Tag Archives: doctor

How to Find Best Work Comp Doctors?

As is the case in any professional group, individual medical provider’s performance runs the gamut of good, bad and iffy. The trick is to find good medical providers for treating injured workers, avoid the bad ones and scrutinize those who are questionable. To qualify as best for injured workers, medical providers need proficiency in case-handling as well as medical treatment.

High-value physician services

The first step is to clarify the characteristics of the best providers, especially in context with workers’ compensation. One resource is an article published by the American College of Occupational and Environmental Medicine in association with the IAIABC (International Association of Industrial Accident Boards & Commissions) titled, “A Guide to High-Value Physician Services in Workers’ Compensation How to find the best available care for your injured workers” It’s a place to begin.

The article notes, “Studies show that there is significant variability in quality of care, clinical outcomes and costs among physicians.” That may be obvious, but it also verifies the rationale for taking steps to identify and select treating doctors rather than pulling from a long list of providers to gain the discount. The question is, what process should be used to select providers?

Approach

Although considerable effort from scores of industry experts contributed to this article, the approach they recommend is complex, time-consuming and subjective. In other words, it is impractical. Few readers will have the expertise and resources to follow the guide. Moreover, one assertion made in the article is simply wrong.

Misstatement

The article states that it would be nice to have the data, but that the data is not available. “Participants in the workers’ compensation system who want to direct workers to high-quality medical care rarely have sufficient data to quantify and compare the level of performance of physicians in a given geographic area.”

Actually, the data is available from most payers whether they are insurers, self-insured, self-administered employers or third-party administrators (TPAs). However, collecting the data is the challenge.

Data silos

The primary reason data is difficult to collect is that it lives in discrete database silos. The industry has not seen fit to place value on integrating the data, but that is required for a broad view of claims from beginning and throughout their course.

At a minimum, claim data should be collected from medical billing or bill review, the claims system and pharmacy (PBM). The data must be collected from all the sources, then integrated at the claim level to get a broad view of each claim. It takes effort, but it is doable. Yet, there remains another data challenge.

Data quality

Payers have traditionally collected billing data from providers, through their bill review vendor. The payer’s task has been paying the bill and sending a 1099 statement to providers at the end of the year. All that is needed is a provider name, address and tax ID so the payment reaches its destination. It makes no difference to payers that providers are entered into their systems in multiple ways causing inaccurate and duplicate provider records. One payment is a payment. The provider might receive multiple 1099s, but that causes little concern.

What is of concern is that when the same provider is entered into the payers’ computer system in multiple ways, it can be difficult to ascertain how many payments were made to an individual provider. Moreover, when the address collected by the payer is a P.O. box rather than the rendering physician’s location, matters become more complicated. This needs to change.

The new request

Now payers are being asked to accurately and comprehensively document individual providers, groups and facilities so the data can be analyzed to measure medical provider performance. They need to collect the physical location where the service was provided and it should be accurately entered into the system in the same way every time. (Note: This is easily done using a drop-down list function rather than manual data entry.)

Most importantly, a unique identifier is needed for individual providers, such as their NPI (national provider identification). Many payers are now stepping up to improve their data so accurate provider performance assessments can be made.

High-value, quality medical providers can be identified by using the data. However, quality data produces better results. Selecting the best medical providers is not a do-it-yourself project. Others will do it for you.

5 Tips to Reduce Outpatient Lawsuits

If a patient or her attorney believes a physician is responsible for a bad outcome at an outpatient medical facility, the facility itself will be sued, not just the physician. Therefore, it is up to the facility to have established procedures and protocols in place to deter the risk of lawsuits. Here are five tips for outpatient medical facilities that may help reduce the risk of lawsuits.

#1. Good patient communication

Communication is the No. 1 issue in any medical setting – outpatient care is no exception. Within outpatient services, patients don’t typically have the same depth of relationship with the doctors as they do with their own primary physician. This often makes them more inclined to pursue legal action in the case of a bad outcome or adverse event. If facility physicians and staff take even a few minutes of extra time to answer all questions and address all concerns, patients and their families will walk away feeling as though they had all the information – even if a bad outcome occurred.

#2. Confirmation of informed consent

The patient is at the outpatient facility because of a medical problem – usually determined by his primary physician – who then referred him to the outpatient facility. It is the facility’s job to confirm that informed consent has occurred between the patient and physician, so policies must be in place to ensure this happens with each and every patient encounter. Patients must be informed of the details of the procedure, the risks and benefits and any alternative treatment options. A procedure should not be performed until informed consent has been confirmed. When patients or their families feel they were provided all available information, they are much less likely to pursue a lawsuit in the case of an adverse outcome.

