Why Physician Scoring Is a Win for Insurers, Employers, Workers – and Physicians
We live in a society ruled by rankings. Websites are devoted to them; YouTube careers have been built based upon them. Which players we select for fantasy teams, where our kids go to college, who can be trusted for a home improvement project, even which restaurant we should try for dinner are decisions guided by scores or stars.
One of the last industries to enlist the power of ratings is medicine, which arguably covers the area where scoring matters most. In fact, scores are essential. Doctors’ decisions can be the difference between life and death, or in the case of workers’ compensation, between an injury that heals properly and one that plagues a patient for the rest of his or her life — be it through a joint that doesn’t quite function as it should, bills that send a patient into debt, or a devastating addiction to painkillers.
Some doctors may not seem fond of physician scoring, viewing it as anything from an unwelcome intrusion to a rigged process. As a physician myself, I don’t particularly enjoy being graded either, but I welcome it if it helps deliver better care for my patients and ultimately lowers the cost of care.
Physician ratings actually offer a surprising number of benefits to doctors — and they are not alone. Insurance companies and employers, as well as patients themselves, also have a lot to gain from data-driven scoring.
Modern Physician Scoring
With a movement toward demonstrable results and pay-for-performance initiatives, physician scoring has become a reality, but it has not been without its hurdles. For example, it traditionally has been difficult to assess norms and establish baselines when dealing with small patient populations. There has also been a lack of consensus around what information matters, why, and which measures should be shared with the general public. Not all of these questions have been resolved, but we are getting there.
The advancement of digital records and the shift to cloud-based systems that enable secure sharing of information have dramatically accelerated the adoption of physician scoring by providing larger pools of data to compare, while public reporting projects paved the way for public disclosures. Yet, there is no standardization of criteria or universal rating system for physicians today.
The idea behind physician scoring is quite simple, however: fairly and objectively measure the outcomes of physicians within a similar scope of practice. You have to compare apples to apples. Artificial intelligence-based systems are now making this possible in a way that analyzes a number of highly specific, measurable data points — such as the cost of claims, the duration or use of opioids, and duration of temporary total disability — on top of basic outcomes across enough doctors and patient populations to come up with sophisticated scoring. To fairly measure a quality is a complex process, but with the latest in data analytics and predictive model programming, it is possible.
How It Works for All
The advantages to physician scoring are obvious for the patient. By seeing a doctor with a higher score, the patient is likely to heal and get back to work faster, lessening the impact on day-to-day life.
At the same time, doctors are pushed to deliver better care and adopt best practices. They are driven to provide evidence-based medicine. As a result, their practices flourish as more business is directed their way.
Armed with the right tools to identify the best physicians who can deliver positive outcomes, payors minimize their own costs in paying for care. Cost savings increase even more significantly when you factor in the ability to minimize litigation from claims that go awry based on botched procedures and untimely or inadequate care delivered from poor-performing doctors. Additionally, claims that are directed to highly ranked physicians are resolved faster. This reduces the amount of time each claims team member has to spend per claim, requiring fewer resources to help more people in less time.
Employers who work with organizations that leverage physician scoring also benefit by receiving reassurance that appropriate care is being given to their injured employees, ensuring their well-being and helping them return to work faster, which lessens the impact on the business. Companies also experience savings and lower their own risk of becoming involved in costly, time-consuming litigation that occurs when workers fail to receive quality care.
At a fundamental level, physician scoring enables each of these groups to unite around the common goal of helping injured workers and moving claims to closure through evidence-based medicine.
Case in Point
Perhaps the best way to showcase how physician scoring works for all is with an example. Suppose I am a representative handling workers’ comp claims. A number of the cases I deal with are in Stockton, California. There is only one knee doctor nearby, and he doesn’t have the best score because of his pricing and the number of opioids he prescribes. I don’t want to have to send all of my patients all the way to San Francisco to see someone else, however.
If my organization relies on data-driven physician scoring, I can use this information to talk to the local doctor, who does good work regardless of the factors above. We can discuss what he needs to do to bring his score up, based on multiple, objective data points and comparisons to other physicians in the area.
When the doctor sees how his pricing and prescriptive practices line up against other area physicians and he recognizes how it affects his business, he makes a few simple changes to increase his score. Greater pricing transparency is achieved, and alternatives to opioids and/or stricter policies regarding their prescription are also put into place. These changes ultimately are in the best interest of patients. They also make it possible for me to feel comfortable referring patients to a well-qualified practitioner.
Additionally, my organization experiences a benefit from my ability to send patients to an in-network doctor who can resolve a claim effectively and efficiently. Patients’ employers also see that proper care is being given to employees who won’t have to miss as much work — particularly in terms of traveling to follow-up appointments. And patients themselves feel better faster without having to overcome the hurdles that can be associated with an injury.
While physician scoring provides a number of benefits overall, at its root it drives important changes in physician behavior, pushing doctors to do better and sustain excellent practices. This improves medical care and patient healing rates across the board, reducing costs and key pain points for all. And that is a very good thing.
About Dr. Paul Kim
Kim is the Chief Medical Officer for Clara Analytics, which provides medical data analytics services to workers’ compensation insurers. He holds a doctor of medicine and master of public health degrees from Loma Linda University and a Masters in Business Administration with a focus in healthcare administration from La Sierra University.
The article first ran in claimsjournal.com