Tips for Building a Medical Provider “A” Team

by Karen Wolfe

The “noise” in the Workers’ Comp industry about increasing medical costs is not subsiding. If anything, the chatter is swelling into a crescendo and much of it is relevant and important. Recent conferences such as the Workers’ Compensation Research Institute (WCRI) underscored the continuing problem of Opioids. Also of concern at the conference was physician-dispensed drugs.

Studies show when Opioids are prescribed inappropriately and when physicians sell patients medications directly from their offices, claim costs increase and outcomes deteriorate. However, while discussion of the topic increases, new initiatives in the industry designed to target the problem are scarce.

Source of the problem

The source of these two major cost problems is certain treating doctors. Doctors are the ones licensed to prescribe drugs and some are abusive. Probably only a few of the doctors are perpetrators, but the trick is to know in advance which doctors they are. Particularly for organizations that have employees geographically spread, this is a continuing challenge.

Networks are not a safe haven

Payer organizations have been lead to believe their networks are their safe haven. If an injured worker is sent to a network provider, a discount on medical services can be assured. Unfortunately, networks are known to contract with every physician and ancillary provider alive, without consideration of the provider’s Workers’ Comp knowledge, interest, or medical integrity. Nor are quality, overall cost, and outcomes considered.

Networks do not vet physician performance. They allege savings based on discounts off medical bills, but the number of bills is not measured. Most networks have not stepped up to apply analytics to provider performance so payers must look elsewhere.

Networks lack necessary data

The only practical way to evaluate provider performance in order to select the best is to analyze the data. The problem for networks is they do not have the scope of data necessary to fairly evaluate performance. They receive medical bills, discount them, take a cut, and pass them back to the payer. But medical bills alone are not adequate for evaluating provider performance.

Data from multiple sources is needed

To understand a provider’s performance, claims level data is also essential. It is needed to evaluate the uniquely Workers’ Comp nuances of return to work, indemnity costs, legal involvement, claim duration, timing, and other key factors.

Opioid data, another source

In the case of Opioids, the best source of data for evaluation is from the Pharmacy Benefit Management program (PBM). The PBM data set contains the detail of what drug was prescribed and when, who prescribed the drug, and where it was filled. However, Indicators of physician dispensing will not be found in PBM data.

Physician dispensing data

Physician dispensing will appear as an item on a normal bill from the treating doctor. The degree to which it is camouflaged will vary and it may or may not be noted by the bill review system. Many bills are summarized by the time they reach the claims adjuster, so adjusters cannot discern which bills are physician-dispensed drugs. Analysis of the data is the best approach, not with the goal of avoiding payment, but to avoid the physician altogether.

Networks are a platform for analysis

Payer organizations should use their network providers as a platform for selecting their A Team. By analyzing the data, the best practice providers will surface and injured workers can be directed to them. Unfortunately, most organizations do not have the necessary resources to accomplish that task.

The solution

The best solution is to invite a third party that specializes in analyzing Workers’ Comp data and identifying the best practice medical providers in your data. Avoiding doctors that prescribe Opioids and those that dispense medications from their offices will save thousands of dollars on any given claim—more than enough for ROI on the third party service. Savings can be measured in reduced claim costs and far better outcomes compared to claims where the perpetrators of these abuses were involved. Identifying the best medical providers and directing injured workers to them are powerfully effective cost containment initiatives.

Karen Wolfe is president of MedMetrics which specializes in medical provider performance analytics with easy user search tools. We analyze your data for you to score providers based on multiple indicators. Visit MedMetrics to learn about MedMetrics Provider Performance Suite of information services, including detailed Provider Performance Analysis and Master Provider Index, a quick search for best practice providers by specialty and geo-zip. For questions, contact karenwolfe@medmetrics.org.

 

 

Teach Your Data to Fight Opioid Abuse

By Karen Wolfe

Workers’ Compensation research, networking communities, and press are overflowing with information about Opioid overuse and how it is negatively impacting claim costs and outcomes. Information about the problem abounds. Opioid abuse is clearly recognized as a serious problem in the industry, clearly evidenced by recent research.

Industry research
An example of recent research on the topic is from Alex Swedlow at the California Workers Compensation Institute (CWCI), “An association was found between greater use of Opioids and delayed recovery from workplace injuries.” Swedlow says it’s not so much that the drugs themselves are costly, rather, it is the collateral damage that accompanies their use.

A recent study from NCCI (National Council on Compensation Insurance, Inc.) is entitled, “Early Narcotic Use Is Indicative of Prolonged Use.” Findings showed that high use of narcotics in the first quarter following injury indicates a higher than average probability of narcotic use in subsequent periods.

The list of studies and articles is long. In fact, a Google search for “Opioid abuse in Workers’ Compensation” draws nearly 100,000 results. Now that the problem is well-defined, the focus shifts to correcting it.

Fixing the problem
MedMetrics recently conducted a small study for EK Health and their Next Step program. The Next Step program leverages EK Health’s many professional medical resources to address complex claims where the injured worker is addicted to prescription medications. They effectively apply expert peer to peer consulting to assist treating physicians in weaning claimants from their prescribed drugs. The EK Health Next Step program is uniquely effective in bringing those old and very complicated claims to closure.

While the EK Health Next Step program is a powerful tool, it could have even greater impact on costs and outcomes if implemented earlier in the course of the claim, well before so much damage and costs have played out. Early awareness and intervention by referral to the experts could have exponentially positive effects.

Identifying risky claims early
Busy claims adjustors are not accustomed to identifying early Opioid use in claims. In fact, hey often do not have the means because many claims systems do not capture prescription detail. Moreover, Pharmacy Benefit Management data, another source of critical information, is usually a separate system and is not readily available to claims adjustors. Consequently, they are unaware of narcotic prescriptions. However, they and others who might intervene could be made aware through computer-aided medical management, by teaching the data to find the problem.

Computer-aided management tools
Industry research and data studies serve to define and clarify the problem, but they can also illuminate a very practical means to resolution. The research contains tips and actual predictors of risky claims. A derivative of research is the knowledge of what to look for in the data.

For instance, the NCCI study identifies a predictor that when narcotics are used for pain early in the course of the claim, it can be indicative of impending trouble. Armed with this well-founded intelligence, the problem can be proactively addressed from the beginning of a claim by continually searching for the prescriptive indicators in the data.

Monitor current data
Concurrent data monitoring is a powerful cost control methodology to identify early Opioid use. By monitoring current data for Schedule II drugs prescribed, claims can be automatically flagged and referred for more intense scrutiny. Claims with this critical information will not be overlooked when using computerized data monitoring.

Likewise, providers who prescribe the drugs outside the accepted medical guidelines such as ACOEM (American College of Occupational and Environmental Medicine) can be monitored electronically. The system can identify providers known for higher Opioid prescription rates. When those physicians are involved in a claim, the system sends an alert to the claims adjustor, medical case manager or other key persons. The system can also send a notification to the prescribing physician.

Notifying the prescribing physician in near real time can serve as a potent preventive tool. It puts physicians on notice to let them know they are being observed.

IT resources
Creating vigorous computerized medical management tools such as these is an IT function. Technicians are required to develop the programs under the guidance of the business leaders who understand medical indicators. Unfortunately, many organizations suffer from scarce IT resources and such initiatives are not implemented. Therefore, outsourcing to a company that specializes in developing computerized medical management tools is the right answer.

To learn about MedMetrics medical management data monitoring, contact Karen Wolfe at 541-390-1680 or karenwolfe@medmetrics.org.