Rating Medical Providers—Part I

This is the first in a four-part series about rating medical providers in Workers’ Compensation.
Part II—How to Evaluate and Rank Medical Providers specifically for Workers Compensation
Part III—Transforming Workers’ Comp Provider Networks into Quality Networks
Part IV—Monitoring Provider Performance for Predictive Profiling

Would you rather pay $6000 for a claimant’s back procedure because the physician is in your network and a discount is guaranteed—or agree to pay more and direct the claimant to a best practice provider, identified by analyzing the data? Unfortunately, the majority of payers in Workers’ Compensation are still choosing the former scenario. Frankly, it is easier to enjoy reports of discounts than it is to analyze provider performance.

Analyzing provider performance requires data gathering and integrating, followed by broad spectrum analysis of multiple performance indicators. Therefore, it’s easier to just accept the discount, regardless of the outcome. But that isn’t enough anymore.

A reliable predictor of high cost in a Workers Compensation claim is a poorly performing medical provider. Individual providers can be naively oblivious to the special needs and conditions in Workers’ Compensation, just inept, or downright fraudulent. Yet, for the most part, Workers’ Compensation provider networks and the payers that use them, do not evaluate and rate provider performance to find and cultivate the good ones. However, the group health industry does just that.

The group health industry is very different from the Workers’ Compensation industry in this regard. In fact, group health has thirty years of experience evaluating physician competency and healthcare quality. Organizations such as NCQA (National Committee for Quality Assurance), JCAHO (Joint Commission on Accreditation of Healthcare Organizations), AMA (American Medical Association) and several private organizations have all worked to identify quality indicators and individuals who use them in their practices to gain best outcomes. Now, after so many years of provider rating, the remaining issues in general health are standardizing indicators of quality across rating organizations and agreeing on how to rate and rank providers fairly.

In fact, the group health industry seems to be barreling forward in its attempts to rate providers. A little Internet surfing bears this out. Check out Healthgrades where 750,000 physicians, 5000 hospitals and 16,000 nursing homes are rated. Physicians can be searched and rated by specialty and conditions treated, a one-stop doctor shopping experience. Not long ago, this would have been considered impertinent. But there is more.

Using Angie’s List one can search physicians by areas of practice alongside carpet cleaners, plumbers and manicurists. Angie’s List uses a customer satisfaction approach to evaluating medical care. As such, it is subjective evaluation, limited to how well-liked the doctor is or how good the patient felt following treatment. Moreover, Zagat, the restaurant guide, was approached not long ago by Blue Cross to help them develop a rating system for physicians. And probably not finally, there’s an app for that—Deep Pocket Series adapted to your mobile where you can conveniently search for many things medical, including neurologists, drug lists and romantic matching for unattached doctors and nurses.

However, even with all the hullabaloo in general health about rating doctors, it is of little note or applicability in Workers’ Compensation. Even if Workers’ Compensation payers were interested, group health physician rating in any of its current forms does not translate well to Workers’ Compensation.

One reason physician rating in general health does not apply to Workers’ Compensation is that the comparative parameters do not equate. In group health, an episode of care is artificially identified in the data so that comparisons can be made “apples to apples”. An episode of care might be a fractured femur, along with all associated doctor’s visits, diagnostics and treatment services. In Workers’ Compensation, the episode of measurement is simply a claim. The parameters are clear—everything from DOI to close. The claim is more encompassing and physician influence extends beyond treatment to wage replacement and legal involvement. Key performance indicators of physician performance in Workers’ Compensation cut a wide swath that would be ignored in group health.

Another difference between the two is definition of quality. In general health quality is defined as those diagnostics and treatments that lead to return to full health, whereas the fundamental goal in Workers’ Compensation is return to work. Both systems are concerned with cost. However, group health costs are primarily controlled by policy design. The policy defines what is paid for specific conditions (diagnoses) and that is the end of it. If it’s not included in the insurance policy or under Medicare or Medicaid or HMO, payments will simply not be made for a medical service. Conversely, in Workers’ Comp the costs include not only medical costs, but multiple other contributed costs.

Because the two systems are so different, methods for rating doctors under group or general health have little meaning in Workers’ Comp. But that begs the question, how can we rate doctors in Workers Comp? That’s the tease—you’ll find answers in Part II of this four part series.

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