Webinar: Succeeding with an Unbundled Claims Management Approach
Unbundling workers’ compensation managed care services can make a lot of sense for some employers. But meeting the demands of a changing environment is a constant challenge whether you are — considering unbundling — have recently unbundled — or want to gauge the effectiveness of your unbundled program. Limited risk management resources, the complexities of data management and transparency, and increased medical costs are combining to push claims executives to improve their approach. Not doing so is to risk bad outcomes, not only for injured workers but for corporate bottom lines.
A diverse panel will offer employer, managed care, and claims executive perspectives on unbundled approaches, including:
- Considerations when unbundling managed care services
- An effective team approach, including the coordination of internal resources and the various vendors involved in unbundled claims management
- Best practices in data management, including addressing the state reporting burden
- Using performance measures to validate the effectiveness of an unbundled approach
Grading the Doctor
Efforts to improve the quality of medical care provided to injured workers are increasingly linked to rating doctor performance.
Yet measuring doctor performance is in its infancy while risk managers said they struggle to define what constitutes “quality” in medical care and to determine whether their injured employees receive it.
“That is one of the things we always struggle with,” said Bill Wainscott, manager of workers’ compensation and occupational health for International Paper in Memphis.
“We are sending employees to doctors and doing everything we can to control the costs, but it is hard to do things to control the quality. We have a lot of programs in place such as provider networks and negotiated medical fees, but it is very difficult to really ensure that the employees are getting the right care and that it is the right level of care and that they are seeing the right doctors within the medical community.”
While workers’ compensation observers commonly equate searching for medical quality with searching for the Holy Grail, the level of care workers receive has a real impact on employers and workers.
“If you don’t look at medical quality, it is going to drive up your costs and the employee is not going to get back to work as quickly,” Wainscott said. “In the long run, we are both going to be hurt, both the employee and International Paper.”
So some insurers, third party administrators, and network providers continue refining their efforts to analyze treatment outcomes and other data necessary to rate doctor performance despite limitations, such as difficulties evaluating physicians in some regions of the nation because of too little existing data on doctor experience when treating injured workers.
The practice is reducing costs and claims durations while increasing discussions between payers and doctors increasingly interested in how information about their claims outcomes might improve the care they deliver, experts said.
Doctors’ increased interest in knowing how worker’s compensation payers view their performance and the methods used to rank them follows from efforts to allow only doctors who exhibit certain performance rankings into “outcomes-based networks,” several experts said.
Limiting involvement in medical provider networks to only those doctors with certain scores evolved from the older practice of allowing any physician agreeing to a price-discount contract to participate in a preferred provider organization.
In one of the more recent evolutions of doctor “score carding,” some organizations are ranking individual doctors so payers can help steer injured workers, as much as state laws allow, to the higher scorers without having to build an outcomes-based network or consider the physician’s affiliation with an existing PPO or network.
Some payers are also linking doctor pay-for-performance strategies and the amount of utilization review conducted to a specific doctor’s ranking.
While ranking doctors is important in a drive to improve care quality for injured workers, just determining what factors might help create universal qualitative indices for assembling networks is challenging, said Bob Evans, national director of network solutions in Chicago for Rising Medical Solutions.
That is especially true when organizations lack enough data to make objective determinations about doctors, he said.
“We do a lot of things related to rating and ranking and making decisions based on qualitative factors,” Evans said. “But one of the challenges we have is very similar to what everybody else [in the industry faces]. What qualitative factor are you going to base a decision on today and do you have enough data?”
Data on doctors who either score very well or score very poorly is typically easiest to obtain, Evans said. The biggest challenge rests with obtaining enough observations on the vast majority of doctors ranking in the middle, he added.
International Paper’s Wainscott faces a similar challenge when trying to send employees to the best doctors in a community. Many doctors have treated too few workers’ compensation claimants to produce enough information for adequately understanding their performance, he said.
“It may be a good thing that you don’t have enough data because that means you are not having a lot of claims, but there are instances where we just don’t have a lot of data for a doctor,” he said.
“I have areas of the country where I don’t have grades for a doctor or maybe I only have one or two doctors graded and they may have middle of the road scores. It may not be bad to use them but I don’t know if they are the best in the community.”
Return to Work the Ultimate Measure
Measures applied to uncovering doctor performance include making inferences about the effectiveness of treatment they render, said Dr. David Deitz, vice president and national medical director for Liberty Mutual in Boston. That is accomplished, for example, by evaluating factors such as patient recovery time when one orthopedic surgeon performs a knee surgery in contrast to recovery time when another surgeon conducts the same operation.
“What we are trying to look at when we look at quality is what is the outcome of treatment and that can be difficult,” Deitz said. “But one of the great things about occupational medicine is you actually have a proxy for recovery and it is called return to work.”
