By Michael Choo, MD, Chief Medical Officer, Paradigm Outcomes
Lately, the use of terms such as “outcomes,” “outcome-driven,” and “outcomes-management” seem ubiquitous among stakeholders in healthcare. The emerging trend of using these new buzzwords throughout our medical industry merits an examination. Just what do these terms actually mean, how are they being used, and how they can be applied in workers’ compensation? A shared understanding and appropriate application will help us get the most from an old idea whose time has finally come.
In general, the contemporary emphasis on outcomes by healthcare policymakers and experts is driving improvements to America’s healthcare delivery system. Specifically, this orientation is accelerating our acceptance of health outcomes as a crucial strategy to address variations in medical care, effectiveness of care, access to health resources, and rising healthcare costs. Although a definition for the term “outcomes” seems intuitive and straightforward, surprisingly, the word’s journey in medicine started centuries ago and has accumulated multifaceted connotations and implications that confound precise definition and utility in the medical industry.
Pioneers of Outcomes in Medicine
Over century and a half ago, Florence Nightingale was the first to demonstrate the benefit of focusing on outcomes. Her focus on mortality of soldiers in barracks and hospitals led to her conclusion that the excess mortality rate was more a function of poor standards in hygiene and living conditions than poor nutrition of soldiers. Armed with this understanding, she facilitated a reduction in mortality rates through improvements in ventilation and environmental hygiene.
About 100 years ago, a Boston orthopedic surgeon named Ernest Codman, MD, pioneered and advocated for the “end-result idea.” He touted the importance of clinical outcomes and performance management in patient care. He was the first American doctor to follow the progress of his patients through their recoveries for one year to observe and document long term outcomes following specific therapeutic interventions. Despite his passionate plea, his idea for transparency in outcomes was too innovative and disruptive to be embraced by his colleagues. Eventually, his efforts around outcomes data resulted in losing his positions at Harvard and Massachusetts General Hospital.
In 1988, Paul Ellwood, MD, published a special report in the New England Journal of Medicine about his concept of outcomes and how outcomes management addressed healthcare issues. He took the lead from Dr. James Putnam’s Shattuck Lecture and acknowledged the important works of renowned health economists and public health experts like Avedis Donabedian, John Williamson, and Robert Brook. As Dr. Elwood reintroduced the potential promise of outcomes management in medicine, he conveyed and acknowledged the importance of timing in successfully applying these great ideas from others1.
It took another 22 years for healthcare to ignite the outcomes movement with the passage of the Patient Protection and Affordable Care Act (PPACA) of 2010. This legislative act was prompted by the country’s priority to find a solution to our impending healthcare crisis and reinvigorate our medical community’s focus on outcomes and value in healthcare. Expectedly, the Centers for Medicare & Medicaid Services (CMS) vigorously took up the banner of health outcomes to ensure its population received the highest value care.
What are Health Outcomes?
In the purest form, outcomes are simply end results. Ergo, health outcomes are the measurable changes in health status resulting from medical care. It is the actual impact of medical care interventions and the health delivery system on the health status of individuals. Traditionally, the medical community has considered health outcomes in terms of biomedical and physiological states such as death, complications, and laboratory values2.
Today, the definition of health care outcomes is much more broad and comprehensive. It has evolved to incorporate the end-results in a patient’s functional status, psychological well-being, and satisfaction with care. The breadth of health outcomes now embraces factors that are meaningful and important to individual patients by aligning medical care with patient preferences, values, and goals.4,5 Overall, health outcomes are now considered a better approach to monitor and improve the overall quality and value of care delivery.
In addition, when discussing health outcomes, it is important to understand that context matters. Health outcomes can and will vary for different populations and groups, different medical conditions and diseases, as well as the individual patient’s demographic, psychological, and social characteristics6. In particular, chronic conditions, where a cure is not possible, require health outcomes that focus more on functional restoration and quality of life since physiological measures are simply inadequate.
Hence, the terms outcome-driven and outcomes-management denote the process of focusing and managing any and all aspects of healthcare delivery including clinical interventions, healthcare practices, care processes, and financing of healthcare system in efforts to achieve the desired health outcomes7.
Workers’ Compensation vs. Group Health
The relevance of health outcomes to the workers’ compensation insurance industry is enormous in light of the lifetime costs associated with medical care and wage replacement from a work-related injury. In general, there is an inverse relationship between health outcomes with overall claim-associated cost. Since workers’ compensation costs can be significantly impacted by an injured worker’s ultimate health outcomes or health status, there is strong impetus to achieve the highest level of well-being, functional ability, social engagement, and return-to-work potential as efficiently as possible.
