Tag Archives: medical provider network

Legislative Preview for Work Comp in 2016

Common wisdom suggests that major workers’ compensation legislative activity won’t take place during an election year. For 2016, that would seem to hold true.

That is not to say, however, that various interested parties will be sitting idly by, waiting for the clock to turn to 2017.

CENTERS FOR DISEASE CONTROL ADD TO THE LIST OF CHRONIC PAIN GUIDELINES

On Jan. 13, the Centers for Disease Control and Prevention (CDC) closed the public comment period for its proposed Guideline for Prescribing Opioids for Chronic Pain. According to the CDC, the guideline is being proposed to offer “… clarity on recommendations based on the most recent scientific evidence, informed by expert opinion, with stakeholder and constituent input considered.”

The guideline goes to great lengths to address two important issues. The first is that current guidelines in many states – both public and private – are based on dated information. The second, which is critical, adds to the growing number of voices to say that best practices for providers include accessing physician drug monitoring programs (PDMP) to reduce the risk of doctor shopping and toxic – and sometimes fatal – mixtures of prescription drugs when the patient provides incomplete histories or none at all of their drug use (both prescription and illicit).

This need to access a PDMP before, and during, treatment with opioids is echoed by the Medical Board of California (MBC) and the DWC. Their comments also underscore a considerable problem facing California policymakers when trying to create incentives for providers to use the Controlled Substance Utilization Review and Evaluation System (CURES) without directly mandating access.

This dilemma is best summed up by the analysis of Senate Bill 482 by Sen. Ricardo Lara (D – Bell Gardens) that is at the Assembly Desk pending referral to committee. The bill, which would mandate participation in the CURES system as well as other measures to curb the abuse of opioids, has garnered opposition from medical associations and one medical malpractice insurer. The opposition, according to analyses by legislative staff, is based on two issues – the first being whether the CURES system is capable of handling the volume of inquiries a mandate would engender, and the second being concern that requiring CURES access will become a standard of care that could subject providers to malpractice liability.

As to the former, this issue arose during the campaign waged against the 2014 ballot measure Proposition 46. According to the non-partisan Legislative Analyst’s Office (LAO), “Currently, CURES does not have sufficient capacity to handle the higher level of use that is expected to occur when providers are required to register beginning in 2016.” This raises an important question – does the CURES system now have the capability to meet the demand that a mandate would create? If it doesn’t, then the legislature needs to understand why.

As to the second issue, it is difficult to comprehend the level of distrust that is subsumed in the position that opposing a mandatory review of possible prescription drug abuse by a patient would establish more potential malpractice liability than knowing that the CURES database exists and not checking it. In time, perhaps, it will be the appellate courts that resolve that issue.

There is no shortage of guidelines that address the appropriate use and cessation of use of opioids for non-cancer chronic pain. The DWC is finalizing its latest iteration on this issue as part of the MTUS. It will differ from both the CDC and the MBC guidelines to some degree, but the overall treatment of this issue is very similar. In addition, the division will be implementing a prescription drug formulary as required by Assembly Bill 1124 by former Assembly member Henry Perea (D – Fresno). That, too, will likely provide opportunities to address the proper use of opioids in the workers’ compensation context, preferably after the chronic pain guidelines are completed.

As noted by the CDC and the MBC, and implicit in the DWC’s guidelines, this is not just a question of UR. If all the work by the division is simply viewed as a more effective way of saying “no” regardless of the circumstances, then the public health issues associated with the abuses of opioids will continue.

Workers’ Compensation Insights is a bi-monthly publication of Prop 23 Advisors. Subscribers will receive in-depth analyses of pending California legislation and regulations, review of important WCAB and appellate court decisions and commentary on trends within the system in California and nationally. To read the rest of this newsletter, click here.

Are MPNs Hindering Quality Care?

Have medical provider networks (MPNs) lived up to expectations of improving access to quality of care while reducing medical costs? Recent accusations raised against Janak K. Mehtani, M.D. (“Mehtani”) before the Medical Board of California, Department of Consumer Affairs, would suggest not. (Specific details relating to case # 02 2012224474, effective Jan. 13, 2015, are available on the Medical Board of California website, under the option “Verify a License.” At time of writing, a hearing had not been held, and the case status description states, “The physician has not had a hearing or been found guilty of any charges.”

