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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, December 13, 2018

Does Your Workers' Comp Medical Management Measure Up?

by Karen Wolfe

Peter Drucker notably said that we can’t manage what we can’t measure. Moreover, regarding Workers’ Compensation medical management, if you can’t measure It, you can’t improve It. Quality medical management is defined, measured, and tracked. Payers in the Workers’ Compensation industry typically do not measure medical management performance and it’s long overdue.

Medical management programs have been in place for decades, developed with the idea of reducing medical costs which now amount to over 60% of claim costs. Among those initiatives are bill review, utilization review, peer review, discounted medical networks, and Nurse Case Management. Yet, in spite of millions of dollars spent on these programs over the years, their impact on cost is misleading or unknown.

Nurse Case Management (NCM)  addresses cost as well as improved outcomes, yet proving value has been challenging. However, technology-driven, analytics-informed performance analysis changes that. Both process and outcome analysis must be addressed.

Analytics-informed measurement
NCM is usually initiated by the claims rep. However, referral conditions and timing are often not consistent or automated while timely mobilization of NCM services are known to positively impact claim outcome. Technology-driven referrals based on knowledge found in the claim data insures appropriate and consistent referrals, relieving the claims professional of the task. Nevertheless, other factors come into play, as well.

Protocol-driven decisions
Referral to NCM is also influenced by whether the NCM is internal to the organization or contracted to a third party. Pressure to minimize costs may reduce or delay referrals. Instead, organizational protocols should be established for referral to NCM that are automatically triggered based on conditions found in the data. This creates a standardized process that can be measured at claim closure in light of outcomes.

In truth, nurse case managers often resist the idea of standardization. They argue their case management process is guided by professional knowledge and experience. While certainly accurate, methods that generate the best results might be overlooked or implemented inconsistently based on individual preference. Protocols are meant to trigger professional intervention based on conditions in the claim.

Success defined
When Drucker says you cannot manage what you cannot measure, he means you cannot know if you are successful unless success is defined, measured, and tracked. Defined success is the outcome of improved medical management.

Defining success in medical management through analytics-informed technology is straightforward. Claim process and outcome factors can be measured by injury type including but not limited to, frequency and duration of medical treatment, return to work, and overall medical costs. Performance on these individual factors is measured and compared to the best performers in the industry.

Organizations gain bragging rights when they score well. They can boast about their scores to clients, prospects, and to senior management because performance is made objective and measurable. More importantly, where improvements are identified, efforts to correct them are immediately targeted. Certification of excellence in medical management wins top honors.

Continued quality
Improvement is not possible without continuous re-evaluation and scoring. Tracking performance measured by the same factors on a regular basis establishes a quality management program for the organization. Actionable insights are gained and converted to business value.

Raise the bar
Measuring, monitoring, and improving medical management in Workers’ Compensation raises the performance bar for all medical management organizations. As participants work to prove and improve their service platform, the entire industry benefits.

Karen Wolfe, BSN, MA, MBA is the founder and President of MedMetrics®, LLC, an independent Workers’ Compensation predictive analytics-informed medical loss management and technical services company. MedMetrics offers intelligent medical management systems that link analytics to operations, thereby making insights actionable and results measurable. MedMetrics provides analytics-informed medical management process and outcome measurement with certification for exemplary measured performance. karenwolfe@medmetrics.org