By Melissa McGarry, Director, Product Implementation, Coventry
When it comes to helping those hurt on the job, it makes sense that one of the best ways to promote strong recoveries is to turn to providers who have demonstrated prowess in treating injured workers.
Last week, we discussed how outcomes-based networks (OBNs) play an important part in ensuring injured workers receive quality care. Here we’ll look at some of the factors OBNs often examine to understand how effective providers are in piloting injured workers’ successful recoveries.
While some OBNs might only consider medical costs, we believe there are some very important factors that can’t be overlooked. These include:
- Claim acuity
- Evaluation & management (E&M) utilization
- Physical medicine utilization
- Imaging utilization
- Major surgery utilization
- Opioid prescribing patterns
- Overall pharmacy utilization and spend
- Treatment duration
- Claim duration
- Medical spend
- Indemnity spend
- Total spend
Examining all of these metrics allows for assembly of an OBN in which providers demonstrate clear depth of experience in treating workers’ comp injuries. Reviewing all claim types and comparing providers to their peers will help to identify those with the best overall claim outcomes.
OBNs enable success by churning through lots of data
For an OBN to reach its peak effectiveness, it’s important to identify the providers who play the biggest roles in worker outcomes. One way to start is by determining the primary doctor responsible for the overall management of an injured worker’s claim. The primary treating provider likely would fall under one of these specialties:
- General practice
- Family practice
- Internal medicine
- Occupational medicine
- Multi-specialty (clinic)
- Multi-specialty (group)
- Urgent care clinic
- Occupational medicine clinic
OBNs also might also include orthopedic surgery facilities even though they likely wouldn’t be considered a primary treating provider on a workers’ comp claim and wouldn’t be measured in the same manner as physicians.
An OBN might set certain minimum thresholds for inclusion in a program. After all, treating only the occasional injured worker isn’t likely to yield reliable data on a clinician’s effectiveness. The best OBNs sift through mounds of data, including the factors listed above, to identify those physicians, physician groups, and even clinics that are best equipped to help injured workers.
We’ve noted that a successful OBN targeting the best results is likely to evaluate a range of measures including medical utilization, indemnity payments, and overall financial performance. Here we’ll break down some of these considerations.
Under medical utilization, an OBN might consider types of imaging ordered, the rate of major surgeries, the length and type of physical medicine, and the prevalence of E&M visits. In the clinical realm, considerations can include use of physical medicine compared against Official Disability Guidelines benchmarks, high management visits, repeat diagnostic imaging, surgical revision rates, and prescribing behavior.
Of course, one of the most important yardsticks for a successful OBN is its ability to help injured workers return to the job in a timely manner. There are numerous factors to consider in this area. They include treatment lag, lost-time rate, indemnity and medical paid per claim, and other expenses per claim.
When evaluating providers, it’s sensible to ensure valid comparisons are made. This means benchmarking a claim against a population of similar claims. Doing so allows for a more like-for-like comparison as well as understanding about the variation in the practice patterns among providers. Using this approach, it’s easier to identify those providers who show consistency within a particular category. By using factors such as location, claim acuity, comorbidity, and body-part matching, it’s possible to compare how well a provider’s history stacks up to a benchmark of a similar claim population.
OBNs help quality rise to the top
As discussed, quality of care matters. So it’s little surprise that the best providers are more adept at treating injured workers more quickly and with better outcomes. That’s good for all involved.
Here’s just one example: In 2020, Coventry reviewed approximately 3.1 million closed claims over a five-year period across nearly 50 jurisdictions. The results for claims treating with an OBN provider compared with claims treating with a non-OBN provider show a clear advantage for the OBN:
- Claim duration was 25–35 percent lower
- Opioid prescriptions were 55–65 percent lower
- Average medical cost was 40–50 percent lower
- Total claim cost was 40–50 percent lower
Of course, there are always variations across states, claim types, and patient populations yet the results make clear that turning to the most accomplished providers can be a win-win-win for not only the injured worker but the employer and the payer as well.
It’s important that any program promoting the most successful clinicians is taking steps to be sure those accomplishments continue. This entails constantly reviewing, and potentially revising, the methodology to ensure the program is measuring what it purports to measure. It also means undertaking periodic reviews of a program’s panels to ensure that providers continue to meet the participation criteria.
Health care in general, and workers’ comp specifically, is getting better about quantifying outcomes and trying to better define value. One way is through use of powerful data analytics. Even a few years ago, the rigor of analysis we see today simply wasn’t possible. But improved technology is opening new opportunities.
Part of what’s so exciting is that it’s not just the networks that are deploying these robust tools. It’s happening all around, including among providers. Tools such as predictive analytics are now helping providers by recommending the best course of treatment for patients given their histories and how they relate to a cohort of patients.
As providers get better at what they do thanks in part to technology, the OBNs in which these clinicians participate will also see further gains in quality. Granted, not all of the promise analytic technology holds for improving outcomes will emerge (PDF) overnight. There will continue to be more work to do yet the promise of what’s to come is exhilarating.
Examining outcomes keeps the focus on workers
Networks focused on outcomes are doing just that — looking at results. That means the attention is on how injured workers recover and get back to living life and not solely on each procedure or on each unit cost. The goal is to consider the big picture.
This approach makes sense because of what we know about the importance of treating the whole person — not just the injury itself. Addressing the biopsychosocial aspects of a claim works alongside and is indeed an important component of quality care provided to an injured worker.
By tapping the most capable providers, it’s more likely that measures such as claim duration, medical utilization, indemnity spending, and overall claim costs will show improvement. Just as important, injured workers are likely to have a better experience and get back on the job that much sooner. This is critical not just for quality of life but also because we know the longer workers are away, the less likely they are to return. Those are the outcomes everyone wants to avoid.
The data-gathering, the evaluating, and the tweaking that are central to how a robust OBN operates are, at their heart, good for workers. That’s because these efforts are in service of increasing the likelihood of a strong recovery. And behind each of the metrics and data points is a worker hoping to get back to work and to rediscover a pre-injury life.
About Melissa McGarry
Melissa McGarry has been with Coventry for more than 10 years and oversees multiple network products including its Outcomes-based Network Program, Exclusive Provider Program, Telemedicine Networks and Auto Network. She has more than 30 years’ experience in the health care industry with deep knowledge of networks, network products, utilization management, and behavioral health. Melissa holds a B.A. in Psychology from The University of Texas at Austin and a Master’s in Educational Psychology from the University of North Texas.
Coventry, a part of the Mitchell | Genex | Coventry organization, offers workers’ compensation, auto, and disability care-management and cost-containment solutions for employers, insurance carriers, and third-party administrators. With roots in both clinical and network services, Coventry leverages more than 40 years of industry experience, claims knowledge, and data analytics expertise. Our mission is returning people to work, to play, and to life, and our care-management and cost-containment solutions do just that.
Coventry is a WorkCompWire ad partner.
This is NOT a paid placement.