Introduction and Overview
Change is one constant in healthcare. And the thing that I have noticed ever since I joined the field of speech pathology as a clinical fellow (CF) is that change is constant, whether it be changes in the company we are providing services for, changes in the regulatory environment, or changes in how we are approaching our patients based on emerging research and practice patterns. One thing I was always very excited about is, how can I best prepare my practice to ensure that I am ready to face these changes -- both current changes, and changes in the future? I hope that today, based on lessons from the field and review of changes that are occurring in the healthcare environment, I can share some pearls of wisdom about how I have done it in the past and ways to do it in the future.
In this course, we are going to review some changes occurring in our healthcare environment. We will especially focus on those changes that will be directly impacting the rehabilitation disciplines, and speech-language pathology specifically. Finally, we will discuss ways that speech-language pathologists can modify their practice to readily adapt to these changes.
Changes within the Healthcare Environment
There is certainly a tremendous amount of disruption within the marketplace. Innovation, industry reform, and better-educated consumers impact how we provide services. Healthcare reform is not something new. We have been talking about it for many years. But certainly, the rate at which it is happening and the breadth of the changes are resulting in changes that are impacting rehab to a greater extent.
First, we will consider mergers and consolidations. Again, this is not something that is brand new. But certainly, the pace has increased. Then we will talk about value- versus volume-based reimbursement. This is really a big deal; it is a big shift in the reimbursement approach. We will then discuss quality requirements, and how the measurement of outcomes is becoming more important and linked to organizations' bottom lines.
We know that Medicare is looking for ways to improve upon the current system. In 1998, the Prospective Payment System went into effect for skilled nursing facilities (SNFs). Since then there have been many voices calling for an improvement in the reimbursement model – one that will promote individualized care for residents using patient characteristics and their specific needs to ensure the most accurate payments for services. Numerous agencies, demonstration projects, and consultants have spent quite a bit of time reviewing and testing all different types of modifications to our current plan.
One quick caveat: this is certainly a general overview of healthcare changes. These are complex topics that could be studied and discussed in much greater depth. I have put together a handout as a reference page that offers multiple resources for individuals who would like to delve into this in a greater level of detail. Honestly, hours of class time could be spent just talking about changes to healthcare that are impacting us, or the system as a whole.
Ultimately, it is important to stay on top of these changes and how they impact your practice. Resources such as those provided by ASHA and other government agencies can give you a snapshot of what changes will impact your work. So our goal today is to touch on some of the regulatory changes that support integration of data collection and quality measurement into regular practice.
Mergers
The current market pressures result in an increase in the number of healthcare organizations that are consolidating services in order to better meet the requirements for data reporting, reimbursement, and integrated networks of care. It is interesting to see the data on merger and acquisition activity among hospital groups: it increased 70% between the years 2010 to 2015, and remained strong through 2016. In fact, 2016 was a record-breaking year for healthcare mergers and acquisitions.
Why is this happening? Certainly, there is great pressure to lower costs. The cost of acquiring needed technology such as electronic medical records, and emerging technologies in surgical interventions and other life-saving techniques, has put significant financial pressure on organizations. Finally, there is pressure to use new ways, such as coordinated care continuums or preferred provider networks, to deliver health care. These allow for more efficient patient movement through different levels of care, and save money.
For speech-language pathologists, this creates an environment of changing administrators, providers, and corporate culture. My experience over the course of 20 years in an evolving healthcare company is that when there were new providers, some of them had extensive experience with speech pathology, and some of them had very little. The quality of their experience was also highly variable; some had very positive experiences, and others not so much. Knowledge and philosophy can also be very variable within our practice. Within our field, we all have had different experiences, and have differing philosophical approaches and styles. Early meetings with new providers allow you to describe your experience and philosophy, and can help you gain trust and build relationships early on, which pays dividends later.
Within the three therapeutic disciplines, the role of the speech pathologist is not always universally understood. In fact, how many of you have had an administrator, a provider, a patient or family member not realize your full scope of practice or expertise?
