Find Revitalization at the Intersection of Technology and Managed Care

By Karen Wolfe

Costs continue to rise

Regardless of the myriad of interventions directed at containing claim costs in Workers’ Compensation, costs continue to increase. Now that the medical portion of claim costs amounts to sixty percent or more, the fact must be acknowledge that traditional managed care initiatives are inadequate. Moreover, new medical costs seem to be appearing from unfamiliar places, leaving no apparent recourse. Costs are finding new avenues of expression in the form of drug costs, complex medical procedures, and exponential costs due to comorbidities.

What now?

Many think everything that can be done, has been done. Managed care programs including provider networks, bill review, utilization review, peer review, and medical case management are conceptually well-founded. Still, outcomes are disappointing. What more can be done?

Starting over is absolutely not an option. Disbanding current managed care programs and creating new ones is completely impractical. Sunk costs of existing programs are huge, and building new ones is not feasible or affordable. Besides, managed care programs in Workers’ Compensation are well-founded conceptually, and based on solid principals. They just need to function more effectively.

Managed care in WC is tired

Managed care programs in Workers’ Compensation are tired. Like much of our country’s infrastructure, they have not been revitalized over the years of their existence. They operate today just like they did twenty years ago. Specifically, most managed care programs have not taken advantage of the exponential advances in technology during their tenure.

Same tenure—different results

Think about it. As recently as twenty years ago (1992 seems like yesterday) Microsoft’s Disk Operating System (DOS) was the predominant operating system for personal computers. PC’s were large, expensive, and scarce in companies. Local area networks were just emerging and required hard-wiring to connect, servers, PC’s and printers. The Internet was not yet available for general use. Significantly, this was also the time of Workers’ Comp managed care ascendency. Yet, it would be some time before managed care programs were even computerized.

Computerization in managed care is relatively recent and the uptake has been laboriously slow. At the same time, evolution in technology has been explosive. Reluctant technology upgrades in managed care have been restricted to hardware and operating software at a pace consistent with Microsoft operating system advances—slow. Little has been done in managed care to exploit technology to actually benefit outcomes.

Technology explosion

In contrast, smart phones have proliferated. It is estimated over 5 billion cell phones are in use worldwide. They are enabled with text messaging, web browsers and cameras, as well as by wireless connectivity in place of landlines to reach remote communities. The iPad and other notebooks have overtaken PC’s in sales. Social networks that enable collaboration on more and more devices proliferate. As recently as 2005, Facebook was a start-up phenomenon, Twitter was still a sound, the cloud was something in the sky, and 4G was a parking space.[1] The flood of technology and its applications has serious and exciting implications for Workers’ Comp managed care.

Differentiate through technology
Underscoring the point, Joel Cawley, the vice president for strategy at IBM is quoted as saying, “Two things will differentiate companies, countries, and individuals from one another. One is analytics. Once everyone is connected, prosperity will depend on how well you or your company can analyze and apply all the data pouring through these networks to optimize your ability to provide better…(services).”[2]

The Workers’ Compensation industry must of necessity step up to the challenge because continuing to do business as usual is ever more unconscionable in light of claim costs and deteriorating outcomes. Workers’ Comp organizations, whether they are insurers, third party payers, self-insured employers, or service providers to the industry, must leverage technology to improve their services and control costs. To do otherwise is dereliction of duty.

Move to the intersection of technology and managed care

Analyze the data to gain insight into best practices and procedures and who is providing them. Leverage the data to find best in class doctors and other providers. Enable current data to inform adjusters and medical case managers of claims containing potentially calamitous conditions. Let technology notify appropriate persons of approaching key benchmarks and other pivotal conditions. Most importantly, act on the findings of analytics.

Actionable analytics

Drive the results of analytics to operations to mobilize appropriate action to intervene in time to prevent further damage. Make analytics and technology work-in-progress tools that lead people to informed decisions and enable them to taking action early enough to contain costs. Most importantly, embrace technology to ramp-up, revitalize, and recharge managed care programs. Use analytics backed by technology to take charge of outcomes. Move to the intersection of technology and managed care.

Learn how MedMetrics will move you to the intersection of technology and managed care, thereby gaining more control of costs and improving outcomes.

 

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[1] Friedman, T., Mandelbaum, M. That Used to Be Us: How America Fell Behind in the World It Invented and How We Can Come Back. Farrar, Straus and Giroux. 2011. Updated by author.

