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)


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)


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


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


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)


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.


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


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


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


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


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Direct Data: SurveyEffective Physician Practices

* = significantly associated with higher PCS scores


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


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


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


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%


Outcomes

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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


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


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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,


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%


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Economic Impact


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%

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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

Documents

Improving Outcomes in Workers Compensation System Efficiencies and Inefficiencies