1 2013 Workers Compensation Benchmarking Study Study Organizer & Publisher: Rising Medical Solutions Principal Researcher & Report Author: Denise Zoe Gillen-Algire, Risk Navigation Group
2 Workers Compensation Benchmarking Study Table of Contents Preface Study Advisory Council Acknowledgments Introduction Executive Summary Methodology i ii iii Study Findings Operational Challenge Survey Participant Demographics Prioritizing Core Competencies Talent Development & Retention Impact of Technology & Data Medical Performance Management Conclusion Appendices Index Appendix A Survey Participant Demographics Appendix B Prioritizing Core Competencies Appendix C Talent Development & Retention Appendix D Impact of Technology & Data Appendix E Medical Performance Management
3 Workers Compensation Benchmarking Study i Preface About the Study The study s impetus evolved from various conversations that study Organizer and Publisher, Rising Medical Solutions, had with industry executives about a gap in available research that focuses on how claims organizations are dealing with daily operational challenges. Their receptiveness to starting a community dialogue spawned the idea to create a benchmark tool that workers compensation claims leaders can use to assess their operational priorities, hurdles, and strategies amongst their peers. Recognizing the need for unbiased research, the study has been guided by an independent Principal Researcher and more than a dozen industry executives on the study s Advisory Council. The involvement of these workers compensation professionals has been critical to creating a framework that produces compelling and impartial data. About the Study Organizer & Publisher, Rising Medical Solutions Rising Medical Solutions (Rising) is a national medical cost containment and care management company that serves payers of medical claims in the workers compensation, auto, liability and group health markets. Rising spearheaded the study idea and has led the logistical, project management, and publication aspects of the effort. About the Principal Researcher & Study Report Author, Denise Zoe Gillen-Algire, MBA, RN, COHN-S/CM, FAAOHN Algire is a Principal with Risk Navigation Group, LLC, and the Practice Leader of the Integrated Health & Productivity Management practice. She is board certified in occupational and environmental health and is a fellow of the American Association of Occupational & Environmental Health Nurses. Bringing more than 18 years of industry experience, her expertise includes insurance operations, medical management, enterprise risk management, and healthcare practice management. Rising Medical Solutions Copyright All rights reserved. The information contained herein and the statements expressed are of a general nature only and do not constitute any specific business or professional advice addressing the circumstances of any particular individual or entity. Rising endeavors to provide accurate and timely information herein, however Rising provides no guarantee that such information is accurate as of the date it is received nor that it will continue to be accurate in the future. No individual shall rely upon or act solely upon such information without additional and appropriate professional advice. Rising makes no express or implied warranties herein. The information contained herein is proprietary and confidential to Rising and shall not be disclosed to any third party without the express written consent of Rising. Under certain circumstances subject to copyright law, brief excerpts of the information contained herein may be quoted directly, translated or summarized provided the correct source is stated immediately following the quotation, translation or summary.
4 Workers Compensation Benchmarking Study ii Study Advisory Council Essential to the creation of the benchmarking study and survey has been the Advisory Council comprised of more than a dozen workers compensation executives who represent national and regional carriers, selfinsured employers, third party administrators, brokerages, and industry consultancies. Their varied voices have guided and shaped the study s focus areas, with the Advisory Council bringing to light some of the most significant operational challenges facing claims organizations today. At every critical juncture from the formation of survey questions to the interpretation of results the Advisory Council has provided thought leadership. Among those executives we thank for their time and commitment are: Gale Vogler Director, Managed Care Acuity Insurance Raymond Jacobsen Managing Director AON Benfield Fred Boothe Vice President of Insurance Services BrickStreet Insurance James Masingill Vice President, Claim Operations Markel FirstComp Insurance Tom McCauley Owner & Consultant Networks by Design Laura Crowe Risk Management Director Presbyterian Healthcare Services Cathy Vines Director, Healthcare Cost Containment Strategy SCF Arizona Tim Gallagher Director, Managed Care Services Tower Group Companies Joe McLaughlin Senior Vice President, Sales & Marketing TRISTAR Insurance Group Tim Mondon Senior Vice President, Bill Review Zenith Insurance