[2] Ibid.

http://www.medmetrics.org

Two Steps to Recharge WC Managed Care

By Karen Wolfe

Having the long-view perspective offers advantages. Sometimes it also generates frustration and occasional surprise. One thing we know is that the workers compensation industry is not given to abrupt change or quick assimilation of new ideas or technology. Moreover, once a process is in place, bringing about change is difficult.

Change resistance

Managed Care (medical cost management) is one of those processes in Workers’ Comp that resists change. While we’ve had managed care programs in place for twenty-plus years, medical costs continue to escalate. The confounding thing is business continues as usual, continues the same services using the same methods, while many hope for different results.

The industry created programs such as PPO networks, medical case management, utilization review, peer review, bill review and other initiatives to contain medical costs and produce better claim outcomes. In doing so, it also built an industry made up of companies and divisions of companies whose chief focus was medical cost containment. Over the years, that focus morphed to organizational preservation through revenue enhancement. Discounting methods and cost saving reporting have been reduced to simple subterfuge, without evidence of quality medical performance or outcomes.  

Starting over

Nonetheless, industry thinking is beginning to change as the elephants in the room are acknowledged. While it might be nice, starting over is not an option. The sunk costs are huge. Yet, many medical cost containment programs in the industry were soundly conceived in the beginning. The challenge is to realign them to achieve the results originally intended. Two major initiatives are necessary.

Follow the money (What else is new?)

Revenue models for managed care programs must be the first target of change. The consumers of managed care, the payers, must demand the change. Purchasing decisions are powerful change agents.

To satisfy the revenue requirements of managed care organizations as they shift their focus requires creative thinking and planning. Revenue should be structured to reward desired behavior and proven outcomes. That will require major process shifting because the current comfort level is entrenched.

Technology-intensified managed care

The second step in revitalizing managed care programs is to reinforce them with intelligent technology. Over the past twenty plus years, while computer technology has advanced exponentially, little has made its way to Workers’ Comp. managed care programs.

Technology offers ample opportunities to maximize cost savings. They include monitoring historic and current integrated data to identify and alert professionals of adverse conditions in claims in real time. Data can be re-presented for business units to be used as decision support and work-in-progress tools. Analytics can discern best medical providers to revamp networks and make the information instantly available to those directing care. Processes can be optimized and corporate standards enforced. Moreover, predictive models can guide strategic business decisions.

Making it happen

The first initiative of change is the more challenging. Changing business rationale carries the risk of revenue reduction or loss in the transition.

Affordable

Happily, infusing technology into operations is much easier and affordable. Do-it-yourself projects can work, but development time and costs can be excessive. However, proven tools are available to recharge managed care programs and begin realizing actual medical cost management.

Learn more about managed care technology “apps” at MedMetrics or contact karenwolfe@medmetrics.org

 

 

 

 

 

Distinguishing Medical Doctors--the Good, the Bad, and the Iffy

by Karen Wolfe

Poorly performing medical doctors are 100% predictive of high costs and poor claim outcomes. When they are also corrupt, the damage can be exponential. We know poorly performing and corrupt doctors are out there. More importantly, we know how to find them.

Joe Paduda’s recent post identifies such a group of doctors in Maryland.[1]  Paduda says, “When a doc knowingly over-treats, increasing the risk of adverse outcomes, potentially harming patients, and driving up costs, with little apparent regard for patient safety or appropriate treatment, one would hope they would be sanctioned pretty harshly.” True enough. Punishing them is appropriate, yet a more proactive approach to managing them is to avoid them altogether. Simply carve them out of networks. Avoiding corrupt and inept medical doctors prevents the needless spiral of adverse outcomes and cost.

Identify the perpetrators

Efforts to solve the problem should center around identifying the perpetrators by means of a well-designed analytic strategy and excluding them from networks. Most agree with this philosophy, yet few networks in Workers’ Compensation have addressed the issue. The data, when analyzed appropriately, will quickly point out medical doctors who perform badly as Paduda describes.

Trail of abuse

Fraudulent medical doctors and other providers leave a trail of abuse in the data. Bill review data, claims payer data, and pharmacy data, when integrated at the claim level including both historic and concurrent data, present a clear picture of destructive treatment practices. These are the corrupt, fraudulent, and abusive doctors. Moreover, they are easily discovered.

