By Michael Gavin, President, PRIUM
When I was seven years old, I bet my uncle $20 that the New England Patriots would beat the Philadelphia Eagles in a regular season, just-another-Sunday matchup. I lost. And perhaps in an effort to warn me off of any future gambling proclivities, he demanded payment. In full. That day marked the beginning of my education in the many differences between “betting” and “investing.” I recognize that’s a distinction not everyone makes, but I also think our industry’s lack of differentiating the two may be holding us back from doing the right thing for injured workers.
In last week’s column, my colleague Mark Pew made an impassioned plea for us to look at the injured worker as a “whole person” and to think about the environment, background, and life experiences of the people we work to serve. Mark’s comments resonate for a multitude of reasons, not the least of which is that any one of us would wish to be treated as he suggests. So why does something so obvious and so universally accepted turn out to be so hard to implement?
Like any other investment, the claims organization or individual professional charged with making the decision has to assess the nature of the investment, the quality of the investment, and the risks associated with the investment. And we don’t do a very good job in our space of defining any of those characteristics.
What services are needed?
First of all, what do we mean when we say things like “cognitive behavioral therapy,” “life coaching,” and “alternative modalities?” Our industry has thought leaders capable of defining these terms, but have we really pushed the necessary education to the point of injured worker interaction and claims management decision making? The phrase “cognitive behavioral therapy” itself has a multitude of potential definitions and nuances. The injured worker might need motivational interviewing to help set new goals for activities of daily living…or he might need help in developing new pain coping mechanisms through mindfulness training…or she might need emotional assistance in navigating feelings of victimization and stress exacerbated by the injury…or he might need all of the above. As we strive for greater specificity in defining needed services, our industry’s collective comfort level with those services will increase, allowing for greater receptivity and deployment of needed interventions.
How do we measure service quality?
If a payer is seeking the lowest-cost network of alternative treatment providers, that payer is going to waste a lot of time and money and have little to show for it. I know it’s popular to extol the virtues of quality-based networks, value-based healthcare purchasing, and pay-for-performance programs. I also know it’s rare to actually implement any of those things at a scale that matters, either clinically or financially. But behavioral health is an area where we, as an industry, might find discrete and differential value by focusing on quality instead of cost. And for those skeptical about the prospect of achieving reliable quality measures in such an apparent gray area of clinical intervention, I suggest taking a closer look at where behavioral health is headed. The advent of feedback-informed-treatment is upon us and will bring with it a host of metrics-driven behavioral health providers who will be able to shed light on what’s working, what’s not, and focus the field on real and reliable outcomes.
What are the risks?
For starters, it might not work. Whatever behavioral health intervention one chooses, regardless of its match to an injured worker’s needs, it may not prove beneficial. Even the best results we see in peer reviewed literature suggest that behavioral science is still, at best, a moderately effective set of interventions. And while I see a path forward to more evidence-based, effective, and replicable interventions in the future, I understand the perception that behavioral interventions today might feel like proverbial “rolls of the dice.” But if we don’t try to fix the broken people we see come into this system, are we not simply trading today’s investment for tomorrow’s reserve adjustment?
Bets are uncertain, out of our control, and sometimes carry heavy risks. Investments are well defined, informed by research and education, and made thoughtfully in search of a return – even if that return isn’t immediate. Taking on the “whole person” and thoughtfully deploying behavioral health interventions is among the smartest investments our industry can make.
About Michael Gavin
Michael Gavin is responsible for the strategic direction and management of PRIUM. He brings deep experience in several major sectors of the healthcare industry to his leadership of the medical intervention company and is the author of the thought-provoking Evidence-Based blog. Gavin frequently presents at such conferences as the National Rx Drug Abuse & Heroin Summit and the National Workers’ Compensation & Disability Conference & Expo.
Before joining PRIUM in 2010, Gavin was a consultant with Kurt Salmon Associates, a leading provider of strategic advisory services to the healthcare provider sector. He is also the former vice president of operations for MDdatacor, Inc., which provided innovative information technology solutions to support pay-for-performance programs. Previously, he was a consultant with The Monitor Group in Cambridge, Massachusetts. He holds an MBA from Emory University’s Goizueta Business School, and a BSBA degree in Finance from Georgetown University’s McDonough School of Business.
An Ameritox solutions provider, PRIUM is a leader in the market for workers’ compensation medical interventions through a collaborative physician engagement process encompassing evidence-based medicine, clinical oversight, and jurisdictional guidelines to ensure optimal financial and clinical outcomes. PRIUM’s ability to secure higher agreement rates with physicians to modify treatment plans and ensure compliance is unmatched. The hallmark of the medical intervention company’s success is to eliminate unnecessary treatment through a comprehensive approach that includes complex medical interventions, utilization reviews, and independent medical exams. Based in Duluth, Ga., PRIUM can be reached at www.prium.com or 888-588-4964.