This article is excerpted from the Occupational Medicine Clinical Care Update, Vol. 16, No. 4, published by the National Association of Occupational Health Professionals.
A clinically based utilization management (UM) system produced significant decreases in practice pattern variation for workers’ compensation diagnostically related groups in an outcome study conducted by Select Medical Corporation, Chicago. The findings were presented by Jamie Stark, Ph.D., Select Medical’s national director of outcomes, at the 2009 American Occupational Health Conference, sponsored by the American College of Occupational and Environmental Medicine. According to Dr. Stark, UM is not intended to restrict services for injured workers or hamper their ability to fully rehabilitate. When appropriately applied, UM guidelines are expected to:
- decrease health care delivery costs;
- make medical providers more accountable;
- facilitate a shift toward outcomes-based medicine;
- prevent unnecessary treatment; and
- help injured workers more efficiently navigate toward recovery.
“Concurrent review can change behavior; retrospective review only changes pricing,” Dr. Stark said. Data that can be used to objectively determine the effectiveness of UM guidelines is scarce. Meanwhile, Dr. Stark noted, that because utilization guidelines are typically developed by third-party, non-clinical entities, the practical utility and clinical appropriateness of such guidelines may be questionable. To overcome these limitations, Select Medical developed clinically based utilization guidelines and incorporated them into a comprehensive UM system deployed as part of standard operating practice in approximately 650 outpatient rehabilitation facilities. The web-based system is coordinated with enterprise electronic medical records, allowing for real-time, concurrent review of medical necessity, Dr. Stark said.
Methods
Following a review of approximately 1 million unique episodes of care, Select Medical initiated a utilization management program intended to decrease variation in total visits and length-of-stay practice patterns. Utilization guidelines were risk-adjusted based on the following criteria: code-specific primary diagnosis; surgery status (yes/no); age (<26 years, 26-55 years, >55 years); and payer classification (workers’ compensation specific). The study featured an analysis of all workers’ compensation shoulder and spine diagnostically related groups over a four-year period. The analysis involved 95,161 patients in 106 risk-adjusted groups. The following inclusion criteria were applied: age >18 years, total visits >one, and n>30 for each risk class. Baseline data were collected from 820 sites between January 2004 and December 2005. Study data were collected between January 2006 and June 2007. Data were analyzed using a chi-squared test for variance utilization with a 90 percent confidence interval.
Results
The study results indicate a significant reduction in practice pattern variation associated with both the total number of visits and length of stay. Overall success rates for meeting the visit utilization targets were increased by approximately 20 percent. Independently, non-surgical classes demonstrated a 7 percent improvement, while surgical classes demonstrated a 55 percent improvement. More than 50 percent of the risk-adjusted classes reduced practice pattern variation for total visits and length of stay; about 70 percent of these improvements reached statistical significance. The results demonstrate the potential for significant cost savings via a reduction in medical (total visit utilization) and indemnity costs (length of stay). Rational development and application of UM guidelines are necessary to ensure the preservation of patient outcomes quality and concurrent workers’ compensation cost reduction, Dr. Stark reported.