So return-to-work durations are among many factors analyzed to determine care quality provided by specific doctors.
Only focusing on outcomes is inadequate, though, said Gregory Moore, president of Harbor Health Systems LLC in Irvine, Calif., which builds outcomes-based networks and benchmarks doctors in existing networks.
Outcomes can show a doctor is exceptionally good, for example, at performing shoulder surgeries, Moore said. But strictly focusing on outcomes may fail to reveal that not all the surgeries performed by that doctor were necessary.
Score carding a physician is a complicated process, he said, in part because it’s common for more than one doctor to treat a claimant. So Moore’s company evaluates medical bills in comparison to outcomes.
Companies ranking physicians said they also look at ease of patient access, attention to medical guidelines, reoperation rates, treatment costs, length of time from the first treatment to the last, and expenses before and after bill review is conducted, among other information.
Research shows that physician networks staffed with doctors exhibiting particular characteristics produce better outcomes, experts said.
For example, recent claims data research from the California Workers’ Compensation Institute shows that doctors participating in California medical provider networks, or MPNs, reduce costs by $590 per claim during the first 24 months of care in contrast to non-MPN physicians, said CWCI President Alex Swedlow.
Those outcomes are associated with the MPN physicians’ greater concordance with treatment guidelines that lower utilization, Swedlow added.
Older CWCI research showed that doctors with greater experience treating occupational injuries are associated with lower treatment costs, shorter return-to-work durations and a lower rate of litigated claims, he said.
Such data suggests that recruiting physicians possessing high levels of experience treating work injuries is a reasonable strategy for building a “high performance network,” Swedlow said.
Organizations that rank providers also said they see positive results.
Sedgwick Claims Management Services Inc. scores doctors nationwide, using a one star to five star ranking system. It found that the average incurred medical cost to treat an injured worker when a five-star doctor provides the first treatment is $3,643. In contrast, the average cost when a three-star doctor provides the first treatment is $6,340, rising to $12,342 when a one-star doctor provides the service.
Sedgwick has found differences in other substantial factors such as lower claims durations associated with higher ranking doctors, said Kimberly George, senior VP and senior healthcare advisor.
The fact that analysis reveals significant disparities in doctor performance and differences in the treatment utilization and costs they generate signifies that medical care quality is obtainable, said Patrick J. Walsh, VP and chief claims officer at Accident Fund Holdings Inc. in Lansing, Mich.
“There are docs out there who are trying to do the right thing and get people well,” he said. “We are seeing that in the data [among doctors that Accident Fund scores]. If that were not the case all these providers would be ranked on top of each other. But we are able to rank them and there is quite a spread between what we call ‘a high performing doctor’ and a ‘low performing physician.’ ”
While some doctors still detest performance grading, an increasing number are concerned about their scores and how to improve them, several experts said.
They are learning more about their effectiveness, Moore said.
Some doctors who believed they were providing exceptional care, for example, are finding in some instance that patients they thought had recovered, instead sought treatment elsewhere.
Moore is not alone in reporting that doctors are learning more about their practices.
When Liberty Mutual Group’s claims data revealed that a clinic treating injured workers dispensed excessive amounts of pain medication, the network clinic doubted the insurer’s information.
But following an internal inquiry, the clinic — whose doctors were otherwise considered good network provider partners by the insurer — learned there was indeed a problem requiring it to bolster its pharmacy controls.
“If you only know three or four good doctors in an area, you want to make sure you are getting to those. It’s not to say there are no other good doctors. It’s just that you have to go with information you have to get a positive outcome.” — Gregory Moore, president, Harbor Health Systems LLC
“Their original response was, ‘You guys got it wrong,’ ” Deitz said. “And we said, ‘OK, let’s talk about it.’ They wound up admitting that there were some things going on in their operation that they weren’t aware of.”
The back-and-forth between the insurer and the doctor group along with the physicians’ willingness to act on the insurer’s evaluation of their clinic operations followed from Liberty Mutual’s efforts to improve the quality of care delivered to injured workers by benchmarking medical provider performance.
In its bid to improve quality, Liberty Mutual invites doctors to respond to its evaluations. It’s a way of opening a dialogue, Deitz said.
Observers said doctor-rating practices will be further encouraged by the Patient Protection and Affordable Care Act and its push to increase medical care quality through accountable care organizations.
As score carding evolves, one of the next frontiers lies in implementing processes that help assure claims adjusters and others in contact with injured workers consistently use the information to help get patients to the higher scorers, Moore said.
Meanwhile, he advised taking advantage of available knowledge about care providers.
“In truth, what we need to focus on is maximizing the use of the best doctors,” Moore said.
“If you only know three or four good doctors in an area, you want to make sure you are getting to those. It’s not to say there are no other good doctors. It’s just that you have to go with information you have to get a positive outcome.”