So Who ARE the “Best” Providers?

At the 2015 SIIA National Conference, James Harvey from Sedgwick and Bruce Singleton from MultiPlan presented a session discussing efforts at identifying medical providers who produce the best outcomes. The session was done in a Q/A format.

How long have you been using outcomes based networks?

• Sedgwick started this in California years ago. They have developed a nationwide system that helps direct injured workers to the highest scoring medical providers. 
• In 2004 Concentra worked with Sedgwick to come up with a scoring system on outcomes based networks. 

Why did you build and deploy outcomes based networks?

• Because our customers were asking for this. Changing network models is an extensive task and takes time. 
• Our goal was to start identifying how we could more efficiently manage claims. The best providers can be given more leeway in the claims management process and require less oversight. 

How do you get started on building an outcomes based network?

• Make sure your organization has the patience to actually measure the results of an outcome based network. This can take time. Traditional discount based networks can produce immediate reports on savings and penetration, where outcome based networks requires the claims to fully develop in order to know the actual outcome of the claims. 

What is the most important consideration in building a network?

• DATA, DATA, DATA
• Not all claims organizations capture the same data. You have to be able to capture all the data necessary to fully evaluate the providers including data around return to work. This component is lacking in many claims systems.
• The analytics team needs to be able to validate the data that is being reviewed. 

Why else is data important?

• It will determine what you can measure, who you can measure, and how reliable the information is. 
• You must have a track record with the data. Some providers may not be able to be scored because there is insufficient data around their outcomes.

How did you decide which providers to score?

• First you need to see which providers can be scored. Primary care physicians have the most touches with injured workers and are thus the easiest to score. Scoring specialists becomes challenging because of a lack of data.

What types of things do you score?

• Opioid prescribing.
• Frequency of diagnostic testing.
• Return to work.
• Frequency of surgery.
• Repeat testing and surgery.
• Physical therapy utilization.
• Following appropriate evidence-based treatment guidelines.

How do adjusters and case managers use the outcomes based networks?

• They match the injured worker with the highest scoring provider in their area. This must be integrated into the claims model for ease of use. 
• The most resistance comes in employee choice states where adjusters do not feel they can make this referral. However if you are advocating for the injured worker and want them to have the best medical outcomes you can still suggest the higher ranking providers as something they should consider.

How do you measure success of the network?

• Look at things like return to work, litigation rates, recidivism (going back off work). 
• You need to take into account variation in states, claims, etc.

What role does provider data play in the outcomes based network?

• If the provider data is not accurate then it challenges the scoring model and the networks. In particular the identifiers on physican, diagnosis and treatment. 
• It is important to keep validating your network to ensure it is current. For example, whether providers are still actively accepting workers’ compensation patients. Injured workers get frustrated if you refer them to a physician who then refuses to treat them. You also need to make sure the address and phone number is current.

Do the providers know how they have been scored?

• They do meet with some of the providers to help them understand the scoring mechanisms. They want provider feedback on whether the issues they are measuring are valid. They also want the physicians they see frequently to understand why they are ranked in a particular category.

Are there areas you found were not appropriate for measurement?

• You cannot just measure based on cost. 
• You also have to make sure you are looking at comparable databases. You need to know the workforce being referred to these providers and whether there differences in ages, fitness, frequency of co-morbid conditions, etc. This can skew results.

What have your claim outcomes been using the highest ranking medical provides?

• 70% faster return to work.
• Lower litigation rates.
• 40% faster claim closure rates.
• Lower prescribing of opioid pain medications.
• Lower denial rates through utilization review.