5 Workers Compensation Benchmarking Study iii Acknowledgments We would like to acknowledge the following industry leaders for providing additional insight and support during the study project as well as heightening industry awareness and survey participation. Thank you for your invaluable assistance: Joe Burgess Senior Executive Vice President, CHSI and Workers Compensation Committee Board Member, Self-Insurance Institute of America (SIIA) Peter Rousmaniere Independent Workers Compensation and Risk Management Consultant and Columnist for Risk & Insurance Magazine Mark Walls Senior Vice President, Marsh and Founder, Work Comp Analysis Group on LinkedIn William Wilt, FCAS President, Assured Research Nathan Yeagle Senior Account Executive, Risk & Insurance Magazine
6 Workers Compensation Benchmarking Study 1 Introduction Like most industries, the workers compensation industry has hurdles that challenge growth and operational effectiveness. Many of these hurdles are commonly a focus of research, with numerous studies published about the state of the workers compensation industry, cost drivers, claim trends, workforce demographics, jurisdictional comparisons, and the like. However, less is reported about how claims peers compare in terms of daily operational challenges, priorities, concerns, skill gaps, and budgets. In response to this need, the 2013 Workers Compensation Benchmarking Study was developed using critical subject matter expertise from the study Advisory Council and an independent Principal Researcher in order to address these prevalent issues claims organizations face today: Prioritizing Core Competencies Measuring Best Practices Incentivizing Operational Excellence Training and Retaining Staff Assessing the Impact of Technology and Data Evaluating Medical Management Performance The study stems from a 60 question survey distributed to claims leaders nationwide from varying disciplines, including: insurance carriers, reinsurance / excess carriers, third party administrators, self-insured employers, insured employers, state funds / mutual funds, government entities, and risk pools. The survey questions set out to generate data that would help claims executives pinpoint operational outliers, advocate for resources in support-challenged areas, and validate existing strategies. The study report has compiled confidential survey results from 258 claims leaders with the aim of supporting the workers compensation community with meaningful information for their instrumental role.
7 Workers Compensation Benchmarking Study 2 Executive Summary Key Challenges The study results indicate that workers compensation claims leaders are facing critical challenges that are limiting their talent pool, technology potential, and performance abilities. These central issues emerge consistently throughout this study as industry peers give dimension to their daily operations, culminating in these widespread challenges: 1 Limited investment in current and future talent development. Less than half of the survey participants provide training to senior-level claims staff and a smaller percentage invest in training new hires. Figure 1 / Survey Question: Does your organization provide technical training and development for senior-level claims adjusters? (258 Responses) Figure 2 / Survey Question: Does your organization have a formal training program for new hire claims staff with little to no experience? (258 Responses) 1% 20% 49% 2% 19% 42% 30% 37% Yes (127) No (78) Unknown (3) Not Applicable (50) Yes (108) No (96) Unknown (4) Not Applicable (50)
8 Executive Summary Workers Compensation Benchmarking Study 3 2 Limited systems integration and use of technology to drive best practices. A third of participants report that no integration exists between their core claims system and their ancillary systems (e.g. Pharmacy Benefit Manager (PBM), Utilization Review (UR), Bill Review), and many report a web-link or manual copy-paste of information as integrated. Study results also indicate room to advance the use of existing and emerging technologies to drive claims best practices. Figure 3 / Survey Question: Does your organization utilize any of the following systems to direct or manage tasks within best practices? Select all that apply: (If no, select Not Applicable ) (258 Responses) 100% 90% 80% 70% % responses 60% 50% 40% 30% 45% 46% 20% 10% 0 Not Utilizing / Not Applicable Claims System Workflow Automation (117) (119) 25% 3% Predictive Analytics Other (64) (7) Note: Respondents were able to select more than one answer for this question
9 Executive Summary Workers Compensation Benchmarking Study 4 3 Limited use of risk / reward strategies to propel top performance from internal staff, vendor partners, and medical providers. Just over 50 percent of participants report using performance strategies with internal staff and considerably fewer use these strategies with medical providers and vendor partners. A significant competitive opportunity exists for claims organizations that implement risk / reward models, particularly with medical management vendors given the prevalence of outsourcing these functions. Figure 4 / Survey Question: Does your organization use risk / reward-based contracting with medical providers? (258 Responses) Figure 5 / Survey Question: Does your organization use performance strategies to incentivize or hold medical management vendor partners accountable? (258 Responses) 4% 10% 12% 17% 86% 71% Yes (9) No (223) Unknown (26) Yes (44) No (184) Unknown (30)