Following the investigation of a lodged complaint relating to this case, the executive director of the Medical Board of California raised the following accusations (1) gross negligence, (2) repeated negligent acts, (3) prescribing dangerous drugs without appropriate examination or medical indication, (4) failure to maintain adequate and accurate medical records and (5) general unprofessional conduct.

These accusations relate to three workers’ compensation claims for services provided between 2008 and 2013. Two claims were identified as belonging to State Compensation Insurance Fund (“SCIF”) (patients JC and RW) while the insurer for the third claim, involving a non-English-speaking 47-year-old female with a history of hypertension and chronic pain (patient GC), was not identified.

This article reviews the claims administrators’ implementation of MPNs with reference to patient GC in the Mehtani case.

Insurers promote their MPNs as being quality medical providers who have undergone extensive credentialing before selection, with continuing quality assurance control of their services. Yet a random sample of insurers’ MPN lookup facilities showed Mehtani — a psychiatrist with a practice Sacramento — being currently available to provide treatment, even though there are very serious accusations currently lodged against him. There is no warning, link or reference to the medical board website to alert an injured employee or the employer.

Information shown on claims administrators’ MPN websites to assist an employee in selecting a provider or medical specialty, such as a psychiatrist, is limited to basic contact details, such as address, phone number, distance from a specified location (such as city or Zip code), gender and language. In the case of Mehtani, there is inconsistency in the list of languages spoken; some MPNs list Hindi and Punjabi, while others include Spanish. Does providing only minimal information limit the opportunity for correctly “matching” the patient (i.e., injured employee) to the medical provider, potentially compromising the physician-patient relationship?

Additional information in psychiatry would provide better opportunities for matching patient with psychiatrist. Sub-specialties such as psychosomatic medicine, addiction medicine or administrative psychiatry play key roles in the selection process. So do special interests such as psychopharmacology and pain management and additional training in psychoanalysis at institutes such as the American Psychoanalytic Association (APsaA). Rapport between the psychiatrist and patient is of paramount importance and is assisted further when matching is based on race, ethnicity and cultural groups.

While a review identified 120 psychiatrists located within two miles of the central business district of Sacramento (CBD), a random selection of insurers’ MPNs identified only one psychiatrist, in this case Mehtani, as being within 200 miles of the CBD. Can this list be considered adequate for the employee to choose a psychiatrist, let alone attempt to “best match” a patient to a psychiatrist?

Some researchers suggest that, in patients with chronic pain, a psychiatrist may be the person best qualified to distinguish between medical comorbidity and concomitant somatic complaints and that the patients require careful multidisciplinary treatment, in which psychiatry can play an important role. Patient GC experienced a number of work-related injuries commencing in 2003 and was first seen by Mehtani in 2008, after experiencing depression and anxiety for two to three years. In line with a multidisciplinary treatment plan, Mehtani referred patient GC out for pain management and to a therapist for cognitive behavior management. Mehtani was to manage medications and provide supportive psychotherapy once a month for 12 months.

But who was responsible for approving and selecting the providers’ Pain management providers are generally listed on MPN lists, but a random selection of MPNs found that cognitive behavior therapists and others providing cognitive behavior therapy, such as psychologists, mental health nurses and psychiatrists, were either not listed or not identified as providing cognitive behavior therapy. This lack further demonstrates the limitations of MPNs in selecting medical providers.

In the multidisciplinary or multidimensional approach to addressing chronic pain, an interdisciplinary approach is also required to maximize a psychiatrist’s role in the treatment plan, where all parties involved work in a coordinated fashion. The overall responsibility of ensuring the multidisciplinary team adheres to a common objective rests with the claims administrator. In the case of patient GC, the claims administrator should have been responsible for all the activities performed by the psychiatrist (Mehtani), the pain management provider, the therapist providing cognitive behavior therapy, the primary treating physician and the pharmacist in cases where medications were being dispensed by an insurer’s pharmacy network or a pharmacy was linked to an insurer’s pharmacy benefit manager (PBM). Pharmacists and pharmacies can be held accountable for failing to identify and verify red flags that may appear when a prescription is presented. In the Mehtani case, the issue of prescribed medications is being raised in the accusations.

