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Driving Value in Workers’ Compensation with Evidence-Based Medicine

States that have adopted and enforced Official Disability Guidelines (ODG) are seeing proof of their efficacy for eliminating costs while maintaining quality of care.
By: | April 5, 2018 • 6 min read

Among developed nations, the U.S. falls near the bottom of the rankings in terms of health care efficiency.

“We spend more money, but don’t necessarily see better results,” said Kim Radcliffe, Senior Vice President, Clinical Operations at One Call. “Excessive care and unnecessary diagnostic testing drives up utilization costs without producing real benefit to patients.”

Evidence-based medicine can help flag unnecessary care, delivering better clinical outcomes at a lower cost. For workers’ compensation payers, achieving efficiency is vital to keeping claims costs in check while getting injured workers back to health as quickly as possible.

States that have adopted and enforced Official Disability Guidelines (ODG) — one of the most well-recognized evidence-based guidelines in the industry — offer real world validation that this approach eliminates costs while maintaining quality of care.

Since Texas adopted ODG in 2007, they have reduced lost-time by 34 percent, dropped medical costs by 30 percent, and subsequently decreased workers’ comp insurance premiums by 51 percent.

The Ohio Bureau of Workers’ Compensation also reduced claim duration and medical costs by more than 60 percent within one year of implementing ODG in 2004. In addition, they decreased treatment delays for the top 30 workers’ comp conditions by 77 percent.

Several other states saw notable improvements, including North Dakota, Kansas, Oklahoma and California, since adopting ODG.

“States that do not enforce evidence-based guidelines via a formal utilization review process often have significantly higher utilization and per-unit costs — and often don’t achieve the same level of outcomes as states that utilize a formal program,” Radcliffe said. “There is a lack of consistency in how evidence-based guidelines are enforced among those states with no formal UR rules.”

Employers in states that do not require utilization review or adherence to evidence-based guidelines can still apply the approach and reap its benefits. But it requires working with the right care management partner.

Case Study: Physical Therapy Interventions

Kim Radcliffe, Senior Vice President, Clinical Operations, One Call

Vendors with expertise in both clinical care and workers’ compensation can drive value for their clients by getting involved directly with patient care. One Call leverages its expertise in evidence-based medicine to work at a peer level with clinicians. Evidence-based guidelines provide a roadmap for that process, setting triggers and benchmarks that help steer care down the most efficient path. Doing so not only restores workers back to health faster, but also keeps costs in line for employers.

One injured worker’s recovery journey offers an example.

After surgery for a total knee replacement, the patient received a referral for a high-end in-patient rehabilitation center. That set off one red flag.

“A referral for high-end rehab is a trigger under the guidelines. Such facilities can be very expensive, and aren’t always necessary when a skilled nursing facility is available and can achieve the same results, for a much lower cost,” Radcliffe said.

One Call’s team intervened and got the patient into a skilled nursing facility instead, saving the payer “tens of thousands of dollars.” They worked directly with nursing staff to establish a one-week timeline and monitored his progress throughout. At the end of the week, all agreed he was ready for discharge.

Then came the second red flag.

The treating physician referred the patient for home health physical therapy visits, but guidelines establish that outpatient therapy is preferable whenever possible.

“We moved him straight to outpatient therapy, which not only saved costs, but also shortened his care timeline,” Radcliffe said.

At the end of the prescribed 16 PT visits, the patient received a second referral for more care.

“A second prescription for PT always triggers a review to determine whether or why the first prescription was not enough,” Radcliffe said. After connecting with the treating therapist and reviewing the patient’s progress, they reached a consensus that more care was not warranted.

“Our guidelines dictate treatment only when it is medically necessary and beneficial,” Radcliffe said. “In this case, it was clearly not necessary, and it would not bring the patient any added benefit.”

Ultimately, the patient was able to return to work two to three weeks sooner due to the interventions and redirection of his care, and the payer saved a total of $68,000.

Gaining Provider Trust by Focusing on Patient Needs

Ultimately, enforcing evidence-based guidelines in jurisdictions that have not formally adopted them is impossible without provider buy-in. Establishing open communication channels earns that buy-in and enables faster claims closure without compromising the quality of care. Communication with clinical care providers is critical to applying evidence-based medicine.

Without oversight, some doctors have a tendency to prolong treatment. From a purely clinical perspective the thought is that more care and attention can’t hurt.

That desire to do what is best for the patient is exactly where providers, payers, claims managers, and of course, patients, can find common ground. The key is to establish a collaborative relationship that considers input from the appropriate parties.

“The best way to implement evidence-based medicine in workers’ comp is through direct peer-to-peer calls, rather than formal utilization review. If we see a red flag, we never recommend a change in the care plan until we have attempted to reach the treating provider,” Radcliffe said.

“That communication is generally well-received, and it increases the provider’s sense of accountability.”

At the heart of evidence-based medicine is a focus on the needs of the patient.

“Doing the right thing for the patient benefits everyone in the long term,” Radcliffe said. “Our culture at One Call is to take a patient-centric approach and make sure the care plan is one that will get them back to a normal life faster. This approach benefits their employer as well.”

An Expert Partner in Clinical Care

An expansive network of medical providers enables One Call to deliver services on a broad scale across the full spectrum of care. One Call determines a quality provider based on their outcomes and utilization record and directs care to the highest quality providers when possible. A commitment to building relationships and earning the trust of providers also facilitates the review process and making adjustments to treatment plans.

