Return-to-Work Sweepstakes

By Karen Wolfe

Recently it seems, Workers’ Compensation industry literature and networking communities are renewing their interest in, and emphasis on Return-to-Work programs. According to WorkersCompensation.com, the Washington state Department of Labor and Industries (L&I) is actively seeking innovative ideas for helping injured workers return to work soon after an injury. Moreover, L&I is offering grants (real money!) for winning ideas!

Grant money for return-to-work projects is available as part of the workers’ compensation reforms passed by the 2011 Washington Legislature and signed into law by Governor Gregoire. Available through the Washington state Safety and Health Investment Projects (SHIP), the grant program funds new projects that develop and implement effective return-to-work programs for injured workers to reduce long-term disability.

The report from WorkersCompensation.com continues, “Promoting new return-to-work projects is an important part of the reforms because research shows that helping injured workers get back to work after an injury helps them recover quicker, reduces long-term disability and lowers overall workers’ comp costs. SHIP grants are designed to encourage new ways of approaching occupational health and safety challenges, as well as promoting cooperation between labor and management.” Wow.

 This initiative reminds me of a return-to-work project in which I participated many, many years ago, one that might have qualified for SHIP grant money. A major grocery chain wanted to create an innovative return-to-work program for their warehouse and shipping workers, something that had not been tried before. They knew keeping those workers at work was key to returning them to full work and also to controlling disability costs.

The Workers’ Comp leaders of this self-insured, self-administered employer engaged the services of the hospital-based occupational health program for which I was the administrator. The idea was that we would help them develop a “Light duty” learning environment for injured workers. Our occupational health service would contribute to creating and presenting lectures, videos, and supplying the educational leaders for the project.

Injured workers were assigned to a classroom where they would benefit from daily lecturers on such topics as nutrition, health, and wellness. The idea was that the content, besides helping employees remain at work during recovery, would also enhance their lives and their health status. It was Wellness 101. Everyone was enthusiastic about the project—except the workers.

It turned out, engaging Teamster-level workers in classroom discussions about the finer points of living well was a challenge. Sitting in a classroom for hours was an anathema for these workers. Frequent smoke breaks were necessary as they heard lectures about the dangers of smoking and the benefits of exercise. I personally began to dread it as much as the workers.

Looking back, asking heavy labor workers to sit in a classroom all day was nothing short of ridiculous. It must have recalled for many of them their years in academia, probably not among best memories for many. Classroom learning was simply not for them and the absentee rate soared. They actually risked their jobs to avoid the return-to-work program!

Not surprisingly, this particular return-to-work program was short-lived. The take-away was that one approach will not fit all employee groups and even if it is creative. “Light duty” or “modified duty” programs must fit individual ability, skills, and optimally, would be in some way related to the injured worker’s regular job. It should make some sense to the worker.

 Nevertheless, this employer should have been honored for creativity, ingenuity, and willingness to try something completely new. It did not work, but it didn’t hurt anyone. The Washington state SHIP may have loved it.

Results Won’t Change With the Same Thinking Used to Create Them

By Karen Wolfe

The medical portion of Workers’ Compensation claim costs continues to increase, according to a recent report by the NCCI. At the same time, managed care methods and programs in the industry that were originally designed to control medical costs have not changed their processes in twenty-five years.

Old thinking

Programs such as medical provider networks (PPO’s, HCO’s, MPN’s) have not changed their approach over time. Most network companies continue to contract with every medical provider everywhere. In exchange for sending providers new patients, the providers offer discounts on units of service. Discounts are reported as savings by the networks.

As a result of this practice, both parties benefit from increases in frequency and duration of service. Providers increase their revenue by increasing units of service and networks boast the savings from discounts. It seems absurd, but the industry continues business as usual while costs continue to escalate.

“We cannot solve problems with the same thinking we used to create them.”  Albert Einstein

In the beginning, discounting units of medical services seemed like a good idea. It created a revenue stream for networks as they signed on new providers and providers were happy with the Workers’ Compensation business gained. Moreover, monthly reports of discounted medical fees made employers and payers feel good.

New thinking 

Now, however, payers are recognizing the problems in this model. They understand quality, effective medical care within the context of Workers’ Comp is more important and usually less costly overall. Payers want to select providers who have proven they can do the job and are willing to pay fair medical fees to get it done.

If networks want to join in, they must figure out how to monetize their products without the discount charade. That is difficult. Nevertheless, while they work to solve their problem, payers can move forward without them. The focus should be on carving out providers from networks, providers who will serve the claimant with quality medical practices while supporting employer needs in the context of Workers’ Comp.

Forward thinking
Forward thinking employers and payers are no longer accepting any and every doctor. Now they are turning to analytics to identify best-in-class doctors, those who are extracts of excellence drawn from larger networks. Yet, that is not easy either. In order to measure medical performance through analytics, several crucial steps must be taken first, none of which are used by traditional networks.

Prerequisites of analytics

Before analyzing the data for objective provider performance, the data itself must be collected, integrated, and improved. Most provider records in Bill Review and claim systems are lacking the level of data quality and essential elements needed for analysis.

Duplicate records and errors

Most computer systems contain duplicate provider records resulting from faulty data entry methods. Obviously, a fair assessment of provider performance cannot be made when an individual provider is spread across several records in the data. This means some claim experience is tied to one instance of the provider and other claims are tied to still other records for the same provider. The records must be corrected and merged.

Unique identifiers

Besides cleansing and merging the data, crucial identifier elements must be added to provider records. Most systems contain provider Tax ID numbers, but those are not unique to individuals. Any number of doctors can use one Tax ID since it is for payment purposes only. The only way to differentiate individuals within practicing groups is to include NPI (National Provider Identifier) and state medical license numbers in provider demographics in the system. Each individual doctor can then be correctly identified and tied to their correct activities. Even so, there are more factors to consider before analyzing medical performance using analytics.

Medical specialty

Medical specialty is important to assessing medical provider performance. In fairness, orthopedic surgeons should be compared against other orthopedic surgeons, not psychiatrists. Many systems do not contain the provider’s specialty but it is important enough to take the trouble to add that information to the system. One way is to interpolate specialties from the CPT (Current Procedural Terminology) codes used by providers in their bills.

Get expert help

Data omissions and inaccuracies prevent good and reasonable assessment of medical performance. Unfortunately, medical provider data in the Workers’ Comp industry is abysmal across the board. Correcting, merging, and optimizing provider records in data systems requires unique skills not usually possessed by claims management system professionals. Get help.

Claim cost results won’t improve when the same old network thinking is used that created them. The way to achieve quality and cost control is to first optimize the data, then evaluate provider performance. Create a subset of excellent providers for a “designer” medical network that will impact claim costs and outcomes.

To learn more about where to get help for correcting and optimizing provider records and analyzing provider performance, contact karenwolfe@medmetrics.org or 541-390-1680. You are also invited to visit MedMetrics.