How to rate medical providers in Workers Compensation—Part II

Part I of this series made the point that while rating providers in group health is a long-practiced endeavor, its elements and parameters have not migrated to Workers’ Compensation. Efforts to translate group health provider quality to Workers’ Compensation have fallen well short of the mark because they omit several factors crucial to Workers Comp. Quality medical performance indicators in Workers’ Comp encompass medical treatment, outcome and cost factors similar to those in general health, but they also include non-medical functions. In Workers’ Comp, those non-medical elements can be primary drivers of cost and outcome.

A major quality goal in Workers’ Comp is return to full work and achievement of that goal rests most significantly with the treating physician. Another major quality goal in Workers’ Comp is return to maximum or full work capacity at the least cost, also largely attributable to the treating doctors. This article, Part II of this series, explores the many non-medical functions of quality in medical treatment for Workers’ Compensation, factors that must be considered in rating doctors.

For instance, multiple and repeated studies have shown that early return to work is a major indicator of better outcomes in Workers’ Comp. (Google search: “Return to Work studies in Workers Compensation”) The generally accepted notion based on these studies is that the sooner employees return to work after a work-related injury, the sooner they are re-acclimated to the job and the lower the overall cost of the claim. Alternatively, the longer the employee is kept off work, the higher the cost of the claim, with reduced chance of ever returning to work. Studies show a 1:1 correlation between length of time off work and returning to work—ever. Treating providers are not the only factor, but they are certainly the major driver in returning the person to work. Therefore, early return to work and reduced overall work loss are key performance indicators for evaluating medical providers. What is a provider’s performance in terms of return to work and how does it compare to others?

Also important to rating provider performance in Workers’ Compensation is the issue of cost. Quantifiable generators of excessive costs are the frequency and duration of medical treatment. Because PPO, MCO and MPN networks discount each unit of service delivered, the tendency of some providers may be to exploit both frequency and duration of treatment services to boost discounted fees. The elements of frequency and duration of medical treatment for specific injury types should be measured and compared with the performance of peers treating similar injuries.

Also, billed costs are comparative quality indicator. Billed costs can be strengthened by combining that number with paid costs or percentage reduction of charges recommended by bill review. One can also evaluate a provider’s performance in terms of claim reopening after closure. Certainly ratings should include outcome data—how did things turn out? Is the employee back at work, permanently disabled or somewhere in between? If a provider is associated with a high rate of settled or litigated claims, that should be considered in the mix.

Providers can be rated specifically for Workers’ Comp by creating an algorithm or a set of algorithms evaluating these factors and executed using data. The algorithms should compare similar specialty providers who have treated like injuries in the same jurisdiction during the same time frame. Moreover, the algorithms should “handicap” individual providers to insure fairness. Consistency is achieved by the computerized algorithms applying the same standards to all medical providers.

Rating doctors and other treating providers can be tricky because multiple variables intrude. How severe is the injury? What are the complicating factors such as obesity or diabetes? How old are the claimants and what kind of work do they do? A fractured ankle for a healthy, middle age male construction worker implies higher risk than a similar injury for a same age male computer worker. The more factors considered, the more accurate the result. Other issues must be considered, as well.

The data used to evaluate provider performance must be derived from a broad spectrum. Raw billing data or bill review data should be integrated with select claim data in order to reach a valid conclusion. Stated again, billing and treatment data must be integrated with loss time and outcome information, usually found in a different system, in order to reach a legitimate result regarding provider performance. Evaluating treatment patterns is instructive and sometimes predictive, but in Workers’ Comp multiple other elements come into play.

Ratings must be transparent, fair, and objective. Fairness and accuracy in developing and measuring provider performance is critical and the indicators are found in the data. Frankly, the Workers’ Compensation industry has been slow to recognize the importance of integrating data from its disparate sources and leveraging it to identify medical best practices and the doctors who use them. The data must be integrated and evaluated using computerized algorithms that measure and monitor provider performance based on a combination of Workers’ Compensation-specific values.

A post was recently submitted by Joe Paduda, “Like it or not, physician ratings are coming”. The title suggests rating doctors is a bad thing. It is not, unless you are a poorly performing provider. Using legitimate Workers’ Comp-specific rating schemes to provide objective evidence for selection and for weeding out the less effective or even fraudulent providers is positive progress. Informed decisions about medical providers based on data will replace personal preferences with unknown outcomes. It will also provide the basis for informed improvement by individual doctors. Moreover, medical provider ratings that are transparent, fair, and objective are available now.

View additional articles by Karen Wolfe under Blogs at www.medmetrics.org