Ohio Workers’ Compensation Managed Care Organization Impact Study Executive Summary Ohio’s Bureau of Workers’ Compensation (BWC) is one of the largest insurers in the United States. Insuring over 240,000 employers, Ohio’s BWC is one of four monopolistic, and the largest state-run, workers’ compensation systems. In the 1990’s, stakeholders came together to develop a plan for improving specific elements of Ohio’s workers’ compensation system. The resulting plan was the Health Partnership Program (HPP). The HPP program introduced managed care into the workers’ compensation system. The medical management of compensable workers’ compensation claims was contracted to Managed Care Organizations (MCOs). Determination of compensability and the payment of indemnity benefits stayed within the Bureau of Workers’ Compensation (BWC). The MCOs were further charged with employer and injured worker education regarding the new system, making the work place safer, setting up transitional/early return-to-work programs, as well as claim reporting procedures in the event of an injury. Included in their services are the processing of First Report of an Injury, Occupational Disease or Death (FROI) applications. Finally, MCOs process medical bills and make provider payments. HPP covers all private state-fund employers as well as public employers, both state and local. HPP went into effect March 1, 1997, requiring certified MCOs to begin medically managing all injuries that occurred on March 1, 1997 or later (Phase 1). Beginning September 1, 1997, the MCOs took over medical management of all claims with dates of injury between October 20, 1993 and February 28, 1997 (Phase 2). MCOs assumed responsibility for medically managing the remainder of claims, those with dates of injury prior to October 20, 1993 (Phase 3), on December 15, 1997. The current number of MCOs is 12. This is down from the initial number of 57 when HPP was initiated in 1997. BWC monitors MCO managed care performance. For example, it measures the effectiveness of the MCOs’ return-to-work efforts using the Measurement of Disability (MoD) metric. BWC also measures MCO FROI timing, FROI data accuracy, bill timing and bill data accuracy. Further, it publishes most of these measures in an annual MCO Report Card, available on www.bwc.ohio.com. Study Overview In 2018, BWC contracted with DXC Technology to evaluate the impact MCOs have had on Ohio’s workers’ compensation system. The evaluation quantified the impact MCOs have had on: ▪ medical management of claims; ▪ return to work; ▪ claim costs; 12/19/2018 1 ▪ duration, etc. Specifically, the evaluation focused on the following analysis vectors: 1. Identification of areas of missed opportunities when comparing Ohio's MCO environment with other payer environments. 2. Identification of areas of potential efficiencies in areas where the MCOs and BWC’s duties intersect and interact. 3. Identification of opportunities for resetting the strategic administrative focus of MCOs in managing Ohio workers' compensation claims. 4. Evaluating the current return-to-work outcome measures and comparison of measures across industry and similar jurisdictions. 5. Evaluating and appropriately providing recommendations on current and potential future methodologies for reimbursing MCOs for services. 6. Evaluating and appropriately providing recommendations on current MCO performance measurements identifying. 7. Evaluating and appropriately recommending changes to current MCO report card and MCO Open Enrollment processes. 8. Evaluating and appropriately identifying best practice approaches to MCO contract negotiations, along with any strategic transition or adjustment recommendations that may be necessary or prudent. This evaluation was divided into five reports: 1. Quantitative and qualitative impacts of MCOs on the Ohio Workers’ compensation system. 2. Evaluation of specific strengths and weakness of the current MCO environment. 3. Assessment of the current MCO performance measurement protocol. 4. Assessment of the current MCO payment and incentive methodology. 5. Analysis of BWC’s approach to procurement of medical management services. Summary of Findings and Recommendations Ohio is a leader in workers’ compensation. When compared to national data, Ohio has fewer work-related injuries than the national average. When injuries do occur, Ohio performs better than the national average and better than other monopolistic workers’ compensation systems at getting injured workers rehabilitated and safely returned to work. DXC collected the feedback of employers and injured workers and found that both stakeholder groups report a high level of satisfaction with the system. Injured workers report efficient, timely, and professional claim handling. Ohio’s employers feel they are receiving prompt and skillful case management, improved rehabilitation, and valuable services from the workers’ compensation system overall. 