controlling quality of care and cost · 2015-07-23 · • before: legal process, decisions by...

CWCI 2015. All Rights Reserved

Controlling Quality of Care and Cost:

The Form and Function of Medical Dispute Resolution

Alex Swedlow California Workers’ Compensation Institute

May 2015

CWCI 2015. All Rights Reserved Exhibit 2

$0

$3,000

$6,000

$9,000

$12,000

$15,000

$18,000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Med Tx Rx MCC ML

Medical Benefits Components at 24 Months Post Injury

+3.8%


$0

$3,000

$6,000

$9,000

$12,000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

-.3%

Medical Benefits Components at 24 Months Post Injury: Medical Treatment


81.7% 78.3% 75.4% 75.6% 73.3% 71.8% 70.8% 69.8% 69.1% 68.3% 66.6%

0%

25%

50%

75%

100%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Med Tx as a Percent of All Medical Benefits

Medical Benefits Components at 24 Months Post Injury: Medical Treatment


7.8% 7.9% 7.0% 6.7% 6.9% 7.2% 7.4%

8.0%

9.4%

11.3%

13.2%

0%

2%

4%

6%

8%

10%

12%

14%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Pharmacy as a Percent of All Medical Benefits

Medical Benefits Components at 24 Months Post Injury: Pharmacy


• 2004 & 2013 Fee Schedules Changes

• Guidelines o 2009 Chronic Pain Management o Opioid Utilization (In Review)

• Rx Dispute Resolution o 45% of all Util Rvw & Ind Med Rvw

• Formularies?

California Workers’ Compensation Rx: $1.2 Billion and Counting

History of Pharmacy Controls


$803 $826 $611 $594

$733 $835 $945

$1,168 $1,432

$1,804

$2,154

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

2011 to 12: +19%

Pharmacy Costs at 24 Months Post Injury:

2010 to 11: +26%

2004 to 2012 +253%


Pharmaceutical Utilization & Cost Schedule II & III Opioid Drug Payments1

1 Calculations are on a calendar year basis

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013S-II 4.7% 5.2% 6.8% 4.1% 4.2% 9.7% 17.3% 20.0% 19.8% 20.1% 19.1% 19.6%S-III 11.1% 10.4% 8.3% 9.5% 9.9% 11.3% 9.9% 10.4% 10.3% 10.5% 10.4% 10.3%

0%

10%

20%

30%

40%

Source: CWCI 2014

Chronic Pain Mgt Guidelines

Opioids and Pain Management


$685 $839

$933 $1,004

$1,336

$1,589

$1,894

$2,173 $2,258 $2,283 $2,330

$0

$750

$1,500

$2,250

$3,000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Medical Benefits Components at 24 Months Post Injury: Medical Cost Containment

2004 to 12: +134%

2011 to 12: +2%


6.6% 8.0%

10.7% 11.3% 12.7%

13.7% 14.8% 15.0% 14.8% 14.3% 14.2%

0%

5%

10%

15%

20%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

MCC as a Percent of All Medical Benefits

Medical Benefits Components at 24 Months Post Injury: Medical Cost Containment


Components of Utilization Review


MTUS

0%

25%

50%

75%

100%

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014Utilization Rvw 21% 40% 45% 49% 48% 49% 51% 50% 49% 51% 51%Med Bill Rvw/Networks 79% 60% 55% 51% 52% 51% 49% 50% 51% 49% 49%

Source: CWCI 2014

Percent of UR Of All MCC


Managing Medical Management

1. Most expensive medical delivery system

2. Absence of supply and demand side controls: • Co-payments, deductibles and a Rx formulary • Contractual language

3. Disputes and dispute resolution • High litigation and medical disputes • Before: Legal process, decisions by judges • Now: Utilization Review (UR) and Independent Medical Review

(IMR ) rely on the Medical Treatment Utilization Schedule (MTUS) evidence-based guidelines

Why is California workers’ comp medical harder to manage?


1. Utilization Review Administration Efficiency?

2. Quality of Care and Efficacy of the MTUS, UR and IMR


Areas of Conflict:


1. UR Efficiency

• New study on efficiency of payor UR;

• Data from division of workers compensation UR Audits 2009–2013


Areas of Conflict:


Utilization Review Efficiency Division of Workers Compensation

UR Audits: 2009–2013

2009 2010 2011 2012 2013 Grand Total

Total DWC Audits 47 49 62 58 64 280

Total Requests for Authorization 1,806 1,843 2,717 2,111 2,715 11,192 1. Untimely Response 2. Faulty Content 3. Improper Distribution Overall UR Rating (Passing Grade = 85%)

Source: CWCI 2015


0.0%

25.0%

50.0%

75.0%

100.0%

2009 2010 2011 2012 2013 GrandTotal

Overall UR Rating 96.8% 97.2% 97.1% 97.5% 97.1% 97.2%

Utilization Review Efficiency Division of Workers Compensation

UR Audits: 2009–2013

Source: CWCI 2015

Overall UR Rating


2. Quality of Care and Efficacy of the MTUS, UR and IMR

Outcomes on Process: • Volume of disputes • Characteristics of disputes • Decisions and their rationale

Next Steps - Outcomes: • Impact on injured worker • Impact on CA system


Areas of Conflict:


