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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