Disability Prevention, Health Care Cost Control and Innovation in Health Care Delivery
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Disability Prevention, Health Care Cost Control and Innovation in Health Care Delivery Historic Changes in WA Workers’ Compensation. IOM-DHS Occupational Health 6/10/2013 Gary M. Franklin, MD, MPH Research Professor Departments of Environmental Health and Neurology University of Washington

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Iom dhs occupational health 6 10 2013 gary m franklin md mph research professor

Disability Prevention, Health Care Cost Control and Innovation in Health Care DeliveryHistoric Changes in WA Workers’ Compensation

IOM-DHS Occupational Health

6/10/2013

Gary M. Franklin, MD, MPH

Research Professor

Departments of Environmental Health

and Neurology

University of Washington

Medical Director

Washington State Department of

Labor and Industries


Iom dhs occupational health 6 10 2013 gary m franklin md mph research professor

Over the past decade: Claims with disability payments are staying open longer


What is the relationship between health care delivery and prevention

What is the relationship between health care delivery and prevention?

Disability Prevention: Changing the Paradigm

Primary preventionPrevent workplace

injuries and illnesses

Secondary preventionPrevent disability among

workers with work-related

injuries and illnesses

Tertiary preventionManage disability to reduce

residual deficit and dysfunction


What are the main categories of risk

What are the main categories of risk?

Disability Prediction in Workers’ Compensation

Most important risk factor categories

Medical

Work

Administrative

Psychosocial

Demographic

Legal

More

Modifiability

Less


Iom dhs occupational health 6 10 2013 gary m franklin md mph research professor

38% Increase since 2001


What has contributed the most to decade long pattern of increased disability duration

What has contributed the most to decade long pattern of increased disability duration?

  • Use of harmful treatments, which contribute to prolonged disability: opioids, spinal surgery (lumbar fusion)

  • Multiple diagnosis problem (eg, TOS)

  • Bad docs


Use of opioids early after a low back injury increases risk of long term disability

Use of opioids early after a low back injury increases risk of long term disability

  • Webster et al, 2007 Spine; 32: 2127-32

    • >450 mg MED associated with 69 additional time-loss days

  • Franklin et al, 2008 Spine 33: 199-204

    • >7 days or 2 Rxs opioids associated with doubling of risk of disability at 1 year


Ca cwci study swedlow et al march 2011

CA CWCI study-Swedlow et al, March, 2011

3% of prescribers account for 55% of Schedule II opioid Rxs

DLI will send letters to all prescribers with any patient on opioid doses at or above 120 mg/day MED

  • Call their attention to AMDG Guidelines and new WA state regulations

  • Associate medical director will meet with these docs personally

    http://www.cwci.org/research.html


Surgical outcomes are universally worse in workers compensation

Surgical outcomes are universally worse in workers compensation

  • Harris et al, JAMA 2005; 293: 1644-1652

    • Reviewed 211 studies, 1966-2003

    • 175 outcome worse, 35 ND, 1 better

    • Meta-analysis of 129 studies (N=20498):

      • Summary odds for unsatisfactory outcome 3.79 (3.28-4.37)


Contrasting policy ca vs wa martin et al under review 2013

Contrasting Policy CA vs WAMartin et al, under review, 2013

*


Index admission costs

Index admission costs*

  • Controlling for age, sex, comorbidity

  • & diagnosis


Washington department of labor and industries lumbar fusion and simps

WASHINGTON DEPARTMENT OF LABOR AND INDUSTRIESLumbar Fusion and SIMPs


Iom dhs occupational health 6 10 2013 gary m franklin md mph research professor

100

80

60

40

20

0

0

1

2

3

4

5

6

7

8

9

10

11

12

Prevent Chronic Disabilitythru Physician Education and Support

Increase use of occupational health best practices to reduce disability

Current

% Patients on disability

Desired

Months of

Lost Work Time

Cheadle A et al. Factors influencing the duration of work-related disability. Am J Public Health 1994; 84:190–196.


Centers of occupational health and education cohes

Centers of Occupational Health and Education (COHEs)

  • Wickizer et al, A communitywide intervention to improve outcomes and reduce disability among injured workers in Washington State, Milbank Q 2004; 82: 547-67

  • http://www.lni.wa.gov/ClaimsIns/Providers/Research/OHS/default.asp


Iom dhs occupational health 6 10 2013 gary m franklin md mph research professor

Dept. of Labor

UW Research

WCAC/HC

Team

& Industries

Business Labor

COHE

Pilot

Advisory Board

Community

Community

Physicians

COHE Organization and Governance


Important components of cohe model

Important components of COHE Model

  • This is a health care system, not an insurance company, intervention

  • Health care institutional support

  • Occupational health leadership

  • Business/labor advisory committees


Important components of cohe model1

Important components of COHE Model

  • Occupational health best practices

  • Quality Indicators

  • Health Services coordination-function reports to the health care providers

  • Information support system

  • Modest payment incentives for best practices


Initial quality indicators

Initial Quality Indicators

  • Process, not specific treatment, indicators

  • Prompt submission of ROA (48 hrs)

  • Telephone call Re RTW by physician

  • Activity prescription

  • 4 week assessment of barriers to RTW


Cohe communities

COHE Communities

Institution-based COHEs

The Everett Clinic

327 providers

~3,000 claims (annual)

Operations began 2007

Harborview Medical Center

Emergency Department

Operations began 2007

Renton COHE

270 providers

~8,500 claims (annual)

