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The MedMetrics blog provides comments and insights regarding the world of Workers’ Compensation, principally, issues that are medically-related. The blog offers viewpoints regarding issues affecting the industry written by persons who have long experience in the industry. Our intent is to offer additional fabric, perspective, and hopefully, inspiration to our readers.

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Tuesday, November 6, 2012

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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