What is the Research and Oversight Council on Workers’ Compensation (ROC)?

1. Controlling Medical Costs and Improving Quality of Care: Lessons from TexasAmy Lee, Research DirectorState of Texas Research and Oversight Council on Workers’ Compensation

2. What is the Research and Oversight Council on Workers’ Compensation (ROC)? • Small state agency with a mission to: • Conduct objective research on workers’ compensation issues; and • Make legislative and regulatory recommendations to the state leadership and ROC Board every biennium.

3. HB 3697 (76th Legislature, 1999) required the ROC to: • Investigate the quality and cost-effectiveness of WC medical care in Texas compared to: • other states; and • other health care delivery systems in Texas.

4. Key Findings from HB 3697 Studies Included: • Texas WC medical costs are higher than other states and other health care delivery systems. • Medical care utilization is high in areas such as surgery, physical medicine, and diagnostic tests. • Relatively small proportion of providers, claims and medical procedures are driving costs. Source: Striking the Balance An Analysis of the Cost and Quality of Medical Care in the Texas Workers’ Compensation System, January 2001.

5. Average Medical Paid Per Claim,Injury Year 1997 Source: Striking the Balance An Analysis of the Cost and Quality of Medical Care in the Texas Workers’ Compensation System, January 2001.

6. Key Findings from HB 3697 Studies Included: • Texas workers also receive medical care for longer periods of time, compared with national guideline recommendations and other states. • More costly and intensive medical care in Texas has not resulted in improvements in worker satisfaction, functional outcomes (i.e., whether the worker got better), or return-to-work outcomes. Source: Striking the Balance An Analysis of the Cost and Quality of Medical Care in the Texas Workers’ Compensation System, January 2001.

7. HB 2600, 77th Legislature (2001) • Grew out of research findings from HB 3697 studies • Basic findings: Texas pays more but does not get more, resulted in the following policy goals: • Increased accountability through improved monitoring of all parties; • More extensive use of medical expertise in agency decision making; and • Emphasis on outcomes rather than medical costs alone.

8. A New Model for Quality Enhancement and Cost Control (Article 1 of HB 2600) • Registration and training for doctors • Monitoring for all system participants • Creation of a Medical Quality Review Panel, new roles for Medical Advisor • Collection of outcomes data • Sanctions and rewards

9. Four Monitoring Programs Envisioned Under Article 1 of HB 2600: • Doctor/Health care provider • Insurance Carrier/URA • Designated doctor • IRO medical dispute decisions (To date 41 doctors and designated doctors have been reviewed by the Medical Quality Review Panel; 24 other doctors pending review.)

10. Four Components to Each Monitoring Program: • Data analysis, to identify potential outliers; • Review of sample cases to determine whether full clinical review is warranted; • Full clinical review on cases in question; and • Progressive sanction program may be initiated.

11. Use of Designated Doctors (DDs) in Impairment Rating and MMI Exams (Article 5) • HB 2600 called for: • Use of DDs instead of RMEs in IR and MMI exams • More flexibility in selecting DDs • Implementation challenges: • How to use new selection criteria (“trained and experienced”) • Move to 4th edition of AMA Guides and new doctor training requirements

12. Medical Dispute Resolution (Article 6) • HB 2600 called for medical disputes to be resolved by Independent Review Organizations (IRO) rather than TWCC staff • Implementation challenges: • Workload shift from agency to IROs • Capacity and concerns of IROs • Payment of IROs: when and how much? • Timeframes for dispute resolution

13. Medical Fee Guidelines (Article 6) • HB 2600 called for: • Conversion to RBRVS reimbursement structure; and • Conversion to Medicare-based payment policies • Implementation challenges: • How to adopt and adapt Medicare policies • How to set conversion factors (pricing) • Interaction with new utilization control efforts • TWCC’s ability to train staff or obtain outside medical expertise

14. Almost Two Years Later, What’s Been Learned? • Drafting rules are one thing; drafting an implementation plan is another; • Many concepts are inter-related and should be treated as such; • Use research findings to prioritize implementation efforts and address key cost drivers first; • Set realistic system goals for controlling overutilization and improving return-to-work outcomes and publish those goals;

15. Almost Two Years Later, What’s Been Learned? • Keep stakeholders working together to reach system goals; • Anticipate data reporting changes that need to occur before the effective date; and • Don’t try to do too much at once because it becomes a nightmare to study later.

16. Contact Information • Research and Oversight Council • on Workers’ Compensation • 9800 N. Lamar Blvd., Suite 260 • Austin, Texas 78753 • (512) 469-7811, Fax (512) 469-7481 • Email: info@roc.state.tx.us • Website: www.roc.state.tx.us