Early
intervention drives better outcomes. It’s a statement that garners little
resistance. Everyone agrees when a problem is found early, the solution is
easier. Thwarting a problem early in its course produces better results. Yet
few systems are in place to guarantee early intervention into problematic
Workers’ Compensation claims.
Early
intervention is a fine idea, but not always pursued. Work flows and systems in
the industry are not typically designed to target the goal. To be effective, early
intervention requires identifying the claims needing attention as soon as
possible in their course, then mobilizing action procedures.
Predictive modeling
One
effort to identify claims early that is widely acclaimed in the industry is predictive
modeling. Elaborate analysis of the data using advanced mathematical methods is
used to identify new claims that will likely become problematic. Regardless of
the sophistication of the math, finding those claims remains a guessing game.
Not every future problematic claim will be tagged. Likewise, claims that do not
meet the modeling criteria, yet migrate anyway, will not be recognized.
Predictive modeling can be helpful but it is imperfect and costly.
Containerizing human responses
Containerizing
human conditions and responses is possible to a point. However, predicting
human behavior is imperfect at best. Moreover, a second step is necessary: consistently
intervening in the identified problematic claims. Once the troublesome claims
are detected, certain action steps must follow.
Data monitoring
A more
practical methodology for identifying costly claims is to monitor the data on a
concurrent basis to uncover dicey conditions in them.
Rather than
predicting which claims will be risky, the conditions that portend risk and cost
in claims are isolated and then identified in claims as they occur.
Technology
is used to find the claims that bear those conditions whenever they occur throughout the course of the claim. All claims are monitored, so none are
missed. No guesswork is involved.
Step two
The
data monitoring approach is powerful, but as with predictive modeling, that is
true only when the next step is taken. Organizations that undertake a process for
identifying risky claims early stand to lose the entire benefit unless they
also structure procedures for intervention. The appropriate persons must be
notified about problematic claims immediately and those persons must act to carry
out the recommended procedures.
Whether
the alert recipients are claims adjusters, medical case managers, or someone
else, they must follow intervention procedures for best results. Using the data
monitoring approach, each condition that is sought in the data should be
associated with a prescribed intervention procedure.
Standardized interventions
Follow
up procedures should be specific so that analyses can be made of their effects.
For instance, when the condition identified in a claim is the third prescription
for a Schedule II drug, the system might be set to alert the medical director. A
standard method of intervention or approach for intervening with the treating
doctor is followed.Another example of a problem is extended medical treatment past a designated point for low back strain. The alert is sent to the claims adjuster whose procedure is to engage a medical case manager to investigate. The investigation procedure is standardized.
Examples of how this works are unlimited, but the important thing is that intervention procedures are analyzed in advance and clearly stated so the actions are consistent across the organization and going forward, regardless of who actually carries out the intervention. Obviously, details of actions may be variable, but the general course should be followed.
Measuring results
The plight of medical case management has long been that results could not be measured. Consequently, medical case management as a strategy has been undervalued.
Categorize interventions
Moreover,
medical case management could not be measured because interventions are
delivered by individuals, even though usually professional nurses, each is
different. However, intervention tactics can be categorized so outcomes can be calculated.
The benefit of using a standardized approach is that outcomes can be compared
and measured by the cause condition and intervention employed.
Automated referral
Claims
adjusters sometimes fail to refer to medical case management for a variety of
reasons. When early intervention procedures are standardized, the referral is
automatically made by the system, thereby eliminating the burden of referral
for claims adjusters. Efficiency is good.
Summary
Simply stated, early intervention is more effective than late intervention. The problems have not yet morphed into catastrophe and are usually easier to solve. Moreover, systems and procedures should be established to automate problem claim identification and follow up procedures. Best results can be pinpointed and continued. Lesser
results can be modified. The upward spiral of quality improvement is
continuous.Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics and technology services company. MedMetrics offers online apps that super-charge medical management by linking analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org
