Tips for Building a Medical Provider “A” Team

by Karen Wolfe

The “noise” in the Workers’ Comp industry about increasing medical costs is not subsiding. If anything, the chatter is swelling into a crescendo and much of it is relevant and important. Recent conferences such as the Workers’ Compensation Research Institute (WCRI) underscored the continuing problem of Opioids. Also of concern at the conference was physician-dispensed drugs.

Studies show when Opioids are prescribed inappropriately and when physicians sell patients medications directly from their offices, claim costs increase and outcomes deteriorate. However, while discussion of the topic increases, new initiatives in the industry designed to target the problem are scarce.

Source of the problem

The source of these two major cost problems is certain treating doctors. Doctors are the ones licensed to prescribe drugs and some are abusive. Probably only a few of the doctors are perpetrators, but the trick is to know in advance which doctors they are. Particularly for organizations that have employees geographically spread, this is a continuing challenge.

Networks are not a safe haven

Payer organizations have been lead to believe their networks are their safe haven. If an injured worker is sent to a network provider, a discount on medical services can be assured. Unfortunately, networks are known to contract with every physician and ancillary provider alive, without consideration of the provider’s Workers’ Comp knowledge, interest, or medical integrity. Nor are quality, overall cost, and outcomes considered.

Networks do not vet physician performance. They allege savings based on discounts off medical bills, but the number of bills is not measured. Most networks have not stepped up to apply analytics to provider performance so payers must look elsewhere.

Networks lack necessary data

The only practical way to evaluate provider performance in order to select the best is to analyze the data. The problem for networks is they do not have the scope of data necessary to fairly evaluate performance. They receive medical bills, discount them, take a cut, and pass them back to the payer. But medical bills alone are not adequate for evaluating provider performance.

Data from multiple sources is needed

To understand a provider’s performance, claims level data is also essential. It is needed to evaluate the uniquely Workers’ Comp nuances of return to work, indemnity costs, legal involvement, claim duration, timing, and other key factors.

Opioid data, another source

In the case of Opioids, the best source of data for evaluation is from the Pharmacy Benefit Management program (PBM). The PBM data set contains the detail of what drug was prescribed and when, who prescribed the drug, and where it was filled. However, Indicators of physician dispensing will not be found in PBM data.

Physician dispensing data

Physician dispensing will appear as an item on a normal bill from the treating doctor. The degree to which it is camouflaged will vary and it may or may not be noted by the bill review system. Many bills are summarized by the time they reach the claims adjuster, so adjusters cannot discern which bills are physician-dispensed drugs. Analysis of the data is the best approach, not with the goal of avoiding payment, but to avoid the physician altogether.

Networks are a platform for analysis

Payer organizations should use their network providers as a platform for selecting their A Team. By analyzing the data, the best practice providers will surface and injured workers can be directed to them. Unfortunately, most organizations do not have the necessary resources to accomplish that task.

The solution

The best solution is to invite a third party that specializes in analyzing Workers’ Comp data and identifying the best practice medical providers in your data. Avoiding doctors that prescribe Opioids and those that dispense medications from their offices will save thousands of dollars on any given claim—more than enough for ROI on the third party service. Savings can be measured in reduced claim costs and far better outcomes compared to claims where the perpetrators of these abuses were involved. Identifying the best medical providers and directing injured workers to them are powerfully effective cost containment initiatives.

Karen Wolfe is president of MedMetrics which specializes in medical provider performance analytics with easy user search tools. We analyze your data for you to score providers based on multiple indicators. Visit MedMetrics to learn about MedMetrics Provider Performance Suite of information services, including detailed Provider Performance Analysis and Master Provider Index, a quick search for best practice providers by specialty and geo-zip. For questions, contact karenwolfe@medmetrics.org.

 

 

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.