『Deconstructing Comp』のカバーアート

Deconstructing Comp

Deconstructing Comp

著者： Yvonne Guibert & Rafael Gonzalez
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Now in Season 6! We are still breaking down complex workers' compensation issues into bite-sized nuggets, one conversation at a time, with one slight twist. We are finally doing what we set out to do when we started: discuss the nuances of our fascinating system in "Cliff Notes" style summaries.


Yvonne Guibert and Rafael Gonzalez approach workers' comp conversations from different backgrounds. Still, they share many things in common, such as their love for family and friends, a passion for Latin culture, and good old-fashioned belly laughs. Join them as they chat with industry friends and colleagues, learn more about their roles, laugh, and have fun along the way. You might learn something along the way! See you soon! ¡Hasta pronto!

© 2026 Deconstructing Comp 出世 就職活動 経済学
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  • Dr. Robert Hall: What Our Rx Data Reveals

    Dr. Robert Hall: What Our Rx Data Reveals
    2026/09/04
    Send us Fan MailGuest Bio Dr. Robert Hall | Medical Director, Optum Workers' Comp and Auto No-Fault12 years leading medical direction and formulary oversight at OptumPhysical medicine and rehabilitation (PM&R) specialist maintaining active clinical practice one day per week with injured workersStrategic voice on PBM industry trends, emerging drug therapies, and AI's role in claims prioritizationOur Conversation We explore pharmacy spending trends, compensability questions around new medications like GLP-1s and migraine medications, and how AI can help claims professionals prioritize without replacing judgment. Our conversation builds on CompPharma's 20th Annual Survey released earlier this year. Dr. Hall provided context from his unique PBM perspective.See the CompPharma 2025 Prescription Drug Management in Workers' Compensation SurveyKey Discussion PointsScript Volume Down, Per-Script Costs Up Prescriptions filled decreased 4%, yet per-script costs rose over 4%. Fewer generic opioids are available, causing providers to transition patients to more expensive alternatives. When lower-cost options aren't working, switching to higher-cost versions becomes the default.Opioid Decline Slowing Opioid spend dropped 7%—slower than the 13% annual declines of prior years. While fewer people are on opioids overall, those taking them can face additional complications such as opioid-induced hyperalgesia, where the pain medication itself makes pain worse. Providers unknowingly increase doses thinking pain is worsening, creating a spiral that drives costs and complexity.Efficiency Remains the Industry's Biggest Gap According to Dr. Hall, despite much progress, feedback from injured workers and treating providers is consistent: speed remains a big issue. Authorization turnarounds, surgery approvals, and medication approvals all lag. Efficiency directly impacts outcomes.GLP-1s: Compensability Questions Without Clear Answers GLP-1 medications (weight loss drugs) are appropriate when weight loss is necessary for surgery or when catastrophic injuries cause weight gain. But with 30-40% of adults overweight or obese, there's a strong incentive to route these expensive drugs through workers' comp claims instead of out-of-pocket. The core tension: just because a drug is medically effective doesn't make it work-related. Clear frameworks are needed to distinguish compensable uses from general health expenses.A parallel exists with migraine medications—highly effective for a common condition (10% of the population), creating similar pressure to tie them to workers' comp when they may not be compensable.Important caveat: GLP-1s carry real risks. Severe nausea, vomiting, diarrhea, pancreatitis, and hospitalizations have occurred. When complications arise, they become part of the claim, adding complexity and cost.PBMs Score Highest on Customer Service PBMs earned their strongest-ever customer service grades in this year's CompPharma survey. Relationships matter as much as technology. Speed, communication, and partnership mindset drive loyalty.AI Adoption Rising—But De-skilling Risk Is Real About one-third of respondents now use AI tools. The cautionary tale: radiologists improved cancer detection with AI, but their standalone diagnostic ability declined after using it. For workers' comp, AI's highest value is prioritization—flagging the 2 catastrophic claims out of 100 that need immediate attention. The goal is to free human judgment for complex decisions, not replace it. We need to keep using and challenging our brains. Early Identification of Catastrophic Claims AI could synthesize accident type, injury location, physician findings, diagnostic studies, and functional capacity to identify claims spiraling toward permanent total or catastrophic status before they explode in cost. Early intervention changes trajectory.The risk: "creeping catastrophic" claims. Injuries that seem manageable but don't close gradually become complex and expensive. Opioid dosing spirals, high-cost alternatives accumulate, and routine claims become catastrophic without anyone realizing when the shift happened.State Variations as a Learning OpportunityFor folks newer to workers' comp, Dr. Hall suggests the 50 different state regulatory frameworks aren't just learning obstacles—they're live experiments in how to approach injury treatment. Professionals entering the industry should embrace this complexity and diversity to build deeper medical and operational knowledge.The Motorcycle Pivot Dr. Hall learned to ride a motorcycle last year after walking away from the idea a decade ago (when a bike cost as much as new kitchen cabinets). He's now ridden 1,000 miles on quiet Sunday afternoons. ¡Muchas Gracias! Thank you for listening. We would appreciate you sharing our podcast with your friends on social media. Find Yvonne and Rafael on Linked In or follow us on Twitter @deconstructcomp
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    51 分
  • Denise Evans: The Case for Unbundling

