Tag Archives: quality of care

State of Workers’ Comp in California

At the 2015 California Workers’ Compensation & Risk Conference, this panel of industry stakeholders weighed in on the overall condition, including cost drivers and legislation, affecting California’s workers’ compensation system:

Moderator: Mark Walls, VP communications and strategic analysis at Safety National

David North, CEO at Sedgwick

Kevin Confetti, deputy chief risk officer at University of California

Ann Schnure, VP risk management, claims, at Macy’s

Dawn Watkins, AIC, PHR, ARM, director integrated disability management at LA Unified School District

Julius Young, partner at Boxer & Gerson

Richard M. Jacobsmeyer, founding partner at Shaw, Jacobsmeyer, Crain & Claffey

The first question was: How does the California’s workers’ compensation system compare with other states?

California ranks #1 in costs compared with the rest of the U.S. California simply has more claims that cost more money. That is why California is the most expensive and complicated state.
Every time California changes a law, the system gets more complex. What influences workers’ comp is far more than just the laws, though. The social norms are different in California. It is a unique culture of employment that affects everything. There are a lot of things that employers and the healthcare community do that are driving these costs.

Why are claims costs so expensive in the Los Angeles basin vs. the rest of California?

Injured employees are transferred away at a larger rate from the primary treating physician of the employer’s choice. There is a very different treatment pattern compared with other states, and this medical treatment is driving costs for employers. Litigation rates are higher, which is part of the culture in that area. Very often, LA attorneys try to take medical control and send the injured employees to the doctors that the attorneys prefer. Attorneys and physicians who have had long-lasting relationships are referring almost exclusively to each other. Attorneys are aggressively advertising to injured workers, and workers are responding.

What else is driving workers’ compensation costs in California as a whole?

Once an employee gets an attorney referral, it is out of the employer’s hands. The employer no longer has the authority to properly take care of the injured worker. California is the only state where, if you do not like what you are paid, you file a lien. This has nothing to do with the quality of care for the injured worker. The root of so many of these issues is the doctor community in the state. Maybe the doctors need to be trained on billing and medical treatment utilization schedule  (MTUS), but it’s believed that some may be billing higher than the fee schedule to see if someone will actually pay the higher rate billed. The most important person in workers’ comp is the injured worker. We should be spending all the money that employers pay on things like bill review on helping the worker heal. Too much of the costs that employers pay are not going to the injured worker.

What concerns do you have about current legislation and case law affecting the system?

We, mistakenly, have allowed legislation to tell us how to comply. It has become much more about the process rather than helping an injured worker get better. Doctors will say how they think they should treat, but have to send the case through utilization review, which sometimes contradicts the doctor’s opinion. This deflates that injured worker’s confidence on whether he is getting the best care. It is possible that doctors are not trained on the MTUS and keep trying to push things through the system that shouldn’t be. We should focus on how to better train doctors on the system. The system is so complicated. What employers need to do is try to stop the employees from getting into the system. We need to intervene fast. Get the employees good, quality medical care quickly and eliminate the potential for them to get stuck in the system.

How do you improve the quality of benefits to injured workers in California?

The least-likely employee to file a claim is the employee who thinks her employer cares about her. Employees are much less likely to litigate cases if the employer is providing them with good care and communication. That’s the gold standard for trying to decrease litigation. It is so important for employers to reflect on how they are treating their injured workers. Are you treating them like a member of your team or just another expense? Often, they are afraid that they are going to lose their job. Let them know what workers’ comp is and what they should expect. It is so complicated. Make sure they are well-informed and understand that return to work means they are not going to lose their job because of an injury. Claims examiners in California have a tough job. We need to hire smart people and give them appropriate workloads. They are the glue that holds everything together. California currently has a shortage of qualified adjusters, and it is a large problem. The industry, as a whole, needs to contribute to this issue so we can get quality people interested in this career path.

It's Not Cost, Stupid – It's Care Transparency!

In my article last month — Care Transparency: What Employers Are Missing! — I wrote about how employers are missing an understanding of how employees are making health care decisions, and how that crucial factor impacts health care costs.

Employers need to meet employees where they are — online. Employers need to provide them with tools that can help their research and decision-making process with robust, accurate, unbiased and evidence-based information. Employers can significantly improve the quality of care consumed by their employees and reduce health care costs by focusing on creating care transparency.

