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MCNTalk: Introduction and Issues

MCN Celebrates Its 30th Anniversary

Members of our MCN-Northeast staff enjoy a 30th anniversary dinner and painting outing!

Members of our MCN-Northeast team enjoy a 30th anniversary dinner and painting outing!

Saturday April 18th  2015 is MCN’s 30th anniversary. It was on that date in 1985 when MCN completed its first evaluation.

From this first IME, MCN grew to become the first (in 1997) IME/peer review company with a national network, and now staffs 25 offices across the country serving hundreds of clients. In 2014 MCN delivered more than 60,000 individual services. Our network of consulting physicians now encompasses over 25,000 options in all specialties across the nation – and is continuously growing.

We are proud of our contributions to society and our communities in addressing the critical questions and challenges of disability and injury and helping to ensure appropriate care for the thousands of individuals whose claims we review and evaluate.

Over the weekend I came across two newspaper articles addressing the very core of why we do what we do. The first was a column by David Brooks entitled “The Moral Bucket List” which includes a brief reference to the Triangle Fire Factory. In response to the fire, one of the worst industrial incidents in American history, New York State established both the State Insurance Fund and the New York Workmen’s [sic] Compensation Law. These acts had ripple effects across the nation and soon many other states enacted such legislation.

The second article was “When Moneyball Meets Medicine” with the follow-up “Disability and Health Care: Calculating How Much a Life Is Worth.”  This is what we help our clients do: each report we produce is a snapshot of a life, a medical history, a course of treatment, a time when a numeric value is placed upon people. Each report we produce helps facilitate a decision that profoundly affects the injured or disabled person’s life and their ability to care for themselves.

Of course most of our days are spent in activities which seem far less profound than all this, and this is reasonable; we would end up paralyzed ourselves if we were so focused on circumstances of the individual lives whose stories cross our desks every day.

This 30-year mark gives us the opportunity to remember the larger picture of what we do and why it matters. As the founder of MCN and as an employer I am proud to have this opportunity to be of service to our society, clients and claimants.  Thank you to all of our clients who trust us with their work, and to our consultants who collaborate with us in our shared tasks.

Most importantly, we thank all the MCN staff across the country whose dedication keeps us going – as well as all of our past employees who over the decades have helped make the company a sustaining and growing organization.

Brian L. Grant MD, President and Founder

MCN's birthday arty includes a some cake!

MCN Achieves Remarkable Performance Metrics for our Clients

LoginScreen-1-rasterizedFrom time to time we wish to update our clients and consultants on company progress and activities. As always we thank our valued clients, for trusting us with your examination and review needs. We also thank our staff nationwide as well as our physician/consultants for their great work in support of MCN. Our staff and managers have worked hard to achieve many notable results, some of which we will share in this report.

The period 2013-2014 has been and continues to be a remarkable one for MCN as we continue to set the standard within the industry for technological and performance advancements. While not the oldest in our space (MCN was founded in 1985) MCN was the first company in the medical assessment field to develop a web presence – thus the valued 3-letter url mcn.com – the first to pioneer online ordering and access, and the first national network, moving from a regional to national presence in 1997. Achievements reached in 2013-2014 include the following:

  • In the second half of 2013 the company released a new information management system after about two years of development. This system is internally called Cadence, and replaced the original system called Andante that we deployed in 2000 (we enjoy musical terms). Cadence is a robust program that contains, in a secure environment, all data pertaining to our work. This includes individual claim files, claimant information, and client tracking as well as physician/consultant information such as credentials and report delivery statistics.
  • MCN has continued to enhance our client portal, a platform where clients may order services, access select information in real-time, and complete functions such as uploading and retrieving files and receiving case status updates.
  • In the coming weeks we are launching an updated provider portal, following strenuous testing and development. This portal allows physician/consultants access to their files for retrieving and reviewing records, editing and uploading reports, and performing other important functions.
  • We are undergoing a security certification process and will receive our SSAE-16 SOC1 certification later this summer.
  • All of our data is maintained at the highest level of security using secure socket layer (https) for data in motion and 256 bit AES (Advanced Encryption Standard) for data at rest.
  • We have significantly grown our URAC-accredited Independent Review Organization (IRO) division, providing peer reviews for healthcare claims for some of the largest carriers in the nation. This team processes evidence-based reports that address medical necessity and appropriateness of treatments or services.
  • We have grown our physician recruiting development department to maintain our status of having a large, comprehensive and national physician network credentialed to the highest standards.

