For decades, payers, employers, state governments, and health care providers have pursued the elusive goal of controlling spiraling medical costs in workers' compensation, trying numerous solutions to lower costs, eliminate the fragmentation that fosters inefficiency, and achieve faster return to work. Now, there is a growing belief that the focus on "cost containment" isn't enough.
The real goal should be better outcomes—and when these better medical outcomes are achieved, the money spent on these cases will achieve a superior return on investment. Rather than a focus on lower unit costs for services, the emphasis should be on achieving less time away from work, while lowering administrative and indemnity costs, which lowers overall claim costs.
Even with this growing realization that medical management was the true answer to the cost dilemma, most organizations were stymied by the challenge to identify and use health care providers who could produce better outcomes for the life of a claim. During a recent conference panel at the 2015 Workers' Compensation Educational Conference (WCEC) in Orlando, Fla., speakers identified the pressing need among workers' compensation professionals to shift their focus toward getting injured workers to the best doctors, as opposed to focusing primarily on discounts and network penetration.
What is needed are programs and clinical oversight wrapped around the ability to direct patients to the top doctors and health care professionals, managing access to the point-of-care further upstream and enabling better patient engagement. The technology now exists to measure claims outcomes by physician, to get injured workers to see these physicians quickly, and to power the systems to keep the care plan on track for a fast and safe recovery.
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The new paradigm
The new system rests on the ability to identify the best doctors through sophisticated technology that measures the outcomes through the life of the claim, tied to the treating physician. Called "physician scorecarding," these systems have been in use and evolving for more than a decade. They now have a body of data showing that when the best doctors are identified and utilized, outcomes are improved, there is less litigation, and overall costs are lower.
Analysis of proprietary data over a five-year period illustrates that physicians who have high scores in producing superior outcomes also reduce medical costs by an average of 20%. Previous studies have shown that treatment by these physicians also shortens the duration of the claim and reduces indemnity costs, further demonstrating that physician scorecarding not only benefits payers but patients as well.
At an event hosted by Harbor Health Systems, data from these programs showed 7.7% lower costs across all claims in the Harbor Medical Provider Network (MPN). Indemnity-related costs were also reduced, achieving the following results:
- 12.5% lower indemnity costs
- 11.2% fewer indemnity claims
- 12.5% fewer days off work
To further enhance performance and outcomes, these best-doctor networks are now being linked to Care Concierge programs that assist both adjusters and injured workers to access the doctors and to successfully navigate the claims management process through to recovery. These systems also monitor the process of the case to ensure that the treatment plan is always on track. The programs can also connect their physicians and the injured worker with other high-performing clinicians for tests and treatments that may be needed, moving the care plan forward quickly and efficiently.
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Three criteria of high-performing doctors
The words "high-performing" or "quality" doctor may be easy to say, but just what are the characteristics of a top doctor?
When determining whether a physician is "high-performing," or providing the best possible care to injured workers, there are three major criteria that should be evaluated.
1. Review and analyze clinical outcomes
- Review the physician's case mix/stratification compared to like specialties within the same jurisdiction. Drill down into tertiary specialties (tight groupings of similar practices based on what the physician is actually doing). For example, whether their primary certification is orthopedics or neurology, if the claims data shows a high volume of spine surgery procedure codes, that's the group to which they will be compared. Define inclusion in these groups by actual treatment codes in claims and bills.
- Look at statistical measures of claim and paid data. Review claim duration. Claims have a beginning, a middle treatment period, an observation period, and an ending. An inability to close claims can be tied to multiple stakeholders: the injured worker, the claims team, and the doctors. However, a doctor that has a high association with claims that don't close timely could be an indicator of a challenge with patient engagement. It's important to have a claim duration that's reasonable and to have that claim closed after appropriate treatment. Analyze the incurred total expense, as there is far more to the total cost of a claim than just the price of one or more procedures. TTD (Temporary Total Disability) days are equally as important as getting someone back to work, and increasing activities will shorten treatment and yield better results. Note the litigation rate of that physician to find outliers. Review the recidivism rate, that is, the reopening of the claim after it's closed.
Related: New Workers' Compensation coding system goes into effect Oct. 1
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2. Examine behavioral outcomes
- Review claims examiner satisfaction.
- Examine patient/injured worker satisfaction.
- Look at the quality of medical office interaction. Office staff can make or break a medical practice, and the attitude of the staff is significant when trying to determine high-performing physicians.
This evaluation is critically important because it relates to both the coordination of the claim among other team members, and the level of patient engagement in the recovery process. Top doctors have a superior capability to engage the patient, to develop that relationship so that the recovery is a partnership. Engaged injured workers are active participants in their recovery.
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3. Find out whether the physician is fulfilling regulatory requirements
- Verify that the physician meets time requirements for submission.
- Make sure the reports are complete, addressing all body parts injured.
- Confirm whether the physician addresses causation in the initial report and upon request of the claims examiner.
- Ensure that the physician documents physical findings upon examination to justify the work status.
Looking at these three areas more closely will help to determine whether physicians can truly be considered high-performing, which in turn determines whether they receive a one-star or five-star rating in scorecarding programs.
The ability to identify the best performing physicians in workers' compensation, to get injured workers to them at the onset of an injury and to manage the care plan to keep it moving forward and on track is a true breakthrough in improving the overall picture for workers' compensation outcomes—both clinical and financial. It is a major step forward in the ability to deliver medical management that will transform the workers' compensation system for all participants.
Linda Lane is president of Harbor Health Systems, a One Call Care Management company that is significantly changing workers' compensation by identifying the best performing physicians for better outcomes at lower overall costs.
Greg Moore, MPH, senior vice president of Innovation for One Call Care Management, supports innovation and success within Harbor Health Systems while bringing his relationships, creativity and experience to identify innovative strategies that drive improved outcomes for all One Call clients.
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