by Margaret Wagner and Karen Wolfe
Background
Building a medical provider community for Workers’ Compensation can be
challenging, regardless of the jurisdiction. Nevertheless, carving out a legislatively-compliant,
outcome-based, quality network is doable and the return on investment is
certain.
Injured workers deserve good medical treatment while employers and
payers deserve transparent and fair costs. Moreover, industry research clearly
shows that poorly performing providers are costly and lead to abysmal outcomes
for injured employees, their families, and employers. This article features
California SB 863 regarding MPN’s (medical provider networks), but the concepts
apply to creating intelligent medical provider networks anywhere.
Traditional medical networks
Medical networks in Workers’ Comp are not new, in fact, PPO’s
(Preferred Provider Organizations) have been around in Workers’ Comp since the
early 1990’s. Traditionally, the network administrator contracts with all physicians
and other treating providers available. The trade is, providers exchange their
discounted fees for increased patient volume. However, quality of medical care
measured by outcomes and acknowledgment of Workers’ Comp nuances such as return
to work are not considered. However, some jurisdictions have made attempts to
modify this practice.
Old SB 899—LC 4616 Medical
Provider Network (MPN)
In April of 2004 the governor of California signed SB 899 into law. It
addressed MPN’s under section LC 4616 (d) stating “In developing a medical
provider network, an employer shall have the exclusive right to determine the
members of their network.”
Encouragement to analyze provider performance is clear under section LC
4616.1, “Economic Profiling means the evaluation of a particular physician,
provider, medical group, or individual
practice associations based in whole or in part of the economic costs or
utilization of services associated with medical care provided or authorized
by the physician, provider, medical group, or individual practice
association.” In other words, quality
and costs matter and should be analyzed and monitored.
Direction of care
An important opportunity in California and many other states is
employers and payers are allowed to direct care for injured employees to
doctors and other medical providers in their medical provider networks. After
selecting the best doctors for a network, injured workers can be directed to
them, a win-win scenario.
Even in states where direction of care is not permitted, payers or
employers who have intelligent networks can give injured employees information regarding
who are the best in class doctors based on objective analysis. Doing so is a
service to employees who will often make use of them in selecting a doctor.
Ramping up—SB 863
The logic of creating an intelligent network with measureable outcomes
was recently fortified with California SB 863, effective January 1, 2013. The
old bill is strengthened under SB 863, LC 4616 (b) (2) and LC 4616 (b)(3) “ Every MPN must establish
and follow procedures continuously to review the quality of care,
performance of medical personnel, utilization of services, facilities, and
costs.”
Quality control
In other words, all MPN plans must have procedures in place to continuously
review the quality of care and costs for medical providers in the network. The
mandate is now even stronger to evaluate and monitor medical provider performance.
No longer is it adequate to contract with medical providers, print the list of
providers in the network, and forget it.
However, many employers and
payers are at a loss about how to analytically select and continuously review
provider performance.
Intelligent networks
Legislative mandates and industry wisdom remove the question about
whether to upgrade network quality through outcome analytics and monitoring. Yet,
selecting the right doctors and other providers, then monitoring, and managing an
intelligent MPN is a business in itself.
Most organizations do not have the appropriate resources and should outsource
to companies that focus on intelligent network design, provider selection
through analytics, review, and management. The following are some details for
building and managing intelligent networks, whether they are legislated or not.
Gather the data
The way to develop an intelligent network is to select the best in
class medical providers determined by analysis of actual performance demonstrated
in the data. Historic data must be combined with current and continually
updated data to evaluate performance now and going forward. Reviews of updated
data should be frequent and regular.
Additionally, the data must be derived from a broad spectrum of sources.
Workers’ Compensation organizations typically segment data into bill review
data, claims, pharmacy (PBM) and other silos such as UR and Medical Case
Management. All are necessary for provider performance assessment. Do not be
misled by those who say bill review data is adequate to the task.
Integrate the data
Integrate the data with claims as the focal point for a complete
picture of the claim. Execute algorithms that analyze the data and score
provider performance based on multiple performance indicators. Individual
medical providers, groups, and facilities should all be analyzed in this regard.
Continuous data update and electronic monitoring insures network and individual
provider quality going forward as prescribed in SB 863 legislation. Maximize
medical network quality and cost control using analytics, thereby complying
with legislation and maximizing positive
benefits.
More about building networks
with intelligence
Next week Part II of this series will add more details of California SB
863 regarding MPN’s and how to create networks with intelligence using
analytics and common sense, an imperative for all medical networks in all
states.
Margaret Wagner is President and CEO of Signature Networks Plus, Networks with Intelligence™. She is considered an expert in network selection, monitoring and management, thereby creating Networks with Intelligence for clients. MWagner@signaturenetworksplus.com
Karen Wolfe is President and CEO of MedMetrics®, LLC, a Workers’ Compensation analytics company. MedMetrics scrubs and enhances provider data in systems, integrates the data from organizations’ disperse systems, then analyzes, scores, and monitors medical provider performance. MedMetrics also offers online “apps” that link medical analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org
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