Healthcare Reform: What Might it Look Like?

I showed this photo to an acquaintance who happens to be an ER nurse. The turkey vulture in the image was sitting on a tree next to the freeway, and the title of the photo was Waiting for Roadkill. That nurse said, “hey, that’s how we feel about ourselves working in the ER!”

There is that certain irony in healthcare in that we get into it because we want to help. But perversely we need people to get sick or injured in order for us to help, to have jobs, to get paid, and fulfill our personal mission to do good. One person’s worst day of their life can be our chance to make a difference, or to have an adrenaline rush or an intellectual challenge.

The same irony applies to healthcare organizations: the unhealthier the population we serve, the more likely that the organization can fulfill its mission, especially if that population has a payment source.

What about the future mission of healthcare organizations? The mission will probably not change, but:  Can we continue to sit like the vulture and keep our beds full and our outpatient departments busy, or is something new headed our way? Below I’ve listed some of the changes that we can expect as part of healthcare reform. And if you are thinking that the Supreme Court is going to strike it all down and we will return to the good ol’ days, think again: The current system is simply unsustainable. These are the good ol’ days! Reform itself will change, but there will be reform of some sort.

Moving From
Paid to take care of sick people. The more procedures and episodes of care, the better the revenue stream.
Moving Towards
Paid to keep populations healthy; the less that high cost care is provided, the better the bottom line. Encourage use of seat belts, obeying speed limits, eating healthy, ambulatory services and so forth.

Moving From
Set our prices and make up for losses on charity and government-paid services through profits on commercial insurance (cost shifting).
Moving Towards
The expectation that all payors will gravitate towards the level of payment made by Medicare. There will be nowhere to cost-shift to.

Moving From
We write things down, scan it, and then we file it away. A box of paper costs $10. Pens are ten cents.
Moving Towards
We document electronically, communicate the information through all levels of care, and assemble the collective data in novel and useful ways to guide our decisions. The patients’ records follow them wherever they go. A comprehensive EMR costs millions of dollars.

Moving From
Do our best and charge for our efforts, even if sometimes we have to re-admit or do-over.
Moving Towards
Payments will be at risk based on measures of quality and patient satisfaction. We will have to absorb the costs of our errors.

Moving From
We do our thing, doctors do their thing.
Moving Towards
Alignment of physicians and hospitals into some version of coordinated care organizations.

Moving From
We do our thing, nursing homes, home health agencies, outpatient providers do theirs.
Moving Towards
Single payment per episode of care, and other “bundled payment” schemes

It will be a challenging time. You’ve probably heard the old saying that “no money, no mission.” Some organizations will likely not survive the changes. I’m confident that the organization that I work for can survive and possibly even thrive in the “going to” future world, but that period of transition will be incredibly challenging because the incentives and payments now and in the future are polar opposites.

Here is what I know rehab providers can do to prepare that is within our control:
1. Reduce costs through control of expenses.
2. Learn how to optimize and most effectively use services. (For an example, in outpatient PT will 3 visits per week be more effective than 2 visits per week? Challenge the conventional wisdom and go with identified best practices.)
3. Where ever possible, measure quality and strive to be the best.
4. If we have an established way of doing things, do it that way always. Variation is costly and leads to errors and uncontrolled processes.
5. Challenge the way we do things, but remember that in a complex system each thing we do is tied to many things that others do; any proposed change needs to be carefully evaluated to avoid unintended consequences.
6. Focus on the mission, and have fun.

Many people get anxious when they face change. I see it differently: It’s an opportunity to become an agent of change, to make a difference in how we do things for years to come. This is a time when we all need to engage in adapting and molding our work to the new future.

Falafel and the Triple Aim

As I am writing this, I’ve just returned from a visit to Portland. I have a favorite restaurant there called Nicholas’. Located near the Convention Center, it serves Mediterranean dishes: Lebanese and Greek. It is one of those many hole-in-the-wall places that has built a huge loyal following over the years. On most any evening there will be a cluster of people outside—regardless of the weather—waiting for a coveted table to become available. The staff is somewhat surly and they only accept cash, but the business has succeeded to the point where they recently opened another restaurant in the Northeast district of Portland.