Approved by Claims

Administrator 75%

Sent to Utilization

Review 25%

UR approves 77% of all reviews

2014 MDR Decision Results Volume & Timing

Initial Treatment Requests

Source: CWCI 2014


2014 MDR Decision Results Volume & Timing

Level of Approved Treatment After Utilization Review

Source: CWCI 2014

Approved After UR

94.1%

IMR Eligible 5.9%


IMR REVIEWS 137,781

Applications 128,103

UR Events 126,772

Claimants 76,718

IMR SERVICE DECISIONS

260,889

Source: CWCI 2015

2014 IMR Decision Results Volume & Timing

2014 Final Determination Letters


020,00040,00060,00080,000

100,000120,000140,000

2003 2005 2007 2008 2010 2012 2013 2014Texas 17,433 13,257 8,810 12,244 7,596 7,939 5,068California


Volume of IMR Decision Letters Texas & California

Source: Texas Dept. of Insurance, Division of Workers’ Compensation; CWCI 2015


020,00040,00060,00080,000

100,000120,000140,000

2003 2005 2007 2008 2010 2012 2013 2014Texas 17,433 13,257 8,810 12,244 7,596 7,939 5,068California 3,723 137,781


Volume of IMR Decision Letters Texas & California

Source: Texas Dept. of Insurance, Division of Workers’ Compensation; CWCI 2015


Result Services % Upheld UR 237,345 91.4% Overturn UR 23,544 8.6%

Total 260,889 100%

Source: CWCI 2015


Utilization Review Denials/Modifications Upheld vs Overturned



Level of Approved Treatment After Medical Dispute Resolution

Source: CWCI 2015

Approved After UR/IMR

94.6%

Denied or Modified

after UR/IMR 5.4%


SERVICE TYPE % of

Services % Upheld RX 44.7% 91.9% DMEPOS 9.8% 93.7% PHYSICAL THERAPY 9.3% 94.0% INJECTION 5.9% 92.2% DIAG TEST & MEAS 4.9% 87.9% SURGERY 4.7% 88.5% MRI/CT/PET 3.8% 89.1% LAB 2.9% 87.3% ACCUPUNCTURE 2.1% 94.1% PSYCH 2.1% 84.9% CHIRO 1.9% 95.4% EVALUATION & MANAGEMENT 1.7% 79.5%

2014 IMR Decision Results By Service

Source: CWCI 2015


RX Detail % RX % Upheld COMPOUND 12% 98% INJECTION 2% 89% TRADITIONAL RX 86% 91% TOTAL RX 100% 92%

SERVICE TYPE % of

Services % Upheld RX 44.7% 91.9%

2014 IMR Decision Results By Pharmaceuticals

Source: CWCI 2015


Region % % Industry

Claims Ratio Los Angeles 36% 24% 1.5 Bay Area 19% 19% 1.0 Inland Empire /Orange 16% 18% 0.9 Valleys 15% 20% 0.8 Central Coast 6% 7% 0.9 San Diego 5% 8% 0.6 North Counties 2% 3% 0.5 Sierras 1% 2% 0.4

2014 IMR Decision Results By Geographic Region

Source: CWCI 2015


44%

83%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1% 2% 3% 4% 5% 6% 7% 8% 9% 10%

Source: CWCI 2015

2014 IMR Decision Results Top 10% of Providers by Volume of Decision Letters

% of Letters 44% 57% 64% 69% 73% 76% 78% 80% 82% 83%

# of Providers

134

267 400

533

666

799 933

1,066

1,199

1,332

% of Provs


PROVIDER %

LETTERS % SERVICES % CLAIMS

% IMR Upheld

PROV 1 1.9% 1.9% 3.1% 91.4% PROV 2 1.6% 3.2% 1.9% 94.7% PROV 3 1.0% 2.3% 1.1% 91.5% PROV 4 0.9% 1.6% 1.2% 94.4% PROV 5 0.9% 1.1% 1.3% 87.3% PROV 6 0.9% 1.0% 1.3% 89.8% PROV 7 0.8% 1.1% 1.1% 90.3% PROV 8 0.8% 1.1% 1.0% 88.8% PROV 9 0.8% 0.9% 1.0% 88.8% PROV 10 0.8% 0.8% 1.0% 86.3% TOP 10 11% 15% 14% 91.3%

2014 IMR Decision Results By Provider

Top 10 Providers

Source: CWCI 2015


0% 20% 40% 60% 80% 100%

HOME HEALTH CARE

CHIRO

PSYCH

PHYSICAL THERAPY

OTHER

DMEPOS

MRI/CT/PET

EVALUATION & MANAGEMENT

NON-SURGICAL PROCEDURE

ALL SERVICES

ACOEM Chronic Pain Mixed OTH

2014 IMR Decision Results IMR’s Decision-Making Process

MTUS Guidelines Cited by Service

Source: CWCI 2015


• After IMR, 95% of Treatment Requests are approved • 45% of all IMR is pharmacy • Results vary by service • Over 80% of IMR decisions are initiated by 10% of physicians • Reviewing treatment requests is complex and requires expertise • Without oversight, injured workers may receive deleterious or

unnecessary care

Exhibit 32

2014 IMR Decision Results Key Findings

Controlling Quality of Care and Cost: The Form and Function of Medical Dispute Resolution


QUESTIONS?

controlling quality of care and cost · 2015-07-23 · • before: legal process, decisions by...

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