Health Care Reform and the Affordable Care Act: One Year Later

 

CombinedSectionsMeeting2015

February 4‐7, 2015

Indianapolis, IN  

www.aptahpa.org HPA The Catalyst is the Section on Health Policy & Administration 

of the American Physical Therapy Association 

Speaker(s):   Edward Dobrzykowski, PT, DPT, ATC, MHS 

Janice Kuperstein, PhD 

Karen Ogle, PT, DPT 

Charles Workman, PT, MPT, MBA 

 

Session Type: Educational Sessions 

Session Level: Intermediate 

 

This information is the property of the author(s) and should not be copied or otherwise used without the 

express written permission of the author(s). 

 

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HealthCare Reform and the Affordable Care Act

Janice Kuperstein PT, PhD, MSEdCharlie Workman PT, MSPT, MBA

Karen Craig Ogle PT, DPTEd Dobrzykowski PT, DPT, ATC, MHS

Disclosures 

• Views of the presenters are independent of University of Kentucky, Baptist Health, and St. Elizabeth Healthcare

• Dr. Dobrzykowski also serves as an independent contractor: Cross Country Education and has a relationship with Focus on Therapeutic Outcomes (FOTO)

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Objectives

With reference to PT environments throughout the continuum of care, identify:

– Status of ACA

– Implication of Medicare Spend

– Implementation strategies for transformation

– Potential models for own environments

– Future issues

– Colleagues who may serve as potential resources 

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Triple Aim (IHI)

• Triple Aim:

– Improve the health of populations

– Enhance the patient experience of care (quality, access, and reliability)

– Reduce or at least control per capita cost of care

Source:  Thomson Reuters Marketscan Database

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Role of physical therapy in physical health promotion, disease mitigation, and injury prevention by life stage: age-related health risk by chronologic age.

Sullivan K J et al. PHYS THER 2011;91:1664-1672

© 2011 American Physical Therapy Association

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PPACA Overview – Implementation Phase

“provide affordable, quality health care for all Americans and reduce the growth in health care spending”

Officially rolled out Oct 1, 2013Law is actually written in two parts:

1. Senate based Patient Protection and Affordable Care Act2. Health Care and Education Reconciliation  Act 

Legal Issues: • Expansion of Medicaid services – State option • Individual Mandate: Justice Roberts – “yes … the law is acceptable under 

Congress’ taxable power”• Employer Mandates

PPACA

Improve Quality

Lower Costs

Improve Access

Key Consumer Provisions

Insurance Reforms

Financing Redistribution

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What ACA does…

1. Insurance Reformsa. Certain preventive care measures without paying co‐pays or 

deductiblesb. Bar insurances from dropping beneficiaries if they get sickc. Keep adult children on insurance until age 26d. Requirement for insurances to use 80‐85% of premium dollar on 

direct medical expenses rather than on administrative costs or profit. 1. Medical loss ratio:  if plan exceed the limit, insurances have to refund the 

difference. 

e. Premium rate hikes controlled: greater than 10% subject to automatic review

f. Prevention of rejecting insurances due to pre‐existing condition.g. Pts have the right to see certain specialists without referral from 

primary care provider

What ACA does…

2. Quality improvement, delivery system changes, and cost containmenta. Patient Centered Medical Homes

b. ACOs: population health management through multi settings system collaborations

c. Independent Payment Advisory Board

3. Health Insurance Coverage expansiona. Select coverage or pay tax penalty

b. Health insurance marketplaces

4. Public Health and Preventiona. Improve population health through preventive measures. 

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Medicaid Expansion – 2/15

ACA Impact On Physical Therapy

1. Provision of “essential health benefits”a. Preventive and wellness servicesb. Chronic disease managementc. Rehabilitative and habilitative services

2. Increase demand for services through consumer acquisitiona. conservative interventions over surgery

Comparative studies on interventionsb. Increase patients per day initially  

3. Cost containment:  reduction in approved visits, reimbursement cuts

4. Private clinic ownership expense hikes in premiums for provision of health insurance to employees

5. Increase in PAC decision making generates opportunities for PT profession and may drive autonomy.

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Courtesy of APTA – Permission requested and granted January 2015

Just Last WeekTuesday, January 27, 2015

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APTA Priorities

Themes Across the Continuum

• Movement towards integrated therapy 

• Realignment of Care models  ‐‐ from management of chronic to preventive to avoid impairments

• Redefining payment methodologies – enhancing PT, how we are identified and our services

• Standardization of therapy:  efforts to curb fraud and abuse

• Accountability for quality services.

