It is well-supported within worker’s compensation that non-pharmacologic methods of treatment, such as physical medicine, are a valuable component of the overall treatment plan. However, less supported is the ability for payers to evaluate and manage the quality of physical medicine services. Although evidence-based guidelines exist as a framework for treatment decisions, payers traditionally have had limited means to objectively measure the impact of services on patient recovery. Without objective measures, it is impossible to assess the clinical value, as well as the cost-effectiveness, of treatment.
Physical medicine encompasses a range of non-pharmacologic services that include physical (PT), occupational (OT), aquatic and massage therapies, chiropractic, acupuncture, and work hardening. When not managed optimally, physical medicine services can contribute significantly to the costs of a claim without facilitating earlier return to work. However, effective application of physical medicine services has been shown to reduce utilization and costs. There are several elements that must be part of a physical medicine program in order to best manage not only the cost, but more importantly, the quality of physical medicine services provided to the injured worker patient:
- Clinical decision support
A program that supports outcomes-based care decisions vs traditional utilization-based models
- Outcomes-based performance assessment
Objective measures and criteria to accurately assess quality and effectiveness of service
- A bigger-picture perspective
A comprehensive platform that considers costs and utilization of physical medicine services within the greater context of the claim
CLINICAL DECISION SUPPORT
The process of ensuring quality care begins early in the claim, where evidence-based guidelines should drive clinical decision-making in regard to how physical medicine services are best implemented into the treatment plan. Quality in this case refers not to price, but rather, adherence to evidence-based and outcomes-focused treatment. Studies demonstrate that clinically appropriate application of PT contributes to reduced utilization and overall spend within a claim. In this sense, quality of service becomes the driver for containment of cost and utilization.
It is this focus on quality, asserts the chief medical officer at Healthesystems, Robert Goldberg, MD, FACOEM, that marks a significant departure from how physical medicine has traditionally been managed. “Right now, claims professionals are typically making decisions solely based on utilization. We need to change the conversation from how many visits are acceptable, and instead ask the question, what level of functional improvement was accomplished during those visits?”
In order to shift the model from one that is largely utilization-based to one that is outcomes-based, claims professionals must have access to a platform that provides them with the support they need to make clinically sound decisions. This is where physical medicine programs within workers’ comp have a significant area of opportunity.
OUTCOMES-BASED PERFORMANCE ASSESSMENT
Evidence-based medicine is only as valuable as the outcomes it manifests; and true outcomes evaluation can only be achieved with objective measures of clinical progress. In simpler terms, to accurately assess a provider’s quality of services, one must use the right yardstick. Comprehensive data should include measures that are overlooked by conventional physical medicine programs, including specific measures of:
- Clinical outcomes (e.g., range of motion, strength)
- High-risk indicators (e.g., fear avoidance, nonadherence)
- Administrative efficiencies
- Vendor performance
- Network data
Equally important are when and how these data are being collected. Solicitation of data from providers at key time points – such as initial assessment, pre-authorization and re-authorization – enables payers to accurately assess quality along the care continuum, allowing them to more effectively manage patient care and provider networks.
Collecting the right data at the right time requires the right platform. Historically, much of the patient or clinical assessment data has not been codified or structured in a way that is actionable to the claims professional. Crucial information – for example, evidence of fear avoidance – is often buried in handwritten notes, where it can be overlooked in the clinical decision-making process. A platform that translates anecdotal information into electronic, codified data enables it to be integrated more effectively into care decisions. These triggers become even more valuable when logic is incorporated to proactively alert claims professionals. Having a more comprehensive data set allows for a more complete and accurate view of the quality of therapy and provider performance for the payer.
A BIGGER-PICTURE PERSPECTIVE
Optimized management of physical medicine must take into consideration the larger role these therapies play in the overall treatment plan for the injured worker. This requires a comprehensive, integrated platform that has the capability to consider costs and utilization of physical medicine services within the greater context of the claim. This means having the ability to merge data that are traditionally disparate in order to accurately measure the impact on other components of treatment, both pharmacologic and non-pharmacologic.
Areas of potential therapy improvements and costs savings with optimized management of physical medicine include:
- Reduced opioid usage
- Excessive/ineffective visits
- Delayed return-to-work
- Prescription medications
- Advanced imaging
- Therapeutic injections
A physical medicine management program that takes a holistic approach to delivering clinically appropriate, quality-based care can drive patient outcomes while also limiting inappropriate utilization and lowering unnecessary or avoidable costs. “When better care decisions are made,” adds Dr. Goldberg, “outcomes improve for all stakeholders. The injured worker regains function, the employer benefits from their employee’s faster return to work, overall costs are lowered for the payer, and the care provider is rewarded for the value they are delivering.”
Healthesystems provides a significantly enhanced physical medicine model that allows payers to more effectively assess quality and manage utilization of physical medicine services. To learn how Healthesystems is redefining how physical medicine and other ancillary services are managed, visit http://www.healthesystems.com/solutions-services/ancillary-benefits.
This is a sponsored post from WorkCompWire marketing partner Healthesystems.