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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, December 3, 2014

Are You an Industry Disruptor? It Can be a Good Thing

by Karen Wolfe

The idea of an industry disruptor might be reminiscent of a classroom prankster, the one who continually distracts to keep the teacher off topic. But no. The term “industry disruptor” is being used to describe organizations with concepts or approaches that significantly impact an industry. Because of their unique presence and ingenuity, industry disruptors change the entire industry—often forever.

Industry disruptors
Think of Steve Jobs’ invention and Apple, Inc.’s implementation of the iPod. It turned the music industry on its side. Jobs could envision completely new products and new ways to use them, so he changed the music world. But the music industry was not the only business he disrupted.

Jobs did not invent the cell phone, but he changed the way cell phones are used. The “smart” iPhone profoundly changed the way we use phones. Now they are small, but powerful hand-held computers with apps that embrace almost any activity. Land lines have become almost obsolescent and old “Ma Bell” would not recognize the industry.

Moving on, Jobs also disrupted the personal computer industry with the iPad. Sales are down for laptops and portable computers because people rely on the simpler iPad for personal use, for e-reading, for movies, and for specific business adaptations. As an example, doctors’ offices now use iPads for data input into EMR’s (Electronic Medical Records). iPads and phones even capture credit cards and signatures.

Jobs could “think different”, actually using that phrase in advertising. He could envision, design, develop, and implement electronic tools that disrupt whole industries. Amazingly, the technology, through the continuous development of apps (purpose-specific applications) has allowed expansion from the original concept into every avenue of life.

Yet another, more recent disruptor is Uber. Uber has taken use of the smart phone a step further, thereby changing the way people travel from point to point in cities. Just tap your phone, and you will be picked up and driven to your destination. No money or credit card transactions are needed because that has been set up in advance on the Uber website.  

Uber has seriously disrupted the stodgy taxi industry as people find the simplicity of Uber quicker and more satisfactory. However, disruptor transition is not necessarily easy. Uber is suffering from growth stumbles and legal push-back from the taxi industry. Resistance is found in many industries.

Disruptors in Workers’ Compensation
Everyone agrees Workers’ Compensation needs updating and improving. Unfortunately, the industry is notoriously resistant to change. What would an industry disruptor create for this industry?

Some say the big change needed is to legislate the employer opt-out option from state regulated systems. Texas and Oklahoma are the change leaders in that effort. However, a group of employers is working in other states to bring about similar legislation. If well-executed, these efforts could significantly impact the industry.

To bring about superior, sustainable change, new applications of technology will be required to monitor consistency, quality, and compliance across jurisdictions. The technology is available. Now a unique application is needed, one that everyone loves to use!

Loving technology
Loving technology is not a sentiment normally found in Workers’ Compensation. That is because most still think of technology as tedious data input and mistrust the output. Nevertheless, creative technology could boost and enhance nearly every activity in Workers’ Compensation.

The ultimate goal in any Workers’ Compensation endeavor is (should be) to optimize the medical care of injured workers at the lowest possible cost. A successful industry disruptor will apply technology in new ways, thereby positively impacting cost and outcome pathways for injured workers and their employers.

Industry disruptors
Any industry disruptor technology will encounter resistance in Workers’ Compensation. However, everyone can contribute to positive industry disruption by simply being open to change. Change might mean doing things differently. It might be willingness to learn about and adopt new technology-based approaches in business operations. It might even mean willingness to love technology.

The point is, a creative new use of technology will change the way the Workers’ Compensation world is managed going forward. Industry disruptors will make that happen.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics and technology services company. MedMetrics analyzes the data and offers online apps that super-charge medical management by linking analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org


Thursday, November 6, 2014

Data is Your Weapon of Choice

by Karen Wolfe

Managing the medical portion of Workers’ Compensation claims can be daunting. The variables are endless. Vendors of all types, extraneous and overlapping events, and even participant attitudes can impact the cost equation. Moreover, injured employee recovery lies in the balance, making the effort essential.

Longstanding methods
Current managed care initiatives have long been in play. They include bill review, utilization review, discounted medical provider networks, medical case management, fee schedules, guidelines, and peer review. That should do the job, but apparently not.

The medical portion of claims continues to rise while its portion of overall case cost is also increasing in most states. Medical costs are 60% of case costs, yet in some states, it is approaching 70%. 