We have a fine group of managers overseeing operations, client service, information systems, human resources, and sales and account management. We are proud of our team, especially the great bench of talent residing at MCN which has allowed us to source most new leaders internally with promotions to their new roles.

We are proud of a number of data points and gains flowing from an initiative started in earnest in the first quarter of 2014. We have challenged many assumptions present in our marketplace that make little sense in the larger scheme of health care. Primary among these initiatives was a decision to more strongly engage our suppliers (our consultant physicians) in being responsible for holding up their end of quality in terms of fully addressing all aspects of their evaluation assignments and being timely in their report delivery.

As a company designed around medical services and led by a physician, we found ourselves asking why the industry that we are in has tended to not expect the best from consultants, instead regularly relying upon inspection and correction by non-clinical staff after the report is provided by a consultant to address any concerns and to achieve quality. Medical training and practice does not include a non-clinician shadowing and correcting doctor errors. Why in the medical review business did this become the norm? Rather, in the world of most health care services, it is expected that doctors are accountable for their work product. Prior to our changes, we relied upon inspection and correction, leading to rework that was often not to up to our standards, and often led to delays in report issuance with the back and forth processes that were required before the report was acceptable. We have been heartened by the results of setting clear standards to consultants. Our consultants by and large welcomed respect and accountability that this involves, and the ability to deliver the quality that they have been trained in and practice in the course of their clinical work.

While our turnaround times have always been competitive with the work of our peers, as a result of these efforts to-date this year we’ve experienced more than a 30% reduction in total turn-around time from date of examination to delivery of report. We have also seen a sizable reduction in rework and clarifications that contribute to this reduced time.

Our new focus embraces modern quality concepts common to hospital initiatives and general business trends. These are often given names like TQM (Total Quality Management), ISO 9000, Six Sigma, and others. All these include a variety of principles including the importance of root cause analysis, continuous improvement, and supplier/contractor engagement and accountability. One basic truism of achieving quality is that it can’t be achieved by inspection and correction – rather, it requires that quality is built in the entire system and involves the engagement of all stakeholders. In our case this means MCN’s clients, consultants, and staff.

We prepared for these changes by sharing the concepts with consultants and staff, redoubling our efforts in orientation and credentialing, and providing clear and concise documentation along with examination files. We communicated the responsibility for consultants to be accountable for producing a finished product within required time parameters, and personally proofing for content and syntax before allowing their signature to be affixed.

Many consultants have expressed support and appreciation of our joint efforts on quality. MCN staff are pleased to be part of this improvement effort as they see the improved impact of their work with less need to engage in frustrating rework, clarifications, or calling on late reports. We are very appreciative of all who have participated in this significant cultural and process change, which is ongoing.

Importantly, the clients’ experience is being positively impacted and is supported by their own data and audits.

One client, a national carrier, provided us first quarter data that demonstrated:

  •  MCN’s average turnaround time is 9.8 days with the contracted time of 15 days being met 92% of the time. Their other vendors have an average turnaround time of 13 days with 81% within specifications.
  • In addition to our superior turnaround, MCN had an exception rate of 3% vs. 20% among competitors serving this client. Exceptions include meeting turnaround specifications as well as 25 other measures including clinical metrics.

It is common to tout one’s processes and attributes but what really matters is how it is experienced by clients. The difference is being experienced and is a source of delight by those who order our services, and one of great pride for the great staff and consultants who are working together to achieve these meaningful results. Our clients are noticing with growth in referrals, and the awarding and renewals of a number of significant and prestigious contracts with global, national and regional companies.

From all of us at MCN, both staff and consultants, we thank our valued clients for their support and business as we work hard to innovate and excel in our field.

