The company just received a patent for its invention.
"It's simply a technology that leverages our historical data to help adjusters and nurses make real-time recommendations for the best possible care for injured workers," said Patrick J. Walsh, vice president and chief claims officer, corporate claims, Accident Fund Holdings Inc. "At the end of the day, it is about getting injured workers to physicians that we have a history with and who have the most experience treating workplace injuries."
What makes the Accident Fund system different is the depth of information available, Walsh explained. It replaces the gut instinct that is typically used to recommend a physician.
"Historically, adjusters, nurses, and the insureds selected physicians based on subjective and anecdotal evidence," Walsh said. "What you really don't know is underlying that experience what is the objective reality relative to return-to-work, light-duty return, medical treatment, costs and duration, frequency of treatment."
The system drills down within provider networks to identify those who are most effective. Walsh makes the analogy of a baseball team with nine great players. Within the group, one could differentiate the various levels of skill and make judgments on historical performance.
How it works. The Accident Fund system uses a data set in a given location. It takes the evidence of individual physician outcomes using a proprietary algorithm, aggregates them, and provides the company with the best possible occupational medical providers by specialty and geographic location.
"One of the things that was fascinating to me is that physicians might treat at multiple locations. At some locations they may be viewed as a higher performing provider while at others they may not," Walsh said. "It takes it down to the treatment location level, not just the individual physician level."
While it's not fully understood why the same provider would perform better at one location than the other, Walsh and his colleagues speculate it could be related to the type of facility, the supporting staff, and/or the available equipment.
In practice, when a claim is initially reported, the injured worker has typically already sought treatment with a physician.
"We ask, 'who is the patient treating with?' and we determine how that physician has performed historically on our claims," Walsh said. "If it is a high performer, they go into the 'control' group -- they are already with a high performer."
While some jurisdictions allow the employer to determine the medical provider, most do not. A claimant who has been treating with a physician having poor performance presents an opportunity for the company to help the worker decide whether to stay with that physician or change physicians. Those who change to a higher performing physician are categorized as a "direct."
"We're using the tool to help us develop panels for an insured, and say 'who do you think the most experienced doctors are? When that injury occurs, consider using this doctor,'" Walsh said. "That's helped us drive more injured workers to these [higher performing] providers right up front. So the control group has increased over time."
As the developers see it, the system has several advantages over the traditional method of selecting physicians, including:
- The ability to control medical costs both outside traditional provider networks and inside provider networks. A key to the system's success is utilization. Where preferred provider organizations typically apply fixed rates or standardized discounts to specific types of medical services, they do not limit the number of procedures performed for an injured worker during a claim. That can be a major cost driver.
- The preferred provider panel can be easily adjusted without moving providers in or out of networks.
- Providers in a preferred provider panel are not incentivized to alter treatment patterns; they are not required to change their treatment practices or discount their services.
The system has been in production for a couple of years even though it was just awarded the patent. Already it is showing signs of success.
"We monitor the cases that go to various tiers of physicians and monitor those costs and those durations and return to work," Walsh said. "We can confidently say we are definitely seeing improved results with return to work and costs when we are able to get these people treated by them."
By Nancy Grover
Read more at the WorkersComp Forum homepage.
July 29, 2013
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