Part III California SB 863, a Guide to Building and Monitoring Networks with Intelligence

by Margaret Wagner and Karen Wolfe

California has defined how medical networks in Workers’ Compensation should be structured and managed. Part I and Part II of this series described how California’s SB 863 LC 4616 (b) (2) and LC 4616 (b)(3) takes medical provider network directives to a new level. The key imperative is, “Every MPN must establish and follow procedures continuously to review the quality of care, performance of medical personnel, utilization of services, facilities, and costs. However, a few additional key points should be considered when selecting and monitoring medical providers for the California MPN or any network.

Beyond legislation

Escalating problems in the industry with Opioid overuse and abuse, as well as physicians who are dispensing medications from their offices are additional factors that must be considered. While the California SB 863 legislation does not address these issues, the data should be scrutinized to identify physicians who demonstrate unfavorable prescriptive practices. Analyzing the data to evaluate physician performance in that regard is essential to vetting physicians for membership in a network. It is also crucial to monitoring networks going forward.

Opioid over-prescribers

Workers’ Compensation literature is replete with information about Opioid overuse and abuse with its disastrous human and resource waste. Unfortunately, measures taken to curb inappropriate prescribing behavior are few and vary widely across the country.

Simply stated, the best way to reduce Opioid abuse is to avoid Opioid over-prescribers. Analysis of the data will identify the perpetrators. They should never be a part of a Workers’ Compensation medical network.

Back to California - CURES

California has a program that approaches the problem by monitoring patient utilization of prescribed Schedule II drugs and making that information available to authorized prescribers and distributors (pharmacies) of controlled drugs.

California’s program is called CURES (Controlled Substance Utilization Review and Evaluation System, and PDMP (California Prescription Drug Monitoring Program). [1] The California Department of Justice, has a Prescription Drug Monitoring Program (PDMP) system which “allows pre-registered users including licensed healthcare prescribers eligible to prescribe controlled substances, pharmacists authorized to dispense controlled substances, law enforcement, and regulatory boards to access timely patient controlled substance history.

The California Attorney General's Office said that if doctors and pharmacies have access to controlled substance history information at the point of care it will help them make better prescribing decisions and cut down on prescription drug abuse in California. The role of the CURES/PDMP entrusts that well informed prescribers and pharmacists can and will use their professional expertise to evaluate their patients’ care and assist those patients who may be abusing controlled substances.

The state’s database known as the Controlled Substance Utilization Review and Evaluation System (C.U.R.E.S) contains over 100 million entries of controlled substance drugs that were dispensed in California. Each year the CURES program responds to more that 60,000 requests from practitioners and pharmacists. The online CURES/PDMP system will make it much easier for authorized prescribers and pharmacists to quickly review controlled substance information via the automated Patient Activity Report (PAR) in an effort to identify and deter drug abuse and diversion through accurate and rapid tracking of Schedule II through IV controlled substances.”
 

Submission of Controlled Substance Data

Pursuant to Health & Safety Code Section 11190, and Business & Professions Code Section 1170, all licensees who dispense Schedule II through IV controlled substances must provide the dispensing information to the Department of Justice on a weekly basis in a format approved and accepted by the Atlantic Associates Inc.(AAI),and the DOJ. Similarly, pursuant to California Health and Safety Code Section 11165(d), dispensing pharmacies and clinics must provide weekly dispensing reports to the DOJ on Schedule II, III, and IV prescription drugs.

For purposes of creating an intelligent MPN, insure any physician under consideration for an MPN in California is a member of CURES/PDMP. That notwithstanding, the data should be monitored continuously to determine actual performance.

Physician-dispensed medications

Another prescription abuse issue not addressed by the California legislation is physician-dispensed medications. While it is portrayed as a patient convenience, and probably is, the medications are prepackaged and extraordinarily costly. Once again, this practice can be monitored in the data. Bills reflecting drugs dispensed by the treating doctor are not monitored by Pharmacy Benefits Managers (PBM), rather, they appear in normal provider billing.

Networks with Intelligence

All medical provider networks serving any jurisdiction should analyze integrated data, meaning all data associated with claims. Integrated data is sourced from claims level systems, bill review systems, PBM systems, and other such as utilization review to understand the broad spectrum of claims and all individuals, organizations, and events touching them. The goal is to select best-in-class doctors by objectively identifying excellent provider performance.

