• T M Wickizer, G Franklin, R Plaeger-Brockway, and R D Mootz.
• Department of Health Services, Box 357660, University of Washington, Seattle, WA 98195-7660, USA. tomwick@u.washington.edu
• Milbank Q. 2001 Jan 1;79(1):5-33.

AbstractThis article has summarized research and policy activities undertaken in Washington State over the past several years to identify the key problems that result in poor quality and excessive disability among injured workers, and the types of system and delivery changes that could best address these problems in order to improve the quality of occupational health care provided through the workers' compensation system. Our investigations have consistently pointed to the lack of coordination and integration of occupational health services as having major adverse effects on quality and health outcomes for workers' compensation. The Managed Care Pilot Project, a delivery system intervention, focused on making changes in how care is organized and delivered to injured workers. That project demonstrated robust improvements in disability reduction; however, worker satisfaction suffered. Our current quality improvement initiative, developed through the Occupational Health Services Project, synthesizes what was learned from the MCP and other pilot studies to make delivery system improvements. This initiative seeks to develop provider incentives and clinical management processes that will improve outcomes and reduce the burden of disability on injured workers. Fundamental to this approach are simultaneously preserving workers' right to choose their own physician and maintaining flexibility in the provision of individualized care based on clinical need and progress. The OHS project then will be a "real world" test to determine if aligning provider incentives and giving physicians the tools they need to optimize occupational health delivery can demonstrate sustainable reduction in disability and improvements in patient and employer satisfaction. Critical to the success of this initiative will be our ability to: (1) enhance the occupational health care management skills and expertise of physicians who treat injured workers by establishing community-based Centers of Occupational Health and Education; (2) design feasible methods of monitoring patient outcomes and satisfaction with the centers and with the providers working with them in order to assess their effectiveness and value; (3) establish incentives for improved outcomes and worker and employer satisfaction through formal agreements with the centers and providers; and (4) develop quality indicators for the three targeted conditions (low back sprain, carpal tunnel syndrome, and fractures) that serve as the basis for both quality improvement processes and performance-based contracting. What lessons or insights does our experience offer thus far? The primary lesson is the importance of making effective partnerships and collaborations. Our policy and research activities have benefited significantly from the positive relationship the DLI established with the practice community through the Washington State Medical and Chiropractic Associations and from the DLI's close association with the Healthcare Subcommittee of the Workers' Compensation Advisory Committee. This committee is established by state regulation and serves as a forum for dialogue between the committee and the employer and labor communities. Our experience thus underscores the importance of establishing broad-based support for delivery system innovations. Our research activities have also benefited from the close collaboration between DLI program staff and UW health services researchers. The DLI staff brought important program and policy experience, along with an appreciation of the context and environment within which the research, policy, and R&D activities were conducted. The UW research team brought scientific rigor and methodological expertise to the design and implementation of the research and policy activities. In Washington State, the DLI represents a "single payer" for the purposes of workers' compensation. As discussed earlier, Washington State, along with five other states, has a state-fund system that requires all employers that are not self-insured to purchase workers' compensation insurance through the state fund. No matter what one feels about the merits or drawbacks of a single-payer system of health care financing, the fact is that such a system creates important opportunities for policy initiatives and for research and evaluation. Our ability to access population-based data on injured workers and to develop policy initiatives through innovation and pilot testing to assess whether proposed changes are really improvements has been critical. Understanding what works within the constraints and complexities of the system on a small scale is critical in order to bring forth policy and processes that will be of value systemwide. Finally, we note that general medical care faces many of the same quality-related problems and challenges as occupational health care. Medical care for chronic diseases, such as diabetes, is often fragmented and uncoordinated. (ABSTRACT TRUNCATED)

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