Documentation required by psychiatrists has been an issue of contention for some time, with many psychiatrists believing that they do not need to perform the same level of documentation generally required for “physiology-based medicine.” Lack of documentation has also been raised in the Mehtani case.

Quality assurance controls for providers can be accomplished in many ways, including automation. Technology is available to monitor diagnoses (DSM-5, ICD-9 and ICD-10), treatments rendered (CPT codes) and pharmaceuticals dispensed through the National Drug Code (NDC) to track treatment and recovery progress, as well as monitor each provider’s contribution to the objectives set by the claims administrator.

Patient GC had 40 visits for “medical psychoanalysis” with Mehtani between 2010 and 2013. All visits would have been invoiced by Mehtani and would have required documentation before payment was made. As lack of documentation was mentioned in the accusation document for all three patients, how was the claims administrator monitoring treatment progress and determining payment for services rendered over the period that Mehtani treated patient GC and the others?

The current health status of all three patients and whether they have returned to normality has not been stated in the accusation document. Patient GC was first injured in 2003, patient JC was injured in 1989, and no injury date was recorded for patient RW. Regardless of the outcome of the Mehtani hearing, could the injured employees file a tort claim against the insurer as to lack of quality care provided by their MPNs? Could a tort claim be filed by the employer against the insurer with regard to lack of controls to vet and verify costs associated with providing medical treatments by their MPNs? Although tort claims by the employee against the employer are not permitted under the workers’ compensation agreement, the insurer and claims administrator are not direct parties to this agreement.

The question remains unanswered, of whether current workers’ compensation medical treatment practices based on group health managed care programs, such as MPNs, are diametrically opposed to the workers’ compensation ethos of “return to work” where “utmost good faith” between interested parties is the aspiration. This article however, suggests that they most probably are diametrically opposed.

For a more detailed outline of the processes and procedures claims administrators can utilize to manage and monitor their medical providers, refer to the article titled, “Treating Pain Pharmacologically,” available from the website managingdisability.com under the Dialogue tab.

How to Manage MPNs in Workers’ Comp

A recent study of the use of medical provider networks ( MPNs) in California by the California Workers’ Compensation Institute (CWCI) found that, “While the use of the networks to medically manage treatment of work-related injuries has fulfilled the legislative intent to encourage network use, over time the MPNs have not lowered the cost of medical care.”

David DePaolo, CEO of WorkCompCentral, says medical cost savings is only part of the picture. MPNs need to be managed because the medical impact on other aspects of claims such as disability, indemnity, return to work and other factors is significant.

So how should networks be managed?

Networks can be managed only by evaluating and monitoring individual performance.

A network is the sum of its parts, the parts being the physicians and other medical providers. A network cannot be managed as a whole. Each individual medical provider acts independently and with differing results. Moreover, each provider, even within groups or facilities, acts independently. Consequently, each must be evaluated and managed individually.

Since networks began in workers’ comp back in the 1980s, their rationale has been that they offer discounts off stated rates for services, which they portray to payers as savings. The assumption is that all medical providers are equal. But no one checked.

No one checked because it was easier to claim savings through discounts than to evaluate the performance of individual medical providers in the network. Evaluating medical performance is especially tricky in workers’ compensation because, in addition to cost and medical treatment factors, there are elements unique to the industry that must be considered. Indicators of quality performance are many and varied.

But indicators can be found in the data. They include medical treatment indicators such as direct medical costs, prescriptions, surgery, hospitalization and medical procedures analyzed by injury type. Non-medical performance indicators that are influenced by medical providers include return to work, indemnity costs and legal involvement, along with ultimate outcome indicators such as claim closure and disability ratings at the close of the claim.

The way to manage networks is to use the data to identify the best providers and monitor their performance.

The data necessary to evaluate medical provider performance, particularly physician performance, can be found in bill review data, claims system data, pharmacy data and the utilization review system. Unfortunately, the data resides in different silos, but, by combining the data from these sources at the claim level, individual provider performance can be measured.

Because the data reflects actual treatment and events, it is objective and quantifiable. Select quality indicators in the data, adjust for case mix and keep them constant over time.

Medical costs have increased to 60% of claim costs, calling into question the benefit of network discounts. The truth is that medical providers long ago learned how to overcome the cost of discounts by increasing treatment frequency and claim duration, as well as prescribing expensive procedures, among other tactics.

