Evidence-Based Medicine Critical Component to Improving Quality Care

In the world of workers' compensation, the goal has always been to get the injured worker back on the job as quickly and as cost-effectively as possible. Making sure the injured employee receives quality healthcare services can be a significant contributing factor in helping you achieve that end result. However, how can employers and carriers truly know that their injured workers are receiving the best care possible?

Workers' Compensation Report recently sat down with Dan Moore, chief operating officer at Forté, a medical managed care firm that partners with insurance carriers, large self-insured employers, and third-party administrators to provide services for workers' comp and liability claims. Moore discussed the issues of quality, the importance of evidence-based medicine, and what employers should be getting from their TPAs and managed care organizations.

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Dan Moore: Quality is a slippery term. What it boils down to for us -- our version of quality -- is getting the patient into the appropriate level of care, in the appropriate environment, and at the appropriate level of service. Measuring this can be a challenge. The way that we try to zero in on quality is through evidence-based medicine.

WCR: What role does evidence-based medicine play in improving or quantifying quality?

Moore: Evidence-based medicine is a term that has been thrown out a lot in recent years. It is the assimilation of scientific data that is categorized to provide a resource for providers on how to best treat the patient and to help them understand the most relevant and up-to-date procedures to treat a patient. Doctors will admit that they are doing what they know, but the pace of technology and science has been progressing at such a rapid pace, and many of them have been out of medical school for a long time.

Evidence-based medicine really started to come to the forefront in the 1970s, but what it translates to today in workers' comp is that we now have guidelines. It can provide a clear flow chart -- these are the conditions and this is what we should do. It is step-by-step instructions from a therapeutic standpoint.

In terms of quantifying quality, it certainly helps. There have been numerous studies out there that have shown, with a broad consensus, that people are not getting the right type of care. Evidence-based medicine is part of our toolbox. It is the information we can give to customers to enable them to talk to doctors so that they can say, "I'm looking at this data, why can't we being doing this or that?''

The complexity of these guidelines is off the charts. We are making significant progress in getting doctors to decipher this stuff, but it is still a challenge.

WCR: What questions should employers ask of their third-party administrators and managed care organizations?

Moore: In selecting a managed care provider, employers need to be looking at what kinds of tools the company brings to the process. Are they being offered a toolbox of products and services, knowledge and content-based materials centered on evidence-based medicine? Customers should be armed with the information they need to go through the process of talking with doctors, and getting injured workers healed and back to the job.

The number one thing that helps us determine whether we are doing a good job for our customers is whether they have a strong understanding of what the treatment plan will look like, and they know what to expect. That is a big part of our job. If you don't have a lot of insight into the treatment plan and the diagnostic step-by-step process, then you need to find a way to get it.

WCR: How do issues such as regulatory and jurisdictional limitations affect the ability to develop quality programs?

Moore: Well, we are certainly seeing state regulators waking up to the idea of evidence-based medicine. We've seen it in recent years in California and Texas with the implementation of the American College of Occupational and Environmental Medicine guidelines.

Regulators seem to be tuning in to the idea that it isn't simply the cost of the eggs, it is the number of eggs that I'm buying. Historically, cost-containment was based on bill review. But what evidence-based medicine has allowed us to do is identify services that should never have been billed in the first place, such as excessive physical therapy, unnecessary surgeries, or chiropractic treatments.

The California Workers' Compensation Institute evaluated more than 170,000 lost time claims and found a large number of surgeries and radiology services that didn't meet the proper criteria, as well as excessive physical therapy and chiropractic care. Unless we are talking about a catastrophic injury and the individual is trying to retrain the body, it is unlikely that someone will need more than six weeks of therapy. We are seeing that regulators are waking up to this and starting to get serious about taking on doctors. They are saying, "We've given you a chance to police yourselves, and it hasn't gone so well.''

January 12, 2009

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