12/19/2018 2 Ohio has a mature claims processing system with indicators in place to ensure accuracy and timeliness of data, such as FROI and bill timing and FROI and bill data accuracy. These indicators are in line with industry standards and are designed to support best practices in medical management. Finally, the BWC holds MCOs to high standards. Currently, Ohio is the only state that requires MCOs to obtain accreditation from the national Utilization Review Accreditation Commission (URAC). Both URAC and BWC audits maintain a high level of quality assurance within MCOs. MCO Environment and Public-Private Partnerships: Challenges and tensions are an inevitable reality of the shared responsibility occurring in public private partnership. In order to evaluate environmental strengths and weaknesses it is important to understand that there is some unavoidable functional overlap between the MCOs and the BWC. This overlap ensures that high-quality service will be provided for injured workers and employers. These shared responsibilities require a balance between accountability and innovation, and occasionally come at the expense of optimal efficiency. Second, as with any public-private partnership, Ohio’s workers’ compensation system deals with the tensions between regulatory oversight and market competition. These qualities of this environment must be acknowledged to understand the framework in which MCOs operate. In identifying and evaluating opportunities for enhancement, we must acknowledge that Ohio’s workers’ compensation system is unique in many ways. The State has greater responsibility for oversight and management. Additionally, managed care organizations do not bear true financial risk as they do in many other managed care environments. As a result, practices that are successful in another state may be inappropriate in Ohio and vice versa. Most evaluated policies and procedures were found to be optimally suited to support this system but opportunities for potential enhancement were identified. Key Recommendations Of the recommendations DXC has made in the five deliverables, three key recommendations are being highlighted here: 1) Monitor lost time claims separately from medical only claims. DXC found that while return to work timing has been decreasing overall, return to work timing for lost time claims (20% of Ohio’s workers’ compensation claims) has increased. This increase in RTW timing for lost time claims is directly correlated with an increased indemnity cost of $700-$1000 per claim. By monitoring lost time claims separately from med only claims, BWC can improve return to work timing and indemnity costs through increased focus on this challenging subset of claims. 2) Align MCO payments to managed care industry. Currently, BWC spends 27% of its total medical benefits on MCO medical management. This is well over what industry standards are for medical administrative payments in other environments. Industry 12/19/2018 3 standards in similar environments reflects a 14% to 15% medical management spending to total medical spending. We recommend Ohio undertake a strategy which appropriately takes into account unique attributes of the Ohio environment to better align payments MCO medical management spending with the managed care industry. 3) Optimize outcome payments to align with contractual expectations and drive continuous improvement. The current system of competitive distribution of outcome payments permits rewards without improvement as long as performance surpasses that of peers. We recommend using defined performance goals to incentivize continuous improvement among MCOs as a whole rather than relative to one another. This would allow BWC to drive continuous, year-over-year improvement. In spite of the fact that Ohio ranks at the highest level of workers’ compensation performance, there are potential opportunities to further strengthen the system. 12/19/2018 4 BWC Board Presentation MCO Impact Study December 19, 2018 .1. DXC.technology Workers’ compensation managed care organization impact study Deliverable 1: Quantitative and qualitative report: Impacts that MCOs have had on the Ohio Workers’ compensation system Deliverable 2: Report identifying the strength and weakness of the current MCO environment, with recommendations on opportunities to further enhance the system Deliverable 3: Assessment of the current MCO performance measurement protocol Deliverable 4: Assessment of the current MCO payment and incentive methodology Deliverable 5: Comparative analysis of BWC’s current approach to procurement of medical management services December 19, 2018 6 2 Objective Evaluation of the impact of managed care organizations on Ohio’s workers’ compensation system. Collecting initial workplace injury reports and transmitting documentation to BWC Management and authorization of medical treatment Medical review and bill payment processing Maintaining provider relations with BWC-certified healthcare providers Return to work services Utilization review Training and education for both employers and injured workers Arrange peer reviews and independent medical evaluations as necessary for treatment decisions Processing treatment appeals through the Alternative Dispute Resolution (ADR) process. Satisfaction