Implementation Plan for Value-Based Health Care in NSW WC and CTP Schemes - Progress report October 2023

1. Development of a value-based health care implementation plan

In December 2021, SIRA released its Implementation Plan for Value-Based Health Care in NSW WC and CTP Schemes (the Implementation Plan). The Implementation Plan sets out 21 initiatives under four work streams to support the implementation of value-based health care (VBHC) in the personal injury schemes (workers compensation and motor accident schemes). These four work streams are:

• Stream 1: Measure health outcomes and costs and improve data quality
• Stream 2: Support enhanced clinical practice
• Stream 3: Streamline administration and reduce leakage
• Stream 4: Develop scheme capability in value-based health care

2. Governance arrangements

SIRA has established a sector-wide VBHC Advisory Committee to provide advice and support our vision for health care.
The VBHC Advisory Committee comprises key senior leaders in insurance, health care delivery, employers, academia, and people with lived experience. The committee has also established working groups to support key activities to streamline administration and support implementation of key VBHC projects, including the low back pain model of care.
SIRA has reset the horizons set out in the Implementation Plan to better align to the strategic priorities and outcomes outlined in SIRA2025 (our strategy).

In July 2021, SIRA published the Value-Based Health Care Outcomes Framework for the NSW Workers Compensation and Motor Accident Injury/Compulsory Third Party Schemes. The health care outcomes framework aims to provide guidance and a structure to measure progress towards and achievement of health outcomes through a series of quantifiable metrics. It is a key enabler to realising SIRA’s vision for VBHC. The key priority areas of implementation for the health outcomes framework are as follows:

• Developing a transparent and systematic approach to monitoring and reporting value for outcomes.
• Developing a service delivery approach that drive improvements in health and wellbeing.
• Developing sustainable end-to-end VBHC models that are embedded across the personal injury schemes.

SIRA has undertaken key activities under the four work streams to implement VBHC in the personal injury schemes.

Key achievements following the release of the Implementation Plan include:

• Observed a stabilisation of health care expenditure growth in the last two financial years after COVID.
• Implemented surgeon and allied health fee reforms which are on track to deliver projected savings in the workers compensation scheme for financial year 2022–23.
• In partnership with the Agency for Clinical Innovation, developed a new model of care for low back pain, which will benefit over 18,000 people with low back pain that enter the personal injury schemes each year.
• Developed a new approach to allied health treatment approval with a revised form to reduce administrative burden for health providers and insurers and increase focus on clinical care.
• Published a range of standardised outcome measures for health providers to screen an injured person’s health status to optimise care pathways in the personal injury schemes.
• Designed new data systems to identify billing practice compliance, including overcharging and over-servicing.
• Obtained new legislative powers to regulate health providers who are not doing the right thing.
• Established a Specialist Support Liaison function to improve outcomes for families impacted by a road fatality.
• Delivered trauma‑informed care training sessions to insurer case managers.
• Undertook qualitative research to understand people’s experience of receiving care and health providers’ experience of providing care to inform our implementation plan.
• The SIRA lived-experience Recover at Work Reference Group developed mental health-focused tools and resources to support people to return to work with improved health outcomes.
• Established a sector-wide VBHC Advisory Committee to help inform the Implementation Plan.

2.1. Stream 1: Measure health outcomes and costs and improve data quality

This stream focuses on ensuring SIRA and scheme participants are delivering VBHC across the personal injury schemes. This is achieved by measuring and monitoring areas for improvement in line with the VBHC Health Outcomes Framework.

2.1.1. Progress on stream 1 initiatives

Work relating to initiative 1.3 Assess data capability of scheme participants will commence at a later stage. This initiative is about identifying and understanding the capability of scheme participants to:

• extract information from electronic or paper sources (data capture)
• transfer information collected offline to an online digital environment (data onboarding)
• collect, organise and access information to inform decision-making (data management)
• exchange information for multiple use cases (data sharing).

As part of SIRA2025, we have enhanced and transformed our digital capabilities to achieve our ambition to be an intelligence-led regulator.

We will continue to work with scheme participants to better understand their current data capabilities and identify opportunities to improve data processes in the personal injury schemes.

2.1.2. Next steps for stream 1 in 2023–24

SIRA is progressing other VBHC activities under stream 1, which includes:

• investigating retrospective billing practices by health providers (aligns to initiatives 1.5 and 3.5)
• developing additional outcome measures for supervision of psychologists (aligns to initiatives 1.1 and 3.5)
• developing digital processes to approve health provider applications (aligns to initiatives 1.4 and 3.5).
• strengthening the approval frameworks and processes for cyber security, data sharing and storage for workplace rehabilitation providers.

We will continue to refine the reporting of health care costs and outcomes so they are meaningful to scheme participants. This includes providing insights on how scheme participants can modify their behaviours to achieve better health outcomes for people injured in workplaces and on the road.

