Alex Swedlow and the good folks at CWCI have published a study that clearly demonstrates the amount of waste in the US health care system, waste generated by nothing other than greed and lousy medicine. While the analysis focused on workers comp, the lessons cross all coverage.
The great thing about workers comp is that unlike health insurance, payers are actually concerned about and financially motivated to ensure claimants get the amount and type of care needed to help them recover and get back to work. And there is a wealth of data to evaluate the effects of medical treatment on RTW.
California changed its workers comp rules a few years ago to limit the number of physical or occupational therapy or chiropractic visits a claimant would get covered by workers comp. The limit was 24 (for each, not together), which all the data suggest is more than adequate to take care of 90%+ of WC medical conditions – surgical or non.
So, what happened?
The average number of PT, OT, or chiro visits per patient dropped by almost half, and the number of patients with more than 24 visits dropped from 30.4% to 9.7% (a decline of 68%). Costs declined dramatically as well.
But did this lead to poorer outcomes?
The results, while encouraging, are not as clear.
While there are data from California that appear to show reductions in the length of disability, the results are muddled by a cap on benefit payments that was also part of the WC reforms. The duration of disability (the length of time claimants were out of work) did decline post-reform. Comparing disability duration two years post-injury, the median length of disability declined by 21.4% (average was down 17.4%).
My sense is the reduction in physical medicine visits contributed to the drop in disability duration – without endless visits to PTs and Chiros to receive ‘care’ that was not helping them recover but merely extending the process, claimants were more likely to be released to return to work.
There’s a lesson here for the non-workers comp world, and policy wonks in particular. It is this – providers overtreat, to the detriment of the patient and the payer. Draconian measures such as flat limits on the amount of treatment do work.
With health reform on the horizon, here’s a great example of the waste in our health care ‘system’, waste that benefits the provider.
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Abusive and fraudulent overuse of medical treatment in physical medicine has been a mainstay of the industry for years, if not decades. As reimbursement rates decreased, procedures and units increased. And who was documenting “necessity”? Certainly not the payers. It was the PTs, chiros and/or their managers/owners. Who was overseeing over-utilization? No one, that is, except for the provider/owners who made sure that maximum billing was the rule.
This is also true of MRI (also known as the physician’s ATM)and other expensive technologies.
If my physician can refer me for MRI, therapy services and to a surgery center – all of which he or she owns – what is their motivation, clinical or financial?
The big question is: Will anything change?
The great thing about work comp and disability insurance is the opportunity to complete the workforce productivity loop from point of injury to return to work/return to function. The CA experience first and foremost demonstrates the impact of the systematic use of evidence-based medicine to deliver outcomes-based, quality medical care. That CA selected the guidelines built from data and experience and overseen by the American College of Occupational and Environmental Medicine represented a dedication to quality rather than promoting a model built by a profit motivated vendor. There is a place in the overall system for academic research!
The next challenge to reduce overtreatment is to reward medical providers through a “return to work/return to function” pay for performance model and eliminate the fee for service utilization shenanigans that have dominated in the past with the introduction of managed care.
You will see better results if you incentivize patients to return to work. The results of the study are no suprise. The providers and therapists were more than likely taking patients at their word indicating “necessity” of continued treatment. When there is no end in sight and “I don’t have to work as long as I’m getting PT” what is the motivation to get better?
If you are worried about their motivation Ken pick another physician
I work for Mayo Clinic, and we’re hosting a national health reform symposium I think you and your readers would find interesting. One of our cornerstone principles is that incentives need to be aligned on a “pay for value” basis, where value is defined as outcomes (quality, safety, service) divided by cost over time. Not just the price tag for a particular procedure, but the cost of caring for the person long-term.
Anyway, our symposium will feature some top thought leaders, and its all about developing action plans and priorities for real change. I hope you and your readers will check out our blog where I’ve described the event (and what Mayo Clinic has been doing in this area for the last few years.) It’s at http://healthpolicyblog.mayoclinic.org/