How to Control Costs by Selecting the Best Doctors

by Karen Wolfe

Getting injured workers to the right doctors from the start is the best way to save dollars. Evidence of this fact is the accumulating industry research that clearly states the well-informed and well-intentioned medical providers produce the best results in Workers’ Compensation. Alternatively, those doctors who rank low on a comparative scale of Workers’ Comp indicators guarantee high claim cost and poor outcomes. Many of the doctors in networks are not well-informed or well-intentioned. Unfortunately, it is up to you to figure out who is who.

Blame is not a solution

That Workers’ Comp medical costs are not successfully controlled is obvious to anyone paying attention. Medical costs, now 60% of claim costs, continue to mount in spite of the most aggressive managed care initiatives. The doctors are blamed, accurately in some cases. However, blame cannot control costs and blame is not a solution.

Scope of cost influence

It is true, medical costs are essentially driven by medical providers, especially medical doctors. Consider their scope of influence on the course of a claim. They are responsible for direct medical treatment costs and they influence the broader scope of care by referral, hospitalization, medical procedures, and prescriptions. They drive indemnity costs by keeping injured workers off work. Those providers who are not well-intentioned can find many ways to exploit abuse the system.

For instance, increasing the frequency and duration of medical treatment are easy means of embellishing costs, while ordering excessive diagnostic testing is yet another means.

Excessive diagnostic testing

Risk and Insurance Journal recently published a news article picked up from Reuters titled, “Medical Don’ts:  Doctors Identify Unnecessary, Harmful Tests, Treatments”[1] It describes an effort on the part of doctors, through their specialty societies, to reduce the number of unnecessary testing. Links to an associated article called “Choosing Wisely” are included.[2]

This article includes lists of specific, evidence-based recommendations that physicians and patients should discuss to help make wise decisions about the most appropriate diagnostic testing and care based on the patient’s individual situation. Each list includes information about which tests and procedures are appropriate for whom. Of note is the fact that while physicians order excessive testing on a routine basis, patients themselves have come to expect certain tests and treatments, thereby compounding the problem.

Causing litigation

In Workers’ Comp curtailing unnecessary tests and treatments can be even more delicate than in general healthcare. Injured workers often feel entitled to more rather than less medical treatment. When claimants feel their medical treatment is curtailed, they can seek their perceived due through the very accessible legal system. Only a Workers’ Comp knowledgeable and sensitive doctor will navigate this course successfully.

Choose the best doctors

The way to choose the best-in-class medical providers is by analyzing the data using the practice behavior indicators suggested here and in the research literature. Besides direct medical bills, measures of cost involve the frequency and duration of medical treatment, as well the kind of treatment. Doctors that order excessive diagnostic testing and medical treatment as defined by the doctors themselves should be held suspect. Doctors who provoke legal involvement should be avoided.

When behaviors of doctors are analyzed, the well-informed in Workers’ Comp will surface. The well-intentioned, meaning they are not abusive or fraudulent, will also be identified.

More is more

For most organizations, the challenge of choosing best practice providers by analyzing the data is the shortage of qualified data within one organization. An organization usually does not have enough data to fairly score provider performance. Moreover, most organizations do not have the necessary internal “know-how”, nor have they integrated their data from all appropriate sources.

Many attempt to analyze provider performance based on bill review data alone. This is inadequate because factors such as return to work, indemnity costs, legal involvement, and outcome are not considered. Claims level data and pharmacy data is necessary in combination with bill review data to do an adequate job.

How to find best-in-class doctors

Therefore, those wanting to control costs by choosing the best providers should obtain provider performance analysis and scoring from a specialty third party that analysis providers based on comprehensive integrated data from multiple sources and multiple organizations.

Visit MedMetrics to learn about MedMetrics’ Provider Performance Analysis and Master Provider Index, tools that analyze provider performance and quick-search for the best. You are invited to read other articles under "Blogs" on this subject and others.
Questions?  Contact karenwolfe@medmetrics.org

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[1] S. Begley. Medical Don’ts: Doctors Identify Unnecessary, Harmful Tests, Treatments. Reuters. February 21, 2013.

[2] http://www.choosingwisely.org/doctor-patient-lists/

http://www.choosingwisely.org/wp-content/uploads/2013/02/Choosing-Wisely-Master-List.pdf