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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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Tuesday, July 31, 2012

Where to Search for Best-in-Class Doctors

A White Paper
by Karen Wolfe

No doubt you have seen the ad for Angie’s List. A good-looking male doctor is pictured with the caption, "He has been nothing but focused, dedicated and concerned about my health and well-being."  If searching for a contractor or hair dresser, this might be a good start. But searching this way for doctors? Absurd!

Finding doctors for injured workers through Angie’s List is a recipe for disaster. Subjective rating of medical treatment is not valid. Few patients understand enough about the science of medicine to venture a worthwhile opinion.

Yet, the methodology behind Angie’s List is a relatively common practice in the Workers’ Comp industry. Employers and payers sometimes survey their claimants in an effort to evaluate doctors. Unfortunately, most claimants report whether the doctor’s office has snacks, magazines they like, and the doctor was nice. The information is hardly a basis for utilizing the doctor and is about as helpful as that found in Angie’s List.

Measuring Provider Performance
Finding the right physicians for injured workers requires objective analysis of actual past performance, not patient opinions. Medical proficiency can be measured in terms of outcome, with the most positive outcomes evidenced by return to full work and reasonable medical costs.  However, in Workers’ Compensation even more focus should be placed on the course of the claim from the non-medical standpoint.

Industry research
Workers’ Comp industry research has clearly identified the attributes of good and bad medical performance. For instance, Dr. Ed Bernacki of Johns Hopkins lists characteristics of “cost intensive” physicians. The study[1], using data from the Louisiana Workers’ Compensation Corporation, found that 3.8% of physicians accounted for 72% of the costs. In other words, a small number of physicians have a profound impact on Workers’ Compensation costs. Bernacki’s study identified the characteristics of these cost intensive physicians. They are elements that can be found in the data and used to monitor and score provider performance.

MedMetrics uses the results of industry research studies to design its algorithms that evaluate and score provider performance. The research identifies provider characteristics and claim events under the influence of providers that should be measured. Using those indicators, providers can be compared in their jurisdictions with others in the same specialty to identify the best-in-class.

Medicine is a cottage industry
Medicine in the US is a cottage industry, with services delivered by individuals to individuals. Consequently, it is difficult for any one organization to gather enough individual provider data to create a critical mass for measurement. The problem is complicated by the fact that in Workers’ Comp states vary in fee schedules and other legal requirements so it is not valid to compare data across jurisdictions.  Nevertheless, provider performance is more accurate and fairer when evaluated across many claims.

The industry needs an independent organization to collect and analyze the data across multiple organizations so that provider performance can be measured more accurately.

Master Provider Index
MedMetrics is offering Master Provider Index. Data are collected from multiple participating organizations, then validated, and integrated. Provider performance is measured across multiple entities’ claims in a state, thereby creating a richer data resource. The combined data is analyzed and provider performance is scored. Finally, a quick-search is offered online so that best-in-class providers can be found in specific geo-zip regions on demand, on-the-fly.

Not Angie’s List
Master Provider Index is not Angie’s List by any means. Provider performance analytics are based on intelligence gained through industry research and performed on data from multiple organizations by state. Based on Bernacki’s study, one can assume saving up to 72% of costs by avoiding cost intensive physicians! Wouldn’t it be worth participating in Master Provider Index to save some portion of that?

For information about how to be a Master Provider Index participant, contact karenwolfe@medmetrics.org You are invited to visit MedMetrics

[1] Bernacki, et.al. “Impact of Cost Intensive Physicians on Workers’ Compensation” JOEM. Vol. 52. No. 1. January, 2010.

Monday, July 9, 2012

How to Make WC Managed Care Effective, Affordable, and Accountable

By Karen Wolfe

In a recent blog, Joe Paduda posed the question “Managed care in work comp: worth the cost?”[1] He continued, "Are we wasting hundreds of millions on ineffective programs, or are these programs holding costs well below what they otherwise would be?" 

Frankly, that this question is asked, whether we are wasting hundreds of millions on ineffective managed care programs, reveals a lot by itself. Why have managed care processes and outcomes not been measured for effectiveness continuously throughout their history? Managed care programs have been applied to Workers’ Compensation for twenty-five years, yet the question of whether they are effective is only now being asked? The fact is, managed care effectiveness is largely unknown because the appropriate technology has not been properly applied to manage, measure and monitor the processes.

