Risk Insider: Jason Beans

‘Drive-By Doctoring’ a Reason for Value-Based Purchasing

By: | September 16, 2015 • 3 min read

Jason Beans is the Founder and Chief Executive Officer of Rising Medical Solutions, a medical cost management firm. He has over 20 years of industry experience. He can be reached at [email protected]

When asked about problems with the U.S. health care system, I often refer to a New York Times article called “After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know.

The article details a patient who received a $117,000 bill from an assistant surgeon he was unaware would be aiding the surgeon. The surgeon he chose was in-network; the assistant was out-of-network and came in while the patient was under anesthesia.

In what other industry, other than U.S. health care, can you receive a service while unconscious, are given no opportunity to learn of (much less agree to) the service or price, and afterwards there is a valid expectation of owing the bill?  I cannot think of one.

The Hidden Costs in Fee-for-Service

Two typical tricks outlined in this article were:

Drive-By Doctoring: It’s very common to have an additional doctor or specialist “pop by” during a treatment. This consultation and/or surgical assist may or may not be clinically supported. In group health, the article illustrates the devastating financial impact such unexpected charges may have on a patient. In workers’ comp, it demonstrates how critical it is to carefully analyze medical charges. While most payers and service providers will certainly notice a $117,000 charge, there can and will be many smaller charges that meet the “drive-by” criteria on a bill.

Out-of-Network Subcontractors: As we’re well aware, many providers (e.g. anesthesiologists, assistant surgeons) working out of a hospital may not, in fact, be hospital employees. It can be difficult to ascertain if out-of-network providers exist at network facilities, and to predict if an episode-of-care might result in subcontractor services.  It is imperative that we find alternate ways to control these unpredictable costs.

A Value-Based Track to Transparency

These practices discussed in the article are purposeful, dishonest and costly, but they need not exist. A transition from fee-for-service models to value-based purchasing in group health, and even slowly in workers’ comp, allows payers to more easily explore pre-negotiated, all-inclusive rate alternatives. These arrangements have many advantages, not the least of which is the elimination of “drive-by-doctoring” or other hidden fees. When everyone agrees to a fair, upfront price, the opportunity and incentive to “game the system” is removed.

The benefits of cost predictability in workers’ comp are readily apparent, but the outcomes and care coordination aspects of value-based purchasing make it equally compelling. These arrangements allow payers to work with providers who meet certain performance parameters, and are further incented to ensure positive outcomes in order to keep costs commensurate with agreed-upon rates. Bundled rates also promote effective coordination amongst multiple providers who are handling varied aspects of treatment and sharing in a single payment.

It’s encouraging to see the gradual shift towards value-based purchasing in workers’ comp. And while this evolution will take time, the momentum towards a model where we do not simply reward quantity of services, but focus on a more holistic approach to patient care and healthcare purchasing is something that workers’ comp is more than capable of.

More from Risk & Insurance

More from Risk & Insurance

4 Companies That Rocked It by Treating Injured Workers as Equals; Not Adversaries

The 2018 Teddy Award winners built their programs around people, not claims, and offer proof that a worker-centric approach is a smarter way to operate.
By: | October 30, 2018 • 3 min read

Across the workers’ compensation industry, the concept of a worker advocacy model has been around for a while, but has only seen notable adoption in recent years.

Even among those not adopting a formal advocacy approach, mindsets are shifting. Formerly claims-centric programs are becoming worker-centric and it’s a win all around: better outcomes; greater productivity; safer, healthier employees and a stronger bottom line.

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That’s what you’ll see in this month’s issue of Risk & Insurance® when you read the profiles of the four recipients of the 2018 Theodore Roosevelt Workers’ Compensation and Disability Management Award, sponsored by PMA Companies. These four programs put workers front and center in everything they do.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top,” said Steve Legg, director of risk management for Starbucks.

Starbucks put claims reporting in the hands of its partners, an exemplary act of trust. The coffee company also put itself in workers’ shoes to identify and remove points of friction.

That led to a call center run by Starbucks’ TPA and a dedicated telephonic case management team so that partners can speak to a live person without the frustration of ‘phone tag’ and unanswered questions.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top.” — Steve Legg, director of risk management, Starbucks

Starbucks also implemented direct deposit for lost-time pay, eliminating stressful wait times for injured partners, and allowing them to focus on healing.

For Starbucks, as for all of the 2018 Teddy Award winners, the approach is netting measurable results. With higher partner satisfaction, it has seen a 50 percent decrease in litigation.

Teddy winner Main Line Health (MLH) adopted worker advocacy in a way that goes far beyond claims.

Employees who identify and report safety hazards can take credit for their actions by sending out a formal “Employee Safety Message” to nearly 11,000 mailboxes across the organization.

“The recognition is pretty cool,” said Steve Besack, system director, claims management and workers’ compensation for the health system.

MLH also takes a non-adversarial approach to workers with repeat injuries, seeing them as a resource for identifying areas of improvement.

“When you look at ‘repeat offenders’ in an unconventional way, they’re a great asset to the program, not a liability,” said Mike Miller, manager, workers’ compensation and employee safety for MLH.

Teddy winner Monmouth County, N.J. utilizes high-tech motion capture technology to reduce the chance of placing new hires in jobs that are likely to hurt them.

Monmouth County also adopted numerous wellness initiatives that help workers manage their weight and improve their wellbeing overall.

“You should see the looks on their faces when their cholesterol is down, they’ve lost weight and their blood sugar is better. We’ve had people lose 30 and 40 pounds,” said William McGuane, the county’s manager of benefits and workers’ compensation.

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Do these sound like minor program elements? The math says otherwise: Claims severity has plunged from $5.5 million in 2009 to $1.3 million in 2017.

At the University of Pennsylvania, putting workers first means getting out from behind the desk and finding out what each one of them is tasked with, day in, day out — and looking for ways to make each of those tasks safer.

Regular observations across the sprawling campus have resulted in a phenomenal number of process and equipment changes that seem simple on their own, but in combination have created a substantially safer, healthier campus and improved employee morale.

UPenn’s workers’ comp costs, in the seven-digit figures in 2009, have been virtually cut in half.

Risk & Insurance® is proud to honor the work of these four organizations. We hope their stories inspire other organizations to be true partners with the employees they depend on. &

Michelle Kerr is associate editor of Risk & Insurance. She can be reached at [email protected]