Tag Archives: barry thompson

Electronic Health Records Hurt Care

Patient care as we know and expect it will diminish because of electronic health records (EHR) requirements. Society will suffer a slow degradation of artful interactive provider attention in deference to “data-field” medicine.

I am not simply referring to the very real and challenging issues in the technical application of EHR systems. Rather, I point out a more serious and insidious future threat to the actual human aura in medical practice.

There exists an unintended but real incentive for doctors and clinicians to consider task-completion as clicking through the data interface rather than interacting with and treating the patient. Legal requirements, reimbursements and potential penalties force EHR to top priority. In turn, clinicians as EHR users become more aware of and anticipate the truncated, template-driven and limited means of expressing case events via electronic reports. Therefore, their interaction with patients may be truncated.

I know this sounds callous and insulting to all good medical providers. To them, I say no insult is intended, and the fault of this perverse incentive is not theirs. They might honestly assess their experience and the actions of peers and associates within their practices given the advent of EHR. To providers, I ask: What about EHR might be sucking the creative life out of your optimal vision for the practice of your specialty?

My most stark encounter with this reality comes from a chance discussion with a longtime friend. She is a nurse practitioner who, for decades, has treated both ER and family-practice patients. As family friends, we never talk shop, and this particular conversation was not solicited by me. I politely asked, “How’s it going?” and got a surprising, soul-baring burst of frustration.

She expressed disdain. She prides herself as a master of triage, symptom investigation, on-the-spot research and communication with involved family members, and she desires to take the wide approach to patient situations as a service to them and to the doctors or specialists who may eventually carry the case, but electronic records don’t allow the narratives or collective points of data she would prefer. As such, her value is diminished, and the patient ultimately gets poor attention.

As she described her situation, I began to understand the rigid decision-tree “intelligence” in narrowing prompts for information based on how case records are initiated. She has persevered and found cumbersome work-around methods (such as editing previous fields to change next options, etc.) to combine or add issues or thoughts to a record beyond the template’s desired straight line of thought. Unfortunately, she explained, taking extra time to do anything is neither advisable nor encouraged because of the volume of patients requiring care.

Quick Tip: The Want for Data Should Not Put the Cart Before the Horse

As a foreshadowing about healthcare in general, consider what the supreme focus on automation and data collection has done to workers’ compensation. I have written extensively about the advent of electronic claim systems, over decades, reducing the adjusting job from that of an intelligent, intuitive personal-interactive specialist to the current task-level data entry clerk. We are now well into the post-paper-file generation of claim adjusters who know their job only as data-interface. Will medical clinicians meet the same fate when our current generation of providers, like my friend, move on? Will future clinicians, knowing only electronic records, assume that the decision tree of the EHR interface supersedes intuitive medicine?

Let’s hope not. Unfortunately, a simple Google search for “problems with EHR” will not sit well with anyone who embarks on some research in this area.

In claim adjusting, as in medicine, we need to intelligently feed the hunger for data but rail against a perverse desire to let automation increase case volumes or assume the template is sacrosanct. I am certainly not against all the good that electronic medical records bring to the party. However, we must first let practitioners do their jobs, not let “data screen medicine” dumb down patient care.

Perhaps provider-run coalitions should dictate standards for ever-improving EHR frameworks and interfaces so their highest-quality, real-time nimble intelligence can be best captured in all patient events. I know at least one nurse practitioner who has a lot to say on that subject.

7 Ways to a Better Work Comp Plan

Although some improvements in workers’ compensation claim results require large investments, resources and complex implementation phases, others require more commitment than dollar investment and are simple in execution yet sublime in positive impact. The seven suggestions that follow are field-tested and proven effective. These seven will not only improve the results of your work comp program but will enhance workers’ respect for their jobs and increase cooperative attitudes. Best of all, these seven can be initiated quickly and with moderate to low effort:

Quick-Tip: Seven Suggestions + Negligible Resources = Zero Excuses

1) Before and after each shift, supervisors can ask if anyone is hurt. This is easy to implement where crews already have before and after meetings. By asking the question, supervisors remind employees that proper work comp reporting is a job requirement. The question also discourages workers who arrive with an existing problem from making it worse on the job or blaming it on the job. This can also reduce late reports. If any injury or illness is identified, then it can be managed immediately.