Happy trails
Happily, the good doctors are also easy to find. Their performance can be measured by multiple indicators in the data and they float to the surface with the best in class. When analyzed over time and across many claims, they consistently rise to the top. However, another category of doctors can present an entirely different challenge.

Good doctors who perform badly

Doctors in this group are highly respected in their profession, often recognized nationally and beyond for their medical expertise. At the same time, their performance from a Workers’ Comp perspective is decidedly inferior. They have high treatment frequency and duration rates.  Claim durations are comparatively long. They may be reluctant to return injured workers to the job, even to modified work. They may not respond to inquiries or complete necessary reports. In other words, while they may be medically talented, they ignore the unique needs of Workers’ Comp. As a result, claim costs are high. Should doctors like this be included in the network?

Decision dilemma

Celebrity doctors can present a difficult public relations problem. Pressure may be applied. Things can get politically contentious within the organization. Why aren’t “the best” included in the network?

Sometimes doctors in this category should be included, but not without evaluating the data. What outcomes are associated with these doctors? What is the disability rating at claim closure? Has the claimant returned to pre-injury status, free of disability and pain relieving drugs? In other words, does the claim outcome exonerate the celebrity doctor regardless of the cost of the claim?

Outcome-based network

Selecting the right doctors and other providers for networks is a complex task. Data from many claims where individual providers are involved must be analyzed to distinguish how a physician performs in the Workers’ Comp world over time. Subtleties of performance must be teased out. Decisions to avoid doctors like the ones Paduda described can be clear-cut. Others may not be so easy.

Go to MedMetrics to learn more about Provider Performance Analysis and Master Provider Index. Click Blogs and review previous articles on this topic. Or contact karenwolfe@medmetrics.org

 

 

 

 

 

 

 

 

 

 

 

 

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[1] http://www.healthstrategyassoc.com/wordpress/2012/10/the-wages-sin-mild-slap-wrist/

 

How to Measue What Might Have Been

By Karen Wolfe

The most difficult cost savings measurement is calculating the savings gained from what did not happen. Call it cost-avoidance measurement. Some say it cannot be done because if it has not happened, it certainly cannot be measured.

However, another point of view says that if placed in the context of assumptions based on analysis of the data, assessing savings for avoidance is doable.

Did the risk ever exist?

The first challenge in this tricky process is proving that a costly situation would have actually occurred given the conditions surrounding it. When it did occur, did the interventions mobilized reduce potential costs?

Do-it-yourself

A sample scenario is examining the data and finding that when a certain combination of data elements occurs, the result is consistently a 20% increase in indemnity costs. One can make the reasonable assumption that whenever that data combination appears in the claim, indemnity payments will increase unless intervening action is taken. That is predictive modeling 101.

Hours of IT time can be spent analyzing the data to tease out conditions that consistently result in cost increases. This do-it-yourself approach is not for everyone, maybe not for any one.

Rocket science

An alternative is the “rocket science” (mathematically sophisticated) approach of predictive modeling.  Formal predictive modeling procedures can be applied to the data to discover costly situations that should be avoided. This is a good approach, but it requires another step: concurrently monitoring the data to identify the risky conditions and taking appropriate action to avoid or minimize them. Nevertheless, the cost savings of avoidance can be claimed using this method.

Short cut

While either of these approaches has the potential to result in appropriately measuring and claiming cost savings, another method abbreviates the process. The short-cut is leveraging industry research and it is an easier, less costly, and more practical for most organizations.

Workers’ Comp industry research studies offer a format for measuring cost avoidance. During the course of research, large data bases are analyzed, usually applying sophisticated mathematical methodologies that identify risks and costs given certain conditions.

Leveraging research

An example of applicable research is the study conducted by Dr. Ed Bernacki and his team at Johns Hopkins University published in 2010.[1] Using five years of data containing closed claims supplied by Louisiana Workers’ Compensation Corporation, the research team first carved out claims where the reserves had increased from $15,000 to $50,000. The idea was to find the claims that had migrated in a negative way and then look for consistent conditions among them. In this case, the research team was seeking characteristics of poorly performing doctors.

Cost-intensive physicians

Amazingly, it was found that in the migratory claims 72% of the costs could be attributed to 3.8% of the physicians. The research team named physicians in this group cost-intensive physicians and identified consistent traits and behaviors associated with them. For instance, the physicians in this group were consistently associated with higher medical costs, longer treatment duration, longer claim duration, and higher indemnity costs.