The growing emphasis on outcomes led to the movement toward outcomes-based networks in workers’ compensation. The premise behind this concept is to achieve better value for injured workers and the workers’ compensation industry by working primarily with those medical providers with the best outcomes related to medical care, as well as claims management. This tactic shifts the focus from a network of preferred providers with the lowest charges for services to those with the best outcomes compiled through available provider performance benchmarks or scorecards.
Unlike workers’ compensation, group health payers typically have a much shorter time horizon of responsibility for medical care, and their outcomes measures tend to be related to the provider’s process metrics, physiologic complications, or mortality. Even the satisfaction of care surveys are limited to a specific care event interaction rather than the overall perspective of the care continuum. That said, group health payers are adopting the health outcomes approach to adjust and refine their medical reimbursement systems, as well as assembling provider networks with better outcomes for better value.
Utility of Outcomes Research
Although the outcome based approach seems quite straight forward, our healthcare industry is currently challenged by the lack or limited availability of outcomes data. This is especially true when it comes to healthcare provider benchmarks. More outcomes research into all aspects of healthcare delivery is needed, from the first clinical encounter to healthcare regulations. The ultimate goal for outcomes research must be knowledge and information that can guide healthcare decisions in achieving the desired result. It is truly all about identifying and determining what and how to do things better in order to attain the desired health outcomes.
Meaningful outcomes research helps discern from real-life practice settings the most optimal treatment patterns, resource utilization, and provider combinations needed to attain the highest health outcomes possible for injured workers with specific characteristics, problems, and risks. Paradigm Outcomes’ experience researching and applying outcome management techniques for catastrophic injuries over more than 20 years demonstrates the practice’s effectiveness in achieving the best possible recovery and return to work status. For example, our outcomes research provides us the capability to evaluate providers’ performance using a proprietary benchmarking system covering specific factors in proficiency, efficiency, resources, quality of care, and service (PERQS) to determine the most effective provider combinations for a given case.
The Future of Outcomes
The next generation of outcomes research will require the collaboration and cooperation of all healthcare stakeholders, including providers, payers, TPAs, and policy makers, to advance our system’s quality and value. Focusing on healthcare outcomes, outcomes-management, and outcomes research will lead to better care, better information about care, better decisions, better value, and improved ultimate health status. The workers’ compensation industry has much to look forward to.
About Michael Choo, MD
Michael Choo, MD, is Paradigm’s Chief Medical Officer. He maintains the company’s relationships with its network of consulting physicians and centers of excellence and is responsible for enhancing clinical operations through clinical analytics, as well as leading outcomes research and development. Dr. Choo earned both a bachelor’s degree and a medical degree in six years at Boston University’s accelerated honors program in medicine. He earned his MBA from the University of Tennessee School of Business Administration. He is a member of the clinical faculty at Boonshoft School of Medicine at Wright State University teaching emergency medicine, internal medicine and family practice residents.
About Paradigm Outcomes
Paradigm Outcomes is the nation’s leading provider of complex and catastrophic medical management, Paradigm achieves 5x better medical outcomes and lowers total costs by 40%. Paradigm accomplishes this by bringing together nationally recognized doctors, expert clinical staff, the best network of care facilities in the country, and more than 20 years of clinical data to guide decisions. Paradigm is the only company of this kind, designed and built specifically to address the needs of those with traumatic brain injuries, spinal cord injuries, amputations, burns and chronic pain, and is the only company to stand behind their promises with medical and financial guarantees. Visit www.paradigmcorp.com to learn more.
1Ellwood PM. Shattuck lecture – outcomes management. A technology of patient experience. 1988. New England Journal of Medicine June 9, 1988 Vol. 318: 1549-1556
2Foundation for Health Services Research. Health Outcomes Research: A Primer. 1994
3AcademyHealth. Health Outcomes Core Library Project. The National Information Center on Health Services Research and Health Care Technology, National Library of Medicine July 14, 2004
4The PCORI Perspective on Patient-Centered Outcomes Research. JAMA October 15, 2014. Vol. 312. No 15: 1513-1514
5Real-world Imperative of Outcomes Research. JAMA August 17, 2011 Vol 306. No. &: 754-755
6Real-world Imperative of Outcomes Research. JAMA August 17, 2011 Vol 306. No. &: 754-755
7Foundation for Health Services Research. Health Outcomes Research: A Primer. 1994