—Sir Isaac Newton, 1642-1727
By Karen O’Hara
The Year of the Rabbit begins on Feb. 3, 2011, according to the Chinese zodiac. In Chinese astrology, the rabbit year is expected to usher in a period of relative calm following the tumultuous Year of the Tiger. The placid rabbit symbolizes luck and negotiation skills, which are both useful in business. On the other hand, the rabbit can be protective and insular, suggesting challenges in the quest for organizational change.
In the event that astrology does not provide sufficient insight for occupational health professionals as they prepare for the New Year, industry experts offer their own forecasts, and interestingly, they provide a similar yin-yang response.
Abundant Opportunities
Peter Rousmaniere, a nationally known workers’ compensation industry consultant and journalist, says he is “not fatalistic” about the future of occupational medicine – whether it is practiced within a larger healthcare organization or in a standalone facility.
“Occupational medicine practitioners have a great opportunity for better recognition in the payer community,” he said. For example, he cited occupational medicine physicians’ ability to detect delayed recovery risk (which is largely psycho-social in nature) and make referrals to specialists who get consistently positive results – “at least from an anecdotal perspective” – as two important attributes.
Conversely, he noted, these attributes are difficult to quantify, and there is a dearth of benchmarks for outcome reporting in occupational medicine clinics. “Another part of the problem is that the payer community is rather fitful about what it wants and how much it will use with regard to outcome reports,” Mr. Rousmaniere said.
The first step for providers is to talk with payers to address any perceived communication problems. “The occupational medicine clinic needs to be able to identify and close any gaps in communication by sitting down with the claims administrators and nurse case managers to discuss the situation,” he said.
Looking ahead, Mr. Rousmaniere expects managed care networks to place more emphasis on provider quality and less emphasis on provider quantity in response to outcome-driven expectations. He said the concept of quality care might be approached in three ways that are not mutually exclusive:
- Attempt to increase performance, e.g., lower medical costs and improve return-to-work success rates for the “average” provider in a network.
- Focus much more proactively on the 5-10 percent of network providers whose performance is rated “subpar.”
- Identify top providers and expert medical advisers who can work with other less-effective providers on performance issues.
Mr. Rousmaniere believes chronic pain management also will be a critical issue for employers and payers in 2011 and beyond. “Chronic pain is associated with about 50 percent of workers’ compensation losses and involves a relatively small number of cases,” he said.
Expect Scorecards
One of the positive impacts of national health care reform (assuming that aspect of the legislation is not repealed) for occupational health programs will be the widespread adoption of provider scorecards, says Maddy Bowling, a seasoned workers’ compensation industry consultant with her own firm, Maddy Bowling and Associates Consulting, Inc.
Affirming Mr. Rousmaniere’s observations, she advises occupational health professionals to follow two complementary trends:
- The market is starting to move away from large preferred provider organizations (PPOs) and toward more selective outcome-based networks in workers’ compensation.
- Physicians, in general, will start to get used to profiling and scorecards, and occupational medicine providers who demonstrate positive results will see benefits in terms of relaxed utilization review requirements and possibly performance bonuses.
“We are seeing a push from our clients in support of outcome-based networks and making sure employers get their injured employees to the best doctors from the start,” Ms. Bowling said. “Payers, especially third-party administrators (TPAs) are saying, ‘There really are outstanding physicians in this area, they know what they are doing and you can tell by their results.’ With appropriate data analysis, you would be surprised how quickly you can figure that out.”
Ms. Bowling has considerable experience with integrating workers’ compensation data to facilitate provider comparisons. Key factors include claim and jurisdictional details, employer and provider demographics, medical treatment, and return-to-work history. She cited cost, disability duration, medical-only, lost work time, and prescription patterns as commonly used metrics in workers’ compensation, but noted that her clients prefer to customize their approach.
Ms. Bowling said the metrics trend also is significant given that the industry has had an “addiction to PPOs,” which are driven by volumes and dollars rather than relationships with physicians and their performance. In addition, she noted that PPOs are no longer as competitive as they once were because consolidation has created a situation in which Coventry Health Care dominates. (Coventry reports it serves more than 5 million members with group and individual health insurance, Medicare and Medicaid programs, and coverage for specialty services such as workers’ compensation.)
“After all these years in the industry, I am thrilled there appear to be employers and payers who are finally focused on outcomes-driven networks,” she said.
Metrics in Our Future
While remaining cautious, Karen Wolfe, president and CEO of MedMetrics® and former software developer, said she is optimistic about industry observer forecasts of business innovation, astute use of technology, and job growth for the coming year.
