How to Optimize the Nurse Case Management Advantage, 2nd Edition

by Karen Wolfe

This is an update to an article posted in January, 2013. The response to it was excellent, suggesting the topic is important.

Traditionally in Workers’ Comp, nurse case management (NCM) services have been widely espoused, yet misunderstood and underutilized. The reasons for underutilization are many. Tension between NCM and claims adjusters for claim ownership is one. Even though overburdened, adjusters often overlook the opportunity to refer to NCM.

Also to blame is the NCM process itself. In spite of professional certification for NCM, the process is poorly defined for those outside the nursing profession. Moreover, and more importantly, NCM has difficulty measuring and reporting proof of value.

Underlying issues

Continuing to do business as usual is not acceptable. NCM needs to address several issues to qualify as legitimate value contributors to the claim process. First, they need to articulate their value. To do that, NCM must computerize and standardize its process, measure and report outcomes, just like any other business in today’s world.

Computerize

NCM is last and least to computerize. When a process is poorly understood, funding and designing an effective software system is impossible. Too often, computerization for NCM is relegated to adding nurses’ notes to the claim system. However, such notes cannot be analyzed to measure outcomes based on specific nursing initiatives.

Package through standardization

Packaging a process is the way to standardize it so it can be understood and valued by others. In most situations, an individual NCM interprets the problem or issue, decides on an action, and delivers the response. The organization’s medical management is thereby a subjective, illusive interpretation rather than a definable, quantifiable product.

Granted, the NCM is a trained professional who reacts to events and conditions in the claim based on a medical knowledge base. But when the product is unstructured, variables in delivery cannot be measured or appreciated.

A process that is different every time can never be adequately defined. Establish organizational standards of conditions in claims to be referred to NCM—without exception. Remove the myriad of decisions made or not made by claims adjusters to involve the NCM. The referral can be automated through electronic claims monitoring and notification. NCM takes action on the issue according to organizational protocol and the claims adjustor is notified at the same time.

 
Measure
When the conditions in claims that lead to intervention by NCM are computerized and standardized, the outcomes or effects can be measured. Apples can legitimately be compared to apples, but not to oranges and tennis balls. Similar conditions in claims are noted and approached the same way every time, so the results can be validly measured.

Results in claims such as indemnity costs, time from DOI to claim closure, or overall claim cost can be compared before and after NCM standardization. Compare across different date ranges for similar injuries going forward to measure continued effectiveness and honing of the process.

Measuring outcomes is the most essential aspect of the process. Value is disregarded unless it is defined, measured, and reported. Many options for measuring success are available when the components are standardized and computerized.

Report

Report and communicate measured outcomes. Never assume others will recognize NCM value without delineating it for them. For non NCM’s, the dots in medical management must be connected to see the picture. Describe what was done, why it was done, and how it was done the same way for similar situations and in context with the organization's standards. Then report the outcome value. Establish a continuing value communication process.

Define process in advance

NCM constituencies should be informed in advance of the process and outcome measurements. Define in advance how problems and issues are identified, executed, and how results will be measured. Then proceed consistently.

Recognized NCM value

Nevertheless, at long last, NCM value is now being recognized. American Airlines recently reported they are adding NCM to their staff and will refer all lost time claims. They cite a pilot project where nurse interventions were documented and measured, proving their value in getting injured workers back to work.

Christopher Flatt, Workers’ Compensation Center of Excellence Leader for Marsh Inc., in an article written for WorkCompWire (http://www.workcompwire.com/) stated, “One option that employers should consider as part of an integrated approach to controlling workers’ compensation costs is formalized nurse case management. Taking actions to drive down medical expenses is an essential component to controlling workers’ compensation costs.”[1]

Industry research and corporate wisdom
Industry research and corporate or professional wisdom regarding risky situations can supply the standardized indicators for referral to NCM. American Airlines uses the standard that all lost time claims should be referred to NCM. But there are many, sometimes more subtle indicators of risk and cost in claims that can be identified early through computerized monitoring and referred for NCM intervention.

Another example of developing standard indicators for referral is based on industry research that shows certain comorbidities, such as diabetes can increase claim duration and cost. These claims should also be referred to NCM for oversight. Yet another example is steering away from inappropriate medical providers who can profoundly increase costs.

Computer-intensified medical management
As a long-ago nurse and a longer-time medical systems designer and developer, I believe the solution lies in appropriate computerized system design. To be effective, the components are those described above. The elements need to be simple to implement, easy to use, and consistently applied. Only then can NCM offer proof of value.

