By Gary Rischitelli, MD, JD, MPH, National Medical Director, ISG Services
Medical costs continue to rise in the workers’ compensation arena, and until all stakeholders are aligned through outcomes-based incentives, the upward spiral will continue. Therefore, effective strategies to manage this expense must systematically address the role of all stakeholders involved in a claim.
Sounds simple, right? Then, why has the industry migrated away from the central leverage point and critical change agent in the claim process—the treating physician?
Who controls medical costs and time loss in a workers’ compensation case? The treating doctor has the “power of the pen” to order treatments and work restrictions despite receiving little, or in most cases, no medical school training in the assessment of functional ability or the crafting of work/activity restrictions. The critical issue isn’t getting workers to return to work, it is getting doctors to release them back to work in most jurisdictions.
Despite advanced technologies and a highly educated workforce, American medicine remains a highly fragmented cottage industry. Doctors who want to see improvements in the delivery of healthcare in the workers’ compensation system need to advocate for optimal medical care that places an emphasis on staying at work or returning to work during the treatment or rehabilitation process. Optimal care does not mean more (expensive) care. It means the precise amount of care that provides the most favorable outcome (restoration of function) with maximum efficiency and minimal waste. On a professional level, doctors who desire change must advocate for payment and delivery systems that reward doctors for good outcomes, and they must, as a community, demand accountability from their colleagues who focus on generating revenue as an outcome rather than producing quality care.
Top-tier performance can be attained with a staff medical director who supports a plan for identifying and developing better relationships with treating providers. The most effective physician oversight involves a collaborative learning strategy with clearly defined expectations for treating providers. Additionally, any provider-centric approach for managing both medical costs and utilization should include more effective use of outcomes-based provider tools and peer-to-peer collaboration.
A) More effective use of outcomes-based provider tools:
Effective measurement of medical outcomes in the population of injured workers is essential. Experience has proven that the unique environment of the workers’ compensation system prevents simple extrapolation of experience from clinical trials and group or government sponsored healthcare. However, most claim management efforts exclude the impact of stakeholder behavior and the synergy of multiple clinical disciplines (medical, nursing, pharmacy, etc.) working together to measure and improve their impact on medical cost containment. Because we understand managing unit costs is only one part of the equation, ISG is committed to the continual improvement of its provider evaluation tool, CONNECT™. Utilizing CONNECT to identify and refer patients to high-performing preferred providers, as well as to educate and elevate under-performing providers has been well received by cost-conscious organizations seeking to include the physician as a key stakeholder in the treatment, rehabilitation and return-to-work process.
B) More effective use of physician advisor and peer review services:
Peer-to-peer interaction can be a crucial component in modifying physician behavior. Developing a direct relationship with a cadre of physicians who understand and apply medical treatment guidelines using the principles of evidence-based medicine is fundamental to the collaborative learning process. Our physician management model begins with strict credentialing requirements and active clinical practice, and includes ongoing monitoring of timeliness, appropriate guideline selection and application, clear documentation of clinical rationale, and successful peer to peer interaction among direct contracted providers and affiliate networks offering these services. These quality leaders review, document and intervene when care is unnecessary, excessive, inadequate or ineffectual.
Finally, providing autonomy to experienced treating providers who are given access to timely analytics will drive positive engagement and collaboration with your physicians. We believe providing the decision makers (physician, examiner, nurse, risk manager, etc.) with relevant claim, financial and bill content through a single data repository populated with data derived from a common data schema and data dictionary should also be a part of your best practices claims management model.
In Part 2, we will discuss specific evaluation metrics to ensure your providers are promoting optimal medical care while maximizing efficiency and minimizing unnecessary costs.
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.