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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, May 28, 2015

Finding Actionable Provider Ratings in Workers’ Comp

by Karen Wolfe

With the tongue-in-cheek title, “When Yelp reviews are better than hospital rating systems” Jason Beans of Rising Medical Solutions discloses the inconsistencies of standard hospital reviews.[1] He cites a Health Affairs study[2] that points out traditional rating systems, those that have been relied upon in the healthcare industry for years, rarely come up with the same results for the same hospital.

Hospital rating systems score hospital performance in an effort to determine quality and safety in hospitals. The Health Affairs study concludes discrepancies among rating systems is likely explained by the fact that each system uses its own rating methods, defines quality differently, and stresses different measures of performance. Apparently, no standards for quality and safety in hospitals are available.

This begs the question of how scoring systems for rating other medical providers differ from those of hospital scoring systems. More specifically, what about those used to score provider performance in Workers’ Compensation? Lest the conclusion be that all provider performance scoring systems lack credibility, it might be instructive to at least loosely compare hospital rating systems with physician scoring in Workers’ Compensation.

Not similar 
They are very different. The conditions, methodology, and approaches are significantly different. The hospital rating systems cited by Health Affairs evaluate general health in acute care settings. To measure cost, they measure an episode of care on a per diem (per day) basis for individual hospital stays, adjusted by diagnosis and procedures. Often subjective reports are used, as well.

On the other hand, measures of quality performance in Workers compensation are unique to the industry and the number of measurable variables are numerous. How a medical provider acknowledges and influences distinctive industry factors along with success of the medical treatment procedures are indicators of quality performance.

Episode of care
One major difference is the episode of care in Workers’ Compensation is not per diem, but is defined by the scope of the claim. An episode of care (claim) is from the date of injury to claim closure and includes all treatment, medical providers, vendors, events, and outcomes that occur during that time. It may or may not include hospitalization, but when it does, those costs and events are included with total claim. In other words, the episode of care is highly definable in Workers’ Compensation. It is broad and comprehensive.

Quality indicators 
A number of non-medical indicators found in the data reflect unique conditions in Workers’ Compensation that are influenced by treating providers. Measures of quality include return to work and indemnity costs, neither of which is medical treatment precisely, but is strongly influenced by the treating provider and affects the cost of the claim. Consequently, these factors must be included in evaluating performance.

Frequency and duration of treatment, as well as duration of the claim are indicators of provider performance. Providers can contain or increase costs described by these factors. Functional outcome described in the data as disability ratings at the conclusion of the claim are also measures of treatment success.

Clinical factors and treatment processes are important quality indicators, of course, and must be included in the evaluation and scoring. Abuse of Schedule II drugs are, for example, a major cost driver in Workers’ Compensation. Dispensing medications is another.

Source data
Each data-rich claim contains the information necessary to evaluate medical provider performance for Workers’ Compensation. Importantly, the data must be integrated from the silos of bill review, claims system, and PBM (pharmacy) in order to achieve a comprehensive picture of the claim and medical providers’ involvement.

Workers’ Compensation can be more complex than general health because it is a legal system rather than a defined benefit. Every claim has administrative aspects as well as medical assessment and treatment. It’s all in the data.

Objective data 
Scores of medical provider quality indicators can be found in Workers’ Compensation data. The beauty is data describes what actually took place during the course of the claim, not what should have happened or an opinion about it. It is concrete and objective. Yelp can’t help.

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. MedMetrics also analyzes and scores medical provider performance. karenwolfe@medmetrics.org

[1] Beans, J. When Yelp Reviews Are Better Than Hospital Rating Systems. May 12, 2015. http://www.riskandinsurance.com/when-yelp-reviews-are-better-than-hospital-rating-systems/

[2] National Hospital Rating Systems Share Few Common Scores and May Generate Confusion Instead of Clarity. Health Affairs. May, 2015. http://content.healthaffairs.org/content/34/3/423.abstract