Welcome to the MedMetrics Blog

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.

Search The MedMetrics Blog

Monday, November 19, 2012

Two Steps to Recharge WC Managed Care

By Karen Wolfe

Having the long-view perspective offers advantages. Sometimes it also generates frustration and occasional surprise. One thing we know is that the workers compensation industry is not given to abrupt change or quick assimilation of new ideas or technology. Moreover, once a process is in place, bringing about change is difficult.

Change resistance
Managed Care (medical cost management) is one of those processes in Workers’ Comp that resists change. While we’ve had managed care programs in place for twenty-plus years, medical costs continue to escalate. The confounding thing is business continues as usual, continues the same services using the same methods, while many hope for different results.

The industry created programs such as PPO networks, medical case management, utilization review, peer review, bill review and other initiatives to contain medical costs and produce better claim outcomes. In doing so, it also built an industry made up of companies and divisions of companies whose chief focus was medical cost containment. Over the years, that focus morphed to organizational preservation through revenue enhancement. Discounting methods and cost saving reporting have been reduced to simple subterfuge, without evidence of quality medical performance or outcomes.  

Starting over
Nonetheless, industry thinking is beginning to change as the elephants in the room are acknowledged. While it might be nice, starting over is not an option. The sunk costs are huge. Yet, many medical cost containment programs in the industry were soundly conceived in the beginning. The challenge is to realign them to achieve the results originally intended. Two major initiatives are necessary.

Follow the money (What else is new?)
Revenue models for managed care programs must be the first target of change. The consumers of managed care, the payers, must demand the change. Purchasing decisions are powerful change agents.

To satisfy the revenue requirements of managed care organizations as they shift their focus requires creative thinking and planning. Revenue should be structured to reward desired behavior and proven outcomes. That will require major process shifting because the current comfort level is entrenched.

Technology-intensified managed care
The second step in revitalizing managed care programs is to reinforce them with intelligent technology. Over the past twenty plus years, while computer technology has advanced exponentially, little has made its way to Workers’ Comp. managed care programs.

Technology offers ample opportunities to maximize cost savings. They include monitoring historic and current integrated data to identify and alert professionals of adverse conditions in claims in real time. Data can be re-presented for business units to be used as decision support and work-in-progress tools. Analytics can discern best medical providers to revamp networks and make the information instantly available to those directing care. Processes can be optimized and corporate standards enforced. Moreover, predictive models can guide strategic business decisions.

Making it happen
The first initiative of change is the more challenging. Changing business rationale carries the risk of revenue reduction or loss in the transition.

Happily, infusing technology into operations is much easier and affordable. Do-it-yourself projects can work, but development time and costs can be excessive. However, proven tools are available to recharge managed care programs and begin realizing actual medical cost management.

Learn more about managed care technology “apps” at MedMetrics or contact karenwolfe@medmetrics.org





Tuesday, November 6, 2012

Distinguishing Medical Doctors--the Good, the Bad, and the Iffy

by Karen Wolfe

Poorly performing medical doctors are 100% predictive of high costs and poor claim outcomes. When they are also corrupt, the damage can be exponential. We know poorly performing and corrupt doctors are out there. More importantly, we know how to find them.

Joe Paduda’s recent post identifies such a group of doctors in Maryland.[1]  Paduda says, “When a doc knowingly over-treats, increasing the risk of adverse outcomes, potentially harming patients, and driving up costs, with little apparent regard for patient safety or appropriate treatment, one would hope they would be sanctioned pretty harshly.” True enough. Punishing them is appropriate, yet a more proactive approach to managing them is to avoid them altogether. Simply carve them out of networks. Avoiding corrupt and inept medical doctors prevents the needless spiral of adverse outcomes and cost.

Identify the perpetrators
Efforts to solve the problem should center around identifying the perpetrators by means of a well-designed analytic strategy and excluding them from networks. Most agree with this philosophy, yet few networks in Workers’ Compensation have addressed the issue. The data, when analyzed appropriately, will quickly point out medical doctors who perform badly as Paduda describes.

Trail of abuse
Fraudulent medical doctors and other providers leave a trail of abuse in the data. Bill review data, claims payer data, and pharmacy data, when integrated at the claim level including both historic and concurrent data, present a clear picture of destructive treatment practices. These are the corrupt, fraudulent, and abusive doctors. Moreover, they are easily discovered.

Happy trails
Happily, the good doctors are also easy to find. Their performance can be measured by multiple indicators in the data and they float to the surface with the best in class. When analyzed over time and across many claims, they consistently rise to the top. However, another category of doctors can present an entirely different challenge.

Good doctors who perform badly
Doctors in this group are highly respected in their profession, often recognized nationally and beyond for their medical expertise. At the same time, their performance from a Workers’ Comp perspective is decidedly inferior. They have high treatment frequency and duration rates.  Claim durations are comparatively long. They may be reluctant to return injured workers to the job, even to modified work. They may not respond to inquiries or complete necessary reports. In other words, while they may be medically talented, they ignore the unique needs of Workers’ Comp. As a result, claim costs are high. Should doctors like this be included in the network?

Decision dilemma
Celebrity doctors can present a difficult public relations problem. Pressure may be applied. Things can get politically contentious within the organization. Why aren’t “the best” included in the network?

Sometimes doctors in this category should be included, but not without evaluating the data. What outcomes are associated with these doctors? What is the disability rating at claim closure? Has the claimant returned to pre-injury status, free of disability and pain relieving drugs? In other words, does the claim outcome exonerate the celebrity doctor regardless of the cost of the claim?

Outcome-based network
Selecting the right doctors and other providers for networks is a complex task. Data from many claims where individual providers are involved must be analyzed to distinguish how a physician performs in the Workers’ Comp world over time. Subtleties of performance must be teased out. Decisions to avoid doctors like the ones Paduda described can be clear-cut. Others may not be so easy.

Go to MedMetrics to learn more about Provider Performance Analysis and Master Provider Index. Click Blogs and review previous articles on this topic. Or contact karenwolfe@medmetrics.org