The Evolving Healthcare Model: The Impact of ACA on Workers’ Compensation and Beyond

Consider the implications to your organization of possible changes in access to care, consolidation of providers and facilities and the use of accountable care organizations. All this is rapidly becoming a reality under the changes to our healthcare system brought on by the Affordable Care Act (ACA). How will this impact your business? What steps can you take to ensure your injured workers have access to the best care? What issues are on the horizon?  This was the subject of a 2015 SIIA Workers Compensation Executive Forum session presented by  Kimberly George, Senior Vice President, Senior Healthcare Advisor with Sedgwick.

Putting politics aside, ACA has resulted in changes to the healthcare delivery model that cannot be undone. There has been significant consolidation of clinics, facilities and provider networks. Things like stand-alone outpatient surgical centers and neighborhood physicians have all but become extinct.  Workers’ compensation needs to respond to the new realities of this healthcare delivery model.

What are the primary Affordable Care Act considerations for workers’ compensation? Many have indicated that cost shifting to workers comp and access to care are the biggest concerns. When you think of access to care, the question becomes will we end up with a tiered medical system where some systems reimburse at higher rates than others. Those who do reimburse at higher rates will have a greater ability to select the providers who deliver superior outcomes and also ensure access to care.

Without question, under the current model there will be an access to care issue. It is estimated that the physician shortfall will be 60,000-90,000. The medical schools are not increasing enrollment to try and fill this gap, so this will have to come from other sources such as increased use of Nurse Practitioners, Physician Assistants and newer concepts such as telemedicine.  The workers compensation systems in many states need to evolve to support these new treatment sources as many states do not currently allow use of them. In the future, we will also need healthcare providers to practice at the top of their license, in other words to provide care where their expertise is needed vs providing more routine treatment that could be done by less than a physician.

The shift from evaluating healthcare providers based on value instead of volume is part of the ACA which the workers’ comp system can benefit with.  Outcomes based networks will become an increased focus on both the group health and workers’ comp side of things.  Early results from physician ranking models are showing significantly better outcomes with the higher ranked physicians, who consistently deliver quicker return to work and lower overall medical costs. On the group health side, more and more insurance carriers are already moving to value-based reimbursement rates where better outcomes results in higher reimbursement rates to the providers. 

Case management will need to focus more on the patient as a consumer, with the case manager playing an active role in ensuring the injured worker receives the appropriate care in a timely manner. A 24/7 nurse triage program can also play a substantial role by directing the injured worker to the correct provider immediately.  Patients are also being encouraged to become more engaged in their medical care and the case managers can play an active role in patient education and medical literacy so these patients can better understand their treatment options and the potential outcomes associated with these option.  

Genomic testing will also become part of an evolving healthcare delivery model. This testing is done once in a patients’ lifetime and can determine exactly what medication will deliver the best results for the patient with minimal side-effects. In just a few years, this genomic testing will become a routine part of a patients healthcare records.