AASCIF
Full article on: aascif.org
David Lupinsky
Vice President, Clinical Product Solutions, Paradigm
The workers’ compensation system is facing an epidemic of negative patient experiences and diminished outcomes for musculoskeletal (MSK) injuries. This injury class, including common diagnoses such as back, knee, and shoulder injuries, is the leading cause of disability and delayed recovery among work-related incidents. These high-spend, high-variation, highly fragmented cases are associated with significant medical, indemnity, and administration costs, inconsistent provider quality, low patient engagement, and unpredictable long-tail outcomes.
Although MSK injuries present challenges across the healthcare spectrum, work-related cases are especially difficult to manage. In a recent analysis, patients undergoing spine surgery after a workplace injury experienced significantly worse results compared to patients in the general health system, despite being a younger population with fewer comorbidities.1 This gap also extends to nonsurgical cases, with a 51% decrease in functional score improvement in physical therapy for workers’ compensation patients versus commercial health cases.2
Bridging such a deep valley between outcomes requires careful analysis and an openness to new approaches. Continuing to rely on the established system will only bring the same results. In contrast, understanding the primary contributors and developing innovative solutions can help our industry break the cycle and improve the state of care for MSK injuries.
Misaligned incentives, limited data, and psychosocial barriers
Why the jarring disparity in outcomes? There are distinct factors unique to workers’ compensation to consider—including payment structures, data access, and approaches to behavioral health.
In the current fee-for-service payment structure for work-related MSK care, financial incentives reward provider activity over outcomes. Although this is a phenomenon we see throughout the healthcare system, a compounding issue in workers’ compensation is that managed care entities also largely operate on a fee-for-service model. Consequently, cases with high oversight, high spend, and poor outcomes typically generate far more revenue than those with optimal outcomes.
Another barrier in workers’ compensation is critical health data that is either siloed off or limited due to a lack of patient reporting. To create effective treatment plans and provide continuity of care, care managers need insightful data that goes beyond what is collected in bill review or by pharmacy benefit managers (PBMs). Collection of health information in workers’ compensation can be limited and exacerbated in cases where there is a guarded or even adversarial relationship between injured workers, claims stakeholders, and providers. Without the ability to understand medical history and identify potential comorbidities and treatment barriers, the workers’ compensation system too often leaves care professionals unequipped to intervene effectively and injured workers left to fend for themselves. Ultimately, this leads to an inability to identify long-tail cases early and take appropriate action proactively.
Finally, workplace injuries are associated with a wide range of psychosocial issues that can become major hurdles to recovery if left unaddressed. According to data from The Hartford, 60% of all costs are driven by approximately 10% of claims that have at least one psychosocial issue present.3 In addition to psychological and behavioral conditions such as anxiety, depression, and sleep disorders, which negatively impact recovery among the general population, injured workers also deal with unique behavioral concerns, including perceived injustice and job dissatisfaction.
For injured workers, these issues often coexist with additional misaligned incentives on the patient side, driven by payment models where care recipients do not directly pay for services. While necessary, this can amplify certain accountability problems compared to general healthcare, where patients are more directly incentivized to seek high-value treatments. What’s more, injured workers can also be motivated by the secondary gain of compensation for time away from work, which can become yet another barrier to recovery and return to productive activity.
Closing the outcome gap with value-based models
While these concerns are deeply rooted in the current system of treating MSK injuries, there are practical, workable solutions that are already being implemented within the workers’ compensation sector.
To improve the state of fee-for-service payment structures, stakeholders must first work to align incentives around an outcomes-focused, value-based approach. This model incentivizes measurable results and demands accountability for the cost of care for injured workers. Basing payments on episodes of care—a single bill for a single injury or event—can have a tremendous impact on lowering costs, improving outcomes, and facilitating administrative efficiencies. By shifting the focus to achieving value in the form of healthy, functioning workers, versus saving money through unit price discounts, workers’ compensation can build a more patient-centered system that still saves payers in the long term.
The next step is identifying cases that are likely to turn into long-tail claims so they can be resourced appropriately. By identifying the highest-risk cases and taking appropriate action early, these cases have a much greater likelihood of seeing recovery and return to work. This requires a close partnership between care management organizations, claims professionals, providers, and payers—in tandem with a deep commitment to evidence-based, data-driven care methodologies.
Finally, to address psychosocial concerns more successfully, care managers must be committed to moving care upstream. Early intervention on behavioral and psychological care is crucial to preventing the need for more extensive intervention down the road. Once again, this requires patient engagement and access to data and the use of innovative approaches. For example, when it comes to gathering key health data from injured workers, surprising evidence shows that patients are more open and honest reporting risk factors to a computer than a human.4 Combining high-value, digitally sourced data with human clinical intervention enables care managers to deliver more effective results.
In one exemplary case, data shared through digital engagement tools helped reveal that an injured worker enrolled in Paradigm’s HERO MSKSM solution was recovering from substance misuse. This critical information enabled the care manager to then take appropriate action on the prescription of opioids for an upcoming surgery. By working closely with the management team and treating providers, the injured patient was able to complete a recovery that included successful opioid weaning and return to full-duty work.
While MSK injuries will continue to be a substantial recovery challenge in workers’ compensation for years to come, there are practical solutions. Platforms aligned around value-based models, upstream care, and balancing digital patient engagement with human clinical expertise offer exciting potential for more successful recovery outcomes. Bringing these models into the marketplace and increasing their adoption can ultimately help the workers’ compensation system break the MSK disability cycle.
Sources
- Effect of workers’ compensation status on pain, disability, quality of life, and return to work after anterior cervical discectomy and fusion: a 1-year propensity score-matched analysis. Hani, U.; Monk, S.H.; Pfortmiller, D.; Stanley, G.; Kim, P.K.; Bohl, M.A.; Holland, C.M.; McGirt, M.J.; J. Neurosurg Spine. 2023 Jul 21.
- Patient-Reported Functional Outcomes after Low Back Pain: A Comparison of Worker’s Compensation and Other Payors. Negrusa S., Thumula, V., et al. WCRI 23-17 February 2023
- The basics of complex claims. Canavan, Eddy. Sedgwick. 2017 May 17. https://www.sedgwick.com/blog/2017/05/17/basics-complex-claims
- It’s only a computer: Virtual humans increase willingness to disclose, Gale M. Lucas, Jonathan Gratch, Aisha King, Louis-Philippe Morency. Computers in Human Behavior. 2014 May 21
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