By Gary Rischitelli, MD, JD, MPH, National Medical Director, ISG Services
In Part 1, we suggested that effective management of cost and quality in medical services must begin with a collaborative effort between the treating provider and the claim management stakeholders. In this article, we will provide specific measurement tools to ensure the most effective treating providers and physician peer reviewers are identified and fully engaged in delivering the highest quality care and implementing best practices for minimizing disability and maximizing successful return to work.
While the term “data analytics” has become widespread within workers’ compensation, we prefer to utilize the term “actionable analytics” to differentiate between information that spurs action and information that simply confirms what we already know. To obtain optimal outcomes in claims management, specific metrics must be collected, measured and monitored to ensure the most effective doctors are treating injured workers.
Primary care physicians, surgeons (orthopedic and neurological), as well as neurologists must be included in the algorithm of an evaluation process since they are collectively engaged in the large majority of work-related injuries. Measuring return to work and the total cost of risk is essential; however, the scoring of less traditional elements such as case duration, ancillary services utilization, and litigation rate, and actually removing poor performers from the network are also critical to the quality and cost formula. Naturally, channeling care to high-performing providers and continuously monitoring their outcomes are industry best practices.
Success in applying science to measure clinical outcomes is reliant upon a holistic and comprehensive approach, which validates and correlates physician engagement through experienced clinical oversight, cutting-edge technologies and a continuous quality improvement feedback loop. Such a holistic approach to improving clinical and return-to-work outcomes should include the following elements:
- Utilize empirical analytic tools to identify the best providers regardless of network affiliations
- Ensure ease of access to the best providers for all stakeholders
- Help the injured worker to engage the best providers utilizing web and mobile technologies
- Monitor the delivery mechanism daily to ensure timely interventions that adhere to national guidelines
Once deployed, claim outcomes should yield double-digit improvements in the average total incurred and paid per claim and the average claim duration rate. Moreover, the impact of high-performing specialists should also result in a lower average total paid per claim as well as a reduction in average total physician visits per claim.
In addition to objective data-based analytical tools, the experience and judgment of peer reviewers should not be underestimated. Peer reviewers often have insight into clinical nuances, patterns of care and community factors that may not be apparent in the data sources. For example, if a provider’s non-certification rate on utilization review is significantly higher than his or her peers, this suggests a propensity to recommend care that is not consistent with evidence-based medical treatment guidelines. This may represent a pattern of care that reflects lack of knowledge of optimal treatment interventions or treatment that is excessive, inappropriate or wasteful.
In an effort to more tightly control the total claim costs for our clients, we manage this critical function internally. Our peer reviewers are thoroughly credentialed, actively practicing physicians, who are consistently evaluated and offered feedback to improve their performance and enhance outcomes on second level review. Some of the specific clinical measurement tools utilized to evaluate our direct contracted providers include:
- Correct selection of the appropriate medical treatment guideline
- Proper application of the guideline in relation to the diagnoses
- Thorough and objective documentation of clinical rationale
- Peer-to-peer dialogue to clarify, discuss and educate both participants in the process
Over time, treating providers will react positively if the approach to measuring clinical performance is clear, objective and includes a consistent, proactive quality improvement orientation that evaluates performance in a mutually respectful, clinically competent peer-to-peer interaction.
About Dr. Gary Rischitelli
Gary Rischitelli, MD, JD, MPH, is the full-time national medical director of ISG Services. As a nationally renowned speaker and practicing physician, Dr. Rischitelli’s expertise is in occupational and environmental medicine and workers’ compensation managed care. His areas of specialty include occupational and environmental medicine, disability evaluation and accommodation, return to work, and fitness for duty. His academic research experience in health services delivery, injury prevention, and occupational infectious disease transmission further qualifies him as an occupational and environmental health expert. In addition to his credentials as a medical physician, Dr. Rischitelli holds a Master of Public Health, a Juris Doctor, and a Certificate in Clinical Research and Human Investigation. He is board-certified in occupational medicine and a Fellow of the American College of Occupational & Environmental Medicine.
About ISG Services LLC
Operating as the nation’s leading healthcare technology company, ISG Services offers a suite of software and services that enable highly targeted data-driven interventions to achieve meaningful impact on outcomes and financial performance. ISG Services utilizes extensive data analytics to identify gaps in care, quality or integrity and applies the appropriate resources to ensure rapid resolution. Our valued clients process their workers’ compensation medical bills through the ISG Services affiliates including well-known affiliates StrataCare, the nation’s premier workers’ compensation bill review software and service provider, and Bunch CareSolutions, offering award-winning, innovative managed care solutions. For more information, please visit: www.stratacare.com or www.bunchcare.com.