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The MedMetrics blog provides comments and insights regarding the world of Workers’ Compensation, principally, issues that are medically-related. The blog offers viewpoints regarding issues affecting the industry written by persons who have long experience in the industry. Our intent is to offer additional fabric, perspective, and hopefully, inspiration to our readers.

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Wednesday, April 25, 2012

Doctor Drives Driver’s Claim Costs

by Karen Wolfe

Our recently published article, “Survey: Employers Want WC Cost Control. Really?”, generated this response from a reader.

“The biggest problem I have is finding the right doctors. If all of my employees were in one location, this would be a piece of cake, but we are a trucking company with drivers who live and work all over the U.S.”

She continued, “I just had a conversation with a doctor’s office this morning about a claimant at the other side of the country. This employee, the claimant, has been off work 6 weeks with a knee injury. X-rays and MRI show nothing acute, the ligaments and cartilage are fine, but the claimant still reports pain. The doctor admits he has no explanation for claimant’s pain complaints. However, instead of releasing claimant back to work or declaring MMI (Maximum Medical Improvement), the doctor referred him to a specialist.”

The frustration experienced by this claim manager is palpable. Yet, the treating physician is probably not fraudulent or abusive of the Workers’ Comp system. He is probably unaware of the impact of his decision to refer. Moreover, he is probably also oblivious to the fact that the longer his patient is off work, the chances of ever returning to work decidedly decrease. The doctor is simply treating the patient as he would his neighbor. But that is often not the best care from a Workers’ Comp viewpoint.

That is the question
The obvious solution is to prevent such dilemmas by selecting only excellent treating providers who understand the Workers’ Comp system. How can they be found? Most provider networks still contract with anyone and everyone, regardless of performance, thereby leaving employers like this one marooned. Yet that tradition is changing and changing fast.

The enlightened movement in the industry quickly gaining traction is outcome-based networks. Many are structured as carve-outs of existing networks suited to individual locations and needs. Providers, particularly doctors, are selected based on actual performance appropriate to Workers’ Compensation derived from comprehensive objective claim data. Analytics are used to evaluate actual performance in multiple categories unique to Workers’ Compensation.

Analysis of individual performance is evidenced in data indictors based on industry research. Among the indicators are frequency and duration of medical treatment, return to work rates, indemnity costs, litigation, direct medical costs, and other factors specific to Workers’ Comp. Comparative provider performance must be state-specific and quality of care is considered.

Medical quality
Medical quality in Workers’ Compensation is important, as it is in general health. Injured workers deserve the best medical care available. However, in Workers’ Comp there is another layer of quality measurement superimposed on what is measured in general health. In general health quality is measured in terms of accepted treatment patterns followed and return to health. However, in Workers’ Comp, measures of administrative factors, such as those indicators listed above, are quality indicators integrated into provider performance evaluation. Return to health is often not as important as return to work.

What to do
Industry enlightenment will drive the solution. People now realize they need better information about which doctors to choose, information based on objective data, not vast lists of doctors’ names and locations. Moreover, you can begin now to make that happen.

Be the solution!
The one prerequisite for analytics is data and the more data, the more accurate the results. MedMetrics is developing a Master Provider Index for individual states. Those who submit data to the project will benefit by having first access to the Master Provider Index online and at the significantly reduced contributor rate.

Contact karenwolfe@medmetrics.org or 541-390-1680 to learn how to become a data contributor. Drive the Master Provider Index project and the solution. Learn more about MedMetrics.