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Improving Outcomes in Workers Compensation

Improving Outcomes in Workers Compensation. System Efficiencies and Inefficiencies. Methods to Determine Effective Patterns of Care. Indirect: Geographic comparisons Inter-system comparisons Quintile comparisons Direct: Systematic reviews of high-grade evidence

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Improving Outcomes in Workers Compensation

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  1. Improving Outcomes in Workers Compensation System Efficiencies and Inefficiencies

  2. Methods to Determine Effective Patterns of Care • Indirect: • Geographic comparisons • Inter-system comparisons • Quintile comparisons • Direct: • Systematic reviews of high-grade evidence • Practice guidelines (ACOEM, AHRQ, state) • Correlations between resources and outcomes • Survey data • Records reviews v. guidelines, searches • Diagnostic and causation accuracy • Resource use v. clinical improvement

  3. Indirect Data:Variance in Costs, Durations (12 states) Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  4. Indirect Data: Variance in Resource Use (12 states) Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  5. Prescriptions/Case

  6. Indirect Data: Variance in Resource Use (GH v. WC) Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  7. Indirect Data Example: Duration of Medical Care by Quintile Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  8. Time loss v. med care Surgery degenerative disease soft tissue complaints Physical medicine TOW, cost of lost time not related to cost, DOMC Cost disproportionate; increases DOMC, TOW Cost linear; increases DOMC, TOW Direct Data:Cox Proportional Hazard Regressions Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  9. Surgery Physical medicine More physicians, diagnoses Physical medicine Surgery No effect on physical or mental functioning scores Both physical and mental functioning scores worse Did not affect TOW Increased TOW (Slightly decreased -- neck ST) Direct Data: Survey, ANOVA Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  10. Characteristics of Top Quintile • There is a disproportionate concentration of costs in the top quintile • Almost all surgeries are in the top quintile • There is a high use of Physical Medicine in the top quintile • Both duration of care and time off work are much greater in the top quintile • Multiple diagnoses, diagnoses outside the first named super group, and diagnoses involving multiple body parts are much more common in the top quintile. • There is a much higher mean and median number of providers in the top quintile. Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  11. Low v. High Cost PatientsLow back pain—MD careCalifornia Data Extrapolated Data source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  12. Low v. High Cost PatientsLow back pain—MD careCalifornia Data Extrapolated

  13. Low v. High Cost PatientsLow back pain--extrapolated—DC care Data source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  14. Reviews of high cost cases Degenerative disorders Many sedentary workers Multiple providers, referrals Multiple body parts, diagnoses Many litigated cases Long durations (2-20 y) Analysis Inappropriate attribution Acceptance of attribution Illogical body part linking Incomplete examinations Diagnoses don’t meet criteria Surgery doesn’t meet criteria Inappropriate TOW No improvement with treatment Characteristics of High Cost Patients Sources: High cost case file reviews, California, 2001/2; Harris, Bengle, Makens. Improving IMEs. Olympia: Washington Dept. L&I, 2002.

  15. Characteristics of High-Cost Claimants • Subjective complaints >>objective • Markedly overweight, deconditioned • Somatization • Multiple complaints • Multiple claims • High use of pain and other medication • Search for a cure • Consent to surgery, procedures

  16. Effect of Internal Health Locus of Control • Significantly higher satisfaction scores • Significantly higher mental functioning scores • Physical functioning scores higher • Did not reach statistical significance •  Median time off work shorter • Trend did not reach statistical significance Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  17. Direct Data: SurveyEffective Physician Practices * = significantly associated with higher PCS scores Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  18. Direct Data: SurveyEffective Physician Practices * = significantly associated with higher PCS scores Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  19. Effective Physician Practices (Early PD rating = about 40%) * MCS = 36.6 if worker thought he or she could have gone back earlier but TOW was 3 wks Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  20. Effective Physician Practices • Accurate diagnosis • Causality attribution • Based on exposure and plausible associations • Basis for prevention of occurrence, exacerbation • Outcome- and time-based treatment plan • Base on evidence of effectiveness and benefit:risk • Appropriateness, no duplication, frequency, duration • Modified duty as soon as possible • Stop when improvement stops • Regular, complete documentation/reporting • Teamwork/communication with NCM, employer

  21. Effective Employer Practices Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  22. (In)Effective Employer Practices * = significant at 0.01 level Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  23. (In)Effective Employer Practices * = significant at 0.01 level Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  24. Outcomes

  25. Incomplete Functional Recovery Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  26. Incomplete Functional Recovery Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  27. Employment Impact Of those not working, Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  28. Economic Impact Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  29. Economic Impact Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001

  30. SummaryEffective Care/Management • Physician/patient discussion and education • Consistency with evidence • Time, benefit:risk based testing/treatment plans • Avoid legally determined medical “science” • Employer behaviors • Modified duty, cooperate with physician, capabilities • Effective and efficient networks • Universally effective medical management • Medical professionals manage medical care

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