Enhancing Workers' Comp Care Quality: Metrics and Methods

1. Methods for Improving and Measuring Quality of Care • California Research Colloquium on Workers’ Compensation • May 1, 2003 • Liza Greenberg, RN, MPH

2. About URAC • 501(c)3 accreditation organization • Stakeholder board of directors • Providers, payers, consumers, regulators • Standards for work comp managed care • UM, CM, network • Workers’ comp performance measures • Research – medical management, CM

3. Targets for Evaluating Health Care Quality • Plan-based measures: • Accreditation • Performance reports • Provider/Provider Group/Clinic measures • Report cards • Profiling • Individual Experience • State and National Surveys • Health plan specific experience

4. Standards for Workers’ Comp UM • Standards for: • Staff qualifications • Clinical review process • Clinical review criteria • Appeals mechanisms • Oversight of delegated functions • Staff credentialing

5. Standards for Workers’ Comp Networks • Network Management • Provider availability and accessibility • Provider contracting • Grievances and appeals • Marketing • Quality Assurance • Program organization and staffing • QA planning • Credentialing of Providers

6. Difference Between Accreditation Standards and Performance Measures • Accreditation examines structure and capabilities compared to standards • Performance measures assess process and outcome information • Accreditation and performance measures complement each other and increase accountability

7. URAC WC Performance Measures • Data can be used for internal QI • Performance data is collected by MCOs through three inter-related tools: • Patient survey • Administrative Data Specifications • Medical Record Audit • URAC’s team developed the tools plus instructions on administration and reporting.

8. Performance Measure Categories • Access • Prevention/ Disability Management • Appropriateness of Clinical Care • Coordination and Communication • Cost/Utilization • Patient/Payer Satisfaction • Outcomes

9. Definitions Developed • Functional elements of a managed care organization • Cases of finding criteria: • low back pain, • knee complaints, • shoulder complaints, • wrist/arm complaints • Time frame for measurement

10. Functional Elements of An MCO • To effectively manage and report on care, an MCO has the following elements: • Provider network management • Case management capability • Utilization management • Financial management / Bill review data • Secondary and tertiary prevention

11. Administrative Data Coordination • Timeliness of case manager contacts (time from referral to contact) • % of cases that are case managed • Length of time from injury to referral

12. Administrative Data • Outcomes - Work Related • Return to work • Prevention • Availability of occupational medicine doctors • Activities of occupational medicine physicians- involvement in leadership • Reporting of injuries to employer

13. Administrative Data Costs • Indemnity costs (TTD, TPD, PTD, PPD, VR) at 60 days, 18 months, at closing, by diagnosis • Medical costs (inpt and outpt medical, inpt and outpt surgery, drugs+therapies) by diagnosis • Total (indemnity, medical, other) by diagnosis • Utilization • Number of specific procedures per 100 cases by diagnosis

14. Patient Survey Measures Coordination Measures • Patient report that assistance received with RTW • Patient report of types of assistance provided Communication Measures • Doctor communicates well with worker • Doctor treats worker with respect • Doctor seeks to understand work environment • Patient receives information re treatment and avoiding reinjury • Patient trusts doctor

15. Patient Survey Measures • Work Related Outcomes • First return to work • Timing of first return to work • Health Related Outcomes • Work related functioning post injury • Physical functioning post injury • Reinjury of same body part

16. Patient Survey Measures Satisfaction • With most frequently seen physician • With MCO's medical services • Access • Accessible location • Wait to see the doctor the day of the appointment • Availability of hours

17. Medical Record Measures • Clinical Care • For low back pain, shoulder complaint, knee complaint and forearm, wrist and hand complaint: Adequate medical history Occupational risk assessment Appropriate activity modification Work restrictions advised, if necessary Appropriate focused physical exam Documentation of attempt to place on modified duty Patient education provided • Communication • Informed consent

18. Technical Challenges in WC Arena • Scope of MCO services varies considerably • MCOs have limited access to data • MCOs have variable quality of data • Cost of data retrieval is considerable (particularly medical record and survey data) • There is lack of consensus on treatment protocols and treatment norms • Case mix and risk adjustment protocols across employers, employees and industries are needed • Sample size

19. Current PM & Quality Activities

20. Performance Reports to Customers

21. Relevant Models for the Future • Medical management trends • Interfaced / integrated UM, CM, DM • Patient education: health call center, internet • Disability management • PPO experience • Disease management model

22. Current & Future Medical Priorities

23. Policy Implications • Need to show ROI for better medical management and disability management • Additional research needed in: • evidence-based care for occupational injuries • measuring outcomes of occupational injuries • interface between clinical and economic factors • Enhanced data systems needed to bring WC systems to comparable level of group health • MCOs need to augment QI efforts with worker-centered measures and surveys • Build demand through consumer, regulatory or purchaser organizations

24. Contact • Liza Greenberg, RN, MPH • Vice President, Research and Quality Initiatives • URAC 1275 K Street, Suite 500 • Washington, D.C. 20005 • (202) 962-8805 • Email: lgreenberg@urac.org