‘Drive-By Doctoring’ a Reason for Value-Based Purchasing
When asked about problems with the U.S. health care system, I often refer to a New York Times article called “After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know.“
The article details a patient who received a $117,000 bill from an assistant surgeon he was unaware would be aiding the surgeon. The surgeon he chose was in-network; the assistant was out-of-network and came in while the patient was under anesthesia.
In what other industry, other than U.S. health care, can you receive a service while unconscious, are given no opportunity to learn of (much less agree to) the service or price, and afterwards there is a valid expectation of owing the bill? I cannot think of one.
The Hidden Costs in Fee-for-Service
Two typical tricks outlined in this article were:
Drive-By Doctoring: It’s very common to have an additional doctor or specialist “pop by” during a treatment. This consultation and/or surgical assist may or may not be clinically supported. In group health, the article illustrates the devastating financial impact such unexpected charges may have on a patient. In workers’ comp, it demonstrates how critical it is to carefully analyze medical charges. While most payers and service providers will certainly notice a $117,000 charge, there can and will be many smaller charges that meet the “drive-by” criteria on a bill.
Out-of-Network Subcontractors: As we’re well aware, many providers (e.g. anesthesiologists, assistant surgeons) working out of a hospital may not, in fact, be hospital employees. It can be difficult to ascertain if out-of-network providers exist at network facilities, and to predict if an episode-of-care might result in subcontractor services. It is imperative that we find alternate ways to control these unpredictable costs.
A Value-Based Track to Transparency
These practices discussed in the article are purposeful, dishonest and costly, but they need not exist. A transition from fee-for-service models to value-based purchasing in group health, and even slowly in workers’ comp, allows payers to more easily explore pre-negotiated, all-inclusive rate alternatives. These arrangements have many advantages, not the least of which is the elimination of “drive-by-doctoring” or other hidden fees. When everyone agrees to a fair, upfront price, the opportunity and incentive to “game the system” is removed.
The benefits of cost predictability in workers’ comp are readily apparent, but the outcomes and care coordination aspects of value-based purchasing make it equally compelling. These arrangements allow payers to work with providers who meet certain performance parameters, and are further incented to ensure positive outcomes in order to keep costs commensurate with agreed-upon rates. Bundled rates also promote effective coordination amongst multiple providers who are handling varied aspects of treatment and sharing in a single payment.
It’s encouraging to see the gradual shift towards value-based purchasing in workers’ comp. And while this evolution will take time, the momentum towards a model where we do not simply reward quantity of services, but focus on a more holistic approach to patient care and healthcare purchasing is something that workers’ comp is more than capable of.
When Yelp Reviews Are Better Than Hospital Rating Systems
There is widespread industry agreement that moving towards reimbursing quality versus quantity of care is an important means for controlling medical costs. But how do we define “quality?” And, how do we quantify “quality”?
A recent Health Affairs study illustrates the difficulty of those questions.
The study reviewed four popular hospital rating services (Consumer Reports, Leapfrog, Healthgrades, U.S. News & World Report), and the measures they used were so divergent that their rankings became strikingly different:
- Not one hospital received high marks from all services.
- Only 10 percent of the hospitals rated highly by one service also received top marks from another.
- Twenty-seven hospitals were simultaneously rated among the nation’s best and worst by different services.
We deal with this frequently in our networks. We’ll have one client “absolutely” refuse to work with a provider, while another “absolutely” demands that same provider in their network.
Why such amazing disparity? It’s apparent that both hospital rating services and our clients utilize different factors to measure quality, and weigh those factors differently.
One scoring system may value cost per episode, while another values cost per diem. Another system might reward great valet parking, while another focuses on infection rates. Even slight variances can massively impact ratings. At this point, a Yelp review is likely just as good … or better.
So how do we get to meaningful provider ratings? It’s clearly a pervasive problem. In Rising’s 2014 Workers’ Compensation Benchmarking Study, medical management ranked as the top core competency impacting claim outcomes, yet only 29 percent of respondents rate their medical providers. As demonstrated by the Health Affairs study, it’s really hard to delineate the best from the worst, and trying to make those determinations can cause organizational paralysis.
So, I recommend starting simple. First evaluate what outcomes are most important. Do you value customer experience, clinical, or financial outcomes and to what degree? Do you weigh factors differently by service type (e.g., MRIs weigh convenience highly; surgeries weigh clinical outcomes highly)? If your measurements don’t correlate with your goals, your process won’t produce valuable results.
Even slight variances can massively impact ratings. At this point, a Yelp review is likely just as good … or better.
After determining your most important factors, then your second step is to carve providers from the bottom. This avoids the inertia that can come from trying to rate “top” providers too soon. It’s much easier to eliminate the outlier providers that cause the majority of bad outcomes to instantly improve your program.
