Employers across the country are looking to provide employees with the largest and widest PPO networks as a means of giving employees choice. Somehow the health insurance industry has determined that networks should be “all-inclusive.” The more medical professionals and facilities in your network, the better your network is. It is time to raise a red flag on this kind of thinking. Before your organization looks to increase employee access to doctors and hospitals, there are three things you must understand about PPO networks.
Larger Networks Can Lead to Larger Plan Costs
You hear it all the time. Insurance carriers battle over who has the largest network both locally and nationally. Now, having a network with a national presence can be appealing if you are an employer with facilities and a workforce scattered across the country. However, a larger network opens the door for greater access to poor-performing physicians and medical facilities. The bigger the network, the greater the odds your employees are accessing doctors and hospitals who are not on the right side of cost, quality and outcomes. As a result, your medical plan’s costs continue to rise year after year.
In a typical medical plan, the majority of the member population will use the plan via day-to-day services such as preventive exams, sick children and the occasional medication. For these folks, a network discount does an adequate job reducing costs for both the member and the health plan. However, imaging, surgeries and hospital stays are driving plan costs today, and it is here where a network “discount” can be misleading. Yes, network discounts are still applied to these services and, yes, the discounts can be 50% or more. However, when facilities are allowed to charge 400%+ of the limit allowed by Medicare, you are not getting much of a deal at all. To put it into simple terms, if I told you my iPhone is worth $2,000 but agreed to sell it to you for a 50% discount, I would still be ripping you off.
Networks Often Block Creativity
Recently, I had an interesting conversation with a national insurance carrier about a mutual client. After a thorough review of the client’s claim activity, we uncovered several facilities that were providing imaging services (MRIs, CT scans, etc.) at a low cost, much lower than the same services provided at other facilities. Knowing this, the client wanted to give members incentives to choose the low-cost facilities when needing imaging services by agreeing to have the health plan pay 100% of the service, saving both the member and the health plan money. However, we were told “no” by the insurance carrier because it had a duty to “keep the rest of the network happy.” If we are going to create change in the health insurance market, employers need to implement creativity into health-plan design. Unfortunately, most PPO networks discourage this kind of thinking.
Remember, there is a place for PPO networks within the healthcare industry. However, if you are an employer looking for creative ways to give your employees access to high-quality, low-cost doctors and hospitals, do not count on PPO networks to pave the way.
How do you manage risk when your company is the biggest employer in the U.S. other than the federal government? Very carefully — and very well, if you’re K. Max Koonce II, the senior director of risk management at Walmart, until recently, when he took a senior position at Sedgwick. You do that partly by taking advantage of an extraordinary amount of data to identify potential problems, to use outcomes analysis to greatly shrink the number of litigation firms you use, to be highly selective about doctors used for workers’ comp and even to set up a full-sized, in-house third party administrator.
But let’s begin at the beginning:
Koonce was born in Mississippi, but his family moved to Bentonville, AR, where he has lived most of his life with his wife and family. He attended Harding University, a private liberal arts university located in Searcy, AR, where he graduated with a BBA in economics. Thinking that economics was not as challenging a career as what he aspired to, Koonce attended the University of Arkansas William Bowen School of Law to obtain his J.D.
He was immediately hired by Walmart upon his graduation in the ’90s and was given the responsibility to set up Walmart’s internal legal defense system for the roughly 30,000 Walmart employees at the time. He and his in-house team of legal aides handled all of Walmart’s workers’ comp and ultimately much of its liability claims. The program worked so well that the governor of Arkansas appointed Koonce as an administrative law judge for the state workers’ comp commission in 1997, with Walmart’s blessing. With Koonce’s departure, Walmart eliminated the internal legal program and transferred its litigation to outside legal firms.
K. Max Koonce II
By January 2000, Koonce was appointed by the governor to the Arkansas Court of Appeals. With a vacancy in the State’s Supreme Court, Koonce ran for State Supreme Court in a partisan election. During the campaign, he shared fond memories of attending all kinds of civic events, fundraisers and county fairs around the state. When he failed to get elected, Walmart brought him back to head its risk management program that same year. The program grew dramatically with his return.
Apart from the U.S. government, Walmart is the largest employer in North America. Nearly 20 million people shop at Walmart every day, and 90% of the U.S. population lives within 15 minutes of a Walmart. If Walmart were a country, it would be the 26th-largest economy in the world. Walmart manages 11,500 retail units in 28 countries; generates $482 billion in annual sales; and has 2.2 million employees (1.4 million associates in the U.S.). Koonce exclaimed that there was no other retail company to benchmark to, so his risk management department had to make up its own risk benchmarks. Interestingly, with a tightly managed work culture and such huge numbers to work with, Walmart’s risk management statistical and actuarial claim calculations have proven to be consistently accurate for many years.
Walmart’s risk management department has grown over the years to more than 40 risk management support personnel. Walmart divides its risk portfolio by working with two competing insurance brokers. Koonce said he had an incredibly talented and dedicated team of risk management professionals working at headquarters in Bentonville. “The analytics and metrics achieved by my experts,” he said, “were as good as any in the insurance industry.” He said that no relevant risk factors in Walmart’s operation went unnoticed.
Walmart’s workers’ comp program is designed to include specific doctors and medical facilities to ensure consistent care of any injured workers. Walmart manages detailed feedback from all of its employees to continue to fine tune its workers’ comp program. Koonce stated that risk management has always been a part of the Walmart culture, going back to its founding by Sam Walton in 1962; Walton wanted to help individuals and communities save money while ensuring that the company’s operations adhere to ethical decision making, good communication and responsiveness to employees and stakeholder.
