Employers across the country are looking to provide employees with the largest and widest PPO networks as a means of giving employees choice. Somehow the health insurance industry has determined that networks should be “all-inclusive.” The more medical professionals and facilities in your network, the better your network is. It is time to raise a red flag on this kind of thinking. Before your organization looks to increase employee access to doctors and hospitals, there are three things you must understand about PPO networks.
Larger Networks Can Lead to Larger Plan Costs
You hear it all the time. Insurance carriers battle over who has the largest network both locally and nationally. Now, having a network with a national presence can be appealing if you are an employer with facilities and a workforce scattered across the country. However, a larger network opens the door for greater access to poor-performing physicians and medical facilities. The bigger the network, the greater the odds your employees are accessing doctors and hospitals who are not on the right side of cost, quality and outcomes. As a result, your medical plan’s costs continue to rise year after year.
In a typical medical plan, the majority of the member population will use the plan via day-to-day services such as preventive exams, sick children and the occasional medication. For these folks, a network discount does an adequate job reducing costs for both the member and the health plan. However, imaging, surgeries and hospital stays are driving plan costs today, and it is here where a network “discount” can be misleading. Yes, network discounts are still applied to these services and, yes, the discounts can be 50% or more. However, when facilities are allowed to charge 400%+ of the limit allowed by Medicare, you are not getting much of a deal at all. To put it into simple terms, if I told you my iPhone is worth $2,000 but agreed to sell it to you for a 50% discount, I would still be ripping you off.
Networks Often Block Creativity
Recently, I had an interesting conversation with a national insurance carrier about a mutual client. After a thorough review of the client’s claim activity, we uncovered several facilities that were providing imaging services (MRIs, CT scans, etc.) at a low cost, much lower than the same services provided at other facilities. Knowing this, the client wanted to give members incentives to choose the low-cost facilities when needing imaging services by agreeing to have the health plan pay 100% of the service, saving both the member and the health plan money. However, we were told “no” by the insurance carrier because it had a duty to “keep the rest of the network happy.” If we are going to create change in the health insurance market, employers need to implement creativity into health-plan design. Unfortunately, most PPO networks discourage this kind of thinking.
Remember, there is a place for PPO networks within the healthcare industry. However, if you are an employer looking for creative ways to give your employees access to high-quality, low-cost doctors and hospitals, do not count on PPO networks to pave the way.
As part of our role as specialists, we wanted to learn more about the risks specific to radiologists, so we reached out to Karen Kruer, RN, CPHRM, and Michelle Foster Earle, ARM, president of OmniSure Consulting Group. Here’s what we learned.
Radiologists are second only to neurosurgeons in claims paid. Their average claim lands at $426,000. Radiology is a unique field of medicine, as it operates in an arena where other physicians cannot: seeing inside the body as a part of the diagnostic process. This specialty also brings a unique set of risks. These are the top five, together with suggestions for reducing risk.
# 1. Error in diagnosis – Of all the lawsuits filed against radiologists, error in the following five diagnoses most commonly leads to lawsuits:
– Breast cancer
– Nonvertebral fractures
– Spinal fractures
– Lung cancer
– Vascular disease
To decrease error in diagnosis, radiologists should have policies and procedures in place to ensure that with every procedure they obtain a complete patient history, know exactly what they are looking for, request further testing if there is any question and review the diagnosis with the ordering physician.
# 2. Procedural complication – There will always be an increased risk when an invasive procedure is performed, and radiology includes many, such as the injection of dye and the insertion of wire stents. However, noninvasive procedures may also increase the risk of complications. Consider an MRI on a patient with metal piercings or devices such as a pacemaker. The best tip for avoiding an adverse outcome is to ensure that a thorough screening is always done before any procedure. For example, the radiologist should know the reason an imaging procedure was ordered, as well as patients’ medical histories and what medications they are taking. Radiologists are trained to look inside a person’s body, but they can also benefit from looking at the outside by putting into place a thorough intake process. Ensuring that support staff is competent and well-trained also goes a long way toward reducing the risk of procedural complications.
# 3. Inadequate communication – Thorough communication with both the referring physician and the patient is essential. Radiologists are referred to for help in diagnosing the disease process, so adequate communication begins first with close contact with the physician who ordered the test. It is important to understand the context of the test-specifically, why it was ordered-and to have a clear picture of the patient’s health. When it comes to patients, the radiologist needs to make certain each patient is given the opportunity for informed consent. That means informing patients of the risks, benefits and any alternatives that can be chosen in lieu of the test.