Moreover, the cost-intensive physicians tended to treat disorders that have variability of treatment options, that is, no clearly defined treatment pathway. The disorders in that group included carpal tunnel, joint pain, intervertebral disk disorders, and psychological disorders. Additionally, certain physician specialties were associated with the characteristics of this group.

The study is rich in detail that can be translated to identify cost-intensive physicians in other databases who are the risky condition in claims. Using the research as a guide, isolate data elements that epitomize the characteristics of cost-intensive physicians.

Once identified in the data, cost-intensive physicians can be avoided. Find the cost-intensive physicians using the criteria demonstrated in the study, then avoid them. Determining the amount of savings is a question of establishing organizational policy based on the study.

Measuring savings of avoidance

Each time a cost-intensive physician is avoided, the savings can be calculated. Referring back to the study, preventing reserve migration is the framework of savings. If in the study the reserves migrated from $15,000 to $50,000, the claim savings assumed when a cost-intensive physician is avoided can be set conservatively or aggressively within that range.

Savings policy

The amount of savings declared is a question of determining the organization’s savings policy statement. An organization should establish standards for how it proclaims savings in claims. The savings policy statement, based on the research might read, “Based in the indicators found in industry research, avoiding a cost-intensive physician saves approximately $15,000”.

Monitoring and documenting

Obviously, none of this is useful information unless it is embedded in an operational process of analyzing the data, identifying cost-intensive physicians, and documenting avoidance. Traditionally, organizations have relied on their medical provider networks, but it turns out most network administrators do not evaluate provider performance on any basis. So it’s back to do-it-yourself or get help.

Nevertheless, it is possible to measure cost saving of what might have been. When placed in the context of assumptions based on research, assessing savings for avoidance is valid. To learn more, you are invited to visit MedMetrics or contact karenwolfe@medmetrics.org.

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[1] Bernacki, et.al. “Impact of Cost Intensive Physicians on Workers’ Compensation” JOEM. Vol. 52. No. 1. January, 2010.

Announcing Release of Master Provider Index!

Another computer-aided managed care service from MedMetrics

Now you can quick-search the best medical providers for Workers’ Comp by specialty and geo-zip directly from the Internet anytime! Master Provider Index analyzes provider performance based on data from multiple payers.

Why?

Because poorly-performing medical providers are 100% predictive of high claim costs in Workers’ Comp!
Imagine the savings derived from simply getting injured workers to the best doctor from the start—or referring to the best medical specialist every time!

Not your basic “Angie’s List”

Master Provider Index is a simple look-up online. Just select the specialty and geo-zip to display a list of the est medical doctors and other providers in that location. It’s that easy to use.

However, in order for Master Provider Index to display only the best medical providers, MedMetrics applies important technical underpinnings and analytics. MedMetrics does the technical heavy lifting and analytics so you can easily find the right doctors, those who are scored best based on the data.

Master Provider Index includes three major technical service components, all critical to the result:

            1) Technical services
            2) Medical performance analytics
            3) Online search
            4) Continuous updates

1.      Technical services

 

Data Import
The only way to evaluate provider performance in Workers’ Comp is to scrutinize and analyze the data. MedMetrics imports data from participants’ bill review, claims adjudication, and pharmacy systems. MedMetrics supplies a list of data items needed and where they are typically found. Participants place the data elements in a file and transmit it to MedMetrics. Data mapping is not required.

Data integration
MedMetrics validates, integrates, and maps the data from participants’ systems. Claimant-identifiable data is not used and participants’ data is placed in their confidential, secure sector of MedMetrics data warehouse. For Master Provider Index, MedMetrics will query data from all participants to analyze provider performance.

Scrub and optimize provider records
Provider records in most data sets are incomplete and contain many duplicates. MedMetrics corrects this by scrubbing and optimizing the provider records and duplicates are merged. Only then can a provider record be added to the Master Provider Index.

Continuous updates
MedMetrics imports data updates quarterly and continually monitors and re-analyzes provider performance. Master Provider Index is refreshed regularly, never assuming provider performance is static.

2.      Analytic services

MedMetrics executes its proprietary algorithms to evaluate the broad-spectrum data and score provider performance, thereby identifying best performing providers. Provider scores are integrated across multiple participant data, thereby creating a robust critical mass of data from which provider scores are calculated.

Medical services in the US are part of a cottage industry, therefore, performance indicators are spread across payers. MedMetrics integrates the provider scores across participants to provide a more robust basis for analysis.