Analytics backed by technology
Stated simply, analytics can determine what processes are most effective and technology can be leveraged to direct the managed care focus to the claims, events, and conditions in most need of attention. That creates efficiency. The managed care focus should be on claims that contain elements that are known to portend trouble, thereby avoiding frivolous activity and extraneous cost.

Inform the process
To ensure managed care methods are effective and to power the processes, both technology and analytics must be applied. Work-in-process electronic software tools must be developed and implemented to translate analytics to action.  Electronic tools specifically designed for Workers’ compensation managed care will inform the process, improve the outcome, and measure its effectiveness. Using technology to continuously monitor historic and current claim data will exact a more perfect result.

How to recharge managed care
Specific essentials are needed to recharge managed care effectiveness and establish its accountability. All are necessary and all are based on technology and analytics that build on existing resources:
  1. Build a unified historic and current data platform
  2. Monitor the integrated data continuously
  3. Analyze the data to discover problematic conditions in claims
  4. Link the analytics to operations with software “apps”
1.      Build a unified and current data platform
The data must be comprehensive, sourced from multiple data silos. Those include bill review data, PBM (Pharmacy Benefit Management) data, and claims system level data. The data must be integrated at the claim level and updated continuously for comprehensive analysis. These basic technological tasks create the platform for performance.

2.      Monitor the integrated data continuously
The unified, concurrent, and continuously updated data platform must be electronically monitored continuously. The crux of computer-aided medical management is maximizing claim monitoring using the technology. Relying on manual monitoring of current and historic data in claims to distinguish those that need attention is not practical or even possible.

Moreover, monitoring current claims data in context with claims history is a technological function that searches for conditions and elements in claims that portend risk and cost. Manual monitoring by even experienced persons cannot begin to approach this goal.

3.      Analyze the data to discover problematic conditions
Rules-based and knowledge-based algorithms built into the underlying software will identify actual or potentially problematic claims. Electronic data monitoring is used to uncover events, diagnoses, and data combinations that are of concern.

Reveal hidden threats
For instance, a diagnosis of diabetes might be documented on a bill by a treating physician on the fourth or fifth visit. Such a comorbidity buried in the data might easily go unnoticed without computer-aided medical management. Yet, technology will uncover it every time.

Identify poor providers
Another example of analytics used to uncover risk is evaluating physician performance. A physician who keeps claimants off work without sound rationale or a blatantly fraudulent doctor who is treating the claimant are both predictive of higher cost outcomes. Yet, when the physician is on the approved panel, no one takes notice. A smart software system will alert appropriate persons apprising them that a low ranking physician is treating the claimant—as it is occurring.

The same smart system will single out best-in-class medical providers so that claimants can be directed to them from the start.

4.      Link the analytics to operations using software “apps”
Analytics must be logically linked to operations. No advantage is gained by performing analytics and letting them languish somewhere in graphic form. Analytics must be made actionable.

When the results of analytics are translated into software tools and alerts for claims adjusters, medical case managers and others, the information can be acted upon before much of the damage is done. Medical provider networks can be converted to quality networks. Claims cannot deteriorate without notice.

Software multiplies intelligence
Bill Gates said software is the multiplier of human creativity and performance. Software makes people do what they do best even better. Managed care programs can be intelligently revitalized by applying technology and analytics to the process, thereby gaining efficiency, accuracy, and accountability.

Paduda concludes: “Paying over a hundred million dollars for network access without clear and convincing proof that they are improving outcomes is not smart.” Also, “Using case management and UR indiscriminately across all providers in all cases is a waste of money and counter-productive.” He is absolutely correct. But it need not be that way. Affordable solutions are available now.

What it takes
A logical and efficient merger of technology and analytics is the only feasible way to resolve the issues in managed care. Automated processes coupled with intelligent analytics will produce the desired results along with the necessary proof of value. Happily, building the system internally, a costly and time-consuming effort, is not necessary.

A knowledgeable managed care analytics outsource will implement the advantages without the hassle, time, or cost of builidng these functions internally. In fact, managed care power apps can be added to the managed care initiatives of any size organization for less than the cost of a part time analyst!

Learn more about MedMetrics or for discussion, contact KarenWolfe@MedMetrics.org

[1] http://www.joepaduda.com/archives/002361.html