Randy Lea MD of the Dartmouth Institute (one of the nation’s leading healthcare research organizations, and my personal favorite) just completed research on value-based care (VBC) in work comp – a timely and much-needed project. Dr Lea presented at last week’s WCRI Conference.

Here are my takeaways.

Spoiler alert – value-based care is not getting much traction – and I don’t think it will.

First, the research was more of a survey of what stakeholders want, expect, can do, and think is necessary to bring VBC than a detailed description of what actually exists today. In that way, it’s helpful as it indicates what factors may/will lead to more VBC in work comp.

As much as I respect the Dartmouth Institute and appreciate Dr Lea’s insights, I found the presentation hard to follow. There was just too much information crammed into too little time.

Stakeholder readiness

Providers – only one engaged in a WC VBC pilot program; many were prepared and waiting, but “there’s no opportunity for them to engage at this time.”

Payers – only one is doing VBC – and that is bundled payments. Payers were more focused on high-performing networks, not real VBC. Also doubt the model will be sustainable.

Regulators – again, only one doing VBS, that one has seen positive results, and is ready to expand. access, quality, and are coordination. Not much going on, but many are at least thinking about it.

Now into the meat – their thinking about how VBC might actually occur in workers’ comp.

Conditions that were popular for inclusion in a VBC model included spine, shoulder, knee, CTS, and co-morbidities plus the condition.

First, we need a regulatory environment that is favorable to VBC. No surprise here, although all recommended employer direction, mandated medical treatment guidelines, reduced fee schedules (?!), reduced UR.

Second, providers need enough patients.

Third, there was a lot of concern around RTW, causation, and impairment and who is involved and how decisions around those key issues will be made and on what basis.

Development guidelines

1. Need a set of values that are shared by the stakeholders that guide development
2. Rewards for good performing providers
3. Transparency across all stakeholders
4. Outcomes focused, not discount-driven
5. Adaptability to current programs and regulatory conditions
6. Fair and quick reimbursement of providers
7. Reimbursement based on guidelines and compliance w MTG
8. Eliminate fee schedules
9. Need real steerage of patients
10. Tight definition of outcomes is mandatory, need real specificity around things like RTW.

Payment types – participants reviewed a variety of types of reimbursement, with most payers looking for bundled payments  – no surprise.

 

I also have to note that my main takeaway was this – work comp is a couple of decades behind the rest of the world – and it isn’t catching up. If anything, we’re falling further behind.

I say this because this is some pretty basic stuff compared to what we see in Medicaid or Medicare.

My view is there are any number of reasons VBC is not going to happen in WC.

1. There are not enough cases; providers won’t be interested in risk-taking if there aren’t enough cases to spread the risk.
2. Providers don’t have to take risk; in many states there’s no or limited employer direction, so no guarantee they’ll get a minimum number of cases.
3. Litigation – providers may have to provide documentation and perhaps testify, something no one wants to risk.
4. Payers are far too wedded to the percentage of savings profit machine.

What does this mean for you?

Bundled payments aren’t really value-based care. And even those are few and far between, for good reason.

There’s been some good research into this – which may be THE key question when it comes to medical marijuana.

The answer appears to be – some do stop using other drugs. And, even better, fewer people die.

Key findings using Medicare data:

• States with medical marijuana laws saw about 10% fewer daily doses of opioids than those without those laws.
• States with dispensaries only (no home cultivation) saw a 14% decrease in opioid doses
• Total savings to Medicare and Medicaid would be about $3.4 billion if all states adopted Medical Marijuana Laws – but the folks buying the marijuana would pay for their cannabis out of their own pockets.

Studies using Medicaid data saw somewhat greater reductions in opioid usage.

Couple observations – there have been massive changes in PDMPs, increases in naloxone usage, tighter state laws and federal guidance on opioids (CDC et al), which may well have had some impact on death rates and lower opioid usage overall (Brian Allen of Mitchell made this point just after I wrote this). Dr Bradford noted that their analysis considered these possible confounding issues.

My big takeaway – there’s a significant reduction in the number of deaths due to opioids when states have access to cannabis. Like a 25% reduction.

Dr David Bradford of the University of Georgia presented this information; he and Ashley Bradford published much of this in a piece in HealthAffairs two years ago; they used Medicare and Medicaid data.

Dr Bradford noted he and Ms Bradford hope to be working with WCRI on a workers’ comp-specific study soon.

Physical medicine – chiropractic, occupational and physical therapy – accounts for about one out of every six dollars of workers comp medical spend.

Key takeaways from DR Rebecca Yang’s discussion of the latest CompScope(tm) report:

The location of PM services has shifted from hospital outpatient to non-hospital locations since 2003.

PM accounted for almost 18% of WC medical costs, with non-hospital totaling 14.6%.

Part of the reason is likely reimbursement; non-hospital care averages $41 per unit, while hospital is almost 50% more expensive at $60; this varies quite a bit by state.

Anecdotally, several payer clients have told me their PM costs have been increasing; some are concerned and others see this as likely – and not unwelcome. This latter group sees PM as a replacement or substitute for more invasive/riskier and expensive care – specifically surgery and opioids.

Don’t have any data to support these anecdotes, but hope to hear from anyone who’s looked into this.

What does this mean for you?

Increasing physical medicine costs may well be a good thing.