New Paradigm for Brain Injury Rehabilitation Providers in Engaging Payers and Insurance Groups

By Michael Choo, M.D., MBA, FACEP, FAAEM, CMRO, Paradigm

We are fortunate to live in an era when the unprecedented pace of scientific discovery and medical innovation drives significant improvement in care delivery and survival of patients with catastrophic injuries, especially brain injuries. Although we certainly welcome these advances, it is imperative to acknowledge that costs are growing at an alarming and unsustainable rate. Concurrently, the purchasing mindset of payers has evolved over the past decade toward a much higher level of scrutiny and a value-discernment.

It is clear that our health care industry needs true collaboration between providers and payers to achieve a meaningful alignment of incentives and to nudge our nation’s prevailing fee-for-service and highly transactional platform toward a more value-based approach that pays for better or best health outcomes.

In the rehabilitation industry specifically, there is a growing need to justify care interventions by demonstrating clear and measurable benefits that are functionally meaningful to patients and families, as well as cost-efficient and cost-effective. This is especially challenging for post-acute care providers, because rehabilitation benefits typically occur incrementally over the care continuum. Additionally, the rehabilitation industry has yet to reach evidence-based consensus on minimum effective dose recommendations for many existing care interventions even as evolving medical technologies have introduced a good number of therapeutics, including rTMS, stem cells, medications for optimizing brain injury recovery, and cognitive and physical rehabilitation modalities.

So, how can a brain injury care provider best demonstrate to payers the value of rehabilitation services?

To best deliver on superior value and outcomes, rehabilitation providers should:

• First: Partner with payers to determine and standardize clinical outcome measures that are truly meaningful to patients and payers.
• Second: Focus on analyzing the actual impact of each treatment modality and ascertain through scientific evidence what the “sweet spot” dosages are for achieving incremental and maximal benefit and for determining the highest therapy associated return on investment.
• Third: Rehabilitation providers must be willing to work with payers on outcomes-based comparative effectiveness measures of new versus existing rehabilitation interventions.

Current trends in health care require rejecting traditional approaches and mandating true collaboration and partnership between providers and payers to align stakeholders’ goals, reduce medical spending and waste, and keep our focus on improving the lives of our injured patients.

About the Author

Michael Choo, M.D., is the chief medical officer and senior vice president of Paradigm. He is responsible for Paradigm’s expert physician networks, centers of excellence, clinical outcomes R&D, and care management optimization including medical innovation effectiveness. He is a clinical faculty member at Wright State University’s Boonshoft School of Medicine teaching emergency medicine and a former hospital CEO for Regional Care Hospital Partners.