Physician Networks

MPNs Not All They’re Cracked Up to Be

Despite early promise, California's provider networks haven't sustained their power to lower workers' comp medical costs.
By: | July 13, 2015 • 3 min read
ACA RIMS

California’s medical provider networks have resulted in increased participation in networks, lower rates of attorney involvement, and higher rates of claim closure. But a new study also shows MPNs have not sustained their ability to significantly lower medical costs in the workers’ comp system.

Advertisement




While not an indictment of MPNs, the California Workers’ Compensation Institute said their findings indicated several shortcomings, including a first-time showing that average medical payments on MPN claims with attorney involvement cost 2 percent more than non-MPN claims with attorneys. The report is based on data from more than 1.8 million claims between accident year 2000 through AY 2011.

“The bottom line is that physician networks now manage most California workers’ compensation treatment, but in recent years the cost savings historically associated with network medical management have declined,” the report said.  After adjusting for claimant characteristics, injury type, and administrative aspects, “average savings associated with network vs. non-network medical management on lost-time claims declined from 16 percent in the preferred provider organization era to 3 percent after MPNs became fully operational.”

MPNs were introduced in California in 2005 and “were intended to ensure appropriate levels of treatment, improve efficiency, better coordinate treatment, and reduce the cost of care,” the authors wrote. They allow workers’ comp payers to use networks of medical providers for injured workers and, unlike prior regulations, allow employers to retain medical control for the life of a claim. Previous research has shown medical provider networks were typically associated with lower costs and facilitated return to work.

The researchers measured the percentage of all claims and indemnity claims in which the primary treating physician involved was a network provider. They also tracked average medical payments for network vs. non-network claims and reviewed the changing nature and characteristics of claims managed inside and outside of a network. Their findings included:

  • Network utilization overall increased from 55.4 percent in the PPO period to 79.5 percent in the full MPN period. For indemnity claims, it increased from 44.2 percent to 77.2 percent.
  • Network claims had higher claim closure rates. However, the rate for network claims at 12 months post-injury decreased from 72.7 percent in the PPO period to 61.2 percent in the full MPN period.
  • The percentage of network indemnity claims with at least one opioid prescription increased from 39.1 percent in the PPO period to 54.5 percent in the full MPN period.
  • Average risk-adjusted medical payments on network claims with opioids were 16 percent less for network claims than for non-network claims in the PPO period, but were 20 percent less in the full MPN period.
  • Average risk-adjusted medical payments on indemnity claims at 24 months post-injury were 16 percent less for network claims than for non-network claims in the PPO era, but were only 3 percent less in the full MPN period.

The authors said there was “considerable variation” among individual networks with “just as many networks generating lower average costs per claim as higher average costs per claim when their results were compared to those of claims managed outside of a network. This suggests not only variations among network physician rosters, but in the medical management and reimbursement systems used by the various networks, as well as in the populations and regions served.”

Advertisement




There were “significant” geographic variations, according to the report. Networks generated significant savings in several areas. However, the savings associated with network management in Los Angeles County “completely evaporated in recent years, with the spread between the average medical payments for network and non-network claims declining from 12 percent in the PPO era to no difference in the full MPN period.”

With provider networks evolving in the California workers’ comp system, “clearly, the clinical and regulatory complexity of providing treatment for occupational injuries requires greater network vigilance than ever before,” the report said.

Nancy Grover is the president of NMG Consulting and the Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at [email protected]
Share this article:

Column: Workers' Comp

Integration Ramps Up

By: | May 6, 2015 • 2 min read
Roberto Ceniceros is senior editor at Risk & Insurance® and chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at [email protected] Read more of his columns and features.

Employer interest in grouping the management of workers’ compensation, nonoccupational disability and employee absence is spreading. The Affordable Care Act, amendments to the Americans with Disabilities Act, employee leave mandates and employer cost-reduction measures are all factors driving the trend.

Some larger employers with more ample risk management resources realized years ago the value of viewing employee health and wellness, disability management and claims administration through one lens.

These trendsetters understood that they faced productivity losses and increased health care costs when employees are ill or absent, regardless of whether the cause is a work-related injury, a nonoccupational disability or the need to care for family members.

