Improving the Accessibility, Costs and Quality of Workers

1
Improving the Accessibility, Costs and Quality of
Workers Compensation Medical Care

• An Orientation Course for Employers
• The Robert Wood Johnson Foundation
• and
• University of Massachusetts Medical School
• Center for Health Policy and Research
• http//www.umassmed.edu/workerscomp

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Accessibility, Costs and Quality of WC Medical
Care

• Learning Objectives
• Familiarize students with research and
  literature on the accessibility, costs and
  quality of workers compensation medical care
• Provide examples of tools to help employers and
  insurers improve the quality of medical care for
  injured workers
• Demonstrate how tools and methods developed can
  fit into the employers prevention and management
  cycle
• Allow students to demonstrate an understanding of
  these principles through group discussion and
  practical application

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Contents of Course Packet

• 1. Copies of PowerPoint Slides
• 2. Toolkit
• 3. Selected Readings
• 4. Website Resources
• 5. Course Evaluation Form

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Course Outline

• Overview of WCHI and this project
• Suggest a definition of quality outcomes for
  workers compensation medical care delivery
• Propose actions employers can take to improve
  access and quality
• Accessibility barriers employers can help
  overcome
• Tools and research employers can use to improve
  their prevention and management programs and help
  ensure quality medical care at the same time
• Group exercise and discussion
• How can this research and these tools be used to
  improve the employer management cycle?
• Evaluation of training

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Overview of the WCHI

• National program of the Robert Wood Johnson
  Foundation
• 6 million initiative spanned 1995 to 2002
• 21 grants awarded in 9 states and D.C.
• Demonstration and evaluation projects in the
  delivery and financing of medical care
• Broad focus on enhancing access, containing costs
  and improving quality
• Evolved into Targeted Change Strategies
  initiated in 2002 builds off lessons learned

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Targeted Change Strategies to Improve Quality of
WC Medical Care

• Building on the lessons learned from the WCHI,
  TCS focuses on bridging the gap between what is
  known and what is practiced, and will help to
  overcome barriers that prevent implementation.
• TCS Objective 2
• Develop training programs for state
• agencies and employers in how to use
• tools and implement best practices

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Improving the Accessibility, Costs, and Quality
of WC Medical Care
Access
Medical Care
Costs
Quality
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Quality Medical Care Delivery

• Quality of care is the degree to which health
  services for individuals and populations increase
  the likelihood of desired health outcomes and are
  consistent with current professional knowledge.
  (Institute of Medicine, 1990)

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Desired Occupational Health Outcomes

• Overall Workers Compensation System Intent
• assure the quick and efficient delivery of
  disability and medical benefits to an injured
  worker and to facilitate the workers return to
  gainful employment at a reasonable cost to the
  employer.FS440.015

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Desired Occupational Health Outcomes

• System Goals
• Prevention of occupational injuries and diseases
  (Prevention)
• Prompt payment of benefits to workers (Access)
• Quality medical care for speedy recovery
  (Quality)
• Adequate and equitable wage loss benefits to
  workers at a reasonable cost to employers (Costs)
• Prompt return to work as soon as medically
  feasible (Quality)
• Self-executing system with prompt, fair
  resolution of disputes that occur (Access)

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Quality Medical Care Delivery

• Quality measures include
• access to care
• timeliness of care
• appropriateness of care
• utilization and cost of care
• efficient coordination of care and communication
  of plans and physical abilities
• prevention of re-injuries and
• satisfaction with care.

• Tool Box Item 1
• URAC Measures for Managed Care Organizations
• www.umassmed.edu/workerscomp

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Access to Care

• Overview
• Factors impacting Access to care for workers
• Primary issues coverage, causation, denials,
  under-reporting and claim filing
• Secondary issues limitations on treating
  provider, authorization for treatment, disputes
  over treatment or utilization, delays in payment
  for services rendered, fee schedule levels, out
  of pocket expenses and geography
• Tertiary issues educational, language and
  knowledge barriers, socio-cultural impacts

• Tool Box Item 4
• UNITE Expanding Access to WC Health for Low Wage
  Immigrant Workers
• http//www.umassmed.edu/workerscomp/grants/grant19
  .cfm

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UNITES Union Health Center, New York

• Previously documented high denial rates and
  delays in care, esp. workers with carpal tunnel
• 79 of claims denied (96 eventually accepted)
• 226 days from physician authorization to
  treatment
• 318 days from physician authorization to surgery
• Likelihood of rejection linked to ethnicity and
  SES
• Model program provides workers with access to
  medical treatment regardless of claim status
• Source Herbert, Robin et al. 1999. Carpal
  Tunnel Syndrome and Workers Compensation
• Among an Occupational Clinic Population in New
  York State. American Journal of Industrial
• Medicine. 35335-342.

