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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, July 30, 2015

Rating Doctors

by Karen Wolfe

USA Today recently published a story about ProPublica, a non-profit news organization that has developed a metric to score surgeons’ performance, comparing them to their peers.[1] The study is intended as a tool for consumers, however, it has generated debate and concern among surgeons who feel they are being unfairly treated.

Rating is not new
What the article neglects to mention is that rating doctors and hospitals is not new in the general health world. Scoring medical providers has been a practice for decades. The Leapfrog Group[2] that scores hospitals has been in business well over twenty years. Doctor Scorecard[3] scores medical doctors and a Google search will offer more.

What is different about the ProPublica analysis is it is based entirely on data and singles out surgeons treating the Medicare population. It also uses an adjustment score for the difficulty of cases analyzed called an Adjusted Complication Rate.

Adjusted complication rate
The ProPublica study includes 17,000 doctors performing what are called low-risk, elective surgical procedures derived from Medicare data. The adjusted complication rate selects cases that are considered low risk, such as gall bladder removal or hip replacement. The study looks for complications such as infection or blood clots that require post-operative care, in this case re-hospitalization.

The cost of post-operative care requiring hospital readmission amounted to $645 million which was billed to taxpayers for 66,000 Medicare patients from 2009 to 2013. Logic says that if surgical complications requiring hospitalization are so costly for Medicare patients, the costs must translate to astounding rates in Workers’ Compensation, as well. However, the study does not directly apply to Workers’ Compensation.

Workers’ Compensation
The ProPublica study does not directly translate to Workers’ Compensation because the study examines Medicare patients only. While some injured workers qualify for Medicare, the majority are healthy, working adults under Medicare age.

What does translate from the study is that evaluating and rating medical doctor performance based on the data is do-able and important. However, it should not be limited to surgeons. The analysis of doctor performance must be comprehensive, accurate, and fair.

Case mix adjustments
Rather than using the limited measure of Adjusted Complication Rate following surgery, a broader view of the claim and claimant is appropriate for Workers’ Compensation. Analysis is not limited to those cases with complications. Instead, all claims are analyzed. Results are adjusted by the claimant’s age, general health (indicated by comorbidities), and also the type and severity of the injury itself. Administrative management analyses are also important in workers’ Compensation such as direct medical costs, indemnity costs, return to work, and case duration, among others.

Level playing field
Case complexity, sometimes presented as Case Mix Adjustment, is important to fairness in rating doctors in Workers’ Compensation. Also, analyzing a broad scope of data elements smooths the variability leading to more accuracy. Fortunately, in Workers’ Compensation, claims have a very wide range of revealing data elements that can be drawn from a payer's multiple data silos.

Provider angst
The ProPublica study has created push back from the physician community for several reasons. For one, gall bladder surgery is often performed in an outpatient setting, so re-hospitalization is a meaningless metric. The same is also true for others of the so-called low-risk surgery category. Moreover, the study names names.

Published ratings
Published provider ratings from a national survey caused much of the angst noted in the USA article. Names were even published in local papers, naming physicians well known in their communities. Doctors cried foul!

Expecting the general population of patients to understand what the ratings mean, regardless of their accuracy is naive. Ratings listed as 2.5 or 1.6 have obscure meanings to the uninitiated. Fortunately, Workers’ Compensation providers do not face that level of exposure. Doctor ratings in Workers’ Compensation are not published for the general public or made available for consumer interpretation

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 link analytics to operations, thereby making them actionable. MedMetrics analyzes data continuously and sends alerts as appropriate. MedMetrics also analyzes and scores medical provider performance. karenwolfe@medmetrics.org

[1] N. Penzenstadler. How does your surgeon rate? New metrics sparks angst. USA Today. July 14, 2015.
[2] http://www.leapfroggroup.org/
[3] http://www.doctorscorecard.com/

Saturday, July 11, 2015

How to Effectively Imbed Nurse Case Management in WC Claims

by Karen Wolfe

Nurse case management (NCM) has a powerful impact on Workers’ Compensation claim cost and outcome. Positive results of nurse involvement have long been anecdotally accepted, however widespread evidence of nurse impact has not emerged and objective proof of value is still missing. Several factors account for this.

Inconsistent referrals
For one thing, NCM’s are usually considered an adjunct to the claims process, called upon in sticky situations. Too often referrals to nurses is a last resort rather than an integral and standardized part of claim management.[1] When claims adjusters have the sole responsibility to refer to NCM’s, it can be subjective, uneven, and therefore unmeasurable.

Besides receiving referrals for sundry issues at different points in the course of the claim, nurses have not clearly articulated their case management interventions. Claims adjusters sometimes misunderstand the nurses’ approach. However, consistent referrals and standardized procedures can bring about major change.

Consistent referrals
Referrals to NCM should be made based on specific medical conditions in claims such as comorbidity like diabetes or problematic injuries like low back strains that tend to morph into complexity and high cost. Specific risky situations found in in claims data should automatically trigger NCM notification.

A recent article published in Business Insurance, “Nurses a linchpin in reducing workers’ comp costs”, points out how Liberty Mutual has developed a tool that notifies claims adjusters of cases that would most benefit from a nurse’s involvement.[2] Decision burdens for claims adjusters are eliminated. Referrals to NCM are automatic based on specific high risk situations found in the claim. Inconsistency disappears and several benefits evolve from this approach.

Process standardization
An operational process can be dissected and categorized, thereby gaining better understanding of its components and relative importance. Review the data to determine which medical conditions in claims result in longer disability, lower rates of return to work, and, of course, higher costs. Select the conditions in claims that should activate an NCM referral.

An example is a mental health diagnosis appearing in the data well into the claim process. A mental health diagnosis appearing during the claim for a physical injury such as a low back strain is a strong indicator of trouble. The injured worker is not progressing toward recovery. However, the only way to know this diagnosis has occurred in a claim is to electronically monitor claims on a continuous basis.

Data monitoring
To identify problematic medical situations in claims and intervene early enough to impact outcome, the data should be monitored continually. Clearly, this is an electronic, not a human function. When the data in a claim matches a select indicator, an automatic notice is sent to the appropriate person.

Standardized procedures
Catching high risk conditions in claims is just the first step. NCM procedures must be established to guide responses to each situation triggered. Standardized procedures should describe what the NCM should evaluate and advise possible interventions. Such processes not only explain the NCM contribution, they assist in documentation and are the basis for defining value.

Measuring value
NCM has been under-appreciated in the industry because measuring apples to apples cost benefit has been impractical. When claims adjusters decide about referring to NCM’s and individual nurses create their own methodology, variables are endless and little is measurable.

In contrast to the subjective approach, specific conditions in claims found through continuous data monitoring can automatically trigger a referral to the NCM. In response, the nurse is guided by the standard procedures of the organization. When referrals are based on specific conditions in claims and response procedures are delineated, outcomes can be analyzed and objectively scored.

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 link analytics to operations, thereby making them actionable. MedMetrics analyzes data continuously and sends alerts as appropriate. MedMetrics also analyzes and scores medical provider performance. karenwolfe@medmetrics.org

[1] K. Wolfe. Early Intervention Drives Better Outcomes, But is Not Really Pursued http://medmetrics.blogspot.com/2014/10/early-intervention-drives-better.html