Using an “outcomes-based” approach to litigation management, Walmart’s team relies on claims data analysis and metrics to choose, evaluate and consolidate the number of workers’ comp attorney firms. Max notes: “This approach forms tighter relations with a smaller number of lawyers to create a ‘one team’ approach to litigation.” In California alone, for example, the mega-retailer reduced the number of legal defense firms from more than 20 to three. The outcomes-based litigation strategy relies on a multivariate analysis using Walmart’s own claims data. Metrics are used to benchmark attorney performance and align specific lawyers with cases depending on claim facts and knowledge about an attorney’s unique skills and experience. At Walmart, claims examiners generally choose specific defense attorneys to maintain a continuing team relationship.
Besides retail store risks, Walmart also manages the largest private trucking firm in the U.S. and delivers more prescriptions than any other retailer. Asked if he had experienced any highly unusual claims during his tenure at Walmart, Koonce said that Walmart is all about awareness, control and consistency and that claims were nearly always within an expected parameter (i.e. slip-and-fall claims) and not horrific, as some employers experience. Each store location, including Sam’s Clubs, have conscientious safety response teams that sweep the stores periodically during their shifts and respond immediately to any safety hazards like floor spills.
A unique feature of Walmart is its subsidiary, a third party claims administrator (TPA) called Claims Management Inc. (CMI), at which Koonce served as president. Located in nearby Rogers, AR, CMI administers the casualty claims, including workers’ compensation, for all Walmart stores. Although most companies with national operations use insurer claims administrators (for non-self-insured operations), or multiple regional TPAs, Walmart’s CMI operation is a sizable TPA of its own with 600 employees. As Koonce explains, “CMI provides the claims oversight the company feels is desirable to maintain good control, communication and consistency.”
Unlike most national companies, Walmart has been able to maintain a highly efficient and focused risk management program through a tight-knit organization consisting of mostly local or regional employees who live and work in Benton County, AR (pop. 242, 321). Most of Walmart’s managers have been employees who have worked their way up the corporate ladder. Sam Walton once said: “We’re all working together; that’s the secret.”
Koonce left Walmart in September to serve as senior VP of client services for Sedgwick Claims Management Services. He was succeeded by Janice Van Allen, director of risk management at Walmart, who started as a store department manager in 1992. Koonce said he’s doing what he loves most at Sedgwick — helping risk managers achieve success with their internal programs.
If a patient or her attorney believes a physician is responsible for a bad outcome at an outpatient medical facility, the facility itself will be sued, not just the physician. Therefore, it is up to the facility to have established procedures and protocols in place to deter the risk of lawsuits. Here are five tips for outpatient medical facilities that may help reduce the risk of lawsuits.
#1. Good patient communication
Communication is the No. 1 issue in any medical setting – outpatient care is no exception. Within outpatient services, patients don’t typically have the same depth of relationship with the doctors as they do with their own primary physician. This often makes them more inclined to pursue legal action in the case of a bad outcome or adverse event. If facility physicians and staff take even a few minutes of extra time to answer all questions and address all concerns, patients and their families will walk away feeling as though they had all the information – even if a bad outcome occurred.
#2. Confirmation of informed consent
The patient is at the outpatient facility because of a medical problem – usually determined by his primary physician – who then referred him to the outpatient facility. It is the facility’s job to confirm that informed consent has occurred between the patient and physician, so policies must be in place to ensure this happens with each and every patient encounter. Patients must be informed of the details of the procedure, the risks and benefits and any alternative treatment options. A procedure should not be performed until informed consent has been confirmed. When patients or their families feel they were provided all available information, they are much less likely to pursue a lawsuit in the case of an adverse outcome.
#3. Proper documentation
Documentation can make or break a case when attorneys become involved. Be sure everything is documented, including all test results as well as the date, time and subject of all conversations with both the referring physician and patient. In the event of an adverse outcome where the court becomes involved, the ability to show all conversations is essential. For example, it can be invaluable to show that the referring physician was spoken to on a specific date and that the patient was given specific recommendations.
#4. Thorough and safe medical records
The outpatient setting leaves many opportunities for accidental breaches simply because so many patients are cycled through the facility on any given day. Printed medical records must be kept safe and strictly out of the public view – and that includes being locked away each night. It’s essential that facilities have protocols in place that diligently track the security of medical records at every step.
#5. Prompt diagnosis
Patients often don’t realize how long it may take for medical tests to return. Some lab tests can take days or weeks. Outpatient medical facilities must have an efficient procedure in place for obtaining results and delivering them to patients and the ordering physician in a timely manner. Let’s say a patient had an MRI because of an unidentified growth in breast tissue. If the MRI indicates suspicion for cancer, how does the facility ensure that test results aren’t getting lost in the shuffle? The cancer could spread and lead to a bad outcome. A system of checks and balances must be in place that helps the ordering physician see the results, and act quickly based on the findings. In an outpatient facility, all staff must be informed as to which test results need to be called in to the referring physician immediately.
Bottom Line – All of these reasons come back to the No. 1 issue: communication. For a busy outpatient facility, it can feel as though there simply isn’t enough time to talk to patients, but, from a risk management perspective, the importance cannot be stressed enough. It’s important to take the time to communicate every step of a patient’s care with her – to listen and answer her questions. Not only does this help to build trust, it can also minimize the risk of a lawsuit. Excellent communication between the provider and patient almost always creates a “win-win” situation.