The ‘tried and true” methodologies have been in place in Workers’ Compensation for about twenty-five years. Basically, the industry is continuing to follow the same pathways while hoping for different outcomes. Enough said.

Save the baby
This is not to say we should scuttle the strategies in place. Instead, the focus should be on updating and intensifying the existing processes to achieve their intended results.

Workers’ Compensation is an industry replete with transactions that are recorded digitally. First reports of injury, bill review, pharmacy benefit programs, and claims system paying bills and documenting events, all continually contributing to the data mass for each claim. Effectively analyzing that data on a concurrent basis and making the business knowledge available to claims adjusters and other decision makers is a powerful approach to strengthening current systems.

Data is your weapon
Analyzing data and converting it to useful information is the key to enhancing current medical management techniques. Writing reports and analyzing trends cannot impact outcomes. Such measures focus on the past that cannot be changed. Data must be utilized in new ways.

The first prerequisite is getting data-derived information to the front lines quickly. The business units should have access to analyzed information as concurrently as possible. Early information sets the scene for early intervention and resolving problematic situations in claims before they spin out of control.

Continuous data monitoring
Distributing information continuously requires that the data be electronically monitored and analyzed continually, not at the end of the month or quarter. When conditions that portend risk occur, the appropriate person is automatically notified. That might be the claims adjustor, medical case manager, medical director, supervisor, or manager. Importantly, the notified person will follow the organization’s approved procedures, thereby lending structure to the process.

Monitoring data and notifying the right people when indicators in claims point to risk mobilizes proactive medical management. Refer to the article, Early intervention drives better outcomes, but is not really pursued.

Other unique data initiatives can be even more compelling.

Select the best to improve networks
Research in the industry irrefutably shows poorly performing medical providers lead to high cost and poor results. Poorly performing doctors in the Workers’ Compensation context are those who have little understanding of the system or deliberately abuse the system through overutilization. Indicators of such poor performance are readily found in the data.

The data will reveal the poor performers, those who ignore basic Workers’ Compensation needs such as early return to work, as well as those who bleed the system with excessive treatment practices.

Treating doctors essentially cause, influence, or control the significant portion of medical costs. Once the injured worker is in the doctor’s care, opportunities to steer the course with medical management methods nearly disappear. Consequently choosing the right physician at the start is essential.

Directing care
Using data analysis to select the best practice doctors is the way to prevent problems and smoothly lead to the most optimal outcome. In many states this is possible and encouraged. In other states directing care is not allowed. Nevertheless, non-traditional applications of analytics can optimize results.

Behavior modification
When directing care to the best doctors is not possible, the next best option is to change the perpetrating doctors themselves. The fact is, people, and maybe especially doctors, do not like to look bad. Presenting them with analytic representations of their performance compared to others of the same specialty in the state is a powerful behavior change methodology. Those who are outliers will begin to move toward the mean.

Changing medical provider performance is not impossible! When they see themselves graphically compared to others based on the data, the information is indisputable. Of course, they will first attempt to push back. One way they argue is to say they treat only the more serious cases. That could be true.

Pièce de résistance
However, the pièce de résistance is to correct for medical severity in performance analytics, thereby leveling the playing field. Those who treat more serious injuries as evidenced in the data are compared only to others who treat similarly difficult cases.

Adjusting for case risk or severity by diagnosis is how to diminish resistance for poorly performing treating physicians. Graphic presentations of comparative performance cannot be disputed. The fairness is built in.

As the treating provider outliers move toward the performance mean, they may never achieve best-in-class, but their outcomes will gradually improve. They will also be aware of continued surveillance so the impact persists. Positioning data in this way is your weapon of choice for a powerful, yet bloodless medical management solution.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics and technology services company. MedMetrics analyzes the data and offers online apps that super-charge medical management by linking analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org



















Tuesday, October 14, 2014

Early Intervention Drives Better Outcomes, But is Not Really Pursued

by Karen Wolfe

Early intervention drives better outcomes. It’s a statement that garners little resistance. Everyone agrees when a problem is found early, the solution is easier. Thwarting a problem early in its course produces better results. Yet few systems are in place to guarantee early intervention into problematic Workers’ Compensation claims.

Early intervention is a fine idea, but not always pursued. Work flows and systems in the industry are not typically designed to target the goal. To be effective, early intervention requires identifying the claims needing attention as soon as possible in their course, then mobilizing action procedures.

