The Future of Value-Based Care in Workers’ Compensation – Part 1

Paradigm − January 9, 2018 − filed under Medical Expertise

Dr. Choo began 2018 with the year’s first Leaders Speak on WorkCompWire. Here’s an excerpt:

The future of the Patient Protection and Affordable Care Act of 2010 is presently uncertain, but our healthcare industry’s steadfast exploration of value-based care models to achieve better outcomes is encouraging.

Although the workers’ compensation industry has always operated independently from mainstream healthcare, issues afflicting the private and government healthcare sectors profoundly impact workers’ compensation.

Similar to Medicare, the workers’ compensation industry’s responsibility for lifetime care creates incentives to facilitate injured workers attaining the best clinical and functional outcomes from any injury, and especially subsequent to catastrophic and/or complex injuries. Taking a longer-term holistic-care approach to recovery care management by measuring and rewarding clinical outcomes, rather than just clinical activities, will improve quality of care and reduce the long tail of lifetime claims costs.

As the Chief Medical Officer of Paradigm Outcomes, I’ve witnessed firsthand how guaranteeing a clinical outcome at a fixed price for catastrophic and complex workers’ compensation claims aligns everyone’s goals to focus on achieving injury recovery and claim management. This value-based care approach essentially is to function as an Accountable Care Organization (ACO) that is proficient in managing our unique population of injured workers with catastrophic and complex injuries.

There are four elements that are crucial to successful value-based care:

  • First, the organization must retool its culture towards a value orientation. Everyone in the system must be injured-worker focused and make decisions based upon achieving the desired clinical outcome. It is not driven by what activity gets reimbursed but rather what helps the injured worker get closer to achieving his/her desired functional outcome.
  • Second, care decisions should be based upon evidence-based medicine with proactive care interventions to avoid medical complications and/or mitigate risk. It’s also about systematically anticipating what and when the injured worker will need specific interventions to achieve the desired clinical outcome faster. This is a much more complex and arduous process than the traditional utilization review process of simply approving or denying requested treatment authorizations.
  • Third, the clinical team of experts must adopt a comprehensive biopsychosocial approach to care and recovery by being diligent about injured workers’ relevant psychosocial behavioral elements. Care managers and providers must go beyond the bio-medical issues in order to achieve the desired clinical outcomes effectively and efficiently.
  • Finally, data analytics capabilities must be robust enough to deliver both clinical and provider performance insights to guide clinical decision making and care facilitation. In addition, a clinical data platform that enables real-time monitoring of clinical outcomes can ensure continuous quality improvement.

Read the entire article here.

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