2.2. Stream 2: Support enhanced clinical practice

This stream focuses on ensuring evidence-informed practice is consistently embedded in the personal injury schemes. This will maximise recovery and promote effective and efficient person centred care across the claims journey.

2.2.1. Progress on stream 2 initiatives

Of the six initiatives under stream 2, all initiatives have been activated.

2.2.2. Next steps for stream 2 in 2023–24

SIRA, in partnership with University of Melbourne, is continuing a large-scale project to identify areas of low value care in the personal injury schemes. This work will inform strategic planning and policy development to support reduction of low value care in both schemes and guide systems and processes to monitor trends in low value services provided to people injured in workplaces and on the road.

We will also:

• explore options to investigate how unwarranted variations in care can be monitored over time, which builds on this important work in low value care
• further develop a VBHC response to psychological injuries in the personal injury schemes.

2.3. Stream 3: Streamline administration and reduce leakage¹

This stream focuses on ensuring scheme case management aligns to SIRA’s value-based approach to health care by streamlining administrative processes to reduce delays in care and achieve better health outcomes and experiences.

Based on advice from the VBHC Advisory Committee, streamlining administration is a key work area to implement VBHC in the personal injury schemes. Therefore, we are focusing on a number of activities under this work stream from 2023–24 and beyond.

2.3.1. Progress on stream 3 initiatives

2.3.2. Next steps for stream 3 in 2023–24

Under stream 3, SIRA is progressing work on:

• a new surgery request form to aid timely approval of surgical procedures by insurers (aligns to initiative 3.2)
• a comprehensive review of medico-legal services, which will be split into phased projects (aligns to initiative 3.4)
• monitoring health providers who charge above maximum fees (overcharging) (aligns to initiative 3.5)
• monitoring health providers who are observed to be over-servicing or not achieving optimal health outcomes for people (aligns to initiatives 3.5 and 4.4)
• monitoring compliance against the workers compensation workplace rehabilitation provider approval framework (aligns to initiatives 3.5 and 4.4)
• refining policies and procedures on regulatory compliance for health providers (aligns to initiative 3.5)
• ongoing approval and monitoring of health providers to ensure they are fit to deliver services in both schemes for people injured in workplaces and on the road (aligns to initiative 3.5).

We will continue strengthening our regulatory capability in this area by improving our systems to collect, analyse and report data in a timely manner. We will also continue our work on fees reforms to ensure the personal injury schemes are financially sustainable.

2.4. Stream 4: Develop scheme capability in value-based health care

This stream focuses on ensuring care meets the expectations of people injured in workplaces and on the road. This is achieved by partnering with scheme participants to embed a shared understanding of VBHC across the personal injury schemes.

2.4.1. Progress on stream 4 initiatives

Of the five initiatives under stream 4, four initiatives have been activated.

SIRA will commence more specific work relating to initiative 4.5 Develop mechanism for clinician peer-to-peer discussion and mentoring across private and public systems at a later stage. Initiative 4.5 is about supporting health providers to ensure they provide safe, high-quality, value‑based care to people injured in workplaces and on the road across the public and private health systems.

As a starting point, we have revised the training for allied health practitioners to work in the workers compensation scheme to cover VBHC principles.

SIRA regularly meets with peak bodies and professional organisations to understand frontline issues experienced by health providers in the personal injury schemes. We will also continue building working relationships with government and non-government organisations, including academics, to:

• leverage knowledge and expertise in VBHC and evidence-based practice
• enhance the connectivity between insurers, employers and health providers across the public and private health systems to achieve better outcomes for people.

2.4.2. Next steps for stream 4 in 2023–24

SIRA is progressing work under stream 4 to:

• investigate health services to determine non-compliance with legislative requirements (aligns to initiative 4.4)
• refine data exchange processes with the Australian Health Practitioner Regulation Agency to monitor allied health practitioners with conditions or restrictions to their registration (aligns to initiative 4.4)
• implement and embed specialist job seeking services with insurers and workplace rehabilitation providers (aligns to initiative 4.4)
• enhance the capability of health providers to deliver person-centred services that matter most to people in an effective and efficient way (aligns to initiative 4.4).

We will continue working closely with scheme participants and other stakeholders, including people with lived experience, to ensure our vision for health care is embedded in the long-term.

3. Next update in 2024

SIRA will provide a further update on its progress on the implementation of VBHC in the personal injury schemes in mid-2024.

Appendix—SIRA’s value-based health care implementation plan initiatives

Stream 1: Measure health outcomes and costs and improve data quality

Stream 2: Support enhanced clinical practice

Stream 3: Streamline administration and reduce leakage

Stream 4: Develop scheme capability in value-based health care

¹Leakage is defined as the expenditure amount associated with anomalous claims beyond the threshold level identified within each category tested that represents the usual range of health care expenditure expected to be observed. The categories tested are over-servicing, overcharging, non-coverage, non‑investigation and payment management. Further information is available on the final report of SIRA’s Health Care Review.