Analytics-Informed Early Intervention Drives Best Outcomes

by Karen Wolfe

Early medical management intervention in Workers’ Compensation drives better outcomes. When a problem is discovered early, finding a positive solution is quicker, easier, and more effective. Moreover, predictive analytics-informed early intervention is even more powerful.

Past is prologue
Even though early medical management intervention is known to work, it is not always pursued aggressively. To be most effective, knowing what to look for in open and active claim data is key. 

The past is a preface to the future. Analyzing historic data to identify the kinds of conditions that have been costly to the organization reveals what to look for going forward. Some conditions are generally known. Examples are comorbidities that accompany injuries and certain problematic or severe injury or illness types. Yet, other less obvious, but troublesome conditions and preemptive situations must be teased out of the data using predictive analytics methodologies.

Predictive analytics
Predictive analytics is a methodology used to identify historic claim conditions that are likely to be troublesome in future claims. Conditions in claims that have led to high costs and poor outcomes in the past are isolated. Once the conditions are pinpointed a system is designed to continually monitor the data going forward and to notify adjusters and medical case managers when those conditions occur.

Continuous data monitoring
A practical method for uncovering problematic claims is to electronically monitor the data to reveal dicey conditions as they occur. Technology is used to find the claims that bear high risk conditions whenever they occur throughout the course of the claim. All claims are monitored continuously, so nothing is missed. Even subtle claim migration is exposed.

Intervention
Data monitoring for conditions discovered through predictive analytics is powerful. Yet, the next step is also essential. Organizations that implement an analytic process for identifying risky claims early stand to overlook the entire benefit unless they also structure procedures for intervention. Importantly, the appropriate persons must be notified immediately and they must carry out the organization’s recommended procedures.

Claims adjusters are often alerted first. However, when medical case managers are alerted as well, the two can execute intervention procedures collaboratively. Claims adjusters may neglect to refer to medical case management as early as they could. But when the automatic referral to medical case management is made simultaneously by the system, that issue is eliminated.

Collateral opportunity
When claims adjusters receive an alert of adverse conditions developing in a claim, they know reserves should be adjusted. Predictive analytics can also inform adjusters of the probable ultimate medical reserve amount for that claim based on history, thereby making reserving easy, timely and accurate.

Measured success
A bonus advantage of an early intervention process informed by predictive analytics is the ability to objectively measure success. At claim closure, costs and other outcomes can be measured and compared with those for similar claims in the past. The savings effects of early problem identification and intervention by claims reps and medical case managers are posted for constituents as objectively measured savings.

Conclusion
Simply stated, early intervention is more effective than later intervention. Damage control is far more achievable. The problems have not yet morphed into catastrophic or irreversible states. Predictive analytics-informed systems and data monitoring can be established to automate tagging problem conditions in claims as they occur. Those who will intervene early are alerted. Finally, reporting objective measurements of success is the payoff.

Karen Wolfe is the founder and President of MedMetrics®, LLC, a Workers’ Compensation, analytics-informed medical management and technical services company. MedMetrics offers online apps and alerts that link analytics to operations, thereby making them actionable and measureable. We don’t do medical management. We make your medical management stronger. karenwolfe@medmetrics.org

 

How Workers' Comp Medical Managers Can Out-Perform Those in Group Health

by Karen Wolfe

We all know the current healthcare system in the US delivers erratic quality at unsustainable, yet ever-increasing costs. Workers’ Compensation medical care is affected by those costs. 

Value-based healthcare

A major shift in the health industry is occurring called value-based healthcare that will also benefit Workers’ Compensation. Embracing select new medical management methodologies put forth in value-based healthcare has the potential to be powerful.

Healthcare transformed 
Value-based healthcare means restructuring how medical care is organized, measured, and reimbursed.[1] It moves away from a supply-driven system organized around what physicians do to a patient-centered system organized around what patients need. (underscore added) The focus is shifted from volume and profitability to patient outcomes needed (quality care). When fully implemented, the overall impact will be nothing less than ground-shifting.

Porter and Lee, healthcare industry strategists at Harvard, have described six value strategies that are necessary to achieve health care industry transformation. Many of the changes are now underway in ACO’s (Accountable Care Organizations) such as the Cleveland Clinic, proving the concept. These defined initiatives produce desired results—quality care at less cost. 

Six components of value-based healthcare

The following briefly describes the methodologies necessary to transform healthcare according to Porter and Lee.

     1.    Integrated Practice Units (IPU’s) meaning multiple specialists practice together resulting in comprehensive and integrated medical care rather than fragmented, duplicated services.

     2.    Measure true outcomes and costs for every patient

When outcomes are measured and reported publicly, providers are under pressure to improve. Fraud and self-dealing are reduced.

     3.    Bundled Payments

Payment bundles are capitated single payments for all the patient’s needs during defined episodes of care such as specific surgical procedures. Providers are rewarded for delivering quality while spending less.

     4.    Integrate Care Delivery Systems

Services are concentrated and integrated to eliminate fragmentation and to optimize the quality of care delivered at any given location.

     5.    Expand geographic reach

Centers of excellence are developed where expertise is gained through higher volume of similar procedures.

     6.    Information Technology

Data mining powerfully enables the first five initiatives and informs services and decisions going forward. 

“Whether providers like it or not, health care is evolving from a proficiency-based art to a data-driven science, from freelance physicians to hospital-employed physicians, from one-size-fits-all community hospitals to vast hospital networks organized around centers of excellence.”[2] 

Value-based medical management in Workers’ Comp

The goal of value-based medical care is to enhance quality outcomes for patients (injured workers) while reducing costs. Focusing on quality (what the patient needs) actually reduces costs.

For group health, the measures are physical and philosophical requiring widespread disruption in how services are organized, delivered, and reimbursed. However, Workers’ Compensation payers can benefit by incorporating three of the six value measures into their medical management process now.

     2.    Measure true outcomes and costs for every patient   (Injured Worker)

Physician performance is scored based on Injured Workers’ experience and outcomes along with cost. Providers who score poorly can be avoided.

     3.    Bundle payments

Bundling is capitating payments for all the services required for procedures such as specific surgical procedures, including all associated pre-op and post-op care. The costs are kept in line because providers need to stay under the cap to be profitable. They also focus on quality because re-do’s, redundancy, and complications add cost to the service bundle, thereby diminishing profits. Prepare to see bundled payment options available to Workers’ Compensation sooner rather than later.

     6.    Information technology

The data in Workers’ Compensation, while siloed, is all organized around individual claims and injured workers. When the data is integrated at the claim level, patient experience, provider performance, outcome, and cost analysis opportunities are unlimited. The more comprehensive and accurate the data, the greater the opportunity for gain.

Those who cling to traditional seat-of-the-pants medical management will be left behind. Those in group health may be hampered by slow regulatory change, organizational upheaval, and resistant providers, while Workers’ Compensation payers are free to adopt transformative value measures now. Organizations that progress rapidly to implement the value agenda will reap huge benefits. 

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 link analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org

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[1] Porter, M. Lee, T. Harvard Business Review—The Strategy That Will Fix Healthcare

https://hbr.org/2013/10/the-strategy-that-will-fix-health-care/ar/1

[2] Cosgrove, T. Value-based Health Care is Inevitable and That’s Good. Harvard Business Review. https://hbr.org/2013/09/value-based-health-care-is-inevitable-and-thats-good/#

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

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

[2] B. Kenealy. Business Insurance. http://www.businessinsurance.com/article/20150610/NEWS08/150619977?tags=|92|329|304