Acting upon the systemic problems facing injured workers and employers 

The core of the problem is related to how we give care when people are injured, whether it be a work-related or non-work-related issue. Thankfully, the solution lies in the problem: better care will provide better outcomes.
Acting upon the systemic problems facing injured workers and employers 

Work Right NW hosts the Prennovate podcast - a series where experts in academia, industrial health and safety, elite athletics and sports medicine come together to discuss the benefits and impacts of the collision of innovation and prevention. Recently, our CEO at Modus, the doctor Ali Alhimiri was invited by Nic Patee to discuss the problems facing injured workers as a result of incentivized treatment. Listen to the full podcast on Work Right NW.

The systemic problems facing injured workers and corporations

If some medical care is good, then surely more medical care is better, right? Unfortunately, this is not how the system typically works. The rate of use of common medical services across the United States varies markedly, however, measures of health are not better where services are liberally provided. In fact, studies report that in areas where people are receiving more services, the quality measures of health are lower.

There is a constant quest for understanding how to integrate prevention and drive for this mission of maintaining and enhancing patient safety as opposed to applying a “quick fix”. 

In today’s world, physicians around the state are financially incentivized to over-treat a patient. However, more treatment is not always in the best interest of the patient's needs and often leads to worse outcomes. 

Monetary incentivization of overtreatment is being increasingly recognized as a major cause of patient harm and excess cost. The American Institute of Medicine suggested that overprescribing of “unnecessary services” is the largest financial burden to the US healthcare system, accounting for approximately $210 billion of the $750 billion spent in excess each year. The current American healthcare system does not penalize physicians for worse outcomes. Instead, they're only monetarily incentivized to prescribe more treatment. This process has led us on this journey to understand how we can integrate prevention into the payment model that benefits both the patient and the physician. 

So, the question is, how?

Firstly, we need to understand how we can give better care when people are injured, whether it be a work-related or non-work-related issue. Below are some of the most prominent systemic problems faced by injured workers and corporations.

Coercion-based medicine: a break of oath?

Patients, when they're injured or sick experience a lot of anxiety and fear, some of which is rational, and most is irrational. The fear factor is inevitable, as most patients would experience a certain level of anxiety or distress when injured or newly diagnosed with a condition. However, some doctors use fear-based messages when counseling patients regarding certain conditions or injuries. 

How often do doctors say things like  “if you don't do this, you might… have permanent nerve damage, be in a wheelchair, have a stroke, die” etc, you get the gist. Although there is no specific data to justify just how many doctors practise this form of communication, patients report such conversations are relatively common in clinical encounters.

So, finding a doctor who can truthfully advise a patient on realistic treatment options would be ideal, as opposed to doctors who try to sell them on unnecessary procedures and surgeries using fear. People take doctors very seriously as they are very highly regarded in society. Sometimes, some doctors would take advantage of that respect, admiration, and instead, prioritize their own interests instead of their patients. 

Despite decades of research, consensus regarding the dynamics of fear-based communication remains elusive. One meta-analysis on fear-based communication found fear-based messages often communicate threatening tones which only sparks behavior changes in the patient - mostly for the worse. Although some physicians believe that fear-based messages drastically improve a patient’s sense of needing to do better, the drastic change in a patient’s behavior following their newly received information may lead to denial or feeling overwhelmed, thereby potentially leading to a loss of trust in the healthcare system and decreased compliance of treatment.

Barriers to choosing the right doctor

When asking to find a reputable doctor, most people would ask a trusted friend, neighbor, or colleague for a recommendation. Most of the time, they will search for their doctor as they would book their hotel reservation - through a Google search. However, a Google search is not always fair to the doctor. Some patients may be thrilled by the great customer service they have received or the amazing office facility, whereas conversely others are disappointed if they don’t receive a miracle quick-fix. Neither of these types of review really indicate if the doctor is truly aligned to your best interests. The point is, it’s very difficult to know! 