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“Providers are organized and reimbursed around what they do, 

rather than what patients need”

Porter M and Lee T. The Strategy that will Fix Healthcare. HBR: 2013; Oct.

Defining PT value:

Value = Quality x Pt satisfaction  Cost

Function is our currency!

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Value

Identify best 

practice

Implement best practice

Measure provider 

performance

Evaluate effectiveness (cost and outcome)

Across the Continuum

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Hospital Value Based Purchasing Program

rewards acute‐care hospitals with incentive payments for the quality of care

how closely best clinical practices are followed

how well hospitals enhance patients’ experiences of care during hospital stays

Medicare Spending

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What is Medicare Spend Accountability?    

• Efficiency component of Value Based Purchasing

• Began Federal Fiscal Year 2015 (Oct. 1, 2014)– Baseline period CY2011

– Performance Period May‐December, 2013

• Federal Fiscal Year 2016– Baseline Period CY12

– Performance Period CY14 

MSPB Measure Ratio• Compares the hospital’s spending level to the average 

spending for all hospitals

Your MSPB score =    Your Hospital’s Average Spending Episode

National Average Spending Per Episode

• If MSPB score is:

>1 = more expensive 

1 = cost is the same

<1 = less expensive

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Episode Cost Inclusions

• Hospitals responsible for managing patient episode costs

*Hospitals IP Stay(s)   *MDs   *SNF   *Rehab   *Home Health 

*Outpatient        *Hospice   *Durable Medical Equipment

• All payments for services Medicare Parts A & B

• Readmissions

• Transfers (except acute to acute)

• Episode Period: 3 days prior to admission to 30 days after discharge

Why is MSPB Important?

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MSPB Amount is the average spending after controlling patients’ health status and regional variation in Medicare payments. 

Cost Buckets

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Impact Act of 2014

Improving Medicare Post‐Acute Care Transformation (IMPACT) ‐President Obama signed into Law on October 6, 2014• The Act mandates that post‐acute 

settings begin reporting of quality measures starting on October 1, 2016, and

• Standardized patient assessment data by October 1, 2018.

• Information is necessary to the development of Medicare PAC payment reform. 

• Legislation will have a significant impact on expediting CMS’ use of data to compare quality, cost and other factors across settings.

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Continuum of Care Defined

Source: Cain Brothers, INTEGRATING ACUTE AND POST‐ACUTE CARE:THE EMERGING MERGING OF THE SECTORS, 2012

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Acute Care Post Op Rehab

• (Shorter LOS):  prevent complications (DVT, infection, PE, and reduce pain/swelling)

• Functional goals:  mobility, encourage ROM, safety and indep with ADLs. 

• Functional tools: (optional) – not transmitted for CMS Iowa, Kansas City, AM‐PAC outcomes measures, patient satisfaction

• Multidisciplinary team– Coach:  surgeons– Physicians– Nursing– PT/ OT/SLP– Case management

Acute Avenues of Opportunity

1. Predictor Tools for Discharge planning to include social factors and function

2. Standardized functional assessment tool options

– Ie G codes, AMPAC 6 clicks, FOTO

3. Transitional Coaches – Decrease Readmissions.‐identify high risk patients

5.   PAC partnerships

‐education, shared accountability, proactive learning. 

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All Patients by Readmit GroupsSorted with Highest $ Variance at the Top of the List

• Other Inpatient Group

– Largest population

– Currently not followed

– Source of Highest Variance

– 80% of Readmissions

All Patients by Discharge Disposition

D/C Home /HH is largest population, and as a whole is least expensive related to the MSPB variance.

