Early MRI Could Mean More Expensive Claims
In a study of work-related lower back pain claims, patients who received an early MRI had medical costs $12,000 higher and were on disability about 120 days longer than those that didn’t have the test, on average.
“One out of every five people that has fairly benign lower back pain gets an early MRI that they really shouldn’t get,” said Dr. Glenn Pransky, director of the Center for Disability research. “They then have a much higher risk to go on to receive a lot of treatments that aren’t necessarily helpful.”
Most likely, physicians have not been well-educated in the proper application of evidence-based medicine and the judicious use of MRIs in assessing back pain.” — Dr. Rupali Das, executive medical director of California’s Division of Workers’ Compensation.
Evidence-based guidelines state that MRI should not be indicated for non-specific, non-radicular lower back pain. And even in instances where “red flag” conditions exist – like severe traumatic injury or possibility for cancer or infection – guidelines suggest a month of conservative treatment before revisiting the need for an MRI.
“This study came from earlier work we had done, where we surveyed providers, giving them case scenarios and asking what they would do as their initial management of acute back pain in a workers’ comp setting,” said Barbara Webster, lead author of the recent study from the Liberty Mutual Research Institute for Safety on the early use of MRI. “And we were struck. Despite what the guidelines said, many of them would order an MRI.”
“Most likely, physicians have not been well-educated in the proper application of evidence-based medicine and the judicious use of MRIs in assessing back pain,” said Dr. Rupali Das, the executive medical director of California’s Division of Workers’ Compensation. “Physicians may be unaware of false positives and lack of specificity with MRIs. It may be easier to order a test than to counsel a patient on proper exercise and behavior. Patients also may play a role in demanding tests and some physicians may find it easier to comply with the request than to explain why a test is not needed or may actually be harmful.”
Those tendencies mean workers’ comp payers end up taking on costs for unnecessary tests and subsequent treatments dealing with issues unrelated to the original claim. That means more time away from work and more expensive claims. Workers’ comp payers may be missing an opportunity to catch inappropriate tests through utilization review, which would help produce better outcomes and contain costs.
“Our studies suggest that requests for early imaging tests should go through utilization review,” Webster said. “It’s likely that if providers are following OEM and ACOEM guidelines, it won’t be certified within the first 30 days.
Das suggested that payers start with “a carrot approach” by providing education on the existing guidelines for treatment, including initial management, and the proper indications that may warrant an early MRI.
“With the involvement of a medical director, the usage of MRIs can be measured, and inappropriate usage assessed,” he said. “Outreach and appropriate intervention should be directed at providers with a pattern of ordering tests inappropriately.”
Fee-for service payment models may incentivize physicians to order more tests, but quality and outcome-based payment proposed by the Affordable Care Act should dampen that trend.
“Many organizations are now educating their members about the proper use of radiologic tests, including MRIs,” Das said. “Hopefully younger physicians will be better educated about evidence-based practices.
MRIs can reveal age-related abnormalities, like compressed and degenerated discs in the spine, that may have nothing to do with what’s causing the back pain, Webster and Pransky said.
“In one study, MRIs found significant abnormalities in 60 percent of people sampled,” Pransky said. “Human tendency is to point to the abnormality as the cause of the pain, and suggest surgery or injection to treat it. It can be hard to dissuade people from thinking that’s not the source of the problem.”
“The natural history of many conditions causing lower back pain is that half of them will resolve themselves without the need for further imaging or surgery,” Webster said.
Hospitals Are Not Getting Safer
Nearly 15 years ago, the Institute of Medicine report “To Err is Human” drew attention to the disturbing number of preventable deaths in hospitals.
According to recent testimony by a panel of patient safety leaders to the Senate Subcommittee on Primary Health and Aging, there has been little progress in addressing this issue in the 15 years since, despite all of the increased regulations. In fact, preventable medical errors in hospitals are now the third leading cause of death in the US, only after heart disease and cancer.
“The problem of patients dying or being harmed because of preventable medical errors in U.S. hospitals remains [a] grave consequence that is not getting enough attention,” according to the Senate subcommittee chairman.
There are five main types of preventable medical errors. The question is, who in our industry is watching out for these errors, and where does responsibility for oversight end and begin?
- Errors of omission: Provider fails to perform an obvious, necessary action, like prescribing a certain medication.
- Errors of commission: A mistaken action harms a patient, like surgery on the wrong body part.
- Errors of communication: Miscommunication or failed communication between providers, or between a provider(s) and patient, such as a failure to warn a patient about the risks of certain activities.
- Errors of context: Provider does not account for the unique constraints in a patient’s life, like not having reasonable access to follow-up care.
- Diagnostic errors: Harm to the patient resulting from delayed, wrong, ineffective, or no treatment.
A recent study by Patient Safety America estimated that the 98,000 preventable error deaths cited in the Institute of Medicine’s original 2000 report may have been severely understated, and the real number could be closer to 440,000 deaths annually.
That is roughly equivalent to 148 September 11th attacks every year.
In fact, preventable medical errors in hospitals are now the third leading cause of death in the US, only after heart disease and cancer.
This is only preventable deaths. It doesn’t include infections and sickness that did not result in death.
Even without human error, the potential for hospital-acquired infections is immense. There are thousands of patients coughing and touching furnishings and other items, which are then touched by relatives and staff. It is almost impossible to prevent the spread of disease and infection in this environment.
And this doesn’t even factor in issues of inappropriate treatment, over-treatment, over-medication, or unnecessary surgeries, which can result in a poor prognosis for individuals who may already be in fragile health.
I am not a big fan of politicizing an issue, but this transcends politics. Hospitals attract the sickest of the sick people. That is what they are there for, but we as an industry need to focus on reducing the potential for preventable deaths in hospitals.