Margaret Wagner is President and CEO of Signature Networks Plus, Networks with Intelligence™. She is considered an expert in network selection, monitoring and management, thereby creating Networks with Intelligence for clients. MWagner@signaturenetworksplus.com

 

Karen Wolfe is President and CEO of MedMetrics®, LLC, a Workers’ Compensation analytics company. MedMetrics scrubs and enhances provider data in systems, integrates the data from organizations’ disperse systems, then analyzes, scores, and monitors medical provider performance. MedMetrics also offers online “apps” that link medical analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org

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[1] http://oag.ca.gov/cures-pdmp

 

WC Medical Cost Control Made Simple and Affordable Through Technology

A White Paper
by Karen Wolfe

Everyone talks about it, but few are taking significant steps to effectively control medical costs in Workers’ Comp. Solutions are available that can significantly impact medical costs, but too few are implementing them. Moreover, the solutions are easy and affordable, leaving payers with the question, “How can continuing business as usual be justified”?

Technology as a cost management tool
The elements of success are already in place. Every payer organization, has data and an IT (Information Technology) department, either internally or through a third party (TPA). Now they need to advance beyond gathering, storing, and reporting data, to developing new capabilities through technology. The objective is to design technology applications that significantly impact claim costs.

Plain data

In its raw form, the data is not very useful. But when it is subjected to analysis and re-presented to business units in a simple and meaningful way, it delivers valuable claim management intelligence. For example, data can be evaluated through analytics to measure medical provider performance.

Transform data

Medical provider files in claims, bill review, and network systems contain the provider’s name, address, and other demographic information. However, the provider record alone cannot divulge the provider’s impact on claims, including cost, return to work, referral patterns, and other critical factors. But when data from bill review, claims level, utilization review, and pharmacy systems are integrated around a medical provider, the resulting information is exponential.

Measure medical provider performance

Medical provider data integrated across systems offers a platform for powerful analysis. Comparing providers of similar medical specialties treating similar injuries will reveal best patterns of medical care. Analyzing frequency of return to work, indemnity costs, legal involvement, and other factors associated with providers in the data will bring best providers for Workers’ Comp to surface and expose the poor performers and abusers. Workers’ Comp industry research shows avoiding the poorly performing providers results in measureable cost savings every time.

Electronic claims monitoring

Additionally, when data is electronically monitored on a continuous and concurrent basis, it can prompt and guide adjusters and medical managers to take timely and appropriate action. An example is electronically monitoring the data for medical doctors’ prescribing behaviors. Automatic alerts of excessive Opioid prescriptions are sent to appropriate persons who initiate damage control. Lives and dollars are saved.

Computer-intensified medical management

Computer-intensified medical cost management through rules-based data monitoring can be applied to scores of conditions and events in claims that portend risk and cost. Using technology to monitor all claims continuously can even preclude elaborate and expensive methods such as predictive modeling. Claims identified as risky through predictive modeling must be monitored going forward. However, monitoring all claims electronically through specifically designed technology insures that no risky claims are missed, including those identified or not identified through predictive modeling. Electronic data monitoring is the more comprehensive, yet affordable solution.

Maintaining status-quo

The IT tasks required to maintain claims systems and properly handle data are considerable. Therefore, additional IT tasks are not viewed favorably. At the same time, business units compete for IT time and are hesitant to request additional IT resources. Therefore, a simple solution that could save millions may be disregarded to avoid internal disruption. Change avoidance guarantees business as usual with no impact on medical costs.

Outsource for repurposed technology

Often the most propitious way to repurpose technology for Workers’ Comp medical cost control is to outsource to Workers’ Comp managed care and technology specialists. To build systems internally that will achieve significant medical cost control can be a daunting and lengthy task. Knowledgeable business unit personnel must translate strategies to IT personnel for design and development. IT personnel must be dedicated to the project and continuing process. Outsourcing is more practical.

Outsourcing extends IT

IT’s role in outsourcing is to transmit data elements in a secure file from each source system. Data integration and mapping is provided by the outsourced company, freeing IT from the burden. Updates to the data are set automatically so IT involvement is minimized. Outsourcing positions IT to oversee the technology project, while extending its capabilities with significantly less time and cost.

