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.