Collaboration is often underappreciated and underutilized as a driver to achieve improved health outcomes. There is no doubt that technology has had a shrinking effect on global communications on the whole. Collaboration, on the other hand, leverages all of the benefits created by human intervention in the health care system (e.g., judgment, logic, sound guidance, etc.) in concert with the advantages gained by today’s technology.
The world may be getting smaller in many ways, but wide divides remain in the care and claims continuum requiring a conscientious focus on collaboration. Only through collaboration will all key stakeholders be connected allowing the sharing of information for sound decision-making and effective problem solving of very complex health issues. Collaboration effectively creates an interactive and adaptable system capable of delivering improved patient health outcomes.
Healthcare IT is Not Enough
The healthcare industry has made staggering progress on the technology front in recent years. Healthcare organizations continually adopt information technologies with clinical decision support (CDS) to prevent potential adverse events that are medication-related or related to an end-user’s lack of familiarity with certain high-risk patient populations. Unfortunately, the inability to share data throughout the care continuum remains a challenge in spite of an investment of more than $26B since 2009.
The challenge is primarily due to a lack of interoperability, or inability for systems or software to exchange and make use of patient information. A patient’s health and health care information is housed in a multitude of environments, which include primary care physician and specialists’ offices, hospitals, pharmacies, laboratories, and even with patients themselves. In the workers’ compensation space, the list of housing environments also includes claim and utilization management systems, insurer systems, etc.
Studies conducted in the last five to six years indicate that while information sharing within a provider group and affiliated hospitals hover around 30%, office-based physicians share information with unaffiliated hospitals and providers outside their office or group approximately just 5% and 12% respectively. These low numbers tell a story of a fractured health care system that inherently limits other verticals’ ability to improve health outcomes, such as workers’ compensation for injured workers. It also tells a story of the lack of collaboration, human to human.
Technology is not enough; a very real need for human intervention exists in order to overcome data sharing challenges due to existing technology limitations.
Collaboration in Workers’ Compensation
The failure of HIT systems to effectively communicate and share information emphasizes the need for human intervention via collaboration efforts in workers’ compensation. I stumbled across a good example of just how effective the act of collaborating can be in the pursuit of improved health outcomes.
A California-based utilization review organization (URO) keeps constant contact with providers practicing within its various medical provider networks (MPN). The contact is intended to minimize denials of treatment requests and expedite the delivery of necessary care to the patient.
Contrary to the stigma UROs have been assigned by some in workers’ comp, utilization review’s sole function is to ensure the appropriateness of care based on the state’s designated treatment standards and other evidence-based resources. In California, the treatment standard assigned presumptive weight is the MTUS treatment guidelines (a.k.a. ACOEM treatment guidelines).
Treatment requests can be denied by UROs for numerous reasons. A common reason for denial is due to an incomplete request including pertinent information needed to complete the utilization review process, or an insufficient base in scientific evidence in the treating provider’s rationale for the requested protocol.
The URO mentioned above takes the time to visit with providers in various MPNs. The focus of this interaction is to build trust, open communication channels and ultimately strong partnerships with these providers. The information that is shared ranges from regulation interpretations and updates, protocol reviews, and education on pertinent evidence-based guidelines.
Strong positive relationships are the foundation for effective collaboration between the URO and MPN for the benefit of injured workers. The relationship becomes a conduit to facilitate appropriate treatment plans leading to better health outcomes. The key that I observed in this model is to avoid contacting providers only when something negative is being relayed (such as a UR denial review). Rather, use every opportunity to touch the provider and their staff with information to support and add value to their practice.
This type of collaboration supersedes the URO’s obligation to the state and the MPN provider. The URO’s main objective is clear: To ensure the patient’s care is not unnecessarily delayed or denied and the provider’s experience with the URO is constructive and beneficial to their practice.
Provider participation in workers’ compensation is often times an issue in states where the administrative burdens to participate in the system outweigh the benefits. This is an issue for both insurers and patients as the quality and availability of medical care tends to decrease; this results in increased disability durations and a rise in indemnity and medical costs.
Having a positive rapport with MPN providers creates a channel for sharing information with the URO, or managed care entity, that may supersede their mutual obligation to one another. A relationship of this nature is monumental to achieving desired outcomes, particularly with some of the issues created by low performing MPNs in California. In other words, collaboration motivates each party to go above and beyond for better results.
This collaboration example has produced a clinically responsible reduction in opioid use among patients that is better than the state average. Risk and disability durations are minimized for patients, employers’ business interruption is decreased while the cost for insurers is well controlled.
Collaboration is extremely important if improved health outcomes are to be achieved. In the absence of interoperability between the systems we utilize in the care and claims continuum, the only adequate substitute is human intervention. Given the state of the available technology, only effective patient-centric judgment, logic, and guidance will bridge the divides throughout the care and claim continuum driving improved health outcomes.
Categories: Evidence-Based Medicine (EBM), Healthcare, Managed Care, Opioids, Uncategorized, Utilization Review
Carlos Luna News 
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