“Reconciling Limited Resources with Unlimited Expectations”

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