10 Executive Summary Workers Compensation Benchmarking Study 5 Five Industry Considerations Invest in talent development and alternative recruitment strategies to drive claims effectiveness. Many organizations face the competing dilemma of a limited pool of experienced claims professionals versus the costs associated with training programs. The industry must be willing to embrace alternative recruiting strategies to bridge the talent gap. Organizations also should consider the value proposition of investing in ongoing training and development as a two-fold strategy: better equipped talent and employee satisfaction ultimately leading to improved claims outcomes. Understand and leverage the capabilities of data warehousing. Well-integrated systems allow organizations to manage core claims management processes more efficiently. Unfortunately, many organizations today use claims systems with limited interface capabilities. A possible solution for organizations with system constraints is using a data warehouse to aggregate and produce meaningful data intelligence. Implement predictive analytics and workflow automation to favorably impact loss trends. There is an industry opportunity to heighten the use of tools, such as predictive modeling and workflow automation, to better identify and manage problematic claims. Loss costs trends can be favorably impacted with smart investments in current and emerging technologies. Use performance strategies with vendor partners. With the increased outsourcing of key operational functions, there is a growing need to leverage risk / reward models that encourage top performance from vendor partners. The data reflects that there is a significant opportunity to escalate the use of these strategies with vendors, as well as with internal staff and medical providers. Incentivizing performance is becoming more important, particularly as claims organizations are being held more and more accountable for tangible metrics and results. Operationalize qualitative and outcome-based performance measures. Many organizations use metrics to evaluate performance; however, the emphasis tends to be on quantitative measures as opposed to qualitative or outcome-based measures. The results show a clear need to better define and structure performance measures that expand upon standard metrics in order to achieve operational excellence.
11 Executive Summary Workers Compensation Benchmarking Study 6 Study Context & Focus Areas Compared to other lines of business, workers' compensation presents a number of unique operational challenges for claims organizations, including: complex compliance requirements, the long-tail nature of workers compensation claims, and conditions leading to higher rates of fraud. These challenges have contributed to increasing loss adjustment expenses (LAE) and poor underwriting results with loss costs in excess of premiums collected. To better understand the daily experience of claims leaders operating in this environment, this study explores how the industry is advancing best practices, investing in talent, using technology, and impacting medical outcomes. The study report provides an in-depth view of these four focus areas: Prioritizing Core Competencies What do organizations consider their core competencies? How do organizations define best practices within core competencies? How do organizations measure effective claims management? Do organizations utilize risk / reward strategies to drive best practices and achieve outcomes? Medical Performance Management Are organizations utilizing medical management outcome measures? How is provider quality measured? With the prevalence of outsourcing medical management to vendor partners, how do organizations measure outcomes and ROI? Is the industry utilizing risk / reward contracting strategies with providers or vendor partners? Talent Development & Retention What is the industry doing to attract and retain the best in the industry? What is the financial investment in training and development at peer organizations? Do organizations include staff development in their strategic goals? Is training customized based on skill level to ensure ongoing development for tenured staff? How do organizations tackle the challenge of knowledge transfer from senior-level staff to less experienced staff members? Impact of Technology & Data How do organizations utilize data to impact / manage operations? What strategies are used to ensure data integrity? What key systems are integrated with claim systems? How do organizations balance process with strategy metrics? How are advanced analytics such as predictive modeling used to enhance operations? Are metrics helping or hindering operational effectiveness?