The internet has become an indispensable information medium for health advice and services. A growing number of people are sharing their health experiences online through forums or rate their patient-physician experience on various physician-rating websites. Studies show that on a whole, physician reviews are mostly positive, however, factual reviews lead to a more favorable attitude toward the physician only if a low number of reviews were received. But, there is no transparent or open way to recognise which doctor will help patients more than others. 

“To give you an example, I practice 15 minutes south of Detroit, and I live about 30 minutes north of Detroit. I can tell you the best doctors in musculoskeletal care around where I practice because I've dealt with them over the years. But I have no idea which one to choose where I live and I'm an insider within the industry. So it's very difficult for everyone, even people working within the healthcare service.” Ali Alhimiri, MD

This system not only affects the patient. It becomes complicated for employers as well, causing difficulties deciding which physician or healthcare service to refer their employees to. As Nic Patee pointed out:  “a multi-state multinational corporation that's got 100,000 employees scattered throughout the US would need to understand those marketplaces in every single city. This poses a considerable challenge.”

The negative impact of fee-for-service

The way we pay for health care is “a pain point for everyone” according to Ali Alhimiri, co-founder of Modus. For patients, about a third of bankruptcies are related to medical bills, employers who pay for the care, and the clinicians who take care of these patients on a daily basis. And they have to chase their bills and make sure that they're getting paid and staying in business. The way we pay for healthcare, most commonly, is via a fee for service. So the more doctors and providers will do, the more they get paid. 

A fee-for-service is the most traditional payment model in the healthcare industry which reimburses physicians based on the volume of services they provide. Essentially, this payment system rewards physicians for quantity as opposed to the quality of service. 

In our opinion, a fee-for-service system discourages long term engagement with a patient due to its transactional nature. 

There's no reward for the overall outcome of that patient, instead, physicians are rewarded for their short-term commitments to care. Modus links the outcome of that patient population to the doctors or therapists who are treating them. Essentially, we are creating an incentive for physicians to be fully engaged and making sure that patients are served well. In turn, physicians do better by doing well for their patients. 

The administrative burden on the physicians

Today, this system treats all clinicians the same way. All doctors have to be paid the same way. They all have to abide by the system’s ludicrous administrative process and collect our bills. This creates a lot of frustration. 

Physicians interacting with the US healthcare system will encounter multiple unnecessary administrative complexities - from filling out intake forms, translating medical records, to sorting out insurance billing. Why? To get reimbursed. This, in turn, not only creates a tedious process for physicians to follow but also creates a considerable financial burden on the US healthcare system. 

According to the Center for American Progress, The US spends nearly $500 billion on billing and insurance-related costs. When looking at other countries, such as Canada for example, reports indicate that the US has 44% more administrative staff, and US physicians spend nearly 50% more time on administrative tasks. One study looking at time spent on the electronic health records systems (EHR) estimated that on average, a US physician spends half of their workday on the EHR, including dealing with billing, coding, ordering, and communication.

Opportunities to improve the healthcare system

Escalating healthcare costs and a continually increasing number of insured Americans have highlighted the necessity for quality improvement in the US healthcare system.

Guiding patients to the right doctors 

Finding a doctor that you can trust is really invaluable. It would create a great sense of well being, and mark as a good gesture for employers to find qualified physicians that service their population. 

What patients really need is a thoughtful doctor that has an inkling of doubt. Some doubt is beneficial. A doctor with healthy doubt is a doctor who has thought deeply about the variations of treatments available. We often hear about ‘the benefits outweighing the risks’ when it comes to treatment. And so, that’s where we come in. We’re here to tell you which doctors have continuously followed best practice standards to ensure patients are getting better, not just providing more care regardless of the outcome of their patients.