Policies and procedures must be in place to handle critical test results. All staff must be informed as to which test results need to be called in to the referring physician immediately. One example would be that of a patient with headaches referred for a CT scan of the head, whose scan shows an aneurysm. Because this is obviously critical and time-sensitive, the results should be called in immediately.
# 4. Failure to recommend additional testing – Better safe than sorry-always err on the side of caution. For example, if a patient visits a radiologist for a mammogram because her physician felt a lump in the breast, and for some reason the radiologist cannot find the lump after a mammogram, should a more invasive test, such as a CT scan, be ordered? The answer is yes. Further testing should always be done. It can mean the difference between life and death (and a lawsuit or not). In the case of a dissecting aneurysm, for instance, if it is missed on the original X-ray and no further testing is performed, it is often too late to save the patient. This can be avoided by liberal recommendation of additional testing.
# 5. Failure to document – Documentation can make or break a case when attorneys become involved. Make certain everything is documented, including all test results, dates, times and subjects of all conversations with both the referring physician and patient. In the event of an adverse outcome where the court becomes involved, the ability to say and show all conversations is essential. Showing that the treating physician was spoken to, at this time and on this date and that the patient was given these recommendations is invaluable for risk reduction. For more information on the importance of documentation, visit this Ultra blog post.
Musculoskeletal diseases, defined as injuries to the soft tissues, currently affect more than one out of every two persons in the U.S. age 18 and older, and nearly three out of four over the age of 65. Low back pain affects at least 80% of adults at some point, with an estimated annual cost of more than $100 billion. Trauma, back pain and arthritis — the three most common musculoskeletal conditions — are the most common reason for patient visits to physicians’ offices, emergency departments and hospitals every year. With the aging U.S. population, musculoskeletal diseases are becoming a greater burden every year.
A determination must be made if the pain generator is muscular or structural, and incorrect diagnoses can lead to inappropriate treatments and, in the worst case, unnecessary surgeries.
About 80% of healthcare and social costs related to low back pain are attributed to just 10% of patients with chronic pain and disability. This statistic suggests that improved interventions to reduce the recurrence of low back pain can underpin significant cost savings and improvement in patient outcomes.
The standard approach to managing soft tissue injuries is to obtain a medical history and perform a physical examination. Imaging or testing usually is not needed in the early phases of treatment. In most cases, the natural history of a soft tissue injury resolves without intervention.
There are excellent tools to diagnose structural abnormalities or nerve injuries. These include imaging studies, nerve condition tests and disograms. X-rays can be used to assess the possibility of fracture or dislocation. Nerve conduction studies may be used to localize nerve dysfunction.
But they are not adequate for soft tissue injury or functional assessments. MRI and CT scans, while excellent tests to evaluate structure, are generally static and not designed to assess muscle function dynamically. In addition, these standard tests all carry a high rate of false positives.
There is no magic bullet or one test that does everything. While many tests are good for what they are designed to evaluate, they are not appropriate to diagnose a soft tissue injury.
Enter electrodiagnostic functional assessment — EFA testing. The EFA is a diagnostic tool that combines and enhances five medically accepted tests: electromyography, range of motion, functional capacity evaluation, pinch and grip strength. The EFA is non-invasive and non-loading. The advantage the EFA presents over performing these tests individually is that it performs all tests simultaneously and in a dynamic fashion.
This equipment has a 510 (k) registration with the Food and Drug Administration as a Class II diagnostic device. Furthermore, the FDA has recognized in the intended use section that the technology can distinguish between acute and chronic pathology, is able to look at referred pain patterns and is useful with treatment recommendations and baseline testing.
Physicians encounter patients daily with complaints of injuries to the soft tissues, particularly the paraspinal muscles. In many cases, objective findings are obvious, but many patients may have injuries that are subtle but continue to cause symptoms. In other cases, the injuries may be less recent, and the physical findings may not be apparent. Direct palpation of soft tissues can, in some cases, reveal the nature or type of injury, but this manner of diagnosis relies on static testing. For some individuals, problems may only be encountered during activity. Measuring muscle activity during range-of-motion testing is difficult at best. The extent to which a patient exerts herself also presents a subjective bias with soft tissue injury.
