Although it appears the Affordable Care Act (ACA) was not intended to affect the workers’ compensation system, it may influence it. Ohio may be less likely to experience some of the hypothetical outcomes discussed for other states, but there is a correlation and potential impact.
Smart Business spoke with David D. Kessler, medical director at CompManagement Health Systems, about how the ACA might affect workers’ compensation.
What aspects of the ACA could be used in the workers’ compensation system?
An important concept with the ACA is the reference to Accountable Care Organizations, which are groups of health care providers who coordinate the care given to their patients. This requires sharing information for informed decision-making among stakeholders.
Workers’ compensation has many moving parts that involve multiple interested parties, creating variable goals. These have the potential to introduce inefficient processes, escalating costs and compromising care for injured workers. Sharing clinical information between parties helps with enhanced decision-making and permits the use of evidence-based best practices. Coordination on this level should reduce duplication of services, potentially reduce medical errors and enhance recovery from an injury, permitting a timely and safe return to work.
It is generally accepted that fee-for-service payment methodology has a tendency to increase utilization for optimizing provider revenues. Although a higher frequency of care in the acute phase may increase initial costs, it can mean achieving long-term goals and better outcomes, lowering costs to employers.
How could the ACA’s expanded benefits affect workers’ compensation?
The ACA may result in healthier employee groups because it covers those who previously had no health care benefits, allowing them to address primary health care needs. A healthier employee population should have lower risks for claim frequency or severity, reducing associated costs from disability and medical care post-injury. Although employers may fear increased exposure for filing claims or prolonged use of services initially, this may lessen when other health care options are offered. However, high deductibles or co-pays may create financial stress to the beneficiary, discouraging greater use of health insurance.
Another common situation in workers’ compensation is when an employee’s current health status or pre-existing condition prolongs recovery and requires additional care, successively producing greater costs. Accurate diagnosis and complete records help the Managed Care Organization (MCO) determine if the requested services are necessary for treatment in a claim. Engagement and personal responsibility from the individual through accessing available health care that may be external to workers’ compensation can help decrease barriers affecting response to treatment.
How might the ACA affect the kind of care provided through workers’ compensation?
Another component of the ACA that affects the workers’ compensation arena is the Patient-Centered Outcomes Research Institute (PCORI), which is designed to improve health care delivery and outcomes. In a comparable process, MCOs in Ohio are required to use Official Disability Guidelines (ODG), which are a meta-analysis of evidence-based protocols that serve as the basis for evidence-based care collaboration. When providers are reluctant to cooperate and discuss evidence-based practices, it impedes achieving ideal outcomes. Utilization management of requested services from the MCO industry is enriched through use of tools such as ODG, and should serve as an educational opportunity for informed decision-making for injured workers, employers and providers. PCORI’s success could facilitate applicable use in the workers’ compensation system.
Although the ACA may not directly impact Ohio workers’ compensation, its focus on the interactive communication of evidence-based medicine for informed decision-making, regardless of the payer or administrative organization, should be the guiding message driving quality, cost-effective, patient-centered care. ●
David D. Kessler, DC, MHA, CHCQM is Medical Director at CompManagement Health Systems. Reach him at (614) 760-1788 or [email protected].
Insights Workers’ Compensation is brought to you by CompManagement Health Systems
