At the WCRI Annual Issues and Research Conference, Randall Lea MD from Alice Peck Day Hospital discussed value-based care. The hospital has been working on a study of value-based care and the workers’ compensation industry. Value-based care has been gaining traction on the group health side but not in workers’ compensation.
Study participants included medical providers, payers and regulators. The hospital found that none of the study targets were overly enthusiastic about the concept of value-based care in workers’ compensation. Survey respondents expressed doubt the model would catch on because of regulatory constraints and a lack of understanding by market participants.
See also: 5 Ways Data Allows for Value-Based Care
A major theme of the survey responses was the need for a change in the regulatory environment to allow for a value-based care system. All stakeholders agreed that without full employer control of medical choice such a model could not function. Providers also pointed out that they would need to be free from utilization review for this to work. You cannot hold providers accountable for outcomes and at the same time limit what treatment they can do.
Another challenge of the value-based model in workers’ compensation is that outcomes are gauged by more than just medical outcomes. Return to work and impairment are concerns in the workers’ compensation area that do not exist in group health.
Regulators were concerned that a value-based model needed to provide incentives to all stakeholders, medical providers, payers AND injured workers.
Another major concern of study respondents was payment/reimbursement. A value-based system needs to provide prompt and fair reimbursement to medical providers. Existing fee schedules would need to be eliminated. Providers were also concerned about having the required volume of patients to make a value-based model worth their effort. The study groups had wide views about what types of payment models would be preferred. Options included bundled, Medicare like, shared risk and fee for service (FFS).
Study participants were also concerned about how outcomes would be measured. For example, is an actual return to work needed, or does a release to modified work achieve the outcome? The medical provider has no control over whether the employer will provide modified work. There are also concerns about how the patient’s satisfaction would affect the outcome measurement. There could be conflict between what the payer seeks to achieve and what the patient wants in terms of care. A good example of this is the challenge around opioid medications.
See also: 3 Key Points on Value-Based Care
The conclusion is, do not expect to see true value-based care systems in workers’ compensation any time in the immediate future. There are too many regulatory constraints that must be overcome.