WorkersCompensation.com
Full article on workerscompensation.com
By: Nancy Grover
Las Vegas, NV (WorkersCompensation.com) – Imagine having a single fee for a particular workers’ compensation injury, perhaps even a pre-set price. Advocates for the idea say it can lead to better outcomes for injured workers and lower costs for payers.
“It’s a shift in how we think about care delivery in workers’ compensation,” said Kevin Turner, chief Clinical Solutions Officer for Paradigm. “Episodic care management … it’s in group health and we think it can work in workers’ compensation.”
During a session at the National Comp conference here, Turner and other speakers touted what they say is the next iteration in the evolution of the healthcare delivery system.
ECM
Where the traditional fee-for-service reimbursement model includes separate payments for each medical service an injured worker receives, ECM bundles all services of a medical event from beginning to end. It’s an integrated approach that involves everyone connected with the injury – with the injured worker at the center.
“The ECM model will work,” said Michael Choo, MD, Paradigm’s chief Medical Officer. “We’re confident it will be moving toward where we need to be in the healthcare industry, which is providing value care.”
ECM, advocates say, works especially well for injuries/illnesses for which there is a clear beginning and an end, rather than chronic conditions. A rotator cuff injury is an example of a condition ripe for ECM, compared to the fee-for-service model.
“Imagine an injured worker who sustained a shoulder injury, and waits 20 days to see a provider, [and one who’s] not necessarily the best for that injury type,” said Kathy Galia, SVP and general manager for Paradigm Clinical Solutions. “There are several visits before the diagnosis is clarified. Maybe an X-Ray or MRI is ordered – maybe too soon. The quality of imaging is not stellar and needs to be repeated. At that point physical therapy is scheduled. The injured worker may miss several [PT] visits. He’ll have continued shoulder pain and is recommended for injections. Perhaps there are delays between injections or the injured worker goes through additional injections that are outside treatment guidelines. Surgery may be recommended. The injured worker may not have the support they need. Surgery is performed, in-patient, and the injured worker stays overnight. On discharge they are told, ‘you’ll get a sling in a few days.’ He goes home without clear post-op instructions. He’s having pain and doesn’t realize it’s normal, so goes to urgent care. They repeat the imaging, and the provider visit. There’s concern about reinjury, so the patient remains out of work. This is hypothetical but we’ve seen this.”
The often fragmented care under this fee-for-service model results in wide swings in costs and recovery times, the speakers said. According to the ODG guidelines cited by the panelists, a rotator cuff injury that results in surgery may cost anywhere from $20,591 to $123,276, with the ‘typical claim’ costing $55,923. Disability days range from 73 in best case scenarios to 393 days, with the average case 211 days out of work.
“How can we improve this?” Galia asked. “One way is with ECM and expertise in the specific care. It’s all about the provider. It must start with high quality and move away from the volume approach; focus on functional capability, focus on the whole person, consider comorbidities. There’s so much inconsistent treatment out there, even with guidelines.”
ECM uses evidence-based medicine, and high-quality providers. It amplifies collaboration in decision making. It focuses on outcomes and incentivizes all stakeholders to look at the end result. And it requires patient engagement.
“If you do all these five things well, you get the outcomes you want – quality of life, more independence and [they are] more engaged in their lives, have faster recoveries and lower costs,” Choo said. “It elevates ownership and accountability of stakeholders to do the right thing.”
ECM and WC
The secret to successful ECM is data, the speakers said. Musculoskeletal disorders are a perfect opportunity to utilize ECM, as there is significant data on those.
“You can see what a good outcome looks like, what a bad one looks like,” Galia said. “You build your episode from there. You have case managers overseeing these programs with condition-specific expertise.”
Getting started should entail looking at data to understand all that goes into an episode and building the treatments that will be bundled in. The treatment model should be developed in collaboration with medical providers to create pathways of care.
Getting payers on board with the idea of ECM may be challenging, the speaker said. For one thing, physicians tend to fear change.
“Providers are trained to be paid for fee-for-service. To change is scary for them. They don’t really know what it implies,” Choo said. “The second, bigger thing is most physicians don’t have data. They don’t really know what it takes, what goes into the bundle. We can share it with them, but most providers don’t have a concept of what goes or should go into the outcome.”
A third impediment to ECM is the fact that there is generally a lack of focus on outcomes in healthcare. “It’s hard to know what it takes to get to the outcome,” Choo said. “So the concept of bundled care is very confusing.”
Developing rapport with providers, building trust and conveying to them that the idea is to provide the best care is vital in order for ECM to work, Choo said. Showing them data is a good place to start.
“I find providers to be very intrigued by this,” Choo said. “Part of the problem why physicians don’t jump on this is because they don’t have benchmarks, they don’t have anyone giving them feedback. If you create a process with two-way communication and give them information on how they are doing and constructive information to help them improve, that goes a long way to get them to adopt these models.”
It’s also important to realize that, even using evidence-based medicine, there is no single solution for every ailment.
“I truly believe that there is a range of care that is appropriate,” Choo said. “There is no one way to take care of the patient. There may be other ways, but maybe the outcome is the same. So a range is OK as long as it doesn’t deviate too far and is harmful.”
Share
Share
Tweet
Email