Better outcomes will be demonstrated by using the correct tools to evaluate the underlying pathology. In Adam Seidner’s paper “Assessing disease and wellness in the occupational setting: Electrodiagnostic Functional Assessment from wired to wireless,” he demonstrated that, when the EFA was implemented as a case management tool, it enhanced the level of discussion among treating providers, injured workers and claim professionals. The study demonstrated that medical and lost wage payments to injured workers and their healthcare providers were 25% lower in the EFA group, for an average savings of $10,000 per claim versus the control group. Most importantly, the average return to work was 213 days in the EFA group versus 275 for the control group, or an average of 62 days sooner. The EFA was able to provide better diagnostic information on soft tissue injuries and return the individual back to activities of daily living sooner. Better patient care leads to better outcomes.
The EFA results are further demonstrated in the paper “Musculoskeletal disorders early diagnosis: A retrospective study in the occupational medicine setting.” The study found EFA test results affected the course of treatment, improved clinical and functional outcomes, increased patient satisfaction and decreased dispute litigation. In fact, 98 of the 100 cases resulted in return to maximum medical improvement with no rateable impairment and full release to active duty. Only 2% of the cases were challenged, and 98% of those in the EFA control group returned to their pre-injury jobs. These cases were tracked over a three-year period.
The EFA-STM baseline program is just another example of better diagnostics providing better patient care. This book-end solution allows for the best care possible for the work-related injury. If a condition is not deemed to be work-related, the individual can still receive the best care and a quicker resolution.
The EFA does not replace the other, well-established diagnostic tests; it is simply a better diagnostic alternative for soft tissue injuries. All the tests can complement one another.
At the end of the day, when it comes workers’ compensation, the issue is providing better patient care. It’s a win-win for all parties.
Neck and back disorders account for an estimated one third of all work-related injuries in the private sector. In only about 5% of all cases is back pain associated with serious underlying pathology requiring diagnostic confirmation and directed treatment, yet magnetic resonance imaging (MRI) is, controversially, often used for diagnosis. New technology can specifically diagnose muscle-related back pain and produce better outcomes.
According to the Centers for Disease Control and Prevention, back pain is the single most common reason Americans seek medical attention, and a U.S. Department of Health study showed that managing this type of health disorder costs $850 billion annually. About 20% to 40% of the working population is estimated to experience back pain at some point, with a recurrence rate of 85%.
The majority of back pain comes from musculoskeletal disorders (MSD), which are treatable through medication and physical therapy. MRI is frequently used to diagnose back pain, yet it is overly sensitive in identifying the cause unless it correlates with an objective clinical exam. European Spine Journal ran an article in February 2012 that found that a considerable number of cases of lumbar disc herniation (HNP) and spinal stenosis that were diagnosed through MRI may have been classified incorrectly. MRI is overly sensitive in exposing structural abnormalities of the spine, but not specific enough to diagnose accurately the cause of the back pain. Even though MRI imaging is commonly used to diagnose the cause of back pain, it is costly, ineffective and contributes to overuse. In fact, lumbar spine scans have risen dramatically in recent years and account for about a third of all MRIs done in some regions, despite the poor correlation between its findings and clinical signs and symptoms.
In addition, there are at least two studies that have been conducted to assess MRI findings in patients without back pain and that have raised concerns. In 2001, Spine published a study of 148 patients; all were asymptomatic, yet an MRI scan showed that 83% had moderate desiccation of one or more discs, that 64% had one or more bulging discs and that 32% had at least one disc protrusion. The second study, published in the New England Journal of Medicine in 1994, found that only 36% of 98 asymptomatic subjects had normal test results from an MRI.
The evidence indicates that it is common for patients who experience back pain to have abnormal MRI scans, regardless of their condition. Spine surgeons, knowing that MRI can be overly sensitive and non-specific in diagnosing back pain, also use discography, a provocative and invasive test, to attempt to accurately pinpoint the cause of pain. In reviewing many studies of this tool, it is clear that even discography can be overly sensitive and often inaccurate in identifying the cause of back pain and in predicting the outcome of surgery. In addition, because it is invasive, discography can actually contribute to further injury in certain patients. Imaging diagnosis for acute back pain often leads to surgery, and complications from unnecessary surgery can prolong back pain or lead to permanent disability.
Because costly imaging studies often fail to produce positive health outcomes for patients with back pain, X-ray, MRI and CT scans should be used primarily for patients with neurogenic disorders or other serious underlying conditions. Because the majority of back pain is musculoskeletal in nature, the primary tools used to diagnose back pain are ineffective.