Trends with Benefits: The Growth of Federal Disability Benefits in the U.S.

One of MCN’s favorite radio programs is “This American Life” from National Public Radio. The March 22, 2013 show, “Trends With Benefits,” was on the massive growth in federal disability benefits in the U.S. Much of this is no surprise to those of us who work in the sector. To quote their blurb:

“The number of Americans receiving federal disability payments has nearly doubled over the last 15 years. There are towns and counties around the nation where almost 1/4 of adults are on disability. Planet Money‘s Chana Joffe-Walt spent 6 months exploring the disability program, and emerges with a story of the U.S. economy quite different than the one we’ve been hearing.”

Well worth a listen. This American Life: Trends With Benefits

And additional information in available from the author on the web at:

http://apps.npr.org/unfit-for-work/

Should Sperm Donors Have to Pay Child Support?

When should the biological father be held financially accountable for a child born from his sperm?

A recent Kansas case demonstrates the collision of the imposition of a medical standard on a decidedly non-medical act.

A number of issues arise in reproduction — individual rights to control their own bodies and reproduce as they see fit, society’s right to ensure financial accountability for children when the custodial parent can’t or won’t provide adequately, the child’s right to adequate care, and the mother’s right to seek child support from the “father” of her child.

There is nothing high tech about sperm donation, but we do face many complex scenarios in cases of assisted reproduction via In Vitro Fertilization using donor eggs and other variations on the old fashioned way of getting pregnant.

Sometimes the situation flows from a simple belief on the part of man and woman who procreate with no intention of having an ongoing relationship who make a verbal agreement that the father will not be responsible for the resulting child, believing the agreement will hold.

I am not aware of a situation where the mother gives up the child to the father with a similar understanding of lack of subsequent responsibility, but could see it happening. People can and do change their minds, especially when the economic burden of raising a child is no longer an abstraction.

Legal adoption appears to be the only situation where one can reasonably and consistently assume that one’s responsibility as father or mother for their child given up, is safe, across all jurisdictions.

In other situations, as the case above, it appears to be “donor beware.” Mothers and the state routinely may seek child support from a father regardless of any prior understanding and, apparently, even with a written contract.

To the degree that the interests of the child, who is not a party to such contracts, bear weight, this may be understandable, if not wise.

Any man asked to help a woman get pregnant who does not want to be psychologically or economically responsible for his offspring would do well to either say no, or seek legal advice in his state.

The father in this case may pay dearly for his ignorance, despite his good intentions.

Now With the Elections Over, We Can Focus on Health Care – A View from the Trenches

By Brian L. Grant, MD

Pundits are debating the meaning of the recent election results. I believe that to some degree the election is a mandate to continue to address our out-of-control health care system and an endorsement by the  electorate to continue to develop and deploy the Affordable Care Act – aka ObamaCare.

Coming at health care as a physician, patient, employer, taxpayer and medical director of a company whose business it is to review medical claims for appropriateness of treatment and utilization – I believe I have both skin in the game and a deep perspective on the problems we face.

Long ago during residency, during my medical rotation, I concluded that so much of care was of little value in providing quality or quantity of life to those whose days were numbered. Those providing the treatment were unable or unwilling to ask the tough questions that would limit care in hopeless situations. Governed by good intentions, physicians were and still are largely expected to treat with little moderation. This decision is supported by the economic rewards of treatment, encouragement by the hospitals they work in, and a fear that denying treatment or moderating the testing provided might expose them to litigation.

I wondered how many people would choose the care received if the system were somehow different, such as their paying directly for care of having the money available for some other use. I continue to ask this question today, while recognizing that many would abuse this choice, denying necessary preventive care to themselves or their children if given the option of diverting their health care spending to another cause.

But absent external controls on utilization and consumption – overuse and unnecessary care is common, and according to some, represents some 750 billion dollars annually, or about 25% of our health spend! This would suggest that we stand to gain far more from curbing spending and utilization than we do from discounting it.

And since patients and their families are largely shielded via insurance from the economic impact of treatment, they lack interest or incentive in invoking the economic self-interest that governs all of us in our non-medical personal spending behaviors, when we are not spending directly for our care.