Efficiency Benchmark December 19, 2018 Value 7 3 MCO Environment in Ohio Shared Responsibility Functional Overlap • • Efficiency Incentives Shared Responsibility • • Public Private Partnership Functional Overlap Quality Upside Only Financial Risk Balance between efficiency and quality. Overlap ensures that quality will be met at the expense of efficiency Balance between accountability and innovation Policy vs. Market • • Regulatory oversight vs market competition Policy vs Market December 19, 2018 8 4 Overall Ohio has a lot to be proud of National Comparisons Injured Worker and Employer Satisfaction Mature Process Indicators Quality Assurance December 19, 2018 9 5 National Comparisons: Ohio is a leader in workers’ compensation Duration of Absence Ohio vs. National, 2016 Source: US BLS Injury Rate per 100,000 Workers Ohio vs. National, 2016 Source: US BLS 24 Days Absent 25 18 20 15 10 5 17 19 25 23 20 15 5 7 Back Ohio 10 10 0 All Injuries 29 30 12 7 Incidence per 100K Workers 35 30 Shoulder Knee 3 5 Back Ohio December 19, 2018 4 2 3 0 All Injuries National 12 Shoulder Knee National 10 Ohio is performing well relative to other monopolistic states * Median Days Absent Ohio vs. National & Monopolistic States Median Days Absent 30 24 25 20 15 10 18 12 10 7 19 17 18 14 12 9 8 5 5 0 20 All injuries 5 6 Back National Ohio Shoulder Wyoming Knee Washington * Comparable Data not available for North Dakota December 19, 2018 11 Injured Worker Satisfaction Overall, I am satisfied with the organization that processed my medical claims. (n = 638) The organization processed my claims in a timely manner. (n = 637) 120 72 22 334 90 106 26 313 119 73 168 Staff at the organization were friendly. (n = 637) Staff at the organization acted in a professional manner. (n = 635) 24 46 181 22 363 34 35 146 Staff at the organization were knowledgable about answering my questions. (n = 632) 36 37 70 127 Staff at the organization responded to questions in a timely manner. (n = 634) Strongly Agree 360 39 39 44 Agree 84 343 340 Disagree Conclusion: Overall, injured workers feel that MCOs add value December 19, 2018 12 Employer Satisfaction 307 MCOs add value to Ohio's workers' compensation system. (n = 1,253) 25 548 58 315 215 MCO management of claims helps workers return to work faster than they would if BWC managed claims directly. (n = 1,248) 60 627 142 487 202 MCO rehab and return to work programs help injured workers transition back into the workplace. (n = 1,241) 446 47 29 517 451 Staff at the MCO were friendly. (n = 1,243) Staff at the MCO responded to questions promptly. 1,239) Strongly Agree Agree 4 250 435 (n = 11 0 523 15 Disagree 36 491 266 100 200 Strongly Disagree 300 400 No Answer 500 600 700 Conclusion: Overall, employers feel that MCOs provide valuable services December 19, 2018 13 Employer Satisfaction 231 MCO's are generally good at handling case management. (n = 1,218) 8 333 223 MCO's have made Ohio's Workers' Compensation system better for workers. (n = 1,237) 25 508 610 55 21 219 426 Staff at the MCO were knowledgeable about answering my questions. (n = 1,242) 5 0 Agree 432 49 334 Overall, I am satisfied with the work that MCO's do. (n = 1,239) Strongly Agree 612 34 Disagree 31 504 276 100 200 Strongly Disagree 300 400 500 600 700 No Answer Conclusion: Overall, employers feel that MCOs provide valuable services December 19, 2018 14 Shared Responsibility Vs. Duplication Shared Responsibility Efficiency Incentives Public Private Partnership Functional Overlap Quality Three Point Contact Upside Only Financial Risk • Operational overlap, not design overlap • Enforcing best-practice deadlines has led to improved FROI timing • Positive impact on injured workers trying to navigate the workers’ compensation system Alternative Dispute Resolution • Duplication of efforts prior to 2009 • Efforts to streamline the process have been successful Document Collection • The Imaging Pilot Project reduced duplicative document collection and streamlined the process of information gathering December 19, 2018 15 Policy vs Market MCO Certification Requirements: URAC Shared Responsibility Efficiency Incentives Public Private Partnership Functional Overlap Quality Upside Only Financial Risk URAC: Utilization Review Accreditation Commission • National best-practice guidelines for healthcare industry and medical case management. • Requires regular announced and unannounced audits of MCOs performed by URAC representative. Ohio requires URAC accreditation • Serves as a basic indicator of competencies that MCOs must have in order to enter the marketplace. • Ohio has required URAC accreditation since 2001-2002 contract years. • Ohio is the only state that requires URAC accreditation for Workers Compensation medical management services. December 19, 2018 16 Policy vs Market Process Indicators – Mature Indicators of Efficiency Shared Responsibility Efficiency Incentives Public Private Partnership Functional Overlap Quality Upside Only Financial Risk Policy vs Market Process indicators have historically been important tools for the BWC when efficiency has been a primary goal Indirectly