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Cleveland Clinic Risk Calculator

Discussion Break

• Please step to the microphone

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Rehabilitation Payment System

Acute Care

Outpatient

Assisted LivingLTAC

Skilled NursingInpatient Rehab

Home HealthLTAC

Post Acute Continuum

Payment Methods 

Acute Care

Inpatient RehabSkilled Nursing

Outpatient

Home Health

RUGsIRF-PAI

MDS

OASIS-C

DRGs

FFS

Observation

LTACH

DRGs

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Post Acute Care Payment Reform 

• Development of a Standardized Patient Assessment Tool

– Continuity Assessment Record and Evaluation (CARE) tool

Are We Asking the Right Question About Post Acute Settings of Care?

DeJong, G. Are We Asking the Right Question AboutPost Acute Settings of Care? APMR 2014;95:218-21

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Does Post-Acute Care Site Matter?

Chan L et al. Does Postacute Care Site Matter? A LongitudinalStudy Assessing Functional Recovery After a Stroke. APMR;94:622-9

Assessed impact of post-acute care site on stroke outcomes

Patients may make more functional gains when post acuteCare includes an IRF.

Inpatient Rehab Facilities (IRF)

• 13 qualifying diagnoses:– CVA– SCI– Brain Injury– Congenital Deformity– Amputation– Major multi trauma– Femur Fx– Burns– Polyarticular RA– Systemic  joint 

inflammation with functional impairment

Other:Neurologic disorders

‐MS‐motor neuron disease‐ poly neuropathy‐muscular dystrophy‐ Parkinson’s‐ advanced OA involving 2 or more WB joints

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IRF Criteria for Total Joints

• Knee or hip joint replacement that also meets one or more of the following specific criteria: 1. underwent bilateral knee or hip joint 

replacement surgery during the acute care

2. hospital admission immediately preceding the IRF admission; The patient is extremely obese with a BMI > 50

3. The patient is age 85 or older. 

Functional outcomes tool:   FIM and patient satisfaction

Functional Independence Measure

• Outcome measure of the severity of disability

• Trademarked by UDS

• 18 categories

• 7 point scale

• Two major categories– 13 motor items

– 5 cognitive items

• Multidisciplinary team scoring over 72 hour observation

• Good Validity

• High internal consistency

• High inter‐rater reliability and test‐ retest reliability

Drawbacks:

‐ Ceiling effect: better for inpt than outpt setting

‐ scoring accuracy and bias

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Are We Asking the Right Question About Post Acute Settings of Care?

DeJong, G. Are We Asking the Right Question AboutPost Acute Settings of Care? APMR 2014;95:218-21

Is the Rate of Rehospitalization Lower Among Patients Discharged to SNFs in Which a Hospital Has a Strong Linkage?

Increase proportion of hospital discharges to a SNF by 10 Percentage points, the likelihood of patients treated by thatHospital-SNF pair to be re-hospitalized within 30 days declinesBy 1.2 percentage points

Rahman M et al. Effect of Hospital-SNF Referral LinkagesOn Reh-Hospitalization. Health Serv Res. 2013 December;48(601).doi:10.1111/1475-6773.12112

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Discharge Functional Status for Patients After Lower-Extremity Joint Replacement Surgery

Are There Differences in Outcomes of Patients Across Three Post-Acute Rehabilitation Settings?

Discharge to HH – patients healthy with social support

Sicker patients- need 24 hour medical and nursing care

Mallinson TR et al. A Comparison of Discharge Functional StatusAfter Rehabilitation in Skilled Nursing, Home Health, and MedicalRehabilitation Settings for Patients After Lower-Extremity Joint Replacement Surgery. APRM 2011;92:712-20

Present Financing

Population Health 

Financing

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“Merely aligning financial incentives between providersof acute and post-acute care will not improve qualityand reduce costs for episodes of care. True coordinationof care is required to ensure the best possible outcomes.”