They were also quicker to garner synergies by collaboratively administering some programs traditionally handled by human resources or risk management departments.

Now we’re seeing brokers that traditionally provided property/casualty services competing with benefits service consultants to advise clients looking to improve employee health and wellness.

But now a trend to comprehensively evaluate the management of short- and long-term disability offerings, workers’ comp, Family and Medical Leave Act, and ADA compliance is spreading among middle-market employers as well.

They are growing increasingly interested in managing employee absences and medical costs — no matter if the cause is rooted in workers’ comp claims, nonoccupational disabilities, or leave laws like the FMLA.

Recognizing the trend, brokers, third-party administrators and insurers are now offering products and services to middle market employers that want to link management of these areas.

Advertisement




Now we’re seeing brokers that traditionally provided property/casualty services competing with benefits service consultants to advise clients looking to improve employee health and wellness.

As those employers move forward to further health and wellness goals they are asking how they might incorporate their workers’ comp program and claims management strategies.

Overall, though, many employers still manage occupational and nonoccupational disabilities in silos.

Thus, they miss opportunities to identify employees at risk for future lost work time.

It’s common for some claimants to cross over, utilizing both occupational and nonoccupational disability systems, according to a February 2015 report from the Integrated Benefits Institute.

IBI President Thomas Parry said he sees more employers now sharing information across the silos, rather than creating a single organizational unit to manage everything.

Broad-based and well-publicized federal regulatory change is spurring the practice of shared management or shared information.

The Affordable Care Act is designed to promote opportunities to gain from wellness and prevention initiatives that impact injury and illness, whether the cause is occupational or not.

Similarly, increased ADA, FMLA and other leave and accommodation law mandates cut across both areas.

And during the recession, many employers cut their risk or disability staffs and now need practices for efficiently managing claims using less human resources.

Those that underwrite their risks and consult on them have taken notice.

 

Share this article:

Sponsored Content by IPS

Managing Chronic Pain Requires a Holistic Strategy

To manage chronic pain and get the best possible outcomes for the payer and the injured worker, employ a holistic, start-to-finish process.
By: | August 3, 2015 • 5 min read
IPS_BrandedContent

Chronic, intractable pain within workers’ compensation is a serious problem.

The National Center for Biotechnology Information, part of the National Institutes of Health, reports that when chronic pain occurs in the context of workers’ comp, greater clinical complexity is almost sure to follow.

At the same time, Workers’ Compensation Research Institute (WCRI) studies show that 75 percent of injured workers get opioids, but don’t get opioid management services. The result is an epidemic of debilitating addiction within the workers’ compensation landscape.

As CEO and founder of Integrated Prescription Solutions Inc. (IPS), Greg Todd understands how pain is a serious challenge for workers’ compensation-related medical care. Todd sees a related, and alarming, trend as well – the incidence rate for injured workers seeking permanent or partial disability because of chronic pain continues to rise.

Challenges aside, managing chronic pain so both the payer and the injured worker can get the best possible outcomes is doable, Todd said, but it requires a holistic, start-to-finish process.

Todd explained that there are several critical components to managing chronic pain, involving both prospective and retrospective solutions.

 

Prospective View: Fast, Early Action

IPS_BrandedContent“Having the wrong treatment protocol on day one can contribute significantly to bad outcomes with injured workers,” Todd said. “Referred to as outliers, many of these ’red flag’ cases never return to work.”

Best practice care begins with the use of evidence-based UR recommendations such as ODG. Using a proven pharmacological safety and monitoring opioid management program is a top priority, but needs to be combined with an evidence-based medical treatment and rehabilitative process-focused plan. That means coordinating every aspect of care, including programs such as quality network diagnostics, in-network physical therapy, appropriate durable medical equipment (DME) and in more severe cases work hardening, which uses work (real or simulated) as a treatment modality.

Todd emphasized working closely with the primary treating physician, getting the doctor on board as soon as possible with plans for proven programs such as opioid Safety and Monitoring, EB PT facilities, patient progress monitoring and return-to-work or modified work duty recommendations.