Going forward, the major hurdle in managing networks effectively is to de-emphasize discounts, while underscoring and rewarding quality performance. To make that financially feasible for the networks, a different approach to discounting should be entertained. For instance, those providers who rate highest in quality performance would be excused from discounts. Likewise, those performing the worst would be discounted the most.

To manage a network, the performance of individuals within it must be evaluated and monitored continually. No longer does it suffice to sign up providers for the network and walk away. When individual provider ratings slip, action should be taken.

Let providers know they are being monitored. It has been proven that observed performance leads to behavior change.

Portrait of a Smart Medical Provider Network in Workers' Comp

Smart is cool, especially in electronics. Smart phones answer their users' most obscure questions instantly. Computers are smart, as are iPads, some TVs and even children's toys. So why can't workers' compensation medical provider networks be smart?

If they were, what would that look like?

Portrait of a Smart Medical Network

A smart medical network contains only the best doctors and other medical providers, those who drive the best results for injured workers and their employers. Moreover, a smart network does not rely on discounts on services as the requirement for participation. Instead, demonstrated positive outcomes are the qualifier for medical provider participation and continuing excellence.

Smart Networks Are Local

A network containing thousands of doctors is of no value to the injured worker. Workers need the closest provider who will treat them effectively and return them to work. The worker’s employer likewise needs the best local provider who will return the worker to pre-injury status in the shortest amount of time at the least cost. Smart networks are composed of this kind of medical doctors.

Network Participation Qualifiers

Smart networks are built by objectively measuring the performance of physicians who have actually treated injured workers. Objective evidence of performance is found in the data. Yet, indicators of performance are typically ignored in traditional networks. They do not measure or monitor the quality of provider performance. They simply contract with any providers and add them to the network directory.

Indicators of Quality

Many indicators of performance found in the data can be used to measure the level of provider performance. In the case of medical treatment of injured workers, the most telling indicators reveal doctors’ awareness and acknowledgement of the nuances of workers’ compensation that ultimately benefit both injured workers and their employers.

Revealing data elements influenced by the treating physician include return to work, medical costs, indemnity payments, legal involvement and disability status at the close of the claim. These outcome indicators in the data are important markers of quality and legitimate criteria for evaluation. Algorithms are executed using the indicators, and providers are scored based on their performance. Performance measurement must be objective and consistent. But performance measurement cannot end there.

Continuous Monitoring

To ensure continued quality, the data must be continuously monitored. Unlike traditional medical networks that contract for discounts with medical providers and go no further, smart medical networks for workers’ compensation continue to monitor for quality. Continuous monitoring is the very definition of medical management:

Good management is making sure what you did stays done!

California SB 863

In fact, California SB 863, effective Jan. 1, 2014 (now!), mandates continuous monitoring of medical provider costs and quality performance. This progressive legislation is an excellent model for selecting and monitoring smart medical networks, regardless of geographic location.

Establishing a smart medical network is essential, and the means are clear and available. However, the transition from traditional networks to smart medical networks can be tricky.

Converting to Smart Networks

Traditional networks are tethered to their established means of revenue generation. Shifting from the discount network model to the smart medical network model is challenging. The most practical approach is initially combining the two models, then weaning from the old model over time.

If the right physicians are a part of a smart medical network, claim outcomes will improve. Injured workers will receive good medical treatment and return to work early and successfully, and costs will be significantly reduced.

Moreover, physicians and other providers who qualify for smart networks should be rewarded. They should not have their fees reduced by discounts. Based on the excellence of their past performance, they should be included in the smart network on a very long leash. Continued performance for continued participation will be monitored scrupulously.

Win-Win

Nevertheless, it should be noted, payers have an obligation to participate in the transition to, and continuation of, smart networks by recognizing and paying for value received. Networks need support and cooperation from payers to integrate and analyze their data, score provider performance and realign medical provider preferences. The benefits will accrue to everyone: payers, networks, employers and injured workers.

Data Participation

Importantly, to achieve optimum results, data must be gathered from multiple sources and integrated for comprehensive claim analysis. Data from only one source, such as bill review, is sorely deficient for accurate analysis of medical provider performance. Claim system and pharmacy data must be added to bill review data at a minimum. Shortcuts in data gathering and analysis are not defensible.