Only after these steps would I recommend trying to establish the “best” providers. The “best” often deal with the most difficult cases, with the longest recovery periods or possibly the “worst outcomes.” It’s easy to see how a gifted surgeon might suffer under many quality rating systems. On a positive note, the transition to ICD-10 will allow provider quality comparisons at a deeper level of specificity never possible with ICD-9. In other words, we’ll actually be able to compare apples to apples over time.
With this three-step iterative approach, you can create and refine measurements that bring real, long-term value to your organization…making your system better than Yelp.
Workers’ Comp: Like a Nasty Divorce
I have followed the ProPublica/NPR article series on “The Demolition of Workers’ Comp,” and the subsequent reactions with interest. From the implication that the system is being decimated at the expense of American workers, to various points of disagreement from industry parties, I have found a lot to consider.
ProPublica ignited a debate that is still alive, and one that I felt it prudent to give considerable thought to before weighing in.
One major realization I’ve come to is that workers’ comp cases can be a lot like a nasty divorce.
In the aftermath, there are two households to support and both sides believe the other is “screwing” them. One spouse is certain they are “right” and the other is clearly “wrong.” But the truth, as it so often does, lies in shades of gray.
I think this is where we find ourselves in the ProPublica debate.
In workers’ comp, employers often have to cover massive costs, typically for a person who is no longer working or producing. The injured worker does not have the same earning power or quality of life.
Nothing the insurer can do will take away the fact that someone has lost a limb or is a quadriplegic. The story is a sad one, no matter what the outcome.
If we can help 10 injured workers have a better life, but cost thousands of U.S. jobs, have we done a good or bad thing for society?
To be frank, when I began reading the ProPublica report, my initial reaction was that it likely amounted to sensationalism masquerading as journalism. There are some well-founded points, though we do everyone a disservice — injured workers, employers, and insurers alike — if we do not look past the anecdotes to the tough questions.
As in a nasty divorce, it is tempting to point fingers and place blame. But if we want to truly understand the realities of workers’ comp today, we must resist the urge to oversimplify.
If you’ve been following all of the punches and counter-punches, then you know significant attention has been given to ProPublica’s use or misuse of statistics. So instead I will touch on some of the other issues raised but in a much broader context.
The Costs of Competition
Workers’ comp does not function in a vacuum, it operates in a national and global free market system. The cost of labor is a major factor in this system and determines where companies hire and expand.
In a global economy, every state and country compete to see if the job can be done better, faster, cheaper. Additionally, labor markets are increasingly competing with robotics and automation.
That means every action has a reaction, and that includes consequences for every increase in workers’ compensation costs and benefits.
If we can help 10 injured workers have a better life, but cost thousands of U.S. jobs, have we done a good or bad thing for society? We have to consider the larger price we may pay for the decisions we make today.
Consider, too, that if employers and insurers cease to turn a profit, they cease to exist.
The ProPublica article contends that worker’s comp reforms are being driven by employers seeking to increase profits. Any dubious math aside, it is important to understand that in insurance, some measure of profitability has more to do with market forces than with work comp laws. Massive amounts of capital are needed to underwrite insurance, and the majority of that capital rests with reinsurers.
Reinsurers invest wherever the risk is lowest and the returns are highest. Higher risk/lower return investments (such as workers’ compensation in U.S. states) will see less capital, subsequently driving prices up, while low risk/high return markets will see a flood of capital that drives prices down.
Overall, insurance profitability must match the market’s profitability or we will have no insurance. What then?
Don’t Oversimplify … or Overcomplicate … Comp
We face tough decisions with no perfect answers in workers’ comp. For example, when a carrier underwrites workers’ compensation, their liability is unknown. Cases from the 1950’s are still open.
There is no way to predict medical improvements. A prosthesis might have been all that was available when a carrier wrote a policy fifty years ago. Now they are expected to cover a robotic limb that can cost hundreds of thousands of dollars. Is that fair? It’s not a simple issue.
Overall, insurance profitability must match the market’s profitability or we will have no insurance. What then?
We as an industry can also complicate matters by tripping over dollars to save pennies. This is devastating to workers and, over time, the payers’ bottom line.
The best payers I have seen jump to take care of injured employees. When you do everything possible to help workers get to pre-injury status or maximum improvement, it’s pretty easy to identify the frauds.
Really, there are two choices in claims management. Distrust everyone until they prove they are legitimate, or assume they are legitimate until they prove otherwise — the latter produces better results.
Despite ProPublica’s implications to the contrary, the vast majority of people I know in workers’ comp are well-intentioned, want the best for injured workers, and want a system that supports them. But we face challenges, and how we address these difficult issues will have far-reaching, even global, ripple effects for employees, employment rates, employers and carriers alike.
We have to approach the tough questions — and answers — we face with the understanding that things are never simply black or white, and reaching solutions often lies in the shades of gray.
Kind of like a good marriage.