MedMetrics supports best practices in workers’ compensation claims and medical case management by insurers, self-insured employers, TPAs, and managed care organizations with a web-based system that tracks utilization and costs, flags at-risk cases, and outliers in need of intervention. Analytical tools are used to support provider and outcome comparisons.
MedMetrics’ ramp-up has been even more a labor of love than Ms. Wolfe anticipated when the company was first launched six years ago: Educating prospective users about the value of data mining in the relatively traditional workers’ compensation world has proved to be a significant undertaking.
“There is a gap between issues people face on the front line and the perspective of the powers that be within an organization,” she said. “I get so frustrated when people don’t effectively use the tools and resources they have at their disposal. My goal is to get the industry to learn how to leverage data in a practical way – not an esoteric way – and give it real meaning at the operational level.
“(The industry) needs to make the effort to streamline and standardize processes to quantitatively value medical case management and improve outcomes. It sounds simple; it is simple. But people don’t do it because it is different from what they are accustomed to doing. It takes a long time to make changes in this industry. But once people make the change, they are amazed with the results.”
Now, with the light bulb clicking on, MedMetrics’ adopters seem to be particularly interested in provider performance analysis.
“The interest is coming from network providers looking at their own providers’ performance and from payers interested in outcomes,” she said. “Network managers are being forced to look at different reimbursement structures and pay based on performance, not just on the volume of services provided.
“This is good news for occupational health providers, who typically show better in comparison to other, non-occupational providers.”
Moving forward, Ms. Wolfe anticipates the development of analytics to accommodate a deeper dive into ratings based on injury severity and other indicators that affect outcomes.
Focus on Physician Education
In the context of national health care reform, 2011 will be a year devoted to developing the role of prevention and helping clinicians understand how they can contribute to the integration of health, safety, and productivity management in the workplace, predicts Natalie Hartenbaum, M.D., a consulting occupational medicine physician and president of the American College of Occupational and Environmental Medicine (ACOEM) Board of Directors.
Dr. Hartenbaum has established several ACOEM task forces to help raise awareness of occupational medicine as a preventive specialty. Initiatives include enhanced education and training for practicing physicians, cultivating contacts with medical students, and developing fatigue risk management interventions for employers.
“Our role in the workplace is a tremendous asset,” she said. “Our goal is to provide the tools physicians need to leverage their knowledge and contacts so they can take full advantage of that opportunity.”
Among noteworthy trends in the coming year, Dr. Hartenbaum advises occupational health professionals to be on the lookout for:
- State workers’ compensation regulatory reform and endorsement of medical practice guidelines as part of efforts to promote evidence-based practice, including detailed assessments by qualified professionals.
- Collaboration among organizations to develop high-value products and physician services in workers’ compensation.
- An emphasis on physician training and credentialing in response to changes in the Accreditation Council for Graduate Medical Education and American Board of Preventive Medicine requirements for completing preventive medicine residencies, pursuing complementary pathways, and obtaining board certification.
- Medical Review Officer activity in response to more restrictive federal regulations governing laboratory testing procedures.
“At the end of my term, I hope people will feel we got a lot accomplished,” she said.
Urgent Care Interface
Occupational medicine will continue to be “a great service line” for urgent care clinics in 2011, but clinic operators need to carefully consider the kinds of services they are capable of providing before expanding, advises Don Dillahunty, D.O., chief executive officer/president of PrimaCare Medical Centers, Dallas, Texas, and president of the Urgent Care Association of America (UCAOA) Board of Directors. Established in 1979, PrimaCare is one of the largest groups of ambulatory medical centers in the Dallas metro area.
Dr. Dillahunty advises clinic operators and clinicians to focus on the fundamentals: quality care, accessibility (hours and location), affordability, and customer service. With respect to expansion opportunities, he sees potential for the development of chronic disease management and prevention programs for at-risk patients in acute care and even retail clinic settings. He also recommends cross-selling to walk-in patients. For example, a worker who has a positive experience with injury care on the occupational health side is likely to come back for personal care.
Whatever the clinic or medical office setting, he anticipates increased demand for experienced mid-level practitioners in urgent care and occupational medicine facilities.
Nationally, Dr. Dillahunty is following Accountable Care Organization (ACO) pilot projects with interest. While it is too early to predict the results, he describes a possible scenario as one in which mega-ACOs become quasi-public monopolies in major markets. (An ACO is a model for managing the continuum of care across institutional settings. The Patient Protection and Affordable Care Act encourages the development of ACOs on a voluntary basis, and a number of health systems are involved in ACO pilot projects.) “The ACO consolidates providers within a system, which reduces competition,” he said.
