FAQ: How to Find the Primary Physician in Claims

by Karen Wolfe

A frequently asked question in Workers’ Compensation medical management is, “How can one determine which is the primary physician in a claim?” The reason for the question is usually an attempt to assign accountability for the outcome of claims. However, the question, if asked slightly differently, can provide much more valuable information.

The wrong question

Whether or not the correct question is asked, gathering information about treating doctors is essential. Knowing all the treating doctors in a claim is important and they can be easily found through analytics (data analysis). However, determining the primary doctor is misleading.

The notion of primary physician suggests assumptions that are inaccurate: that the primary physician has control of a claim. Rarely does one physician have full control. But one physician might have the most influence. Therefore, a more telling question is, “Who is the predominant physician in the claim?”

Predominant physician

The predominant physician in a claim is the one who has had the most influence on claim cost and outcome. That information can also be found in the data.  However, predominance cannot be measured in dollars billed or paid to physicians. Specialists, especially surgeons, will surface using dollars as the identifying metric. Those identified may or may not be the most influential in the course of treatment or outcome. Predominant physicians are the ones who encounter the injured worker most frequently.

Influence and Impact

An indicator of physician predominance in the data is how frequently they were face to face with the injured worker. Frequent encounters with the same physician will significantly influence the course of the claim, leading to positive or negative results. It is one measure of medical provider performance.

The treating physician who is seen more frequently by the injured worker will impact return to work, recovery, and often directly influence whether the claimant seeks litigation. Identify the best physicians using predominance in the claim data as one factor. Rather than directing injured workers to any physician in the network, select the doctors with better results, especially those who have greater influence in claims with positive outcomes.

New networks

Traditional discount networks do not evaluate provider performance regarding claim cost and outcome. Employers and their claims administrators are now undertaking that task and redesigning their networks by carving out the best performers. The only sure way to do that is to examine the data, especially provider performance data measured by multiple indicators. One of the indicators that should be evaluated is physician predominance in claims.

A groundswell is occurring in Workers’ Compensation, a dramatic shift from traditional medical provider discount networks to quality, outcome-based networks. Increasingly more organizations are evaluating their providers in networks and carving out the best-in-class doctors. Creating a “designer” network of the best doctors by analyzing the data guarantees improved claim outcomes.

Karen Wolfe is the founder and president of MedMetrics®, LLC, an Internet-based Workers’ Compensation analytics company. MedMetrics applies analytics and technology to evaluate medical provider performance, to significantly strengthen medical management in Workers’ Compensation, and to link the analytics to operations by means of user apps, thereby making the analytics actionable.

 

Moneyball and the Art of Workers' Comp Medical Management

by Karen Wolfe

Recently I watched “Moneyball”, the movie for the third or fourth time. The story is compelling, as is the book by the same name that preceded it.[1]

Moneyball is based on the concept called sabermetrics, defined as "the search for objective knowledge about baseball." The central premise of Moneyball is that the collective wisdom of baseball insiders, including players, managers, coaches, and scouts over the past century is subjective and flawed. The book argues that the Oakland Athletics general manager, Billy Beane took advantage of analytic, evidenced-based measures of player performance in order to field a team that could compete successfully against far richer teams in major league baseball. During the 2002 season, the Oakland ‘As’ won enough games to make the playoffs in spite of a meager salary budget and "inferior" players.

Even though the two industries are diametrically dissimilar, distinct parallels can be drawn between Moneyball, a story about the Oakland Athletics baseball team and Workers’ Compensation Medical Management.

Similar Resistance to analytics

One comparison that can be drawn between the two is resistance to adopting analytics as a knowledge tool. Baseball insiders and managers opposed Beane’s analytics, sometimes vehemently. Long-held beliefs among baseball insiders promoted measures of performance such as stolen bases and batting averages. Beane’s metrics debunked the old methods, revealing unrecognized strengths in lesser-known, more affordable players.

Similarly, Workers’ Compensation leaders have relied on traditional medical provider networks and personal preferences to select medical doctors. If doctors are in a network and offer a discount on medical services, all is good. Yet, industry research has shown that not all doctors are equal. Doctors and other medical providers who understand and acknowledge the nuances of Workers’ Compensation drive better outcomes. It’s a matter of finding those doctors.

Finding best performers

The purpose of Moneyball sabermetrics is the same as Workers’ Compensation medical metrics—to find the best performers for the job. The way to do that in baseball is to analyze the data defining actual performance in terms of outcome—games won. In Workers’ Comp the data must be scrutinized to find doctors who drive positive claim outcomes. In both cases, a variety of metrics are used to support the most effective decisions.

Performance indicators

As in baseball, the goal in medical management is to apply objective information to decision-making using evidenced-based measures of performance. For both industries, cost is a factor. However, in Workers’ Compensation, the cost of medical care must be tempered by other factors:  What is the duration of medical treatment? What is the return to work rate associated with individual doctors? What providers are associated with litigated claims?

As in baseball, the list of indicators for performance analysis is long. However, the sources of data differ significantly.

The data challenge
In baseball, all the data necessary for analysis is neatly packaged in games played. Statistics are gathered while the game is in progress. In Workers’ Comp the data that informs medical management resides in disparate systems and must be gathered and integrated in a logical manner.

Essential data lives in bill review systems, claims adjudication systems, pharmacy (PBM) systems and can also be found in utilization review systems, peer review systems, and medical case management systems. The data must be integrated at the claim level to portray the most comprehensive historic and current status of the claim. Data derived from only one or two sources omits critical factors and can distort the actual status or outcome of the claim.

Once the data has been integrated around individual claims, meaningful analysis can begin. Indicators of performance can be analyzed with new conclusions drawn about the course of treatment and medical provider performance. Moreover, concurrently monitoring the updated claim data leads to appropriate and timely decisions.

Data positioned as a work-in-progress tool

In baseball, the data is used as a work-in-progress information tool. Decisions about the best use of players are made daily, sometimes hourly. Workers’ Compensation medical management can do the same. Systems designed to monitor claim details and progress can alert the appropriate persons when events or conditions portend complexity and cost.

Industry status

Analytics in baseball is not exclusive to the Moneyball Oakland Athletics. All of major league baseball now relies heavily on its use. Unfortunately, there are still only a few visionary “Billy Beane’s” in Workers’ Compensation medical management. Yet, applying analytics for cost and quality control is simple, affordable and can be adopted quickly by all.

Karen Wolfe is the founder and president of MedMetrics®, LLC, an Internet based Workers’ Compensation analytics company. MedMetrics applies analytics and technology to significantly strengthen medical management in Workers’ Compensation and to link the analytics to operations by means of user apps, thereby making the analytics actionable.

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[1]Lewis. M. Moneyball: The Art of Winning an Unfair Game 2003. The film “Moneyball”, starring, Brad Pitt was released in 2011.