What is needed is a tool that effectively diagnoses a musculoskeletal disorder. Electrodiagnostic Function Assessment (EFA) is an emerging technology that is a non-invasive and safe diagnostic device registered with the FDA. It can distinguish between spinal, neurogenic and MSD conditions, which can greatly help physicians reach a specific diagnosis. This is especially true in terms of workplace injuries, where MSD conditions are prevalent and difficult to diagnosis and treat, given that the complaints are often subjective.
The following are two case examples where EFA technology, in combination with a neurosurgeon’s evaluation, was used to make accurate diagnosis and treatments:
In the first case, a 34-year-old patient sustained a work-related injury from repetitively using an air-powered grinder. As a result of a court-ordered independent medical exam (IME), the patient went to a neurosurgeon with complaints of bilateral, radiating neck pain and numbness in his right hand. After undergoing an EFA examination, it was found that his resting readings were within normal limits for all muscle groups evaluated. The EFA did indicate non-significant spine and muscular irritation, with chronic muscular weakness. The patient then underwent an MRI, which was abnormal, showing diffuse stenosis but no herniated discs or neural impingement. The IME doctor deemed he was not a surgical candidate and recommended treatment with conservative, site-specific physical therapy and muscle relaxants. The EFA and neurosurgeon prevented unnecessary surgery and were able to help with appropriate care to get this case satisfactorily closed.
The second case involved a 30-year-old mechanic who sustained a work-related injury, straining his neck while opening the hood on a semi. The EFA revealed no muscular irritation, but spinal pathology revealed an issue in the neck area that could be clinically significant. In addition, the EFA findings indicated acute neck pain, increased curving of the spine and loss of range of motion. In this case, the IME neurosurgeon requested an MRI, which confirmed the findings of the EFA examination. The MRI further showed a herniated disc consistent with the patient’s symptoms and exam. The patient failed physical therapy, and appropriate surgery was recommended. The patient underwent surgery and had an excellent outcome.
In both of these cases, the administering physicians were able to make exceedingly accurate diagnoses by having the correct tools available to them. This would not have been possible without the assistance of the EFA. By using the appropriate diagnostic tool, each physician was able to render a more accurate diagnosis and appropriate treatment, which not only assisted the patient but helped to lower healthcare and workers’ compensation costs.
The use of MRI or other imaging technologies alone in diagnosing causes for back pain can be misleading and inaccurate in localizing pain generators. However, a more accurate diagnosis can be made when used in conjunction with the findings of EFA, so that appropriate site-specific treatments can be provided, leading to better patient outcomes and improved healthcare.
The authors invite you to join them at the NexGen Workers’ Compensation Summit 2015, to be held Jan. 13 in Carlsbad, CA. The conference, hosted by Emerge Diagnostics, is dedicated to past lessons from, the current status of and the future for workers’ compensation. The conference is an opportunity for companies to network and learn, as well as contribute personal experience to the general knowledge base for workers’ compensation. Six CEU credits are offered. For more information, click here.
Comment from Brent Nelson, Area Medical Director/Medical Director Occupational Medicine AZ at NextCare Urgent Care:
Very interesting article. As a physician treating and managing providers who treat work related injuries, I am often surprised at the number of referrals I see for advance imaging for back/neck pain. I was trained in an industrial athlete model for treating musculoskeletal injuries and one of the key points in the model is that an MRI or other advanced imaging should only be ordered to confirm a diagnosis, not find one. When this method is employed, the use of the imaging is less, and the findings are usually accurate and directly related to the complaint.
When an MRI is ordered simply for back pain that is not responding to treatment as well as expected, and the provider does not have a clear idea of what the problem may be, ambiguous findings may serve only to muddy the waters and increase the cost of treatment and possibly even result in unnecessary procedures. A bulging or ruptured disk without nerve impingement, annular tear, facet arthropathy, etc. are findings that may exist in asymptomatic populations, and may not be the cause of the pain.
A very detailed and thorough examination should always be performed at each visit, and this coupled with a detailed history should lead to an accurate diagnosis.
Quality of physical therapy must also be assessed when patients do not return to baseline as quickly as expected. Is the patient being treated by a physical therapist with experience in sports medicine? These PTs tend to have a better outcome for back and neck pain. Is there an indication for kinesio taping? Would an IFC/stim unit help breach a plateau? These are all considerations in treatment that may help with resolution prior to an MRI.
And again, an MRI should be ordered to confirm a diagnosis, and is most often indicated for a persisting radiculopathy or for an injury that may have resulted in an acute facet injury (not the same as degenerative changes in facet joint).
