SLIDE 1
Assessing the Effects of California Reforms on Quality of Care: The Value of Higher Quality Care
Teryl Nuckols, MD, MSHS
SLIDE 2 In 2003, California Implemented Utilization Management (UM) As One of Several Reforms
- In other healthcare settings, UM has reduced overuse
– Best used selectively because claims review is costly
- In WC, UM is difficult to apply at this time
– RAND found existing guidelines are not high quality – California payors found the best guideline hard to apply for UM – Claims review can increase costs by delaying receipt of beneficial care and, thus, return to work – Resolving disputes often involves litigation
- California workers’ comp costs are better controlled
- However, UM does nothing to ensure that injured workers receive
beneficial care
SLIDE 3 Outline
- National research on quality of care
- Quality of care in workers’ comp
- Strategies for improving quality
- Next steps in California WC
- Implications for other states
SLIDE 4
A Landmark RAND Study Found U.S. Adults Receive Right Care Only About Half the Time
Low Back 68% 32% Shoulder & Knee
Not Right Right Care Not Right
57% 43%
Right Care
All Health Care
Source: RAND, McGlynn 2003.
SLIDE 5
The Two Principal Quality Problems, Overuse and Underuse, Often Occur Simultaneously
Care that could produce substantial benefit
SLIDE 6 The Two Principal Quality Problems, Overuse and Underuse, Often Occur Simultaneously
Care that could produce substantial benefit Care for which risks
SLIDE 7 The Two Principal Quality Problems, Overuse and Underuse, Often Occur Simultaneously
Care provided Care that could produce substantial benefit Care for which risks
SLIDE 8
The Two Principal Quality Problems, Overuse and Underuse, Often Occur Simultaneously
Underuse:
46% of Patients
Overuse:
11% of Patients
SLIDE 9 Outline
- National research on quality of care
- Quality of care in workers’ comp
- Strategies for improving quality
- Next steps in California WC
- Implications for other states
SLIDE 10
In Workers’ Compensation Settings, Many Injured Workers Probably Do Not Get The Right Care
?% ?% Not Right Right Care
SLIDE 11 Overuse and Underuse Are Costly to Workers and Employers
- Workers’ health is not likely to
improve—and may decline
- Medical costs are unnecessary
- Workers’ health is not likely to improve
– Increases temporary and permanent disability – Creates need for more care
Overuse Underuse
SLIDE 12
In One Rigorous Study, Better Care Reduced Time on Temporarily Disability by 37%
3.7 5.9 1 2 3 4 5 6 7 TD (Weeks) PD (% of Claims) Medical & Disability Costs ($1,000s) Higher quality Usual care
Source: Abasolo 2005.
SLIDE 13
Better Care Reduced the Number of Temporarily Disabled Workers Who Became Permanently Disabled by 50%
3.7 1.1 5.9 2.2 1 2 3 4 5 6 7 TD (Weeks) PD (% of Claims) Medical & Disability Costs ($1,000s) Higher quality Usual care
Source: Abasolo 2005.
SLIDE 14
And Better Care Reduced Medical and Disability Costs by 37%
3.7 1.1 1.968 5.9 2.2 3.154 1 2 3 4 5 6 7 TD (Weeks) PD (% of Claims) Medical & Disability Costs ($1,000s) Higher quality Usual care
Source: Abasolo 2005.
SLIDE 15 Outline
- National research on quality of care
- Quality of care in workers’ comp
- Strategies for improving quality
- Next steps in California WC
- Implications for other states
SLIDE 16
There Are Three Ways To Evaluate Quality of Care
Resources Outcomes Actual Care
By Avedis Donabedian
SLIDE 17 Evaluating Actual Care Is Most Informative
Resources Outcomes Actual Care
- Identifies problems and needed changes
- Supports comparisons even when patient
populations differ
- Minimal time lag
- Providers often support rigorous measures
- Rather complicated—and costly
Pros Cons
SLIDE 18 Promising Strategies for Evaluating Actual Care
- 1. Utilization management (UM)
- 2. Report cards
– Doctors or hospitals – Medical groups or networks – A state workers’ compensation system
SLIDE 19
- 2. Report Cards Have Several
Advantages Over UM Alone
- Address both underuse and overuse
- Enable payors to
– Be proactive rather than reactive – Contract based on quality – Use UM selectively
– Track changes over time – Determine effects of new policies
SLIDE 20
- 2. Report Cards Have Several
Advantages Over UM Alone
- Address both underuse and overuse
- Enable payors to
– Be proactive rather than reactive – Contract based on quality – Use UM selectively
– Track changes over time – Determine effects of new policies
SLIDE 21
Hypothetical Example
For State WC Systems, Report Cards Can Monitor Quality Trends
10 20 30 40 50 60 70 80 90 100 2005 2006 2007 2008
Right care
SLIDE 22
Hypothetical Example
For State WC Systems, Report Cards Can Highlight Important Quality Problems
10 20 30 40 50 60 70 80 90 100 2005 2006 2007
Return-to-work planning Right care
10 20 30 40 50 60 70 80 90 100 2005 2006 2007
Inappropriate back surgery Wrong care
SLIDE 23 Outline
- National research on quality of care
- Quality of care in workers’ comp
- Strategies for improving quality
- Next steps in California WC
- Implications for other states
SLIDE 24 A6655-24 03/06
RAND/UCLA Demonstration Project
- Demonstrate quality measurement in California
workers’ compensation system
- Develop quality measures for carpal tunnel
- Develop tools for applying the measures and
pilot test them against data
- Measure quality in several medical networks
- Develop sample report card comparing networks
- Translate findings into an ongoing quality-
monitoring system
Purpose Approach
SLIDE 25 RAND/UCLA Demonstration Project
- Demonstrate quality measurement in California
workers’ compensation system
- Develop quality measures for carpal tunnel
- Develop tools for applying the measures and
pilot test them against data
- Measure quality in several medical networks
- Develop sample report card comparing networks
- Translate findings into an ongoing quality-
monitoring system
Purpose Approach
Supported by the California Commission on Heath and Safety and Workers’ Compensation and Zenith Insurance
SLIDE 26 RAND/UCLA Demonstration Project
- Demonstrate quality measurement in California
workers’ compensation system
- Develop quality measures for carpal tunnel
- Develop tools for applying the measures and
pilot test them against data
- Measure quality in several medical networks
- Develop sample report card comparing networks
- Translate findings into an ongoing quality-
monitoring system
Purpose Approach With additional funding partners, we could produce a complete set of nationally applicable measures
SLIDE 27 Outline
- National research on quality of care
- Quality of care in workers’ comp
- Strategies for improving quality
- Next steps in California WC
- Implications for other states
SLIDE 28 Implications for Other States
- Quality of care is important in workers’ compensation
– Low-quality care impedes recovery & increases cost
- Quality of care for injured workers should be evaluated
– Monitoring actual care is most informative approach – Addresses overuse and underuse
- Report cards and pay-for-performance are promising
strategies for monitoring and improving care
- RAND and UCLA are developing nationally applicable
quality measures for carpal tunnel syndrome
SLIDE 29