3.      Online search tool

 

Master Provider Index users simply go online to select medical specialty and geo-zip. Users pick from a list of specialties and enter three to five digits of a zip code. Entering fewer numbers of the zip code broadens the geographic search.

Best practice providers are listed instantly on the screen. Providers include individuals, clinics, and facilities.

Easy, yet powerful

How easy it is for claims adjustors, medical case managers, plant or store managers, and others to quickly find the right provider for the situation. Provider location and contact information is displayed instantly. Licensed participants have unlimited access to Master Provider Index for all persons they authorize. Master Provider Index is always on, instant, and available from anywhere.

Contact karenwolfe@medmetrics.org now to become a participant and receive special pricing for Master Provider Index available only until the end of 2012.

Learn about MedMetrics' other computer-aided power apps that recharge managed care in Workers’ Compensation.

 

 

 

How to Manage Medical Providers in Workers' Comp

By Karen Wolfe

Medical providers and payers Workers’ Comp have long been at odds. Looking for reasons leads to speculation about discrepancies in points of view regarding injuries and appropriate medical treatment, providers who are resistant or oblivious to Workers’ Comp issues such as return to work, and the reimbursement tug-of-war.

Solutions

Solutions aimed at controlling treatment and costs by limiting payment have been implemented. Fee schedules enforced by individual state laws and CMS (Centers for Medicare and Medicaid Services) are designed to manage the cost of treatment. Additionally, bill review services enforce the scheduled rates with recommend pay. Importantly, these solutions do not manage treatment practices and processes.

Employers attempt to control the situation by engaging providers in their production processes. A plant walk-through is encouraged. Some advise taking medical doctors to lunch. On the other side of the same coin, medical providers attempting to lure business often ply claims adjusters and employers with gifts or treats. It all begs for a more scientific approach.

The power of observation

Fact: Subjects, when they know they are being observed, change their behavior for the positive. Research has proven the point repeatedly.

Hawthorne effect

Recall the “Hawthorne Effect”. One definition is, “A term referring to the tendency to work harder and perform better when they are participants in an experiment. Individuals may change their behavior due to the attention they are receiving from researchers rather than because of any manipulation of independent variables.[1]

Sentinel effect

Another concept used to describe managing behavior through observation is known as the sentinel effect. Strictly speaking a sentinel is defined as "a soldier stationed as a guard, either to challenge persons drawing near and to allow to pass only those who give a watchword, and, in the absence of this, to resist them and give an alarm." Applied to managed care, it is observing and reporting behavior, particularly in medical service utilization.[2]

Quantum physics

Taking the idea a step further, even in the “nano” world of molecular cell biology, the effects of observation have been scientifically measured. When cells are observed they seem to “know” they are being observed and they change form. While citing quantum physics might be pushing the limits of this argument, the concept of changing behavior through observation is supported.

Observing medical providers

The point is if medical providers are observed objectively, consistently, and concurrently, and if they know they are being observed by means of information feedback, their treatment behavior will change. Medical providers can be observed objectively, consistently, and concurrently through data monitoring.

Applying the metrics

Observing behavior through data monitoring is the first step. Analytics must be applied to the data so that the performance of individual providers, clinics, and facilities are compared objectively and fairly. They must be compared “apples to apples” meaning providers should be compared to those with similar specialties, treating similar injuries in the same state. 

Sharing the results

The way providers know they are being observed is through information feedback. Show them how they compare to others like them with objective reports. No such guideline has been available to them previously and many have no knowledge or evidence they are outliers. When lunching with providers review their comparative analyses. It is a platform for education and change.

All medical providers are just people or groups of people. None of them wants to show poorly in a graphic presentation of comparative performance. Professional pride, personal ego, and simple business economics will drive the desired results.

Use technology to observe, analyze, and report provider performance. Select only the best practice providers whenever possible to avoid claim cost and complexity.

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[1] http://psychology.about.com/od/hindex/g/def_hawthorn.htm or Google Hawthorne Effect.

 

[2] http://www.managedcaremag.com/archives/0601/0601.preauthorization.html  or Google Sentinel Effect.

 

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Unleash the Power of Real-time Data Monitoring for Managed Care

By Karen Wolfe

Data monitoring means applying technology and analytics to gain real-time intelligence and decision support in claims management. Moreover, data monitoring is the way to link analytics to operations, thereby making them actionable.

