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You call THAT an “outcome”?!

OK, let’s agree that the best metrics to measure workers’ comp claims are:

  • speedy and
  • sustained recovery,
  • return to work, and
  • medical cost.


  • reductions below billed charges, or
  • discounted medical costs, or
  • network penetration, or
  • litigation rate, or
  • case management “impact”, or
  • successful denials of treatments.

The latter are process measures – NOT outcomes. Yes, process can drive outcomes – but often does not. (See discussion of mythical “savings” from WC bill review and PPO)

How to evaluate a program, vendor, network, provider group, or delivery system:  First, what types of information are relevant and for what? (we’ll get to benchmarks in a bit)

or…anecdote vs data, and treatment records vs, aggregate reports.

from Statistically Funny

  1. Using the outcomes metrics listed above, review their reports – aggregate reports that is – across their patient population. This will tell you two things; the entity’s overall “results,” how they think about outcomes, and what metrics they use.
  2. Ask a lot of questions, such as:
    1. Who selected these metrics, and what is their relevant experience, education and training?
    2. Why did you choose those metrics?
    3. Explain each metric, how it is helpful, its limitations, and the research you conducted to elect that metric.
    4. What other metrics did you consider? Why didn’t/don’t you use them?
    5. What is the statistical validity of your data?
    6. How do our results compare to the rest of your customers?
      1. Why are they similar/different?
    7. What would you like to include but didn’t, and why not?
    8. How are other customers using this information?
    9. How are you using this information?
    10. How do you see your outcomes measures evolving in the future?

Be prepared to be underwhelmed…and do NOT allow your vendor to provide case-specific reports or findings instead of aggregate data.

Vendors love to cite specific cases, which a)distracts you from their overall impact and b) is way more interesting as it is “real” and not just a bunch of numbers and statistics.

That’s NOT to say those specific case notes/treatment records aren’t fact the next step – once you’ve decided the vendor produces good “outcomes” – is to find out how they do that.

And that is where and when case notes/treatment records can be quite useful…they show HOW the vendor delivers the outcomes.

So how do we know if outcomes are “good”, that is, if injured workers are being treated appropriately and employers/taxpayers are well served?

Enter an industry bugaboo – comparisons to meaningless/wrong/misleading “benchmarks.”

That, dear reader, is the subject of the next post.

What does this mean for you?

The mistake most work comp payers make is skipping the first – and by far the most important step – evaluating vendor performance based on REAL outcomes.


12 thoughts on “You call THAT an “outcome”?!”

  1. Hey Joe. well said. if we focus on decreasing the duration of disability with as good an outcome (evidence based) for the patient/employee then everybody wins except the attorneys. all data models should be built around that concept. My 3 cents. have a great day!

    1. thanks for the note Troy – coming from a very experienced provider it resonates.

      Evidence indeed!

      be well Joe

  2. Yes! I have been making this argument for years. UR “savings” from denials of care that actually lead to longer disability, more friction, and delayed recovery and case closure are not savings at all. I have always asked clients to measure their year over year trends. In short we consider our programs successful when we can show an impact on overall claims costs, when lost-time is reduced, and claims close sooner.

  3. Hey good to see your blog today Joe. Tracking real outcomes is important in all aspects of healthcare no matter who the payer. But, it is good to see someone mentioning real results not fake ones. All that matter in a work comp case is disability duration, return to work, function (not pain) and cost. Many providers track outcomes these days but the payers do not seem interested. Not sure why that is? Though, it is very frustrating as it costs providers time and money to do so. Providers are doing it because it is the right thing to do and we want to know. Shouldn’t payments to providers be based partially if not wholly on outcomes? Results are the true golden egg. CMS is tracking outcomes via their MIPS (Merit Incentive Payment System) program but we still don’t know where that is heading. For now we are told a possible small bonus. Payers it is time to start putting your money where your mouth is. Thanks for bringing awareness to the matter.

    1. Thanks for the note Mark.

      I’ve some familiarity with value based care, ACOs and the like; CMS’ Center for Medicare Innovation (CMI) is funding many projects/pilots in an effort to find how best to drive and reimburse quality, outcomes-positive (my words not their’s) care. Suffice it to say to date results have been underwhelming.

      Alas few workers’ comp payers are paying attention to outcomes…if they were they wouldn’t be using big PPOs and paying percentage of savings for illusory “savings”.

      be well Joe

  4. Hi Joe. I hope all is well. I was discussing these very issues at lunch today with our Physician Director of Medical Management and our NCM Supervisor. Your assessment and comments are spot on! Thanks.

    1. Hello Don and thanks for the note…hopefully others are having those same conversations.

      be well Joe

  5. Great post, Joe! When vetting MSP vendors, ask how their MSAs facilitate claim closure & settlement? How quickly do they turn around the MSA and how aggressively to they pursue cost mitigation? How do their CMS submitted MSAs compare to CMS’s benchmark averages for medical and pharmacy? What percentage of their MSAs are approved by CMS the first time, and what’s their success rate when challenging CMS? Look forward to your benchmark post!

    1. thanks for the note Rita.

      I’d suggest these aren’t “outcome” measures per se but mostly process metrics useful for evaluating a specific service type.

      I’ve only cursory knowledge of the MSA business…perhaps a useful outcome metric might be percentage of claims settled with or without an MSA, case mix adjusted.

      be well Joe

    1. Thanks Mike – appreciate the follow.

      I edited your comment as I don’t allow marketing-type stuff in the comments section.

      be well Joe

Comments are closed.

Joe Paduda is the principal of Health Strategy Associates



A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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