We need to focus on directing people to healthier options — whether non-surgical alternatives, the best providers, or non-hospital based surgeries and treatment.
We may never know when our actions prevent a health complication, or even death, but any time we can lower a patient’s risk, everyone is better off.
Beware of Medical Hyper-Inflation!
Historically, medical inflation rates nationwide have been fairly consistent. However, data is now showing that medical inflation is not a “one size fits all” phenomenon, with hyperinflation spikes occurring in some locations…but not others.
This geographical conundrum means hyperinflation can occur as narrowly as two hospitals having dramatically different charges on the same street in Anytown, USA. So, uncovering these anomalies is akin to finding the proverbial needle in a haystack.
“In recent years, workers’ compensation saw claim frequency decline, while severity rates went up. This basically means that increased job safety has offset increased medical costs,” explained Jason Beans, CEO of Rising Medical Solutions, a national medical cost management firm. “So, whenever a client’s average cost-per-claim went up, it was almost always caused by catastrophic, outlier-type claims.”
But beginning in 2013 and extending into 2014, Beans said, things changed. “I’ve never seen anything like it in my 20-plus years in this industry.”
“Our analytics made it very clear that small pockets around the country are experiencing what could only be described as medical cost hyperinflation. The big spikes in some clients’ claim costs were driven by a broader rise in medical costs, rather than catastrophic claims or severity issues.”
– Jason Beans, CEO, Rising Medical Solutions
Data dive uncovers surprising findings
On a national level, most experts describe medical costs increasing at a moderate annual rate. But, as often is the case, sometimes a macro perspective glosses over a very different situation at a more micro level.
“Our analytics made it very clear that small pockets around the country are experiencing what could only be described as medical cost hyperinflation,” explained Beans. “The big spikes in some clients’ claim costs were driven by a broader rise in medical costs, rather than catastrophic claims or severity issues.”
This conclusion is supported by several key data patterns:
- Geographic dependency: While many payers operate at the national level, only relatively small, geographically clustered claims showed steep cost increases.
- Median cost per claim: The median cost per claim, not just the average, increased greatly within these geographic clusters.
- Hospital associated care: Some clusters saw a large increase in the rates and/or the number of services provided by hospital systems, including their broad array of affiliate locations.
- Provider rates: Other clusters saw the same hospital/non-hospital based treatment ratios as prior years, but there was a material rate increase for all provider types across the board.
- Utilization increases: Some clusters also experienced a larger number of services being performed per claim.
One of the most severe examples of hyperinflation came from a large Florida metropolitan area which experienced a combined 47 percent workers’ compensation healthcare inflation rate. Not only was there a dramatic increase in the charge per hospital bill, but utilization was also way up and there was a shift to more services being performed in a costlier hospital system setting.
“The growth of costs in this Florida market stood in stark contrast to neighboring areas where most of our clients’ claim costs were coming down or at least had flat-lined,” Beans said.
An Arizona metropolitan area, on the other hand, experienced a different root cause for their hyperinflation. Regardless of provider type, rates have significantly increased over the past year. For example, one hospital system showed dramatic increases in both charge master rates and utilization. “Even with aggressive discounting, the projected customer impact in 2014 will be an increase of $773,850 from this provider alone,” said Beans.
ACA: Unintended consequences?
So what is going on? According to Beans, a potential driver of these cost spikes could be unintended consequences of the Affordable Care Act (ACA).
First, the ACA may be a contributing factor in recent provider consolidation. While healthcare industry consolidation is not new, the ACA can prompt increased merger and acquisition efforts as hospitals seek to improve financials and healthcare delivery by forming Accountable Care Organizations (ACO). ACOs, the theory goes, can take better advantage of value-based fee arrangements in existing and new markets.
“As hospital systems grow by acquisition, more patients are being brought under hospital pricing structures – which are significantly more expensive than similar services at smaller facilities such as independent ambulatory surgery centers and doctors’ offices,” Beans said.
Unfortunately, there is little evidence that post-consolidation healthcare systems have become more efficient, only more expensive. For example, a recent PwC study reported that hospital IT infrastructure consolidation alone is projected to add 2 percent to hospital costs in 2015.
Another potential ACA consequence is group health insurers may have less incentive to keep medical costs down. An ACA provision requires that 85% of premium in the large group market must be spent on medical care and provider incentive programs, leaving 15% of premium to be allocated towards administration, sales and subsequent profits. “Fifteen percent of $5000 in medical charges is a lot less than 15% of $10,000,” said Beans. “This really limits a group health carrier’s incentive to lower medical costs.”
How do increased group health rates relate to workers’ comp? In some markets, a group health carrier may use its group health rates for their work comp network so any rate increase impacts both business types.
In the end, medical inflation is inconsistent at best, with varying levels driven by differing factors in different locations – a true “needle in the haystack” challenge.
What to do?
Managing these emerging cost threats, whether you have the capabilities internally or utilize a partner, means having the tools to pinpoint hyperinflation and make adjustments. Beans said potential solutions for payers include:
- Using data analytics: Data availability is at an all-time high. Utilizing analytical tools to spot problem areas is critical for executing cost saving strategies quickly.
- Moving services out of hospital systems: Programs that direct care away from the hospital setting can substantially reduce costs. For example, Rising’s surgical care program utilizes ambulatory service centers to provide predictable, bundled case rates to payers.
- Negotiating with providers: Working directly with providers to negotiate bill reductions and prompt payment arrangements is effective in some markets.
- Underwriting with a micro-focus: For carriers, it is vital that underwriters identify where these pockets of hyperinflation are so they can adjust rates to keep pace with inflation.
“This trend needs to be closely watched,” Beans said. “In the meantime, we will continue to use data to help payers of medical services be smarter shoppers.”