Value-based Reimbursement
Value-based reimbursement focuses on outcome measurement and paying for quality care, rather than paying for services regardless of outcomes as the fee-for-service model did in the past. This reflects a shift from “volume-based” to “value-based” care. The Accountable Care Act mandates this change from volume- to value-based care. Most of you have heard of ACOs, or accountable care organizations. ACOs are seen as the bridge from the past fee-for-service model to the current value-based system. ACOs were able to integrate care among multiple levels of providers who share a common set of quality criteria and cost definitions, based on a specific population. This shift from volume-based to value-based means that resources are shifted to the area where the most impact can be demonstrated. The shift will not just be about changing reimbursement models, but will increasingly drive how corporate decisions are made.
One way to think of value-based reimbursement is to consider bundled payments. This alternative payment model prospectively determines a payment that will cover the hospital stay and services, immediately post-hospitalization, for a single, predefined episode of care. There are variations in type of bundling. There are some that are associated with acute hospital stays and post-acute care together; some are just post-acute care bundling only. Others are associated with an in-patient stay and include all physician services. There are also different mechanisms for determining the bundled payment amount that consider factors such as primary and discharge diagnosis and comorbidities; initial functional assessment; age, sex, and other demographic information; cross-reference of patient descriptors to average Medicare costs; etc. The advantages to post-acute bundling include fostering efficiency in health care delivery, reducing hospital readmission rates, fostering quality improvement, stimulating development of evidence-based knowledge, and reducing the cost of the acute care episode and associated post-acute care. In fact, in pilot programs, facilities that apply to participate in a bundling program actually agree to a 2-3% payment discount compared to average Medicare payments.
This means that institutions are focusing more on population management, affordability, and the patient experience, and SLPs must be able to demonstrate high quality care with measurable outcomes. As we make this shift, rehabilitation therapists need to understand hospitals' motivation with these bundling programs. Hospitals will be the most common entity to manage rehabilitation services, and will be motivated to limit rehabilitation services to those that reduce costs in overall care, including the prevention of hospital readmissions. Of all the services rendered by speech-language pathologists, dysphagia services will be in greatest demand. Motivation for speech-language services may be postponed until 30 days after the discharge date. This is similar to historical trends in acute care hospital prospective payment practices through discharge. Again, speech pathologists need to be able to demonstrate to hospital administrators the potential value of their services at every level or stage of care.
Quality Changes
Quality is a measurement of resources invested in patient services that result in positive outcomes. One of the measures that receives a lot of attention is hospital readmission, and this is a very important one for speech pathologists. We know that currently, 20% of all hospitalized Medicare beneficiaries go to skilled nursing facilities following their hospital stay. Of these, 25% are readmitted to the hospital, costing Medicare 14.3 billion dollars. That certainly gets a lot of attention. Starting in fiscal year 2018, skilled nursing facilities will be penalized for patients who are readmitted to the hospital within 30 days of their discharge from the hospital to the SNF.
The IMPACT Act (Improving Medicare Post Acute Care Transformation) establishes a uniform system of measures for reporting outcomes across all post-acute care settings. This includes home health, inpatient rehabilitation facilities, skilled nursing facilities, and long-term care hospitals. The IMPACT Act was signed into law in October 2014. It requires the Center for Medicare and Medicaid Services (CMS) to develop standardized patient assessment data on specific quality measure domains for post-acute care facilities. This standardized data allows for comparisons across these settings, and possibly for the development of one payment system across all four settings. Facilities, rather than individual providers, report IMPACT-related data. Therapists are not required to report on this until 2019, when they may be opted in, and eligible for reporting.
Shift from PQRS to MIPS. The Physician Quality Reporting System (PQRS) will shift to the Merit-Based Incentive Payment System (MIPS). If we use PQRS as a reference for some potential categories of quality measurement, then there are several that relate directly to speech pathology. These include screening for dysphagia and rehabilitation treatment options, and rehabilitation services ordered following stroke. There are three related to dementia: staging of dementia, dementia counseling, and measurement of cognitive function in dementia. Finally, there are two related to Parkinson's disease: the cognitive impairment measure and dysfunction assessment, and rehabilitation treatment options.