12 Workers Compensation Benchmarking Study 7 Methodology The study focus was guided by nine facilitated think-tank sessions with the independent Principal Researcher and the Advisory Council Members, as well as one-on-one conversations and correspondence. The study report is based on the industry-wide survey results of 258 respondents, including claims managers, directors, and executives. The research was conducted using a confidential online survey tool. The Principal Researcher developed the survey tool structure and questionnaire. The survey incorporated a total of 60 partially categorized and closedended questions including demographic, dichotomous, rank order scaling, multiple choice, constant sum, and random order question sets to reduce response bias. Survey invitations were directed to leaders who oversee claims operations and were sent through direct invitations as well as various industry channels. All invitations included an opt-out link allowing recipients to remove themselves from study communications. The study and survey design began in February The survey was open for a total of 32 days from May 22, 2013 through June 23, Participants were allowed to exit the survey at any point during the questionnaire and were given the option to receive a copy of the study report in exchange for completing the survey. Responses Received 258 completed responses 84 incomplete responses (incomplete responses were excluded from the study results) Average response time to complete the survey was 19 minutes The Principal Researcher completed the data validation and analysis, as well as authored this study report.
13 Workers Compensation Benchmarking Study 8 Survey Participant Demographics About the Survey Participants Participants include workers compensation professionals who oversee claims operations, with Managers and Directors representing the largest respondent population followed by Vice President and C-Suite executives. The survey responses include participation across industry sectors, with insurance companies, self-insured employers, and third party administrators (TPAs) representing the greatest participation by organizational type. Figure 6 / Survey Question: Role / Level of Responsibility (258 Responses) 39% (100) 29% (74) 21% (53) 12% (30) <1% (1) Manager Director Vice President C-Level / Executive Other Table 1 / Survey Question: Organization Type (258 Responses) count % Insurance Company 77 30% Self-Insured Employer 61 24% Third Party Administrator 36 14% Insured Employer 30 12% Governmental Entity 25 10% Risk Pool 11 4% Other 11 4% State Fund / Mutual Fund 4 2% Reinsurance Company / Excess Insurance Company 3 1% Participants include a broad representation of small, midsize, and large organizations. Organization size was measured by total annual premium and total annual claims dollars paid (see Table 2), as well as employee headcount. Table 2 / Survey Question: Organizational Size Total Annual Premium & Total Annual Claims Dollars Paid (258 Responses) Total Total Annual Annual Claims Premium Dollars Paid count % count % < $100 Million % % >$100 Million to $350 Million 42 16% 48 19% >$350 Million to $750 Million 9 3% 14 5% > $750 Million 24 9% 20 8% Unknown 31 12% 33 13% Not Applicable 41 16% - - See Appendix A for all results related to "Survey Participant Demographics"
14 Study Findings - Survey Participant Demographics Workers Compensation Benchmarking Study 9 Participant Geographic Focus Most survey participants are located in their organization s corporate headquarters (see Figure 7). Organizations with regionally-based workers' compensation business have modestly greater representation, with 57 percent of participants reporting claims operations in one or more regions and 43 percent reporting workers compensation business nationwide. Figure 7 / Survey Question: Corporate Headquarters or Regional Office Location (258 Responses) 100% Figure 8 / Survey Questions: - Geographic Focus - National or Regional in Scope (258 Responses) - Indicate the regions your company currently manages workers compensation claims. Select all that apply. (Conditional question for respondents who answered yes to Regional in Scope) (147 Responses) Geographic Focus: National in Scope 43% (111) Regional in Scope 57% (147) Midwest 39% South 35% Northeast 26% Southwest 20% West 20% California 18% % responses 0% 80% Corporate Headquarters (206) 20% Regional Office (52) Note: Respondents could select more than one region
15 Study Findings - Survey Participant Demographics Workers Compensation Benchmarking Study 10 Appendix A Index Survey Participant Demographics For more information on the survey participants demographic data, please refer to the below tables and figures in Appendix A. >> Go There A-1: A-2: A-3: A-4: A-5: A-6: Role / Level of Responsibility Organization Type Location Type Method of Claims Management Business Focus Geographic Focus A-6.1: Regional Classification A-7: A-8: A-9: Organization Size Total Claims Dollars Paid Segmented by Organization Type Organization Size Total Annual Premium Segmented by Organization Type Organization Size Total Employee Headcount