Third party payments also mean that the costs of treatment are not responsive to competition, since everything is expected to be paid for at whatever price may be charged. Third party surrogates including insurance carriers, bill reviewers, and companies such as MCN whose work aims to control excessive and unnecessary costs are attacked by stakeholders including patients, providers, drug manufacturers, device manufacturers and hospitals when limits or denials are suggested or imposed.

As an employer, I have experienced annual increases well into the double digits in proposed premiums for our staff, only curbed by increasing co-payments, deductibles and some of the premium increases to the employees. This means less income for staff as their personal health spend increases – a trend common across the economy. The rate of increase has appeared to curb a bit over the past two years, perhaps in response to the reforms underway that improve the structure of the system by spreading risks to a wider population of insured individuals.

I grudgingly accept the need to provide coverage for employees, all the while wondering why this is the case. Staff do not receive company-paid housing, food or education; they get a paycheck to pay for some, and we all pay taxes to pay for other universal needs such as education. Why is healthcare a unique outlier by being tied to employment? How do we as a society rationally defend employer-based health-care given the outcome? The consequences are well-known.

They include most notably the lack of paid insurance for dependents and spouses under most employer plans,  total lack of coverage for many working people whose jobs don’t provide coverage, the unemployed, students, and those who are self-employed and either can’t afford care or choose to gamble by not buying coverage. Since hospitals do not turn away patients needing emergency care, those without coverage are either forced into economically dire straits if they have any money left over to pay, or the rest of us pay for their care via cost-shifting by these institutions to those who can and do pay. This results in higher premiums for those with insurance and the employers paying for them.

In a nation that extols the virtues of small business and entrepreneurs, how many men and women who might take the risk to strike out on their own are deterred from doing so because they can’t afford the high cost of individual health care, especially if they or a member of their family has preexisting risk that makes insurance unavailable or unaffordable. One would think that those who claim to champion a creative economy would insist upon health care being available and affordable to all. Yet by and large this was and is not the case.

As a patient and physician, I have had the opportunity to consume and provide care and see hospital bills that were extraordinary in their complexity and impenetrability, including excesses in line item charges, and inclusion of items that were not necessary in a particular case but dispensed to all patients admitted as standing orders. If you have the occasion to be hospitalized, call and ask for the multi-page actual bill submitted to your carrier rather than the several line summary they send you describing what was billed, what was paid, what was discounted and what you owe as a balance. It will be an eye-opener!

As a taxpayer I am aware of the massive multi-trillion dollar size of the US system, representing about 18% of our GDP or around a third more than those of other industrialized nations that have better public health metrics including infant mortality and life-spans. This excess spending decreases our national productivity and imposes burdens on all, and riches on a few.

Reasonable people can and should debate the details and the specifics; but like defense spending, entitlements and other massive expenses – health-care should be debated and addressed with data, not ideology! Those who believe that continuing the system with minor alterations are advocating the structural equivalent to putting lipstick on a pig. Concluding that this will somehow lead to meaningful change is either naive or willfully deceptive.

I struggle with the concept of personal freedom vs. personal responsibility, the role of government and who should pay for choices. Others do as well. Thus the debates on public health and safety, lifestyles, chronic illness and self-determined behaviors and how much the government should regulate what we do, how we consume and who should pay for these choices. Many entries in MCNTalk have addressed these topics that include obesity, tobacco, vaccinations, and those who question if and how these should be regulated and who should pay. Again one can debate the details and the ideology, but we can’t escape the expensive outcomes for individuals and society.

Democracy is a participatory sport in a game with real consequences for all. We wish our legislators well, thank them for their service and will be there loudly exercising our freedom along with them in the coming years.

This Company & Family Failed the New York Times Test

By Brian L. Grant MD

The recent fungal meningitis outbreak traced to a Massachusetts-based compound pharmacy is tragic for the many current and potential victims. And it was entirely preventable based upon the reports of major manufacturing breaches.

The New York Times article, “Spotlight Put on Founders of Drug Firm in Outbreak,” illustrates how a company and their family failed the New York Times test.