The new quality reporting initiative, the MIPS, replaces both the PQRS as well as the value-based modifiers, which providers have used in the past to demonstrate quality outcomes. The MIPS will consist of four categories: The first is quality – formerly the PQRS; the second is Clinical Practice Improvement Activities; the third is Advancing Care Information, which was formerly the Meaningful Use Act of Electronic Medical Records; the fourth is resource use.
As I mentioned, therapy professionals are currently excluded from this system and will not have to provide quality data until 2019, when they may be opted into the program.
Readmission reasons related to SLP practice. The most important takeaway from all of this is that we must consider that speech-language pathologists may need to measure quality in outcomes in the near future. I mentioned earlier that readmissions are going to be an important outcome for speech-language pathologists. A good example of the quality metrics that are being obtained is the rate of readmission to the hospital following discharge from a post-acute facility. If you look at the reasons why patients return to the hospital, there are some numbers related to our scope of practice. Out of the 15 most common readmission diagnoses, there are four that relate to us: the first is pneumonia (7%); the second is aspiration pneumonitis of food or vomitus (4%); the third is respiratory failure (2.7%); the fourth is delirium, dementia, and amnesic and other cognitive disorders (2.2%). These are ranked based on occurrence, with the percentage incidence noted in parentheses. These four reasons are important to be aware of so that we may justify the value of our services not just in the present, but also for future positive outcomes of our patients. Allowing speech pathologists to get involved early and appropriately, and to follow through and provide care as needed, can increase positive outcomes down the road by reducing the opportunity for readmissions. This ties in with how we collect data and talk about our outcomes, to make people aware of how we are directly involved in this.
Impact of These Changes on Speech-Language Pathology
Certainly, you do not want to be taken by surprise. You want to be prepared. You want to have an increased emphasis on outcomes and justification as to why a certain resource must be used for each patient. The most important thing is not for SLPs to know all of the regulatory details; rather, we just need to understand the overall trends toward using data to justify services, and then use these trends to set practice patterns and be prepared to demonstrate outcomes in a measurable way. You are ideally ready to answer the questions before they are asked. In other words, being prepared in how you set up your practice, how you provide your therapy, and how you communicate it is going to be extremely impactful.
Speech pathologists must be seen as critical members of the team, rather than optional. We need to make sure that the rest of the care team understands that we should be utilized not just for patients with strokes or dysphagia, but also for other degenerative neurological disease, for cognitive changes following hospitalization in the elderly, and at the end of life. It is important that we regularly educate others on the breadth of our experience.
If rehabilitation payments are directly impacted by quality and outcome reporting, it will be important for clinicians to have integrated data collection systems and quality measures into their practice. By starting to utilize these in your practice, you will be better prepared and able to adapt to regulatory changes in the future. I might argue that we are often underutilized. By improving other team members' understanding of our areas of expertise, we can better serve our patients by receiving referrals more appropriately. You want to be ready. One way to do that is to be prepared for alternative payment models. We know that Health and Human Services has a goal for transitioning the Medicare fee-for-service models to alternative payment models by 50%, and to link 90% of their payments to outcome measures by the end of 2018. That is rapidly approaching. You do not want speech pathology to be considered an optional member of the team. This might require you to educate your providers to refer on admission for certain key diagnoses. In the short term, we can escape the obligation to report quality data, but we must keep in mind the relationship of our data collection to the transition to value-based payments. Ultimately, the goal is to ensure that you are providing services to all of the patients in your facility that you can assist, given your skills.
ASHA is on top of these changes in the marketplace. They have modified their strategic plan to prioritize making data available for quality improvement and demonstration of value. They have prioritized providing information about quality metrics and data collection, and sharing data with members, that will assist in justifying SLP value.