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Employer Opportunity to Improve Access to Care

• Primary Access Barriers
• Require all your vendors and subcontractors to
  carry workers compensation coverage
• Require your TPA/Insurer to promptly investigate
  and make compensability decisions and facilitate
  the reporting of denied medical expenses to the
  health carrier
• Communicate directly with the worker about
  benefit coordination issues and help problem
  solve and facilitate communication between
  administrators and with the health carrier to
  ensure your workers get prompt, effective medical
  care

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Employer Opportunity to Improve Access to Care

• Secondary Access Issues
• Measure the timeliness of treatment
• Know results of and continually improve your
  system to authorize care
• Make sure your service providers know your
  standards and give them feedback on their service
• Problem solve issues of geographic access
• Be aware of how fee schedule levels affect care

• Tool Box Item 5
• Mid-America coalition's uniform workability
  form and employer benchmarks
• www.umassmed.edu/workerscomp/grants/grant11.cfm

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Community Based Collaborative Approach to
Improving Workers' Compensation Medical Care

• Importance and Implications
• Use of mutually agreed upon communication form
  can speed return to work and help employers
  evaluate the quality of care their employees are
  receiving
• Results
• Development of Uniform Workability Form
• Communication from health care provider to
  employee and employer on physical status
• Gathering of information for Employer Benchmarking

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Community Based Collaborative Approach to
Improving Workers' Compensation Medical Care

• Benchmarks developed and measured
• Type of Injury
• Provider visits per case
• Modified duty as an option
• Work status of patient after initial visit
• Time between events
• Time for information from provider to er
• Treatment plans ordered
• Diagnostic tests ordered
• Frequency of referrals ordered

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Employer Opportunity to Improve Access to Care

• Tertiary Access Issues
• Adapt services to the culture and language of
  your workforce

• Tool Box Item 4
• UNITE Expanding Access to WC Health for Low Wage
  Immigrant Workers
• www.umassmed.edu/workerscomp/grants/grant19.cfm
  

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Quality Medical Care Delivery

• Quality measures include
• access to care
• timeliness of care
• appropriateness of care
• utilization and cost of care
• efficient coordination of care and communication
  of plans and physical abilities
• prevention of re-injuries and
• satisfaction with care.

• Tool Box Item 5
• Mid-America Coalition on Health Care
• www.umassmed.edu/workerscomp/Tool_Box/measures_qua
  lity/benchmarks.cfm

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Quality Medical Care Delivery

• Quality measures include
• access to care
• timeliness of care
• appropriateness of care
• utilization and cost of care
• efficient coordination of care and communication
  of plans and physical abilities
• prevention of re-injuries and
• satisfaction with care.

• Tool Box Item 2 and 12
• Dissemination and Implementation of ACOEM Medical
  Practice Guidelines
• www.umassmed.edu/workerscomp/grants/grant1.cfm
• Minnesota Workers Compensation Program
  Mandatory Treatment Parameters
• Evaluation www.umassmed.edu//workerscomp/grants/
  grant16.cfm

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Quality Medical Care Delivery

• Quality of care is the degree to which health
  services for individuals and populations increase
  the likelihood of desired health outcomes and are
  consistent with current professional knowledge.
  (Institute of Medicine, 1990)

22
Treatment Guidelines

• Attempt to define generally accepted treatment
  standards for specific conditions
• Most recent are those developed by the American
  College of Occupational and Environmental
  Medicine (ACOEM)
• ACOEM guidelines are evidence based and can be
  used for prevention, management and clinical
  evaluation of common work related health problems

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Minnesota Workers Compensation Program
Mandatory Treatment Parameters Evaluation

• Importance and Implications
• Are treatment guidelines being used and do they
  make a difference?
• Results
• 70.8 of workers studied were provided compliant
  treatment (Source Stratis Health Care)
• Less time away from work
• Similar outcomes on
• Pain relief
• Physical functioning
• Satisfaction with care

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Quality Medical Care Delivery

• Quality measures include
• access to care
• timeliness of care
• appropriateness of care
• utilization and cost of care
• efficient coordination of care and communication
  of plans and physical abilities
• prevention of re-injuries and
• satisfaction with care.