affects medical management and the goal of returning the injured worker to work These activities measure areas designed to support efficiency, effectiveness and quality in the system • FROI timing and FROI data accuracy ensure that the injured worker is treated quickly. • Bill timing and accuracy make sure that employer premiums are used efficiently. MCO Responsibility Collecting initial workplace injury reports and transmitting documentation to BWC Medical review and bill payment processing Activity Timing FROI timing Monthly FROI data accuracy Monthly Bill timing Monthly Provider bill data accuracy Monthly Inpatient hospital bill payment accuracy December 19, 2018 Quarterly 17 Opportunities to Improve: Moving from better to best Outcome Measures (Measurement of Disability and Exceptional Performance Indicators) MoD score - Focus on lost time claims Process Measures On Site Case Management December 19, 2018 18 Analytic Methods • Mixed-methods (quantitative and qualitative analysis) • Contextualized with industry, market and medical data • Analytical expertise in medical management of conditions studied Surveys and Interviews Episode-based Bill Analysis December 19, 2018 Industry Benchmarks 19 Episodes of Care An Episode of care is a defined set of services provided to treat a clinical condition or procedure Episode of Care enhanced data allows stakeholders to focus on cost, services and quality. • The episode of care algorithm uses codes reported on claims or bills to analyze treatment and condition groups for specific time periods • Episodes are an analytical lens examining the value of care delivered for the treatment of specific injuries, disease conditions and procedures. • Ohio Ohio Department of Medicaid • • • 43 Episodes of Care for Acute, Chronic and Behavioral Health 33M claims examined 5M Episodes Created 18,000+ Providers Measured Tennessee TennCare December 19, 2018 • 48 Episodes of Care for Acute, Chronic and Behavioral Health • 18M claims examined • 2.5M Episodes Created 20 Compare performance over time within and outside of BWC environment These Episodes represent 50% of missed days and 20% of claims Consolidated view of MCO impact on utilization and return to work Utilization Knee Arthroscopy Total Injured Workers Shoulder Injury Cost Return to Work Low Back Pain Episodes of Care are detailed, standardized comparisons of care provided to treat specific injuries Identify opportunities for improvement December 19, 2018 21 MCO impact evaluation: Quality and Cost Quantify the impact MCOs have had on: ▪ medical management of claims ▪ return to work ▪ claim costs ▪ duration December 19, 2018 22 You Can?t Manage What You Can?t Measure MOD EPIs Episodes Process .1. DXC.technology December 19, 2018 Medical Care Quality & Cost Containment Improvement in performance on measured quality metrics Medication management: • Reduction in opiate usage • Reduction in high-risk prescribing of opioids and benzodiazepines Improvements in control of low value, high-cost care • Reductions in repeated MRI, increases in conservative/incremental imaging • Repeated emergency visits December 19, 2018 24 Medical Care Quality & Cost Containment Proportion of BWC claims Medical Only Claims • 7 days or less off work • Average duration of absence is improving if all claims grouped together (medical + lost time) Lost Time Claims • Greater than 7 days off work • The average duration of absence is increasing if lost time claims are examined separately December 19, 2018 Lost LostTime Time 20% 20% Medical Only 80% 25 Return to work timing: improving All three episode types showed Improvements in return to work following injury in recent years • Average duration of absence is decreasing for all claims when both medical only and lost time claims are evaluated together • 80% of BWC claims are medical only 51.56 76.30 164.37 2017* *2017 data incomplete at time of report Both Medical & Lost Time December 19, 2018 26 Return to work timing: • All three episode types showed poor RTW results when evaluating lost time claims separately from medical only claims. • The duration of absence is not improving and is increasing for lost time claims. Lost Time Only *2017 data incomplete at time of report December 19, 2018 27 Opportunity for improvement based on episode analytics data: RTW for lost time claims Excellent progress in the system overall Both Medical & Lost Time Lost time claims not experiencing the same improvement Conclusion: Issue of visibility for lost time claims. By grouping the two claim types, trends in this important 20% of claims are obscured. Lost Time Only Recommendation: • Continue evaluating both claim types to monitor system overall • Stratification of medical only and lost time claims to provide greater visibility into trends in RTW for claims of each type. December 19, 2018 28 Shared Responsibility Efficiency Evaluation of Outcome Performance Evaluation Measure: Measurement of Disability (MoD) Incentives Public Private Partnership Functional Overlap Quality Upside Only Financial Risk Goal: Evaluate MoD metric used to measure MCO performance