Workers' Comp Provider Networks Need to Consider Social Determinants of Health

Traditional methods for measuring physician quality in workers’ comp have used quality measures based on adverse events: mortality rates, hospital readmissions and, in terms of Workers Comp, delayed return to work. As such, the process for selecting WC Network Physicians, may unintentionally overlook providers who do a better job of treating injured workers impacted by Social Determinants of Health (SDOH). Why? Because injured workers with SDOH factors such as restricted access to care, low income or education, lack of transportation and housing are the workers most likely to experience adverse health outcomes. Providers treating that group are measured poorly – not due to the quality of their medical care, but because of adverse events coming from SDOH factors totally out of their control. Continuing with this criterion for network selection deprives injured workers quality care from some very fine physicians, inappropriately measures and penalizes physicians, and ultimately costs employers by excluding some of the best providers in their WC Networks.

What is Quality Healthcare? Problem Example – Common Sense Answer

Which doctor is better: 1) One treating a healthy population in a well-off suburb, with residents diligent in their healthcare, well-educated, physically fit, with access to good nutrition, housing and transportation and few adverse events? Or, 2) The doctor working at the free clinic where the population has lacked adequate healthcare, has a low socio-economic status, poor nutrition, and difficulty accessing healthcare resulting in justifiably higher complication rates? Measures of quality based on adverse events would clearly penalize the second doctor who may be clinically as good or better than the first.

What can be done to address SDOH?

The federal programs Medicare and Medicaid now require billing codes – known as Z codes – to document SDOH issues, such as homelessness, divorce, death in the family, or relationship problems. Workers comp insurers can begin requiring such medical codes in claims as a way for the providers and case managers to gather a complete picture of the injured worker. This is clearly a big shift in the workers’ comp world, but we know that it exists in other areas. (Business Insurance

For providers delivering high-value care, what does it take and what are the barriers? There is growing recognition that to achieve measurable improvements in patient health, high-value care requires addressing proximal social determinants of health.(American Medical Group Association) How do we deliver a personalized experience and meet injured employees where they are in their journey to recovery? Social determinants of health are a big part of the answer as studies on this topic estimate that the health care one receives only impacts 10 to 20% of health outcomes. (Enlyte) Interest in social determinants among physicians is often based on work experience. Those who work at academic medical centers or who work with patients on Medicaid are usually on the lookout for problems caused by nonmedical factors. However, physicians who treat patients with mostly private health insurance or workers’ comp may be less concerned with social determinants because they assume their patients’ income or education level insulates them. Nevertheless, research shows that up to 80% of the factors that influence health take place outside an exam room. (Texmed) Physicians with more than 30 percent of their patient panels on

Medicaid are significantly more likely to see the link between housing security, income, and transportation in achieving patient wellness and return-to-work. And providers who engage in many value-based payment models are more likely to recognize SDOH than providers who engage in more fee-for-service models, including workers’ comp. (PatientEngagementHIT)

What is a fair method to measure Quality? Level of Experience

Provider Ranking System™ (PRS) uses a predictor of quality that is measurable for every medical provider: level of experience in the specific services that they provide. This is backed by medical evidence as the best proxy measure to predict a good health outcome. SeeDoes Practice Make Perfect in Healthcare? Experienced doctors also know when not to do a procedure. They are focused on doing what they do best and do not add inappropriate procedures or unnecessary diagnostics. Higher performing providers do not cost more, and when considering better outcomes, they cost less. With PRS, you can identify high-performing medical providers to lower healthcare costs through improved health outcomes. PRS has over one million providers per year for over ten years. For every reimbursable service they perform, providers are ranked nationally, regionally, & locally. Hospitals were added on 5/15/23, with rankings linked to their affiliated doctors. All providers are also ranked within medical specialty according to a Composite Ranking Score, along with a letter grade.

Summary

Employers need to recognize that while an injured worker’s recovery depends on timely and appropriate medical care, it is also impacted by social determinants of health. (Charity First) According to Safety National’s Conference Chronicles, 80% of an employee’s recovery is largely determined or influenced by factors outside of the clinical setting. (Safety National) Getting the best outcomes for injured workers involves much more than just treating the actual injury. Their recoveries depend on a variety of additional factors such as whether they have access to healthy food and clean water, their ability to travel to medical appointments and the extent of support they have. Increasingly, workers’ compensation payers are finding that these SDOH have a significant impact on the healing process and a worker’s ability to return to work. (Property Casualty 360)

Conclusion

SDOH factors will always be with us. That said, regarding quality medical care for injured workers, employers must level the playing field and be sure that physicians are being chosen to treat Workers Comp patients based on fair, measurable, transparent criteria, using a 100% available quality predictor: level of experience meets those criteria. PRS clients have discovered that the highest performing providers may not be the ones traditionally selected to treat workers’ comp patients. For a medical procedure, the best ultimate outcome – within worker’s comp or not – is achieved by using the doctor who is most proficient at that procedure.