How to Manage Medical Provider Networks in WC

by Karen Wolfe

David DePaolo posted a response to the CWCI’s[1] recent study of the use of networks in California and their related savings entitled “MPN Means Managed”.[2] The CWCI study compares three network formats in California since the year 2000: PPO’s 2000-2002, the transitions years from PPO’s to MPN’s, 2003-2008, and MPN”s 2009-2011.  “While the use of the networks to medically manage treatment of work-related injuries has fulfilled the legislative intent to encourage network use, over time the MPN’s have not lowered the cost of medical care.”[3]

DePaolo says medical cost savings is only part of the picture. MPN’s need to be managed because the medical impact on other aspects of claims such as disability, indemnity, return to work, and other factors is significant.


So true. But if networks mean managed—the question is how?


Networks can be managed only by evaluating and monitoring individual performance.


Network—a sum of its parts
A network is the sum of its parts, the parts being the physicians and other medical providers in the network. A network cannot be managed as a whole. Each individual medical provider acts independently and with differing results. Moreover, each provider, even within groups or facilities, acts independently. Consequently, they must be evaluated and managed individually.


Since networks began in Workers’ Comp back in the 1980’s, their rationale has been discounting services to create savings. Units of service are discounted and portrayed to payers as savings. The assumption is that all medical providers are equal and all offer equal, quality medical care. But no one checked.


Evaluating provider performance
No one checked because it was easier to claim savings through discounts than to evaluate the performance of individual medical providers in the network. Evaluating medical performance is especially tricky in Workers’ Compensation because in addition to cost and medical treatment factors there are elements unique to the industry that must be considered. Indicators of quality performance are many and varied and they can be found in the data.


Quality indicators 
Quality indicators include medical treatment indicators such as direct medical costs, prescriptions, surgery, hospitalization, and medical procedures analyzed by injury type. Non-medical performance indicators that are influenced by medical providers include return to work, indemnity costs, and legal involvement, along with ultimate outcome indicators such as claim closure and disability ratings at the close of the claim.


The way to manage networks is to Identify the best providers and monitor their performance.


Objective evaluation 
The data necessary to evaluate medical provider performance, particularly physician performance, can be found in bill review data, claims system data, pharmacy data, and the utilization review system. Unfortunately, the data resides in different silos, but by combining the data from these sources at the claim level, individual provider performance can be measured. 

Because the data reflects actual treatment and events, it is objective and quantifiable. Select quality indicators in the data, adjust for case mix, and keep them constant over time.

Swapping discounts for quality
Medical costs have increased to 60% of claim costs, calling into question the benefit of network discounts. The truth is medical providers long ago learned how to overcome the cost of discounts by increasing treatment frequency and claim duration, as well as prescribing expensive procedures, among other tactics. Discounts on more looks like more savings.


Going forward, the major hurdle in managing networks effectively is to de-emphasize discounts, while underscoring and rewarding quality performance. In order to make that financially feasible for the networks, a different approach to discounting should be entertained. For instance, those providers who rate highest in quality performance would be excused from discounts. Likewise, those performing the worst would be discounted the most.



Managing the network
To manage a network, the performance of individuals within it must be evaluated and monitored continually. No longer does it suffice to sign up providers for the network and walk away. When individual provider ratings slip, action should be taken. Moreover, let providers know they are being monitored. It has been proven that observed performance leads to behavior change.

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

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[1] California Workers’ Compensation Institute. http://www.cwci.org/research.html

[2] D. DePaolo. MPN Means Managed. DePaolo’s Work Comp World. June 10, 2015. https://www.workcompcentral.com/depaolo/index/post/1670487372170531417

[3] Ibid.

Do You Know Who Your Best Doctors Are?

by Karen Wolfe

In Workers’ Compensation, the medical provider network philosophy has been in place for years. Most networks were developed using the logic that all doctors are essentially the same. Rather than evaluate performance, the focus was on obtaining discounts on bills, thereby saving money.

Physician selection by adjusters and others has frequently been based on non-objective criteria. Those include familiarity, repetition, proximity, and sometimes just assumption or habit. Often the criteria is something as flimsy as, ‘We always use this doctor” or “The staff returns my calls”. The question is which doctors really are best and why?

Assumptions

The first assumption that must be debunked is that discounts save money. Doctors are smart—no argument there. So to make up the lost revenue for discounted bills, they increase the number of visits or services to the injured worker or extend the duration of claims by prolonging treatment. To uncover these behaviors, examine the data.

Recommendations

Amazingly, even doctors do not always make the best choices about other doctors. They may recommend doctors whom they know socially, professionally, or by informal reputation, but they may not know how they actually practice. They may not know a physician upcodes bills, dispenses medications, or over-prescribes Schedule II drugs. The data will reveal that information.

Referrals

Doctors may be unaware they are adding to claim complexity by referring to certain specialists. Again, familiarity and habit are often the drivers. On the other hand, duplicity among providers is fraudulent behavior and it can be uncovered by examining the data.

Clustering

Analysis of data can expose clustering of poorly performing, abusive, or fraudulent providers referring to one another. The analysis may also divulge patterns of some providers associated with certain plaintiff attorneys.

