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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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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