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  • No Turning Back: 4 Ways Bundled Payments Will Change Rehab Care

    Maybe the biggest ICYMI issue in physical therapy so far this year is the impending implementation of Medicare's Comprehensive Care for Joint Replacement model (CJR), a program that will require hospitals in 67 metropolitan areas to use bundled payment systems for total knee arthroplasty (TKA) and total hip arthroplasty (THA). The system launches on April 1.

    You may have some familiarity with the immediate impacts of the CJR on physical therapists (PTs) and physical therapist assistants (PTAs), but the model, and others like it, also set the stage for even bigger shifts in how rehabilitation professionals interact with the health care system.

    In the February issue of Physical Therapy (PTJ), APTA's research journal, APTA Executive Vice President of Public Affairs Justin Moore, PT, DPT, laid out the top 4 long-term practice implications of payment bundles. The article, appearing in PTJ's new "Point of View" feature, provides much more detail (as well as an explanation of how we've arrived at this moment in health care), but here's a quick take on that list:

    1. Bundled care's 3 biggest components, in order: data, data, and data.
    Patient measurement tools will be standardized and integrated into practice, and PTs and PTAs will need to strengthen their profession by strengthening the data that support it. Bottom line: Expect to be participating in registry programs such as the upcoming APTA Physical Therapy Outcomes Registry.

    2. Practice guidelines will be even more important than they already are.
    It will be increasingly important that the entire care team understands the ways PTs and PTAs contribute to the overall treatment process. Everyone will need to know what to expect, which means practice guidelines will play a vital role. As Moore writes, "further development of clinical practice guidelines will only facilitate the inclusion of rehabilitation professionals in the development of the care pathways."

    3. It's not just about you; it's about the team.
    Interprofessional education and practice will become a crucial component of care. Every provider involved in a bundled system will need to understand how the various elements of care are supposed to work (see #2 above) and how they fit in to the system. "Knowing if, when, and in what role rehabilitation professionals are involved in the continuum of service comprising a bundle is essential for success at a patient, system, and provider level," Moore writes.

    4. Bring along your business acumen.
    "The management of resources is essential to best deploy limited access in the most efficient and effective fashion," is how Moore puts it. What that means is, the move to bundling and other value-based systems will require PTs and PTAs to be more savvy when it comes to analyzing what they're doing and at what cost—something that will require "measurement beyond a service-level mentality," Moore writes.

    Read the entire Point of View (a new commentary feature) in the February issue of PTJ, and check out an overview of the CJR featured in the March edition of PT in Motion magazine. Although APTA's March 24 webinar on the CJR is full, a recording of the event will be made available in the days that follow.


    • I normally don't comment on blogs or posts...but I must admit in light of reading an article on the apta website yesterday regarding the fact that physician owned PT results in twice as many visits and lesser quality of one on one care than private practice PT...learning about bundling in this post concerns me even more. I am a practice owner in a small rural community. It frustrates me beyond measure that any payment model would want to reward those systems more! The monopolies in health care today (both large insurance companies and large medical systems) remind me of the ma bell monopoly in the 80s and the horrible too big to fail banking scandal of the 2000s. When will free market exist in healthcare? Ever? When will patients simply chose where THEY want to receive care? Not where they are TOLD to go? It's well beyond frustrating.

      Posted by Lori on 3/22/2016 9:06 AM

    • I agree Lori. It is definitely frustrating beyond belief! I am also a small private practice owner that believes whole heartedly in trying to continue a model of one on one high-quality care with a manual therapy approach. I have had to make cut backs in other areas in order to be able to survive in the current insurance model. We are reimbursed less and less by insurance companies with more paperwork and hoops to jump through and meanwhile expenses keep rising. Something needs to be done to rein in the monopolies in health care so that quality can prevail.

      Posted by Melinda on 3/23/2016 11:18 PM

    • Lori, I am a recent graduate, so I do not have a full and great understanding of the proposed bundle system. However, to my knowledge providers will be given a lump sum of money to spend how they see if. If they do not manage the patient well and the patient requires more treatment to get better, then they will loose money. However, if the therapists and other team members perform excellent therapy and get their patients back to where they want to be faster and in less visits, they will get more money. Based on this understanding wouldn't these physician owned PT clinics where more visits are required to recover be actually loosing (or making less) money compared to a private practice with well trained therapists providing exceptional care? If my understanding is incorrect, please correct me as I would like to learn more and understand how this payment system will work.