#3. Proper documentation

Documentation can make or break a case when attorneys become involved. Be sure everything is documented, including all test results as well as the date, time and subject 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 show all conversations is essential. For example, it can be invaluable to show that the referring physician was spoken to on a specific date and that the patient was given specific recommendations.

#4. Thorough and safe medical records

The outpatient setting leaves many opportunities for accidental breaches simply because so many patients are cycled through the facility on any given day. Printed medical records must be kept safe and strictly out of the public view – and that includes being locked away each night. It’s essential that facilities have protocols in place that diligently track the security of medical records at every step.

#5. Prompt diagnosis

Patients often don’t realize how long it may take for medical tests to return. Some lab tests can take days or weeks. Outpatient medical facilities must have an efficient procedure in place for obtaining results and delivering them to patients and the ordering physician in a timely manner. Let’s say a patient had an MRI because of an unidentified growth in breast tissue. If the MRI indicates suspicion for cancer, how does the facility ensure that test results aren’t getting lost in the shuffle? The cancer could spread and lead to a bad outcome. A system of checks and balances must be in place that helps the ordering physician see the results, and act quickly based on the findings. In an outpatient facility, all staff must be informed as to which test results need to be called in to the referring physician immediately.

Bottom Line – All of these reasons come back to the No. 1 issue: communication. For a busy outpatient facility, it can feel as though there simply isn’t enough time to talk to patients, but, from a risk management perspective, the importance cannot be stressed enough. It’s important to take the time to communicate every step of a patient’s care with her – to listen and answer her questions. Not only does this help to build trust, it can also minimize the risk of a lawsuit. Excellent communication between the provider and patient almost always creates a “win-win” situation.

Why U.S. Healthcare Is So Mediocre

In my capacity as benefits consultant, I often hear employees say they know we have the most expensive system in the world, but they feel that is a fair trade-off because we have the U.S. healthcare system is the best in the world.

Well, let me disavow you of that notion. Every metric measurable shows that we have a mediocre system, at best! The World Health Organization ranks the U.S. healthcare system as 37th in the world, strictly based on outcomes. That puts us tied with Slovenia but significantly behind Costa Rica, Saudi Arabia, Colombia and the bankrupt country of Greece.

Part of the reason for the poor results, I believe, is because we don’t ask hard questions on the quality of care we receive (and likely wouldn’t get answers, if we did). Does anyone know the readmission rate or infection rate of the hospital they are about to have a surgical procedure in?

Stephen Dubner of Freakonomics fame asked the following question: There are two major cardiology conferences each year, where more than 7,000 of the top cardiologists and thoracic surgeons go for one to two weeks each; what happens to the quality of care in their facilities while they are gone?

I tried to imagine: Would I want to even go to the hospital knowing the top doctors were away?

To get to the answer on quality of care, Dubner used 10 years of data from Medicare looking at more than 10,000 patients with emergency types of heart conditions (like heart attacks) so that patient choice of facility is largely removed as a variable. The baseline for the comparison against the work of these top doctors was data from teaching hospitals, even though conventional wisdom says, “Take me to the facility with the top doctors and keep me away from a teaching hospital. I don’t want any residents cutting their teeth on me!”

The answer: If you were brought to a teaching hospital for a heart attack, your mortality rate was about 15%. Mortality rate at a non-teaching hospital, with those top doctors, the week before or week after the convention was 25%! This is a HUGE swing! This means that, for every 100 heart attacks brought in, 10 more people die when the top doctors are around!

Let me put this in perspective. If you look at all treatments given for a heart attack, like beta blockers, Plavix, stents, angioplasty, aspirin….all these COMBINED reduce mortality by 2% to 3%!

Here is another interesting point. The amount of invasive treatments, like angioplasty and stents, are used in about 33% FEWER cases when the cardiologists are away.

Okay, so wait a second. Did I just say that better care is given when the top doctors are away, and, at the same time, less severe treatments are being administered and fewer dollars are being spent?

That sounds pretty counter-intuitive. Let me give my take on why.

When I think of a “top” cardiologist, an image comes to mind. He has lots of gray hair (not sure why my mind imagines a male, but it does), and has been doing cardiac surgery for decades. Does this sound about right?

