With the recent news that the CMS' Bundle Payment Program has delivered "mixed results" during its initial year under operation, there remains an eagerness among providers and payers to identify best practices for success in these total cost-of-care initiatives.
As the basic premise behind these programs is enhanced care coordination to reduce readmissions, minimize unnecessary costs, and improve outcomes, there is an enormous opportunity for those providers who are able to prove value and advocate for themselves with data.
This idea is especially true for providers operating in traditionally siloed specialties, such as physical therapy and other outpatient rehab-centric professions that have not operated by data-driven processes. The question of "how can we best use PT" is not a new one, but it becomes more complicated without hard proof backing up efficacy and cost effectiveness. Additional challenges are present, as these professions did not adopt EMRs on a widespread level and have been slow to measure outcomes.
Due to a confluence of these factors, physical therapists have long been thought of as "nice guys in polo shirts" who give you exercises to do at home when suffering from a sore back. However, as evidenced by the opioid epidemic, musculoskeletal (MSK) costs, and complications from unnecessary or risky tests and surgeries, the value of both treating pain and returning patients to full function cannot be overstated. 2016 has already presented our industry with a bevy of research and studies showing how risky unnecessary surgeries and chronic pain can be for our patients, and a surge of interest in outpatient rehabilitation is one byproduct of this growing awareness.
Bridging the Gap
For a tangible example of how physical therapy can meaningfully impact these new payment models, one needs to look no further than the situation unfolding around knee and hip surgeries– the most common inpatient procedures for Medicare beneficiaries.
These tend to be high-cost, high-utilization surgeries where price varies greatly—ranging from $16,500 to $33,000 per procedure. Medicare notes that more than 400,000 total hip knee and total knee procedures were performed in the United States in 2014, at a cost of more than $7 billion for the hospitalization portion of recovery alone, up from $6.6 billion in 2013.
Most striking is this statistic: 40% of spending is related to how these patients are managed once they leave acute care, with studies showing that most hospitals have no guidelines around the proper management of these patients in the post-acute setting.1
Recognizing the severity of this situation, the CMS has established a bundled payment program – the Comprehensive Care for Joint Replacement Model Initiative (CJR). The fundamental purpose of the CJR is testing a payment model for episodes of care initiated by hospital stays for hip and knee joint replacements. Under the CJR, hospitals are at financial risk for the care provided during the initial hospital stay plus 90 days after discharge from the hospital.2
In other words, once a patient undergoes surgery, the hospital needs to do everything in its power to ensure the patient does not suffer an adverse event or readmission post discharge – making successful rehabilitation a key factor for full reimbursement.
Utilizing Physical Therapy
The role of physical therapists in the CJR model is clear. Theoretically, if hospitals are truly invested in keeping costs low, they can employ post-acute care managers to oversee the discharge of patients to data-validated, best practice outpatient centers and rehab providers. Further, research has shown that patients were 2.9 times more likely to be readmitted when a physical therapist's discharge recommendations were not followed.3
Bundled payment models like the CJR are promising. A study of a bundled payment program for lower extremity joint replacements in the Baptist Health System published in the Journal of the AMA4 showed significant reductions in post-acute care costs when those costs were included in the bundle.
As such, no longer can risk-bearing organizations afford to send patients to a one-size-fits-all provider, now they must account for multiple factors involved in successful rehab. Important questions must be considered, such as "can my patient handle the travel distance for rehab?" and "is this practice really equipped to deal with their complex needs?"
From a PT perspective, if you can demonstrate that yes, you are able to effectively treat these patients to decrease post-op complications and readmissions, hospitals would have every incentive to partner with you. Fortunately, the advent of integrated revenue cycle management and outcomes measurement systems mean that PTs are fast accruing data that highlights their value.
In the coming years – and possibly months – these "data feeds" could enable savvy physical therapists to better advocate for their services, and add another dimension to clinical decision-making for CJR patients.
