Methods for Improving and Measuring Quality of Care
California Research Colloquium on Workers’ Compensation
May 1, 2003
Liza Greenberg, RN, MPH
About URAC
• 501(c)3 accreditation organization
• Stakeholder board of directors Providers, payers, consumers, regulators
• Standards for work comp managed care UM, CM, network
• Workers’ comp performance measures
• Research – medical management, CM
Targets for Evaluating Health Care Quality
Plan-based measures: Accreditation Performance reports
Provider/Provider Group/Clinic measures Report cards Profiling
Individual Experience State and National Surveys Health plan specific experience
Standards for Workers’ Comp UM
Standards for: Staff qualifications Clinical review process Clinical review criteria Appeals mechanisms Oversight of delegated functions Staff credentialing
Standards for Workers’ Comp Networks
Network Management Provider availability and accessibility Provider contracting Grievances and appeals Marketing
Quality Assurance Program organization and staffing QA planning
Credentialing of Providers
Difference Between Accreditation Standards and Performance Measures
• Accreditation examines structure and capabilities compared to standards
• Performance measures assess process and outcome information
• Accreditation and performance measures complement each other and increase accountability
URAC WC Performance Measures
• Data can be used for internal QI
• Performance data is collected by MCOs through three inter-related tools: Patient survey Administrative Data Specifications Medical Record Audit
• URAC’s team developed the tools plus instructions on administration and reporting.
Performance Measure Categories
• Access
• Prevention/ Disability Management
• Appropriateness of Clinical Care
• Coordination and Communication
• Cost/Utilization
• Patient/Payer Satisfaction
• Outcomes
Definitions Developed
Functional elements of a managed care organization
Cases of finding criteria: low back pain, knee complaints, shoulder complaints, wrist/arm complaints
Time frame for measurement
Functional Elements of An MCO
To effectively manage and report on care, an MCO has the following elements: Provider network management Case management capability Utilization management Financial management / Bill review data Secondary and tertiary prevention
Administrative Data
Coordination Timeliness of case manager contacts
(time from referral to contact) % of cases that are case managed Length of time from injury to referral
Administrative Data
Outcomes - Work Related• Return to work
Prevention• Availability of occupational medicine doctors• Activities of occupational medicine physicians- involvement in
leadership• Reporting of injuries to employer
Administrative Data
Costs Indemnity costs (TTD, TPD, PTD, PPD, VR) at 60
days, 18 months, at closing, by diagnosis Medical costs (inpt and outpt medical, inpt and outpt
surgery, drugs+therapies) by diagnosis• Total (indemnity, medical, other) by diagnosis
Utilization• Number of specific procedures per 100 cases by
diagnosis
Patient Survey Measures
Coordination Measures• Patient report that assistance received with RTW • Patient report of types of assistance provided
Communication Measures• Doctor communicates well with worker
• Doctor treats worker with respect
• Doctor seeks to understand work environment
• Patient receives information re treatment and avoiding reinjury
• Patient trusts doctor
Patient Survey Measures
Work Related Outcomes First return to work Timing of first return to work
Health Related Outcomes Work related functioning post injury Physical functioning post injury Reinjury of same body part
Patient Survey Measures
Satisfaction With most frequently seen physician With MCO's medical services
Access Accessible location Wait to see the doctor the day of the appointment Availability of hours
Medical Record Measures
Clinical Care For low back pain, shoulder complaint, knee complaint and forearm, wrist and hand complaint:
Adequate medical history
Occupational risk assessment
Appropriate activity modification
Work restrictions advised, if necessary
Appropriate focused physical exam
Documentation of attempt to place on modified duty
Patient education provided
Communication Informed consent
• Scope of MCO services varies considerably
• MCOs have limited access to data
• MCOs have variable quality of data
• Cost of data retrieval is considerable (particularly medical record and survey data)
• There is lack of consensus on treatment protocols and treatment norms
• Case mix and risk adjustment protocols across employers, employees and industries are needed
• Sample size
Technical Challenges in WC Arena
Current PM & Quality Activities
Service quality studies (e.g., efficiency of operations) 92%
Staff performance assessments (e.g., monitor staff compliance to UM criteria)
98%
Medical management performance (e.g., track utilization indicators)
89%
Morbidity and mortality outcomes 23%
Clinical performance (e.g., benchmark their program data to national norms)
35%
Cost savings performance 78%
Coordination of care 54%
Patient satisfaction 83%
Provider profiling (e.g., utilization and cost profiles) 45%
Provider profiling (e.g., practice patterns compared to guidelines) 29%
Performance Reports to Customers
Volume of cases managed 85%
Average length of stay 78%
Length of stay information by diagnosis 59%
Disposition of cases (e.g., such as the number of approvals, denials or pended cases)
75%
Benchmarks of customer specific data to population data
53%
Benchmarks of customer specific data to national norms
47%
Savings reports 66%
Relevant Models for the Future
Medical management trends Interfaced / integrated UM, CM, DM Patient education: health call center, internet
Disability management
PPO experience
Disease management model
0 17
90
4021
46
33
8180
9592
96
7470
79
9597
39
24
6058
42
0
20
40
60
80
100
120
Types of Medical Management Services
Per
cent
age
of C
ompa
nies
current
forcast
Current & Future Medical Priorities
Policy Implications
• Need to show ROI for better medical management and disability management
• Additional research needed in: evidence-based care for occupational injuries measuring outcomes of occupational injuries interface between clinical and economic factors
• Enhanced data systems needed to bring WC systems to comparable level of group health
• MCOs need to augment QI efforts with worker-centered measures and surveys
• Build demand through consumer, regulatory or purchaser organizations
Contact
Liza Greenberg, RN, MPH
Vice President, Research and Quality Initiatives
URAC 1275 K Street, Suite 500
Washington, D.C. 20005
(202) 962-8805
Email: [email protected]