In this article, we have explained the types of tools that will be effective in supporting employee decisions and that employees will really use in making care and treatment decisions. WiserTogether's research of patient decisions across the top 200 health conditions shows that of the 22 unique factors that patients typically use in evaluating treatments, quality of care tops the list. Cost does not even make the top five. In other words, cost is not the primary decision driver for patients, and consumers do not seek out cost tools when they begin making decisions. This explains the low utilization that organizations see when they offer cost transparency tools as a stand-alone service.

Health Affairs1 recently published an article that found that patients object both to discussing health care costs with clinicians and to considering costs in deciding among comparable clinical options. It is also well-known that despite the payer's best efforts, patients do not factor in payer and employer cost burdens when making health and care decisions, despite the fact that payers cover a majority of the costs. Economists have a term for this phenomenon that patients exhibit, called the “Tragedy of the Commons.” This concept means individual decision making is driven by personal benefit and ignores the implications of those decisions on third parties and the common good.2

Studies show that patients faced with a treatment decision can only process a limited number of factors. In its 2012 research that showed quality of care is the most important factor patients consider when making health care decisions, WiserTogether found that only seven of the 22 factors carry enough weight to qualify as first-tier factors for patients. Those seven factors are explained below.

Importantly, patients also indicated differences in how open they were to information about a factor coming as an expert opinion versus information coming in the form of experiences of other patients.

WiserTogether found that for the following four factors, patients want accurate information about the experiences of other patients. For each treatment, patients wanted to know the following:

  • Treatment Effectiveness — How effective did other patients say the treatment was for them?
  • Treatment Popularity — What percentage of patients in a situation like mine use the treatment?
  • Treatment Speed — How fast did other patients start to see a difference, and how long was the recovery?
  • Treatment Side Effects — What side effects have other patients experienced, and how severe were they?

For the remaining three factors, patients wanted expert opinion:

  • Scientific Evidence — Which treatments are best supported by medical evidence?
  • Consequences of Delay — What might happen if I wait to have the treatment or decide not to have it?
  • Treatment Duration — How long will the treatment last?

The results seen were independent of whether the information was available. Patients ranked out-of-pocket costs as a second-tier factor they are willing to consider when making a health care decision. Patients also report that finding information about any of the seven top-tier factors is extremely hard, and the current tools/support systems provided are inadequate.

Research has shown that patients seek out such information prior to making a health care decision, and the information gathered influences their commitment to follow through on a treatment.

Employees repeatedly state that they are overwhelmed with health information and need help finding content that is relevant to their situation. Tools that help them understand their options, evaluate those options based on personal preferences and constraints, and succinctly communicate their questions and concerns to their providers can supply the missing link. Treatment selection and shared decision support tools — whether used by the patients directly or in consultation with a provider — help support patient decisions and effective interactions with providers.

Effective and engaging tools need to offer the following:

  • Personalized treatment selection based on the patient's demographics, co-morbidities, personal preferences, and financial constraints.
  • Need to provide (at least) the seven top-tier decision-making factors to assist employees' evaluation of options along with cost and plan coverage.
  • Be easily accessible online anywhere, including at point of care set-ups.

Employees are adopting these tools at very high rates, as these tools are aligned with the natural behavioral process people follow in making health care decisions. Such tools are helping employees become informed health care consumers who understand choices and are able to make wiser choices based on their values. These tools also are helping to reduce the knowledge gap between the providers and patients and to create more confident health care consumers who can start engaging with providers in making shared and effective health care decisions.

Having said that, WiserTogether's Patient-Centered Care Index (PCCI) shows that the provider community is a long way from treating patients as an equal partner. In my next article, I will write about specific areas where providers are underperforming in delivering patient-centered care and how they often treat themselves differently than they treat their patients.

This article is co-authored with Gregg Rosenberg, Ph.D., Chief Product Officer at WiserTogether, Inc. and author of A Place for Consciousness (Oxford University Press).

1 “Focus Groups Highlight That Many Patients Object To Clinicians' Focusing On Costs,” Sommers, Goold, McGlynn et al.; Health Affairs, 32, no.2 (2013): Pgs 338-346.

2 “The Tragedy of the Commons Revisited,” Rafid Fadul; New England Journal of Medicine, no. 10 (2009): Pg 361.

Medicare Implements Value-Based Purchasing

aka Medicare Tries Some New Carrots and Sticks!