Operations began 2002

Eastern WA COHE

935 providers

~16,000 claims (annual)

Operations began 2003


Cohe results wickizer et al medical care 2011 49 1105 1111

COHE resultsWickizer et al, Medical Care 2011; 49: 1105-1111

  • 20% reduction in likelihood of one year disability, 30% reduction for back injuries

  • Among COHE participating doctors, high adopters of best practices had 57% fewer disability days than low adopters

  • http://www.ncbi.nlm.nih.gov/pubmed/22015667


Key results from cohe pilots

Key Results from COHE Pilots

  • 20% reduction in likelihood of one year disability, 30% reduction for back injuries

  • Among COHE participating doctors, high adopters of best practices had 57% fewer disability days than low adopters


Rates of reduced disability days

Rates of Reduced Disability Days

  • Based upon the COHE regression model, the number of reduced disability days per 1,000 injured workers treated was:

    • Renton: 4,800 days (13.2 years) of disability avoided per 1,000 workers treated

    • Spokane: 5,800 days (15.9 years) of disability avoided per 1,000 workers treated


What have we learned from the cohes

What have we learned from the COHEs?

  • Health care in large communities can be re-organized to provide more highly integrated Occ Health best practices

  • Reorganization is possible with modest financial and non-financial incentives

  • Maintained worker choice of provider without a mandate to direct care

  • Improved satisfaction at all levels in the community

  • From our standpoint, a small investment for big return from both the human and the $ standpoint

    Contrast this experience with the 2004 CA reforms mandating medical provider networks-impact short lived, very low satisfaction among providers and workers-Off the shelf PPOs and MCOs have no impact on preventing disability


Distribution of quality of care

Average Medical CostsAverage Disability Costs

Questionable Health/Disability Outcomes

Moderate to High Medical Costs

Moderate to High Disability Costs

Poor Health/Disability Outcomes

Low or AverageMedical CostsReduced Disability Costs

Excellent Health/Disability Outcomes

High Medical Costs

High Disability Costs

Very Poor Health/Disability Outcomes

CommunityPhysicians

Clinical Efficiency

Poor

Good

Zone 1

Zone 2

Zone 3

Zone 4

(Costs & Quality)

Distribution of Quality of Care

Patterns of poor quality care that presents injured workers a risk of harm typically require other (non-COHE) interventions (minimum standards & risk of harm)

  • Incentives for quality indicators known to improve outcomes

  • Resources to help docs apply them (CME, HSCs, reminders)

  • Geared toward improving well-intentioned Zone 2 & 3

  • COHE Model: Identify high performers to serves as mentors


2011 wa leg ssb 5801 2011 defining harm for the first time in any jurisdiction

2011 WA Leg: SSB 5801 (2011)-Defining harm for the first time in any jurisdiction

  • The department may permanently remove a provider …when the provider exhibits a pattern of conduct of low quality care that exposes patients to risk of physical or psychiatric harm or death. Patterns that qualify as risk of harm include, but are not limited to, poor health care outcomes evidenced by increased, chronic, or prolonged pain or decreased function due to treatments that have not been shown to be curative, safe, or effective or for which it has been shown that the risks of harm exceed the benefits that can be reasonably expected based on peer- reviewed opinion


Screening for disability risk linked to delivery of occ health best practices

Screening for Disability Risk Linked to Delivery of Occ Health Best Practices

Positive Functional Recovery Questionnaire (FRQ)

  • Not worked for pay in past two weeks

  • Pain greater than 5 on VAS

  • Back and leg pain OR pain in multiple body sites

    Functional Recovery Interventions (FRI)

  • Graded exercise/activity

  • Address low recovery expectations

  • Address any fear of usual activity reinjuring or worsening condition

  • Flag additional HSC focus on RTW


New cohe subacute early chronic quality indicators

New COHE subacute/early chronic quality indicators

  • Four weeks after care begins (up to 8 weeks after care begins), unless contra-indicated, AP referral for PT-supervised time-limited graded exercise program if worker not progressing sufficiently in self-managed activity program

  • AP referral of IW to activity coaching (weekly contacts with a trained activity coach using structured sessions and materials aimed at re-integrating the IW into life activities, including work) if worker still off work 4 weeks after care begins and no contra-indications for activity coaching

  • IW ratings of pain and function are obtained at each visit, using the 2 question Graded Chronic Pain (Von Korff) instrument


New cohe t ransition quality indicators better hand offs

New COHE transition quality indicators-better “hand-offs”

  • For IWs having surgery, there is a documented pre-op assessment of RTW capacity and specific goals related to RTW post-op

  • For IWs who have surgery, the HSC assists in transitioning the patient back to primary care after surgery when requested by surgeon

  • For IWs having surgery, there is an integrated post-operative team (e.g., COHE-delivered care) that will evaluate the patient if RTW goals are not met by 8 weeks post-op (12 weeks for lumbar fusion)


Ideal community based workers comp health care

Ideal Community-Based Workers’ Comp Health Care

COHE-Primary Occ Health Care

Surgical/Specialty

HSC

Medical Home to prevent/treat chronic pain


Iom dhs occupational health 6 10 2013 gary m franklin md mph research professor

THANK YOU!

For electronic copies of this presentation, please e-mail Laura Black

[email protected]

For questions or feedback, please

e-mail Gary Franklin

[email protected]


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