June 5, 2015
Finding Actionable Provider Ratings
by Karen Wolfe
Accurate provider ratings can be found in workers' comp claims data, but it must be integrated, not left in the silos where it typically exists.
With the tongue-in-cheek title, “When Yelp reviews are better than hospital rating systems” Jason Beans of Rising Medical Solutions discloses the inconsistencies of standard hospital reviews. He cites a Health Affairs study that points out that traditional rating systems, those that have been relied upon in the healthcare industry for years, rarely come up with the same results for the same hospital.
Provider ratings score hospital performance in an effort to determine quality and safety in hospitals. The Health Affairs study concludes that discrepancies among provider ratings systems are likely explained by the fact that each uses its own rating methods, defines quality differently and stresses different measures of performance. Apparently, no standards for quality and safety in hospitals are available.
This raises the question of how scoring systems for rating other medical providers differ from those of hospital scoring systems. More specifically, what about those used to score provider performance in workers’ compensation?
Lest the conclusion be that all provider performance scoring systems lack credibility, it might be instructive to at least loosely compare hospital rating systems with physician scoring in workers’ compensation.
The conditions, methodology and approaches are significantly different. The hospital rating systems cited by Health Affairs evaluate general health in acute care settings. To measure cost, they measure an episode of care on a per diem (per day) basis for individual hospital stays, adjusted by diagnosis and procedures. Often, subjective reports are used, as well.
On the other hand, measures of quality performance in workers’ compensation are unique to the industry, and the number of measurable variables is numerous. How a medical provider acknowledges and influences distinctive industry factors along with success of the medical treatment procedures are indicators of quality performance.
Episode of Care
One major difference is that the episode of care in workers’ compensation is not per diem, but is defined by the scope of the claim. An episode of care (claim) is from the date of injury to claim closure and includes all treatment, medical providers, vendors, events and outcomes that occur during that time. An episode may or may not include hospitalization, but when it does, those costs and events are included with total claim. In other words, the episode of care is highly definable in workers’ compensation. It is broad and comprehensive.
A number of non-medical indicators found in the data reflect unique conditions in workers’ compensation that are influenced by treating providers. Measures of quality include return to work and indemnity costs, neither of which is medical treatment precisely, but is strongly influenced by the treating provider and affects the cost of the claim. Consequently, these factors must be included in evaluating performance.
Frequency and duration of treatment, as well as duration of the claim, are indicators of provider performance. Providers can contain or increase costs described by these factors. Functional outcome described in the data as disability ratings at the conclusion of the claim are also measures of treatment success.
Clinical factors and treatment processes are important quality indicators, of course, and must be included in the evaluation and scoring. Abuse of Schedule II drugs are, for example, a major cost driver in workers’ compensation. Dispensing medications is another.
Each data-rich claim contains the information necessary to evaluate medical provider performance for workers’ compensation. Importantly, the data must be integrated from the silos of bill review, claims system and PBM (pharmacy) to achieve a comprehensive picture of the claim and medical providers’ involvement.
Workers’ compensation can be more complex than general health because it is a legal system rather than a defined benefit. Every claim has administrative aspects as well as medical assessment and treatment. It’s all in the data.
Scores of medical provider quality indicators can be found in workers’ compensation data. The beauty is that data describes what actually took place during the course of the claim, not what should have happened or an opinion about it. It is concrete and objective. Yelp can’t help.