Simple XRays when conservative treatment begins to fail can give hints as to underlying degenerative issues which mean patient will take a little longer to return to baseline, and help prevent advanced imaging being ordered prematurely.
In short, the physical exam should give a good physician an idea of the problem and advanced imaging ordered only when one wants to confirm a suspected diagnosis.
The importance of knowledgeable physicians and therapists working in collaboration, and involving the carrier during the process, is often overlooked (and often times hard to find). The majority of the time, the patients answers to questions and an appropriate physical exam will give one the answers to the questions about origin of pain and indicated treatment.
A few weeks ago I taped the first episode of my new public radio show. I thought I sounded good enough, and the producer assured me that I would sound even better after I got over my cold. This would have been reassuring, except that I didn’t have a cold.
Fearful of being fired my first day on the job, I immediately called my primary care physician (PCP) to get some advice on how to sound less hoarse. The doctor’s office promptly scheduled a visit with an Ear, Nose & Throat specialist, only four days later.
The specialist scoped my nose and announced that I had polyps in my sinuses. She said she would schedule me for a CT scan of the sinuses, and offered three alternative treatments, which, she added truthfully, may or may not work.
Steroid-based nasal spray
Steroid-based nasal spray with a three-week course of antibiotics
Day surgery followed by a saline flush for a week
“So,” she asked, about seven minutes into the appointment, “which do you want to do?”
“Um,” I replied. “Shouldn’t we try the most conservative therapy first?”
“Well, you could.”
I begged off the surgery by quite correctly observing that I wasn’t very adept at flushing my nose out, so that I would prefer one of the non-surgical alternatives. “I’m not sure I need the antibiotics because I don’t think this is bacterial,” I said.
“A lot of patients report relief with the antibiotics,” she replied, almost as if she were cast as the “before” picture in an evidence-based medicine textbook.
“Isn’t three weeks a long time to be taking antibiotics?” I asked.
“Yes. Some people say that.”
I opted for the nasal spray. I elected not to schedule the sinus CT scan. Seemed like a lot of cost and inconvenience … and didn’t I just get a diagnosis anyway? So I didn’t follow up on it.
Except that the sinus scan was thoughtfully scheduled for me, as I learned when a scheduler called me the very same day. I ignored my first voicemail from the scheduler, but after the third I realized they really did expect me to show up (that very Friday, no less), and it occurred to me I might get billed unless I affirmatively called to cancel the appointment.
And, that is what is wrong with fee-for-service medicine. Most well-insured people would have gone along with the recommended program, getting the scan, the surgery, and who knows what else.
The bottom line is, in twelve short minutes, this visit encapsulated everything that is wrong with traditional fee-for-service medicine, of the type that someday, with any luck, is going to be replaced by capitated ACOs using patient-centered medical homes, supported by electronic medical records (EMRs), to refer to salaried specialists who don’t get to bill a big chunk of money each time they do a surgery.
Except that this practice is already a designated patient-centered medical home, it already uses an EMR, it is already partially capitated by its major health plan, and its specialists are already salaried.
That is the “punchline,” and explaining a joke often ruins it, but healthcare isn’t a joke so I’ll explain.
Just changing practice incentives may not change the behavior of individual physicians, especially specialists who even in most capitated practices are/will still be paid on the basis of work performed, somehow, to some degree. (In this practice, work performed affects physician salary for the following year.)
Further, patient satisfaction also factors into compensation, and what can be more satisfying for patients than promptness and responsiveness and action? As for the checks-and-balances provided by the EMR, it turns out that the EMR is what expedited the referral in the first place. Years ago it had been noted that I had a deviated septum (like about half the world, as it turns out). That information was duly stored in my EMR, so that my primary care physician had grounds to make a referral at her fingertips, without needing me to see her first.
The coda on this story? To try to overcome this hoarseness, I took the steroidal nasal spray twice a day for a week. Then I read the FDA insert, which listed the following as a side effect: hoarseness. I stopped the spray, and told this story to my producer. My producer suggested tea with honey during each taping, surely the most conservative therapy … and I still have my job.
So domestic policy wonks in the Washington, DC market can now hear me on The Big Fix Saturdays at 4 PM on WAMU 88.5, at least through January 15, when the funding runs out. I’m still a bit hoarse, but thanks to my producer I no longer sound like that guy on Boardwalk Empire whose vocal chords were blown up during World War I.
Postscript: The first episodes have already aired, and while a few people complained, not without justification, about my hosting skills, no one wrote in to say: “This guy sounds like he needs his polyps removed.”