Official Disability Guidelines (ODG) • National set of guidelines with multiple functionalities assisting medical management • Also has a RTW estimator which we selected to validate Set out to validate the effectiveness of MoD in terms of its ability to measure MCO performance December 19, 2018 29 Policy vs Market Tested MoD and ODG’s Return to Work Prediction Goal: Determine which was more closely aligned with actual days absent Finding: Greater agreement between MoD scoring and actual days absent than ODG RTW vs. days absent Recommendation: • Maintain the calculation methodology of MoD • Update diagnosis coding used for MoD calculations from ICD-9 codes to ICD-10 • Update the benchmark data used for evaluation of claim duration and diagnosis severity – Updating is currently in progress December 19, 2018 30 Greater agreement between MoD scoring and days absent than ODG RTW vs. days absent. Tighter line indicates better agreement between tested disability metric and actual duration of disability December 19, 2018 31 Exceptional Performance Indicators Shared Responsibility Efficiency Incentives Public Private Partnership Functional Overlap Quality Upside Only Financial Risk Introduced in 2016 in order to emphasize specific highvalue actions in medical management 1. Medication management • Initiative Policy vs Market • Benchmark 2. Vocational rehabilitation 3. Transitional work 4. Legacy return to work 5. Wellness programs Conclusion: Data are new, but the nature of EPIs is aligned with best practice to drive continuous improvement in a nontraditional risk-sharing model Recommendation: Continue to collect MCO performance data on these indicators evolution of performance measurements and benchmarks December 19, 2018 • Expected Medical Management Identify goals and objectives where incentives are applicable Develop and implement initiatives, models and targets As incentives become routine, they become an expectation rather than an incentive Measure performance, apply analytic tools and report outcomes • Measures 32 Shared Responsibility On-Site Case Management Efficiency Incentives Public Private Partnership Functional Overlap Quality Upside Only Financial Risk Policy vs Market Situations where on-site case management services may be needed include: 1. Verbal communication barrier. 2. Disagreements or misunderstandings of treatment plan hindering RTW. 3. At the request of the injured employee. 4. Facilitate initial emergency treatment to expedite medical care. Appropriate use of on-site case management for high-value cases is of great value: • Expected as part of medical case management in other environments where MCOs bear financial risk. • In Ohio MCOs do not share financial risks for medical costs so incentivization may be required in this environment, even though on-site case management is an expected part of claims management in other circumstances. We recommend that MCOs and BWC reevaluate medical management guidelines and consider development of a payment structure that would reward high-value use of on-site case management, only when intense medical management is required. December 19, 2018 33 Shared Responsibility Efficiency MCO Administrative Payments: Moving from better to best Incentives Public Private Partnership Functional Overlap Quality Upside Only Financial Risk Policy vs Market Aligning administrative payments with industry standard Revising competitive MoD outcome payments December 19, 2018 34 Administrative Payment Comparison Plan Type Median % of Premium for Admin. Costs Managed Care Plan, insured** insured 14% 14% Managed Managed Care Care Plan, Plan, ASO ASO 8.5% 8.5% Indemnity Indemnity and and PPO PPO Indemnity Indemnity and and PPO, PPO, ASO ASO 15% 15% 8.6% 8.6% Medicaid** Medicaid 13.8% 13.8% Services provided by MCOs • First Report of Injuries • Medical Management Services • Provider Relations • Return to Work Services • Quality Assurance • Employer Services • Provider Bill Processing in a timely, accurate manner • Alternative Dispute Resolution • Peer-review * Ohio BWC MCOs are most similar to these plan types based on services offered. December 19, 2018 35 Key Differences in Managed Care Environments 1. Ohio MCO provide services that are not perfectly comparable to other environments. 2. In a traditional full-risk-reward managed care environment, savings and risk are transferred to the MCO. 3. MCOs in other environments have different tools, types of leverage and obligations. 