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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, June 26, 2013

Data Integrity--Y2K All Over Again?

by Karen Wolfe

Remember Y2K?
“January 1, 2000, that is the day that was to change all of our lives. That was the day that the computers on which we all depended would fail us. That was the day that all of our luxuries of daily life would crumble, and we would be once again forced to live without electricity, running water, heat. The great Y2K scare is what it was called. The scare was that all of our computer systems around the world would cease to function on December 31, 1999.”[1] They did not.

Drawing a parallel in WC
The hype and fear of Y2K were paralyzing for some and organizations spent large sums of money to reprogram computers in preparation. Indeed, there is far less anxiety about the veracity of medical provider data in Workers’ Comp claims and bill review systems. Yet, medical provider records in Workers’ Comp are just as lacking as the year date in systems prior to 2000 and the ramifications could actually be consequential.

Opportunity cost
The Y2K issue prior to the late 1990’s was caused by limited disk space that was conserved by using only two digits for the year. The number of bytes that would fit on a screen and in the memory of the machine was limited. On the other hand, the cause of limited medical provider data is simply a matter of traditionally paying the bill efficiently. Only name, address, and Tax ID is needed. However, inadequate and inaccurate medical provider data is opportunity cost for the industry.

New applications
No longer is the industry interested in using medical provider information for bill payment only. Provider records in systems are key to evaluating provider performance beyond direct fees for service. Medical providers impact return to work, indemnity costs, claim duration, and other factors. The indicators can be found in the data.

Who knew?
Medical provider records have recently risen to the level of essential information for quality and cost control. In order to evaluate individual medical providers, medical groups, and facilities, the data in provider records must be non-duplicative, accurate, and complete. Yet, most databases contain multiple records for the same, and presumably the same provider. Moreover, the records are incomplete, especially regarding unique identifiers such as state license numbers or NPI (National Provider Identifier) numbers that distinguish individuals.

Duplicate provider records
One of the major problems found in most Workers’ Comp data is duplicate medical provider records. Duplicates are a problem because the records for an individual are dispersed over multiple records and can only be evaluated separately rather than collectively. The cumulative data for a provider cannot be assessed until duplicate provider records are merged.

Duplicate provider records occur for many reasons. Some organizations simply add a new provider record to their database when a new bill is received, without checking to see if the provider already exists in the data. This is simple to correct administratively, by requiring data entry persons to check the data for the existing provider. A more reliable solution is to create systems with search and select utilities that limit “add” authority. However, duplicate records occur for other reasons as well.

Duplicate medical provider records can also occur when the same provider is added to the database, but the name is spelled differently, a different suffix is used, and when initials or abbreviations are entered differently. Computer systems read these as different and allow adding the new one. Similar address inconsistency has the same result. Using Ste, Ste., and Suite might result in three separate records for the same person or entity. The solution is using basic record search and select from a drop down list. Moreover, correcting the existing data by scrubbing the database is worth the time and cost.

Optimize medical provider records
Tax ID, so important to paying a bill is nearly useless when evaluating medical provider performance because multiple persons often use the same Tax ID. Establishing a critical mass of data associated with one provider is difficult, and duplicate records simply dilute the information further. Certainty about individual identity is critical and the only way to achieve that is with state license numbers.

License numbers
Unfortunately, NPI numbers, established by the CMS (Centers for Medicare and Medicaid Services) are abused by some. Notorious medical providers apply for and receive multiple NPI numbers. State license numbers are the most reliable and should be added to provider records in databases to differentiate individuals.

Medical specialty
Including medical specialty in the provider record increases its value exponentially. The most accurate, fair, and illuminating evaluation is comparing peers. Comparing neurosurgeons to dermatologists on some performance indicators makes little sense. Pain specialists, for instance, usually receive complicated cases late in the game and should be compared to other pain specialists, not those who treat acute injuries. Medical specialties are vital to evaluating performance accurately.

What to do
While it may not be Y2K, the impact of poor data might be greater for Workers' Comp organizations. Systems should contribute to medical cost management intelligence. However, many cannot because of data quality. Scrub and optimize existing data and establish protocols that prevent continuation of status quo. Outsourcing to a third party specialist is easy and the return on investment certain.