Nearly everyone in Workers’ Comp is trying their hand at analytics now. The problem is that organizations that have implemented analytics do not seem to know what to do with them. Analytics are great for reporting activity and corporate status to boards of directors and shareholders. Analytics uncover cost drivers and are impressive when graphically presented in annual reports. But analytics must be taken to the next level to actually impact costs or improve claim outcomes. To be truly effective, analytics must be linked to operations, thereby making them actionable. One way to achieve that is through concurrent data monitoring.

Unified and concurrent data platform

Claim data must be gathered from all relevant sources and integrated in a single platform. In Workers’ Compensation, organizations still find their data spread across multiple silos. Bill review, pharmacy, claims adjudication, and medical case management are all important deposits of data. However, claims cannot be adequately analyzed unless the full scope of data is gathered, integrated, and available for comprehensive assessment concurrently.

Some say bill review data alone is adequate for medical analysis. Yet, bill review data cannot reveal work status or return to work, indemnity costs, or final disability rating. These data, derived from the claims adjudication system, must be considered in combination with billing data in order to draw reasonable conclusions. Claims should be evaluated holistically, not in fragments by assorted participants.

Computerized data monitoring

Manual data monitoring is humanly challenging, if not impossible. The detail in claims, including many events over a period of months and years, cannot be absorbed or retained even by the most astute claims adjusters. Moreover, new information is added to claims continually that must be combined with historic information within a claim. Only a well-designed computerized system can handle the job.

For data monitoring to be valuable, it must be consistent and never random. A computerized data monitoring system can scrutinize all the data once it is integrated at no greater effort or cost than to monitor just a few items. It is a matter of thoroughness in system design and development. The computer can do it all, and do it accurately and consistently.

Computer-aided medical management

Computerized medical data management is always on and always alert. Rules-based conditions and data combinations in the broad scope of a claim trigger automatic alerts to the appropriate persons. The burden of watching every claim and remembering its historic facts, then combining the history with current conditions is impossible without computerized assistance. When claims adjusters and medical case managers receive alerts, they focus on claims that need the most attention, thereby optimizing efficiency and outcomes.

Standardized processes

Traditional claims management and medical management processes rely on individual ingenuity, knowledge, and skill. As a result, processes are rarely standardized within an organization. Individual performance and outcomes are rarely measured. However, with computerized, real-time data monitoring the organization’s quality output is monitored, individual performance is audited, and results are reportable.

The early discovery advantage

Importantly, computerized data monitoring insures early concurrent discovery of calamitous conditions in claims such as creeping claim severity, repeated opioid prescriptions, and comorbidities, to name a few . Uncovering such situations as they occur can save millions and prevent disastrous outcomes.

Analytics must be made actionable by leveraging the technology and pushing it into operations through computerized concurrent data monitoring, Data becomes a work-in-process tool, thereby achieving measureable efficiency and cost savings.

For more information, contact KarenWolfe@medmetrics.org and visit MedMetrics.

 

 

 

Predictive Analytics in WC Made Easy and Affordable

By Karen Wolfe

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 so they can be avoided?

Applying analytics

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 find the data, what to look for, and how to apply the knowledge gained from analysis to achieve improved results.

Data can offer a clear picture of actual provider performance. Evaluating physician and other provider performance is a matter of scrutinizing the data using industry research to learn what to look for. In fact, leveraging published industry research is the way to skip the laborious and expensive regression analyses and other predictive modeling methods.

Industry research reveals 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 were involved. 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.

Search

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

Indicators of performance

When the indicators of performance are identified, they can be tagged in the data to analyze individual providers. Providers associated with a preponderance of negative indicators will fall into the lowest class category. On the other hand, those whose results are exemplary will rise to the top—best in class.

Where to find the data

Billing data tells the story of diagnoses, treatments and the billed amounts. However, billing data by itself is never broad enough in scope to evaluate providers because it tells only a part of the story. Claim adjudication level data tells another part of the story. It describes the actual paid amounts, return to work, the amount of indemnity paid, and whether legal was involved. But there is more.

Analyzing PBM (Pharmacy Benefit Management) data is imperative. Overuse 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 could and should be.

Provider performance should be scored by claim 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 that should be measured. Analyzing multiple data indicators from disparate data sources is powerful in describing physician performance. It is also objective and fair.

Integrating the data for analysis

Any one Workers’ Compensation data source by itself is inadequate for the purpose of evaluating provider influence. 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 (billing or bill review, claim adjudication systems, and pharmacy data), then integrating current and historical data are 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 using research as a guide.

