A major quality goal in Workers’ Comp is return to full work. Responsibility for achieving 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 treating doctors. This article, Part II of this series, explores the many non-medical functions of treatment that spell quality in Workers’ Compensation, factors that must be considered in rating doctors’ performance.
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 successfully returning to work. Studies show a 1:1 correlation between length of time off work and returning to work—ever. Treating providers are the major driver in returning claimants to work. Therefore, early return to work and reduced overall work loss are key indicators for evaluating medical provider performance.
Also important to rating provider performance in Workers’ Compensation is the issue of cost. Two quantifiable generators of unnecessary costs are excessive frequency and duration of medical treatment. Because PPO, MCO and MPN networks discount each unit of service delivered, the tendency of some providers is to exploit both frequency and duration of treatment to overcome their 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.
Another comparative quality indicator is direct medical costs. Moreover, billed costs can be enriched as a performance indicator by combining that number with paid amounts or percentage reduction of charges recommended by bill review.
Of critical importance is evaluating providers in terms of claim outcome—how did things turn out in the claims where they were involved? Is the employee back at work, permanently disabled or somewhere in between? What is they provider’s record on that score? If a provider is associated with a high rate of litigated claims, that should also be considered in the mix, as well.
Providers can be rated specifically for Workers’ Comp by creating a set of algorithms measuring these factors using data. An algorithm is simply a process, usually mathematical, used to solve a problem or reach a conclusion. Algorithms should be used to compare similar types of providers who have treated like injuries in the same jurisdiction during the same time frame. Consistency is achieved because the computerized algorithms apply the same standards to all medical providers.
Rating doctors and other treating providers can be tricky because multiple variables intrude. Evaluating treatment patterns is instructive and sometimes predictive, but in Workers’ Comp multiple additional elements come into play. 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 greater risk and more cost and complexity than a similar injury for a same age male computer worker. The more factors considered, the more accurate the result. Data rich with detail will produce the most reliable results.
The data used to evaluate provider performance should be derived from more than one source. Raw billing data or bill review data should be integrated with select claim data in order to reach a valid conclusion. Stated differently, billing and treatment data must be integrated with loss time and outcome information, usually found in a different system, in order to reach legitimate conclusions regarding providers.
Ratings for medical providers 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 leverage it to identify medical and non-medical best practices along with 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 unique values.
A post was recently submitted by Joe Paduda, "
Look for Part III of this series: Transforming Workers’ Comp Provider Networks into Quality Networks
View additional articles by Karen Wolfe under Blogs at www.medmetrics.org