Controlling Medical Costs and Improving Quality of Care: Lessons from Texas Amy Lee, Research...
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![Page 1: Controlling Medical Costs and Improving Quality of Care: Lessons from Texas Amy Lee, Research Director State of Texas Research and Oversight Council on.](https://reader035.fdocuments.in/reader035/viewer/2022081700/56649e175503460f94b03609/html5/thumbnails/1.jpg)
Controlling Medical Costs and Improving Quality of Care:
Lessons from Texas
Amy Lee, Research DirectorState of Texas Research and Oversight Council
on Workers’ Compensation
![Page 2: Controlling Medical Costs and Improving Quality of Care: Lessons from Texas Amy Lee, Research Director State of Texas Research and Oversight Council on.](https://reader035.fdocuments.in/reader035/viewer/2022081700/56649e175503460f94b03609/html5/thumbnails/2.jpg)
What is the Research and Oversight Council on Workers’ Compensation
(ROC)?
• Small state agency with a mission to:
– Conduct objective research on workers’ compensation issues; and
– Make legislative and regulatory recommendations to the state leadership and ROC Board every biennium.
![Page 3: Controlling Medical Costs and Improving Quality of Care: Lessons from Texas Amy Lee, Research Director State of Texas Research and Oversight Council on.](https://reader035.fdocuments.in/reader035/viewer/2022081700/56649e175503460f94b03609/html5/thumbnails/3.jpg)
HB 3697 (76th Legislature, 1999) required the ROC to:
• Investigate the quality and cost-effectiveness of
WC medical care in Texas compared to:
– other states; and
– other health care delivery systems in Texas.
![Page 4: Controlling Medical Costs and Improving Quality of Care: Lessons from Texas Amy Lee, Research Director State of Texas Research and Oversight Council on.](https://reader035.fdocuments.in/reader035/viewer/2022081700/56649e175503460f94b03609/html5/thumbnails/4.jpg)
Key Findings from HB 3697 Studies Included:
• Texas WC medical costs are higher than other states and other health care delivery systems.
• Medical care utilization is high in areas such as surgery, physical medicine, and diagnostic tests.
• Relatively small proportion of providers, claims and medical procedures are driving costs.
Source: Striking the Balance An Analysis of the Cost and Quality of Medical Care in the Texas Workers’ Compensation System, January 2001.
![Page 5: Controlling Medical Costs and Improving Quality of Care: Lessons from Texas Amy Lee, Research Director State of Texas Research and Oversight Council on.](https://reader035.fdocuments.in/reader035/viewer/2022081700/56649e175503460f94b03609/html5/thumbnails/5.jpg)
Average Medical Paid Per Claim, Injury Year 1997
$1,139 $1,214 $1,266
$2,205
$1,408$1,364
$870
$1,817
$1,569
$0
$500
$1,000
$1,500
$2,000
$2,500
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One-Year Post-Injury
Source: Striking the Balance An Analysis of the Cost and Quality of Medical Care in the Texas Workers’ Compensation System, January 2001.
![Page 6: Controlling Medical Costs and Improving Quality of Care: Lessons from Texas Amy Lee, Research Director State of Texas Research and Oversight Council on.](https://reader035.fdocuments.in/reader035/viewer/2022081700/56649e175503460f94b03609/html5/thumbnails/6.jpg)
Key Findings from HB 3697 Studies Included:
• Texas workers also receive medical care for longer periods of time, compared with national guideline recommendations and other states.
• More costly and intensive medical care in Texas has not resulted in improvements in worker satisfaction, functional outcomes (i.e., whether the worker got better), or return-to-work outcomes.
Source: Striking the Balance An Analysis of the Cost and Quality of Medical Care in the Texas Workers’ Compensation System, January 2001.
![Page 7: Controlling Medical Costs and Improving Quality of Care: Lessons from Texas Amy Lee, Research Director State of Texas Research and Oversight Council on.](https://reader035.fdocuments.in/reader035/viewer/2022081700/56649e175503460f94b03609/html5/thumbnails/7.jpg)
HB 2600, 77th Legislature (2001)
• Grew out of research findings from HB 3697 studies
• Basic findings: Texas pays more but does not get more, resulted in the following policy goals:
– Increased accountability through improved monitoring of all parties;
– More extensive use of medical expertise in agency decision making; and
– Emphasis on outcomes rather than medical costs alone.
