Evidence-based medicine can help reduce medical risk, measure medical treatment quality and ultimately improve the quality of care of injured workers. In this session at RIMS 2021, experts from Gallagher Bassett discussed using evidence-based medicine to improve health outcomes and its adoption within the workers’ compensation industry.
- Jeffrey Austin White – Senior Vice President Product Development, Gallagher Bassett
- Joe Powell – Senior Vice President Analytics, Gallagher Bassett
Medical Treatment Practices are a Black Box
One of the most elusive goals in managing workers’ compensation claims is determining which claims are likely to go off track. This can ultimately lead to poor outcomes for the injured worker and clients. Perhaps the most challenging to anticipate is if the injured worker is getting the appropriate medical care, but early intervention can help promote the right choices. For non-medical professionals, identifying treatment patterns on a claim can be like working with a black box—it’s extremely difficult to understand, especially when you include the number of medical professionals administering different medications within a claim. The application of evidence-based medicine can help simplify the process for non-medical professionals.
What is Evidence-Based Medicine?
Evidence-based medicine is a documented reference that establishes the standard of care and best practices in medicine. These can be found in medical journals and enforced by federal and state laws. The standards are typically derived from peer-reviewed scientific research aiming at proving and disproving treatment protocol. When practices are proven to make an impact and benefit the client, their use is encouraged. Alternatively, if their use fails to make an impact, use is discouraged. Workers’ compensation has several evidence-based medicine standards, of which two have emerged as leaders:
- The Official Disability Guidelines
- The MD Guidelines
The guidelines are compiled based on the outcomes of tens of millions of claims. They represent the collective knowledge derived from what medical providers have learned, what research has demonstrated and what claims data suggests.
Treatment Guidelines and Improved Outcomes
How do we know that evidence-based medicine leads to improved outcomes? In 2016, a study was conducted to measure their correlation and impact, in partnership with Johns Hopkins School of Medicine and the Bloomberg School of Public Health. This study examined over 40,000 indemnity claims grouped into two buckets: those with higher than median compliance and lower than median compliance. The claims with higher than the median compliance resulted in a 38% reduction in total medical cost and 13% reduction in duration when the severity mix adjusted.
Evidence-Based Medicine Today
The reality is that most treatment guidelines today are focused on a reactive, episodic or cost-focused approach. Workers’ compensation tools, like utilization review and dispute resolution, are primarily focused on savings and do not take a proactive approach to care. Often if the wrong direction to care was taken, it’s too late to make changes. So how do you affect the quality of care and cost? A shift toward continuous monitoring of medical treatment quality across the life of a claim. This allows intervention when the quality of care is deteoriating proactively. And rather than just denying payment, the correct clinical resource can get involved to steer the claim back on track.
Increasing Treatment Compliance Practice
The practical application of evidence-based practices relies on a proactive approach to your claims management strategy. These steps can be applied to your strategy to improve overall outcomes:
- Optimize provider network performance. Evaluate network performance and treatment compliance across specialties to promote good care providers and remove poor care providers.
- Promote direction of care at the point of injury. Direct injured workers to medical providers with good claims outcomes and high compliance at the onset of the claim.
- Refer to case management. When compliance with treatment guidelines falls below a critical threshold, leverage medically trained professionals and clinical programs to review care plans.
- Reporting and monitoring. Use dashboards and reports to isolate and identify areas of opportunity and monitor the impact on claims.