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.

Why We Do What We Do

I subscribe to a rehab listserve.  Many times, the discussion threads take a hopeless or angry tone when the various contributors try to predict the future of healthcare and the profitability of their businesses.  Such was the case recently, when many private practive PT business owners lamented the cuts in payments, the over-regulation, healthcare reform and the general state of the economy.  I think there may even have been mention of the end of the Mayan calendar!  (OK, I made that part up.)

But one contributor, Thomas Howell PT, from Idaho, wrote the following.  I think he summarized nicely my thoughts on the subject.

I am tired of the doom and gloom AND I am tired a discussion that hasn't once focused on the patient. At its root healthcare is and always will be about caring for people. Ask me if things are harder than 10 years ago and I would say firmly NO. I have more tools from equipment to outcomes tools and more research evidence than ever before to guide what I do and allow me options for care that are successful and repeatable.

Patients/clients are receiving care that, even when limited by insurance, is still way better than I ever could have imagined 24 years ago when I started PT school. In addition, I have opportunities outside of traditional PT care to establish a business model with, from fitness to wellness to women's health. 25 years ago a majority of PT practices survived only by contracting with home health or SNF's because the reimbursement was much worse than it was today.

What is harder is to use physical therapy purely as a business to get wealthy but you know what - that's not what this profession is all about. I am about profit as much as any American business person and agree that we have too many regulations but at the same time my motivation is not profit but treating patients. Every day I am thankful for the opportunity to make a difference in people's lives.

Yes, maybe our profession will become a profession that we cannot make a huge profit any more but does that diminish it or what we do day in and day out as healthcare professionals? I don't think so and I would bet many other colleagues would agree. Ask yourself if you would still be in the profession if you could only earn what teachers make in your area. Would you still be in the profession? I know plenty of PT's that would because patient care and making a difference in people's lives is the most important thing to them as it is to me.

Amen.

Publication In Impact Magazine

I'm honored to say that I've authored an article published in the June issue of Impact, the journal of the private practice section of the APTA. My contribution to this  issue was to share the lessons learned from some of our experiences with compliance audits conducted by our Medicare Administrative Contractor, Noridian. Since many private practices have not had the experience of going through such audits, I decided to share a bit of practical knowledge with the PT community.

I cannot link from here to the article, but I do want to post right now some corrections that will appear in a future issue; so for those to have landed here from that article, here goes a dose of humble pie:

Dear Editor:
I wish to correct several factual errors in my article entitled “Preventive Medicine for Surviving a Medicare Audit.” None of the “Lessons” from the article change; those are still my recommendations. In the interest of complete accuracy, however, here are the corrections:

1. In my article, I stated that CERT audits are pre-payment, and that if the results of a CERT audit show a high error rate, there may be consequences. CERT audits are post-payment, and charts are selected randomly. In the Comprehensive Error Rate Testing Program (CERT) the purpose is to establish a Medicare FFS paid error rate, which is done through a small random sample of provider claims. If a claim has been found to be paid in error by the CERT contractor, the FI/MAC is responsible for initiating repayment activities.

2. I stated that my organization had been subjected to a CERT audit which found a high error rate, followed by another audit to validate that we’d changed our practices. In fact, those were probe audits, initiated by our MAC, and conducted on a pre-payment review basis. It is the probe audit that can result in consequences, including follow-up probe reviews to reassess the provider error rate. And it is the probe audit that, if compliance is not demonstrated, may result in being placed on a correction action plan as referenced in the Medicare Program Integrity Manual up to and including more serious sanctions such as a referral to the Program Safeguard contractor or the ZPIC, or in the most dire of circumstances to the OIG.

3. Also, for clarification, the error rate is calculated based on charges in error compared to total charges. "…the error rate is the dollar amount of submitted charges billed in error (minus any confirmed underbilled charges) divided by the total amount of submitted charges for the services medically reviewed”

I apologize for these errors, which are mine alone. And I would like to acknowledge Nancy Beckley, a fellow author in the June IMPACT for her collegial and professional assistance in clarifying these issues.

It demonstrates one more lesson for the readers: This stuff is very technical and complex. It’s best to get professional help in preparing your business for the inevitable audits that are coming, and in responding to audits that do occur.

Our Lymphedema Screening Program Gets Airtime

Today Pim S and I were interviewed on local TV about our department's new lymphedema screening program.  Click on this link to view the interview.

RVMC Physical Therapy Balance Master

Michaela Begg is shown here with the latest version of the SMART Balance Master.  We took delivery on this device in January, and she's already excited about the possibilities for improved therapy and assessment of patients with balance disorders.

I must say, I'm a bit honored to take Michaela's photo, since she is (when she's not being a physical therapist) an accomplished photographer.  (Check out her website here.)  She was gracious about the whole process.

Michaela brings 20 years' of experience to our outpatient neuro services: she began her career in Michigan working with some of the original developers of the Balance Master technology.  (At that time, it was being developed for some NASA research.)

The SMART Balance Master helps clinicians differentiate between visual and proprioceptive in origins of balance disorders, or whether the problem is due to integration of those two systems.  Using the shifting force-plate platform, it allows therapists to do reflex testing, as well.  Another feature is the ability to measure visual-ocular reflex, with normative data for comparison.  Of course, this tool has many other applications as an adjunct for biofeedback.

Michaela said, "I love the way that once we know where the issues are with balance, then we can set up training on this device, and we also know specifically what to do [in therapy] outside of the machine."  She goes on, "Although there's a lot of other tools, I'm constantly surprised at how often I find something that I don't expect [with a patient], or how often I don't find something that I thought that I would find.  It's pulling out information that I otherwise can't get using other tests."

We're lucky to have both the SMART Balance Master and Michaela as part of our services!