• Tool Box Item 6
• Anatomy of Medical Costs and Utilization,
  Stacey Eccleston et. al.,
• Workers Compensation Research Institute, March
  2002
• www.wcrinet.org

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Medical Care CostsHow much variation in costs
from state to state?
Source Workers Compensation Research Institute
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Workers Compensation Medical Costs Why Such
Variation?

• Medical Cost Number of services X Cost per
  service
• Do the number and costs per service vary that
  much?

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Do the number and costs of services vary that
much?YES

• Number of visits provided per claim varies from
  14.7 in WI to 28.5 in CA
• Average cost per visit varies from 179 in MA to
  343 in WI
• Average services per visit varies from 2.7 in WI
  to 3.6 in TX
• Average payment per service varies from 59 in Ca
  to 127 in WI
• Source Workers Compensation Research Institute

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Employer Impact on Workers Compensation Costs

• Over 50 of prevailing workers compensation
  costs are directly attributable to a companys
  response to injured workers and their claims
  (Askey 1988)
• Michigan study found TEN fold differences in
  injury frequency between high and low costs
  employers in same 29 industries (Habeck, Hunt,
  Leahy, and Welch 199?)
• Employers can lower their costs through
• Safety and prevention
• Management, climate and culture
• Disability prevention and management

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Employer Opportunity to Improve Medical Costs

• Dont be short sighted high quality treatment
  resulting in early return to work and recovery
  of maximum physical functioning will be your best
  investment
• Use medical peers to discuss appropriateness and
  utilization issues treatment plans and negotiate
  prices (look for opportunities to pay more for
  quality)
• Provide providers with information and let them
  help with prevention efforts

• Tool Box Items 7
• Disability Prevention Principles in the Primary
  Care Office, McGrail, Lohman and Gorman,
  American Family Physician, February 2001
• Rescuing Lost Productivity, Parry and Molmen,
  Health and Productivity Management, 2002

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Quality Medical Care Delivery

• Quality measures include
• access to care
• timeliness of care
• appropriateness of care
• utilization and cost of care
• efficient coordination of care and communication
  of plans and physical abilities
• prevention of re-injuries and
• satisfaction with care.

• Tool Box Item 3 and 4
• UNITE Expanding Access to WC Health for Low Wage
  Immigrant Workers
• http//www.umassmed.edu/workerscomp/grants/grant19
  .cfm
• Mid-America Coalition on Health Care
• www.umassmed.edu/workerscomp/Tool_Box/measures_qua
  lity/benchmarks.cfm

31
Quality Medical Care Delivery

• Quality measures include
• access to care
• timeliness of care
• appropriateness of care
• utilization and cost of care
• efficient coordination of care and communication
  of plans and physical abilities
• prevention of re-injuries and
• satisfaction with care.

• Tool Box Item 8
• Maximizing Outcomes in the Federal WC System
  (FECA) Through
• Integrated Case Management
• www.umassmed.edu//workerscomp/grants/grant6.cfm

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Maximizing Outcomes in the Federal WC System
(FECA) Through Integrated Case Management

• Importance and Implications
• To enhance case management within the federal
  workforce
• To introduce initial measures for managing care
  for federal workers
• To test an innovative approach for incorporating
  worksite hazard prevention with the medical care
  experience.

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Maximizing Outcomes in the Federal WC System
(FECA) Through Integrated Case Management

• Results
• A 2-day specialty training of nurse case managers
  resulted in
• Claimants of trained nurses receiving 1.5 times
  as many recommendations for worksite
  accommodations
• 1.4 times as many recommendations were
  implemented
• Trained nurses were more likely to make
  recommendations on addressing workstation layout,
  computer-related improvements, furnishings,
  accessories, and lifting and carrying aides
  whereas untrained nurses were more likely to
  suggest light duty and lifting restrictions

34
Quality Medical Care Delivery

• Quality measures include
• satisfaction with care.

• Tool Box Item 9, 10, and 11
• "What Do Injured Workers Think About Their
  Medical Care and
• Outcomes after Work Injury?" Rudolph, L, Dervin,
  K, Cheadle, A, Maizlish,
• N, Wickizer, T. Journal of Occupational and
  Environmental Medicine,
• Vol 44, Number 5, May 2002. 
• URAC Injured Workers Survey
• www.umassmed.edu/workerscomp/pdfs/Appendix4-1.pdf
• The Development and Testing of A Standardized
  Workers Survey As A Tool
• For The Potential Development of a National
  Interstate Database for the
• Study of Workers' Compensation Medical Care
  Outcomes (WINS)
• www.umassmed.edu/workerscomp/grants/grant17.cfm
• www.winsonline.net

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What do injured workers think?

