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Workers comp could learn from health care quality playbook


ANAHEIM, Calif. — The focus on quality of care in the health care industry is currently seen as a way to improve patient outcomes, but experts say such an initiative is also needed in workers compensation in order to drive quality of care for injured workers.

“Performance quality measurement is increasingly seen nationally as the cornerstone of building a better health care system, but in workers comp we are not really focusing on the quality of the care and the outcome,” Edward Canavan, Riverside, California-based vice president of workers compensation practice and compliance at Sedgwick Claims Management Services Inc., said Wednesday at the 2016 California Coalition on Workers’ Compensation Conference in Anaheim, California.

Denise Zoe Algire, the Pleasanton, California-based national director of managed care and disability for grocery store chain Albertsons Cos. who is also a registered nurse and board certified in occupational health, agrees.

“Unfortunately in the workers comp industry, most don’t really look at clinical quality at all to determine provider quality and performance,” she said.

Sources at the conference said one of the key initiatives for driving the quality of care is the process of choosing physicians.

“In order for workers comp to get better outcomes from the doctors that are selected and improve the quality of the care given, it starts at the hiring,” said Michael Sullivan of the El Segundo, California-based law firm Michael Sullivan & Associates L.L.P.

Ms. Algire said in the health care sector, it’s standard for physicians to be re-credentialed with every network that they work with every two to three years, depending on their internal policies.

“But unfortunately, on the workers comp side there are no standards,” she said, adding that most networks do not do this effectively — if at all — and if they are leasing their network, they need to hold their network partner accountable. She advises that credentialing be done every two years at a minimum.

She said it is her company’s policy to have all of their workers comp specialists board-certified. “That is a baseline standard — and if you think about it, you would want a board-certified specialist to be treating you and your family members,” she said, adding that having board-certified along with fellowship-trained standing is even better.

As an example, a physician having additional training in their area of specialty such as a board-certified fellowship-trained orthopedic spine surgeon or orthopedic total joint muscle skeletal surgeon “is the optimal baseline requirement” for allowing providers in your network.

Other things to look into are licensing, verifying drug enforcement administration and malpractice history and hospital privileges, she added.

“This is all very time intensive, but it’s really important to the process,” Ms. Algire said.

“We also use evidence-based medicine as a measurement of provider quality, but when we look at the care outside of evidence-based medicine we look over a period of time,” she explained. “If there is one request outside of prescriber-based medicine we don’t think we need to get rid of that doctor.”

Evidence-based medicine is important, but they are only guidelines, she said.

“I don’t say we draw a hard fast line in the sand” in the terms of guidelines. There are times that the doctor has well-documented and supported clinical rationale for when treatment needs to be outside of those guidelines, she added.

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