In the handling of work related injuries, quality medical treatment is essential in obtaining a good medical result and a swift return to work. These two elements have a significant impact on the total case cost of workers' compensation, writes Anne E. Kirby.
Employers and insurers alike have worked to control costs associated with workers' compensation and in doing so, several issues have become clear. The first issue is that the closer to the time of injury one intervenes with an injured worker, the sooner one can have an impact on the outcome of care. The second issue relates to the quality and depth of the medical approach used to treat injured workers. Finally, it is the measurement of costs and the impact of directing care which enables insurers and employers to make decisions based on outcomes to further increase program effectiveness. In this discussion we will look at the practices being used today which have the greatest impact on the management of care and costs associated with workers' compensation injuries.
The reporting of a workers' compensation claim is mandated by individual state jurisdictions and is required by the insurance carrier or third party administrator to initiate a workers' compensation claim. According to one study, the national average for reporting injuries is 26 days from the time of injury. According to Richard Silton, president of First Notice Systems, Inc., a Boston based call center which collects initial claims reporting information, for each day a claim is not reported, the cost to an insurer is an additional $830. The compression of time yields significant savings for their customers and offers a huge incentive for outsourcing. Twenty four hour coverage 365 days a year and the ability to report any kind of claim offers a value to customers who are trying to manage their own expenses at the same time they are managing the costs of the employers they insure. The first report is so important because it is the notice that a claim exists, and therein lies an opportunity to intervene to manage the cost. Direction of care to a primary occupational healthcare center at the time of injury can have enormous impact on the provision of quality care and total cost.
In order to have an effective workers' compensation program, employers and insurers need to set goals and then share them with the various constituencies associated with the program. For the sake of discussion however, let us assume that the goals of every employer are to get every injured employee the best healthcare fast and to get every employee returned to work as soon as appropriate. The use of the primary care occupational physician to deliver the care is the perfect vehicle for reaching the above goals. From the perspective of Dan Thomas, president and chief operating officer of Concentra Managed Care, Inc., "Our health services division provides injury and non injury care aimed at providing the best quality care to injured workers." Outcome analysis demonstrated by Concentra Medical Centers have demonstrated that certain factors are important to successful, cost-effective resolution of workers' compensation cases: quality medicine delivered right the first time, physician-employer communication, frequency of timing of rechecks, timing of consultations and tests, and closure of cases by the treating medical center.
Quality medicine delivered right the first time
Delivering care right the first time depends on the quality of the process to implement and integrate with the employer or insurer purchasing services. This process is important because it establishes a personal relationship with employers and helps them understand their ownership in making sure that access to care occurs quickly. This process also helps determine the employer's service level expectations. Next, the implementer, a health service representative, consults with the employer to determine all of the employer's occupational healthcare needs. A good team will recognize that there are many players who can positively impact a strong primary care program and they will identify all of the external stakeholders associated with the employer. Finally, the occupational health provider will build and load the employer's information system master file. This includes service level expectations and establishes all external stakeholder relationships. The establishment of structure for information reporting at the initiation of the program, builds customer value and determines the ability of the provider to document success in reviewing the outcomes.
Effective physician employer communication
In the primary care occupational healthcare model, the physician may have performed non-injury related services, which tend to build credibility with the center as a healthcare provider. For example, many companies require preplacement physicals, and while this serves as a valuable baseline for the company hiring benchmark, it is a relationship builder between the employee, employer and physician. This also markedly increases a physician's understanding of specific job requirements and their impact on physical capability. Strategy focused on return to work and early comprehensive medical care improves the speed in which an injured worker returns to productivity. The communication between physician and employer has resulted in a high percentage of cases returning to work without any lost time and in those cases with lost time, the duration of an average case is only 8-12 days.
Manage the frequency of timing of rechecks
In the Concentra Medical Centers model, the primary care physician controls the frequency and timing of rechecks. Utilizing detailed outcome analysis, the provider knows what the average length of treatment for an individual with a certain job may be and as such is able to provide not only medical evaluation and treatment but physical therapy services as well. In the typical case, there are 3 visits to a physician and in 30%-35% of the cases referred, 5.5 visits to a physical therapist. Given the fact that the average time to discharge from the primary care setting is 18 days, this approach utilizes more care upfront than the typical HMO model which emphasizes managing the cost and limiting care assuming that many cases will resolve themselves. The difference in the workers' compensation case is that for every day an individual loses time from work, his employer (at least indirectly) and insurer will be paying for the cost of indemnity, which can represent up to half of the total cost of a case.
Control the timing of consultations and tests
Strong relationships with specialists for consultation and further treatment is important for maintaining the aggressive management instituted at the beginning of the injury care process. The occupational health center staff secures appointments with specialty and ancillary providers within 48 hours and verifies appointments are kept. Long-standing relationships with specialists over the last 19 years and access to FOCUS Healthcare, the largest workers' compensation preferred provider network dedicated to occupational healthcare, enables the primary care provider at a Concentra Medical Center to continue to manage the timing of consultations with specialists and further diagnostic testing. Physicians refer to a small and select group of specialist providers who understand the uniqueness of workers' compensation. The volume of referrals assures preferential appointments and the specialist's timely communication of medical findings and course of treatment. The bottom line is to avoid the denial of any resources which may speed diagnosis, treatment, and a safe return to work.
Closure pattern of cases by primary care center
Dedicated staff in each market are equipped to follow the entire episode of care to ensure timely and appropriate healthcare. This not only helps identify value but also points out areas for program change and evaluation of protocols. The diagram (Figure 1) shows the network of information communication which needs to be performed in order to meet the needs of the specific employer and insurance program payer as well as to collect detailed information on a summary level. Figure 1 demonstrates the substantial investment in information technology required to link the employer level information along with the requirements needed to satisfy the policyholder. The data repository and data warehousing architecture allow for the creation of an employer master file with employer specific protocols. It also allows for the creation of a payer program master file with payer specific protocols. The system collects all relevant medical encounter data and clinical information for each provider visit and documents the primary occupational healthcare program process effectiveness. This in turn facilitates outcomes and best practice analyses by offering "report card" type reporting.
Managed care arrangements and the general trend toward managed care activity on the healthcare benefits side has had a major impact on the utilization and direction of care activity on the workers' compensation side. Employers who work with primary occupational healthcare providers to keep the quality of healthcare high are likely to see substantially improved cost trends in their workers' compensation cases. Earlier reporting and planned deliberate use of resources in work related cases combine to reduce overall costs. However, without the systems infrastructure to evaluate provider performance, utilization of care, and return to work data, the effectiveness of such programs cannot be realized. The national average of 26 days to report an injury indicates that there is considerable room for improvement of reporting injuries and many opportunities to direct care from the time of injury. A denial of services or a decrease in resources early on in a case will only serve to increase costs over time and will do nothing for the satisfaction of employers and employees alike. In workers' compensation, the most valid measurement of effectiveness of a program is the loss cost per employee per year. The key to success is managing the process.
Anne Kirby is currently vice president of product development for Concentra Managed Care, Inc., a Boston based outsource provider of service for the management of injuries in the auto, disability, health, and workers' compensation markets. Ms Kirby has written and spoken widely about various topics in the workers' compensation and integrated disability products areas.