“It comes down to doing the right thing for the right reasons for the right injury at the right time. To manage chronic pain successfully – mitigating disability and maximizing return-to-work – you have to offer a comprehensive approach.”
— Greg Todd, CEO and founder, Integrated Prescription Solutions Inc. (IPS)

 

Alternative Pain Management Strategies

IPS_BrandedContentUnfortunately, pain management today is practically an automatic move to a narcotic approach, versus a non-invasive, non-narcotic option. To manage that scenario, IPS’ pain management is in line with ODG as the most effective, polymodal approach to treatment. That includes N-drug formularies, adherence to therapy regiment guidelines and inclusive of appropriate alternative physical modalities (electrotherapy, hot/cold therapy, massage, exercise and acupuncture) that may help the claimant mitigate the pain while maximizing their ongoing overall recovery plan.

IPS encourages physicians to consider the least narcotic and non-invasive approach to treatment first and then work up the ladder in strength – versus the other way around.

“You can’t expect that you can give someone Percocet or Oxycontin for two months and then tell them to try Tramadol with NSAIDS or a TENS unit to see which one worked better; it makes no sense,” Todd explained.

He added that in many cases, using a “bottom up” treatment strategy alone can help injured workers return to work in accordance with best practice guidelines. They won’t need to be weaned off a long-acting opioid, which many times they’re prohibited to use while on the job anyway.

 

Chronic Pain: An Elusive Condition

IPS_BrandedContentSoft tissue injuries – whether a tear, sprain or strain – end up with some level of chronic pain. Often, it turns out that it’s due to a vascular component to the pain – not the original cause of the pain resulting from the injury. For example, it can be due to collagen (scar tissue) build up and improper blood flow in the area, particularly in post-surgical cases.

“Pain exists even though the surgery was successful,” Todd said.

The challenge here is simply managing the pain while helping the claimant get back to work. Sometimes the systemic effect of oral opioid-based drugs prohibits the person from going to work by its highly addictive nature. In a 2014 report, “A Nation in Pain,” St. Louis-based Express Scripts found that nearly half of those who took opioid medications for more than a month in their first year of treatment then refilled their prescriptions for three years or longer. Many studies confirm that chronic opioid use has led to declining functionality with reduced ability to recover.

This can be challenging if certain pain killers are being used to manage the pain but are prohibitive in performing work duties. This is where topical compound prescriptions – controversial due to high cost and a lack of control – may be used. IPS works with a reputable, highly cost-effective network of compound prescription providers, with costs about 30-50 percent less than the traditional compound prescription

In particular compounded Non-Systemic Transdermal (NST) pain creams are proving to be an effective treatment for chronic pain syndromes. There is much that is poorly understood about this treatment modality with the science and outcomes now emerging.

 

Retrospective Strategies: Staying on Top of the Claim

IPS_BrandedContentIPS’ retrospective approach includes components such as periodic letters of medical necessity sent to the physician, peer-to-peer and pharmacological reviews when necessary, toxicology monitoring and reporting, and even addiction rehab programs specifically tailored toward injured workers.

Todd said that the most effective WC pharmacy benefit manager (PBM) provides much more than just drug benefits, but rather combines pharmacy benefits with a comprehensive ancillary suite of services in a single portal assisting all medical care from onset of injury to RTW. IPS puts the tools at the adjustor fingertips and automates initial recommendations as soon as the claim in entered into its system through dashboard alerts. Claimant scheduling and progress reporting is made available to clients 24/7/365.

“It comes down to doing the right thing for the right reasons for the right injury at the right time,” Todd said, “To manage chronic pain successfully – mitigating disability and maximizing return-to-work – you have to offer a comprehensive approach,” he said.

SponsoredContent

BrandStudioLogo

This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with IPS. The editorial staff of Risk & Insurance had no role in its preparation.




Integrated Prescription Solutions (IPS) is a Pharmacy Benefit Management (PBM) and Ancillary Services partner to W/C and Auto (PIP) Insurance carriers, Self Insured Employers, and Third Party Administrators who specialize in Workers Compensation benefits management.
Share this article: