Measuring Quality of Care: More Urgent, Easier to Do | Peter RousmanierePeter Rousmaniere

Why do occupational medicine clinics in Aurora, Colorado, vary so much in their quality of services to injured workers?

The leading workers’ compensation insurer in the state, Pinnacol Assurance, names and rates the clinics in that city. You can find the scores at Pinnacol’s Clinic Performance Initiative website.

The insurer, whose CEO Philip Kalin’s prior work was as a health care executive, measures how occupational medicine clinics address modified duty, are timely in submitting records, and are accurate in reporting maximum medical improvement. (The insurer also performs its own clinic evaluations.)

One might quibble with the scoring criteria. There appears to be no measure for speed and completeness of recovery. The big fact, however, is that the insurer believes that it can measure medical provider performance, that performance varies by a lot, and that quality matters.

There’s been a lot of anecdotal evidence that quality of care varies, but anecdotes are just personal opinion conveyed and twisted by word of mouth. And they don’t come with credible data.

That’s changed. Unbeknownst to many in the workers’ compensation field, researchers have gathered systematic evidence that quality of medical care varies, and to huge degree. A claims payer stuck with a disproportionate share of its claims being treated by poor scoring providers is at a distinct disadvantage.

The urgency of knowing how your doctors are performing is driven home by three factors. First, many claims payers find that their medical spending is concentrated in a relatively small number of providers. It makes solid sense to know whom you’re in bed with often.

Second, providers don’t change their performance stripes much unless they have a compelling reason to do so. If you have to steer treatment away from or to a particular provider, you better these days be able to document why.

Third, claims payers can indeed influence where their injured workers get their care, even in so-called employee choice states.

The core competencies for physicians in treating work injuries are well known and documented. For instance, a 2001 study reported that when doctors made a positive recommendation for return to work after 30 pays post-injury, there was a 60% higher RTW rate.

The most comprehensive statement of performance expectations for occupational medicine providers is found in the American College of Occupational and Environmental Medicine’s 2006 publication, “Preventing Needless Work Disability by Helping People Stay Employed.”

The Louisiana Workers’ Compensation Corporation began to measure doctor performance carefully about seven years ago. In contrast to commercial insurers and third-party administrators, who tend to keep their doctor analyses to themselves, LWCC published some key findings. The insurer teamed up with Johns Hopkins University as co-author of a 2010 article. The article reported that its tightly designed provider network brought lost time injured workers back to work 45% faster and reduced claims costs by 46%.

More recently, the Accident Fund has collaborated with Johns Hopkins to compare doctors. This year, the Fund published an article showing stark differences in outcomes between doctors who dispense drugs from their offices and those who do not. Dispensing is associated with much worse outcomes.

The California Workers Compensation Institute has been comparing provider performance for more than 10 years. In 2003 it reported that the claims treated by providers with very large injured worker case loads were 56% less costly than the claims treated by providers with tiny case loads. The average duration of disability for most experienced providers was 17 days vs. 30 days for the least experienced providers.

In 2011 the CWCI found that a very small percentage of physicians, around 3% of the total, were responsible for more than 65% of the opioid and other Schedule II drug payments in California. Over half of Schedule II prescriptions were used to treat minor back injuries.

Claims payers have been gearing up their internal resources for doctor evaluation for some time. The West Coast is particularly well populated with experience in comparing doctors. Harbor Health, Axiomedics, and Medmetrics, headquartered in California or Oregon, measure provider performance for their clients.

And, measuring is getting easier, thanks to better quality data. Chicago-based Maddy Bowling, principal at Maddy Bowling Consulting, Inc. says it is much easier today to integrate medical encounter data from bill review with clean relevant claim data. “We are much better able to measure provider performance against factors such as disability duration, costs, frequency of litigation and other factors clients might want to use for comparison across providers.”