• Results of Injured Worker Survey in California
• Over 30 of workers felt their doctors did only a
  fair or poor job of explaining things to them
• 13.3 of workers reported some or a lot of
  trouble getting medical care
• Nearly 25 of 813 injured workers interviewed
  were not satisfied with the medical care they
  received after their work injury
• Routine assessment of patient satisfaction and
  outcomes after work injuries could identify
  important opportunities for improving the quality
  of medical care for injured workers

Source Division of Workers Compensation
Department of Industrial Relations - California
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Medical Care Delivery

• What other factors affect access, costs and
  quality in workers compensation and what can
  employers do?
• Medical Factors
• Legal and Regulatory Factors
• Economic Factors
• Political Factors
• Employer/Insurer Management Issues
• Psychosocial and Socioeconomic factors

• Tool Box Item 5
• Controlling Rising WC Medical Costs An
  Employers Checklist,
• by Ann Clayton

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How Can You Impact the Quality and Cost
Effectiveness of Medical Care?

• Measure and evaluate current medical services
  provided to your employees (Tool Box Items 1,
  2, 4, 7, 10)
• Help coordinate medical services for severely
  injured or those workers not showing progress or
  those workers who present potential complicating
  factors for recovery (Tool Box Items 1, 7, 8)
• Facilitate communication between HCP, patient and
  supervisor
• (Tool Box Items 1, 4)
• Review, evaluate and pay bills promptly and
  communicate reductions or items disallowed
  (eliminates barriers to access)
• Gather data that will help improve your program
  (Tool Box Items 1, 4, 8, 9, 10)

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Quality Medical Care

• Should be an important part of the
  puzzle

Management Culture
Safety and Prevention
Disability Management and Return to Work
Injury Response
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Employers WC Management Activity Cycle
Management Culture, Prevention, Orientation And
Education, Policies and Procedures (PLAN)
Medical treatment, medical and disability
management, return to work planning and
Implementation (DO)
Injury Response (DO)
Revise policies and procedures, Meet with
servicing providers, Make purchasing decisions,
Enhance focus and communicate results (ACT)
Data review and analysis, Evaluation of claims
and medical services (CHECK)
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Group Exercise

• Using the Employers Workers Compensation
  Management Cycle, discuss additions to your
  program that would likely improve the access and
  quality of medical care for your workers and help
  achieve better outcomes for your company as well

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How Can Claims Handlers and Case Managers Help
Employers?

• Review employers injury response and management
  systems recommend improvements facilitate the
  choice and evaluation of treating or coordinating
  physicians to maximize timeliness, quality care
  and outcomes for workers
• Ensure prompt reporting, investigation,
  evaluation and payment or denial of claims and
  communicate results honestly and promptly
• Help educate health care providers and facilitate
  communication between HCP, patient, employer and
  carrier
• Become part of the early response, ongoing
  communication and resolution team for the
  employer and injured worker
• Provide important data that will help the
  employer manage and improve the health and well
  being of their workforce and protect both their
  financial and human resources.

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SummaryImproving Access, Costs and Quality of
Workers Compensation Medical Care for Your
Employees

• Choose the medical providers you refer your
  injured workers to carefully and monitor your
  employees satisfaction with that care
• Manage your workplace effectively
• Have effective systems for preventing, responding
  to and managing on the job and off the job
  injuries
• Strive for an overall healthy workforce
• Benchmark your medical outcomes related to
  access, costs and quality and keep working on
  improvements

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Prevention

• Primary Prevention - e.g. worker selection,
  orientation and training, physical conditioning
  and general health promotion, ergonomic design to
  decrease physical stress and repetition.
• Secondary Prevention - appropriate medical
  management, reasonable accommodations and
  ergonomic redesign

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Ergonomics and Prevention

• Ergonomics is the study of humans at work to
  understand the complex interrelationships among
  people, their work environment, job demands, and
  work methods.
• Implementation of ergonomic principles is the
  most effective tool available to employers to
  decrease the incidence of musculoskeletal injury,
  disease, and disability.

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Disability and Absence Management

• Team approach is critical
• Communication between health care provider,
  injured workers, supervisors, and HR essential.
• Coordination/integration and consistency of
  benefit plan content, definitions, rules and
  responsibility necessary.

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Improving the Accessibility, Costs and Quality of
Workers Compensation Medical Care

• An Orientation Module for Employers
• Training Evaluation

47
Thank You!

• Ann Clayton
• annclayton_at_aol.com
• 781-402-0012