Many
believe medical quality is sacrificed when attempting to control costs. The
logic assumes the way to achieve quality medical care is to deliver more of it.
The other side of the same reasoning is that less medical care means less
quality. However, the cost-quality balance is not a zero sum game.
Zero sum games
A zero
sum game means that when one element of the equation prevails, the opposite is
suppressed. That would mean efforts to control medical costs by reducing the
amount of medical care will result in poor medical quality. Cost control
efforts such as not authorizing treatments and procedures necessarily result in
poor quality.
Coexisting factors
However,
these supposed opposites can, and should coexist in managing the medical
portion of Workers’ Compensation claims. Quality is not counter to cost
management in medical treatment. For instance, managing the number of visits or
encounters, prescriptions, and the number of specialists the claimant
encounters are just a few ways to limit medical services that may, in fact,
improve quality.
Visits and services
On the
one hand, the treating doctor should see the injured worker often enough to
understand, direct, and maintain control over the recovery process. Yet, some
physicians embellish their revenue flow by seeing patients more frequently than
necessary. To manage excessive utilization of office visits and services,
evaluate the data to learn what is reasonable and what is disproportionate. To
be effective, the data must be monitored concurrently so that intervention has
an impact.
Analyze the data
The way
to objectively measure excessive visits is to monitor and analyze the data. For
specific injuries in a given jurisdiction, what is the mean number of medical
visits? Outliers can be interpreted to mean either the treating physician is fraudulent
or the claimant is in trouble. Either way, focused attention to the matter is
needed.
Standards and legislation
A
claims payment organization can set standards for what should be considered the
threshold of excessive for given conditions. Beyond that point, the claim is
examined and intervention initiated. Some states legislate frequency of care.
The
state of California, for instance, has placed limits on the number of physical
therapy and chiropractor visits. The data system can mobilize notification to
the appropriate persons when the benchmark is approaching so that limits are
not exceeded. Applying similar methods to a variety of medical visits and
services adjusted by diagnosis and other factors such as age and comorbidity
will similarly impact costs while sustaining quality.
Over-prescribing
Another
example of balancing quality and cost is controlling frequency or volume of
services by electronically monitoring prescription practices, especially those
for Schedule II or Opioid drugs. The literature is replete with examples of
ineffective and poor outcomes when Opioids are over-used. By monitoring current
data, usage and cost can be checked through appropriate intervention.
Over-referring
Yet
another indicator found in the data reflecting excessive medical treatment is multiple
medical referrals. Too often when the patient is not improving, the doctor’s
response is to refer to specialists. The data gives up that information by noting
the number of medical providers and specialists involved in a claim. Assuredly,
a claim with multiple specialists is a claim in trouble, or at least
progressing poorly, needing attention.
Surgery
Industry
research speaks for itself. Consider this Washington state study, “Long-term
Outcomes of Lumbar Fusion Among Workers Compensation Subjects: An Historical
Cohort Study”[1]
This study concluded, “Lumbar fusion for disc degeneration, disc herniation,
and/or radiculopathy in a workers comp setting is associated with significant
increase in disability, opiate use, prolonged work loss, and poor RTW status.”
Intervene early
Monitor
the data to discover outliers early so that interventions will effectively
impact outcomes. The key to supporting quality while impacting cost is
identifying potential problems early. The longer an issue persists, the more
challenging it is to correct it.
Balancing quality and cost
Consider
both medical quality and cost control equal goals. They are not mutually
exclusive nor is it a zero-sum game. The medical profession itself is
recognizing and addressing the issues of over-prescribing, over-testing, and over-treatment.
Medical managers need to assist in the process.
Karen
Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics company.
MedMetrics offers online apps that super-charge medical management by linking
analytics to operations to make them actionable. karenwolfe@medmetrics.org
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