Industryweek 12811 Medical Care Costs Risks

Making Value-Based Medical Care Work in an Occupational Setting

Jan. 17, 2017
The U.S. healthcare system has undergone significant changes over the years. One transformation that likely will stand the test of time is the industry's transition from fee-for-service to value-based care payment models, which helps reduce cost while improving quality.

The U.S. healthcare system has undergone significant changes over the years. One transformation that likely will stand the test of time is the industry's transition from fee-for-service to value-based care payment models, which helps reduce cost while improving quality.

By 2018, the Centers for Medicare and Medicaid Services (CMS) plans to move 85 percent of its fee-for-service payments to reimbursement based on achieving quality, outcome and cost metrics.1 This new payment structure will have a major impact on occupational health, as the current focus on the number of patients treated will shift to cost effectiveness and health outcomes.

Although this shift will affect all fields of medicine, occupational medicine physicians will be tasked to adhere to evidence-based medicine even more closely.

An obstacle that physicians currently are facing is that much of the available evidence, in the form of research and resources, is outdated or unsubstantiated, which can lead to overtreatment, variations in care and potentially longer recovery times. These variations create high cost and waste and substantiate the fact that the occupational health community has not fully embraced evidence-based care. Consequently, workers are being exposed to unnecessary risks when it comes to treatments, prescriptions and more.

Addressing the Opioid Epidemic

One such risk is the overprescribing of opioids, given that the annual impact of the prescription opioid epidemic in the United States has reached $55 billion.2 A National Safety Council survey shows that 99 percent of primary care physicians are prescribing opioid medicines for longer than the three-day period recommended by the Centers for Disease Control and Prevention.3

Additionally, the survey found that 74 percent of doctors incorrectly believe morphine and oxycodone are the most effective ways to treat pain when other medications have proven to be more effective. 4

An evidence-based formulary can help stem this crisis by ensuring patients receive an effective treatment the first time. For example, a non-opioid, such as the antidepressant Cymbalta, frequently delivers optimal outcomes for pain management.

A truly evidence-based formulary presents this medication to physicians as an appropriate alternative to opioids. The formulary guides the physician to prescribe the medication and provides supporting research to share with insurers to help facilitate approval of the claim. As a result, the patient can begin taking the medication – and also return to the workforce – more quickly.

As our nation addresses the opioid epidemic, evidence-based formularies give physicians the tools they need to prescribe patients more effective alternatives to opioids.

Case Study: California Division of Workers' Compensation

Unfortunately, many providers who do want to incorporate more evidence-based protocols into their practices are using guidelines and formularies that are backed by questionable or antiquated research and not regularly updated. These providers, in turn, inadvertently may place their patients at risk by relying on unsubstantiated recommendations, creating more variation in care while increasing costs – exactly what value-based care strives to eradicate.

There are, however, reliable and updated evidence-based guidelines and tools that are being adopted nationwide. A prime example of this is the state of California, which recently based its Medical Treatment Utilization Schedule (MTUS) drug formulary on the American College of Occupational and Environmental Medicine's (ACOEM's) formulary recommendations, which are widely considered the gold standard in effective treatment of work-related injuries and illnesses.

Additionally, the state's Division of Workers' Compensation is updating its MTUS medical guidelines to align with most recent ACOEM practice guidelines, which meet the highest standards set by the Institute of Medicine for quality guidelines. Both moves are pivotal, and both recognize the importance of aligning evidence-based drug recommendations with the patient's condition and phase of care.

Three major goals drove the formulary development, according to state leaders. The first is to provide the best evidence-based care and drug recommendations for workers; the second is to expedite appropriate treatment and the third is to reduce the administrative burden and costs. All three goals are not only applicable to employers, payers and healthcare providers but patients as well.

Evidence-Based Medicine Advances Occupational Health

Evidence-based guidelines and formularies arm occupational physicians with the research and tools they need to achieve optimal outcomes and promote efficiency by giving them access to data that enables them to make the most effective decisions practicing under value-based care programs.

Evidence-based resources, however, need to be continually reviewed to ensure accuracy and reliability. Tools such as formularies and disability duration tables – which display the number of days patients will require to recover from a procedure or condition and resume normal activities – require scientific, unbiased scrutiny from a diverse and highly qualified medical advisory board. Point-of-care accessibility also would improve care efficiency and allow physicians and patients to have face-to-face discussions about their recovery.

In addition, evidence-based guidelines should be used alongside predictive modeling tools to set patient and employer expectations. For example, a patient with a low back fusion who could no longer do heavy lifting would benefit from a predictive modeling tool that incorporates demographic, job class and coexisting medical condition information to calculate recovery times. With this information, the patient, in conjunction with his employer and case manager, could explore realistic recovery or job options. As a result, the patient would be able to return to the workforce in a new job, remaining productive, rather than relying on disability compensation.

Preparing for the Future

Value-based care and associated payment programs that compensate providers based on quality-of-care metrics and cost management will continue to be more widely adopted.
To adapt to this environment, healthcare providers must have the tools to deliver the proven-effective treatments that result in better patient outcomes and higher reimbursements. An evidence-based formulary is one such tool that not only helps providers succeed under these new care models, but also can deliver long-term, safe and productive recoveries for American workers.

Greg Vanichkachorn, M.D., is the corporate health director for Kalispell Regional Healthcare in northwest Montana. He is board certified in both occupational medicine and family medicine. For the past seven years, Vanichkachorn has served as the medical director for a multifaceted occupational medicine clinic. More recently, he has applied himself to population health management for employer groups and general patient populations.

1"Better Care. Smarter Spending. Healthier People: Paying for Value, Not Volume, CMS Fact Sheet, Jan. 26, 2015,
2"The Opioid Epidemic by the Numbers," U.S. Department of Health and Human Services,
3Teater, Donald, MD, "Evidence for the efficacy of pain medications." The National Safety Council. Report. 2014.
4Teater, Donald, MD, "Prescriber attitudes and behavior related to prescription opioid pain medication." Presentation: National Safety Council. 2016.

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