By CYRIL TUOHY, managing editor of Risk & Insurance®
The way Donald M. Duford, president and chief operating officer of One Call Medical Inc., a PPO in advanced radiology and neurodiagnostic services sees it, workers' comp claims adjusters need help.
Adjusters need to call on experts to perform and interpret an MRI or electromyography (EMG) test, for example, to tell them exactly what is wrong with an injured worker. Is it a back injury? Is the injury hiding something else? Does this MRI need further review by a specialized radiologist who can help the adjuster? Or is the possibility of a disability even in question?
Niggling questions, perhaps, but in the workers' comp world, they are vital, because the cost of an open claim or, worse, a misdiagnosed injury can end up costing a carrier hundreds of thousands of dollars.
An MRI or CT scan can provide valuable diagnostic information but only if you have qualified radiologists reading the image. So, the question for Duford has been how to identify the quality providers who consistently perform good diagnostic scans and provide accurate test interpretations.
The answer is to create what Duford calls "centers of excellence," which group together the best radiologists or the best neurodiagnosticians together in separate networks to which adjusters or workers' comp payers have access.
Creating centers of excellence isn't Duford's idea alone, of course. His clients--medical directors and managed-care providers--are clamoring for it, and in other industries, such centers of excellence have existed for years.
"In the ideal world, they (adjusters) would know who the good doctors are and who the good treaters are," Duford said.
In such a world, there would be less "management," by which he means less paper shuffling, less scrounging around separate databases for good radiologists and wading through fewer layers of people to get to the right person.
No one would argue with that. But the real world is never ideal, particularly in workers' comp, and there are very specific reasons why it's been so difficult to get the treatment plan right the first time and thus improve the outcome of a workers' comp claim.
Part of the problem is that there is no central database to which workers' comp claims adjusters can go to find the top providers, said Duford.
"There's a data collection challenge because data is fragmented, so there's a challenge in terms of outcomes about what's good and what's bad," he said. "We do 400,000 tests a year so we have a big database, but the average payer has one-tenth of that," said Duford.
There's another reason why adjusters are having trouble getting to the best experts to help them read a scan. It's because workers' comp payers are focusing on unit costs instead of quality, Duford said.
"Payers have a very limited view of physician practice patterns, and the workers' comp claim is such a small part of the physician's practice that it's of limited value," Duford said.
Workers' comp in total may be 15 percent or less of a given doctor's practice, and even the largest comp payers would be a fraction of that so they don't have nearly the amount of data they need to be able to tell whether one doctor's office is better at treating workers' comp injuries than another.
"Even the big group-health payers have a challenge in finding outcomes at the doctor level because they have 6 percent or 7 percent of the doctor's practice," he said.
As a result of this fractured view of physician practice patterns, payers may end up using doctors who perform unnecessary tests and may either overtreat or undertreat the patient. Due to less-than-optimal physician referrals, adjusters may end up authorizing medical treatment without reliable diagnostic information.
November 30, 2009
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