Years ago I learned the concept of the “New York Times Test”. This imaginary test refers to the importance in business and life of upholding standards of behavior and avoiding adverse actions that might cause one to end up on the cover of that venerable journal.

In other words, when considering an action or omission, one might ask themselves how they would feel if the action or outcome of one’s decision were to land on the cover of the Times. Would one be proud, or running for cover under a cloud of shame and perhaps liability.

This outbreak appears from public accounts to be a failure of leadership by the owners of the company, and a culture internally where good men and women were either unaware of the breach, or if aware (which I suspect must have been the case for at least some), chose to do nothing.

Errors of this magnitude appear systemic and not accidental. And in drug manufacturing and other mission critical endeavors where lives are at stake when there are errors, the results may not be recoverable. One can’t help but wonder what logic permitted these errors and omissions to be practiced.

More facts will undoubtedly develop with future investigations and litigation. And more than one business school lesson will flow from these events.

In the past we at MCN have confronted value breaches in our own industry. These include inconceivably brief exams and routine unnecessary ordering of imaging and other actions that may be expedient and profitable but uncalled for.These and similar acts dishonor the integrity of medicine and the patients who are compelled to attend such examinations.

To our dismay, such behaviors continue in certain settings, lowering the bar of quality and integrity for those involved, and provide cover for those who wish to criticize our industry as a whole.

We at MCN have pledged to not knowingly engage in such actions, call them out when we see them, and walk away from opportunities to follow along. We think it is long overdue for those in health services to remember and hew to their honorable medical roots. A decent living will follow.

It is much easier to act in a way where their integrity is not sacrificed. While short-term profits may take a hit by saying no to short-cuts and actions that don’t reflect the highest values, living and acting based upon such values drives long-term profits, satisfied clients, employees, and shareholders.

Behaving ethically should not be extraordinary or heroic. It should be expected and normal.

Several days on the blog – progress report and request

556 hits since starting, and a relatively small number of subscribers. Have realized that many filters block blogs at work, so for those who can’t access it at work or don’t have the time, they might want to subscribe or access the blog from their personal email.

Two requests – please consider subscribing, which will mean getting notice of new messages, which one can schedule daily, weekly or whenever there is a post.

And please consider commenting on something posted that you have reaction to. Don’t be shy. Get the conversation going.

Welcome to MCNtalk – a discussion group for you

MCNtalk, which has existed for many years as an email broadcast, is being converted into a blog. Advantages include the ability for prior articles to be stored, indexed and accessed by readers, as well as a robust ability to include many features and full user control of how or if they receive notifications of new postings or comments.

In addition, this blog will be readily available on the web for subscribers and non-subscribers alike.

It is a work in progress and we hope to add many enhancements over time.

The address is http://www.mcntalk.com

Your comments and ideas are welcome as well as requests to add a particular site or blog to the featured list. We also welcome links to articles of interest, or even your own idea pieces.

Our goal is to present articles of interest and potential relevance to those who deal with medical issues in claims management, disability, injury and related legal and administrative issues, as well as those who have a general interest in health-care issues. I am linking to blogs that focus on health care politics but we will do our best to steer clear of partisan and acutely political matters. We recognize that our readership is diverse and that there is no shortage of good sources for thoughtful comments, reflections and positions on current political issues.

This does not mean that the occasional article will not be controversial, and we welcome divergent comments. Inclusion of a particular article does not necessarily imply agreement with the stated position by MCN or it’s staff.

The original MCNTalk email list will be used for periodic reminders about the blog and recent articles. But we encourage direct subscription via the button on the upper left, which will provide immediate notice of new postings. You may change your subscription preferences or unsubscribe at any time.

We welcome comments but they should be signed, courteous and relevant to the posting. We will tread gently into the world of comments and initially screen them before posting, perhaps opening them up to non-screened postings for repeat commentators or all.

If you have ideas or thoughts about making MCNTalk more effective and relevant – send them to us at MCNTalk@mcn.com.

Thank you.

Brian L. Grant, MD
Chairman and Medical Director