4. Differing duration of medical management. December 19, 2018 36 MCO Administrative Payments 2017 2016 2015 Medical Benefits Paid* $461,780,100 $492,913,038 $510,064,188 Total MCO Fees Paid $170,797,091 $169,229,310 $170,688,324 Total Paid $632,577,191 $662,142,348 $680,752,512 27% 26% 25% Total MCO Fees Paid (%) *Medical Benefits Paid do not include PBM costs. Conclusion: Administrative payments made to Ohio MCOs is greater than that observed in other environments December 19, 2018 37 MCO Payments 2017 2016 2015 2014 2013 2012 2011 2010 $180 $160 $140 $120 $100 $80 $60 $40 $20 $0 2008 2017 2016 2015 2014 2013 2012 2011 2010 2009 80K fewer open claims per year 2008 1,500 1,400 1,300 1,200 1,100 1,000 900 800 700 600 2009 Available MCO Payment per Year (In Millions) Statutorily Open Claim Volume by Year (In Thousands) Open Claim Volume per year has decreased but MCO payments have remained constant December 19, 2018 38 34 MCO Administrative Payments Amount Paid to MCOs per Statutorily Open Claim by Year $2,200 $2,000 $1,800 $1,600 $1,400 $1,200 $1,000 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 The cost per statutorily open claim is increasing each year. December 19, 2018 39 MCO Payments Additional Recommendations: • Align MCO payment with industry standard in terms of MCO payments as a percentage of total expenditures. • • While taking into account unique requirements and objectives of the HPP. Incentives and outcome payment methodologies should be further evaluated and reconsidered. • In concert with well-established benchmark targets and appropriate risk distribution. • In order to align with industry standards, we recommend the BWC adjust the MCO medical management payment to reflect industry standards while taking into account Ohio’s unique environment. • The distribution of administrative and outcome payments need to reflect the goals and objectives of the HPP and use incentives to mirror what exists in a traditional MCO environment. December 19, 2018 40 Changes to MoD Payments • Current payment distribution: – A pool of money is fully distributed among MCOs. – Success is defined relative to peers MCOs instead of an absolute threshold. – Competitive distribution permits rewards without improvement as long as performance surpasses that of peers. • Creation of an acceptable performance threshold may better serve the goals of the HPP because: – Incentivize continuous improvement among MCOs as a whole rather than relative to one another. – Allow BWC to drive continuous, year-over-year improvement through defined performance goals. – Risk-reward December 19, 2018 • Performance Benchmarking focuses on identification and obtainment of best practices and rewards continuous improvement • Competitive Benchmarking focuses on the performance in the metric and is best used when the goal is to determine the relationship and distribution of peers -Six Sigma performance evaluation best practices 41 Topic Report area Evaluation Satisfaction Excellent Impacts that MCOs have had Return to work - overall on the Ohio workers’ Operational Ability compensation system Cost savings Conduct a satisfaction survey of workers & Employers once every two years Excellent Good Good Return to work – lost time claims Room For Improvement Market competition and Open Enrollment Good Identifying the strengths and Duplication of Labor weaknesses of the current Clinical Editing and Medical Bill Review MCO environment Assessment of the current MCO performance measurement protocol Recommendation Monitor RTW separately for lost time claims Room For Improvement Continued reinforcement of labor division protocols Room For Improvement MCOs adopt competitive editing & review criteria Development of process & outcome indicators Room For Improvement Updates underway to reflect performance achievement levels & drive improvement MoD Accuracy Excellent Continue with current MoD scoring Administrative benchmarks Room For Improvement Update performance achievement levels to drive improvement MoD Score benchmark data Needs Revision Update benchmarking data & use ICD-10 codes Exceptional Performance Indicators Good Continuing to collect MCO performance data on these indicators & refine benchmarks Room For Improvement Assess performance relative to acceptable thresholds Room For Improvement Reevaluate guidelines for on-site case management and incentivize appropriate use when intense medical management is required. Needs Revision Align MCO payment to market standards MoD based outcome payments Assessment of the current MCO payment and incentive On-site Case management methodology Administrative Payments Quality Assurance Monitoring Comparative analysis of BWC’s State Comparisons current approach to procurement of medical Performance Benchmarks management services Incentive Strategies Excellent Excellent Consider Trusted Provider Networks Good Increase data timing and accuracy thresholds Room For Improvement Optimize incentives to align with contractual expectations and drive continuous improvement December 19, 2018 42 December 19, 2018 Appendix Additional supporting data DXC.technology A Episodes of care as a measuring tool Inj Li ry Treatment Rec every 1- a! ss_ss 9% a return te werk rij Receverv Iviedirsei fellow-Up services Oversight and Appropriate Incrementpi use monpgement of follow?up core of prescriptipn impging drugs .1. DXC.technology 19 2018 ecem er .1. DXC.technology December 19, 2018 45 KNEE ARTHROSCOPY Quality Metric 1 SHOULDER INJURY LOWER BACK PAIN Quality Metric 1 Quality Metric 1 a Quality Metric 2 Quality Metric 2 Quality Metric 2 l?I CLINICAL QUALITY METRICS Quality Metric 3 Quality Metric 3 Quality Metric 3 3CD Quality Metric 4 Quality Metric 4 Quality Metric 4 ii. Quality Metric 5 l??l