16 Workers Compensation Benchmarking Study 11 Operational Challenge: Prioritizing Core Competencies Many organizations are challenged with competing areas of core competencies The workers compensation industry has experienced significant change, with the traditional role of Claims Examiner now frequently being shared with other departments or outsourced to vendor partners. Prioritizing where to focus resources is an important strategic skill for industry leaders. This area of the study explores what organizations consider core competencies, how resources are aligned with core competencies, and how best practices and outcomes are defined and measured. Top 3 Core Competencies ed Most Critical to Claim Outcomes Key Considerations What do organizations consider their core competencies? How do organizations define best practices within core competencies? How do organizations measure effective claims management? Do organizations utilize risk / reward strategies to drive best practices and achieve outcomes? Disability / RTW Management Medical Management Compensability Investigations Prioritizing core competencies most critical to claim outcomes 100% Figure 9 / Workers Compensation Claims Cost Trends Indemnity 46% 54% 53% 47% Medical 58% 42% 70% 30% [projected] Survey participants rank disability management and medical management as the top two issues critical to claim outcomes (see Table 3). This finding reflects the reality most workers compensation organizations experience with medical spend representing nearly 60 percent of total claims costs i a figure that s expected to rise. According to the Insurance Information Institute, workers compensation medical is projected to reach 70 percent of total claims costs by ii A serious concern for employers and insurers alike, medical inflation has outpaced the Consumer Price Index (CPI) for the past 25 years, with the cost of medical care more than tripling. iii Source: Denise Zoe Gillen-Algire, Workers Compensation Market Trends Presentation See Appendix B for all results related to "Prioritizing Core Competencies"
17 Study Findings - Prioritizing Core Competencies Workers Compensation Benchmarking Study 12 Disability management, ranked the number one priority critical to claim outcomes, is often parallel to proactive medical management. Numerous studies show that the probability of employees returning to any form of employment decreases sharply the longer they are off work. iv Participants also rank compensability investigations high in priority. Although conducted with low frequency over the claim life cycle, the potential impact compensability investigations have on outcomes is significant, particularly if key information is not detected or overlooked. Table 3 / Survey Question: in order of highest priority the core competencies most critical to claim outcomes, with 1 being the "highest priority" and 10 being the "lower priority." (258 Responses) Overall Total Score Percentile Disability / RTW Management % Medical Management % Compensability Investigations % Case Reserving % Litigation Management % Oversight Governance & Internal Controls % Bill Review % Fraud & Abuse Detection % Recovery Management % Vocational Rehabilitation % Measuring best practices within core competencies Many organizations use metrics to gauge operational performance; however, the emphasis tends to be on quantitative measures as opposed to qualitative or outcome-based measures of performance. A key focus of this study area is benchmarking how organizations structure performance measures to expand on standard metrics. Of the responses, 72 percent report measuring best practices within core competencies, while 28 percent report there are no / unknown metrics for best practices displaying room for improvement. Survey data also reflects that, on average, only 56 percent of all participants measure performance in the top three areas ranked most critical to claim outcomes. Additionally, only 65 percent of participants report that they use an audit or quality assurance program focused on claim outcomes. These findings indicate an opportunity for the industry. Quantitative vs. Qualitative and Outcome- Based Measures of Performance There s a tendency in the industry to check off all the boxes to meet quantitative measures, yet still not effectively impact claim outcomes. Including both quantitative and qualitative measures helps organizations go beyond tasks just passing a sniff test to achieving real operational excellence. -Laura Crowe, Study Advisory Council Member & Director of Risk Management, Presbyterian Healthcare Services
18 Study Findings - Prioritizing Core Competencies Workers Compensation Benchmarking Study 13 Table 4 / Survey Question: Please indicate, on average, how often your organization measures best practices / performance within core competencies for each area. (186 Responses) Response Count Real Time Semi- Total /Daily Weekly Monthly Monthly Quarterly Biannually Annually Disability / RTW Management Medical Management Compensability Investigations Case Reserving Claim Resolution Litigation Management Oversight Governance & Internal Controls Bill Review Recovery Management Fraud & Abuse Detection Vocational Rehabilitation Note: Conditional Question for respondents who answered yes to measuring best practices / performance within core competencies Using systems to drive best practices Facilitating best practices through claims system workflow automation, advanced analytics, and predictive modeling has gained significant interest on the industry s operations side, yet survey results indicate some progress can be made in adoption of these technologies. Nearly half of survey participants are not using systems to direct or manage tasks within best practices (see Table 5). Of those respondents who are using systems, 46 percent use workflow automation to drive best practices, which typically involves triggering certain claim activities to achieve optimal outcomes. Additionally, 25 percent of respondents report using predictive analytics. Predictive modeling differs from traditional business analytics in that it uses mathematical models to gain insights from data to develop variables that predict the likelihood of claim development. Early adopters utilize predictive modeling to foster more competitive underwriting practices and enhance claims decision-making throughout the claim life cycle. v A clear opportunity exists to use predictive modeling to better identify and manage claims with the potential to impact loss costs favorably.