With more than 200 on-staff licensed physical therapists, occupational therapists, certified hand therapists, chiropractors, nurses and dental professionals, One Call’s clinical specialists can engage directly with providers and communicate about clinical issues clearly and effectively.

“A high-level of clinical coordination and in-house clinical expertise is what drives our process,” Radcliffe said. “We focus on what is appropriate and when for a specific injury. Through our Gold Standard Review process, we can identify when an approach isn’t working and use clinical pathways to find a better approach.”

“We can fill in the gap for states that have not formally adopted evidence-based guidelines or utilization review procedures. In states that have, we help them execute it.”

Ultimately, this level of clinical oversight helps to create a consistent level of care for workers’ compensation patients — no matter what jurisdiction they live in.

To learn more about One Call’s services for the workers’ comp industry, visit http://onecallcm.com/.

 

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This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with One Call. The editorial staff of Risk & Insurance had no role in its preparation.




One Call is the nation’s leading provider of specialized solutions to the workers’ compensation industry. One Call’s solutions enable faster, more efficient and more cost-effective claims resolution with a focus on injured workers’ needs across the continuum of care.

Risk Management

The Profession

As a professor of business, Jack Hampton knows firsthand the positive impact education has on risk managers as they tackle growing risks.
By: | April 9, 2018 • 4 min read

R&I: Who is your mentor and why?

Ellen Thrower, president (retired), The College of Insurance, introduced me to the importance of insurance as a component of risk management. Further, she encouraged me to explore strategic and operational risk as foundation topics shaping the role of the modern risk manager.

Chris Mandel, former president of RIMS and Risk Manager of the Year, introduced me to the emerging area of enterprise risk management. He helped me recognize the need to align hazard, strategic, operational and financial risk into a single framework. He gave me the perspective of ERM in a high-tech environment, using USAA as a model program that later won an excellence award for innovation.

Bob Morrell, founder and former CEO of Riskonnect, showed me how technology could be applied to solving serious risk management and governance problems. He created a platform that made some of my ideas practical and extended them into a highly-successful enterprise that served risk and governance management needs of major corporations.

R&I: How did you come to work in this industry?

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From a background in corporate finance and commercial banking, I accepted the position of provost of The College of Insurance. Recognizing my limited prior knowledge in the field, I became a student of insurance and risk management leading to authorship of books on hazard and financial risk. This led to industry consulting, as well as to the development of graduate-level courses and concentrations in MBA programs.

R&I: What was your first job?

The provost position was the first job I had in the industry, after serving as dean of the Seton Hall University School of Business and founding The Princeton Consulting Group. Earlier positions were in business development with Marine Transport Lines, consulting in commercial banking and college professorships.

R&I: What have you accomplished that you are proudest of?

Creating a risk management concentration in the MBA program at Saint Peter’s, co-founding the Russian Risk Management Society (RUSRISK), and writing “Fundamentals of Enterprise Risk Management” and the “AMA Handbook of Financial Risk Management.”

A few years ago, I expanded into risk management in higher education. From 2017 into 2018, Rowman and Littlefield published my four books that address risks facing colleges and universities, professors, students and parents.

Jack Hampton, Professor of Business, St. Peter’s University

R&I: What is your favorite book or movie?

The Godfather. I see it as a story of managing risk, even as the behavior of its leading characters create risk for others.

R&I: What is your favorite drink?

Jameson’s Irish whiskey. Mixed with a little ice, it is a serious rival for Johnny Walker Gold scotch and Jack Daniel’s Tennessee whiskey.

R&I: What is the most unusual/interesting place you have ever visited?

Mount Etna, Taormina, and Agrigento, Sicily. I actually supervised an MBA program in Siracusa and learned about risk from a new perspective.

R&I: What is the riskiest activity you ever engaged in?

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Army Airborne training and jumping out of an airplane. Fortunately, I never had to do it in combat even though I served in Vietnam.

R&I: If the world has a modern hero, who is it and why?

George C. Marshall, one of the most decorated military leaders in American history, architect of the economic recovery program for Europe after World War II, and recipient of the 1953 Nobel Peace Prize. For Marshall, it was not just about winning the war. It was also about winning the peace.

R&I: What about this work do you find the most fulfilling or rewarding?

Sharing lessons with colleagues and students by writing, publishing and teaching. A professor with a knowledge of risk management does not only share lessons. The professor is also a student when MBA candidates talk about the risks they manage every day.

R&I: What is the risk management community doing right?

Sensitizing for-profit, nonprofit and governmental agencies to the exposures and complexities facing their organizations. Sometimes we focus too much on strategies that sound good but do not withstand closer examination. Risk managers help organizations make better decisions.

R&I: What could the risk management community be doing a better job of?

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Developing executive training programs to help risk managers assume C-suite positions in organizations. Insurance may be a good place to start but so is an MBA degree. The Risk and Insurance Management Society recognizes the importance of a wide range of risk knowledge. Colleges and universities need to catch up with RIMS.

R&I: What emerging commercial risk most concerns you?

Cyber risk and its impact on hazard, operational and financial strategies. A terrorist can take down a building. A cyber-criminal can take down much more.

R&I: What does your family think you do?

My family members think I’m a professor. They do not seem to be too interested in my views on risk management.




Katie Dwyer is an associate editor at Risk & Insurance®. She can be reached at [email protected]