Tool Box

Measures of Quality

URAC - List of PERFORMANCE MEASURES and Rationale

Access to care: Timely care for an injury or illness can influence both the level of disability associated with the injury, and the duration of disability. Access to care includes a number of dimensions that can be influenced by an MCO. These include ease of getting an appointment with a physician, ability to see a physician in a convenient location, and ability to communicate with the physician and office staff. An effective MCO will ensure that its network of providers offers appropriate access to the insured population.

Appropriateness of care: Care for injuries can be complex. However, for many injuries, guidelines are available for physicians indicating the course of standard treatment for an uncomplicated injury. In some cases, inappropriate treatments may result in delayed recovery and return to work. An MCO should ensure that providers in its network practice according to guidelines for best practices in treatments of injuries. Return to work: Return to work (RTW) may be influenced by many factors, some not under control of the MCO.

However, RTW can be enhanced by factors that are under the control of the MCO and its network providers. For example, network providers can promote return to work by understanding the nature of the worker's job, establishing and communicating reasonable work limitations, and recommending appropriate RTW releases. The MCO can be held responsible for ensuring that its network of providers promotes return to work as a goal and prescribes appropriate lengths of absence, and for providing necessary support (for example, case management) to implement the goal.

Utilization: Research has shown that use of clinical services is much higher for workers' compensation injuries than for similar injuries outside of the workers' compensation system, yet there is often no clinical rationale for higher utilization. An MCO can promote the appropriate level of services by monitoring rates of certain procedures and comparing those rates to local practices, guidelines, or other similar groups. It can provide feedback to providers within its network if the network average is different from benchmarks set by MCOs treating similar populations. While tracking utilization does not provide any information about whether a particular procedure is right for a particular patient, it can help an MCO measure patterns of care for its population that may indicate overly high use of service or very low use of service.

Medical costs: Medical costs are related to use of services and the price per service. The MCO directly influences both of these factors. MCOs should be expected to report on the cost of service per type of injury so that the value of the MCO can be compared to other MCOs and to non-managed care.

Worker satisfaction with care: Return to work success is associated with injured workers' satisfaction with their employer and their perception of how they were treated when injured. MCOs influence satisfaction by providing patients with appropriate assistance, linking them with high quality physicians, and recommending appropriate RTW approaches. MCO providers influence satisfaction through their interactions with the patients. Workers can provide very important information about the quality of care they received from providers, and their own readiness to RTW. Assessing worker satisfaction enables purchasers to understand which MCOs are able to both manage care and satisfy the patients with the quality of care. Measurements of worker satisfaction provide a balance to ensure that MCOs have the incentive to make improvements in aspects of care important to patients, as well as in managing cost and utilization.

Coordination of services: Some injured workers may require a complex array of services ranging from acute care to specialty care to rehabilitation services. Coordination of care can result in reduced delays in care such as tests and procedures, and more rapid return to work. Assisting the patient to navigate this potentially complex system may also improve satisfaction with care. An efficient MCO will ensure that services provided through its network are well coordinated to minimize lost time and maximize recovery.

Communication between employers, providers and injured workers: Successful return to work requires effective communication between provider, employer, insurer and injured worker. Each party must understand the nature of the work, modifications that would be needed to return to work, and expectations for return to work. Good communication between patients and providers is essential to an effective therapeutic relationship; communication between patients, providers, employers and insurers is essential to ensure that RTW goals, activity limitations, and job modifications are established and comprehended by all parties. The MCO should be accountable to ensuring that providers, patients and employers are informed of treatment and RTW goals.

Prevention of re-injuries and subsequent injuries: One frequent and adverse consequence of return to work is occurrence of a re-injury. Re-injuries can be prevented if 1) RTW occurs when the patient is truly ready, 2) the patient and employer have taken steps through education and job modification, to eliminate the initial cause of the injury. MCOs can be held responsible for ensuring that contracted providers educate patients about steps for preventing injuries.