Appealing to Employers
Heartland Health in St. Joseph, MO, is an example of a progressive health system engaged in developing an ACO model. Heartland has created an entity, Community Health Improvement Solutions, to work closely with partners such as Aetna, one of the nation’s leaders in health and disability insurance, and its own Heartland Corporate Health Services/Occupational Medicine (HOM) program to address the needs of target populations.
Heading into 2011, the organization’s overriding objective is to leverage the ACO model to “capture the population in our service area,” improve community health, reduce employers’ costs, and maintain a reasonable margin system-wide, said David Cathcart, D.O., Corporate Health Services/HOM medical director. As envisioned, self-insured employers would have the option of selecting a globally priced package of services designed to improve workforce health and productivity and reduce work-related injury, illness, and disability.
“We believe that capturing our own population is the only way for an Accountable Care Organization to be successful within the context of community health,” he said. “Right now everyone is trying to figure out how they fit within the ACO.
“Our major clients understand the long-term benefits of disease management and wellness,” he said. “The insurance companies also understand it…Aetna is promoting prevention through Heartland so employers get the wellness connections piece.”
One of the barriers to success with the ACO approach is free will or patient choice. If a patient opts out of one system to try another, “we can’t offer them the kind of savings or quality we think would exist when working within one system with an ACO model,” Dr. Cathcart said.
Decisions emanating from the Centers for Medicare and Medicaid Services will be key drivers in the process, Dr. Cathcart said. For example, if Medicare introduces a reimbursement formula allocating a lump-sum payment for taking care of a large population of people, it will be incumbent on health systems to develop similar formulae for the delivery of services to smaller target populations, such as the workforce.
Despite the magnitude of the undertaking, Dr. Cathcart remains passionate about the possibilities.
“It is really hard to make an impact one patient at a time,” he said. “Occupational medicine is a preventive specialty. If I leave a legacy, it will be impacting a large population for the better in terms of their health while reining in costs.”
“Occupational medicine is a preventive specialty. If I leave a legacy, it will be impacting a large population for the better in terms of their health while reining in costs.”
“Occupational medicine is a preventive specialty. If I leave a legacy, it will be impacting a large population for the better in terms of their health while reining in costs.”
Primary Care Impetus
Jewels Merckling, NAOHP Board president, advises occupational health colleagues to keep an eye on activity on the group health side of the equation. Ms. Merckling has a somewhat unique perspective, having recently accepted a position as vice president of enterprise sales for software developer Integritas, Inc., after serving as vice president of provider development for Stoneriver P2P Link (both companies are members of the NAOHP Vendor Program), and as director of a hospital-affiliated occupational health program in Missouri.
“We are seeing health care reform-driven activity from group health insurers and benefits administrators that are likely to affect occupational health programs,” she said. Her advice to occupational health professionals is twofold:
- Carefully evaluate the technology your program is using and make sure your vendors are moving in the direction of data sharing and management.
- Be proactive with product development.
“You cannot continue to sit on the same service line,” she said. “You have to expand your thinking. Talk to your doctors. Tap into existing expertise and build a service around it. For example, why is pain management so often a standalone practice when it is a logical extension of occupational health?”
Along with other industry observers, she anticipates the healthcare delivery model may evolve into one featuring greater integration of primary care into blended urgent care-occupational medicine practices. She cited two developments on the horizon as an illustration: Humana’s acquisition of Concentra, the nation’s leading national occupational medicine-urgent care clinic network (see related article), and Aetna’s acquisition of Medicity, Inc.
Medicity’s health information platform enables the transmission of diagnostic test results, fact sheets, and transcribed documents from hospitals directly into physicians’ electronic health records (EHRs) and practice management systems. When the acquisition was announced, Aetna’s Chief Financial Officer Joseph Zubretsky said Aetna was entering the “new frontier” of information technology to help doctors and clients control costs.
The Aetna-Medicity deal follows a similar move by UnitedHealth Group Inc., the nation’s largest insurer by sales, another sign that insurance companies are diversifying to cope with the healthcare overhaul law.
In August, Ingenix, a UnitedHealth Group company, reported it agreed to acquire Axolotl Corp., a company specializing in mental health information exchange (HIE) services. The Axolotl management team reports it will help lead Ingenix’s healthcare community connectivity efforts.
Ingenix already has an established presence in workers’ compensation and disability management. For instance, its Employer Services division has more than 20 years of experience in data analysis to support improved management of healthcare costs, workforce health, and productivity. And, its “integrated disability business case development” product reportedly identifies such key factors as the nature and cause of injuries regardless of the payment type, injury and re-injury rates, and workers’ compensation and non-occupational experience for similar diagnoses.
Disability and workers’ compensation norms used by Ingenix are derived from customer experience and information obtained from the Work Loss Data Institute’s Official Disability Guidelines.
