Episodic Care: Delivering on the Promise of Value-Based Coordinated Treatment: Risk and Insurance

Fragmented care negatively affects everyone in the workers’ compensation system, especially injured workers.

Providers working in silos contribute to diagnostic uncertainty, disengagement from treatment, and ineffective care pathways. Specifically, when injured workers do not receive managed and coordinated care, it can mean unnecessary surgeries, risk of prescription drug addiction, and delayed return to work.

On the payer side, this all adds up to increased treatment and compensation costs, contributing to an exorbitant total cost of care.

Workplace musculoskeletal (MSK) injuries are a frequent source of workers’ compensation claims and a stark example of the barriers that fragmentation of care can create.

By integrating and coordinating the patient experience, managed episodic care programs for musculoskeletal injuries can keep the promise whole-person, values-based treatment.

With HERO Episodic^SMParadigm offers an industry-unique solution designed to deliver guaranteed musculoskeletal injury outcomes and financial value, including fixed-cost, bundled pricing for surgical episodes.

This solution leverages clinical expertise and care management resources developed over decades of managing complex and catastrophic injuries.

The goal is a guided, evidence-based approach designed to increase patient engagement.

To do this, HERO Episodic combines people-driven care coordination, value-based payment models that lower the total cost of care, and data-driven care journeys using best-in-class provider networks.

Episodic care that puts patients at the center

“The current system can be very isolating for injured patients,” said Kathy Galia, director of clinical solutions for Paradigm.

“Even for a relatively common MSK injury like a torn shoulder, an injured worker can expect to be assessed and referred to multiple providers.”

Michael Choo, MD, Paradigm’s Chief Medical Officer, agreed, “In cases that aren’t managed properly, patients may turn to multiple physicians and healthcare providers, from radiology specialists for diagnostic imaging, to pharmacists for various prescription medications, physiotherapists for rehabilitation, chiropractors for manipulations and several physicians including pain management specialists for corticosteroid injections and surgeons for surgical procedures.

In many current models of care, these practitioners typically work independently and do not see the big picture.

“This type of unmanaged care creates a need for coordination that is too often left to the injured worker,” Galia said.

“Patients may feel unsettled by lack of knowledge about their condition, confusion about available treatments, and uncertainty about gaps in care.”

These factors are at the root of why seemingly low-risk musculoskeletal injuries frequently result in runaway costs of hundreds of thousands of dollars, extended duration of claims, and return-to-work delays of hundreds of dollars. days, according to industry data.¹

In contrast, a dedicated RN care manager with injury-specific experience and training can ensure patients feel informed and receive the right care at the right time.

“With the HERO Episodic model, injured workers with an MSK diagnosis have immediate access to a team of condition-specific care coordinators and exclusive clinical pathways,” Dr. Choo explained.

In addition to a dedicated Episodic RN Care Manager, Paradigm Medical Directors with specialized expertise in specific diagnoses – including rotator cuff injuries, meniscal tears and herniated discs – guide care plans and consult a network of leading specialist suppliers.

“Injured workers will have a single point of contact who is invested in their case and who they can go to for advice or with any questions regarding the care process,” Galia said.

This solution also provides a technology-driven, two-way patient engagement platform that provides injured workers with increased information and education about their care.

This unprecedented level of patient engagement is why Episodic HERO can achieve lower disability rates and ensure maximum medical improvement (MMI) and release to return to work.

She continued, “From day one, we are increasing real-time communication and support to foster a positive, recovery-oriented mindset in these patients.

Reduce total cost of care by creating better pathways

“The concept of value-based episodic care is rooted in better outcomes and lower costs,” said Rey Quinones, vice president of product management for Paradigm.

“Any solution claiming to be value-based really needs to understand how these two goals work together.”

HERO Episodic has been carefully designed to achieve a guaranteed outcome for non-surgical and surgical musculoskeletal injuries, while reducing the total cost of care.

Achieving both of these goals requires extensive data and deep clinical knowledge to keep every patient on track.

“For musculoskeletal injuries, the decision point for surgery is crucial. Unnecessary surgeries have a major impact on cases from a recovery and cost perspective,” Dr. Choo said.

“Paradigm’s established, expert-driven, data-driven platform provides the clinical roadmap and decision support that avoid unnecessary or ineffective procedures through a proven, evidence-based model. “

While non-surgical cases are expertly managed and committed to achieving maximum medical improvement, or jurisdictional equivalent, and release to return to work, if surgery is deemed necessary, pricing is aggregated on a fixed cost, with full risk transfer until these results are achieved.

Quinones explained, “The framework we have established is based on a mixture of geographic data, patient risks and procedures. Our unique approach of tying the surgical package to the achievement of results enables our clients to set reliable reserves. »

Galia pointed out that surgical packages are really only one aspect of responsible episodic care.

“There is a misconception that bundled payments equal value-based care. Consolidation is just one spoke in the wheel of a responsible, value-based model that delivers real financial value.

She continued, “Effective care pathways that maximize functional outcomes and achieve lower disability rates ultimately mean permanence of claims settlement and lower compensation costs. Combining this with the savings from avoiding unnecessary procedures and reducing treatment costs, HERO Episodic actually lowers the total cost of care.

Evolve an established value-based model

For over 30 years, Paradigm has delivered guaranteed results and financial security through systematic care management^SM model.

This approach analyzes the basic medical needs and costs to achieve an outcome, taking into account the physical, emotional and environmental attributes of each injured worker.

“HERO Episodic leverages the same resources we’ve developed over decades to achieve predictable accuracy and guaranteed results for complex and catastrophic injuries. This includes medical costs reduced by 32% and return-to-work rates nearly six times higher, according to a Independent study 2020said Dr. Choo.

“Paradigm has always provided true value-based, accountable care that aligns patient needs through proprietary clinical pathways and a curated network of best-in-class providers. We are now evolving this model for a broader class of musculoskeletal injuries. »

“The move towards coordinated, outcome-focused treatment with a lower total cost of care is the future of our industry,” Galia noted. “HERO Episodic will provide end-to-end service to workers dealing with musculoskeletal injuries that can transform the way we think about care and cost.”

Learn more about HERO EpisodicParadigm’s innovative, results-driven solution for musculoskeletal injuries.

1. Source: ODG by CWM.

This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Paradigm. The editorial staff of Risk & Insurance played no role in its preparation.

Paradigm is an accountable specialty care management organization focused on improving the lives of people with complex and catastrophic diagnoses and injuries. The company has pioneered value-based care since 1991 and has an exceptional track record of generating the best outcomes for patients, payers and providers. Deep clinical expertise underpins every part of Paradigm’s business, including its risk-based clinical solutions, case management services, high-value specialty networks, home health, and healthcare programs. payment integrity. Paradigm is headquartered in Walnut Creek, California, and offices across the United States. For more information, please visit www.paradigmcorp.com.