MedMetrics®, LLC offers Medical Intelligence Profiles with Alerts, an online app that serves as a smart container for an organization’s medical management standards and rules of referral. MedMetrics monitors all claims continuously and sends electronic alerts when conditions in a claim match those in a profile. This and other MedMetrics apps link medical analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org

[1] http://www.workcompwire.com/2013/01/christopher-flatt-the-case-for-formalized-nurse-case-management/?utm_source=WCR+Daily+1%2F22%2F13+-+A+New+Leader+Speaks%21&utm_campaign=WCR&utm_medium=email

 

Portrait of a Smart Medical Provider Network in Workers' Comp

by Karen Wolfe

Smart is cool, especially in electronics. Smart phones answer their users' most obscure questions instantly. Computers are smart, as are iPads, some TV's, and even children's toys. So why can't Workers' Compensation medical provider networks be smart? If they were, what would that look like?

 

Portrait of a smart medical network

A smart medical network contains only the best doctors and other medical providers, those who drive the best results for injured workers and their employers. Moreover, a smart network does not rely on discounts on services as the requirement for participation. Instead, demonstrated positive outcomes are the qualifier for medical provider participation and ongoing excellence.

Smart networks are local

A network containing thousands of doctors is of no value to the injured worker. Workers need the closest provider who will treat them effectively and return them to work. The worker’s employer likewise needs the best local provider who will return the worker to pre-injury status in the shortest amount of time at the least cost. Smart networks are comprised of this kind of medical doctors.

Network participation qualifiers

Smart networks are built by objectively measuring the performance of physicians who have actually treated injured workers. Objective evidence of performance is found in the data. Yet, indicators of performance are typically ignored in traditional networks. They do not measure or monitor the quality of provider performance. They simply contract with any providers and add them to the network directory.

Indicators of quality

Many indicators of performance found in the data can be used to measure the level of provider performance. In the case of medical treatment of injured workers, the most telling indicators reveal doctors’ awareness and acknowledgement of the nuances of Workers’ Compensation that ultimately benefit both injured workers and their employers.

Revealing data elements influenced by the treating physician include, but are not limited to, return to work, medical costs, indemnity payments, legal involvement, and disability status at the close of the claim. These outcome indicators in the data are important markers of quality and legitimate criteria for evaluation. Algorithms are executed using the indicators and providers are scored based on their performance. Performance measurement must be objective and consistent. But performance measurement cannot end there.

Continuous monitoring

To insure continued quality, the data must be continuously monitored. Unlike traditional medical networks that contract for discounts with medical providers and go no further, smart medical networks for Workers’ Compensation continue to monitor for quality. Continuous monitoring is the very definition of medical management:

Good management is making sure what you did stays done!

California SB 863

In fact, California SB 863, effective January 1, 2014 (now!), mandates continuous monitoring of medical provider costs and quality performance. This progressive legislation is an excellent model for selecting and monitoring smart medical networks, regardless of geographic location.

Establishing a smart medical network is essential and the means are clear and available. However, transitioning from traditional networks to smart medical networks can be tricky.

Converting to smart networks

Traditional networks are tethered to their established means of revenue generation. Shifting from the discount network model to the smart medical network model is challenging. The most practical approach is initially combining the two models, then weaning from the old model over time.

If the right physicians are a part of a smart medical network, claim outcomes will improve. Injured workers will receive good medical treatment, return to work early and successfully, and costs will be significantly reduced.

Moreover, physicians and other providers who qualify for smart networks should be rewarded. They should not have their fees reduced by discounts. Based on the excellence of their past performance they should be included in the smart network on a very long leash. Continued performance for continued participation will be monitored scrupulously.

Win-win

Nevertheless, it should be noted, payers have an obligation to participate in the transition to, and continuation of smart networks by recognizing and paying for value received. Networks need support and cooperation from payers to integrate and analyze their data, score provider performance, and realign medical provider preferences. The benefits will accrue to everyone: payers, networks, employers and injured workers.

Data participation

Importantly, to achieve optimum results, data must be gathered from multiple sources and integrated for comprehensive claim analysis. Data from only one source such as bill review, is sorely deficient for accurate analysis of medical provider performance. Claim system and pharmacy data must be added to bill review data at a minimum. Shortcuts in data gathering and analysis are not defensible.

Change momentum

Network administrators are gradually stepping up to the challenge of shifting to smart networks. Momentum toward smart networks will be exponential with payer participation, resulting in quality improvement and cost control all around.

Karen Wolfe is President and CEO of MedMetrics®, LLC, a Workers’ Compensation analytics company. MedMetrics integrates the data from organizations’ disparate data systems, then analyzes, scores, and monitors medical provider performance. MedMetrics also offers online “apps” that link medical analytics to operations, making them actionable for optimized medical management. karenwolfe@medmetrics.org