Link analytics to operations

Analytics results of any variety that remain in graphic form, in a brochure, or pinned to a wall are useless in the effort of actually 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 and others 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 and actionable.

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

Where to Search for Best-in-Class Doctors

A White Paper
by Karen Wolfe

No doubt you have seen the ad for Angie’s List. A good-looking male doctor is pictured with the caption, "He has been nothing but focused, dedicated and concerned about my health and well-being."  If searching for a contractor or hair dresser, this might be a good start. But searching this way for doctors? Absurd!

Finding doctors for injured workers through Angie’s List is a recipe for disaster. Subjective rating of medical treatment is not valid. Few patients understand enough about the science of medicine to venture a worthwhile opinion.

Yet, the methodology behind Angie’s List is a relatively common practice in the Workers’ Comp industry. Employers and payers sometimes survey their claimants in an effort to evaluate doctors. Unfortunately, most claimants report whether the doctor’s office has snacks, magazines they like, and the doctor was nice. The information is hardly a basis for utilizing the doctor and is about as helpful as that found in Angie’s List.

Measuring Provider Performance
Finding the right physicians for injured workers requires objective analysis of actual past performance, not patient opinions. Medical proficiency can be measured in terms of outcome, with the most positive outcomes evidenced by return to full work and reasonable medical costs.  However, in Workers’ Compensation even more focus should be placed on the course of the claim from the non-medical standpoint.

Industry research

Workers’ Comp industry research has clearly identified the attributes of good and bad medical performance. For instance, Dr. Ed Bernacki of Johns Hopkins lists characteristics of “cost intensive” physicians. The study[1], using data from the Louisiana Workers’ Compensation Corporation, found that 3.8% of physicians accounted for 72% of the costs. In other words, a small number of physicians have a profound impact on Workers’ Compensation costs. Bernacki’s study identified the characteristics of these cost intensive physicians. They are elements that can be found in the data and used to monitor and score provider performance.

MedMetrics uses the results of industry research studies to design its algorithms that evaluate and score provider performance. The research identifies provider characteristics and claim events under the influence of providers that should be measured. Using those indicators, providers can be compared in their jurisdictions with others in the same specialty to identify the best-in-class.

Medicine is a cottage industry

Medicine in the US is a cottage industry, with services delivered by individuals to individuals. Consequently, it is difficult for any one organization to gather enough individual provider data to create a critical mass for measurement. The problem is complicated by the fact that in Workers’ Comp states vary in fee schedules and other legal requirements so it is not valid to compare data across jurisdictions.  Nevertheless, provider performance is more accurate and fairer when evaluated across many claims.

The industry needs an independent organization to collect and analyze the data across multiple organizations so that provider performance can be measured more accurately.

Master Provider Index
MedMetrics is offering Master Provider Index. Data are collected from multiple participating organizations, then validated, and integrated. Provider performance is measured across multiple entities’ claims in a state, thereby creating a richer data resource. The combined data is analyzed and provider performance is scored. Finally, a quick-search is offered online so that best-in-class providers can be found in specific geo-zip regions on demand, on-the-fly.

Not Angie’s List
Master Provider Index is not Angie’s List by any means. Provider performance analytics are based on intelligence gained through industry research and performed on data from multiple organizations by state. Based on Bernacki’s study, one can assume saving up to 72% of costs by avoiding cost intensive physicians! Wouldn’t it be worth participating in Master Provider Index to save some portion of that?

For information about how to be a Master Provider Index participant, contact karenwolfe@medmetrics.org You are invited to visit MedMetrics

[1] Bernacki, et.al. “Impact of Cost Intensive Physicians on Workers’ Compensation” JOEM. Vol. 52. No. 1. January, 2010.

How to Make WC Managed Care Effective, Affordable, and Accountable

By Karen Wolfe

In a recent blog, Joe Paduda posed the question “Managed care in work comp: worth the cost?”[1] He continued, "Are we wasting hundreds of millions on ineffective programs, or are these programs holding costs well below what they otherwise would be?" 

Frankly, that this question is asked, whether we are wasting hundreds of millions on ineffective managed care programs, reveals a lot by itself. Why have managed care processes and outcomes not been measured for effectiveness continuously throughout their history? Managed care programs have been applied to Workers’ Compensation for twenty-five years, yet the question of whether they are effective is only now being asked? The fact is, managed care effectiveness is largely unknown because the appropriate technology has not been properly applied to manage, measure and monitor the processes.