      Posted by Alex on 3/24/2016 1:40 AM

    • I am in total agreement with Lori. Where does private PT practices stand in this model. The APTA suggests that we align ourselves with a hospital. Where in the world will that work? The hospitals in my "metropolitan" area have 2 and 3 PT clinics. I don't get the overflow, I get the patients that want quality care and leave that system to receive real hands on PT. Please tell me what hospital will give up their share of this bundle so their patient can have better care. Frustrating is only the tip of my emotions, I am infuriated!

      Posted by Darlene Wooldridge on 3/24/2016 8:22 AM

    • Actually bundled payment should have a positive effect on these physician owned practices. Because the hospitals are the entities at risk in the CJR, they will be making decisions about who to collaborate with. Both costs of episodes and outcomes will have an affect on the financial impact on the hospitals that in the absence of risk/reward sharing collaborations, are the only ones at risk. This will necessitate that they create collaborations with outpatient therapy clinics with good cost and quality outcomes and put pressure on the physicians to either improve the performance of their clinics or get out of the business. While the hospitals cannot mandate where patients receive their outpatient therapy, they can, and will, provide outcomes data to the patients to assist them in making an informed decision.

      Posted by Debra Christian on 3/24/2016 11:38 AM

    • None of those 4 points is news. Isn't that why we spend so many years in school and training? What it really means is we'll have to dance to Medicare's tune in order to receive less reimbursement. When are we going to start to have an honest dialogue with peers and our primary representative body, the APTA?

      Posted by Brian P. D'Orazio DPT, MS, OCS on 3/24/2016 10:32 PM

    • I commented on this previously, but don't see that here. I'm in agreement with Lori's frustrations. Additionally, there is no data to substantiate that this method of care will produce better results. The primary methodology relates to limited intervention, without comparison groups to substantiate the validity of the original assumption that limited care will be as good as more conventional approaches. This is a research project taking place without consent of the patient. There appears to be no oversight on the project as it relates to outcomes, or more to the point the oversight comes from the party that most benefits from its implementation. What happened to " evidence based care "? What happened to ethics? Were they just words to make us feel better, that now can be discarded because a government agency tells us to do this? Let's be honest about this, it's about saving Medicare's budget at the expense of citizens. This country has a history of experimentation on prisoners, blacks, the cognitively challenged and now it will be on Medicare patients. We shouldn't be excited about this, we should be outraged. We should be marching on Congress. Where are our ideals; where is our conscience?

      Posted by Brian P. D'Orazio DPT, MS, OCS on 3/25/2016 3:24 PM

    • Lori, Unfortunately, the situation has gotten and is getting worse and worse. The situation can be summed up by the following: little by little more and more will be controlled by fewer and fewer. We do not have a free market and, in fact, completely free markets rarely exist and if they do briefly come to exist, they are quickly subverted by the conjoined interests of a political and private power trust. This situation has been the case throughout history, going back centuries. We no longer have unfettered capitalism. We have a corrupted form of crony capitalism. As long as we count on government and corporate insurance entities for our existence, we will continue to be largely powerless pawns in this process. Wealth will progressively be extracted from us and flow to more powerful hands. Surface explanations will be proffered as to how this whole process is beneficial for the patient, for us, and for the third parties but the reality is, those explanations are simply being used to manipulate us into the behavior desired by our controllers. And if you try to step outside the system, which has been a solution in the past and up to the present, you will find that the system is increasingly being designed and structured to either make you comply or to exclude you. It's a sad state of affairs and unfortunately, our organization and many in it are unwittingly becoming quislings to the process. This is a phenomenon which goes far beyond our profession and encompasses the entire milieu of our present day political, economic, financial, monetary, and social system.

      Posted by Brian Miller on 3/26/2016 12:01 PM

    • Lori articulated my situation, concerns, and fears perfectly. This system will be the death of many small individual practices that provide excellent evidence-based care, but that just won't be able to compete against the corporate monopolies. Drug companies control M.D. decisions and practice; Medicare controls us. I am beyond sad for the patient and our profession.