Well, this doctor was trained in medical techniques 30 or 40 years ago, and he has likely been sued for malpractice, perhaps multiple times (which leads to “defensive” medicine). He frequently has ownership or at least compensation tied to the profitability of the facility where he practices. These traits lead to more care and often inappropriate (or unnecessary) care. The younger doctors, meanwhile, are less jaded by malpractice, less engaged in profits and more recently trained.

I ask you to question EVERYTHING when it relates to care. Assume nothing. One thing is clear; the more involved the patient is in her own care, the better the outcomes (and the lower the costs, too)!

Better Way to Rate Work Comp Doctors?

USA Today recently published a story about ProPublica, a nonprofit news organization that has developed a metric to score surgeons’ performance, comparing them with their peers. The study is intended as a tool for consumers, but it has generated concern among surgeons, who feel they are being treated unfairly.

What the article neglects to mention is that rating doctors and hospitals is not new in the general health world. Scoring medical providers has been a practice for decades. The Leapfrog Group, which scores hospitals, has been in business much more than 20 years. Doctor Scorecard scores medical doctors, and a Google search will offer more.

What is different about the ProPublica analysis is that it is based entirely on data and singles out surgeons treating the Medicare population. It also uses an adjustment score for the difficulty of cases analyzed called an adjusted complication rate.

The ProPublica study includes 17,000 doctors performing what are called low-risk, elective surgical procedures derived from Medicare data. The adjusted complication rate selects cases that are considered low risk, such as gall bladder removal or hip replacement. The study looks for complications such as infection or blood clots that require post-operative care, in this case re-hospitalization.

The cost of post-operative care requiring hospital readmission amounted to $645 million, which was billed to taxpayers for 66,000 Medicare patients from 2009 to 2013. Logic says that if surgical complications requiring hospitalization are so costly for Medicare patients, the costs must translate to astounding rates in workers’ compensation, as well. However, the study does not directly apply to work comp doctors.

The ProPublica study does not directly translate to workers’ compensation because the study examines Medicare patients only. While some injured workers qualify for Medicare, the majority are healthy, working adults under Medicare age.

What does translate from the study is that evaluating and rating medical doctor performance based on the data is do-able and important. However, it should not be limited to surgeons. The analysis of doctor performance must be comprehensive, accurate and fair.

Rather than using the limited measure of adjusted complication rate following surgery, a broader view of the claim and claimant is appropriate for workers’ compensation. Analysis is not limited to those cases with complications. Instead, all claims are analyzed. Results are adjusted by the claimant’s age, general health (indicated by co-morbidities), and the type and severity of the injury itself. Administrative management analyses are also important in workers’ compensation such as direct medical costs, indemnity costs, return to work, and case duration, among others.

Case complexity, sometimes presented as case mix adjustment, is important to fairness in rating doctors in workers’ compensation. Also, analyzing a broad scope of data elements smoothes the variability, leading to more accuracy. Fortunately, in workers’ compensation, claims have a very wide range of revealing data elements that can be drawn from a payer’s multiple data silos.

The ProPublica study has created pushback from the physician community for several reasons. For one, gall bladder surgery is often performed in an outpatient setting, so re-hospitalization is a meaningless metric. The same is also true for others of the so-called low-risk surgery category. Moreover, the study names names.

Published provider ratings from a national survey caused much of the angst noted in the USA article. Names were even published in local papers, naming physicians well-known in their communities. Doctors cried foul!

Expecting the general population of patients to understand what the ratings mean, regardless of their accuracy, is naive. Ratings listed as 2.5 or 1.6 have obscure meanings to the uninitiated. Fortunately, workers’ compensation providers do not face that level of exposure. Doctor ratings in workers’ compensation are not published for the general public or made available for consumer interpretation.

How to Live Longer? Drink More Coffee

This idea is taken from The Doctor Weighs In post by Dov Michaeli.

As the article says, “Coffee drinkers have a reduced risk of dying prematurely from all causes, and consequently live longer.” Coffee is a “vice” that is most worthy, and one to be embraced.

Some health attributes of coffee include reduced risks of death from:

  • Cardiac arrhythmia
  • Type 2 diabetes
  • Dementia
  • Pneumonia
  • Lung disease
  • Accidents
  • Strokes

That’s quite a list. The good news is that a 50-cent cup of coffee works as well as a five-dollar cup. Any amount of coffee is better than none. According to results of a study by the National Institutes of Health (NIH), “Compared with people who drank no coffee at all, men and women who drank six or more cups per day were 10% and 15% less likely, respectively, to die during the study.”

Don’t tell wellness true believers about this. They may want to start charging coffee-free employees a higher health payroll deduction.