An integrated model of risk management built on integrity equates to success for all
Integrity. It’s a concept many are familiar with, meaning having strong individual moral principles or moral uprightness.
This basic foundation of integrity may represent a singular ideal, driven by many individual choices to do the “right thing.” Integrity is most intimately measured within oneself.
Integrity can also mean a state of being whole and undivided. When acted out collectively around common goals, the power of integrity - in community - is unmatched. While this value is often tossed around as a general expectation in business, is it infused as it should be in the day-to-day exemplifying this ideal?
A real-world application of integrity can be realized within the integrated model of risk management and workers’ compensation managed care, providing the most return when multiple parties are committed to championing one common goal - the injured worker.
When all aspects of managed care programming are optimized independently, and integrated appropriately, the enhanced model soars for the client and the provider, while also providing the quality of care that the injured worker rightfully deserves. Integration with integrity is truly a world where everyone wins.
“The integrated model is exemplified though understanding of program controls and the detailed intertwining of provider networks, utilization review, medical bill review, and case management. A properly unified holistic system has greater opportunity to provide excellence in care. This leads to an emphasis on productive and expedient return-to-work pathways as well as the achievement of balanced levels of satisfaction across the board — for providers, clients and the injured workers,” said Zebrah Jahnke, Vice President of Business Development at EK Health Services Inc.
PROVIDERS WIN
Providers, the ones we need most are often the ones we short-change. Let’s flip the model on its head and consider how we can incentivize providers to want to treat our injured workers.
In a unified model with integrity at the center, an emphasis is placed on positive experience and engagement. By ensuring fair and rapid reimbursement, reviewing treatment requests thoroughly and completely, and removing friction on the back-end of the process, the integrated model creates a more desirable setting for providers to treat workers’ compensation patients — perhaps inviting more quality physicians into our networks.
“At EK Health, we have seen this come to fruition in our fully integrated program,” Jahnke explained. “In a client's recent annual stewardship with the fully integrated model, we shared results touting a 5% pure appeal rate and 99% timeliness in utilization review, a duplicate rate of 5.9% and reconsideration rate of 4.9% in bill review — underscoring increased provider satisfaction and efficiency of the model.”
Quality of care from providers is the heart of what we collectively hope to provide for those who have been injured while on the job. When providers project this level of satisfaction in the process, their compliance with the process improves and more opportunities exist for injured workers to receive the best quality of care, improving outcomes for clients/payors.
CLIENTS ARE VICTORIOUS
Clients are the ones whose dollars we steward. If integrous stewardship is not the focus of every process designed and decision made, we are not giving clients what they deserve.
When we raise the level of care by channeling to quality providers, treatment plans are more quickly established. This shortens the duration of treatment, limits the need for more clinical oversight/management by nurses and reduces client fees.
Additionally, when utilization review decisions are integrated with the medical bill review process, the fees for utilization review pay off with greater savings and – bonus, greater provider accountability. If the integration does not exist, it could mean hundreds of thousands of dollars in fees paid on utilization review are simply wasted.
Taking it even further, when utilization review and bill review are integrated with case management, information obtained in one area can immediately identify needs in another.
Jahnke described this further by saying that, “Identifying opportunity is the key to changing trends, which ultimately impacts our client’s bottom lines. At EK Health, our role is two-fold, taking care of our client’s injured workers and protecting our client’s costs.”
INJURED WORKERS TRIUMPH
Injured workers, the ones we are entrusted to serve, are burdened by process.
Our industry has morphed into being transaction-based instead of care-based. When all programs are working cohesively in a constructive manner, with integrity at the forefront, the model places priority back on the injured worker, where it belongs.
By incentivizing quality providers to participate in our system and also emphasizing expedited care throughout the course of treatment, perhaps the injured worker’s experience will run smoother and better.
A better experience for those at the center of what we do, without unnecessary wait times and limited treatment options, decreases stress levels, removes barriers to rehabilitation, and allows the opportunity for workers to re-enter the workforce and regain some normalcy – which is what workers’ compensation ultimately stands for.
“An integrated model with integrity at its core may appear overly optimistic to some, however, working with integrity often means doing what is right, even when it’s hard. When a full commitment is made to an integrated model with integrity, and it is appropriately configured with all parties working in tandem, we can see a direct correlation to its success,” explained Jahnke. This success is experienced through the following:
- Increased levels of transparency
- Superior combined tools to evaluate claims outcomes and performance metrics
- A deeper bottom-line impact
- Clearer pre-identification of cost drivers and program trends
- Increased expedience and quality of patient care
- Safer and faster return of the employee to productive work
- Decreased duration of treatment plans and duration of claims
- Lower medical costs - overall, per claim, per bill, and per treatment
With committed execution and possible outcomes such as these, an integrated model coupled with integrity provides a world where everyone comes out on top.
The key to harnessing the power of this model is to truly understand how all of the programs can work together to provide harmony – while unapologetically taking the crucial steps forward to keep the injured worker the priority at all times. When we ultimately do what’s right, we simply can’t go wrong.
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