    Denise Evans: The Case for Unbundling
    2026/08/21
    Send us Fan MailIn our latest episode, Yvonne and Rafael talk to Denise Evans, Director of Claims at Staffmark Group.Guest Bio:Denise Evans | Director of Claims, Staffmark Group37 years in the workers' compensation industryNational temp staffing program leadership—managing claims across multiple industries and statesStrategic program architect and industry connector; active in the National Council of Self-InsuredsOur ConversationIn this episode, we tackle unbundling—a strategic choice most self-insured companies face, but few really understand. It affects your costs, outcomes, control, and flexibility.The Choice: Bundled vs. UnbundledBundled: You contract with a carrier or TPA. They handle provider networks, vendor relationships, and medical management. You get discounts from their preferred partners and operational convenience in exchange for limited control. It's predictable. It's hands-off.Unbundled: You build and manage your own program, or parts of your program. You choose providers, set vendor relationships, own day-to-day decisions. You lose some negotiated discounts but gain control and flexibility.For most companies, bundling is the default. The real question is whether it actually works for your business.You Don't Have to Unbundle Everything at Once: Here's what most people miss: unbundling doesn't have to be all or nothing. You can be selective and phased. Build the option into your contract, then unbundle component by component as your capacity grows. Denise unbundles specific areas where control matters most to Staffmark—nurse case management, pharmaceutical, DME, bill review, transportation, translation. The point is to move at your own pace rather than changing the entire program all at once. That's what distinguishes companies that successfully unbundle from those that get overwhelmed and abandon it.Why This MattersThe case for unbundling: When you need control over outcomes that matter to your business—return-to-work rates, duration management, cost containment. You have a specific workforce (or multiple workforces) requiring tailored medical management. You have the internal capacity to manage vendors.Denise's example: Staffmark handles employee leasing and staffing. Workers move between client sites, industries, and states. A one-size-fits-all bundled network doesn't work. They unbundled to have more agility—the ability to build relationships with providers who understand Staffmark's unique recovery demands.The case for bundling: You want predictability. You lack bandwidth for vendor management. You'll accept good-enough outcomes for operational simplicity.The hard truth: Unbundling isn't cost-cutting. It's an investment. You're paying for vendor management infrastructure, relationship-building, and reporting sophistication to defend your program to carriers. Without that capacity, you'll end up worse off than you started.The Core QuestionIs your current program structure actually supporting your business outcomes?If your business depends on a specific workforce profile, recovery timeline, or outcome metric—and your bundled program doesn't optimize for that—you're paying for convenience while leaving money on the table.If you unbundle without infrastructure to manage it, you're paying more for worse results.Let the decision be driven by what you're optimizing for. Not cost. Not convenience. What outcome matters most? Then ask: which structure gets you there?Your Carrier Relationship ChangesUnbundling shifts accountability. When you bundle, the carrier owns program quality and accountability. When you unbundle, you do.Carriers will want data, evidence of sound decisions, transparency into what's working. If your unbundled program underperforms, that becomes a negotiation point at renewal—and it can be expensive.This is why infrastructure matters. You need reporting, metrics, proof points to show carriers your program is solid. If you can defend your approach with data, you have leverage. If you can't, you're vulnerable.Workforce Complexity Drives the DecisionStaffmark operates across temp staffing—workers move between client sites, industries, and geographies. Claims span manufacturing, healthcare, and logistics in the same population.A bundled one-size-fits-all network becomes a liability. You need providers who understand different recovery demands across industries and can move fast. Unbundling becomes a business necessity, not a luxury.Single-industry, stable-geography workforce? Bundling's convenience might be your sweet spot. Complex, multi-industry workforce? You may not have a choice.The Fragmentation FactorManaging a national program across 50+ state regulations, different medical networks, and different carrier relationships is expensive and fragmented.The companies doing this well aren't isolated. They're connected to others solving the same problems. They attend conferences not for networking, but because that's how they hear about approaches that ...
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    57 分
  • Andrea Mills: Empathy as Infrastructure

