1. Methods for Improving and Measuring Quality of Care California Research Colloquium on Workers’ Compensation May 1, 2003 Liza Greenberg, RN, MPH

2. About URAC 501(c)3 accreditation organization Stakeholder board of directors  Providers, payers, consumers, regulators Standards for work comp managed care  UM, CM, network Workers’ comp performance measures Research – medical management, CM

3. Targets for Evaluating Health Care Quality Plan-based measures:  Accreditation  Performance reports Provider/Provider Group/Clinic measures  Report cards  Profiling Individual Experience  State and National Surveys  Health plan specific experience

4. Standards for Workers’ Comp UM Standards for:  Staff qualifications  Clinical review process  Clinical review criteria  Appeals mechanisms  Oversight of delegated functions  Staff credentialing

5. Standards for Workers’ Comp Networks Network Management  Provider availability and accessibility  Provider contracting  Grievances and appeals  Marketing Quality Assurance  Program organization and staffing  QA planning Credentialing of Providers

6. Difference Between Accreditation Standards and Performance Measures Accreditation examines structure and capabilities compared to standards Performance measures assess process and outcome information Accreditation and performance measures complement each other and increase accountability

7. URAC WC Performance Measures Data can be used for internal QI Performance data is collected by MCOs through three inter-related tools:  Patient survey  Administrative Data Specifications  Medical Record Audit URAC’s team developed the tools plus instructions on administration and reporting.

8. Performance Measure Categories Access Prevention/ Disability Management Appropriateness of Clinical Care Coordination and Communication Cost/Utilization Patient/Payer Satisfaction Outcomes

9. Definitions Developed Functional elements of a managed care organization Cases of finding criteria:  low back pain,  knee complaints,  shoulder complaints,  wrist/arm complaints Time frame for measurement

10. Functional Elements of An MCO To effectively manage and report on care, an MCO has the following elements :  Provider network management  Case management capability  Utilization management  Financial management / Bill review data  Secondary and tertiary prevention

11. Administrative Data Coordination  Timeliness of case manager contacts (time from referral to contact)  % of cases that are case managed  Length of time from injury to referral

12. Administrative Data Outcomes - Work Related Return to work Prevention Availability of occupational medicine doctors Activities of occupational medicine physicians- involvement in leadership Reporting of injuries to employer

13. Administrative Data Costs  Indemnity costs (TTD, TPD, PTD, PPD, VR) at 60 days, 18 months, at closing, by diagnosis  Medical costs (inpt and outpt medical, inpt and outpt surgery, drugs+therapies) by diagnosis Total (indemnity, medical, other) by diagnosis Utilization Number of specific procedures per 100 cases by diagnosis

14. Patient Survey Measures Coordination Measures Patient report that assistance received with RTW Patient report of types of assistance provided Communication Measures Doctor communicates well with worker Doctor treats worker with respect Doctor seeks to understand work environment Patient receives information re treatment and avoiding reinjury Patient trusts doctor

15. Patient Survey Measures Work Related Outcomes  First return to work  Timing of first return to work Health Related Outcomes  Work related functioning post injury  Physical functioning post injury  Reinjury of same body part

16. Patient Survey Measures Satisfaction  With most frequently seen physician  With MCO's medical services Access  Accessible location  Wait to see the doctor the day of the appointment  Availability of hours

17. Medical Record Measures Clinical Care  For low back pain, shoulder complaint, knee complaint and forearm, wrist and hand complaint: Adequate medical history Occupational risk assessment Appropriate activity modification Work restrictions advised, if necessary Appropriate focused physical exam Documentation of attempt to place on modified duty Patient education provided Communication  Informed consent

18. Scope of MCO services varies considerably MCOs have limited access to data MCOs have variable quality of data Cost of data retrieval is considerable (particularly medical record and survey data) There is lack of consensus on treatment protocols and treatment norms Case mix and risk adjustment protocols across employers, employees and industries are needed Sample size Technical Challenges in WC Arena

19. Current PM & Quality Activities

20. Performance Reports to Customers

21. Relevant Models for the Future Medical management trends  Interfaced / integrated UM, CM, DM  Patient education: health call center, internet Disability management PPO experience Disease management model

22. Current & Future Medical Priorities

23. Policy Implications Need to show ROI for better medical management and disability management Additional research needed in:  evidence-based care for occupational injuries  measuring outcomes of occupational injuries  interface between clinical and economic factors Enhanced data systems needed to bring WC systems to comparable level of group health MCOs need to augment QI efforts with worker- centered measures and surveys Build demand through consumer, regulatory or purchaser organizations

24. Contact Liza Greenberg, RN, MPH Vice President, Research and Quality Initiatives URAC 1275 K Street, Suite 500 Washington, D.C. 20005 (202) 962-8805 Email: lgreenberg@urac.org