Predictive modeling
One effort to identify claims early that is widely acclaimed in the industry is predictive modeling. Elaborate analysis of the data using advanced mathematical methods is used to identify new claims that will likely become problematic. Regardless of the sophistication of the math, finding those claims remains a guessing game. Not every future problematic claim will be tagged. Likewise, claims that do not meet the modeling criteria, yet migrate anyway, will not be recognized. Predictive modeling can be helpful but it is imperfect and costly.

Containerizing human responses
Containerizing human conditions and responses is possible to a point. However, predicting human behavior is imperfect at best. Moreover, a second step is necessary: consistently intervening in the identified problematic claims. Once the troublesome claims are detected, certain action steps must follow.

Data monitoring
A more practical methodology for identifying costly claims is to monitor the data on a concurrent basis to uncover dicey conditions in them.

Rather than predicting which claims will be risky, the conditions that portend risk and cost in claims are isolated and then identified in claims as they occur.

Technology is used to find the claims that bear those conditions whenever they occur throughout the course of the claim. All claims are monitored, so none are missed. No guesswork is involved.

Step two
The data monitoring approach is powerful, but as with predictive modeling, that is true only when the next step is taken. Organizations that undertake a process for identifying risky claims early stand to lose the entire benefit unless they also structure procedures for intervention. The appropriate persons must be notified about problematic claims immediately and those persons must act to carry out the recommended procedures.

Whether the alert recipients are claims adjusters, medical case managers, or someone else, they must follow intervention procedures for best results. Using the data monitoring approach, each condition that is sought in the data should be associated with a prescribed intervention procedure.

Standardized interventions
Follow up procedures should be specific so that analyses can be made of their effects. For instance, when the condition identified in a claim is the third prescription for a Schedule II drug, the system might be set to alert the medical director. A standard method of intervention or approach for intervening with the treating doctor is followed.

Another example of a problem is extended medical treatment past a designated point for low back strain. The alert is sent to the claims adjuster whose procedure is to engage a medical case manager to investigate. The investigation procedure is standardized.

Examples of how this works are unlimited, but the important thing is that intervention procedures are analyzed in advance and clearly stated so the actions are consistent across the organization and going forward, regardless of who actually carries out the intervention. Obviously, details of actions may be variable, but the general course should be followed.

Measuring results
The plight of medical case management has long been that results could not be measured. Consequently, medical case management as a strategy has been undervalued.

Categorize interventions
Moreover, medical case management could not be measured because interventions are delivered by individuals, even though usually professional nurses, each is different. However, intervention tactics can be categorized so outcomes can be calculated. The benefit of using a standardized approach is that outcomes can be compared and measured by the cause condition and intervention employed.

Automated referral
Claims adjusters sometimes fail to refer to medical case management for a variety of reasons. When early intervention procedures are standardized, the referral is automatically made by the system, thereby eliminating the burden of referral for claims adjusters. Efficiency is good.

Simply stated, early intervention is more effective than late intervention. The problems have not yet morphed into catastrophe and are usually easier to solve. Moreover, systems and procedures should be established to automate problem claim identification and follow up procedures. Best results can be pinpointed and continued. Lesser results can be modified. The upward spiral of quality improvement is continuous.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics and technology services company. MedMetrics offers online apps that super-charge medical management by linking analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org

Monday, September 29, 2014

ICD-10 Delay Fatigue

by Karen Wolfe

Right now we would be launching the long-anticipated shift from ICD-9 to ICD-10 scheduled to commence October 1, 2014—that is, until CMS was ordered to make yet another change to the deadline. The newest deadline is October 1, 2015. The inevitable is put off for another year. Delaying implementation of ICD-10 is a relief for some, but grinding for others. Without a doubt, continued delays significantly impact costs and benefits for the healthcare system.

Delayed rollout
According to Michele Hibbert-Iacobacci, CMCO, CCSP, Vice President of Information Management and Support at Mitchell International, “On March 31, 2014 the ICD-10-CM/PCS (International Classification of Diseases-10th Revision, Clinical Modification and Procedural Coding System) implementation was delayed in the United States due to the Senate approved a bill (H.R. 4302). This update to the obsolete ICD-9-CM/PCS was a requirement in the Health Insurance Portability and Accountability Act (HIPAA) for all covered entities. Workers’ compensation has been excluded as an industry that is not covered under HIPAA (non-covered entity); however, the providers submitting the medical bills to workers’ compensation payers are covered entities. By proxy, the workers’ compensation industry needed to prepare to accept ICD-10-CM/PCS by the implementation date of October 1st 2014 and the majority of payers and vendors were ready to process bills by that date.”

