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: lgreenberg@urac.org