Do You Know Who Your Best Doctors Are?

by Karen Wolfe

In Workers’ Compensation, the medical provider network philosophy has been in place for years. Most networks were developed using the logic that all doctors are essentially the same. Rather than evaluate performance, the focus was on obtaining discounts on bills, thereby saving money.

Physician selection by adjusters and others has frequently been based on non-objective criteria. Those include familiarity, repetition, proximity, and sometimes just assumption or habit. Often the criteria is something as flimsy as, ‘We always use this doctor” or “The staff returns my calls”. The question is which doctors really are best and why?

Assumptions

The first assumption that must be debunked is that discounts save money. Doctors are smart—no argument there. So to make up the lost revenue for discounted bills, they increase the number of visits or services to the injured worker or extend the duration of claims by prolonging treatment. To uncover these behaviors, examine the data.

Recommendations

Amazingly, even doctors do not always make the best choices about other doctors. They may recommend doctors whom they know socially, professionally, or by informal reputation, but they may not know how they actually practice. They may not know a physician upcodes bills, dispenses medications, or over-prescribes Schedule II drugs. The data will reveal that information.

Referrals

Doctors may be unaware they are adding to claim complexity by referring to certain specialists. Again, familiarity and habit are often the drivers. On the other hand, duplicity among providers is fraudulent behavior and it can be uncovered by examining the data.

Clustering

Analysis of data can expose clustering of poorly performing, abusive, or fraudulent providers referring to one another. The analysis may also divulge patterns of some providers associated with certain plaintiff attorneys.

Management practices

Treating doctors influence claims and their outcomes in other ways. Management indicators unique to Workers’ Compensation such as return to work, indemnity costs, and disability ratings can be analyzed in the data to spotlight both good and poor medical performance. These outcome indicators are either directed by, or influenced by the physician and they can be uncovered through data analysis.

Clinical quality

Claims adjusters and other non-medical persons simply cannot evaluate the clinical capability of medical providers, especially doctors. Performance analysis must take place at a higher level. Evaluations for specific ICD-9 diagnoses and clinical procedures such as surgery must be made. Frequency, timing, and outcome can be examined in the data in context with diagnoses and procedural codes, thereby disclosing the excellence or incompetency of physicians.

Negative clinical outcomes that can be analyzed include, but are not limited to hospital readmissions, repeated surgery, or infection. Physicians associated with negative medical outcomes should be avoided.

Fairness

When analyzing clinical indicators for performance, care should be taken to compare only similar conditions and procedures. Without such discrimination, the results are dubious. Specificity is critical.

When using data analysis to find the best doctors and other medical providers, fairness is also important. Provider performance should be compared only with similar specialty providers for similar diagnoses and procedures. Results will not be accurate or reliable if performance analysis is not apples-to-apples.

Pushback

Medical providers may question data analysis to evaluate performance claiming they treat the more difficult cases. The data can be analyzed to determine diagnostic severity as well. Diagnostic codes in claims can be measured and scored, thereby disclosing medical severity.

Find the best practice doctors

Now is the time to step up to a much more dignified and sophisticated approach to selecting medical providers. Decisions about treating physicians must be based on fact, not assumption or habit.  Fortunately, the data can be analyzed to locate the best-in-class and expose the others.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics and technology services company. MedMetrics analyzes the data to score medical provider performance and offers online apps that super-charge medical management by linking analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org

 

A Healthy Disrespect for the Impossible

by Karen Wolfe

When people are extraordinarily successful, examining their characteristics, values, and attitudes can be instructive. The rest of us can learn from them and possibly adopt some of them to advance our own goals. Larry Page, co-founder of Google is an example of one who has achieved exceptional heights. Peering into his thought process can be enlightening.
 

Page says, “Have a healthy disrespect for the Impossible”. While the statement may not be original with him, it does reflect his world view.

Disrespect the impossible

To conceive and develop the Google concept and then the massive company, its young founders had to have a very healthy disrespect for the impossible. Others besmirched the idea of collecting all the information in the world and then making it available to everyone in the world. Not only was it a bold idea, it was thought by most to be ridiculous and impossible. But Larry Page and Sergey Brin had a very healthy disrespect for the impossible. They made it happen.

The concept of disrespecting the impossible could be entertained by those of us in the Workers’ Compensation industry. True, few of us are likely to reach the pinnacle level of Larry and Sergey, but we can borrow some of their bold thinking to get past the assumptions and barriers that keep us from achieving more.

Everyone agrees Workers’ Compensation as an industry needs a healthy nudge to try new things. The industry is known for its resistance to change. Refer to the article, “Are You an Industry Disruptor? It can be a good thing.”[1] Maybe the way to change the industry, to be an industry disruptor, is to begin with an attitude of disrespecting the impossible.

The impossible in WC

Many people in general, including those in the Workers’ Compensation industry focus on why something cannot be done. Reasons for this notion are many, but probably cultural tradition plays a role. Creativity and inventiveness are not expected or appreciated. Too often, the best way to keep a job in corporations is to keep your head down and avoid being noticed. Spearheading a new idea is risky.

Stonewalling new ideas or doing things differently or adopting new technology in an organization thwarts creative thought and certainly diverts progress. I was once told we have a very good product, but to incorporate it would mean doing things differently in the organization. So the answer is automatically no!

Check assumptions

We all know the old saying about the word ass-u-me. It actually packs some truth. To avoid the trap, check assumptions for veracity. Incorrect assumptions can be highly self-limiting.

Problem-solve

Begin the process of problem-solving with new thinking—disrespect the impossible. What could be done if the perceived barriers did not exist? What could be accomplished if new methods were invented and implemented?

Tenacity

Probably the most important ingredient for achievement in any context is tenacity. It’s easy to quit when the barriers seem daunting. Tenacity combined with a disrespect for the impossible might be the unbeatable formula.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics and technology services company. MedMetrics analyzes the data and offers online apps that super-charge medical management by linking analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org

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[1] http://medmetrics.blogspot.com/2014/12/are-you-industry-disruptor-it-can-be.html