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.

Term Of The Day – Future Medicals

Workers comp future medicals demand accurate calculations from claims adjusters. The medical part of the total incurred and reserves requires many more calculations than the indemnity part of the reserves. Indemnity reserving possesses much more structure than any medical forecasting.

Each human body heals differently depending upon genetics, lifestyle, medication management, type of injury, and many more other factors. Adjusters should not just post a reserve that required very little thinking. Most insurance carriers and TPA’s provide the adjusters with very involved future medicals reserve sheets with a breakdown of medical costs. How adjusters use these sheets causes a large amount of debate in the insurance community.

Typically, employers are responsible for medical expense payment if associated with their employees’ on-the-job injuries. These medical benefits are often lifetime benefits (employers are generally on the hook for future meds for the injured employee’s lifetime as long as the medical expenses are related to the underlying job injury). In some states however,

the employee’s right to future meds can be terminated when the employee and employer agree to the terms and a judge or appropriate administrative authority approves the agreement