Benefits of ICD-10
The move from ICD-9 to ICD-10 reflects substantial advances in medicine that have occurred during the last three decades. ICD-9 includes 17,000 diagnostic codes whereas the ICD-10 has 155,000 codes, reflecting much more detail and differentiation in diagnoses.

The result of the expanded and updated coding will enhance disease and injury definition with more accurate payment specificity. Yet, continued delays have placed a burden on billers, suppliers, and payers. The rollout delay means both time and cost burdens throughout the healthcare and insurance industries.

Costs of delay
“Scores of provider, supplier, payer, education and training organizations have spent millions of dollars preparing for the expected medical coding upgrade.”[1]  The delay can be translated to measureable lost costs when you consider turnover of trained personnel and training refreshers needed for others.

One challenge that will be encountered is sporadic or uneven use of ICD-10 codes before and after the deadline requiring handling both sets of codes. There will be those who begin using the new coding early and those who never believed the day would come. The latter group could lag long.

Accommodation will be made for old coding and dual coding. Bills will be submitted using either and both. Therefore, decisions must be made regarding payment. Will the payment organization assume the task of converting the codes?  Should reimbursement be denied those not in code compliance? Systems will need to accommodate both to navigate the transition.

The drop-dead date for ICD-10 will come, whether it occurs October, 2015 or some later time. When that happens, procrastinating further will not fly. Reimbursement will depend on accurate and timely coding.

The positive side
Frustration and exasperation notwithstanding, there are those who are thankful for the delay because they were not ready for October, 2014. They now have time to meet the new deadline. Those who were ready for the launch can now perfect the processes they created.

Bite the bullet
Many, if not most organizations were ready for the 2014 deadline. The test for them is to sustain sharp readiness for another year. That is costly, and it is also tiring.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics and technology services company. MedMetrics offers online apps that super-charge medical management by linking analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org

[1] Barlow, R. Coders teeter on tightrope of relief and tension. Health Management Technology. September, 2014. www.healthmgttech.com.

Monday, September 15, 2014

MedMetrics Claim Risk Score is Now Available

Claim Risk Score

Scored diagnoses predict claim risk
  • Each claim has a risk score based on diagnostic severity
  • MedMetrics continuously monitors bill review data
  • When a diagnostic risk point is reached in a claim, an alert is sent
  • No guessing which claims will be problematic
  • MedMetrics does it all for you!
Serious conditions and migrating claims cannot go unnoticed!

Learn more:
"A Better Way to Measure Claim Risk"

It’s easy, affordable, and POWERFUL!

Karen Wolfe, President/CEO
MedMetrics, LLC
Workers’ Compensation Medical Analytics
541-390-1680 (v)
541-388-1422 (f)

Wednesday, August 27, 2014

A Better Way to Measure Claim Risk

Insurance Thought Leadership has just published an article by Karen Wolfe of MedMetrics,
"A Better Way to Measure Claim Risk"

MedMetrics provides this diagnostic claim risk scoring tool. It's quick, easy, and affordable.
Contact: KarenWolfe@MedMetrics.org

Monday, August 18, 2014

Validation for Making Data a Work-in-Progress Claim Management Tool

by Karen Wolfe

According to a recently published White Paper by LexisNexis®, Data makes all the difference. The article, “More Data, Earlier: The Value of Incorporating Data and Analytics in Claims Handling”, states that carriers can reduce severity payments by up to 25 percent.[1]

The article further states that “PC carriers have implemented real-time data and analytics to enhance risk management, streamline processes and reduce costs. Yet historically within the claims function, data and analytics have mostly been isolated in the special investigative unit (SIU).  
LexisNexis believes that carriers should use data and analytics as an operational tool first, and an investigatory tool second. We conducted a study to investigate the effect of having more data earlier in the claims process and found that claims with more data are resolved faster, with lower overall costs.”

The study is about bodily injury claims, not about Workers’ Compensation, but the findings can logically be extrapolated and applied to Workers’ Compensation. Applying data early and throughout the claims process will result in lower costs, efficiency, and improved outcomes.