“Occasionally, you hear a doctor  who would say “ I did this surgery because it's the last resort” -  which makes absolutely no sense because it would be the equivalent of hiring an arsonist to burn down your house for a pest extermination, leaving you homeless, and with a bigger problem than you originally had. So, applying something as a last resort, implies that it would be beneficial - and a lot of times, it's not. The right philosophy should be we're treating someone because we think the benefit outweighs the risk and the harm that comes out of the treatment." Ali Alhimiri, MD

Modus Clinician’s responsible autonomy 

One of the most effective strategies to curtailing this financial drain and poor quality is to adopt a population-based Capitation model. A capitation fee is a healthcare payment system that pays doctors a fixed amount per patient. It can be an effective alternative to fee-for-service in certain situations. The capitation model creates incentives for efficacy, preventative care, and cost control.

One of the key benefits of a capitation system is the decreased costs of overhead and administration for the clinicians. Physicians can bypass the administrative burden as they would not have to wait to be reimbursed for their services, allowing practice to be more focused, productive, and tailored towards better patient care.

However, a capitation system does have flaws of its own, which incentivizes doctors to enroll as many patients as possible, then withhold necessary care that patients need in order to demonstrate lower costs. None of this benefits the patient. If, however, the system were to monitor not just cost, but also patient function, we prevent that from happening. 

And this is where we at Modus intersect. We want to add four keymetrics to the capitative fee to incentivize physicians to provide better care. Currently, physicians acquire a flat monthly rate for each patient they enroll. Providers are reimbursed for every patient admitted within a set time frame, regardless of the quality of care they receive. As such, providers may want to save money by incentivizing physicians to implement less expensive procedures and medications instead of evidence-based, reliable, guideline-recommended alternatives.

Building trust through transparency

We need a system of trust. A system with a trust score that rewards doctors based on their ability to provide reliable and quality care to patients and minimize poor function outcomes and higher expenses. 

With Modus, we promote clinicians’ responsible autonomy by allowing them to prove to themselves that they can build their trust, based on our scoring system. As such, we reward these doctors and show both employers and the public that they are trusted doctors who will prioritize your care over their financial incentives.

Modus: the system to combat the problems

Modus identifies the physicians offering the best quality of care, although not always the cheapest, but will esure their patient’s function improves.

Building a trusting relationship between patients and doctors

Modus built a system that uses publicly available data from Medicare and other organizations as well as employers’ own claim data to categorize care. With the information available we set two separate criteria:

  • Aggressive care
  • Non-aggressive care

Using this model, we can tell what percentage of the population had received aggressive care compared to the rest of their claims. The same process can be applied to providers regardless of their geography. By telling us the state you are in using zip code, we can relay information on the ratings for aggressive versus non-aggressive care to almost all types of musculoskeletal providers, interventional pain management,  surgeons, therapists, physical medicine, and rehab doctors. 

In our way of interpreting data, we can recognise doctors who practice aggressive care - which we define as care that leads to opioid dependency and long term disability - which is often very expensive. We aim to find doctors who provide better care at a competitive rate. We are not looking for the cheapest doctors, but instead, the ones providing the best care.

Focusing on the right quality metrics

Therefore, we here at Modus have devised a system based on trust, grading healthcare providers on their trust score following four key metrics. These are as follows:

  1. Best practice: We assess the ability of the doctor to follow best practice guidelines. 
  2. Patient-reported function: We assess whether or not the patient’s function has reportedly improved following treatment. We do this using a survey.
  3. Patient satisfaction: By taking into account patient satisfaction rates we can assess whether or not a certain physician is actively providing lower levels of care or whether they have had a few anomalies.
  4. Cost: We take into account the costs of certain physicians and compare them with the quality of patient care they provide. Our goal is to provide patients with reliable physicians regardless of their cost, assuming that the quality of care they provide is consistently beneficial.

With the above four metrics, The Modus algorithm will dedicate a single overall rating to any physician or healthcare provider. As a result, clients of Modus benefit from using only the safest, most effective doctors. This benefits their employees or members with better quality care, faster recovery, lower disability rates and reduced opioid dependency - all at lower cost. 

Listen to the full podcast

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