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