Catastrophic injuries, medically complex cases and chronic pain remain difficult challenges for all stakeholders in the workers’ compensation industry. To achieve greater results, the injured workers in these situations require care from those proficient in specialized skillsets and capabilities that extend beyond what is acceptable for more common, straightforward injuries.
In Part 1, I discussed value-based care and how it can be applied in Workers’ Compensation. Now, I’d like to specifically address value-based care in complex and catastrophic workplace injuries and how such a systematic approach can deliver better clinical outcomes at a lower lifetime cost.
What Drives the Cost and Volatility in Complex Injuries?
Catastrophic and medically complex injuries are inherently very complicated with a high degree of medical instability during the acute or early phase of injury management. Additionally, there is a strong association with an expansive list of medical and surgical complications that occur in post-acute periods, which can significantly confound the recovery and medical costs associated with these injuries. Even more vexing is the harsh reality that many catastrophic injuries result in some level of permanent residual impairments, leading to unexpected and distressful adjustments to one’s body image and/or self-image.
Ultimately, the extent of medical problems, complications, and changes in psychosocial aspects that occur throughout the care continuum drive the high levels of volatility and costs associated with these injuries. Furthermore, and not surprisingly, due to the high level of medical volatility, the long-term financial exposure from medical costs is currently much higher than the indemnity cost, and continues to grow.
How Can an ACO Approach Manage Cost and Volatility?
A value-based care approach, essentially functioning as an Accountable Care Organization (ACO), requires a system of effective communication, collaboration, clinical expertise, and innovation that integrates evidence-based medicine, robust data analytics, and a culture of continuous quality improvement.
Consultative medical specialists with extensive knowledge and subject-matter proficiency related to the precise diagnosis are essential to catastrophic injury care management. The medical specialists must have not just literature-associated knowledge, but also significant clinical insights gleaned through years of experience specific to given diagnosis, treatment, medical complications, and recovery trajectory. Furthermore, it is important to have medical specialists who embrace the principles of functional restoration and an outcomes-oriented injury recovery process.
As previously noted, the complexity of catastrophic injuries mandates careful attention to biomedical issues as well as psychosocial factors. Better results come from giving attention to each of the three components for a strong recovery: biomedical, psychological, and social factors. This can be likened to a three-legged stool, which will fall over without legs of equal length. This biopsychosocial model for recovery is easier said than done; it requires clinical providers to be proficient and experienced in this methodology.
Robust Data Analytics
A crucial piece of the puzzle that can powerfully support and augment the effectiveness of care management teams is access to insightful and actionable data specific to catastrophic injuries. To mitigate and manage the high medical volatility and uncertainty, clinical analytic capabilities can guide the proactive delivery of helpful resources to the appropriate group of individuals at a crucial time, achieving lower rates of complications and better outcomes.
Examples of clinical outcomes-driven analytics for catastrophic injury conditions:
- Frequency benchmarks of common and high-impact medical problems associated with these conditions
- Short-term and long-term consequences of treatment decisions and care-management decisions related to given injury conditions
- Clinical milestones and timelines typically required in order to achieve specific long-term outcomes
- Identification of specific clinical, confounding risk factors with high-impact potential and early risk-stratification decision tools for proactive interventions and care planning (e.g., psychosocial-behavioral risks, obesity/Body Mass Index risks, etc.).
Such outcomes-driven analytics with actionable benchmarks and decision-making support tools are essential to support clinical providers in effectively managing the challenges innate to catastrophic injuries. In addition, deep experience and actionable data speak volumes with clinical providers, especially when it comes to guiding clinical options, medical treatments, and care plans.
Outcomes and Accountability Driven Culture
The final requirement for managing volatility and uncertainty of catastrophic injuries is the appropriate mindset of the clinical teams involved. To obtain consistent achievement of effective outcomes, the care-management organization and its clinical members must possess and demonstrate a strong culture of accountability and reliability to drive actions and plans to help prevent risks, errors, and problems from occurring and/or their recurrence. The alignment of every stakeholder in the organization to the purpose of achieving effective functional outcomes contributes to successful care management.
What Do You Mean by Effective Functional Outcomes?
Being functional-outcome driven allows alignment of incentives across the care continuum rather than the ineffective transactional processes inherent in PPOs, utilization review, and other managed-care cost savers, which are exacerbated by the current fragmented healthcare delivery system.
By proactively addressing and preventing failures in care delivery, failures of and/or lack of care coordination, and the waste associated with over-treatment and under-treatment, a focus on functional outcomes not only improves clinical results but also significantly reduces the inefficiencies inherent in our healthcare system.
Similar to an ACO, a value-based care approach allows problem management, mitigation of clinical risks, and avoidance of medical complications to guarantee clinical outcomes for catastrophic injury cases, resulting in highly satisfied patients, providers, and medical cost savings over time.
Paying all medical expenses until the outcome is achieved reduces uncertainty for payers, enabling the clinical team to focus on the most effective treatment plan for the injured worker, rather than individual medical costs and volume of services. Ultimately, everyone benefits from the best outcomes.
About Dr. Michael Choo
Michael Choo, Paradigm Outcomes chief medical officer and senior vice president, maintains Paradigm’s relationships with network of physicians and centers of excellence. Responsible for enhancing clinical operations, research, and development. He teaches emergency medicine, internal medicine and family practice residents at the Wright State Boonshoft School of Medicine.
About Paradigm Outcomes
Paradigm Management ServicesParadigm Outcomes is the nation’s leading provider of catastrophic and complex case management, Paradigm achieves 5x better medical outcomes and lowers total costs by 40%. Paradigm accomplishes this by bringing together nationally recognized doctors, the best providers in the country, and 25 years of clinical data to guide decisions. Paradigm is the only company designed and built specifically to address the needs of those with acquired brain injuries, spinal cord injuries, amputations, burns and chronic pain, and is the only company to stand behind their promises with medical and financial guarantees. For more information, visit www.paradigmcorp.com.