2) Provide injured employees with a “rights and responsibilities” manual that is branded with the company logo. Many state WC offices provide adequate templates for this purpose. The manual serves as a reminder to employees that the WC process is connected to their employer and their job.

3) Devise a simple monthly WC/safety summary report that goes to executive management. Place a copy on public bulletin boards so staff is aware that executives monitor the related programs. This promotes the seriousness of WC and safety.

4) Work with your third-party administrator (TPA) or insurer to institute a “no fill” list of dangerous narcotic prescriptions that will automatically trigger a refusal and review by appropriate medical resources. Most claim organizations have such lists already. It is a matter of demanding this level of service from your claims or managed care vendor.

5) Require supervisors to make weekly calls to employees out on temporary total disability (TTD) and have weekly chats with employees on modified duty. This would be a simple general talk to ask how they are doing and if they need anything. This is a powerful motivator and reminder of the employee’s value and the fact that a return to their regular job is anticipated. It can also identify problems in the claim that need to be addressed.

6) Write a simple standard “Return to Work (RTW) Expectation” letter that will immediately be given to every claimant’s treating doctor. This will cause doctors to recognize your transitional duty program, understand their expected role and enhance cooperation. The letter will reduce the likelihood of a claimant’s refusal to participate in early RTW and reduce the reliance of doctors on a claimant’s version of RTW opportunities.

7) Make employees aware of WC costs in personal terms. “Dollars” are not as meaningful as referring to units produced or operating time. For example, if employees are aware they work the first 45 minutes of every shift or produce a certain number of pieces per shift, week or month just to cover WC costs they will relate to the problem. Track costs creatively to have impact.

Give these a try. Commit to changing the WC perspective in your organization. My experience says it will pay off.

Promoting Peace of Mind in Work Comp

An employee’s peace of mind is equal in concern with the physical injury when it comes to a worker’s comp claim. An upset employee can lose motivation, incur a bad attitude and rationalize the over-use or abuse of WC benefits. I am adamant that employee satisfaction is as key a factor in WC claim outcomes as it is in overall employee productivity and job performance.

It is not the adjuster’s primary role to manage an employee’s peace of mind at the start of a new report. While we expect good “bedside manner” from an adjuster, she must reserve a defensive position and be a “bad-cop” if necessary. An astute employer sees the opportunity in meeting an employee’s concerns at the time of an injury. It is like adding another critical brick to strengthen the foundation of employee satisfaction.

The immediate task can be simple. A little bit of confident communication goes a long way. Step one is to put yourself in the injured employee’s shoes and imagine being faced with an inability to work. It is not a comfortable feeling.

Quick Tip: Prepare a “Top-10” Information Sheet for Quick Use

Concept: Include a quick-reading “Frequently Asked Questions” checklist as part of an overall information packet for new WC claimants.

Suggested Top 10 and Recommended Answers:

1) Which doctor do I use? – Identify the preferred list, contracted clinic or emergency facility. Explain degrees of employee choice if any does exist in your jurisdiction.

2) What if I can’t do my job? – “If the doctor determines you cannot perform your job, we will try to match you with a temporary alternate assignment. If there is no ability for you to work, your wages will be paid as a WC benefit.”

3) How much will I be paid? – Provide the statutory calculation formula for the comp rate and specify that the employee’s specific rate will be determined by the claims adjuster within 48-72 hours.

4) When do I start getting checks? – Explain the jurisdictional waiting period.

5) How do medical bills get paid? – “All bills will be paid directly to the doctors/providers. You do not pay any bills for accepted and covered treatment.”

6) Do I need an attorney? – “We will help facilitate your benefits. An attorney is not necessary unless you face a disputed issue and want it to be heard by a judge. However, it is your option and right to consult an attorney at any time.”

7) What do I do next? – Explain any other internal steps and forms; explain that an adjuster will make contact and go over additional information. If you have a designated adjuster, provide a name and contact info.

8) What about my health benefits / 401k contributions, etc? – Explain your policies and the jurisdictional requirements that continue benefits during a WC claim

9) Will I lose my job or be fired? – Explain that filing a WC claim is not a basis for termination but also reserve the right for progressive discipline because of safety violations, attendance, job abandonment, fraud and any internal policies that might relate to WC situations.

10) What if I have other questions? – Provide a designated internal WC contact with an open-door policy.

