Tuesday, March 29, 2016

Carrot? Or Club?

There's a trend percolating in workers' compensation about incentive based medicine.

The basic theory of incentive based medicine is to reward physicians for ensuring good, quality care is provided injured workers/patients to promote faster recovery, less disability, return to health and ultimately return to work.

In theory this all sounds good.

But as with anything that we think is a good idea, others will abuse the trust, and try to steer the world towards their special interest profit motive.

That's a concern that has arisen with the latest news that certain networks have either deployed or are developing economic profiling programs about physicians in their networks.

Yesterday, WorkCompCentral News reported that the Harbor Health Systems network and MPNs for Zenith, Liberty Mutual and the State Compensation Insurance Fund are using economic profiling to determine the top-performing doctors within their networks, and have promised to reward the best performers with extra compensation.

It is also reported that Coventry Health Systems says its "in the preliminary stages" of developing its own incentive program.

According to the news story, State Fund has a separate MPN provided by Harbor that does not offer financial incentives. But another Harbor plan offers financial rewards to doctors with the best track records for "efficiency."

Zenith's plan says incentives "may be provided," and Coventry says it hasn't determined what incentives, if any, will be part of its program.

The Harbor plan says that the disability rating at case closure is one of the factors that will affect a doctor's efficiency rating under the incentive programs. The duration of the claim, the duration of the medical treatment and the costs of the claim are also factors.

According to one source who wished to remain anonymous, in addition to looking at the direct cost of the treating physician, other factors was whether an attorney was on the case and how long the case had been ongoing. This source is concerned that if he or his clinic does not comply with corporate directives on any one particular case that punishment will be delivered; in other words the economic profiling will be used as a club, rather than a carrot...

While the Labor Code expressly allows MPNs to do economic profiling and to offer incentive programs based on doctor performance, the plan administrator must file a description of the program policies and procedures with the Division of Workers' Compensation.

The question being posed is just how much of an incentive program is disclosed in the filings, and whether there are "back room" criteria not subject to public review.

The division of opinion to the story broadcasts a stark and wide understanding of the issues, of the plan, and whether performance based incentive plans should even be a part of the work comp schema.

Here are some of the comments posted thus far to the story:

"It is absolutely ridiculous that Harbor will only compensate at 100% of OMFS if physicians basically don't do surgery, don't order MRI, no meds and limit physical therapy to 6 visits. Anything outside of this regiment the physician gets less than OMFS."


"Are we the only ones concerned? As a TPA, we deal with attorney selected MPN physicians. Many of these MPN physicians even address their progress reports to the attorney with a CC to us, the TPA."


"I agree that the insurance company should not be allowed to incentivize doctors, but when I read CAAA's response I laughed. 'They're supposed to be paid to practice medicine, not to improve the numbers of an insurance company's bottom line,' he said. Insert applicant attorney law firm name in for the insurance company in the previous sentence. That's been going on for decades."


"Notice the outrage geared toward, 'will my client get a lower rating?" = 'will my fee be affected?' Rather, shouldn't the interest be whether the treatment was effective in returning my client back to work or preinjury status??? Or even, is this a provider who overbills, overprescribes or frequently requests treatment outside of MTUS, ODG or ACOEM?"


Harbor Health posted a reply:

"Not only is there no connection to whether a doctor reduces the amount a care delivered to an injured workers, the model works quite the opposite from the concern expressed. A provider who delivers better health outcomes can in fact spend more on care than their peers and actually score in the top 20% of the benchmarking. This is because our model focuses on total outcomes; cost is only one of several factors measured and it is measured in the aggregate with medical spend, indemnity spend, and claims expense. A doctor can actually drive higher spend in medical if that investment results in better cure rates, reduced lost time, and reduced litigation."


Frankly it's ludicrous that anyone has to provide any financial incentive to do the right thing, but this is work comp and at the end we only have human motivations to work with. I get it, and if the rules really will deliver better medicine, and the injured worker truly is benefited, then great!

However, transparency is really the question: One person's motivation is another person's deception ... there's a line of tolerance that defines disputes.

Jean-Louis Guillard, is a Swiss lawyer. He posted a thought provoking article on LinkedIn a couple weeks ago about ethics in business and that fuzzy line of tolerance.

"[T]he scope of the compliance or ethics message is somehow limited and the technicalities are hidden into legal jargon," Guillard writes. "'We do not offer bribes'. Indeed, but do you pay when asked?"

That same logic is applicable in reverse.

"We reward good outcomes."

Indeed, but who defines the "good outcomes," and do you punish for transgression from any particular corporate directive?

1 comment:

  1. The Dr. that helped me get my claim reopened by being honest in my care, told me that if he did what he did for me for everyone ells, the wc system would go broke. Alls he did was be honest about my condition. When Dr.s are more concerned about weather or not the comp system will make out or not, rather then being honest about our conditions, something is wrong. My Dr. needs to be more worried about me and my condition, then he is about protecting comp rates. When Dr.s are more concerned about comp rates than they are about the patients before them, something is very wrong with our system. We need workers comp, and our bargain, but we also need our Dr.s to care about us, more so than the corporations bottom lines.

    Thanks as always for a great report, it's great to have you back. You were missed. Peace

    PS, I have settled my wc claim in WA State, they agreed they angst my mental health over having Dr.s trying to water down my condition so as to try to deny the claim to start with. The money was not worth the fight, but fighting for what was right, made all me and my family have had to go through, worth it. Now Im back in the job market, a broken bag of used goods, searching for a position that does not harm my back more. The Dept spent more money trying to denying me, than if they would have just helped me out with care and voc services to start with. Any way thanks again, for all you do.