True Patient-Centered Care
While the CJR is one solution to a complex problem, there are alternatives to bundled-payments that seek to ensure patient-centered care at an earlier stage. Since knee and hip surgeries are performed at such prodigious rates, there is some level of uncertainty over their overall efficacy. In many cases, experts believe that alternatives such as physical therapy or injections may be preferable for patients' individual needs – and providers should be encouraged to consider these options.
New models of care, such as the Center for Orthopedic Research and Education Institute's (CORE) condition-based approach, will be the key to preventing unnecessary procedures in the future.5 This idea of a condition-based approach means that participating physicians are incentivized to choose a high-value treatment upon seeing the patient, rather than simply recommending surgery as part of the CJR program.
In doing so, providers can consider patients' needs and make a decision using evidence and data-validated analytics (including data about PT's efficacy). The caveat for initiatives similar to the CORE Institute's is that organizations are required to take on significant risk for patients' well-being, meaning that it is high-risk, high-reward.
In other words, the onus is on all parties to select and deliver optimal treatments. We may truly be seeing the end of the "cut first, ask questions later" attitude, and if implemented correctly, care coordination will result.
As stated before, this is an enormous opportunity for physical therapists to join the greater healthcare continuum. If a PT practice can prove they mitigate symptoms and improve function in ten sessions – as opposed to a $10,000 dollar surgery that involves weeks of rehab regardless – then there is clear impetus to use their services.
Looking Ahead
Collaboration is always core to the successful delivery of care, and new models will reward all parties who fully commit to this idea. There are obvious impediments to the idea of a fully integrated care model, with interoperability being chief amongst them. Once we break down siloed information systems and start to have a clear idea of what "quality care" means, then those who have data to back up their claims/decision making will profit enormously.
While knee and hip replacements are a pressing issue that we must solve, it is clear that the rehabilitation industry has an integral role to play in 2017. MSK spending is through the roof, the opioid epidemic is crippling budgets and causing a divide amongst health professionals, and many of these problems come down to mistakes made during the early assessment of patients' conditions and the proper management of their pain – two areas in which PTs truly specialize.
Case in point: increasing evidence points towards physical therapy's efficacy for reducing utilization costs, imaging rates, and opioid use – three areas which have led to healthcare inflation.6 With the rapid digitization of outpatient rehab, it seems evident that more research and data will only help to reinforce this point.
Looking ahead, PT interventions have never been more poised to make an impact, and the industry is now ready to demonstrate effectiveness – a fact that many healthcare organizations are quickly realizing.
By: Jerry Henderson, PT, Vice President of Therapist Success at Clinicient
Bio: Jerry Henderson brings more than 25 years experience as a physical therapist to Clinicient, and serves as "the voice of the therapist" in all company undertakings. A serial entrepreneur, Jerry has started four rehab-oriented companies, one of which evolved into Clinicient. He has deep roots in physical therapy, and brings an immense amount of industry thought leadership to the company's therapist-facing activities.
Jerry co-founded the Independent Private Practice Physical Therapy Association, a non-profit corporation to organize independent physical therapists for local legislative action. He also speaks regularly at industry conferences, and is published frequently in professional journals.
Jerry holds a BS degree in Physical Therapy from the University of Utah.
Connect with Jerry on LinkedIn.
1 http://ptjournal.apta.org/content/92/2/251
2 http://www.healthcostinstitute.org/files/HCCI-Issue-Brief-Unrestricted-Access-to-Physical-Therapy.pdf
3 https://www.huronconsultinggroup.com/Insights/Whitepapers/Healthcare/~/m edia/F8669FA8EE8D406AA822F0D1F5242CBB.ashx
4 http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2594805
5 https://hbr.org/2016/12/a-payment-model-that-prevents-unnecessary-medical-treatment
6 http://www.healthcostinstitute.org/files/HCCI-Issue-Brief-Unrestricted-Access-to-Physical-Therapy.pdf
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