The Best of Claims, the Worst of Claims

It was the best of claims; it was the worst of claims… the age of wisdom, the age of foolishness… belief vs. incredulity… hope vs. despair… etc., etc. The iconic opening paragraph from Charles Dickens’ A Tale of Two Cities makes one realize such conflicts do exist in the same space and time, albeit through different personal perspectives. Such is the reality in workers’ comp claims, where the single biggest factor in outcome is often the claimant’s attitude.

A client claim-audit project offers a jarring comparison between two claim files from different parts of the country. The claims exemplify how little control we actually have over an employee’s attitude in the disability management process, and show how vastly different the human tolls can be.

Both claims were in excess of 10 years old. Both involved exaggerated and evolving symptoms with eventual narcotic prescriptions for “pain management.” At approximately the same time, however, each took a different path.

One claimant found her own reasons and will-power to end the years she spent on prescribed pain-killers. She entered a drug treatment process on her own, eventually stopped her prescriptions and found a full-time job. The other claimant dove deeper into narcotic addiction and exhibited classic drug seeking behavior – such as “losing” his prescriptions and requiring early refills. He tested positive for other illegal drugs once his rightfully suspicious physician initiated a monitoring program.

There was no appreciably different set of claim management tools or tactics used for the claims – the stark difference in outcome came down to the want of the individual… an almost impossible aspect for the day-to-day claim practitioner or human-resources manager to reach or control. And, at the time of my audit, the claims were equally easy to close.

The woman free of prescriptions and carrying a full-time job was simply no longer a claimant. She was probably very happy to have her case closed and the dark chapter of her life over. We decided on an administrative closure of the claim.

On the other hand, the gentleman was barred from his erstwhile treating physician and pain management clinic for abusing meds and refusing a drug treatment program. A host of independent medical opinions indicated the man did not require further meds for the old injury. His everyday behavior was highly unfocused and erratic, apparently causing no attorney to take his WC case. He lived out of a tent in a relative’s backyard.

The man’s claim was also an easy administrative closure because of lack of any foreseeable prosecution. I have to admit his situation nicked at my coat of cynicism, the one layered thick from years in this profession. I hated the plain fact that he was a doomed victim of a WC system enabling his addictive conditions.

To my good readers, I ask: Which closure would you rather preside over?

Quick-Tip: Know When to Hold ‘Em But Don’t Wait to Fold ‘Em

Concept:

When reasonable medical treatment has no impact, quickly consider other options. A claimant with misguided intentions or extraneous problems and no desire to be “cured” might just be his own worst enemy and using the WC claim as a primary enabler.

Suggestions:

– Find appropriate ways to incorporate employee assistance programs (EAPs) or other specialty counseling services to support employees or WC claimants who have debilitating outlooks or possible addiction issues.

– Maintain a “no-fill” position on narcotic prescriptions. This will give you and your defense team at least an opportunity to block dangerous drugs before they are automatically initiated.

– Consider any “chronic pain” diagnosis to indicate maximum medical improvement (MMI). “Chronic” as a term arguably fits MMI. Try to settle the case under that premise. Fight the diagnosis and treatment plan, as a means to pressure settlement. If the plaintiff’s side argues against an MMI determination, then demand a treatment outlook and timeline that results in stopping pain medication.

– For claims with long-term narcotic situations, seek peer reviews to ascertain if the regimes are excessive and if a recommendation for detoxification is appropriate. Specifically set up medical evaluations to confirm addiction and substance abuse tendencies.

– Never presume a claimant with the wrong attitude and bleak outlook will be cured by any type of treatment. Know when you are wasting time and money. You must sense and act on this early. Don’t rely on adjusters to raise questions, as their inclination is to keep treating as long as medical opinion approves. You must take the role of disruptor.

Bottom line” It is distressing that workers’ comp enables addiction. Closing such cases is not always pretty. Learn from the disasters and take more responsibility in the future. Recognize that claimant attitude and outlook are of primary importance, for good or for bad.

Managed Care Isn’t Managed or Care

It is time to get angry. I plead with you all to recognize the king’s new clothes as he stands indignantly naked between the 300-pound gorilla and the elephant in this room called workers’ compensation. I am hereby calling out an industry that has turned “managed care” into “manipulated cost,” with a shameful lack of transparency and a churning mass of workers’ compensation claims.

