FOTO Rehab Outcomes Blog

Worker Compensation Payer Concerns

Written by Selena Horner | Jul 13, 2015 10:15:00 AM

I'll be the first to admit that in my state treating a patient who has worker compensation as a payer is easy. The laws in Michigan do not shackle my autonomy. Costs could go through the roof because no one is attempting to address the need for value in the payment model. Although some employers do choose to use a network as a solution for cost containment, it really doesn't matter because legally I am not required to be a member in any network. Michigan also has a fee for service payment schedule that is determined by the state. I have a feeling, for my state, before any impactful changes will occur, the laws will need to change to allow an alternative payment model.

Creating alternative payment models for worker compensation claims will be tricky. State lines will play a role in value based purchasing for this payer. When employers begin to tackle their medical costs problem for injured employees, their solutions may vary due to state laws. For this payer group, hopefully it won't take forever for legislative changes allowing for a focus on quality when determining payment for services.

Why should we care about the payer and the payer's pain and assisting them with cost containment? If we are a pawn in the process, we have no opportunity to lead the discussion or provide solutions that are win for the injured worker, win for us and win for the payer. 

What happens if we allow the payment model to be designed by legislators and worker compensation payers? I can almost guarantee, a "simple" solution may happen that focuses on a case by case type of management process and reduces utilization. What does this mean? It means that at a whim, number of allowed rehabilitation visits will be "capped" for each individual injured worker and the "capped" number of visits will not be determined by any solid science.

If we change our role from pawn to knight, we can lead the discussion. If you were to plot out the various companies within a 15 mile radius around your clinical practice, is every single company a great company? Are all employees completely happy with their role, position and people within their company? Do the majority of the patients you treat have worker compensation as the main payer?

I would be willing to bet that when it comes to designing an alternative payment model for this particular population, the concept of payment based on how low can you go isn't helpful for anyone (including the payer). Yes, you heard me right - that "solution" really doesn't work. I know this because in California, the worker compensation law changed to cap visits to physical therapists and occupational therapists. Each were limited to 24 visits per injury. Because limiting visits is a silo solution, the data actually indicated increased cost. The cost was shifted to medication cost.

How can we be knights leading the discussion? We should introduce the concept of the right patient at the right time receiving the right interventions. What if a clinician's track record in outcomes were included in the payment model equation? As a whole, I'm sure the majority of clinicians do not have the bulk of their patient load dedicated to patients who have been injured at work. A payment model could incorporate past clinical performance. What if there could be a system that would actually predict how much functional change should happen and within a defined number of visits? And what if the predictive analytics were based on risk-adjusted data so patients were equalized? I'd even like to toss in penalties. Why not? If a patient doesn't reach rehabilitation clinicians at the right time to receive the right interventions, someone upstream should be penalized for making a poor clinical decision. Why not build accountability and responsibility into the equation to change behaviors in all the silos involved in care for work related injuries?

Until next time,

~Selena