Consider the expert physician model for better comp outcomes

There's been a sea of change in the workers' comp system. Instead of focusing on discount medical providers, many experts are looking at improved outcomes -- both to help the injured worker recover faster and to save money for the employer.

One of the latest methods is called the expert physician model. It's a complete 180 degree turn from the traditional model for case management in workers' comp.

"The traditional model has always been the independent medical examiner model," said Mark Walls, assistant vice president of claims for St. Louis-based Safety National. "You get an IME to confirm or dispute what the treating physician is recommending, and if there is a dispute, you more often than not end up in litigation."

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The expert physician model, on the other hand, focuses on getting the correct medical treatment for the injured worker. Highly respected physicians are called in to consult on a case. "What really makes it stand out is the physicians involved in doing these case reviews are some of the leading experts in the field nationally," Walls said.

Walls' belief and passion for the model led him to develop the session, The Expert Physician Model: How to Improve Medical Outcomes While Lowering Costs. To explain the difference between the traditional and expert physician models, he gave a hypothetical example of an employee with an injured back who was recommended for surgery by the treating physician.

"Traditionally, Dr. X recommends surgery, so you send the injured worker off to see the company physician who says, 'no, they don't need it.' Then you litigate and the injured worker doesn't get better," Walls said. "With the expert physician model, you send the report off to an expert physician, who says 'yes' or 'no' and why the patient should or should not have it." The expert physician is then available to discuss the case with the treating physician.

The expert physicians are selected from one of a small but growing number of organizations that harness some of the most well-known, highly respected physicians in the world. Two such organizations are Paradigm Management Services out of New Jersey, and the Boston-based Best Doctors, both of which will be represented on the panel.

Cost savings/issues. In addition to doing what is best for the injured worker, advocates say the expert physician model is good for the bottom line. "It's all about getting the best treatment for injured workers because, frankly, that's how you save money on costs," Walls said. "You avoid unnecessary treatment, treatment that could potentially be harmful to the worker. That's kind of the whole goal of it."

While it's starting to gain traction, the expert physician model has not spread quickly yet. One reason is the waiting time to actually see savings.

"That's the biggest objection to it, it tends to have higher upfront costs than the more traditional model," Walls said. "But when you step back and look at it, at the end of the day, you can achieve a very significant cost savings by avoiding unnecessary conflict, unnecessary treatment, unnecessary surgery."

As Walls explained, the traditional model would typically involve added costs -- for an IME, for benefits while the dispute continues, and, if the employer loses the case, for the surgery. "The goal," he said, "is to expedite things."

Because of the additional upfront costs, the model is best used in specific cases. During the session, the panelists will explain which cases lend themselves to this, more than the traditional model.

"The model is designed for higher risk cases, things like back surgeries and chronic pain," Walls said. "The types of cases that turn into the large cost drivers in workers' comp."

During the session, the speakers will explain how and when to apply the expert physician model to drive improved outcomes and significantly reduce a company's medical costs. They will also offer attendees tips to recognize the medical red flags that indicate an expert physician should be involved.

"It's just really gaining traction in the workers' comp space. That's really why I wanted to do a session on it. I think it's something that needs to be recognized," Walls said. "More and more you're hearing conversations about outcomes. That's what this is all about. This is an outcome driven model."

The 20th annual National Workers' Compensation and Disability Conference® & Expo takes place at the Las Vegas Convention Center, Nov. 9-11. The conference, produced by LRP Publications, includes three keynote presentations and more than 25 breakout sessions. For complete information and to register, visit www.wcconference.com.

Read more at the WorkersComp Forum homepage.

October 17, 2011

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