The Shift to Guaranteed Outcomes and Lower Total Cost of Care for Workplace Musculoskeletal Injuries

WorkCompWire
Full article on www.workcompwire.com
By: Michael Choo, MD; FACEP; FAAEM; CMRO | Chief Medical Officer & SVP, Paradigm

How Value-Based, Episodic Care Coordination Reduces Total Cost and Reaches Treatment Goals

Workplace musculoskeletal (MSK) injuries—such as shoulder strain/sprain, knee strain/sprain, or back strain/sprain—are among the most common incidents that take workers off the job. Despite their frequency, even a relatively uncomplicated MSK diagnosis can still result in substantial barriers to recovery and return to work. Injured workers in the current system report high rates of dissatisfaction and disengagement with care.¹ Employers and plan sponsors regularly encounter delayed return to work, which contributes to high disability rates and high total claim costs for these cases.

In short, what should be a routine and low-risk recovery trajectory too often leads to exorbitant costs and negative treatment outcomes.

The Problem: Fragmented, Fee-for-Service MSK Care
When the Centers for Medicare and Medicaid Services (CMS) examined similar issues in general health care, they found causes that easily apply to workers’ compensation. Namely, fragmented, uncoordinated care delivery, incentivized by fee-for-service payment models. Injured workers too often find themselves bounced from provider to provider, all of whom are working and billing separately, while “flying blind,” without any accountable oversight or clear foreseeable outcome.

For workplace MSK injuries, this can mean missed appointments, inaccurate diagnoses, low-value or ineffective treatments, disengagement with physical therapy, unnecessary surgeries, or delaying necessary surgery. This can put injured workers at risk for drug dependency and mental health problems, both of which may further drive costs and inhibit recovery. Industry data estimates these cost overruns starting in the hundreds of thousands of dollars, and months of delayed return to work for many of these types of cases.²

The Fundamentals of Episodic Care
The solutions for this unfortunate and undesirable status quo do exist. The fundamental concept, as laid out by CMS, is episodes of care, or episodic care. The concept of episodic care is based on coordinating medical services and combining alternative payment initiatives, or bundling, to achieve the optimal treatment outcome. According to a report published by RAND Corporation, one episodes-of-care-based program resulted in total savings to Medicare of $52.3 million.³

Translating these ideas to benefit MSK injuries has tremendous upsides for workers’ compensation. Any successful program addressing the needs of injured workers and program stakeholders should be based on these key components:

• Holistic clinical guidance and oversight
• Proven, data-driven care pathways
• High-quality provider networks
• Performance-driven payment models that promote provider accountability

Paradigm became a leader in managing complex and catastrophic workplace injuries through an expert-driven data-guided platform leveraging the aforementioned elements. After more than three decades of successfully managing the most challenging cases, Paradigm is now using its proven model and clinical resources to deliver guaranteed outcomes for MSK injuries through an innovative episodic care platform.

HERO Episodic Brings Guaranteed Outcomes to MSK Injuries
With HERO Episodic^SM, Paradigm has developed an industry-first care management solution for MSK injuries. HERO Episodic is designed to lower total cost of care and improve patient engagement and outcomes through an evidence-based model built for guaranteed outcomes.

HERO Episodic delivers:

• A dedication to patient engagement: Injured workers gain immediate access to a team of condition-specific care coordinators, including an RN Care Manager and Paradigm Medical Directors who have expertise in specific diagnoses. Additionally, care delivery is facilitated through a two-way, technology-driven patient engagement platform.
• The right care at the right time: Extensive clinical expertise, a comprehensive library of case data, and evidence-based treatment pathways keep injured patients on track. The crucial decision point for surgery is based on geographical data, procedural data, and risk scoring—for maximum accuracy to avoid unnecessary procedures.
• Unparalleled provider relationships: Paradigm has built strong relationships with top providers in injury treatment and rehabilitation, and offers access to a handpicked ortho-spine network, based on outcomes analysis and internal provider scoring.
• Value-based payment structures: Nonsurgical cases continue on a monthly basis, committed to achieving maximum medical improvement (MMI) and release to return to work (RRTW) or the jurisdictional equivalent. Surgical cases are bundled on a fixed-cost basis, with full risk transfer and guaranteed MMI and RRTW from the injured worker’s physician. The goal is to incentivize providers to coordinate care and focus on better outcomes.

On the program sponsor side, HERO Episodic is designed so clients can set reliable reserves, and provides financial value through lower indemnity costs and, ultimately, lower total cost of care. For injured workers, this product offers a higher level of support and communication to foster a positive, recovery-focused mindset that is designed to get people back to their families, jobs, and communities.

The underlying approach that has helped Paradigm achieve proven results in catastrophic injury management is at the core of HERO Episodic. Paradigm’s proven results include 32% lower lifetime medical costs and nearly six times higher return-to-work rates, compared to industry benchmarks, as revealed by a 2020 independent study. Paradigm is confident that their same commitment to whole-person care, evidence-based treatment, and total cost savings will enable even more people to achieve life-changing outcomes.

Contact Paradigm to learn more about HERO Episodic, their innovative, outcomes-focused solution for MSK injuries.

Partner Post:
This is a sponsored post from WorkCompWire marketing partner Paradigm.

Notes
¹Source: Paradigm Proprietary Research, 2018.
²Source: ODG by MCG.
³Source: Analysis of Bundled Payment, Rand Corporation.