Pilot program focuses on health, not function

Employees have more say in choice of providers

A groundbreaking Minnesota pilot program seeks to focus on employees’ lives and total health rather than just their functions as employees. A coalition of labor, employers, health care providers, insurers, and state government agencies is implementing a series of pilot programs on what it calls the "coordinated benefits model" of health care delivery for injured employees. (See related story, p. 19.)

The innovative model makes no distinction between an injury that occurs on the job and one that occurs away from the workplace. In either case, the employee reports initially to his primary care physician, who remains the "gatekeeper" throughout the treatment period. This ensures a level of employee choice not usually found in the traditional workers’ compensation model, where injured employees are referred to an entirely new set of health care professionals.

The majority of the funding for the pilot program comes in the form of a $254,270 grant from the Princeton, N.J.-based Robert Wood Johnson Foundation. It is the nation’s largest philanthropy devoted exclusively to health and health care, with total assets of more than $5 billion and annual grants totaling more than $170 million.

"Rather than looking at benefits, we want to turn the focus back to the employee. Our real emphasis will be on managing the health and the disability of the employee simultaneously," explains Gary Westman, acting manager of the State Workers’ Compensation Program in St. Paul.

Participants in the Twin Cities coalition include: Allina Health System, Blue Cross/Blue Shield of Minnesota, Fairview Hospital & Health Care Services, HealthPartners, HealthSystem Minnesota, and the Buyers Health Care Action Group (BHCAG). Four employer members of BHCAG (Dayton Hudson Corporation, Minnegasco, Norwest Corporation, and Rosemount), along with the state of Minnesota and Blue Cross/Blue Shield, will serve as pilot employers. The two-year demonstration project calls for pilot sites to begin implementation in 1998, following a one-year developmental phase.

Under the coordinated benefits model, "We protect employee choice, which is a unique concept in managing workers’ comp," notes Marilou Calasanz, manager of the workers’ compensation program at Norwest, a financial holding and services company, and project coordinator for the coalition program. (Norwest has outsourced 50% of Calasanz’s time to the coalition as a "like-kind" contribution).

Under the current system used by coalition members (all are self-insured), there is annual open enrollment for health care, during which employees select specific physicians, as opposed to an insurance plan. "But under workers’ comp, they most often end up seeing different types of providers — specialists, mainly in occupational health — because we direct them to," explains Westman. "That goes against the grain of what most employees want. They have already made a choice, a provider they have confidence in, so we plan to use the resources of that person to coordinate their care. It will undoubtedly increase patient satisfaction."

Employee frustration, which Calasanz says is a common occurrence in workers’ comp cases, also will be reduced. "Through the development of the pilot programs, things will become much more streamlined for the employee," she says. "For example, during the determination of liability period, when the decision is made as to whether an injury is work-related or not, there can be a delay in receipt of benefits. That’s part of the frustration of working through two different systems."

The employee-focused system also places greater emphasis on the recovery of the employee as a complete individual — not simply as a worker.

"In most practices today, physicians focus on returning people to health; returning them to function comes up at the end of the equation," says Westman. "We feel it will be there at the time the employee first comes in. Hopefully, by educating employees, supervisors, and doctors, we can create a system where the idea of paying attention to function is always part of health care delivery."

The definition of "function," says Calasanz, extends far beyond the employee’s job description. "If I am a stay-at-home homemaker, I should be able to know whether I can lift my child," she explains. "Often that type of medical advice has not been as available from providers in non-work-related injuries, because it just hasn’t been their [providers’] practice."

Cost savings also anticipated

Calasanz anticipates considerable cost savings for both employers and providers under the new system because "needless" duplication will be eliminated.

"Efficiencies will be achieved through ease of administration," she says. "For example, you might have an employee or patient who, during the period in which a determination needs to be made as to whether the injury is work-related or not, may be accessing both systems unbeknownst to each, thereby duplicating paperwork."

Quality of care also should improve, she predicts. "When your definition of health care includes maximizing function, employees will not only recover from surgery, but they can return to their social and occupational environment more quickly as well. This, I believe, will result in a healthier population."

Cooperation means everybody wins

One of the unique aspects of the coalition, she adds, is that its success depends on the collaborative efforts of many organizations, a number of which consider each other competitors. "We need the cooperation of all parties involved: patients first and foremost; the health care delivery system, which must support a paradigm shift; employers; and health plans," she says.

The ultimate goal, she asserts, is "maximizing the function of the employee population, whether they have a work-related or non-work-related disability. That is a ‘win-win’ situation for everybody — including the patient."

[Editor’s Note: For more information on the Minnesota Coalition’s efforts, contact: Gary Westman, acting manager, State Workers’ Compensation Program, St. Paul, MN. Telephone: (612) 296-8190.]