Tag Archives: silo

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?


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.


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.

Move Workers’ Comp Out of the Silo

Over the last three-plus decades, employers have grappled with dramatic increases in healthcare and workers’ compensation costs, according to the Centers for Medicare and Medicaid Services. Workers’ compensation costs climbed more than 40% just in the last five years in California, according to the Oregon Workers’ Compensation Premium Rate Ranking Summary. At the same time, the lost time and productivity associated with injuries and illnesses add to the urgency to find a new approach to managing these costs.

Wellness programs that support and encourage employee health are popular, deployed today in more than 60% of companies with three or more employees, according to Kaiser Family Foundation and Health Research and Educational Trust research. While some believe that the benefits of wellness programs are overstated, all of the recent attention on wellness and the costs of healthcare and workers’ compensation warrants a new look at the bigger picture.

Employee health and its associated costs continue to be managed in a silo — separate from, and somehow unrelated to, workers’ compensation and “lost time” programs. Yet, these initiatives are related, and smart companies should be integrating data around workers’ comp, healthcare and productivity, to identify ways to support employees, thereby reducing costs, increasing productivity and ultimately resulting in a healthier workforce.

Breaking Down the Silos

In many organizations, group health plans and workers’ compensation programs are managed separately, often with finance responsible for workers’ compensation and HR managing the health plan. Because of the occupational/non-occupational nature of the claims — and the two distinct systems for their management — this historic division made sense when overall healthcare costs were a small component of organizational spending.

However, research is finding that viewing these programs — along with their corresponding components, such as safety, wellness, disability and leave management — as competing concerns in separate silos is short-sighted and counterproductive.

For example, based on recent research by Kaiser, we now know that smokers in the workforce are 40% more likely, and obese workers twice as likely, to have a work injury than non-smokers or leaner counterparts. Other corresponding data demonstrate similar links — obese workers who have a work injury generate seven times greater medical costs and spend 13 times more time away from work.

Organizing in traditional silos can create a hidden incentive to shift cost and risk to another internal program (“that injury happened on the job, didn’t it?”) rather than working together to reduce or eliminate the costs for the benefit of the company as a whole. Viewing these issues in a vacuum masks the true nature of healthcare costs, as is easily seen when data is analyzed in an integrated fashion. The traditional silos prevent organizations from (a) realizing improved productivity and the profit it brings and (b) maximizing the potential of internal efforts such as safety or wellness programs.

Taking an Integrated Approach

Kaiser Permanente has studied this approach and offers some startling numbers. Figures provided by the Workers’ Compensation Insurance Ratings Bureau of California (WCIRB) show the losses per indemnity claim nearly doubling since 1998, to a total of nearly $90 billion. The holistic view provided by new data enables Kaiser to look at employee health, workers’ compensation and workplace safety through a broader population health management lens.

Other insurance companies are starting to roll out programs that look at synergistic and more holistic opportunities for employee health to drive down costs, improve productivity, boost the bottom line and help employees enjoy better health. These programs help companies understand the total cost of health and safety by looking at the employee benefits and workers’ compensation costs, as well as absenteeism and “presenteeism” (an employee who is physically present at work but unproductive because of health problems or personal issues). These programs look at lost productivity, as well as identifying the specific risk factors that are driving up costs. By determining what can be modified, and creating specific action plans, employers are able to realize lower health costs, fewer on-the-job injuries and faster recoveries.

Let’s use smoking as an example. In addition to increased workers’ comp costs, numerous government and academic studies tell us that:

  • Smokers lose an average of 6.0 workdays per year — almost double the absenteeism of non-smokers;
  • Smoking exacerbates the effect of chronic disease on productivity;
  • Smokers are less likely to exercise and more likely to be heavier drinkers;
  • Smokers are estimated to spend between eight and 30 minutes a day in unsanctioned smoking breaks. This equates conservatively to more than 33 hours per year of lost time, just because of unsanctioned smoking breaks. At 15 minutes per day, the total lost productivity rises to 62.5 hours annually;
  • Lower direct healthcare and lost-time costs equal improved profit, as does greater employee productivity and morale. Combining these efforts strengthens efficiencies and drives greater profit improvement.

While the concept and math are simple, changing deeply entrenched organization models, long-standing procedures and practices and the outmoded personal attitudes and behavior they encourage and reinforce is challenging. But it can and should be done. By finding the right consulting partner, companies can tear down the silos and look at the world through a broader lens of integrated, holistic safety, health and wellness. Everyone — the organization, its people and the stakeholders — will win.