Moving in opposite directions

Risk & Insurance, March, 2005 by Peter Rousmaniere

Last November, I spent six days in workers' comp conferences where I engaged in dozens of conversations and attended scores of product demonstrations. I woke up bleary-eyed on the last day with this disquieting notion. The missing information about claims is becoming in the eyes of many data vendors a very big black hole. As the leading vendors fill the hole, its existence will become more painfully obvious to industry participants who don't.

Do you want me to get more specific? Then I will. In the next couple of years any major medical cost-containment vendor, third-party administrator, national insurer, Fortune 500 workers' comp manager who cannot execute the following functions may have some explaining to do:

* Describe quantitatively the top performing medical providers in each major category, by state.

* Show quantitatively how you are adjusting up or down the use of special claims interventions, such as ease management, independent medical examinations, and fraud investigation.

* Walk into any Kinko's, get online, and find the entire, up-to-date, digital record of an open claim.

Advances can, alas, heighten the awareness of backwardness. As more people advance, those who do not--those the black hole threatens to swallow--face a looming darkness.

In the space of 24 hours at the workers' comp meeting I met vendors at both extremes.

Sedgwiek Claims Management Services, the third-party administrator, is fervently on course to enable these functions for its clients.

But at least one major vendor who has been selling claims-profiling services for years could not provide me with even the most straightforward of time series of profiling results.

Our industry has always been data-driven. But people on the buy and sell sides in this industry are significantly upgrading the quality of their data.

This is happening in an inconsistent pace. The trend is irreversible, led by three steeds: information technology advances, more sympathetic IT staffs, and fresh blood in the buyer community.

Don't underestimate the psychological effect of Web-search technology, coming to your hard drive soon. We should respect the subliminal expectations the Google experience has on people as they turn at work to face computer screens of claims, account or insurance policy detail.

The conventional approach in the past was to keep data analysis to the size of a peanut. As a wag working at Sedgwick said to me, the rule was, "Rate it, pay it, move on." The new rule is to seek the best economic endpoint and mobilize every decision point, every data element, to achieve that end.

California's momentous reforms appear to have set off a tidal wave of improvements to information system infrastructures. This happened in Ohio when the monopolistic state fund ramrodded managed care into the system in the mid-'90s. I bet the nation as a whole will feel the impact.

Many users of data will on a day not far off sit up and say, "You have this here big huge blank space in the middle of these reports, and we just figured out what it is. You're not reporting on what we actually want to do with your provider network, or medical bill review, or special investigations, or adjuster deployment. Kindly fill that hole."

That hole has been there all the time. It has just become bigger and bigger in eyes of the beholder.

PETER ROUSMANIERE, a Vermont-based consultant and writer, is a regular columnist for Risk & Insurance[R]. He can be reached at www.riskletters.com.