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Value Based Care and Centers of Excellence Matched Pair for Work Comp

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Value-based Care and Centers of Excellence – A Winning Combo for Injured Employee, Employer, Carrier/TPA and Medical Provider

If a provider mixes Value-based care and Centers of Excellence, the result may be what Workers Comp has been searching for in the last 40 years.   WCRI hosts a webinar next week on Centers of Excellence.

Feel free to read my article on Centers of Excellence from earlier this week.

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Two of the up-and-coming areas of medical treatment in Workers Compensation fills a great need for:

  • Better communications
  • Specific treatment to a certain population
  • Better cost projections <<critical for adjusters setting reserves
  • Enhanced outcomes
  • Instills trust of Work Comp and medical treatment systems – check out the WCRI injured employee results surveys-wow! They won the vaunted Comp Laude award this year for those studies.
  • Controls cost
  • More industrial-based medicine

The above list considers on a few points of what I think the newest and best trend in medical treatment for injured workers.   The Centers of Excellence Model has sustained high-levels of very specific care for specific serious injuries (Burn Centers, Brain Injury Center, etc.).

One caveat – not all traumatic injury treatment providers are considered Centers of Excellence.

Centers of Excellence Concept

The one very expensive yet needed Centers of Excellence are closed head injury treatment centers.  Those medical and rehab providers,  while expensive,produce amazing results.   I referred quite a few patients to them and have recommended them in my claims consulting practice often for the very serious cranial and upper spinal injuries.   The work they do often reaches the miraculous level.

One drawback remains the cost of out-of-state treatment in Workers’ Comp claims. Fee schedules are gone when the treatment moves across state lines.  Please do not mistake that as a critique.

One of the considerations is the cost.   One of the main criticisms of the  staff at any Centers of Excellence comes from the paperwork required by Workers Comp carriers/TPA’s.  The staff wants to spend every second of their time improving the injured workers’ lives, not getting multiple authorizations every week.   I  find that hard to criticize in such serious cases.

The local Center of Excellence, which I referred seriously injured workers to is Duke University Medical Center.   One cannot forget the University of North Carolina Medical Centers or WakeMed Centers of Excellence.   All three help keep Raleigh as one of the top places for medical care in the nation.

Value Based Care Concept

The new medical treatment term that has gained traction in health coverage originates from outcomes and cost as the determining factors.   For the mega-claims, the Centers of Excellence could be considered as value- based care.

PBMs (Pharmaceutical  or Pharmaceutical Based Management) systems became a natural beginning for the value-based care model in Workers Comp.  Last year, I attended a session at the NWCDC Conference on value-based care.  I realized the significance of what the session covered  after-the-fact.

I said at the time of the NWCDC session – this will not work in Workers’ Comp.  I now say that I was a little hasty in my decision.   WCRI also presented a webinar on value-based care.   Dr. John Lea presented earlier this year on value-based care and now will present a webinar on Centers of Excellence on October 12th.

Combination of Both

A combination of both concepts would allow for:

  • Reduced paperwork for Centers of Excellence
  • Keep injured employees in-state for the fee schedules
  • Instill trust in injured employees <<critical
  • Very specialized industrial medicine clinics in a certain area
  • Payment providers (carriers/TPAs) more readily make payments
  • Avoid injured workers having multiple Independent Medical Exams and  external Second Opinions
  • The list could go on for a long time

Please do not consider this one of those recycled topics that appear in workers comp every few years.  Value based medicine and especially Centers of Excellence wield a unique concept.

 

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James Moore

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Mgmt Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
  • WorkCompCentral.com
  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
  • Workers Compensation.com
  • LinkedIn, Twitter, Facebook and other social media sites
  • Various trade publications

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