      Posted by KIM MAZIK on 3/27/2016 3:41 PM

    • Darlene made a great point that these big hospitals have their own PT outpatient clinics so you can guess they want to keep the money in their system. Isn't this the same as a POPS practice? Referring to your own therapists. If people would actually read the article about the POPS and TKA patients they would see that they may have had more visits but they charged less. No where did the article says outcomes were less and the title was proven wrong. Please re-read the article and really look at the facts. More visits but less charges proves the POPS practice are charging less. Both practices had reasonable visit amounts and it woukd be interesting to know if these pts had home health in addition or they went home post hospital and straight to outpatient. Wake up read your facts. We let this bundling happen with no thoughts that it is the same concept except it is a hospital system now that will monopolize the money. Let's quit pointing fingers and do what's best for the pts no matter who treats them and how many letters they have after their names.

      Posted by Norah Riniolo on 3/28/2016 4:45 PM

    • Eric, yes, theoretically, the best care is also the care with the most value, and the best provider should win in the end. The problem I see is that the system is rigging itself so that the medical systems (not the private practioneers- PPs) will be the trial providers for the bundling process. I would be truly amazed to hear of a hospital system farming out PT to PPs to improve their efficiencies. We alone are not big enough to do them enough good. And we, PPs, are not a unified group with clout. And if the systems did use us, it would be on some contract basis that would minimize what the PPs could make. So, CMS or medicare will be deciding which "system" offered the best value. And years later when all the data is processed, and revealed and a decision needs to be made, it won't have data from or even include the option of private practioneers. And by then there may not be any PPs in practice. anymore.

      Posted by john on 3/28/2016 4:54 PM

    • Unfortunately our national organization has co-opted the private practice section to placate the large hospital systems, large insurers and government interests. The unintended consequences of bundling will continue to squeeze operating income from already efficient and successful private practices to somehow become "more savvy" (per article). This will put private practice at serious risk of survival under any insurance model. The reality as it is playing out is that the incentive is for the hospital systems to keep all services bundled under their umbrella. We are seeing that now with decreasing referrals for outpatient PT - with some care provided per home programs and telehealth with no value on our services. It is, as previously mentioned, a grand experiment on the medicare beneficiaries with no concrete and evidence based data to base these decisions - only monetary savings are used as a benchmark of success. It is monopolistic, unethical and against free market principles that make the prospect of being in private practice, employing many people, serving our community and providing high quality care a delicate and difficult endeavor.

      Posted by jamesseykot on 3/29/2016 8:29 PM

    • Being knee deep in coordinating therapy's role in bundle programs, OP therapy is the landing spot of choice for our programs. We are actively trying to avoid inpatient rehab settings due to its high costs. We are using a third party to coordinate and collect patient outcomes who report back to the committees about patient outcomes at OP facilities. The OP facility is the patient's choice.We track to see if a setting helps reduce readmissions and provide high quality care via a selected outcome tool. i.e. AMPAC, PROMIS 10, etc. I would strongly recommend that OP clinics coordinate with the local hospitals to improve communication. we really are focused on who provides excellent care with efficiency.

      Posted by Arley J on 4/28/2016 9:37 PM

    • Now that 2016 is over and many hospitals have implemented bundled payments, I am interested in hearing from those who posted here. My local hospital is sending fewer patients to SNF's, and I am assuming even fewer go to out-patient rehab.

      Posted by Ellen on 1/9/2017 7:21 PM

    • I am the daughter-in-law of a now deceased recipient of these "bundled" services. My late mother-in-law, age 81, was convinced that she would best recover from her THA at home with OP support. I do feel that the doctors preyed upon her fears that she would never leave a SNF once admitted, and capitalized upon her cultural fears of American healthcare institutions (she was an immigrant). The night after her surgery, she fell in the hospital. She was not injured, so she was sent home the next day as planned. Within one week at home, where she lives alone, she fell. She passed away later that night. There was no autopsy (her DPOA was talked out of that, too) so I cannot say that the fall and the resulting death could have been prevented if she were in a SNF. However, if were are going to be empirical about the benefits of OP services, I want to see falls as part of the data being collected.

      Posted by Heather Knoeferl, OTR/L on 6/2/2017 3:31 PM

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