Ackerly DC and Grabowski DC. Post-Acute Reform- BeyondThe ACA. NEJM 2014;370(8):689-691

Constructive Strategies (SNF)

– Case management– Efficiency– EB interventions– Mobility programs 

• More than 50% of Medicare beneficiaries have multiple conditions: 

i.e. diabetes, arthritis, hypertension, kidney disease, obesity, COPD  

• Nearly one in five admitted patients to hospitals are readmitted within 30 days • Significant impact from hospital readmission penalties

Opportunity to provide value!

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Where Are We Headed?

• Transformation underway to value based healthcare purchasing profoundly impacts current financing paradigms

Ambulatory patient management will be key for population health management

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Patient Population 

Chronic

Relatively healthy‐active

Some Disease Factors

Relative healthy‐inactive

Adapted from Advisory Board

Rehab Value in These Population Segments

• People with risk factors– Diabetes

• Congestive Heart Failure (CHF)

• Chronic Obstructive Pulmonary Disease

• Multiple Sclerosis 

• Parkinson’s• Osteoarthritis• Obesity

• People healthy but inactive

– Exemplary care

– Exercise

– Prevention

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ACA Impact on Volumes

Number of newly insured driving increased need for services:

Impacting access?

Outpatient Rehabilitation Changes

• EMR

• Use of Functional Measures

– OPTIMAL

– AMPAC

– FOTO

Outpatient function‐severity based

Physical therapy classification and payment system

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Patient Reported Outcomes (PRO): The New Gold Standard?

Use of evidence based practice

•Did your patient’s improve?

•How much did they improve?

•How many treatments are needed?

•Which interventions are effective?

•How do you compare to your colleagues?

Outcomes Utility:

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Does Specific Interventions Impact Outcomes?

Examine associations between McKenzie training, functional status at discharge, and utilization in patients received physical therapy for low back pain

Slightly greater improvement of 0.7 to 1.3 points in FS at discharge

Difference was clinically important when treated by therapists with some McKenzie training

Reduction in utilization was 0.6 to 0.9 visits

Deutscher D et al. Physical Therapists’ Level of McKenzie Education,Functional Outcomes, and Utilization in Patients with Low Back Pain.JOSPT 2014;44(12):925-936

Does Practice Setting Influence Clinical Outcomes and Efficiency in Outpatient Services?

• Patient outcomes data abstraction (FOTO) over 12 months in 2011‐2012

• Results suggest that patients experience more efficient care when receiving physical therapy in hospital outpatient settings compared to private practice settings

• Difference in improvement between settings is less than the MCID of 9 points

Childs JD et al. Implications of Practice Setting on Clinical OutcomesAnd Efficiency of Care in the Delivery of Physical Therapy Services.JOSPT 2014;44(12):955-963

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FOTO

• Patient subjective questionnaire with risk‐adjusted comparisons

• Large nationwide database

• Over 70 research based publications

• Medicare compliance

• Multiple areas

C.A.R.E tool/B‐Care

• Continuity Assessment Record and Evaluation– What is it? Standardized patient assessment instrument to measure 

patient severity in hospitals and post acute care settings

• B‐Care is a streamlined version of the care tool– being considered for use within the Bundled Payments for Care 

Improvement (BPCI) Initiative

• Four domains: – Medical severity– Physical functional impairments– Cognitive functional impairments– Social support/ environmental factors

3 year pilot – first reports to be available March 2014

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Optimal Outcomes Project(Outpatient Physical Therapy Improvement in Movement Assessment Log)

How might a clinician participate in the emerging 

payment models for health care?

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Where Are The Opportunities?

• Develop strategies and tactics around population health management

• Optimize efficiency in each practice segment 

• Build collaboration “upstream” and “downstream”

• Position for more integration

Don’t Lose Sight of Market Changes!

Uninsured to insured transition

Aging population

High deductible plans

Patient co-payments

Patient co-insurance levels

Supply/demand of clinicians

Technology advancements

Disruptive competitors-Google, Wal-Mart, Solo-Health, Walgreens

Social media

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• Please step to the microphone

“Progress is impossible without change, and those who cannot change their minds cannot change

anything.”

George Bernard Shaw