Workers' Compensation & Managed Care

Evaluating Initiatives

In order to determine the success of a workers' compensation managed care program, it is critical to design an appropriate evaluation strategy.

Dr. David Michaels provided a conceptual framework for how to design a complete workers' compensation evaluation strategy. He discussed the following aspects of a workers' compensation managed care initiative that might be studied:

• Structure (e.g., qualifications of the provider and prevention teams; quality assurance programs; appropriate referral networks).
• Process (e.g., timely and appropriate care; quality of information; injury prevention).
• Outcomes (e.g., costs—medical, wage loss, administrative, legal; return to work; function; duration of disability; satisfaction).

Dr. Michaels described how such evaluations normally involve the comparison of a "treatment" group (i.e., the population being exposed to the initiative) and a "control" group, emphasizing the need to adequately account for differences between the groups with respect to personal characteristics (e.g., injury type, age, gender, and pre-injury wages), place (employer size, disability policies, insurance carrier characteristics, and regional differences), and history/time.

Dr. Gerald Kominski discussed the State of California's 24-hour coverage pilot and some of the challenges that he and his team have faced in evaluating the pilot. This pilot was conceived as a way to address problems due to overlaps and gaps in coverage and used the evaluation parameters of costs, including medical, disability, and non-work costs and outcomes, including return-to-work time, functional status, litigation, vocational rehabilitation, and employee satisfaction. The State used claimant, employer, and enrollment surveys as their evaluation tools.

Some of the evaluation difficulties encountered were:

• Limited access to claims data.
• Difficulty in getting in touch with claimants to survey their satisfaction due to employer resistance.
• Problems analyzing data due to the fact that most of the enrollment was in one managed care organization that did not maintain the same type of data for their occupational and group health programs.
• The setting of unrealistic time lines.
• Difficulties determining what aspects of the State's intervention resulted in cost savings.
• Problems finding and recruiting employers to participate in control groups.

Reference

Donabedian A. The Quality of Care and How It Can Be Assessed. Journal of the American Medical Association 1988;260(12):1743-8.

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