    Andrea Mills: Empathy as Infrastructure
    2026/08/05
    Send us Fan MailIn our latest episode, Yvonne and Rafael talk to Andrea Mills, President of Ametros.Guest BioAndrea Mills | President, Ametros | Workers' Comp Professional AdministratorNearly 20 years in the workers' compensation industry8+ years with Ametros, currently in her ninth yearLeads the largest professional administration company in the workers' comp space, serving both workers' comp and liability casesSince the recording of this episode, Ametros has expanded Medicare Advantage Plan support and is now available in all states except New York. For more information, visit info.ametros.com/medicare-consultation. Any references to savings are for informational purposes only. Savings are not guaranteed, and past performance or historical results are not indicative of future outcomes.Here are highlights of our conversation with Andrea: 1. The Settlement Cliff: When Support Suddenly StopsInjured workers spend an average of six years in the workers' comp system with full support: medical care, case managers, adjusters. Then settlement happens. Suddenly, most of that infrastructure disappears. They're left managing complex healthcare needs, settlement funds that need to last them years or a lifetime, and ongoing medical treatment entirely on their own.This is the gap Ametros fills.DC micro lesson: The industry has built systems for managing active claims. But we haven't built strong systems for managing the post-settlement phase. There's a resource cliff, and injured workers are expected to navigate it alone. Ametros stepped in to solve this problem. 2. Professional Administration Isn't Process. It's Presence.Ametros helps injured workers manage settlement funds, navigate their healthcare journey, and access the support they need after settlement. Referrals come from adjusters, Medicare Set-Aside vendors, and plaintiff attorneys who all recognize the same truth: injured workers need expert, compassionate support they can actually rely on after their claim is settled. DC micro lesson: Professional administration is about showing up for someone vulnerable and saying, "We're going to help you figure this out." It's about showing up for injured workers and helping them feel at ease and secure about their future medical care. 3. Medication Management: The Invisible Cost of Chronic ConditionsAfter settlement, injured workers face the full cost of their prescriptions for the first time. Chronic pain medications can cost thousands per month. Ametros works with injured workers to find the best alternatives, manage costs, navigate insurance, and ensure medications and care remain affordable.DC micro lesson: What happens to prescriptions after settlement is not a sidebar in the claim story. It's often the center of the story. Ametros helps injured workers think through their long-term care needs and identifies the best options. 4. Empathy Isn't Soft. It's Infrastructure.Ametros doesn't just talk about empathy; they've operationalized it. It's woven into hiring, training, and accountability. It's infrastructure. When injured workers interact with Ametros, they feel seen. That's not accidental. DC micro lesson: We need to stop treating empathy like it's a mindset hack. Start asking: How is empathy built into your processes? How do you hire for it? Coach for it? Help people build capacity for it? Until you answer these questions, you're not operationalizing empathy. You're just talking about it.5. Capacity Comes From Boundaries, Not Gritting It OutAndrea models protecting her own capacity: family time, travel (hello, Italy!), life outside work. Ametros's leadership team protects these boundaries for their teams too. You can't show up for injured workers if you're running on empty. You can't make people feel seen if you're depleted.DC micro lesson: How your team shows up for injured workers is directly connected to how you show up for your team. Capacity isn't something you demand from people. It's something you protect for them.A Final ThoughtAmetros solved a problem the industry had been overlooking: injured workers settling their cases and then disappearing into a resource void. They stepped into that gap and said, "We can do better." That's how you move an industry forward.Kudos to the team at Ametros for winning the Gold Stevie® Award for Sales & Customer Service in the Contact Center of the Year – Other Service Industries category. This recognition is well-earned by a team that puts injured workers' needs first.¡Muchas Gracias! Thank you for listening. We would appreciate you sharing our podcast with your friends on social media. Find Yvonne and Rafael on Linked In or follow us on Twitter @deconstructcomp
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    40 分
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