Tag Archives: infection

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.

OSHA Should Help on Infectious Diseases

OSHA’s promulgation of an infectious disease rule/standard to protect healthcare workers and employees in healthcare facilities from microorganisms that cause illness and infection would be a welcome expansion of the work OSHA has already done related to bloodborne pathogens.

A standard of national caliber would not apply any more pressure to healthcare employers than they already place on themselves to protect the patients and healthcare workers they serve. On the contrary, a rule would highlight the importance of the safety and health of healthcare workers.

However, just when we, as a nation, are designing programs to protect healthcare workers from exposure to emerging infectious diseases, like Ebola virus, small businesses say, “No thanks, OSHA, we’re all good.” Just recently, the Small Business Advocacy Review (SBAR) Panel issued a report to OSHA Assistant Secretary Dr. David Michaels that said small healthcare businesses (to include ambulatory surgery, doctors’ offices, dental offices, specialty clinics and dialysis centers, to name only a few) weren’t interested in better protections for their workforce.

Small entity representatives (SERs) decided that the guidance that is already in place is good enough and that OSHA would just be adding more requirements. The SBAR report stated:

Many SERs felt that this rule would overlap with and/or duplicate other relevant guidelines and regulations, including, for example, materials issued by the Centers for Medicare and Medicaid Services (CMS), the Joint Commission and other voluntary accrediting organizations, and state accrediting boards.

SBAR has a point: Guidance is in place from CMS, the Joint and others, like CDC. But the guidance is almost completely to protect the patient, not the worker.

The American Public Health Association (APHA) disagrees with the SBAR panel and firmly believes that an OSHA standard should be fast tracked to protect the working public. The APHA issued a national policy statement just last month.

We learned from the Ebola exposures in Dallas that those infected after exposure were the healthcare workers, not other patients. If a patient enters an emergency department feeling generally ill, it is not typically the other patients who are potentially exposed to a yet-to-be-identified pathogen; rather, it is the string of healthcare workers with whom the patient comes into contact. Those include workers who examine the patient, take vitals, take blood or other specimens, assess, diagnosis and eventually treat. In the case of the Dallas Ebola victim, that was dozens of healthcare workers both in and outside of the hospital over more than a week’s time.

The population of healthcare workers that a standard like OSHA’s infectious disease standard could protect is vast. It is typically in smaller healthcare settings that greater protections are needed, as these operations often intersect more closely with the community and have lesser controls in place compared with hospitals or larger health systems. In fact, nearly 10% of the U.S. working population is employed in healthcare settings of all sizes, and healthcare will generate millions of new jobs through the next decade (Bureau of Labor Statistics 2013). This sector of the workforce represents the largest segment of employment growth in the U.S. and serves the largest proportions of Americans, ensuring proper and timely diagnosis, treatment and care. Healthcare employment is marked as the industry sector with the largest growth (2.4%).

Better controls to protect our most important healthcare assets — its workers — are needed now.

OSHA’s bloodborne pathogens standard (BPS) alone will not address these important and constantly emerging occupational risks associated with hazards that are not often visible to the naked eye.  Promulgating an infectious disease role nationally, much like CalOSHA did with its aerosol transmissible diseases standard (ATD, §5199), would provide OSHA the opportunity to work with healthcare facilities and providers of care to develop standards that protect their employees from not just physical or chemical hazards, but biologic ones. Healthcare facilities would have the ability to control the environment of patient care and make it safer for all who enter: patients, family, friends, volunteers, contractors and caregivers alike.

This standard, if done right, has the potential to provide the following benefits:

–       Prevent transmission of microorganisms that cause illness and infection

–       Improve safety for healthcare workers

–       Make care for patients safer

–       Increase the viability of the healthcare work force and the healthcare economy

–       Reduce costs associated with workers’ compensation, time away from work, staff turnover

–       Provide a collaborative, bridge-building role with other U.S. agencies like CMS, CDC and the Food and Drug Administration (FDA)

–       Serve as a model for other countries

OSHA’s continued journey down the path of promulgating an infectious disease standard illustrates the role that it can play in bridging the gap between infectious disease and occupational safety and health experts.