Improving Outcomes in Workers Compensation System Efficiencies and Inefficiencies.
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Transcript of Improving Outcomes in Workers Compensation System Efficiencies and Inefficiencies.
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
Interstate variance
Position Amount Variance
Cost 3 $1800 2xDuration of medical care
1 21 weeks > 2x
Time off work 1 29 weeks > 3xManaged care DOMC
4 weeks 5 x
4
Indirect Data: Variance in Resource Use (12 states)
Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001
Interstate variance Position Type Variance
Physical medicine
1 Modalities, ther. ex, other
> 3 x
Tests 1/2 Xrays/ MRI, NCV/EMG
1.2—3 x
Injections 1 ESI, CT, arthrograms
2 x
Inter-professional resource use
chiro v. phys med
> 2x
5
Prescriptions/CasePharmaceutical Claims Per Patient, 1997
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
CA CO FL GA KY MN NJ OR TX
State
Nu
mb
er o
f P
resc
rip
tio
ns
6
Indirect Data: Variance in Resource Use (GH v. WC)
Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001
Intersystem variance Variance
Cost 4.5 x
Injections 2 x
Manipulation 3.5 x
Therapeutic exercise > 2 x
Electro testing 3 x
7
Indirect Data Example: Duration of Medical Care by Quintile
Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001
8
Direct Data:Cox Proportional Hazard Regressions
• 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
Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001
9
Direct Data: Survey, ANOVA
• 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)
Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001
10
Characteristics of Top Quintileo There is a disproportionate concentration of costs in the
top quintileo Almost all surgeries are in the top quintileo There is a high use of Physical Medicine in the top quintileo Both duration of care and time off work are much greater
in the top quintileo Multiple diagnoses, diagnoses outside the first named
super group, and diagnoses involving multiple body parts are much more common in the top quintile.
o 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 care
California Data Extrapolated
Service Lower 80% Top 20% Guidelines
Office visits 4 20 4
X-rays 1 8 0
MRI 0 3 0
NCV 0 46 0
Data source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001
12
Low v. High Cost PatientsLow back pain—MD care
California Data Extrapolated
Service Lower 80% Top 20% Guidelines
Therapeutic Exercise
18 40 Up to 10
Modalities 15 75 Up to 20
Work Hardening 0 80 Unproven
Epidurals 0 18 0
Laminectomies 0 >1 inappropriate
Fusions 0 0.5 inappropriate
13
Low v. High Cost PatientsLow back pain--extrapolated—DC care
Service Lower 80% Top 20% Guidelines
Therapeutic exercise
6 81 Up to 10
Modalities 45 137 Up to 20
Manipulation 17 170 Up to 10
Work hardening 0 156 Unproven effectiveness
Data source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001
14
Characteristics of High Cost Patients
• 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
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
Effect of Physician DIscussion on Median Physical Function
0
5
10
15
20
25
30
35
40
Discussion Topic
Med
ian
Ph
ysic
al
Fu
ncti
on
Sco
re
Median PCS Yes
Median PCS No
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
Effect of Physician Discussion on Median Time Off Work
0
2
4
6
8
10
12
14
16
18
Activi
ties
to d
o sa
fely
at w
ork
and
hom
e
How to
man
age
pain
How to
pre
vent
reinj
ury
Choice
of d
iffere
nt tr
eatm
ents
Med
icatio
n sid
e eff
ects
Mut
ually
agr
eed
on R
TW d
ate
Chang
ing w
ork
sche
dule
Arrang
ing fo
r oth
ers
to h
elp d
o wor
k
Arrang
ing to
hav
e sp
ecial
tools
or e
quipm
ent
Discussion Topic
Median TOW Yes
Median TOW No
19
Effective Physician Practices
Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001
Practice/
perception
MCSw/
MCS w/o
TOW w/
TOW w/o
Right RTW time* 51.5 41.5 13 wks 18 wks
* MCS = 36.6 if worker thought he or she could have gone back earlier but TOW was 3 wks
(Early PD rating = about 40%)
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
Practice PCS w/
PCS w/o
MCS w/
MCS w/o
TOW w/
TOW w/o
Mutual choice of physician
ns ns 51.7 44.7
/42.0
5 wks 15/16 wks
Cooperate w/ doc 39.2 32.2 49.9 38.2 11 wks 17 wks
Understand capabilities
40.3 33.2 51.1 38.6 12 wks 16 wks
Mod. duty 36.6 33.3 ns ns ns ns
Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001
22
(In)Effective Employer Practices
Texas Other States
Good employer before the injury 65.6% 62.1%
Fair performance appraisals 47.2% 47.4%
Had difficult supervisors before the injury * 27.0% 18.9%
Treated employee with respect before and after * 44.8% 54.7%
Did not believe employee was hurt 26.9% 26.3%
Questioned whether injury was work related 20.0% 21.1%
Fired employee after claim or RTW * 17.2% 5.3%
* = 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
Texas Other States
Worked with doctor re treatment, RTW * 43.2% 58.9%
Tried to understand tasks able to perform * 38.5% 48.4%
Did not seem concerned about safety * 33.5% 22.1%
Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001
Outcomes
25
Incomplete Functional RecoveryReported Work Functional Abilities
Texas Injured Workers
0.0%10.0%
20.0%30.0%40.0%50.0%
60.0%70.0%80.0%
90.0%100.0%
Ability
Pro
port
ion
of W
orke
rs
Worse
Same
Better
Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001
26
Incomplete Functional RecoveryInterstate Comparison of Decreased Work Ability
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Work Ability
Pro
po
rtio
n o
f W
ork
ers
Texas
Other States
Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001
27
Employment Impact
Texas Other states
Working * 64.4% 75.4% Not working * 35.6% 24.6%
Texas Other states Unable to work because of work injury 51.3% 46.4% Unable to work for other reasons * 16.6% 0.0% Retired * 10.6% 32.2% Looking for work 21.5% 21.4%
Of those not working,
Source: Harris, Bengle, Makens, Lee, et. al. Striking the Balance. Austin: ROC, 2001
28
Economic Impact
Economic Impact - First Six Months Texas Other States
Dipped into savings 25.4% 20.0% Used food stamps, welfare, etc. 7.9% 1.0% Borrowed money 20.0% 10.5% Moved to a smaller dwelling 5.0% 1.0% Had problems with bills * 27.6% 15.8% Spouse had to work 8.8% 6.3% Lost health insurance coverage 9.7% 4.2% Went into credit card debt 12.0% 7.4% Car sold, repossessed 4.6% 1.1% Home sold, foreclosed 1.1% 0.0%
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
Economic impact - After first six months Texas
Other States
Dipped into savings 12.0% 9.5% Used food stamps, welfare, etc. 7.4% 4.2% Borrowed money 13.1% 7.4% Moved to a smaller dwelling 6.3% 1.1% Had problems with bills * 15.1% 7.4% Spouse had to work 4.0% 3.2% Lost health insurance coverage 7.1% 3.2% Went into credit card debt 10.5% 4.2% Car sold, repossessed 7.2% 2.1% Home sold, foreclosed 2.7% 1.1%
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