At the 2016 National Workers’ Compensation and Disability Conference, David Jones from Express Scripts, Inc., and Peter Greaney from WorkCare, Inc., presented a case study in how Express Scripts used telephonic case management to improve their claims results.
Express Scripts is a pharmacy benefit management service that is one of the largest dispensers of medications in the nation. Their headquarters features a state-of-the-art distribution center where all their mail-order prescriptions are filled. They have 120 locations in 35 states around the United States.
A couple years ago, Express Scripts merged with their largest competitor, which more than doubled their workers’ compensation exposures. The two companies had different approaches to how they managed their claims so the new company had to determine the best way to deal with their workplace exposures with this larger company. Express Scripts was self-insured, so the money being spent on claims was their own. The majority of their claims were minor with repetitive trauma being the leading accident cause.
Express Scripts decided their priorities were clinical triage, return-to-work collaboration, prompt claims reporting and nurse case management. They wanted 24/7 nurse triage so their injured workers could talk to a clinician immediately. They also wanted the employees to have access to follow-up conversations with the nurses.
They implemented their call center on 10-01-13, which was staffed with nurses and physicians with occupational physician oversight. The claims were reported by the triage vendor to the employer and their claims administrator. If the employee needed off-site treatment, the triage vendor followed up with the physician that the injured worker saw. They also put an on-site nurse case manager and clinic at their location in St. Louis that had 6,000 employees.
They felt the benefits of the on-site nurse case manager helped fill the gap between initial triage and claims administrator. There was also an emphasis on return to work and treatment coordination and ongoing medical case management.
After one year, they had a 30% reduction in overall claims and a 20% reduction in claims per 100/FTE. A big reason for this reduction is the telephonic nurse being able to recommend self-care initially for minor claims then following up to see if they needed to follow up with a physician. They also saw a 33% dip in attorney representation, indicating that the employees seemed satisfied with the program. There was a 40% decrease in lost time claims.
There were savings associated with both better claim results and lower administrative costs due to the decrease in claims volume.
This program would not be appropriate for all companies. It was successful for Express Scripts due to the combination of one large location plus many locations across multiple states. It took 24 months for the savings to start to show up as costs were up after the first year. When you implement a new program, you need to give it time for the results to actually show up.