Quality Care Movement

At the 2015 Workers’ Compensation Educational Conference in Orlando, a panel discussed the shift from networks focused on discounts and penetration to that of quality of care and outcomes received by injured workers.  The panel consisted of:

• Greg Moore – President, Harbor Health
• Kimberly George – Senior Vice President, Sedgwick
• Dr Jacob Lazarovic – Chief Medical Officer, Broadspire
• Mark Walls – Vice President Communications & Strategic Analysis, Safety National

Key components to an outcomes-based scoring model are:

• Claim duration
• Return to work
• Recidivism (reopening rate)
• Following established treatment and return-to-work guidelines (ODG)
• Litigation rate
• Medical and indemnity paid
• Claims team surveys
• Billing, pre and post bill review
• Peer comparison

The scoring model needs to capture both variations in severity type, and whether the employer is cooperative with providing return to work. The model needs to be constantly updated to keep it current.  If your model is pulling from bill review data, it can be receiving updated data on a daily basis. Evaluating billing data before and after bill review offers insights into fraud, waste, abuse and new trends. The provider or clinic score can be updated on a quarterly basis based on the data.  Scoring may not be as frequent for smaller entities without a statistically-accurate sample of claims with which to score quarterly.  Communication with the entire claims team is important for effective use of the program. Having the data without it being actionable at the desks and in the field is useless. Engaging providers in the scoring process and outcomes scores will drive success because it will educate providers on opportunities and outcomes.

One of the challenges in ranking can be whether you are scoring an individual provider versus groups or health systems. Often times you end up scoring on the group or health system data because the individual data is not statistically significant, or the billing information provided is not sufficient to classify items by individual physician.

The business model for an outcomes-based network moves away from the traditional model that looks at discount below fee schedule and proximity to the employer. Instead, it focuses on those providers that deliver the best outcomes for injured workers. When you identify those best physicians, you need to pay them fairly, even if that means more than the fee schedule. The additional money you spend on a fee for service basis will easily be recovered in duration and utilization of treatment.  The modeling of outcomes allows an outcomes-based network to offer value-based reimbursements, which incentivizes physicians to engage in the outcomes program and improves overall performance.

This also requires a shift in how the networks are compensated. Instead of their fees being based on a percentage of savings below fee schedule, their fees are based on a per-bill basis.

The outcomes from these networks has been very favorable. Data presented from over 147,000 claims in California showed that the cost per claim for a five-star provider was 16 times less than what was delivered by a one-star provider. Average lost time days was 10 times greater with one-star providers versus five-star. Duration of the claim was nine times greater for a one-star versus a five-star.