![Page 8: Controlling Medical Costs and Improving Quality of Care: Lessons from Texas Amy Lee, Research Director State of Texas Research and Oversight Council on.](https://reader035.fdocuments.in/reader035/viewer/2022081700/56649e175503460f94b03609/html5/thumbnails/8.jpg)
A New Model for Quality Enhancement and Cost Control
(Article 1 of HB 2600)
• Registration and training for doctors
• Monitoring for all system participants
• Creation of a Medical Quality Review Panel, new
roles for Medical Advisor
• Collection of outcomes data
• Sanctions and rewards
![Page 9: Controlling Medical Costs and Improving Quality of Care: Lessons from Texas Amy Lee, Research Director State of Texas Research and Oversight Council on.](https://reader035.fdocuments.in/reader035/viewer/2022081700/56649e175503460f94b03609/html5/thumbnails/9.jpg)
Four Monitoring Programs Envisioned Under Article 1
of HB 2600:
• Doctor/Health care provider
• Insurance Carrier/URA
• Designated doctor
• IRO medical dispute decisions
(To date 41 doctors and designated doctors have been reviewed by the Medical Quality Review Panel; 24 other doctors pending review.)
![Page 10: Controlling Medical Costs and Improving Quality of Care: Lessons from Texas Amy Lee, Research Director State of Texas Research and Oversight Council on.](https://reader035.fdocuments.in/reader035/viewer/2022081700/56649e175503460f94b03609/html5/thumbnails/10.jpg)
Four Components to Each Monitoring Program:
• Data analysis, to identify potential outliers;
• Review of sample cases to determine whether full clinical review is warranted;
• Full clinical review on cases in question; and
• Progressive sanction program may be initiated.
![Page 11: Controlling Medical Costs and Improving Quality of Care: Lessons from Texas Amy Lee, Research Director State of Texas Research and Oversight Council on.](https://reader035.fdocuments.in/reader035/viewer/2022081700/56649e175503460f94b03609/html5/thumbnails/11.jpg)
Use of Designated Doctors (DDs) in Impairment Rating and MMI Exams
(Article 5)
• HB 2600 called for:– Use of DDs instead of RMEs in IR and MMI
exams– More flexibility in selecting DDs
• Implementation challenges:– How to use new selection criteria (“trained and
experienced”)– Move to 4th edition of AMA Guides and new
doctor training requirements
![Page 12: Controlling Medical Costs and Improving Quality of Care: Lessons from Texas Amy Lee, Research Director State of Texas Research and Oversight Council on.](https://reader035.fdocuments.in/reader035/viewer/2022081700/56649e175503460f94b03609/html5/thumbnails/12.jpg)
Medical Dispute Resolution (Article 6)
• HB 2600 called for medical disputes to be resolved by Independent Review Organizations (IRO) rather than TWCC staff
• Implementation challenges:– Workload shift from agency to IROs– Capacity and concerns of IROs– Payment of IROs: when and how much?– Timeframes for dispute resolution
![Page 13: Controlling Medical Costs and Improving Quality of Care: Lessons from Texas Amy Lee, Research Director State of Texas Research and Oversight Council on.](https://reader035.fdocuments.in/reader035/viewer/2022081700/56649e175503460f94b03609/html5/thumbnails/13.jpg)
Medical Fee Guidelines (Article 6)
• HB 2600 called for:– Conversion to RBRVS reimbursement structure;
and– Conversion to Medicare-based payment policies
• Implementation challenges:– How to adopt and adapt Medicare policies– How to set conversion factors (pricing)– Interaction with new utilization control efforts– TWCC’s ability to train staff or obtain outside
medical expertise
![Page 14: Controlling Medical Costs and Improving Quality of Care: Lessons from Texas Amy Lee, Research Director State of Texas Research and Oversight Council on.](https://reader035.fdocuments.in/reader035/viewer/2022081700/56649e175503460f94b03609/html5/thumbnails/14.jpg)
Almost Two Years Later, What’s Been Learned?
• Drafting rules are one thing; drafting an implementation plan is another;
• Many concepts are inter-related and should be treated as such;
• Use research findings to prioritize implementation efforts and address key cost drivers first;
• Set realistic system goals for controlling overutilization and improving return-to-work outcomes and publish those goals;
![Page 15: Controlling Medical Costs and Improving Quality of Care: Lessons from Texas Amy Lee, Research Director State of Texas Research and Oversight Council on.](https://reader035.fdocuments.in/reader035/viewer/2022081700/56649e175503460f94b03609/html5/thumbnails/15.jpg)
Almost Two Years Later, What’s Been Learned?
• Keep stakeholders working together to reach system goals;
• Anticipate data reporting changes that need to occur before the effective date; and
• Don’t try to do too much at once because it becomes a nightmare to study later.
![Page 16: Controlling Medical Costs and Improving Quality of Care: Lessons from Texas Amy Lee, Research Director State of Texas Research and Oversight Council on.](https://reader035.fdocuments.in/reader035/viewer/2022081700/56649e175503460f94b03609/html5/thumbnails/16.jpg)
Contact Information
Research and Oversight Council on Workers’ Compensation
9800 N. Lamar Blvd., Suite 260 Austin, Texas 78753
(512) 469-7811, Fax (512) 469-7481
Email: [email protected] Website: www.roc.state.tx.us