19 Study Findings - Prioritizing Core Competencies Workers Compensation Benchmarking Study 14 Table 5 / Survey Question: Does your organization utilize any of the following systems to direct or manage tasks within best practices? Select all that apply. (258 Responses) Segmented By Organization Type respondent # by organization type Not Utilizing / Not Applicable 45% 27% - 33% 57% 57% 73% 25% 64% 64% Claims System Workflow Automation 46% 64% 100% 67% 31% 30% 18% 75% 28% 27% Predictive Analytics 25% 40% 33% 19% 15% 23% - 50% 20% 18% Other 3% 3% - - 2% 3% 9% - 4% 9% All Responses Insurance Company Reinsurance / Excess Insurance Company Self-Insured Employer Third Party Administrator Insured Employer Note: Respondents were able to select more than one answer for this question Risk Pool State Fund / Mutual Fund Gov't Entity Other Using risk / reward strategies to drive best practices and achieve outcomes A common challenge for industry leaders is how to balance incentives (rewards) and penalties (risks) that drive outcomes and operational excellence most effectively. The survey measured the use of incentives and penalties to achieve best practices for both internal staff and vendor partners. Results demonstrate an opportunity for the industry to harness these strategies better. With the increased outsourcing of key operational functions, there is a growing need to leverage risk / reward strategies with vendor partners that encourage top performance, particularly as claims organizations are being held more and more accountable for performance by their own customers internal and external. Survey Question: Does your organization utilize incentives for staff or vendor partners to achieve best practices / performance measures? 51% use incentives for staff 29% use incentives for vendor partners Survey Question: Does your organization utilize penalties for staff or vendor partners when best practices / performance measures are not met? 52% use penalties for staff 35% use penalties for vendor partners
20 Study Findings - Prioritizing Core Competencies Workers Compensation Benchmarking Study 15 Appendix B Index Prioritizing Core Competencies For more information on all survey question results and additional benchmark analyses related to this focus area, please refer to the below tables and figures in Appendix B. >> Go There B-1: B-2: ing of Core Competencies Most Critical to Claim Outcomes Segmented by Organization Type Segmented by Role Type Manager Segmented by Role Type Director, VP, & C-Level / Executive Use of Best Practices / Performance Measures within Core Competencies B-2.1: Measurement Areas for Best Practices / Performance within Core Competencies B-2.2: Measurement Frequency for Best Practices / Performance within Core Competencies B-3: B-4: B-5: B-6: B-7: B-8: Systems Used to Direct or Manage Tasks within Best Practices Segmented by Organization Type Use of an Audit or Quality Assurance Program Focused on Claim Outcomes Use of Staff Incentives to Achieve Best Practices / Performance Measures Use of Staff Penalties When Best Practices / Performance Measures Aren t Met Use of Vendor Partner Incentives to Achieve Best Practices / Performance Measures Use of Vendor Partner Penalties When Best Practices / Performance Measures Aren t Met i NCCI, State of the Workers' Compensation Line, May 2009, slide 36, available at: https://www.ncci.com/documents/ais-09-sol-complete.pdf ii Robert Hartwig, Insurance Information Institute, available at: iii Department of Labor (Bureau of Labor Statistics); Insurance Information Institute, available at: iv American College of Occupational and Environmental Medicine (ACOEM). (2006). Preventing needless work disability by helping people stay employed. Journal of Occupational and Environmental Medicine, 48, v Contingencies; Workers Comp Predictive Modeling Comes of Age, available at: