Case Management: Thyroid Joey Tabula Mayou Martin Tampo Korina Ada Tanyu.
Click to edit Master title style Presented by: Joey Page President of Essential Risk Solutions...
Transcript of Click to edit Master title style Presented by: Joey Page President of Essential Risk Solutions...
Click to edit Master title style
Presented by:Joey Page
President of Essential Risk Solutions
Excellence in Risk Management through Enterprise Risk Management
Learning Objectives Today
• What is ERM?• How does it fit within a Public Entity structure?• Public Sector ERM• Why should we expand our thinking?• TRM & ERM: Key comparisons• ERM – Who’s doing it?• Who’s ready for ERM?• ERM tools & resources
Why ERM? Why Today? Why you? Why Me? Why your Entity?
• Summed up, Public Entity’s need the concepts of ERM today more than ever to survive-not simply to exist
• Why TODAY? Simple, economics will drive you to ERM more than anything else.
• Who has unlimited funds to balance your budget?• ERM Process helps you go through processes
that helps find funding or unnecessary services.
So What Is Enterprise Risk Management?
Enterprise Risk Management defined:
“Enterprise Risk Management (ERM) is a process, affected by the organizations leadership, applied in a strategy setting, and across the organization, designed to identify potential events that may affect the organization, and manage risk(s) to be within its risk appetite, to provide reasonable assurance regarding the achievement of the organization’s objectives.”
Let’s Break It Down
• Process – ongoing and fluid throughout the organization structure • Affected – every person at every level• Applied in Strategy Setting – you have to have a game plan• Applied Across the Organization – no one is left out • Designed to Identify Events – good and bad• Reasonable Assurance – yes management; it works • Geared to Achieve Objectives – touches every department, every
school
Sounds good, looks pretty on paper, has all kinds of cool buzz
words, and it works. So why this topic???
Reality checking in government:
• No one is held accountable for much of anything• More silos in government than grain silos in the Mid-
West
• Yes, we have a budget, but theoretically we will not be shut down if we run out of money( CA has seen some Entities go belly-up; The whole state is on the brink of financial collapse)
• Most organizations see Risk Managers as claims handlers
• Most Within The Risk Management Community Are Waiting To Be Told To Look Into ERM
Why Broaden Risk Mgmt?
• Yellow Springs, OH – This village near Dayton will lose $140,000 in income tax revenue when Antioch College closes next year due to lack of money, taking with it 160 jobs and 300 students (USA Today – Wednesday, August 8)
What revenues does your entity rely upon? Are there “non-essential” services that might be cut? Any potential risks associated with that??
Why Broaden Risk Mgmt?
• Pittsburgh, PA – 11 teachers 2 counselors “furloughed” in addition to 160 teachers who retired last year. District is dealing with declining enrollment with student population down by 1,500 from last year (USA Today – Wednesday, August 8)
• Dallas, Ft Worth, Plano, Austin, San Antonio had to build in furlough days to help balance budgets this year
What happens when you have fewer employees doing more, fewer resources available to employees & declining morale??
Why Broaden Risk Mgmt?
• NYC, NY – 3 city traffic enforcement agents were arrested and charge with writing >46 falsified parking tickets, to make it appear they had been busy (but no worries, the bad tickets will be voided) (USA Today – Wednesday, August 8)
How long does it take to recover from a bad reputation??
Why Broaden Risk Mgmt?
• What if your entity has a great crisis response plan in place to deal with a flu pandemic but you haven’t coordinated it with surrounding entities, the state, local hospitals or private businesses?
• How many have had a coordinated discussion of IT risks across your organization? Consider on-line payments, private medical information, sensitive financial data, student records...
• Have all of you along the Gulf Coast really sat down and worked thru the logistics of working together before, during, and after a hurricane? FEMA?????
(TPCG just entered into inter-local with Monroe)
ERM: A Few Key Issues
• Very broad approach to risk• Risks identified by risk owners, not “experts” –
mitigated by them, too• Tied to strategic objectives• Risk ownership• ERM “thinks forward”
Real issue for risk managers with ERM today is it is finance and/or internal audits based.– If you are not in one of these two areas, you will probably
never see ERM.– RM’s in Public Sector are not involved in the Finance side of
the equation unlike their private sector counterparts.– If you have not been provided ERM by your current broker, you
will not see it any time soon.– If you have not gone out to bid in a long time, and do not plan
on going out to bid soon, you will never see it.– If your risk manager does not get out of their office to
investigate accidents, conduct facility audits or visit the troops – they are less inclined to try anything new, including ERM.
• Or maybe you looked into it and just cannot imagine ERM working in your entity
• QUESTION?– Has anyone in the audience today ever considered ERM
for their organization?– Is anyone considering or in process of implementing ERM?– (Will anyone even consider ERM?)
Comparing TRM & ERM
TRM• Grew out of safety &
insurance purchase• Risk = bad• Framed by mgmt
process; focuses on problem solving to reduce & mitigate risk
• Focuses on insurable risks
ERM• In US, emerged from
financial & banking indus.
• Risk = bad + good?• Framed by
measurement & control processes; focuses on strategic objectives
• Wide focus on ALL risk
TRM & ERM
TRM
• Starts at the bottom??• Reports to Legal, HR,
Finance or Manager• Risk Management Policy
across org?• Accident review
committee, safety or RM committee
ERM
• Starts at the top??• Reports to CEO, audit
committee or CFO• ERM mandate
established• Interdisciplinary
advisory council or RM steering comm.
Hazard Risks
Financial RisksExternally driven
Property Damage
Employee injury
Public Liability
Natural disasters
Interest rates
Asset values
Loss of funding
Tuition stability
Distance Learning
Information
systems
Regulatory
environment
StrategicRisks
Operational Risks
Changes in Student Needs
Alliances
Image/Reputation
R&D
Intellectual capital
Campus Safety
Student activities
Cash flow
Campus life issues
Internally driven
Interest rates
Loss of funding
Risk Quadrants - HE
Hazard Risk
Risks that are generally covered by insurance, and that result in non-financial asset impairment.– Natural hazards– Physical damage to tangible assets– Injury to students, faculty, staff and visitors– Environmental impairment– Injury to citizens on parks, in Civic Centers– Automobile accidents– School bus accidents– Workers’ Compensation
Financial Risk
Risks related to the financial well-being of the institution. This includes such things as:– Interest rate volatility– Revenue stability– Cash flow– Asset value– Investments– GASB 45– Auditing Standards by Rating Agency’s
Strategic Risk
• The risk that an institution will be unable to fulfill its mission as a result of its failure to adapt to the changing needs of its stakeholders and operating environment, or its failure to implement all or part of its strategic plan. This includes:– Intellectual property– Distance learning– Changes in demographics– Alliances– Competition by other entities for limited Local, State or Federal
Programs and resources, including Employee’s (yes, you do have competition)
– Economic Climate
Operational Risk
Risks related to the operation of the institution and its facilities. This includes:– Information technology– Student activities– Succession planning– Board composition– Purchasing procedures– Accounting practices
ERM: Who’s Implemented COSO?
Private Sector
• Wal-mart – world’s largest retailer• Unocal Corporation – one of world’s largest oil &
gas co’s• General Motors – world’s largest vehicle
manufacturer• FirstEnergy Corp – 4th largest investor-owned
electric utility in US• Toyota-U.S.A.
ERM – Higher Ed
• University of CA system• University of CO system• Maricopa County Community College District • IL State University• UNC – Chapel Hill• NCSU – ERM Initiative• Abilene Christian University
ERM in Public Entities
• Maricopa County, AZ• State of WA• Bonneville Power (Portland, OR)• Plano,TX??
Emerging…• NM Association of Counties• Dallas/Ft Worth International Airport
I am not aware of anyone in Louisiana public sector practicing ERM at this time
Public Entities “Ripe” for ERM
• Looking for “what’s next?”• Want to be visionary, forward thinking about risk• Good upper-level support for RM• Solid, functional RM program with a good leader• Not an organization in turmoil, with strong “silos”
and turf issues
A Few ERM Resources
• Check out the Australian Standard – http://www.saiglobal.com/shop/script.asp
• URMIA Journal & new ERM initiative – www.urmia.org
• RIMS ERM Center of Excellence is evolving at www.rims.org
• COSO – www.coso.org
• IIA (Internal Auditors) www.theiia.org
• Develop Your Own Standard
So What Does ERM Look Like
Sample Employee Survey
Risk Ranking Tool
Risk Register
Still not able to get arms around ERM?
– Introducing –
• PERS or Public Entity Risk Solutions• We took the best of the COSO standard that
would or could fit in the Public Entity Framework and created PERS to work from
WHY? I can’t even understand all the different Standards out there. Nor is there one applicable to Public Entity’s.
PERS – Old Fashion Risk Management
• About visiting and working across silos • Helping other departments be better at what they
do• Do what you can with what you have• Communicate – Risk is not a vacuum• It is about bringing all the stakeholders together
to better manage the entities risk
Why the name change to PERS?
Simple:• Public Sector Brass dislikes anything new for the most
part and like things they know very little about even less
• Plus, if they looked up ERM, they would see more about it pertaining to the private sector…
And why should government ever be run like a business????
Remember: With ERM, you must think outside the box
How is Risk Management Evolving?
Transactional
Traditional Risk Management – Hazard-based risk identification & controls– Compliance issues addressed separately– Safety & emergency mgmt handled separately– Purchases insurance to cover risks– A “siloed” approach – risks are not integrated or
managed broadly across the organization– Risk Manager is the insurance buyer
Risk is bad – focus is on transferring risk
Integrated
Advanced Risk Management– More proactive about preventing and reducing risks– Integrates claims mgmt, contracts review, special event
RM, prevention & training, insurance and risk transfer techniques
– Cost allocation used for education and accountability– Lowers insurance costs (over time)– More collaboration – as depts. are willing– Risk Manager may be the risk owner
Risk is an expense – focus is on managing risk
Strategic
Enterprise-wide Risk Management– A wide range of risks are discussed & reviewed, including
reputational, human capital, strategic & operational – Aligns RM process with strategy and mission– May include “upside risks” (opportunities)– Helps manage growth, allocate capital & resources– Risks are owned by all & mitigated at the department level– Many risk mitigation tools available– Risk Manager is the risk facilitator & leader
Risk is uncertainty – focus is on optimizing risk
How is Risk Management Evolving
Risk Management Perspective
Traditional Risk Management • Hazard-based risk identification & controls• Compliance issues addressed separately• Safety & emergency mgmt handled separately• Purchases insurance to cover risks• A “siloed” approach – risks are not integrated or managed broadly across the organization• Risk Manager is the insurance buyer
Advanced Risk Management• More proactive about preventing and reducing risks• Integrates claims mgmt, contracts review, special event RM, prevention & training, insurance and risk transfer techniques• Cost allocation used for education and accountability• Lowers insurance costs (over time)• More collaboration – as depts. are willing• Risk Manager may be the risk owner
Transactional
Strategic
Risk is bad – focus is on transferring risk
Risk is an expense – focus is on managing risk
Risk is uncertainty – focus is on
optimizing risk
Integrated
Who’s Responsible for Risk?
C.M. Owns Risk
RM Steering Comm. Oversees Risk
Mgmt. & EmployeesIdentify & Mitigate Risks
Everyone is ResponsibleFor Risk
Risk Management Steering Committee
• City Manager ,Parish President, Superintendent• Executive Directors, Asst Superintendents• Entity Attorney• Budget Director• Finance Director• Risk Manager
Risk Management Steering Committee
• Ad hoc committee originally formed to approve large claim settlements.
• Scope expanded to provide direction and oversight, via RM, to treatment of risk throughout the Entity.
• Committee meetings have evolved from claims handling to risk tolerance.
• Approve Insurance Programs, Self Insured Retentions
Managers Need to Understand under ERM
• They are Risk Managers• Accepting and managing risk is their
responsibility• The ultimate success of the City, as well as their
personal success, depends on how well they accept and manage risk
• We don’t just tell them what they can’t do• We help them optimize risk taking• Risk is a partner with Operations
The New Face of Risk
• A systematic approach to managing the risks associated with opportunities in a consistent and coordinated manner, across the entire organization.
Stakeholders
• Residents• Taxpayers• Citizens• Employees
These are the constituencies that entity leaders and management strive to satisfy. An amazing balancing act to say the least.
Goals of ERM
• Protect the Entity from risks that prevent it from achieving its objectives
• Increase the efficiency and effectiveness of operations by decreasing frictional costs associated with risks and optimizing the allocation of resources
• Increase opportunities by treating the associated risks within the entity’s risk appetite
• Increase stakeholder value
Implementation Plan – Steps
Communicate to ALL appropriate stakeholders– Plan the project– Conduct risk assessments– Rank & prioritize risks– Identify risk owners & mitigation options– Implement mitigation efforts & track results– Monitor & revise as necessary
• This needs to be communicated to all appropriate stakeholders
Entity ERM Process
Entity’sVision Entity’s Goals Risk Framework Identify Risk
Universe Risk Workshop Control & Action Workshop
MonitorEvaluateManage
Vibrant, Safe, Sustainable
City
Premier Cityin Which to
Live
CategorizeRisk
Survey Stakeholders
CrossDepartmental
DiscussionsEvaluate Risk Develop Timeline
Vital Economy Livable and Sustainable Community
StandardizeFramework/
Language
Compile Results
IdentifyAdditional
Risk
EvaluateExistingControls
Take Action
High Degreeof mobility
“Service Excellence”
Reference Benchmark Share Data Prioritize Risk Identify
Deficiencies Monitor Progress
Abundance of Educational, Recreational and Cultural
Diverse Business Center
ScheduleWorkshop
DevelopAction Plan Address Gaps
Opportunities
Safe, Efficient
Travel
AssignResponsibility Report Results
ERM Implementation Plan
Project Plan 0-18 mos.
Risk Assessment 12-30 mos.
Risk Ranking 24-42 mos.
Mitigation Options & Owners
36 – 54 mos.
Implementation & Tracking
48-60 mos.
Reporting; Monitor & Modify
60-60+ mos.
Develop draft planImplement Mgmt Self
Assessment SurveyPrioritize risks from Mgmt
Survey
Clarify responsibilities & develop tools & resources as needed (heat maps, etc.)
Use subsequent surveys to benchmark & track
changesReport to management
Develop talking points for Risk Manager to use with
key decision-makersDevelop employee survey
Rank risks from employee survey & categorize into
risk register
Report to steering committee; identify risk
owners & responses
Steering committee or subcommittees to report
Annual report to all employees & council
Discuss talking points w/ Management
Interview managers & key stakeholders (?)
Incorporate data from interviews (if appropriate)
Meet with risk owners to identify mitigation
strategies & benchmarks
Utilize internal audit to validate processes?
RM & steering committee recommends
changes/revisions
Discuss talking points with Executive Directors. (3)
Consider an entity-wide risk assessment workshop
Identify risk categories: strategic, operational,
financial, human capital, technology, legal &
regulatory
Develop dashboard reporting tools for
management
Review Plan with steering committee
Consider a dept-specific ERM project
Identify Risk ChampionsIdentify & Consult with
Risk Champions
Risk Assessment – What if?
• What could happen that would keep you from doing tomorrow the things you are doing today?
• What keeps you up at night?• What could go wrong in your area?• What could go wrong in another area that would
impact your area?• What little things could go wrong that, taken in the
aggregate, could add up to significant problems?• What’s going on outside the City that could go
wrong and impact you?
ERM Discovery Questions
Operating procedures– Is this operating method being performed at optimum levels?– What steps can be taken to improve operations to better serve its
core customers?
Service Level– How can services be enhanced or improved considering the
importance rankings?– Are services being provided at the most efficient level?
Staffing– Is staff being provided where it is needed so that customers can be
serviced efficiently and quickly?– Are there efficiencies that can be obtained by combining services
within or with other departments to better service its core customers?
Outsourcing– Are services that are now being outsourced making sense to
outsource?– Are there other services that make sense to outsource?
Revenues– How can revenues be maximized while maintaining and enhancing
service levels?– Identify new revenue streams to offset enhanced service levels
Enterprise Risk
• Requires a new approach – not all risk is bad or a problem
• Requires a new approach – not all risks are insurable
• Requires a new approach – Teamwork and eliminate Silo’s
Public Entity Risk Solutions (or ERM)
Vision– To be the primary source of expertise and guidance for
optimizing risk taking decisions, in support of the Entity’s objectives.
Mission– To provide the leadership, methodology and tools
necessary to support operating management in its responsibility to optimize risk taking decisions
Risk Management
Mission StatementTraditional– To promote health and safety, and to minimize financial
risks to the Entity by creating a safe environment for its employees, citizens, and visitors.
Enterprise– To provide the leadership, methodology and tools
necessary to support operating management in its responsibility to optimize risk taking decisions
An excerpt from an entity’s long range planning document
“As new development dwindles, the challenge becomes sustaining the quality of life through the protection and enhancement of existing assets.”
So Why Has ERM Not Hit The Public Sector?
• Because we do not operate Government like a Business
• The “A” word that is historically absent in the Public Sector-ACCOUNTABILITY
• We operate in Silo’s in Government• Brokers either lack knowledge or are fearful they
may lose paycheck if you go to ERM• RISK Managers have not thought outside the box
Problem from a Risk Management perspective
• Historically, Risk Managers are not risk takers (old school)
• Been brain washed by the insurance industry as to what their role is
• Lack the fundamental training required to implement ERM
• Are comfortable where they are in the organization• Won’t rock the boat• Are overlooked in the entity’s decision process because
old school known as nay-sayers• Not much fun at parties
• ERM until just recently has been a threat to public entity insurance brokers and risk managers. – Big Brokerage outfits have put ERM into practice
for their private sector clients, not Public clients– Smaller Agency’s have not had a need to
implement – Silo mentality– Risk Managers are not looking out for the future
ERM Bridges Silo’s
Cherish the thought of us working together until we are forced to-Hurricane Katrina
So where does ERM fit in at the public sector level?
• Data available tells us it is a fit with everything we do in the Public sector
• Any and all Departments, Schools, Divisions can improve with ERM
• Works for the smallest to the largest program• Fits wherever decisions need to be made
ERM Today
• Departments interact consistently in making decisions
• Each department provides input that will be impacted
• All options are thrown on the table for discussion• Each department has a vote in the decision• Issues like funding, maintenance, insurance, are
brought out in advance. • Decisions are no longer made in a vacuum
In other words, those that could be impacted by a purchase, or a program, or something new are brought together collectively to decide what is best for the Entity as a whole
Making the switch to ERM
• Homework• Someone needs to facilitate the process• Starts at the top and moves downward in the
organization• Is implemented from the bottom up• Everyone comes to realize they are their own risk
manager• Risks are identified, and ranked• Risks identified are scored• A plan is put in place to mitigate risks
A Risk Assessment is a lengthy process, but is the most critical part of the ERM process if it is to be implemented successfully.
Is it too much of a burden to implement? Not really
• Start with one or a few departments• Pick Departments or Directors or Managers that
are motivated• Start with those that will guarantee you success.
Early failures dooms the best ERM game plan you lay out
(Not a burden, but without a champion, can be tough to implement. And it requires a risk manager with a passion for what they do)
Example #1
Success in a Solid Waste Department. – Had highest injury incidents– Their employee’s worked all over the City– Work without direct supervision– Had a mixed bag of educational levels– Had no computer access– The Director had a higher vision and needed to shine– Was over running budget annually– And we were motivated in Risk Management because we
had done our homework, knew what ERM could do for them, had Broker support, and our own reputation was on the line if it failed
Example #1
In this example:– Rolling workforce– No access to technology– Picking up waste was priority #1 for our constituents– Majority male workforce, Director was female– Decisions crossed different disciplines
• Equipment Services• Accounting• Payroll• Purchasing• Warehouse• HR• Risk Management
Example #1
Results– Implemented Self Directed work teams– Representatives from other disciplines added on the
team– Implement Gain sharing– Established Benchmarks to prove success– Established on-line training using surplus computers– Goal oriented
Example #1
The results were positive– Cost to operate decreased– Budgets were maintained– Accidents went down– Complaints declined– Attendance improved– Morale improved– Win, Win, Win
We in Risk had a signed agreement with the Director what was expected of us as did all other stakeholders– (Show copy of memo)
Another Example
• Want to save money quick using ERM=HEALTHCARE
• Who can afford healthcare today, much less the years to come?
• Healthcare costs will bankrupt many an entity in the very near future
• Retiree healthcare• GASB 45• The current presidential agenda???
Learning Objectives Today
If you are like most entities, you probably have a broker or consultant.– Higher deductibles– Larger co-pays– Plan Design Changes– Employee’s can no longer afford further cost shifting
NONE OF THESE HAVE WORKED TO CONTROL HEALTHCARE COSTS
On-Site Clinics
• Controls healthcare costs at the point of service• Is the perfect ERM modeling opportunity in any
organization? Big or Small• Can address Workers’ Compensation as well as
Group Benefits
Opening an Occupational Clinic success story
• After a 4 year struggle had Top Management support
• Started trying for Group Healthcare Clinic• Ended up only with Occupational Clinic• Pulled Committee together• Feasibility studies• Good benchmarking data• Conducted needs assessments with all
departments-police, fire, health, public works, parks
What we were able to accomplish:
• Provided Occupational Care that was uncontrollable at Doc in the Box Occupational Clinics
• Provided preventive inoculations for departments and did not take that money, they kept it for other pressing needs
• Saved FD $60,000.00 alone• Return to work quicker• Reduced overall WC costs• Did it less costly in house vs. outside contractor
SAVINGS-The real proof
• Reduced allocated expenses by over 55% • Lowered WC costs over $350,000.00 after
expenses• Allowed other departments to use it (Health
Department Screenings and programs; FD Health and Wellness programs)
• Could have saved Health Fund $650,000.00 but that was the only silo we had against us
For other Entity’s
• Odessa has had double digit healthcare cost decreases 4 years running
• Mesquite and Mesquite ISD partnered on a clinic and are reporting millions of dollars in healthcare cost and pharmacy costs savings (they operate a pharmacy in their clinic).
Other success stories
• Travis County (now operates 3 clinics, about to open pharmacy
• Rockwall ISD just opened a clinic part-time and is seeing savings
• Amarillo• Garland• San Angelo (Clinic and Pharmacy)• City of Corpus Christi out for feasibility study
• The ERM process and combating rising healthcare costs go hand in hand
• Also works for the budget process• Works if done by one section or entire operation• Once you implement, TRM goes out the window
Be forewarned, in the near future, you will have
to have ERM in place to get the highest bond rating.
Better begin implementation of ERM soon if you are going to be issuing new debt in the near future.
The Future of ERM in the Public Sector
1. Encourages multi-jurisdictional partnering for a common cause
2. Sharing of resources – cross jurisdictional agencies will work together (School District and Parish collaborations; Police and Fire; City Police and Sheriff’s Dept; etc)
3. Eliminates duplication of services4. Builds TEAMWORK5. Saves money for all involved as costs go down
when you work thru decisions together
The biggest challenge for Public Entities in implementing ERM is bridging silos
Opens door for cross jurisdictional agencies to work together and save taxpayers money
What’s the point again?
• To prepare for negative events (traditional risk)• To bring new risks into awareness• To understand risk relationships, influence &
overlaps• Better decisions, fewer surprises• Achieving entity’s goals & objectives
Conclusion
Is ERM right for you? – Depends on your willingness to work hard, break down
silo’s– If you need new revenue sources to help balance your
Budget
Can it work?– It is working and will work with any issue or program. – Can work real quick with Top Management support– Will work for each of you
• Now is the perfect time to consider ERM to tackle the tough economic forecast you are facing. It is a work in progress and requires someone dedicated to the process. It will save you money that you didn’t know you could save!
• Are you ready for excellence in Risk Management thru Enterprise Risk Management?
You better be or you may not be able to balance your budgets in the near future without drastic measures
being taken. And it may cost you more money to borrow if your Bond Rating is lowered
Acknowledgements
Dorothy Gjerdrum, ARM-P– Executive Director– Gallagher’s Public Entity & Scholastic Division
John Billingham ARM– Loss Control Consultant– Self employed
Questions
Thank You!
For more information:
Joey PageEssential Risk Solutions
Website: www.essentialrisksolutions.comEmail: [email protected]
Office: (214) 725-7797Cell: (972) 742-2334Fax: (214) 509-9715
Real Examples
City XYZ 2005-06 2006-07 2007-08
With TPA With TPA XYZ Model
Claims & Ancillary Charges $300,000 $300,000 $220,000
PEER Review $16,861 $16,450 $0
Bill Review $55,646 $47,579 $12,399
Utilization Review/Pre-cost $54,438 $49,280 $9,510
Durable Medical Equipment $19,767 $19,490 $6,114
Diagnostic (X-rays, MRI) $33,582 $28,490 $5611
Total $480,294.00 $461,295.00 $253,634.00
Actual Savings
Claim Utilization 2007 2008 Average visits per injury 3.5 per claim 1 per injury Average visits before referral 4.5 per claim 1 per
injury Average # of x-rays per claim 16.1 per claim 8
per claim
Utilization Control with On-Site Clinic Model