Early data

In Worker’ Compensation, having early and comprehensive data is a fait accompli. The First Report of Injury (FROI) from the employer and in many states, the treating physician, launch the data collection process. The claim is set up in the payer’s claim system and continually fed by additional data. Bills from medical providers and others are streamed through bill review systems, then to claims systems. Events such as litigation, court dates, and bills paid are documented in the claims system. Pharmacy is managed by the PBM (Pharmacy Benefit Management), thereby setting up an additional database for the claim. Most also collect utilization review and medical case management data. The question is not the data, but what is done with the data. How can it be applied?

Sitting data

Unfortunately, in Workers’ Compensation, voluminous data sets often remain in separate silos. The focus in Workers’ Compensation for the last twenty-five years has been on collecting the data. Now the question is, how to make data an operational tool and achieve the kind of positive results reported in the LexisNexis study. Doing so requires a different approach to data management.

Integrated data
Making data a useful work-in-progress tool is a matter of first integrating the data. This is not as difficult as is often portrayed by many IT departments. Nevertheless, the request and funding must come from the business units where data integration is also not usually a priority. Until business managers understand the value of converting data to actionable knowledge, little will be done.

Actualized data
To actualize the data for useful application, it must be analyzed and re-presented to the business units in ways that can be easily accessed, understood, and applied. The data is transformed to knowledge, knowledge about conditions in claims, approaching benchmarks, and performance of vendors.

Knowledge is actionable, not the data.

Actionable knowledge
Actionable knowledge is derived from analysis of the data. To achieve measureable cost savings, continuously monitor the integrated data, analyze it, and re-present it to the business units in the form of understandable knowledge, thereby making it actionable. Individuals can be prompted by the system to take specific actions based on the knowledge, thereby creating a structured and powerful approach to claims management with measurably positive results.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics and technology services company. MedMetrics offers online apps that super-charge medical management by linking analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org

[1] A.Hassib and T.Fannin. LexisNexis. June, 2014 insurance.sales@lexisnexis.com


Tuesday, July 29, 2014

A Trail of Abuse--Spotting Medical Fraud in Workers' Compensation

by Karen Wolfe

While there is considerable talk about fraud in Workers’ Compensation, the chatter usually refers to claimant or employer fraud. Unfortunately, fraud and abuse also occurs in medical management.

Medical fraud
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 also know how to find them!

When a doctor knowingly over-treats, costs increase and outcomes are compromised. Disciplining such providers by not paying them is one solution, but a more proactive approach to managing them is to avoid them altogether. Identify the bad doctors and carve them out of networks. Avoiding corrupt and inept medical doctors prevents the needless spiral of high costs and adverse outcomes resulting from misbehavior.

Identify the perpetrators
Efforts to solve the problem should focus on identifying the perpetrators by means of a well-designed analytic strategy. Most agree with this philosophy, yet few medical networks in Workers’ Compensation have seriously addressed the issue. The data, when analyzed appropriately, will point out medical doctors who perform badly.

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 undesirable practices. Outliers float to the surface.

Among the outliers found in the data are exploited frequency and duration of medical treatment. Fraudulent providers have higher treatment frequency and duration than their counterparts. Other outliers found in the data involve use of the most costly treatment procedures, selected as first option. The timing of treatment can produce evidence of corruption such as when more aggressive treatments like surgery are selected early in the claim process.

Subtle abuse
Some of the more subtle forms of medical fraud involve manipulating the way bills are submitted. Corrupt practices attempt to trick standard computerized systems. They consistently overbill, knowing the bill review system will automatically adjust the bills downward. But systems can miss subtle combinations of diagnoses and procedures and allow payment. If a doctor consistently overbills, what is the motive?

Likewise, some practitioners bill under multiple tax identifiers and from different locations. Unless these behaviors are being monitored, computer systems simply create different records for different tax ID’s and locations, making the records appear as different doctors. When attempting to evaluate performance, the results are skewed. Provider records must be merged and then re-evaluated to arrive at more realistic performance scores.

Another method used by disreputable providers is to obtain multiple NPI numbers (National Provider Identifier) from CMS (Centers for Medicare and Medicaid Services). Once again, the data is obfuscated and deliberately made misleading.

Referral “rings”
The data can also be analyzed to discover patterns of referral among less principled providers and attorneys. Referral patterns can be monitored.

Litigation association
Medical abuse also occurs in other ways. The data can be scrutinized to find doctors who are consistently associated with litigated cases. That may mean they are less effective medical managers or it could be an indicator they are part of a strategy to encourage litigation and certain attorney involvement. Kickbacks are not in the data, but the question is raised.

