Global and Longitudinal Outcomes

Posted by Albert Holt, MD on January 19, 2011 under General, Systematic Care Management | Read the First Comment

Welcome to Outlook on Outcomes.  As Chief Medical Officer, my goal for this blog is to provide current information and perspective on health care with a specific focus on catastrophic care and chronic pain.  To start that process, I would like you to consider health outcomes from a global and longitudinal perspective.

The model of care for workers’ compensation revolves around the idea that carriers “own” the costs of medical care associated with the specific workplace injury and its sequelae for the lifetime of the worker.  In other words, they have both global and longitudinal responsibility for the costs for delivery of care.  In comparison, group health carriers “own” the cost of medical care only for the term of the coverage or policy, which typically lasts for one year.  So, while they have global responsibility, it is for a limited time horizon.  Understanding the lifetime responsibility of workers’ compensation carriers will help to understand why the ultimate outcome is important to both the injured worker and the carrier.

Dr. Nathan Cope, who founded Paradigm 20 years ago after many years working with catastrophically injured workers, developed a program that focused on how to eliminate the challenges and barriers to getting injured workers the best outcome from their injury.  He understood that workers’ compensation had this unique lifetime responsibility and perceived the need for a better approach to getting superior outcomes through efficient and effective care.  He also recognized that there are many variables which account for the variation in care received: demographic and clinical variables of the individual, utilization characteristics of the system and providers (overuse, underuse, misuse and abuse of resources), as well as medical cost variation based upon geography, local laws and practice patterns, and availability of services.

Dr. Cope took the opportunity to create a systematic approach of assessment, intervention and expert clinical oversight to get injured workers prompt, efficient and effective health care that had as its goal the best possible clinical outcome.  In other words, he asked, “What was the best outcome that could be achieved by planning and coordinating resources appropriately?”  His idea was that this comprehensive approach would get better clinical outcomes and reduce wasteful spending.  Since that time, the approach has been validated in spinal cord, traumatic brain, burn and complex traumatic injured workers and their ability to return to function and work.

There are several reasons that this approach works well.  First, workers’ compensation carriers view the injury from time of loss until final resolution of outcome.  In other words, instead of looking at the injured worker in a 12-month period like a group health patient, workers’ compensation carriers have responsibility to see the injured worker through to the final resolution of injury.  Second, everyone wins if the injured worker gets the best clinical recovery and returns to work—the injured worker, the employer and the insurance carrier.  The better the recovery that is achieved, the more able the worker is to return to a productive life and the less financial cost of care for the carrier (as a result of the reduction in future ongoing care needs due to the recovery).

To get there, one has to maintain a longitudinal focus on care with an eye toward how each element of treatment impacts that final goal of the best possible outcome.  The approach includes the acute care, rehabilitation care and subsequent long-term care that may be required.  Dr. Cope’s approach to these high complexity, catastrophic cases is to conduct detailed clinical assessments supported by comprehensive, expert-led clinical plans that weigh how the individual components of care factor into the final outcomes.  Obviously, not every injured person needs the intensity of resources that Paradigm provides its catastrophically injured workers.  Collectively, the medical expertise exists in our healthcare system to facilitate planning for injured workers, or anyone, and simply needs to be applied. 

As we look at health care for the future, wouldn’t it be interesting to consider a global and longitudinal approach to providing health care for each individual?  Shouldn’t we strive to understand how the choices along the way impact the final outcome at the end of a long life?  How can we account for those choices in a meaningful way so as to encourage the propensity to achieve the best outcomes in our own health?