We decided to try the new restaurant. I’ve always believed that expansion is the test of a small business, especially a restaurant.  With expansion, often the service or food quality fails to meet the standard set by the original location.  I’ve seen many instances where adding another store will actually cause both to fail. Not so in this case. Our wait staff was actually a bit less surly, the food was as excellent as ever, and they appeared to be accepting credit cards. I saw many customers who seemed to be of Middle Eastern descent, so the local ethnic acceptance of the restaurant remains strong in the new location. I felt that the money we paid for dinner was well spent.

I believe they’ve succeeded in their expansion. And I could relate their success to our own goals at Asante. Since healthcare is entering the era of the Triple Aim (improved outcomes, enhanced patient experiences and reduced costs) we might be able to glean some lessons from this small business.

What we are measuring is reliability, consistency, and efficiency. On the evening of my visit, Nicholas’ achieved that trifecta of value: My expectations regarding food and service quality were either met or exceeded, and the price had not gone up. Can we say the same regarding the expectations of our customers?

At Asante, we do pretty well at efficiency. Doing well at reliability would mean that we always achieve the desired result, and consistency means that we use standard methods to achieve those results. (After all, how can we improve a process that is inconsistent?) Right now, as an organization, we have room to improve in those areas of consistency and reliability. And, as you should know, unless we are top-tier in all areas of measurement a payment penalty will be imposed by Medicare in the very near future. Imagine the challenges to us as an organization if we are still trying to improve ourselves when we are experiencing additional reductions in payments.

We will be striving to standardize and improve our processes, our patient experience and our patient care protocols in the coming months and years. This standardization sometimes goes against the grain of healthcare professionals, but the organizations who are exceeding the average benchmarks have already proven that this is the pathway to improve performance.

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Fourth of July

Our next important national holiday is, of course, the Fourth of July. We’ll see lots of flags, picnics, parades and alcohol consumption (with a likely spike of business in our ED). We tend to think of the day in terms of whether or not we have to work on the holiday.

These photos were taken about half way between Cuba and Florida last March when I was on vacation. The captain of our cruise ship spotted this tiny boat, loaded with 18 souls and what appeared to be a very underpowered outboard motor, heading north from Cuba. It had no shade, and who knows what provisions. I doubt there was more than 12 inches between the waterline and the gunwale. When the boat was spotted, the seas were very calm but I have no doubt that if any significant swell or wind appeared the boat would have been swamped and all aboard would have perished.

Hundreds of passengers on the ship watched from the rail as our Captain stood by waiting for a Coast Guard cutter to arrive about an hour after he’d spotted the refugees. The cruise ship passengers represented those privileged people from all over the world who, a few hours before, were collectively complaining about the freshness of the unlimited buffets or quality of the coffee, or whether the spa or casino on our ship was any good. The contrast between us and those on the little boat could not have been greater.

It made me appreciate what the holiday really represents: A special freedom that has been fought for and that is still being perfected in this country. And a freedom so coveted—in spite of its imperfections—that these 18 people took a long-shot risk of their lives to achieve it. Thanks to those who have worked to preserve this country’s freedoms.

Our own Geneva Craig is one of our freedom fighters: She participated alongside of Rev. Martin Luther King Jr. in many of the civil rights marches and demonstrations during the 1960’s. She was there at Bloody Sunday in Selma. The courage that it took to step up and peacefully absorb the violence delivered to the marchers is another marker for the meaning and value of our freedom. Thank you, Geneva.

Several of our staff have also either served directly in the Armed Forces, or kept the faith while their loved ones served. Thank you all, too.

I’ll be pausing a little longer this year to reflect on what this day means. I hope that you do, too. Be safe, enjoy.

CERT Audit: Most Common Therapy Errors in Noridian's Territory

Here's a summary of the common denials for errors found during Noridian's audits of all providers of physical therapy in the past three years. The data below is taken from the reports found here.

2009, May
97110 Therapeutic Procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
Missing copy of signed/dated treating physician's certification/recertification of the Physical Therapy (PT) plan of treatment for the billed DOS and daily PT log including times and units of service. Also need daily treatment note.

