There have been several tentative efforts to bring provider profiling to workers comp, with decidedly mixed results. The problems are the usual – bad data, not enough data, poor coding, and insufficient claims counts coupled with widely varying severity making it very difficult to compare physicians.
One of the leading managed care firms in the southeast, CHOICE Medical Management, just announced their new effort in provider practice analysis, and it looks promising. According to CHOICE’s news release;
“”This is the first provider analysis in the industry using data from the whole claim, medical, indemnity and total claim costs, as well as administrative processes,” Tom Barrett, CHOICE president said.”
Providing access to all data, including the critical indemnity and return to work (RTW) data, is vital to assessing the performance of comp docs. With so many dollars riding on return to work, failing to consider this may lead to highly misleading conclusions.
Aetna has also been working on provider profiling, using their extensive database of group health information in an attempt to identify docs that can treat work comp cases effectively. While I admire their effort, there are several key problems with this.
1. RTW is not contemplated in managing a group health patient episode, so there is no way to assess the impact of the physician on disability.
2. Many group health-oriented docs don’t and/or won’t take workers comp patients.
3. Two of the key WC specialties, occupational medicine and physiatry, are either non-existent or barely represented in group health networks. And occ med docs provide a lot of the primary care and case management in comp. How you can assemble a network or assess outcomes without looking at occ med and physiatry is a mystery to me.
4. Group health decisions are often complicated by reimbursement, copay, and deductible issues. There is ample evidence that patients make decisions based in part on their financial impact on the patient. Such is not the case in comp, which is “first dollar, every dollar”.
5. Several studies indicate that medical care for certain conditions is just different for work comp patients than for those covered by group health. Back pain/strain is one example. While all of us agree that a back is a back, the reality is the financial, motivational, and regulatory differences inherent in group and comp drive different medical practice.
What does this mean for you?
A comp-based provider analysis will likely lead to better understanding of comp cost drivers.
Feb
13
This is certainly encouraging and I applaud Choice’s efforts. As you know, efforts to find a “right” answer to provider performance profile go back many years (you and I having been part of an exercise to get at provider profiling in our UHC days). Assuming the age-old hurdles of bad, unavailable, or incomplete data have been overcome in some way, the question remains how do you properly communicate and educate the provider community in a proactive manner? I think a logical leap is to also begin factoring in outcomes measurment (an even trickier proposition in comp).
If you look at the recent pilots launched by CMS for the Medicare and Medicaid populations, you see that they feel strongly that if you develop an outcomes based incentive program for the physician community, you should expect to see costs lower, patient satisfaction increase, and a general improvement in the health of your population. While the results are not in, and there will be those who dispute whatever results are reported, it is promising to see a real effort to get one’s hands around outcomes measurement and the satisfaction of both provider and patient…not just an analysis of what docs prescribe too much relative to others. As we all know, as goes traditional healthcare, eventually goes comp…so this could bode well for the future of comp outcomes measurement. I can’t wait.