Effective October 1, 2012 Medicare is rolling out its new incentive program for hospitals where 1% of hospital payments are withheld by Medicare in a “pay for performance” or P4P program, with incentives paid out based upon performance against 20 quality metrics. Seventy percent of a hospital’s score will be based on 12 specific measures based upon performance to guidelines and protocols. The remaining 30 percent of a hospital’s value-based purchasing payment will be based on how it scored on random surveys of patients following discharge. These questions include ones asking how well their doctors and nurses communicated, whether rooms were clean and quiet and whether pain was dealt with promptly. Overall this is expected to redistribute nearly $1 billion among hospitals serving Medicare patients. These payments are funded by the 1% hospital withhold.

In addition, Medicare is also assessing a penalty to more than 2,200 hospitals with higher than average readmission rates. Hospitals with the highest rates for heart attack, heart failure and pneumonia patients will lose 1 percent of their regular reimbursements. This is expected to result in almost $300 million of savings. The penalty grows to 3% by October 2015.

This activity is a new step for Medicare. Before now its pay for performance programs were limited to those voluntarily participating in various programs. The new programs are mandatory for most acute care hospitals.

So what does this mean for the consumer? Is this a good things or a bad thing? Many are fearful that the government is starting to seriously meddle with their opportunity to get good health care. Some fear that hospitals are going to be pushing people out of the hospital too soon. Some are afraid that hospitals are going to be motivated more by the money than by what is right.

As a health care consultant who has practiced in this area for most of my 41+ year career, I am pleased to say I am more encouraged about this initiative than discouraged. This effort is a net positive to our quality of care. Here are some of my comments and reactions:

  • Quality of care can readily be measured and compared to evidence-based clinical guidelines: The P4P program implemented by the government includes both specific clinical measures and direct patient surveys. It’s not just based upon the numbers, but includes both measurable performance criteria and actual patient experiences. Today our firm’s studies show that a significant portion of inpatient care historically reimbursed by Medicare is potentially avoidable. Longer than needed hospital stays generally reduce the quality of care and create a significant opportunity to acquire hospital based infections (e.g., MRSA) or perhaps even incur an injury or accident while hospitalized. The bottom line — hospitals should not be a desired place to be unless you are getting needed care only available in a hospital. One physician once stated, “hospitalization is a bad outcome of ambulatory care”.
  • Behavior follows reimbursement: As hospitals are motivated to perform better they will find a way to accomplish that. As with most businesses, when held accountable they will perform. In the past, performance wasn’t a high priority and our results demonstrate that quite nicely. Hospitals for the most part have been paid on a fee-for-service basis, getting more for doing more.
  • Incentives have to be meaningful: I am concerned that the 1% withhold will not have an adequate impact on the performance change. One percent falls into the “rounding” category. Until more meaningful the performance change will not be adequate. Our studies suggest that as much as 35% – 45% of today’s Medicare hospital days are potentially avoidable. Until we see the chance for major improvement we are still only impacting the edges of our opportunity.
  • Redo’s are unacceptable: Readmission for particular conditions are evidence that the previous admission ended poorly. Sometimes patients are not appropriately treated or diagnosed and more work is required. Early discharge when care is not completed appropriately is a sign of bad quality. Early or prompt discharge when care is completed is a sign of good quality. Lengths of stay are generally too long or excessive on the average, not on every patient. However, you have to identify which patients can be discharged on a timely basis. Statistics show that as much as half of Medicare patients fall into a category known as the “uncomplicated” patient, a patient that can match ideal performance and medical criteria. The other half of the patients require additional care because of delayed recovery and other complications. The high quality institution will monitor and measure this and keep those needing longer stays and discharge those which no longer need care without delay. This incentive program is a good thing and those hospitals not appropriately discharging their patients need to be held accountable. Kudos to Medicare for this bold step.
  • “Early” might not be “too early”: Many times individuals complain that someone was discharged too early. In reality the standard many patients and family members use to determine this is flawed. It might be earlier than what someone else experienced, but it doesn’t necessarily mean it is too early. Timely is important. Health care resources are scarce and we should only use them when appropriate. An extra day here and an extra day there adds up to significant waste. The average net charge per day in my region is close to $4,500. Is it really worth $4,500 to stay in a setting that is really not much better than a not-so-fancy hotel? Evidence based clinical criteria helps everyone understand when a patient is appropriately progressing towards discharge. When built on the most efficient path, with monitoring for indications that complications are necessary which might require additional days, patients are more appropriately discharged. As a result, costs go down, patients experience higher quality, and re-admits are reduced.

Medicare has introduced some useful and very helpful tools to improve our health care system. The private sector is already using many of these tools and will model more after these programs. Hopefully this will provide an improved foundation to make even more improvements to our health care system.