97140 Manual Therapy Techniques, one or more regions, each 15 minutes
Missing (1) the physician order for physical therapy, (2) the physical therapy evaluation, (3) the plan of care and (4) the treatment notes.

2008, November
97110 Therapeutic Procedure, one or more areas, each 15 minutes
Missing copy of signed/dated treating physician's certification/recertification of the Physical Therapy (PT) plan of treatment for the billed DOS and daily PT log including times and units of service. Also need daily treatment note.

97140 Manual Therapy Techniques, one or more regions, each 15 minutes
Missing (1) the physician order for physical therapy, (2) the physical therapy evaluation, (3) the plan of care and (4) the treatment notes.

97530 Therapeutic Activities, Direct, Patient Contact by Provider, Each 15 minutes.
Missing Physician (MD) order for Physical Therapy (PT), MD certification/recertification for PT, PT Plan of Treatment/Evaluation and PT notes to include minutes, Flow Sheet

2008, May
97110 Therapeutic Procedure, one or more areas, each 15 minutes
Missing copy of signed/dated treating physician's certification/recertification of the Physical Therapy (PT) plan of treatment for the billed DOS and daily PT log including times and units of service. Also need daily treatment note.

97530 Therapeutic Activities, Direct, Patient Contact by Provider, Each 15 minutes
Missing Physician (MD) order for Physical Therapy (PT), MD certification/recertification for PT, PT Plan of Treatment/Evaluation and PT notes to include minutes, Flow Sheet

97140 Manual Therapy Techniques, one or more regions, each 15 minutes
Missing (1) the physician order for physical therapy, (2) the physical therapy evaluation, (3) the plan of care and (4) the treatment notes.

97116 Therapeutic proocedure; gait training (includes stair climbing)
Missing daily treatment flowsheet that lists specific therapeutic activities/exercise performed and actual time involved performing each activity. Also requires certifcation and re-certification.

These findings from past audits are likely to guide the focus of future audits, not only with CERT but also with Medicare-RAC and Medicaid-RACs.

Government Review of Rehab in Nursing Homes

The Office of the Inspector General recently released a report about "questionable billing" which found: [Our] findings raise concerns about the potentially inappropriate use of higher paying RUGs, particularly ultra high therapy. The findings also indicate that the current payment system provides incentives to SNFs to bill for ultra high therapy and for high levels of assistance when these levels of care may not be needed. We recognize that the Centers for Medicare & Medicaid Services (CMS) is making several changes to the RUGs in fiscal year 2011. However, more needs to be done to reduce the potentially inappropriate and significant increases in payments for ultra high therapy and other higher paying RUGs.

Based on these findings, we recommend that CMS:

Monitor overall payments to SNFs and adjust rates, if necessary.

As CMS makes changes to the number of RUGs, it should vigilantly monitor overall payments to SNFs and adjust RUG rates annually, if necessary, to ensure that the changes do not significantly increase overall payments.

Change the current method for determining how much therapy is needed to ensure appropriate payments. The amount of therapy that the SNF provides to the beneficiary during the look-back period largely determines the amount that Medicare pays the SNF. CMS should consider several options to ensure that the amount of therapy paid for by Medicare accurately reflects beneficiaries’ needs. CMS should consider requiring each SNF to use the beneficiary’s hospital diagnosis and other information from the hospital stay to better predict the beneficiary’s therapy needs. In addition, CMS should consider requiring that therapists with no financial relationship to the SNF determine the amount of therapy needed throughout a beneficiary’s stay. CMS should also consider developing guidance that specifies the types of patients for whom each level of therapy, including ultra high therapy, is appropriate.

Strengthen monitoring of SNFs that are billing for higher paying RUGs. CMS should instruct its contractors to monitor SNFs’ use of higher paying RUGs using the indicators discussed in this report. CMS should develop thresholds for the indicators and instruct its contractors to conduct additional reviews of SNFs that exceed them. If SNFs from a particular chain frequently exceed the thresholds, then additional reviews should be conducted of the other SNFs in that chain.

While this has no direct impact on our hospital therapy services, it is one more indication that (1) CMS is focused on inappropriate payments to providers, and that (2) overutilization of therapy services is on their radar screens. We can expect that in one form or another, hospital and outpatient therapy services will feel a similar squeeze.