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  • Medicare Reaches Value-Based Payment Goal a Year Ahead of Schedule

    Medicare's march toward payment systems that are tied to value and not volume has been moving along at a faster-than-expected clip, according to the Department of Health and Human Services (HHS), which says that Medicare has reached its goal to tie 30% of all payments to value-based systems nearly 1 year ahead of schedule.

    According to an HHS announcement, growth of alternative payment models including accountable care organizations (ACOs) and bundled payment systems have allowed Medicare to shift $117 billion out of a projected $380 billion away from fee-for-service payments. HHS says that this shift has resulted in better care and greater savings, including $411 million savings in 2014 attributed to ACOs participating in the Medicare Shared Savings and Pioneer ACO programs.

    The move away from quantity was a major feature of the Affordable Care Act (ACA), which created programs such as Medicare Shared Savings and the Center for Medicare and Medicaid Innovation.

    In a fact sheet from the Centers for Medicare and Medicaid Services (CMS), the agency says that the transition to more alternative payment systems has coincided with other improvements in health care, including a 17% drop in hospital-acquired conditions, lower hospital readmission rates, and slower growth in per-enrollee spending.

    "Alternative payment models, such as bundled payments or [ACOs], make doctors and hospitals attentive to the total costs of treating a patient at a high level of quality over time," CMS states. "This focus makes care more accessible to patients, including after-hours availability, quicker follow-up, more seamless transitions from one doctor or clinician to another, fewer repeated or duplicative tests, and keeping patients healthier overall."

    Many physical therapists and physical therapist assistants are already involved in alternative payment systems (and some are even helping to pioneer approaches through APTA's Innovation 2.0 program), but that involvement is bound to increase soon, when CMS launches its Comprehensive Care for Joint Replacement (CJR) program. That system, which will require hospitals in 67 metropolitan areas to participate in a bundled payment program for total knee and total hip replacements, is set to start April 1.

    APTA has been helping its members keep up with the transition to value-based and collaborative care models, most recently developing resources to help PTs and PTAs understand the CJR. The association will host a webinar on the program on March 24.

    At an even broader level, the association has developed a new alternative payment system for the profession. Called the Physical Therapy Classification and Payment System (PTCPS), it's a system that uses a severity-intensity framework as a basis for payment, rather than a procedural-based, fee-for-service system. The evaluation codes associated with the new system will be implemented January 1, 2017.

    "The new coding system that will begin in January marks an important step for the physical therapy profession toward exactly the kinds of models CMS says will be the future of health care," said Carmen Elliott, APTA vice president of payment and practice management. "The fact that CMS is achieving its transition goals sooner than expected makes it even more important that we continue to work together to develop a model that will help the profession thrive in a quickly-changing environment."

    Why does the move toward value-based systems matter, and what's the big picture? Check out this article from APTA's series, "Physical Therapy: A Profession in Transformation."


    • The ACA initiatives are fundamental failures based on flawed assumptions. Changes in costs are likely short-term based on reduced care; the same outcome that we all witnessed in the early and mid-1990's with HMO incentives being paid to PCP's to limit referrals to specialists. ACO's are formed by a group of MD's who pay to belong to a hospital based program incentivized by CMS to save money under the assumption that better communication will result in reduced costs vs. the assumption in the 1990's that specialists were the cause of increased expenses. Because the MD's want to recoup their membership fees, they are gradually finding ways to limit treatment, but this doesn't equate to value...or at least that assumption is likely premature. Hospital readmission rates are being gamed by hospitals who can't afford the penalties charged by CMS. Rather than re-admit patients, they house them in the ER for up to 2 days so they don't have to claim them are re-admits. I hope the APTA can help us survive this debacle. For hospital PT's, they are frustrated by admin staff reducing their time with patients, and for PP PT's, we are forced to reduce treatment times to keep from being investigated by OIG. The alternative is to treat longer and eat the time...which many of us are doing because the lack of ethics involved in providing less than optimal care is very hard to survive. It caused me to retire early. All of this is wrong for patients and wrong for our profession. This isn't about value, this is about saving the government money and nothing else. This is about businesses trying to survive. This is about the same issues we see in Europe and Canada. As someone who grew up across the border from Canada, I can tell you their health care system was poorly received by it's citizens who routinely came across the border to find care....assuming they could afford to pay out of pocket. This is the same 2 tiered system seen in most European countries. Everyone is being placed at risk by these changes...everyone but CMS that is!

      Posted by Brian P. D'Orazio DPT, MS, OCS on 4/29/2016 10:57 PM

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