Karen Wolfe is the founder and president of MedMetrics®, LLC, a Workers’ Compensation analytics company. MedMetrics specializes in medical provider performance analysis, including provider file scrubbing and optimization. MedMetrics also provides powerful online “apps” that link analytics to operations, thereby making cost management intelligence actionable. Visit MedMetrics to learn more or contact karenwolfe@medmetrics.org

[11] www.quetek.com/dictionary/y2k-scare.html

Saturday, June 15, 2013

Study Finds Less than 7% of Medical Providers in WC Generate Over 70% of Costs

by Karen Wolfe

Only a few
MedMetrics® recently conducted a “spot check” data analysis in three states to measure what percent of medical providers generate most of the costs. The findings were consistent across all three states. Less than 7% of medical providers generate over 70% of Workers’ Compensation claim costs.

The three states MedMetrics studied were California, Texas, and Florida. What prompted the study was the FAQ (Frequently Asked Question), “How do you know the results from Berncki’s Louisiana study can be translated to other states?”

Dr. Edward Bernacki and his team from Johns Hopkins conducted a study of the Louisiana Workers’ Compensation Corporation data titled, “Impact of Cost Intensive Physicians on Workers’ Compensation”[1] Bernacki’s Louisiana study revealed less than 4% if physicians were responsible for 72% of costs. While the Bernacki and MedMetrics results are not exactly the same, the proximity and consistency is glaring.

The percentage of cost intensive medical providers in the MedMetrics study were California 6.5%, Texas 6.38%, and Florida at 6.60%. The difference between the Bernacki and MedMetrics studies in this regard can be attributed to slight differences in study structure and time frame. Also the Bernacki study limited medical providers to medical doctors, while MedMetrics examined all treating medical providers. The fact remains, only a small percentage of medical providers generate most of the costs in Workers’ Compensation. That should be a manageable problem.

Other identifiers
Bernacki, in a recent presentation to the SIIA (Self Insurance Institute of America) Executive Summit in St. Louis also identified other characteristics of cost intensive physicians found in his study. Among other indicators were longer medical treatment duration, longer claim duration, higher indemnity costs, as well as high medical costs. Moreover, the study contains even more information about the identity of costly physicians, all important to understanding and measuring provider performance.

Cost intensive providers are in the data
Both studies demonstrate cost intensive medical providers can be identified in the data. Similarly, best performing providers can also be identified. They will be associated with shorter treatment durations, shorter claim durations, and lower indemnity costs for similar injuries, among other factors. Best practice providers should be singled out and included in networks and injured workers should be directed to them.

Conference takeaway
Bob Wilson of  Workers’Compensation.com recently published a summary of the same SIIA Conference titled, “SIIA Shows Choosing the Right Doctor is the Best Prescription”[2] “One of the big takeaway points for me was how important selecting the right doctor is in the process of treating an injured worker. And by the right doctor I do not mean the cheapest. I mean the best; The one with the best outcomes. It was blatantly clear from the sessions at this conference that the best medicine is also, in most cases, the best cost control.”

Wilson continues,This has unfortunately not been a priority area for our industry. We have assembled massive networks of physicians with an eye largely focused on procedural costs and negotiated discounts, and it appears this practice is costing us money and sacrificing the health of those in our care over the long run.”

Choose doctors carefully
In another recent article, Price Shopping Your Company Doctor Will Cost You[3] Rebecca Shafer, J.D. of Amaxx Risk Solutions, Inc. states Key Criteria For Doctor Selection Should Not Be Perceived Price Discount. Many employers rely on the HMO, PPO or the medical provider network to provide a medical provider for the injured employees. This approach often ends up with doctors that keep the injured employee off work longer than necessary. Often the key criteria for being a member of the HMO, PPO or medical provider network is a willingness to accept the HMO’s, PPO’s or medical provider network’s fee schedule arrangement. These same medical providers may offset their lower profit per visit by requiring the employee to come in to be checked more frequently, or by extending the number of times the employee is seen (and the time off work).”

1.     Industry studies show only a few doctors and other medical providers generate most of the costs in Workers’ Comp claims.
2.     Medical fees are only a part of cost and they can be manipulated by providers.
3.     Other factors contributing to claim costs include longer medical treatment duration, longer claim duration, and higher indemnity costs.
4.     Payers have been misled in thinking discounts on medical service fees reduce claim costs.
5.     Cost intensive medical providers can be found in the data.

It begs the question, why are cost intensive doctors in networks? They can be identified in the data and avoided. Likewise, best practice providers can also be found in the data and injured workers should be directed to them.

Karen Wolfe is the founder and president of MedMetrics®, LLC, a Workers’ Compensation analytics company. MedMetrics specializes in medical provider performance analysis. Its analytics and technology are leveraged to provide powerful online “apps” that link analytics to operations, thereby making them actionable. Visit MedMetrics to learn more or contact karenwolfe@medmetrics.org.