Tag Archives: physician

Where To Search For Best-In-Class Doctors

No doubt you have seen the ad for Angie’s List. A good-looking male doctor is pictured with the caption, “He has been nothing but focused, dedicated and concerned about my health and well-being.” If searching for a contractor or hair dresser, this might be a good start. But searching this way for doctors? Absurd!

Finding doctors for injured workers through Angie’s List is a recipe for disaster. Subjective rating of medical treatment is not valid. Few patients understand enough about the science of medicine to venture a worthwhile opinion.

Yet, the methodology behind Angie’s List is a relatively common practice in the Workers’ Comp industry. Employers and payers sometimes survey their claimants in an effort to evaluate doctors. Unfortunately, most claimants report whether the doctor’s office has snacks, magazines they like, and the doctor was nice. The information is hardly a basis for utilizing the doctor and is about as helpful as that found in Angie’s List.

Measuring Provider Performance
Finding the right physicians for injured workers requires objective analysis of actual past performance, not patient opinions. Medical proficiency can be measured in terms of outcome, with the most positive outcomes evidenced by return to full work and reasonable medical costs. However, in Workers’ Compensation even more focus should be placed on the course of the claim from the non-medical standpoint.

Industry Research
Workers’ Comp industry research has clearly identified the attributes of good and bad medical performance. For instance, Dr. Ed Bernacki of Johns Hopkins lists characteristics of “cost intensive” physicians. The study1, using data from the Louisiana Workers’ Compensation Corporation, found that 3.8% of physicians accounted for 72% of the costs. In other words, a small number of physicians have a profound impact on Workers’ Compensation costs. Bernacki’s study identified the characteristics of these cost intensive physicians. They are elements that can be found in the data and used to monitor and score provider performance.

MedMetrics uses the results of industry research studies to design its algorithms that evaluate and score provider performance. The research identifies provider characteristics and claim events under the influence of providers that should be measured. Using those indicators, providers can be compared in their jurisdictions with others in the same specialty to identify the best-in-class.

Medicine Is A Cottage Industry
Medicine in the US is a cottage industry, with services delivered by individuals to individuals. Consequently, it is difficult for any one organization to gather enough individual provider data to create a critical mass for measurement. The problem is complicated by the fact that in Workers’ Comp states vary in fee schedules and other legal requirements so it is not valid to compare data across jurisdictions. Nevertheless, provider performance is more accurate and fairer when evaluated across many claims.

The industry needs an independent organization to collect and analyze the data across multiple organizations so that provider performance can be measured more accurately.

Master Provider Index
MedMetrics is offering Master Provider Index. Data is collected from multiple participating organizations, then validated, and integrated. Provider performance is measured across multiple entities’ claims in a state, thereby creating a richer data resource. The combined data is analyzed and provider performance is scored. Finally, a quick-search is offered online so that best-in-class providers can be found in specific geo-zip regions on demand, on-the-fly.

Not Angie’s List
Master Provider Index is not Angie’s List by any means. Provider performance analytics are based on intelligence gained through industry research and performed on data from multiple organizations by state. Based on Bernacki’s study, one can assume saving up to 72% of costs by avoiding cost intensive physicians!

1Bernacki, et.al. “Impact of Cost Intensive Physicians on Workers’ Compensation” JOEM. Vol. 52. No. 1. January, 2010.

Predictive Analytics In Workers' Compensation Made Easy And Affordable

It's a safe bet that claims will not have a happy ending if the treating physician has a history of being associated with poor claim outcomes. In fact, physicians rated poorly in analytic studies based on past performance are 100% predictive of high costs and inferior outcomes in future claims where they are involved. The question is, how can those providers be identified so they can be avoided?

Applying Analytics
Whether the cause of poor performance is misunderstanding Workers' Compensation or deliberate fraud, the claim results will be dismal. Nevertheless, in order to analyze provider performance, one must know where to find the data, what to look for, and how to apply the knowledge gained from analysis to achieve improved results.

Data can offer a clear picture of actual provider performance. Evaluating physician and other provider performance is a matter of scrutinizing the data using industry research to learn what to look for. In fact, leveraging published industry research is the way to skip the laborious and expensive regression analyses and other predictive modeling methods.

Industry Research Reveals What To Look For
Exposing substandard providers is a matter of integrating and analyzing the data to understand the course of the claim and the providers who were involved. Selecting the data items to monitor can be guided in the first instance by industry research. Organizations such as the National Council on Compensation Insurance, the California Workers' Compensation Institute, and the Workers' Compensation Research Institute continually publish their research based on data they collect from members. These organizations offer research regarding medical issues causing cost escalation in the industry, and usually make results available from their individual websites.

Search
Academia and other organizations produce and publish research, as well. The best way to access other research is to use Google or other search engines to find research studies regarding specific issues and interest areas. For instance, if the concern is low back pain, simply use Google to find research and scholarly articles on the topic as it relates to Workers' Compensation.

Indicators Of Performance
When the indicators of performance are identified, they can be tagged in the data to analyze individual providers. Providers associated with a preponderance of negative indicators will fall into the lowest class category. On the other hand, those whose results are exemplary will rise to the top — best in class.

Where To Find The Data
Billing data tells the story of diagnoses, treatments and the billed amounts. However, billing data by itself is never broad enough in scope to evaluate providers because it tells only a part of the story. Claim adjudication level data tells another part of the story. It describes the actual paid amounts, return to work, the amount of indemnity paid, and whether legal was involved. But there is more.

Analyzing Pharmacy Benefit Management data is imperative. Overuse of prescribed narcotic pain relievers is now a major concern in Workers' Compensation medical management. Prescribing excessive opioids is unconscionable, but the guilty are often not identified and avoided as they could and should be.

Provider performance should be scored by claim outcome combined with costs and other factors. Unless the initial injury was catastrophic, return to work following a workplace injury is often a function of medical management that should be measured. Analyzing multiple data indicators from disparate data sources is powerful in describing physician performance. It is also objective and fair.

Integrating The Data For Analysis
Any one Workers' Compensation data source by itself is inadequate for the purpose of evaluating provider influence. Only the broad scope of data concerning a claim can provide a clear picture of the claim and provider culpability in outcome. Therefore, collecting the data from its various sources (billing or bill review, claim adjudication systems, and pharmacy data), then integrating current and historical data are crucial steps in provider performance analytics. The next steps are identifying, evaluating, and monitoring the data elements that are indicators of performance both from the medical and Workers' Compensation viewpoints using research as a guide.

Link Analytics To Operations
Analytics results of any variety that remain in graphic form, in a brochure, or pinned to a wall are useless in the effort of actually containing costs. The findings must be functionally applied to operations to make them actionable. Information regarding best (and worst) in class doctors identified through the methods discussed here must be made available to network managers and others in a usable form. Moreover, the information should be specific, current, dynamic, easily accessible, and contain objective supportive detail. The work of analytics is not complete until its results are operationalized and actionable.