Coordination is Everything! Edward J. Bernacki, MD, MPH Professor of Population Health Executive Director of Health Solutions The University of Texas at Austin Dell Medical School TAC-County Management & Risk Conference Embassy Suites Hotel and Conference Center 1001 E. McCarty Lane San Marcos, Texas April 11, 2019
Optimal Workers’ Compensation Medical/Claims Management • Immediate assessment and correction of the workplace by safety professionals • Diagnosis, treatment and follow-up performed at a convenient site by engaged medical providers • Referrals to skilled specialists with knowledge of the workers’ compensation system • Nurse case manager facilitates the diagnostic and treatment process or constrains inappropriate care
Optimal Workers’ Compensation Medical/Claims Management (Cont.) • Continuous, close management of injury and comorbidities to assure early return-to-work and appropriateness of medical care • Information transfer between all parties – safety, medical, claims, and supervisors – Twice monthly “Rounds” to discuss claimants’ work place modifications and treatment • Performance metrics shared with all parties quarterly
MEDICAL AND INDEMNITY LOSSES (PER 100 $ OF PAYROLL) BY YEAR FOR LOST TIME CLAIMS (JHU/JHHC) $0.90 $0.80 $0.70 $0.60 Cost (per $100 of payroll) $0.50 $0.40 $0.30 $0.20 $0.10 $0.00 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08 ‘09 ‘10 ‘11 ‘12 ‘13 ‘14 ‘15 ‘16 ‘17 Fiscal Year Losses for New LT Claims Losses for Old LT Claims
Clinic Comparisons of the Top 5 Most Frequented Clinics for PT by PT Visits Categories, Non-Surgical, Closed, Indemnity Claims CLINIC NAME AVERAGE MEDICAL COST AVERAGE PT COST AVERAGE INDEMNITY COST Overall 0-3 4-9 10-14 15+ Overall 0-3 4-9 10-14 15+ Overall 0-3 4-9 10-14 15+ CLINIC A $15,022 $984 $3,563 $6,537 $14,507 $1,323 $200 $824 $1,378 $2,976 $7,557 $1,322 $5,614 $14,295 $13,664 CLINIC B $25,273 $1,828 $3,916 $7,144 $16,404 $1,753 $316 $1,005 $1,996 $4,427 $6,064 $2,300 $4,050 $7,511 $15,842 $29,041 $2,241 $4,022 $6,432 $14,669 $3,713 $537 $1,631 $3,069 $6,712 $6,207 $2,712 $2,939 $4,340 $11,592 CLINIC C $3,130 $971 $3,468 $7,948 $273 $44 $556 $1,074 $978 $893 $1,235 CLINIC D CLINIC E $35,358 $1,817 $4,740 $7,724 $17,688 $1,850 $292 $1,066 $1,989 $4,635 $5,497 $2,227 $4,124 $7,144 $16,578 CLINIC NAME AVERAGE # of PT Visits AVERAGE # of PT Services/Visit Lost-Time (Months) Overall 0-3 4-9 10-14 15+ Overall 0-3 4-9 10-14 15+ Overall 0-3 4-9 10-14 15+ CLINIC A 2.8 0.1 7.0 11.0 25.1 3.2 2.3 3.3 3.5 3.4 0.9 0.5 1.4 2.2 4.4 CLINIC B 8.6 0.9 6.1 11.9 26.3 3.4 3.0 3.6 3.6 3.6 1.9 0.8 1.4 2.4 4.8 CLINIC C 13.6 1.3 6.5 12.2 27.5 5.3 5.0 5.5 5.5 5.3 2.0 0.9 1.1 1.5 3.7 CLINIC D 0.1 0.0 6.7 12.0 1.5 0.5 0.5 1.2 2.8 CLINIC E 7.3 0.6 6.2 11.6 26.4 3.4 3.4 3.7 3.9 3.7 1.6 0.8 1.3 2.1 4.6
LWCC Louisiana Network “Quality medical management aggressively applied by empowered, yet, accountable physicians trained and disciplined in common occupational care management methods and unencumbered by precertification requirements, will minimize cost and disability.”
Selection of OG Healthcare Providers • 200 policy holders with largest number of claims • Occupational medicine providers located near 200 largest insureds • Occupational medicine providers name practitioners in referral network • Ground rules established
LWCC Omnet Gold (OG) Design • Managing Care Physician (MCPs) make up the core of OG • Initial treatment • Track medical care • MCPs are occupational medicine practitioners • Supporting healthcare providers are orthopedic surgeons, neurosurgeons, physiatrists, chiropractors, and physical therapists
Omnet Gold Claims Processing Injury Occurs MCP LWCC Claim Reported Injured Employee to LWCC – Referred or Identified Compensability Determined by MCP and Case Flagged Case Accepted by MCP Case Mgr, and File Opened - Case Rep.and Case Mgr Assigned Voc. Consult. Assigned Treatment Provided Cases Tracked by Case by MCP And Mgr, Case Rep and Prof Specialty Healthcare Health Care Serv. Providers Prof. Health Care Serv. MCP Case Mgr. and Voc. Consult. Coordinates Medical Coordinates RTW Care and RTW With MCP Case Mgr
Comparison of Mean Cost and Lost Time by Type of Injury (International Classification of Diseases, 9 th Revision [ICD-9] Codes); OG versus Non-OG Claims
Proportion of Lost Time Claims (Closed) by Claim Duration Proportion of Lost Time Claims (Closed) by Claim Duration Non-OG OG 100 90 80 70 60 % Closed 50 40 30 20 10 0 1-180 days 181-360 days 361-720 days >720 days Claim Duration
Average Claim Cost by Claim Duration Non-OG OG 50000 45000 40000 35000 Cost per Claim ($) 30000 25000 20000 15000 10000 5000 0 <90 90-180 181-365 366-445 446-730 >720 Claim Duration (days)
UTHA Workers’ Compensation Patient Flow Algorithm
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