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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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Sunday, September 16, 2012

How to Manage Medical Providers in Workers' Comp

By Karen Wolfe

Medical providers and payers Workers’ Comp have long been at odds. Looking for reasons leads to speculation about discrepancies in points of view regarding injuries and appropriate medical treatment, providers who are resistant or oblivious to Workers’ Comp issues such as return to work, and the reimbursement tug-of-war.

Solutions aimed at controlling treatment and costs by limiting payment have been implemented. Fee schedules enforced by individual state laws and CMS (Centers for Medicare and Medicaid Services) are designed to manage the cost of treatment. Additionally, bill review services enforce the scheduled rates with recommend pay. Importantly, these solutions do not manage treatment practices and processes.

Employers attempt to control the situation by engaging providers in their production processes. A plant walk-through is encouraged. Some advise taking medical doctors to lunch. On the other side of the same coin, medical providers attempting to lure business often ply claims adjusters and employers with gifts or treats. It all begs for a more scientific approach.

The power of observation
Fact: Subjects, when they know they are being observed, change their behavior for the positive. Research has proven the point repeatedly.

Hawthorne effect
Recall the “Hawthorne Effect”. One definition is, “A term referring to the tendency to work harder and perform better when they are participants in an experiment. Individuals may change their behavior due to the attention they are receiving from researchers rather than because of any manipulation of independent variables.[1]

Sentinel effect
Another concept used to describe managing behavior through observation is known as the sentinel effect. Strictly speaking a sentinel is defined as "a soldier stationed as a guard, either to challenge persons drawing near and to allow to pass only those who give a watchword, and, in the absence of this, to resist them and give an alarm." Applied to managed care, it is observing and reporting behavior, particularly in medical service utilization.[2]

Quantum physics
Taking the idea a step further, even in the “nano” world of molecular cell biology, the effects of observation have been scientifically measured. When cells are observed they seem to “know” they are being observed and they change form. While citing quantum physics might be pushing the limits of this argument, the concept of changing behavior through observation is supported.

Observing medical providers
The point is if medical providers are observed objectively, consistently, and concurrently, and if they know they are being observed by means of information feedback, their treatment behavior will change. Medical providers can be observed objectively, consistently, and concurrently through data monitoring.

Applying the metrics
Observing behavior through data monitoring is the first step. Analytics must be applied to the data so that the performance of individual providers, clinics, and facilities are compared objectively and fairly. They must be compared “apples to apples” meaning providers should be compared to those with similar specialties, treating similar injuries in the same state. 

Sharing the results
The way providers know they are being observed is through information feedback. Show them how they compare to others like them with objective reports. No such guideline has been available to them previously and many have no knowledge or evidence they are outliers. When lunching with providers review their comparative analyses. It is a platform for education and change.

All medical providers are just people or groups of people. None of them wants to show poorly in a graphic presentation of comparative performance. Professional pride, personal ego, and simple business economics will drive the desired results.

Use technology to observe, analyze, and report provider performance. Select only the best practice providers whenever possible to avoid claim cost and complexity.


Thursday, September 6, 2012

Unleash the Power of Real-time Data Monitoring for Managed Care

By Karen Wolfe

Data monitoring means applying technology and analytics to gain real-time intelligence and decision support in claims management. Moreover, data monitoring is the way to link analytics to operations, thereby making them actionable.

Nearly everyone in Workers’ Comp is trying their hand at analytics now. The problem is that organizations that have implemented analytics do not seem to know what to do with them. Analytics are great for reporting activity and corporate status to boards of directors and shareholders. Analytics uncover cost drivers and are impressive when graphically presented in annual reports. But analytics must be taken to the next level to actually impact costs or improve claim outcomes. To be truly effective, analytics must be linked to operations, thereby making them actionable. One way to achieve that is through concurrent data monitoring.

Unified and concurrent data platform
Claim data must be gathered from all relevant sources and integrated in a single platform. In Workers’ Compensation, organizations still find their data spread across multiple silos. Bill review, pharmacy, claims adjudication, and medical case management are all important deposits of data. However, claims cannot be adequately analyzed unless the full scope of data is gathered, integrated, and available for comprehensive assessment concurrently.

Some say bill review data alone is adequate for medical analysis. Yet, bill review data cannot reveal work status or return to work, indemnity costs, or final disability rating. These data, derived from the claims adjudication system, must be considered in combination with billing data in order to draw reasonable conclusions. Claims should be evaluated holistically, not in fragments by assorted participants.

Computerized data monitoring
Manual data monitoring is humanly challenging, if not impossible. The detail in claims, including many events over a period of months and years, cannot be absorbed or retained even by the most astute claims adjusters. Moreover, new information is added to claims continually that must be combined with historic information within a claim. Only a well-designed computerized system can handle the job.

For data monitoring to be valuable, it must be consistent and never random. A computerized data monitoring system can scrutinize all the data once it is integrated at no greater effort or cost than to monitor just a few items. It is a matter of thoroughness in system design and development. The computer can do it all, and do it accurately and consistently.

Computer-aided medical management
Computerized medical data management is always on and always alert. Rules-based conditions and data combinations in the broad scope of a claim trigger automatic alerts to the appropriate persons. The burden of watching every claim and remembering its historic facts, then combining the history with current conditions is impossible without computerized assistance. When claims adjusters and medical case managers receive alerts, they focus on claims that need the most attention, thereby optimizing efficiency and outcomes.

Standardized processes
Traditional claims management and medical management processes rely on individual ingenuity, knowledge, and skill. As a result, processes are rarely standardized within an organization. Individual performance and outcomes are rarely measured. However, with computerized, real-time data monitoring the organization’s quality output is monitored, individual performance is audited, and results are reportable.

The early discovery advantage
Importantly, computerized data monitoring insures early concurrent discovery of calamitous conditions in claims such as creeping claim severity, repeated opioid prescriptions, and comorbidities, to name a few . Uncovering such situations as they occur can save millions and prevent disastrous outcomes.

Analytics must be made actionable by leveraging the technology and pushing it into operations through computerized concurrent data monitoring, Data becomes a work-in-process tool, thereby achieving measureable efficiency and cost savings.

For more information, contact KarenWolfe@medmetrics.org and visit MedMetrics.