Health System Intervention: Back of the Envelope to Statewide Transformation of Occupational Health Care Delivery

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1 Health System Intervention: Back of the Envelope to Statewide Transformation of Occupational Health Care Delivery 7 th Annual Conference on the Science of Dissemination and Implementation Bethesda, Maryland December 9, 2014 Thomas Wickizer, PHD, MPH College of Public Health Ohio State University 1

on the Science of Dissemination and Implementation Bethesda, Maryland

2 Evaluation and Implementation Team WA State Dep t of Labor and Industries (DLI): Gary Franklin, MD, MPH, Medical Director, DLI and Research Professor University of Washington Robert Mootz, DC, Associate Medical Director, DLI Roy Plaeger-Brockway, MPP, Project Manager, DLI University of Washington: Tom Wickizer, Ph.D., Professor Deborah Fulton-Kehoe, Ph.D, Research Scientist Terri Smith-Weller, RN, COHN, Research Coordinator Jeremy Gluck, Ph.D, Research Scientist 2

Plaeger-Brockway, MPP, Project Manager, DLI University of Washington: Tom Wickizer, Ph.D., Professor Deborah Fulton-Kehoe, Ph.

3 Presentation Topics Topics: Project context of workers compensation (WC): Highly adversarial environment: business vs. labor Poor quality and outcomes Poor satisfaction Pilot design and implementation strategy Pilot evaluation methods and findings State law and institutionalization of pilot Lessons learned regarding implementation of intervention Take Home Point: Successful dissemination and implementation will be fostered by: Strong executive leadership Meaningful organizational learning Ongoing strong stakeholder involvement and support Identification of principles to guide the implementation effort Good science for implementation and evaluation 3

of pilot Lessons learned regarding implementation of intervention Take Home Point: Successful dissemination and implementation will be fostered by: Strong executive

4 Washington State Workers Compensation WA State WC is organized as a state fund system administered by Dep t of Labor & Industries (DLI) All employers who don t self-insure must, by law, purchase WC insurance through DLI Thus DLI is the single payer for WC health care DLI insures 2/3 of the non-federal workforce in WA 4

t self-insure must, by law, purchase WC insurance through DLI Thus DLI is the

5 Bad News WC Disability Prevention: Good News Bad News Workers who remain on disability for longer than 2-3 months have greatly reduced chance of returning to work Good News Effective occupational health care can reduce the likelihood of long-term disability 5

reduced chance of returning to work Good News Effective

6 Changes in Disability Status among Injured Workers in WA State 100 % Workers Receiving Disability Payments Early Intervention Period Time Loss Duration (months) 6

Payments 80 60 40 Early Intervention Period 20 0 0

7 DLI Managed Care Pilot Cost Findings (n=2,217) Cost per claim $900 $748 $750 $600 $450 $300 $150 $587 $342 $625 Key Finding $0 Medical Cost Managed Care Disability Costs FFS Cheadle, Wickizer, Franklin et al. Medical Care

Key Finding $0 Medical Cost Managed Care Disability Costs

8 Beginning Organizational Learning and Policy Study DLI executive management embraced findings of managed care pilot evaluation Working closely with stakeholder business-labor group, Wickizer and team conduct 18-month policy study to assess feasibility of designing a quality improvement (QI) initiative Policy report adopted and sets forth key principles for QI initiative: Increased provider accountability Improved worker and employer satisfaction Improved outcomes, with key outcome defined as reduced work disability 8

designing a quality improvement (QI) initiative Policy report adopted and sets forth key principles for QI initiative: Increased

9 Occupational Health Services (OHS) Quality Improvement Intervention 9

10 OHS Project WA State OHS Project initiated in 1998: To improve quality and outcomes of occupational health care To enhance patient and employer satisfaction OHS is not managed care No restrictions placed on provider choice 10

To enhance patient and employer satisfaction OHS is not

11 System Redesign through OHS Four quality indicators, representing an occupational best practice, linked to physician payment incentives Each time a physician performed a best practice he/she received added payment Community-based pilot centers for occupational health and education (COHEs) Quality improvement (QI) activities: Care coordination Mentoring and CME for community MDs Disseminate treatment guidelines and best practices information See Wickizer et al. Milbank Quarterly 2001 &

occupational health and education (COHEs) Quality improvement (QI) activities: Care coordination Mentoring and CME for

12 OHS-COHE Organization Dep t of Labor & Industries UW Research Team Pilot Community COHE Business/Labor Advisory Group Community Physicians 12

13 Location of COHE Pilot Sites Renton Spokane 13

14 Intervention Components Quality Improvement Component Structural Change Components Physician Continuing Medical Education (CME) Health Services Coordinators Information technology Quality Improvement Objective Enhance physician knowledge and training in treating occupational injuries Improve care coordination Improve communication with employers to promote return to work Reduce provider administrative burden Improve patient tracking Financial Incentive Component Enhanced provider payment Promote best practices - Submission of accident report - Use of activity prescription form - Communication with employer - RTW impediments assessment 14

communication with employers to promote return to work Reduce provider administrative burden Improve patient tracking Financial Incentive Component Enhanced

15 OHS Evaluation 15

16 Intervention & Comparison Groups Renton Intervention Group 26,367 10,725 Comparison Group 45,772 Spokane Intervention Group 24,222 Comparison Group 9,245 Comparison-group: all cases treated by MDs in COHE target area not participating in pilot. 16

Group 24,222 Comparison Group 9,245 Comparison-group: all

17 Outcome and Covariate Measures Outcomes assessed: Off work on disability at one year post injury Total disability days Disability and medical costs Covariates Age Gender Type of injury Provider specialty Industry Provider claim volume 17

Disability and medical costs Covariates Age Gender Type of

18 Evaluation Findings 18

19 Measure Statistical Results All Cases Statistical (Marginal) Estimates Back Sprain Cases High Adopter vs. Lower Adopter Cases On disability at 1 year (OR).79 *.63 *.63 * Disability days days * days * days * Disability costs - $267 * - $542 * - $384 * Medical costs - $145 - $191 - $372 * P <.01 ROI > 3:1 See Wickizer et al. Medical Care December

63 * Disability days - 3.3 days * - 8.1 days * - 6.

20 Passage of State Law Expanding COHE on a Permanent Statewide Basis In March 2011, WA State Governor signed a law expanding COHE on a permanent statewide basis Key factors underlying passage of the law: Good science underlying evaluation results Strong bipartisan support from business and labor stakeholder groups 20

basis Key factors underlying passage of the law: Good science underlying

21 Summary and Concluding Points Passage of legislation institutionalizing the DLI QI initiative on a permanent statewide basis represents a highly successful dissemination-implementation effort Keys to success were: Strong ongoing stakeholder support from business and labor DLI organizational learning that occurred over time in support of pilot work and innovation Presence of an idea champion in the form of the DLI Medical Director Good evaluation science that produced credible results the legislature could act on 21

22 Summary and Concluding Points (2) Currently COHEs are delivering care in 38 of 39 WA counties By July 2015, 3,500 physicians will be treating 50,000 COHE patients annually Further analysis will document the effects of this expansion Thank You! Thomas Wickizer, PhD 22

Workers Compensation - A Summary of the Quality and Performance Problem in Washington State

Workers Compensation - A Summary of the Quality and Performance Problem in Washington State Reducing Worker Disability and Improving Quality in Washington State Workers Compensation: Evaluation Findings and Lessons Nachemson Memorial Lecture Institute for Work and Health Toronto, October 22,