Decades ago, the cottage industry of bill review provided a legitimate and needed service directly between healthcare provider and payer. Fast forward to the scheme that has evolved, with some healthcare networks and other consortiums that purchase services conspiring with some insurers and third-party administrators (TPAs). These arrangements may set up shadowy deals where medical goods and services are marked up by intermediary agents and where perpetrators split the profits — at the expense of unknowing employers.

Sadly, there is little outrage from employers. Perhaps the amounts seem negligible while the methods seem to be an acceptable cost of doing business. Risk managers have so much else to think about. Maybe managed care is considered to be essential, so no one in their right mind would question it.

I believe the employer-buyer holds a false sense of security that we need to get beyond. The drip-drip-drip of money siphoned from actual employee care needs to finally strike a collective nerve so that real change can happen. To that end, I want to list some considerations that I hope will spark outrage and lead to change.

Quick Tip: Managed Care Food for Thought; Indigestion Guaranteed:

Cognitive Dissonance: Claims providers justify bill-review fee schemes based on the notion that there are no controls from provider-sources… but wait a minute… they also take network fees because they apparently can control bills from provider sources! Anyone feel mildly conflicted trying to reconcile this logic? How can both facts exist?

Deliberate Mystery: Bill review as founded decades ago should no longer be necessary. Today’s technology obviates the premise that all WC bills need to be hand-checked against a fee schedule or that licenses for CD-ROMs holding schedules or “reasonable and customary” data are valuable. When it comes to group health, providers make it their business to know what deductibles and reimbursements apply while you stand at the window. Why is WC a deliberate mystery?

Technology Hypocrisy: The WC claims industry purports to have data and IT capability that can predict and fast-track claims, allowing ever higher (arguably untenable) adjuster caseloads, yet when it comes to monitoring fees pretends we are still in the 1990s. I submit that today’s technology can lock healthcare providers into correct billing. Aggregate provider monitoring/auditing by the adjusting entity can support accuracy. High automation and negligible cost should make fee oversight an included aspect of claim service, with network affiliation requiring providers to contribute to the technology. As our national provider base moves into more hospital-centered conglomerates, there are far more IT resources available on the provider end.

Core Responsibility: TPAs and insurers are paid to adjust benefits per state statutes. But charging a percentage of savings for medical care in a state with a fee schedule is as ridiculous as would be charging a percentage of “savings” for reducing an average weekly wage to the statutory comp-rate. What is the difference when it comes to core claim adjusting obligations?

No Repeat Value Added: We can agree that complicated in-patient bills are worthy of review and that fees for that review are justified. But there routinely are recurring bills from the same providers on the same file. After the initial adjustment, why should claim payers charge a fee for adjusting the exact same bill repetitive times? Seriously… there is no value added in charging for a task already performed. Here is an exercise: Look at your claim payment register to see the same $1.15 bill review fee and $5.32 network fee charged on the same $48 physical therapy bill over and over and over. Maddening, isn’t it?

How Would You Feel?: Let’s make it personal. What if your homeowners or auto insurer mandated your use of a repair-provider-network? Your damaged car gets fixed, and you are presented with a bill marked up by the network — not knowing what the actual body shop charged. You pay your deductible, leaving “profit” for your insurer and network to split… Hmm…

Low-Quality Reality: Network discounts have come to roost, leaving healthcare provider frustration high and quality of care low. I submit that higher quality deserves higher fees.

New Network Charge: Efforts to define, seek and sustain quality should be at the forefront of network effort. Can you imagine providers competing based on quality to join exclusive, well-paying networks? Astute, unbundled and self-administered employers that seek medical quality often pay more with confidence and get better results. Today’s bundled programs beget providers willing to work cheap and approach profit on a volume-of-treatment basis. More visits means more weeks/months/years open equals more money for the entities otherwise trusted to resolve claims. Isn’t this reality the opposite of what should be managed care?

Employers… Get angry: Start asking questions and making demands. Let’s start with disclosure of end-provider fees. Ask your legislators to crack this issue open and make corrections accordingly. I call upon some major broker to take the lead and create a “Managed Care Bill Of Rights.” Wouldn’t that be a great distinction?

Bottom Line: The insurance/claims/managed care industry cannot beg for the trust of those served while skimming treatment dollars. Fix the problem.