Management practices

Treating doctors influence claims and their outcomes in other ways. Management indicators unique to Workers’ Compensation such as return to work, indemnity costs, and disability ratings can be analyzed in the data to spotlight both good and poor medical performance. These outcome indicators are either directed by, or influenced by the physician and they can be uncovered through data analysis.

Clinical quality

Claims adjusters and other non-medical persons simply cannot evaluate the clinical capability of medical providers, especially doctors. Performance analysis must take place at a higher level. Evaluations for specific ICD-9 diagnoses and clinical procedures such as surgery must be made. Frequency, timing, and outcome can be examined in the data in context with diagnoses and procedural codes, thereby disclosing the excellence or incompetency of physicians.

Negative clinical outcomes that can be analyzed include, but are not limited to hospital readmissions, repeated surgery, or infection. Physicians associated with negative medical outcomes should be avoided.

Fairness

When analyzing clinical indicators for performance, care should be taken to compare only similar conditions and procedures. Without such discrimination, the results are dubious. Specificity is critical.

When using data analysis to find the best doctors and other medical providers, fairness is also important. Provider performance should be compared only with similar specialty providers for similar diagnoses and procedures. Results will not be accurate or reliable if performance analysis is not apples-to-apples.

Pushback

Medical providers may question data analysis to evaluate performance claiming they treat the more difficult cases. The data can be analyzed to determine diagnostic severity as well. Diagnostic codes in claims can be measured and scored, thereby disclosing medical severity.

Find the best practice doctors

Now is the time to step up to a much more dignified and sophisticated approach to selecting medical providers. Decisions about treating physicians must be based on fact, not assumption or habit.  Fortunately, the data can be analyzed to locate the best-in-class and expose the others.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation medical analytics and technology services company. MedMetrics analyzes the data to score medical provider performance and offers online apps that super-charge medical management by linking analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

Announcing Release of Master Provider Index!

Another computer-aided managed care service from MedMetrics

Now you can quick-search the best medical providers for Workers’ Comp by specialty and geo-zip directly from the Internet anytime! Master Provider Index analyzes provider performance based on data from multiple payers.

Why?

Because poorly-performing medical providers are 100% predictive of high claim costs in Workers’ Comp!
Imagine the savings derived from simply getting injured workers to the best doctor from the start—or referring to the best medical specialist every time!

Not your basic “Angie’s List”

Master Provider Index is a simple look-up online. Just select the specialty and geo-zip to display a list of the est medical doctors and other providers in that location. It’s that easy to use.

However, in order for Master Provider Index to display only the best medical providers, MedMetrics applies important technical underpinnings and analytics. MedMetrics does the technical heavy lifting and analytics so you can easily find the right doctors, those who are scored best based on the data.

Master Provider Index includes three major technical service components, all critical to the result:

            1) Technical services
            2) Medical performance analytics
            3) Online search
            4) Continuous updates

1.      Technical services

 

Data Import
The only way to evaluate provider performance in Workers’ Comp is to scrutinize and analyze the data. MedMetrics imports data from participants’ bill review, claims adjudication, and pharmacy systems. MedMetrics supplies a list of data items needed and where they are typically found. Participants place the data elements in a file and transmit it to MedMetrics. Data mapping is not required.

Data integration
MedMetrics validates, integrates, and maps the data from participants’ systems. Claimant-identifiable data is not used and participants’ data is placed in their confidential, secure sector of MedMetrics data warehouse. For Master Provider Index, MedMetrics will query data from all participants to analyze provider performance.

Scrub and optimize provider records
Provider records in most data sets are incomplete and contain many duplicates. MedMetrics corrects this by scrubbing and optimizing the provider records and duplicates are merged. Only then can a provider record be added to the Master Provider Index.

Continuous updates
MedMetrics imports data updates quarterly and continually monitors and re-analyzes provider performance. Master Provider Index is refreshed regularly, never assuming provider performance is static.

2.      Analytic services

MedMetrics executes its proprietary algorithms to evaluate the broad-spectrum data and score provider performance, thereby identifying best performing providers. Provider scores are integrated across multiple participant data, thereby creating a robust critical mass of data from which provider scores are calculated.

Medical services in the US are part of a cottage industry, therefore, performance indicators are spread across payers. MedMetrics integrates the provider scores across participants to provide a more robust basis for analysis.

3.      Online search tool

 

Master Provider Index users simply go online to select medical specialty and geo-zip. Users pick from a list of specialties and enter three to five digits of a zip code. Entering fewer numbers of the zip code broadens the geographic search.

Best practice providers are listed instantly on the screen. Providers include individuals, clinics, and facilities.

Easy, yet powerful

How easy it is for claims adjustors, medical case managers, plant or store managers, and others to quickly find the right provider for the situation. Provider location and contact information is displayed instantly. Licensed participants have unlimited access to Master Provider Index for all persons they authorize. Master Provider Index is always on, instant, and available from anywhere.

Contact karenwolfe@medmetrics.org now to become a participant and receive special pricing for Master Provider Index available only until the end of 2012.

Learn about MedMetrics' other computer-aided power apps that recharge managed care in Workers’ Compensation.