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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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Monday, February 25, 2013

How to Control Costs by Selecting the Best Doctors

by Karen Wolfe

Getting injured workers to the right doctors from the start is the best way to save dollars. Evidence of this fact is the accumulating industry research that clearly states the well-informed and well-intentioned medical providers produce the best results in Workers’ Compensation. Alternatively, those doctors who rank low on a comparative scale of Workers’ Comp indicators guarantee high claim cost and poor outcomes. Many of the doctors in networks are not well-informed or well-intentioned. Unfortunately, it is up to you to figure out who is who.

Blame is not a solution
That Workers’ Comp medical costs are not successfully controlled is obvious to anyone paying attention. Medical costs, now 60% of claim costs, continue to mount in spite of the most aggressive managed care initiatives. The doctors are blamed, accurately in some cases. However, blame cannot control costs and blame is not a solution.

Scope of cost influence
It is true, medical costs are essentially driven by medical providers, especially medical doctors. Consider their scope of influence on the course of a claim. They are responsible for direct medical treatment costs and they influence the broader scope of care by referral, hospitalization, medical procedures, and prescriptions. They drive indemnity costs by keeping injured workers off work. Those providers who are not well-intentioned can find many ways to exploit abuse the system.

For instance, increasing the frequency and duration of medical treatment are easy means of embellishing costs, while ordering excessive diagnostic testing is yet another means.

Excessive diagnostic testing
Risk and Insurance Journal recently published a news article picked up from Reuters titled, “Medical Don’ts:  Doctors Identify Unnecessary, Harmful Tests, Treatments”[1] It describes an effort on the part of doctors, through their specialty societies, to reduce the number of unnecessary testing. Links to an associated article called “Choosing Wisely” are included.[2]

This article includes lists of specific, evidence-based recommendations that physicians and patients should discuss to help make wise decisions about the most appropriate diagnostic testing and care based on the patient’s individual situation. Each list includes information about which tests and procedures are appropriate for whom. Of note is the fact that while physicians order excessive testing on a routine basis, patients themselves have come to expect certain tests and treatments, thereby compounding the problem.

Causing litigation
In Workers’ Comp curtailing unnecessary tests and treatments can be even more delicate than in general healthcare. Injured workers often feel entitled to more rather than less medical treatment. When claimants feel their medical treatment is curtailed, they can seek their perceived due through the very accessible legal system. Only a Workers’ Comp knowledgeable and sensitive doctor will navigate this course successfully.

Choose the best doctors
The way to choose the best-in-class medical providers is by analyzing the data using the practice behavior indicators suggested here and in the research literature. Besides direct medical bills, measures of cost involve the frequency and duration of medical treatment, as well the kind of treatment. Doctors that order excessive diagnostic testing and medical treatment as defined by the doctors themselves should be held suspect. Doctors who provoke legal involvement should be avoided.

When behaviors of doctors are analyzed, the well-informed in Workers’ Comp will surface. The well-intentioned, meaning they are not abusive or fraudulent, will also be identified.

More is more
For most organizations, the challenge of choosing best practice providers by analyzing the data is the shortage of qualified data within one organization. An organization usually does not have enough data to fairly score provider performance. Moreover, most organizations do not have the necessary internal “know-how”, nor have they integrated their data from all appropriate sources.

Many attempt to analyze provider performance based on bill review data alone. This is inadequate because factors such as return to work, indemnity costs, legal involvement, and outcome are not considered. Claims level data and pharmacy data is necessary in combination with bill review data to do an adequate job.

How to find best-in-class doctors
Therefore, those wanting to control costs by choosing the best providers should obtain provider performance analysis and scoring from a specialty third party that analysis providers based on comprehensive integrated data from multiple sources and multiple organizations.

Visit MedMetrics to learn about MedMetrics’ Provider Performance Analysis and Master Provider Index, tools that analyze provider performance and quick-search for the best. You are invited to read other articles under "Blogs" on this subject and others.
Questions?  Contact karenwolfe@medmetrics.org

[1] S. Begley. Medical Don’ts: Doctors Identify Unnecessary, Harmful Tests, Treatments. Reuters. February 21, 2013.

Thursday, February 7, 2013

How to Operationalize the Insights of Analytics

by Karen Wolfe

Organizations are anxious to execute analytics, but their leaders are baffled about how to apply the knowledge gained. Portraying colorful graphics depicting the results of analytics in executive reports has zero effect on costs or outcomes. In order for analytics to have an impact, they must be fused into the operational process.

Simply stated, analytics is the term used to describe data analysis of any kind. Analytics should not be confused with predictive modeling which is also analyzing data, but the goal of predictive modeling is to predict what is likely to happen when a specific set of circumstances occurs. Stated differently, predictive modeling predicts what claims are at risk for specific costs and conditions.  In predictive modeling, highly advanced statistical tools are used to identify the set of conditions that are then considered predictive. Predictive modeling is one form of analytics.

Analytics is the broader term applied to data analysis. Aside from predictive modeling, it is designed to provide the organization with knowledge and insight into their business processes. Garden variety analytics are used to identify trends and cost drivers. However, neither predictive modeling nor any other analytics can change organizational behavior or outcomes.

Operationalize analytics
Analytics (data analysis) can be powerful as a means of understanding business processes, organizational strengths, and especially cost drivers, but that is not enough. Analytics offers understanding, but that is only the first step. To impact the organization, its workers, and its clients, the insights gained from analytics must be transformed into timely operational initiatives and enforced through work-in-process electronic tools.
According to Rachel Alt-Simmons, SAS, “As competitive pressures increase the need for organizations to master analytics, internal analytic teams have increased their statistical sophistication, but are struggling to operationalize their insight.”[1] The problem is they are missing the very significant step of translating the findings to the operational process.
Actionable analytics
Analytics, regardless of the variety, must be linked to operations to make them actionable. The dots must be connected between analysis, decision, and action. The way to do that is to translate knowledge to action using designed technology.

Workers should not be expected to interpret sophisticated mathematical analyses, but they can act on the derived re-portrayed information. An example is comprehensive data analysis of medical provider performance re-presented as a score or rank compared to their peers. Rather than struggling with multiple analytic indicators of performance, workers should make informed decisions based on interpreted, understandable information found immediately at hand.

Analytic delivery framework
Rules-based technology combined with continuously monitored historic and current data, can send workers early notification of adverse conditions in a claim. Workers can be alerted of poorly performing providers, questionable prescriptions, severe diagnoses, comorbidities, cost benchmarks, and a myriad of other conditions of known risk as they occur in claims. Moreover, the technology can enforce organizational standards by including action steps (procedures) with the alerts.

Organizations using sophisticated predictive modeling initiatives should also take the next step by applying their results to the analytic delivery framework. Regardless of the level of statistical sophistication, the information derived must be delivered in a practical way to claims adjusters, nurse case managers, and others who make decisions and take action regarding claims. Only then will analytics empower workers, impact costs, and improve outcomes.

Analytics inspired—technology powered
Results of analytics must be implemented consistently and structured so that the intended cost control initiatives are achieved. Analyzing the data and delivering the results of analysis to workers will inform decisions and actions, thereby creating maximum value for customers, constituencies, and the organization itself.
Learn about MedMetrics analytic delivery framework or contact karenwolfe@medmetrics.org

[1] Alt-Simmons, R. Balancing Creativity and Control: Bringing Process Discipline to Predictive Analytics. SAS. January 21, 2013.