Quality Medical Care at Lowest Cost Case Management

8. Appropriate Treatment –Concurrent Review –Retrospective Review –Pre-Admission Certification Medical Bill Review Quality Medical Care At Lowest Cost Utilization Review

9. Network Management Size of Network Discounts Capitation Keep Out of Office-Prevention Disease Management Immunization-Wellness

10. Size of Network Indemnity-Fee For Service PPO Discounts HMO Tight

11. Network Management Size of Network Discounts Capitation Keep Out of Office-Prevention Disease Management Immunization-Wellness

12. Utilization Review Network Management Case Management Building Blocks of Workers Compensation Managed Care

13. Treatment Protocols – –Different for Workers Compensation Nurse MD, EE, ER Quality Medical Care at Lowest Cost – –Indemnity Cost early return to work Case Management

14. Appropriate Treatment – –Concurrent Review – –Retrospective Review – –Pre-Admission Certification – –Starts with First Report of Injury Medical Bill Review Quality Medical Care At Lowest Cost Utilization Review

15. Size of Network Discounts Capitation Keep Out of Office-Prevention – –Drug Free Workplace Disease Management Immunization-Wellness = Loss Control Network Management

16. Size of Network Indemnity-Fee For Service PPO Discounts HMO Tight=Occupational Medicine

17. Size of Network Discounts Capitation Keep Out of Office-Prevention – –Drug Free Workplace Disease Management Immunization-Wellness = Loss Control Network Management

18. Late 1990’s, 2000 Accident & Health Model More Choice –Point of Service Options –Financial Disincentives –Less Primary Care Gatekeepers

19. Late 1990’s, 2000 Accident & Health Model More Emphasis on Disease Management Better Quality –Credentialing –Data Less Capitation

20. Late 1990’s, 2000 Accident & Health Model Hospitals, MD’s/Reimbursement Rates Workers Compensation 1998 Accident Year Combined Ratio 122 Health Insurance A National Political Issue

21. Implications for Workers Compensation More Difficult Case Management More Difficult Utilization Review More Importance on Network

22. Implications for Workers Compensation 24 Hour Coverage Disability Management Internet Agents/Brokers Health Providers Risk Managers Claimants

23. Agents/Brokers Rating Issuance Inquiry

24. Risk Managers First Report of Injury EOB’s Loss Control Surveys

25. Health Providers Medical Bills –Hospitals –MD’s Provider Notes –Utilization Review

26. Claimants Content –Protocols –Hospital Process –Questions Medical Bill Information Longer Term Case Management 7 X 24