This month at the National Workers’ Compensation & Disability Conference (NWCDC) in Las Vegas, Dr. Silvia Sacalis, VP of Clinical Services at Healthesystems, partnered up with Dr. Adam Seidner, Chief Medical Officer at The Hartford, to deliver the session Defining, Delivering and Measuring Valued-Based Care Within Workers’ Compensation.
If you weren’t in Las Vegas this year, or were unable to attend the session, here are 5 key takeaways:
- Workers’ comp is lagging, but learning
Value-based care and reimbursement models have gained traction in commercial healthcare over the last few years, but over the last decade Medicare has truly been at the forefront in implementing programs intended to align their payment system with the quality of care provided.This notably began with the Hospital Value-Based Purchasing Program via the passing of the Affordable Care Act, and more recently with MACRA, as well as the upcoming Merit-Based Incentive Payment System (MIPS), which will align payments with individual providers’ performance in certain practice areas, including quality of care. CMS has implemented these programs to support the triple aim of delivering better care for individuals, improved population health, and lower costs. These concepts increasingly resonate within workers’ compensation organizations as the conversation moves beyond price per pill to focus on better overall financial and clinical outcomes.However, the move toward a value-based model first requires the alignment of stakeholder incentives, and the complexities within workers’ compensation have made it challenging thus far to plot a clear path forward – Dr. Seidner highlighted a significant difference in workers’ comp being the onus of indemnity payments on the payer.
- Quality reigns over quantity
Unlike the long-utilized fee-for-service model, which rewards volume of services and frequently drives overtreatment, a value-based reimbursement structure places the patient’s well-being at the forefront by incentivizing a focus on outcomes and appropriate service utilization. This includes not only assessing whether the appropriate service occurred, as Dr. Seidner pointed out, but when it occurred – i.e., did it occur within a timeframe where it is proven to be most effective?Here, data analytics play a starring role as predictive models and advanced analytics enable more precision and more personalized care. From a measurement and tracking perspective, Dr. Sacalis emphasized that establishing a set of clinical metrics is crucial to assessing the outcomes of an intervention or set of interventions on the health of an individual or a population.
- Physicians are already participating
Approximately 70% of physicians have already participated in some type of value-based program, and the majority of these physicians have gained additional compensation from them as a result – demonstrating that it does pay to do the right thing.
- Accountability is key
The value-based model creates an aspect of shared risk among stakeholders that in many cases can help align incentives. Problems arise, however, when one stakeholder is held accountable for factors they can’t control – e.g., physicians negatively impacted by factors in the employer environment, such as the lack of a return-to-work program.
- There is no one-size-fits all model
There are a number of different models within the spectrum of value-based care, from the capitation model that allots single monthly payments to reimburse care across a population, to payments associated with procedural episodes of care, to a true patient-centered payment model that reimburses based on the comprehensive scope of services, both planned and unplanned, that will effectively treat a particular condition – rather than focus on volume of services.
While some provide greater accountability and/or strike a better balance between under and over utilization than others, Dr. Seidner postulated that different payment models may be appropriate for different cases, and a hybrid model may be on the horizon for the workers’ comp industry.
Even fee-for-service has its role, he stated, as it can encourage utilization of under-utilized services. Regardless of the model utilized, metrics such as patient preferences, return to work, quality of life, and over or under utilization of services all must be a part of the formula.
For a conversation on the role PBMs can play in the future of value-based care in workers’ comp, watch the video interview with Dr. Sacalis and Matt Hewitt, Healthesystems EVP and General Manager of PBM Services, moderated by Roberto Ceniceros of Risk & Insurance magazine.
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