Value-Based Models: Where Does Workers’ Compensation Fit In? 

Case Management Focus

Sarasota, FL (WorkersCompensation.com) -- As value-based payment models move into all areas of healthcare, many are asking where workers' compensation fits in.  

Many view value-based contracting as relating to case rates, pay-for-performance, risk-based payments, risk-reward, bundled payments, and an outcomes-based payment model. To some degree, each is correct, but go deeper; value-based contracts would be more appropriately thought of as an umbrella term rather than a single idea.  

Workers' Compensation Organizations must consider value-based payment models to improve care while controlling costs.    

According to a Coventry Brief, five elements are needed to form a meaningful workers’ comp Value-Based Care Model (VBC) 

1. Remove the financial incentive to treat more in order to move away from volume-based or fee-for-service contracting. The VBC model strips out the payment structures that reward activity over outcome.  

2. Predictive pricing for providers and payors: This requires reaching an agreement with providers on what it takes to treat an overall illness or injury and return the injured worker to the condition he or she was in prior to the injury. Data gathered over time helps payers and providers be better predictors of the cost of care.  

3.  Alternative to fee-for-service: When a payment is rendered for each service, there is a perverse incentive to do more to get paid more. Value-based payment models are designed to pay for better outcomes regardless of the services required to reach that outcome.  

4.  Shared opportunity for the provider and the payor: This concept centers on risk-reward and underscores the goals that the provider and payor share. Payers working with providers to pay incentives for outcomes must be part of any plan. Doing so will help networks retain good providers who go the extra mile to reach positive outcomes like helping the injured worker heal naturally vs. surgical interventions and return to work once the injured worker is ready. You have to have appropriate payment models for this to work, but it is doable.  

5. Outcomes focus: The model should be adjusted to deliver the correct mix of services so that an individual can achieve the best outcome.  

When these core principles are intact, it is fair to consider the approach value-based payment models offer. Value-based payment Models fit workers' compensation well, as money is not the issue in workers' compensation. Plans pay for medical care and resources needed to assist the injured worker in getting back to work. 

Nurse Case Managers are central to achieving positive outcomes while containing costs. They do this individually by connecting with an injured worker early, seeing that medical care is rendered to stabilize the injured worker and help them transition through the system in a coordinated and safe manner. Resources are obtained to help the injured worker to be self-sufficient and overcome barriers that prevent them from returning to gainful employment. Working with a team of professionals like specialty physicians, therapists, vocational specialists, employers, adjustors, and the injured worker is critical to achieving outcomes that allow the injured worker to find gainful employment while meeting the worker's restrictions. Case Managers advocate for patients to reach their goals and document outcomes along the injured worker’s journey.  

Have value-based payment models reached your area of practice yet? Let me know how you are working in this new model of care and the outcomes you are seeing. You can reach me at allewellyn48@gmail.com  

Reference:  

Defining Value-Based Contracting Requires More than a Few Works: https://www.coventrywcs.com/sites/default/files/2022-05/Coventry-Value-Based-Contracting-Whitepaper-20170601.pdf 

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