Risk & Insurance
Full article on riskandinsurance.com
By: Paradigm
As the need for treatment that empowers and engages patients with musculoskeletal injuries grows, episodic care offers improved outcomes and reduced total cost of care.
Fragmented care negatively affects everyone in the workers’ compensation system—especially injured workers. Providers working in silos contribute to uncertainty about the diagnosis, disengagement from treatment, and ineffective care pathways. Specifically, when injured workers don’t receive managed, coordinated care, this can mean unnecessary surgeries, the risk of prescription drug dependency, and a delayed return to work. On the payer side, that all adds up to increased treatment and indemnity costs, contributing to an exorbitant total cost of care.
Workplace musculoskeletal (MSK) injuries are a frequent source of workers’ compensation claims, and a powerful example of the barriers that care fragmentation can create. By integrating and coordinating the patient experience, managed episodic care programs for MSK injuries can deliver on the promise of wholeperson, value-based treatment. With HERO EpisodicSM, Paradigm has an industry-first solution built to achieve guaranteed outcomes for workplace MSK injuries and financial value—including fixed-cost, bundled pricing for surgical episodes.
This solution leverages clinical expertise and care management resources developed across decades of managing complex and catastrophic injuries. The goal is a guided, evidence-based approach designed to increase patient engagement. To do this, HERO Episodic combines people-focused care coordination, value-based payment models that lower total cost of care, and data-driven care pathways utilizing best-in-class provider networks.
Episodic Care that Places Patients at the Center
“The current system can be very isolating for injured patients,” said Kathy Galia, Paradigm Chief Clinical Solutions Officer. “Even for a relatively routine MSK injury such as a shoulder tear, an injured worker can expect to be evaluated and referred to multiple providers.”
Michael Choo, MD, Chief Medical Officer for Paradigm agreed: “In cases that aren’t managed properly, patients can bounce around multiple physicians and care providers, from radiology specialists for diagnostic imagery, to pharmacists for various prescription medications, to physical therapists for rehab, chiropractors for manipulations, and multiple physicians, including pain management specialists for corticosteroid injections and surgeons for surgical interventions.” Under many current care models, these practitioners typically work independently and don’t have a view of the larger picture.
“This type of unmanaged care creates a need for coordination that is too often left to the injured worker,” said Galia. “Patients can feel unsettled by lack of knowledge about their medical condition, confusion about available treatments, and uncertainty about gaps in care.” These factors are at the root of why seemingly low-risk MSK injuries frequently result in runaway costs in the hundreds of thousands of dollars, prolonged duration of claims, and return-to-work delays in the hundreds of days, according to industry data.1
In contrast, a dedicated RN care manager with injury-specific experience and training can ensure patients feel informed and are receiving the right care at the right time. “With the HERO Episodic model, injured workers with an MSK diagnosis have immediate access to a team of condition-specific care coordinators and proprietary clinical pathways,” explained Dr. Choo.
Along with a dedicated Episodic RN Care Manager, Paradigm Medical Directors with specialized expertise in specific diagnoses—including rotator cuff injuries, meniscal tears, and disc herniations—guide care plans and consult with a best-in-class network of specialty providers.
“Injured workers will have a single point of contact who is invested in their case and who they can go to for guidance or with any questions about the care process,” said Galia. This solution also provides a two-way, technology-driven patient engagement platform that gives injured workers increased information and education about their care. This unprecedented level of patient engagement is why HERO Episodic can achieve lower disability ratings, and guarantee maximum medical improvement (MMI) and release to return to work.
She continued, “From day one, we’re increasing real-time communication and support to foster a positive, recovery-focused mindset in these patients.”
Lowering Total Cost of Care by Building Better Pathways
“The concept of value-based episodic care is rooted in better outcomes and reduced costs,” said Rey Quinones, Vice President of Product Management for Paradigm. “Any solution claiming to be value-based has to truly understand how those two objectives work together.” HERO Episodic has been carefully designed to achieve a guaranteed outcome for both non-surgical and surgical MSK injuries, while reducing the total cost of care.
Achieving both objectives requires extensive data and deep clinical knowledge to keep each patient on the right track.
“For MSK injuries, the decision point for surgery is crucial. Unnecessary surgeries have a major impact on cases from the perspective of both recovery and cost,” said Dr. Choo. “Paradigm’s established expert-driven, data-guided platform provides the clinical road map and decision support that avoid unnecessary or ineffective procedures through a proven, evidence-based model.”
While nonsurgical cases are expertly managed and committed to achieving maximum medical improvement, or the jurisdictional equivalent, and release to return to work, if surgery is deemed necessary, pricing is bundled on a fixed-cost basis, with full risk transfer until these outcomes are achieved. Explained Quinones, “The framework we’ve established is based on a blend of geography, patient risk, and procedural data. Our unique approach of binding the surgical bundle to the achievement of outcomes enables our clients to set reliable reserves.”
Galia stressed that surgical bundles really are just one aspect of accountable episodic care. “There is a misconception that bundled payments equal value-based care. Bundling is just one spoke in the wheel of an accountable, value-based model that provides true financial value.”
She continued, “Effective care pathways that maximize functional outcomes and achieve lower disability ratings ultimately mean permanency of claim settlement and lower indemnity costs. Combining this with savings from avoiding unnecessary procedures and lower treatment costs is how HERO Episodic really delivers reduced total cost of care.”
Evolving an Established Value-Based Model
For more than 30 years, Paradigm has delivered guaranteed outcomes and financial certainty through its Systematic Care ManagementSM model. This approach analyzes the core medical needs and costs to reach an outcome, considering the physical, emotional, and environmental attributes of each injured worker.
“HERO Episodic leverages the same resources we have developed for decades to achieve predictable accuracy and guaranteed outcomes for complex and catastrophic injuries. This includes 32% lower medical costs and nearly six times higher return-to-work rates, according to a 2020 independent study,” said Dr. Choo. “Paradigm has always delivered true value-based and accountable care that aligns patient needs through proprietary clinical pathways and a curated network of best-in-class providers. We are now evolving
this model for a broader class of MSK injuries.”
Moving toward coordinated, outcomes-focused treatment with a lower total cost of care is the future for our industry,” noted Galia. “HERO Episodic will deliver end-to-end service for workers dealing with MSK injuries that can transform the way we view care and cost outcomes.”
Learn more about HERO Episodic, Paradigm’s innovative, outcomes-focused solution for
MSK injuries.
1. Source: ODG by MCG.
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