Affordable
Outsourcing medical cost management through outsourced technology is simpler, quicker, and much less costly than developing new medical cost management technology internally. Outsourcing technology to target medical costs through analytics and data monitoring is very affordable and offers favorable and timely cost benefits results. Doing nothing cannot be justified.

Karen Wolfe is the President and CEO of MedMetrics®, LLC, an online Workers’ Compensation analytics company. MedMetrics links analytics to operations to make them actionable for medical cost control.

How to Stop Opioid Use in Workers’ Compensation, a White Paper

Rather than trying to rescue drowning victims, we should find out who is pushing them in the water upstream—and stop them!

It’s no secret opioid use in Workers’ Compensation has reached the critical level, having escalated over the past ten years. The issue is serious, not only because of the cost in dollars, but it also has a human toll. Productivity in the workplace is jeopardized, the risk for new injuries is exacerbated, and claimants’ lives are devastated by addiction. Much has been written and important studies have been conducted on the topic.

Recent studies illuminate the problem
A central location that links to recent studies and articles on the topic along with serious discussion is found on Linkedin, the Work Comp Analysis Group. The studies by NCCI and CWCI are convincing. The only reasonable conclusion is that the problem is real, it is serious and it is growing. Specifically, the increase in drugs as a percentage of claim costs is disturbing. Moreover, the studies also show overutilization is the cost driver, not increases in drug costs. This article is offered by way of contributing a tool to the solution side of the problem.

The solution side of the issue
To address the solution side of the issue, it seems only logical that efforts are directed to the upstream source, those who prescribe the drugs. That narrows the scope considerably since only specially-licensed MD’s can prescribe DEA (Drug Enforcement Administration) controlled drugs. Moreover, only those drugs that have been prescribed and billed through the Workers’ Comp system are causing huge increases in claim costs. Consequently, the spotlight of prevention should focus on the prescribing doctors.

Of course, illicit drugs and drug trafficking exist everywhere. While these drugs may contribute to reduction in employee productivity and risk of new injuries, illicit drugs will not impact pharmacy costs in Workers’ Compensation claims. Only prescribed drugs can do that.

Using analytics to nab the perpetrators
As a Workers’ Compensation analytics company, MedMetrics analyzes and quantifies physician performance based on the data. Networks, insurers, TPA’s, and self-insured employers are increasingly using this information to create outcome-based, quality medical provider networks. MedMetrics includes prescribing behavior along with multiple other performance indicators analyzed for individual providers.

Not as easy as it would seem
Identifying physicians who overprescribe Schedule II drugs should be easy. According to the studies they comprise only a very small percentage of treating physicians. However, analyzing physician performance in Workers’ Comp requires collecting data from multiple sources. Billing data is needed for diagnostic and treatment information, though billing for drugs is typically not found there. Yet, some is, particularly when physician dispense the drugs themselves.

Additionally, claims data is needed to evaluate outcomes of the treatment such as lost time, actual paid amounts, and disability ratings. Yet another data set is needed, that of prescribed drugs found in Pharmacy Benefit Management (PBM) data.

Adding to the complexity of what would otherwise seem simple is the proliferation of drugs in this category. Many of the drugs are opioids, meaning they are artificial versions of the real thing—morphine. As new iterations of these drugs emerge, so do new drug names and NDC’s (National Drug Code) that is supposed to identify them. The DEA (Drug Enforcement Agency) classifies the drugs with still another set of codes.

Overall provider performance analysis
Once collected from the various sources, the data must be integrated, validated and analyzed. Comprehensive data analysis that is very simply described here provides a complete picture of provider performance in context with conditions in the entire claim. When provider performance is evaluated using all the key factors, a fair determination can be made about providers’ practices.

Link analytics to action
Those charged with carving out quality networks can make use of this information about individual physician performance, including prescribing behavior on an ongoing and current basis. Moreover, they also have in hand the objective and tangible rationale for removing poorly performing physicians from their networks.

MedMetrics takes this process a step further. User organizations can elect to be notified when a low-ranking physician, including those who have been identified as over-prescribers of Schedule II drugs submit a bill. This “head-up“ approach allows organizations to proactively intervene, thereby linking analytics to action.