Analytics backed by technology

Stated simply, analytics can determine what processes are most effective and technology can be leveraged to direct the managed care focus to the claims, events, and conditions in most need of attention. That creates efficiency. The managed care focus should be on claims that contain elements that are known to portend trouble, thereby avoiding frivolous activity and extraneous cost.

Inform the process

To ensure managed care methods are effective and to power the processes, both technology and analytics must be applied. Work-in-process electronic software tools must be developed and implemented to translate analytics to action.  Electronic tools specifically designed for Workers’ compensation managed care will inform the process, improve the outcome, and measure its effectiveness. Using technology to continuously monitor historic and current claim data will exact a more perfect result.

How to recharge managed care
Specific essentials are needed to recharge managed care effectiveness and establish its accountability. All are necessary and all are based on technology and analytics that build on existing resources:

1. Build a unified historic and current data platform
2. Monitor the integrated data continuously
3. Analyze the data to discover problematic conditions in claims
4. Link the analytics to operations with software “apps”

1.      Build a unified and current data platform
The data must be comprehensive, sourced from multiple data silos. Those include bill review data, PBM (Pharmacy Benefit Management) data, and claims system level data. The data must be integrated at the claim level and updated continuously for comprehensive analysis. These basic technological tasks create the platform for performance.

2.      Monitor the integrated data continuously

The unified, concurrent, and continuously updated data platform must be electronically monitored continuously. The crux of computer-aided medical management is maximizing claim monitoring using the technology. Relying on manual monitoring of current and historic data in claims to distinguish those that need attention is not practical or even possible.

Moreover, monitoring current claims data in context with claims history is a technological function that searches for conditions and elements in claims that portend risk and cost. Manual monitoring by even experienced persons cannot begin to approach this goal.

3.      Analyze the data to discover problematic conditions

Rules-based and knowledge-based algorithms built into the underlying software will identify actual or potentially problematic claims. Electronic data monitoring is used to uncover events, diagnoses, and data combinations that are of concern.

Reveal hidden threats

For instance, a diagnosis of diabetes might be documented on a bill by a treating physician on the fourth or fifth visit. Such a comorbidity buried in the data might easily go unnoticed without computer-aided medical management. Yet, technology will uncover it every time.

Identify poor providers

Another example of analytics used to uncover risk is evaluating physician performance. A physician who keeps claimants off work without sound rationale or a blatantly fraudulent doctor who is treating the claimant are both predictive of higher cost outcomes. Yet, when the physician is on the approved panel, no one takes notice. A smart software system will alert appropriate persons apprising them that a low ranking physician is treating the claimant—as it is occurring.

The same smart system will single out best-in-class medical providers so that claimants can be directed to them from the start.

4.      Link the analytics to operations using software “apps”

Analytics must be logically linked to operations. No advantage is gained by performing analytics and letting them languish somewhere in graphic form. Analytics must be made actionable.

When the results of analytics are translated into software tools and alerts for claims adjusters, medical case managers and others, the information can be acted upon before much of the damage is done. Medical provider networks can be converted to quality networks. Claims cannot deteriorate without notice.

Software multiplies intelligence

Bill Gates said software is the multiplier of human creativity and performance. Software makes people do what they do best even better. Managed care programs can be intelligently revitalized by applying technology and analytics to the process, thereby gaining efficiency, accuracy, and accountability.

Paduda concludes: “Paying over a hundred million dollars for network access without clear and convincing proof that they are improving outcomes is not smart.” Also, “Using case management and UR indiscriminately across all providers in all cases is a waste of money and counter-productive.” He is absolutely correct. But it need not be that way. Affordable solutions are available now.

What it takes

A logical and efficient merger of technology and analytics is the only feasible way to resolve the issues in managed care. Automated processes coupled with intelligent analytics will produce the desired results along with the necessary proof of value. Happily, building the system internally, a costly and time-consuming effort, is not necessary.

A knowledgeable managed care analytics outsource will implement the advantages without the hassle, time, or cost of builidng these functions internally. In fact, managed care power apps can be added to the managed care initiatives of any size organization for less than the cost of a part time analyst!

Learn more about MedMetrics or for discussion, contact KarenWolfe@MedMetrics.org

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[1] http://www.joepaduda.com/archives/002361.html