Here’s Why Value-Based Care Is the Medical Approach Workers’ Comp Needs to Embrace

Value-based care will transform the way that medical providers treat injured workers. At the upcoming National Workers’ Compensation and Disability Conference, experts from Healthesystems will explain how it can work at your organization.
By: | November 13, 2018 • 3 min read

Value-based care remains a few years away from broad application in workers’ compensation, but the conditions are ripe for its expansion into injured worker medical treatment.

Described as a “patient-centered approach,” value-based care refers to health-provider reimbursement models expected to incentivize doctors and others to improve patient outcomes. It’s an alternative to the currently dominant medical-provider reimbursement system called fee-for-service.

Silvia Sacalis, vice president of clinical services, Healthesystems

Fee-for-service arrangements reward doctors for specific activities, such as paying them a set amount for each patient visit. That can promote quantity of care over quality of care, observers argue. Value-based care, in contrast, rewards medical providers for outcomes resulting from their treatments for a patient’s specific injury or health condition.

Workers’ comp lags in adopting value-based care, unlike its ongoing application across the nation’s general health care systems. Value-based care or value-based reimbursement outside of workers’ comp is farther along, in part, because Medicare shifted its provider reimbursement arrangements to encourage its expansion.

But claims-payers’ desire to manage rising workers’ comp medical costs by improving injured-worker treatment will drive value-based reimbursement’s advancement into workers’ comp, said Silvia Sacalis, vice president of clinical services at Healthesystems.

“I do think it is imminent in workers’ compensation that we will get to that place because health-care costs are unsustainable,” she said. “I am very encouraged, in talking with payers, that they have a significant focus on the injured worker and the true improvement of clinical outcomes for injured workers.”

It may not happen within the next year or two, but “we will get there in the next three to five years, if we want to ensure we are managing costs effectively,” Sacalis added.

Sacalis will speak on “Delivering and Measuring Value-Based Care Within Workers’ Comp” during the 2018 National Workers’ Compensation and Disability Management Conference & Expo being held Dec. 5-7 at Mandalay Bay in Las Vegas. Adam Seidner, chief medical officer at The Hartford, will join Sacalis to deliver the presentation.

Healthesystems’ Silvia Sacalis discusses the spread of value-based reimbursements into workers’ comp.

Sacalis is also confident value-based care will expand into worker’s comp because claims payers share a common challenge with Medicare and purchasers of commercial health care insurance. The challenge lies in attempting to align value with the price of care.

Value-based reimbursement can help address the challenge by fostering the use of evidence-based treatment guidelines and state-specific drug formularies to obtain desired return-to-work objectives and the functional restoration of injured workers.

Matt Hewitt, executive vice president, general manager of pharmacy benefit management, Healthesystems

“All the ingredients are there” for value-based care’s spread into workers’ comp, agreed Matt Hewitt, executive vice president, general manager of pharmacy benefit management at Healthesystems.

Value-based care provides an opportunity to step back from narrowly focusing on the price of medical treatments, or prescription drugs, toward unlocking processes and interventions that improve patient outcomes and return to work, Hewitt said.

Those “value-creating processes” would integrate technology, regulatory information, and evidence-based tools that can help pharmacies, claims adjusters, and doctors improve their decision making, Hewitt elaborated.

There is a lot of value in that,” Hewitt said. “That is about providing the right care to the patient.”

While value-based care’s expansion into workers’ comp will come, work remains to develop the necessary infrastructure, such as analytics, that can track and measure the success of outcomes.

Healthesystems’ Matt Hewitt elaborates on value-creating processes.

“We would need to be working really closely and partnering with our payers to come up with an aligned set of outcome measures that we want to start tracking and measuring that can actually lead to better return to work as well as functional restoration,” Sacalis said. &

Roberto Ceniceros is senior editor at Risk & Insurance® and chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at [email protected] Read more of his columns and features.

4 Companies That Rocked It by Treating Injured Workers as Equals; Not Adversaries

The 2018 Teddy Award winners built their programs around people, not claims, and offer proof that a worker-centric approach is a smarter way to operate.
By: | October 30, 2018 • 3 min read

Across the workers’ compensation industry, the concept of a worker advocacy model has been around for a while, but has only seen notable adoption in recent years.

Even among those not adopting a formal advocacy approach, mindsets are shifting. Formerly claims-centric programs are becoming worker-centric and it’s a win all around: better outcomes; greater productivity; safer, healthier employees and a stronger bottom line.


That’s what you’ll see in this month’s issue of Risk & Insurance® when you read the profiles of the four recipients of the 2018 Theodore Roosevelt Workers’ Compensation and Disability Management Award, sponsored by PMA Companies. These four programs put workers front and center in everything they do.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top,” said Steve Legg, director of risk management for Starbucks.

Starbucks put claims reporting in the hands of its partners, an exemplary act of trust. The coffee company also put itself in workers’ shoes to identify and remove points of friction.

That led to a call center run by Starbucks’ TPA and a dedicated telephonic case management team so that partners can speak to a live person without the frustration of ‘phone tag’ and unanswered questions.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top.” — Steve Legg, director of risk management, Starbucks

Starbucks also implemented direct deposit for lost-time pay, eliminating stressful wait times for injured partners, and allowing them to focus on healing.

For Starbucks, as for all of the 2018 Teddy Award winners, the approach is netting measurable results. With higher partner satisfaction, it has seen a 50 percent decrease in litigation.

Teddy winner Main Line Health (MLH) adopted worker advocacy in a way that goes far beyond claims.

Employees who identify and report safety hazards can take credit for their actions by sending out a formal “Employee Safety Message” to nearly 11,000 mailboxes across the organization.

“The recognition is pretty cool,” said Steve Besack, system director, claims management and workers’ compensation for the health system.

MLH also takes a non-adversarial approach to workers with repeat injuries, seeing them as a resource for identifying areas of improvement.

“When you look at ‘repeat offenders’ in an unconventional way, they’re a great asset to the program, not a liability,” said Mike Miller, manager, workers’ compensation and employee safety for MLH.

Teddy winner Monmouth County, N.J. utilizes high-tech motion capture technology to reduce the chance of placing new hires in jobs that are likely to hurt them.

Monmouth County also adopted numerous wellness initiatives that help workers manage their weight and improve their wellbeing overall.

“You should see the looks on their faces when their cholesterol is down, they’ve lost weight and their blood sugar is better. We’ve had people lose 30 and 40 pounds,” said William McGuane, the county’s manager of benefits and workers’ compensation.


Do these sound like minor program elements? The math says otherwise: Claims severity has plunged from $5.5 million in 2009 to $1.3 million in 2017.

At the University of Pennsylvania, putting workers first means getting out from behind the desk and finding out what each one of them is tasked with, day in, day out — and looking for ways to make each of those tasks safer.

Regular observations across the sprawling campus have resulted in a phenomenal number of process and equipment changes that seem simple on their own, but in combination have created a substantially safer, healthier campus and improved employee morale.

UPenn’s workers’ comp costs, in the seven-digit figures in 2009, have been virtually cut in half.

Risk & Insurance® is proud to honor the work of these four organizations. We hope their stories inspire other organizations to be true partners with the employees they depend on. &

Michelle Kerr is associate editor of Risk & Insurance. She can be reached at [email protected]