Resources
Physician "Quality"
Lessons from the World of Workers' Compensation
Over the last decade, the conversation around the definition and measurement of physician quality has generated much heat, and little light. The absence of meaningful, comparative data has compounded this problem, providing just enough fodder for competing "authorities" to argue their perspective, but not enough to convince their skeptics. Little consensus has emerged and patient advocates, payers, employers, providers, regulators, and researchers continue to talk past each other.
Perhaps the key problem is the definition of "outcome." For the purposes of this monograph, a reasonable working definition of the term is "the impact of the treating physician on the health status of the patient." As we are focused on physician quality, we will set aside the outcomes studies focusing on one specific condition or treatment, such as the excellent work funded by Agency for Health Care Policy and Research during the 1990s, drug and/or technology-centered research. Unfortunately, we are left with little current, publicly available, physician-specific data with which to work.
There are two general varieties of physician profiling; those that use provider data, such as medical records, and those conducted by payers. Provider-centric patient outcome studies utilize medical records, treatment notes, and scoring processes, and typically do not incorporate objective outcomes data, such as improvements in physical or emotional functionality or return to pre-injury or illness activities/employment. While self-scored instruments are commonly used, these suffer, by definition, from the subjective views of the survey completer.
Payer-based outcomes studies usually incorporate bill data and occasionally medical records data as well. An obvious limitation is the question of what happens when no more bills are generated, or no more records are received by the payer. The assumption can be, and sometimes is, made that the patient has recovered, especially if the medical records and bill data indicate an appropriate progression along a clinical path. However, this is only an assumption. The employer may have changed health plans, the patient may be seeking treatment under a spouse's plan or otherwise changed insurers, or perhaps the patient is now seeking treatment from alternative health care providers, who are typically not reimbursable under a commercial health plan. Or, the patient has grown frustrated and stopped seeking medical care or has died.
These limitations have led to the present state of stasis. With little objective data, a lack of confidence in the comparability and consistency of underlying treatment data, and most problematic, no consensus on or source of data for the "outcome" itself, the physician-profiling outcomes argument has, quite simply, been stuck.
A study published in 2003 by Alex Swedlow and Laura Gardner of the California Workers Compensation Institute (CWCI) may provide the best hope yet for "unsticking" the argument. In retrospect, the utility of a workers compensation-based analysis appears obvious.
Unlike group health, under workers' compensation, the employer is legally responsible for the payment of all medical bills resulting from treatment for the injury or illness, as well as compensation for wages lost if the claimant cannot work. This liability does not end with the plan year or change in insurers; the original insurer "owns" the claim until it is closed. With most claims, closure occurs when the claimant fully recovers and returns to full employment. In those cases where the injured worker does not fully recover, the claim may be settled with a payment or series of payments to the claimant, providing a financial and legal assessment of the "outcome".
CWCI's report is notable not only for solving the "outcome definition" problem. It utilizes a (reasonably) consistent database (California workers' compensation payer data), covers a large number of patients (1.1 million), over a credible time period (eight years), treated by a large number of providers (over 40,000). Unlike group health, provider, or third-party studies, the CWCI study indicates that a relatively few "expert" providers deliver by far the best outcomes and lowest medical costs for workers compensation cases. While the report, entitled "Provider Experience and Volume-Based Outcomes in California Workers Compensation," is worthy of careful and detailed analysis, two findings are particularly pertinent to any discussion of physician quality.
- The medical costs of claims treated by the highest-volume workers compensation providers were LESS THAN HALF that of their peers who treated the fewest workers' compensation cases. Providers with only one claim in the study period averaged $19,856 total cost per claim, compared to providers with more than a thousand claims, who averaged $8,707.
- This cost differential did not come at the price of poor outcomes. For temporary disability claims (those claims where the claimant was temporarily off work due to the injury or illness), the average length of disability for the highest-volume providers was less than half that of the lowest-volume providers, (17.2 days vs. 35.9). This differential was consistent for permanent disability claims.
- Case-mix adjusting the data reinforced the findings - high volume providers consistently delivered lower costs, faster return to work, and more frequent return to work than their lower-volume colleagues.
As employers, health plans, and regulators seek to better understand the impact of the treating physician on the patient, they would be well-served to closely examine the work done by CWCI. While the outcomes themselves are instructive, CWCI's methodology, state-wide scope, and ability to link the treating physician to objective outcomes demonstrate the potential impact of effective assessment of physician quality.
Joseph Paduda, Principal of Health Strategy Associates, is an independent consultant focused in the Workers' Compensation and managed care markets. His clients include large Workers' Compensation insurers, managed care organizations, self-insured employers, and software and systems companies. Prior to his present position, Mr. Paduda was vice president of MetraComp, a United HealthCare Company specializing in the application of managed care techniques to the Group Disability and Workers' Compensation industry. Paduda was responsible for marketing, sales, and account management. Paduda holds a Master's of Science Degree in Health Management from the American University and is a frequent speaker on managed care issues. He lives and works in Madison, Connecticut and can be reached at 203 245 1249 or jpaduda@healthstrategyassoc.com
Copyright 2004 Health Strategy Associates/Joseph
Paduda - All Rights Reserved
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