How to Find “Best in Class” Doctors

It’s a safe bet that claims will not have a happy ending if the treating physician has a history of being associated with poor claim outcomes. In fact, physicians rated poorly in analytic studies based on past performance are 100% predictive of high costs and inferior outcomes in future claims where they are involved. The question is, how can those providers be identified?

Applying analytics
Evaluating physician and other provider performance is a matter of scrutinizing the data. The data offers a clear picture of actual provider performance. Whether the cause of poor performance is misunderstanding Workers’ Compensation or deliberate fraud, the claim results will be dismal. Nevertheless, in order to analyze provider performance, one must know where to look for the data, what to look for, and how to apply the knowledge gained from analysis to achieve improved results.

Where to find the data
Billing data tells the story of diagnoses, treatments and the billed amounts. However, billing data is never broad enough in scope to evaluate providers because it tells only a part of the story. Claims level data tells another part of the story. It describes the actual paid amounts, the amount of indemnity paid, whether legal was involved, and the final disability rating, the ultimate outcome indicator. But there is more.

Investigating PBM (Pharmacy Benefit Management) data has become imperative in recent years. Overuse and abuse of prescribed narcotic pain relievers is now a major concern in Workers’ Compensation medical management. Prescribing excessive opioids is unconscionable, but the guilty are often not identified and avoided as they should be.

Provider performance should be weighted by outcome combined with costs and other factors. Unless the initial injury was catastrophic, return to work following a workplace injury is often a function of medical management. Analyzing multiple data indicators from disparate data sources can describe individual physician performance.

Integrating the data for analysis
Any one Workers’ Compensation data source by itself is inadequate for the purpose of evaluating providers. Only the broad scope of data concerning a claim can provide a clear picture of the claim and provider culpability in outcome. Therefore, collecting the data from its various sources and integrating current and historical data are the first two crucial steps in provider performance analytics. The next steps are identifying, evaluating, and monitoring the data elements that are indicators of performance both from the medical and Workers’ Compensation viewpoints.

Industry research tells what to look for
Exposing substandard providers is a matter of integrating and analyzing the data to understand the course of the claim and the providers who contributed to poor claim results. Selecting the data items to monitor can be guided in the first instance by industry research. Organizations such as NCCI (National Council on Compensation Insurance), CWCI (California Workers’ Compensation Institute), WCRI (Workers’ Compensation Research Institute) continually publish their research based on data they collect from members. These organizations offer research regarding medical issues causing cost escalation in the industry, and usually make results available from their individual websites.

Academia and other organizations produce and publish research, as well. The best way to access other research is to use Google to find research studies regarding specific issues and interest areas. For instance, if the concern is low back pain management, simply use Google to find research and scholarly articles on the topic as it relates to Workers’ Compensation. Google is an extraordinary resource in that regard.

When the indicators of performance are identified, they can be applied to analyze providers. Providers tagged with a preponderance of negative indicators will not fall into the best in class category. On the other hand, those whose results are exemplary will rise to the top—best in class.

Link analytics to operations
Analytics results of any variety that remain in graphic form, in a fancy brochure, or pinned to a wall are useless in the effort of containing costs. The findings must be functionally applied to operations to make them actionable. Information regarding best (and worst) in class doctors identified through the methods discussed here must be made available to network managers in a usable form. Moreover, the information should be specific, current, dynamic, easily accessible, and contain objective supportive detail. The work of analytics is not complete until its results are operationalized, thereby linking analytics to implementation.

Learn more about MedMetrics analytics or contact karenwolfe@medmetrics.org.