This session, which was entitled How Good Are You?: A Value-based Approach to Neurologic Physical Therapy, comes from several presenters including Rhonda Abbott, Alice Bell, Anna de Joya, Matt Elrod, Zahra Kadivar, Laura Martin, Aimee Perron, Eileen Tseng-Stultz.
As Medicare and Medicaid prepare to change to a value-based system of reimbursement, we therapists are being drug along for the ride. I had no idea what “value-based” even meant and I bet a fair amount of my colleagues don’t have a clue either. So the point of this lecture was to give a snap shot of what that system will look like from a clinician’s stand point and what we can do NOW to make sure we are show casing our value for the world to see.
First of all, an equation:
So that’s what value is. Now, what does that look like?
Medicare has started us down this road all ready. They have required us to use outcome measures at eval, re-eval and discharge with G-codes for several years. New in 2017 they are having us define each patient’s complexity with the 3 levels of evaluation codes. So I’m assuming, now knowing that equation, that after a couple years of collecting data on the complexity side of the equation, we’ll have some reasonable guesses to have the tiered reimbursement system they’ve been discussing in place.
Change is always scary, especially when it comes to the manner in which we get paid. BUT I think this will be a positive change in the PT world, once we embrace it. The current manner of being paid is a one-size-fits-all fee for volume. If Sally, PT can get 32 easy patients done in one day (I’ve seen job listings for caseloads that high plenty of times), she gets paid a lot more than me, Bria, PT who only does 6 difficult patients in a day. This system does not care that I need super expensive equipment, like a harness system (more on those in a later post, by the way!), or functional e-stim to provide quality treatment for my patients. It doesn’t care that I need not only myself, but often extra staff in the form of a technician to assist me when providing hands-on care for these patients. I think with this new system, it will be more readily apparent that quality care has more overhead and should therefore be paid more. All of this evidenced in outcomes of course. I’ve never understood why the medical payment system doesn’t take quality into account. Other areas in the service industry do. I am very willing to pay more for a burger at a steakhouse that is made of grade-A angus beef and is presented well on a plate than a fast food burger in a paper wrapper that may or may not have beef in it at all. (Ask me about THAT story.) Why can’t medicine be the same way? I think this new system will align us more the rest of the service industry’s payment methods.
So what do we DO to make our services more valuable? We need to look at what we can control in this equation.
We can’t control the complexity of the patients. But we can control how good we get at identifying how complex they are. We can educate ourselves through reading things like I linked to above and attending seminars and courses on the topic. Also, practice, practice practice! We can also use measures to determine the patient’s social and psychological factors, which are contributing factors to the complexity codes. I’m personally not very good at measuring these things and I don’t think the profession as whole is very good at it either. Some of the measures the presenters mentioned included: “The Patient Education Retention Assessment” (this one may have been specific to that presenter’s company, couldn’t find it on the web), “Patient Activation Measure” (looking at the risk of the patient to be readmitted to the hospital, comply with recommendations/medicines, etc.), measures of health literacy (more on this topic later!), cognition (Mini-Mental Exam comes to mind for me, but is one many), patient perceived functional deficits (Patient-specific Functional Scale) and basic mobility (Physical Performance Test). The paper and pencil tests we could train our front desk people to administer. Perhaps we could train a technician to perform the basic mobility task. That way those items don’t take up valuable evaluation time.
We can also take a look at the upper side of the equation– the outcomes. This is where we can really go to town. APTA has recently launched The Registry, a national outcomes database. “The Registry enables PTs to make improved, data-informed clinical decisions, track and benchmark outcomes against industry data, and help define the future of payment for physical therapist services.” This will help us see how we stack up against industry standards of care; therefore, growing us as clinicians into making the best clinical decisions we can for quality patient care, and demonstrate our value to ourselves, the payors and patients.
To make this useful we have some work to do on the ground level. We need to make ourselves better at selecting and administering outcome measures. Personally, I keep a notebook filled with any outcome measures that I’ve felt might be useful EVER in the clinic. Now, that notebook is HUGE and getting bigger all the time. (I need to add the ones mentioned above!) So what we need to do there is par down to the ones that are most useful in the populations we treat the most (more on that later too!) and again, practice, practice, practice. The outcomes will demonstrate our superior clinical decision making to make the best strides toward our patient’s goals.
There’s another strategy: improving our clinical decision making skills. Several of the presenters had ideas for this as well that they are already utilizing on the ground. They mentioned participating in programs that improve program quality such as the Exercise is Medicine global health initiative and the Balance in Action fall risk management program. I would dare add that picking up certifications and specializations also falls in this category on an individual level. They also recommended several knowledge translation activities. The first was called a “look-in” where a supervising therapist observes a clinician in a treatment session and then they discuss the decision making processes seen in the session together for about an hour, clinician to clinician, not in any kind of puntative manner. Another was staff meetings in which you all discuss and educate one another in outcome measures. This way the outcome measures you use and how you use them are standardized in your clinic. They also recommended monthly “case scenarios” where clinicians meet together over lunch and one clinician presents a case they’ve had– the history, initial findings, etc. Then the clinicians collaborate together to make clinical decisions in the case. Kind of like a Create Your Adventure book, except with a plan of care. The case could be a past case or a current case. If it’s a past case, it would be useful to see other clinicians’ thoughts and compare to your own decision pathway. In a current case, it would be useful to get a fresh person’s views on a difficult case. These activities facilitate strengthening decision making muscles!
As I mentioned, this was a difficult topic for myself to comprehend and I am certainly NO expert in billing. I hope I’ve laid out something that is useful and digestible here, so you can start amping your value NOW and prepare yourself to be valued!