Change Momentum

Network administrators are gradually stepping up to the challenge of shifting to smart networks. Momentum toward smart networks will be exponential with payer participation, resulting in quality improvement and cost control all around.

Moneyball and the Art of Workers' Comp Medical Management

Recently, I watched “Moneyball,” the movie, for the third or fourth time. The story is compelling, as is the book by the same name that preceded it.1

“Moneyball” is based on the concept called Sabermetrics, defined as “the search for objective knowledge about baseball.” The central premise of “Moneyball” is that the collective wisdom of baseball insiders, including players, managers, coaches, and scouts over the past century, is subjective and flawed. The book argues that the Oakland Athletics general manager, Billy Beane, took advantage of analytic, evidenced-based measures of player performance to field a team that could compete successfully against far-richer teams in Major League Baseball. During the 2002 season, the Oakland A's won enough games to make the playoffs in spite of a meager salary budget and “inferior” players.

Even though the two industries are diametrically dissimilar, distinct parallels can be drawn between baseball and workers’ compensation medical management.

Similar Resistance to Analytics

One similarity is the resistance to adopting analytics as a knowledge tool. Baseball insiders and managers opposed Beane’s analytics, sometimes vehemently. Long-held beliefs among baseball insiders promoted measures of performance such as stolen bases and batting averages. Beane’s metrics debunked the old methods, revealing unrecognized strengths in lesser-known, more affordable players.

Similarly, workers’ compensation leaders have relied on traditional medical provider networks and personal preferences to select medical doctors. If doctors are in a network and offer a discount on medical services, all is good. Yet, industry research has shown that not all doctors are equal. Doctors and other medical providers who understand and acknowledge the nuances of workers’ compensation drive better outcomes. It’s a matter of finding those doctors.

Finding Best Performers

The purpose of “Moneyball” Sabermetrics is the same as workers’ compensation medical metrics—to find the best performers for the job. The way to do that in baseball is to analyze the data defining actual performance in terms of outcome—games won. In workers’ comp, the data must be scrutinized to find doctors who drive positive claim outcomes. In both cases, a variety of metrics are used to support the most effective decisions.

Performance Indicators

As in baseball, the goal in medical management is to apply objective information to decision-making using evidenced-based measures of performance. For both industries, cost is a factor. However, in workers’ compensation, the cost of medical care must be tempered by other factors:  What is the duration of medical treatment? What is the return-to-work rate associated with individual doctors? What providers are associated with litigated claims?

As in baseball, the list of indicators for performance analysis is long. However, the sources of data differ significantly.

The Data Challenge

In baseball, all the data necessary for analysis is neatly packaged. Statistics are gathered while the game is in progress. In workers’ comp, the data that informs medical management resides in disparate systems and must be gathered and integrated in a logical manner.

Essential data lives in bill review systems, claims adjudication systems and pharmacy (PBM) systems and can also be found in utilization review systems, peer review systems, and medical case management systems. The data must be integrated at the claim level to portray the most comprehensive historic and current status of the claim. Data derived from only one or two sources omits critical factors and can distort the actual status or outcome of the claim.

Once the data has been integrated around individual claims, meaningful analysis can begin. Indicators of performance can be analyzed with new conclusions drawn about the course of treatment and medical provider performance. Moreover, concurrently monitoring the updated claim data leads to appropriate and timely decisions.

Data Positioned as a Work-in-Progress Tool

In baseball, the data is used as a work-in-progress information tool. Decisions about the best use of players are made daily, sometimes hourly. Workers’ compensation medical management can do the same. Systems designed to monitor claim details and progress can alert the appropriate persons when events or conditions portend complexity and cost.

Industry Status

Analytics in baseball is not exclusive to the “Moneyball” Oakland Athletics. All of Major League Baseball now relies heavily on its use. Unfortunately, there are still only a few visionary Billy Beanes in workers’ compensation medical management. Yet, applying analytics for cost and quality control is simple and affordable and can be adopted quickly by all.

1Lewis. M. Moneyball: The Art of Winning an Unfair Game 2003. The film “Moneyball”, starring, Brad Pitt was released in 2011.