Calling a spade…
Many doctors who skirt ethical practices would be shocked to be called fraudulent. Yet that is exactly what it is. Changing the name does not whitewash the behavior.

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

Outcome-based networks
Selecting the right doctors and other providers for networks is a complex but important task. Data from many claims where individual providers and groups are involved must be analyzed to distinguish how physicians perform in the Workers’ Compensation context over time. Subtleties of questionable performance can be teased out of the data. The most powerful approach is to monitor the data in real time so that interventions effectively thwart the perpetrators.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics and technology services company. MedMetrics offers online apps that super-charge medical management by linking analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org

Monday, July 14, 2014

Balancing Medical Quality and Cost A Zero-Sum Game?

by Karen Wolfe

Many believe medical quality is sacrificed when attempting to control costs. The logic assumes the way to achieve quality medical care is to deliver more of it. The other side of the same reasoning is that less medical care means less quality. However, the cost-quality balance is not a zero sum game.

Zero sum games
A zero sum game means that when one element of the equation prevails, the opposite is suppressed. That would mean efforts to control medical costs by reducing the amount of medical care will result in poor medical quality. Cost control efforts such as not authorizing treatments and procedures necessarily result in poor quality.

Coexisting factors
However, these supposed opposites can, and should coexist in managing the medical portion of Workers’ Compensation claims. Quality is not counter to cost management in medical treatment. For instance, managing the number of visits or encounters, prescriptions, and the number of specialists the claimant encounters are just a few ways to limit medical services that may, in fact, improve quality.

Visits and services
On the one hand, the treating doctor should see the injured worker often enough to understand, direct, and maintain control over the recovery process. Yet, some physicians embellish their revenue flow by seeing patients more frequently than necessary. To manage excessive utilization of office visits and services, evaluate the data to learn what is reasonable and what is disproportionate. To be effective, the data must be monitored concurrently so that intervention has an impact.

Analyze the data
The way to objectively measure excessive visits is to monitor and analyze the data. For specific injuries in a given jurisdiction, what is the mean number of medical visits? Outliers can be interpreted to mean either the treating physician is fraudulent or the claimant is in trouble. Either way, focused attention to the matter is needed.

Standards and legislation
A claims payment organization can set standards for what should be considered the threshold of excessive for given conditions. Beyond that point, the claim is examined and intervention initiated. Some states legislate frequency of care.

The state of California, for instance, has placed limits on the number of physical therapy and chiropractor visits. The data system can mobilize notification to the appropriate persons when the benchmark is approaching so that limits are not exceeded. Applying similar methods to a variety of medical visits and services adjusted by diagnosis and other factors such as age and comorbidity will similarly impact costs while sustaining quality.

Another example of balancing quality and cost is controlling frequency or volume of services by electronically monitoring prescription practices, especially those for Schedule II or Opioid drugs. The literature is replete with examples of ineffective and poor outcomes when Opioids are over-used. By monitoring current data, usage and cost can be checked through appropriate intervention.

Yet another indicator found in the data reflecting excessive medical treatment is multiple medical referrals. Too often when the patient is not improving, the doctor’s response is to refer to specialists. The data gives up that information by noting the number of medical providers and specialists involved in a claim. Assuredly, a claim with multiple specialists is a claim in trouble, or at least progressing poorly, needing attention.

Industry research speaks for itself. Consider this Washington state study, “Long-term Outcomes of Lumbar Fusion Among Workers Compensation Subjects: An Historical Cohort Study”[1] This study concluded, “Lumbar fusion for disc degeneration, disc herniation, and/or radiculopathy in a workers comp setting is associated with significant increase in disability, opiate use, prolonged work loss, and poor RTW status.”

Intervene early
Monitor the data to discover outliers early so that interventions will effectively impact outcomes. The key to supporting quality while impacting cost is identifying potential problems early. The longer an issue persists, the more challenging it is to correct it.

Balancing quality and cost
Consider both medical quality and cost control equal goals. They are not mutually exclusive nor is it a zero-sum game. The medical profession itself is recognizing and addressing the issues of over-prescribing, over-testing, and over-treatment. Medical managers need to assist in the process.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics company. MedMetrics offers online apps that super-charge medical management by linking analytics to operations to make them actionable. karenwolfe@medmetrics.org