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

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 a retired senior editor of Risk & Insurance® and the former chair of the National Workers' Compensation and Disability Conference® & Expo. Read more of his columns and features.

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