You see health care changes happening all around you as a provider, and maybe you've even experienced them as a consumer. As much talk as PTs hear about these changes, what PTs often encounter are individual mandates, rule revisions, and payment adjustments—none of which necessarily capture the big picture.
This big picture is important to understand. While it won't help you decipher the latest reimbursement rule from CMS, it will help you see the general lay of the land—and seeing the lay of the land right now will help you anticipate what's to come. Here are 3 big drivers behind the changes happening now, and the ones to come.
Collaborative care. On its face, it makes sense: to be truly effective, truly patient-centered, providers and patients need to work together to create one seamless process that achieves the desired outcome. Translating that idea into organizational arrangements, processes, and payment systems is another matter. Models have been created and tweaked, and new ones are being developed all the time. Right now, you're likely to hear about—or find yourself participating in—accountable care organizations (ACOs), bundled payment models, and patient-centered medical homes (PCMHs). Learn the basics and stay on top of developments through APTA's Collaborative Care webpage. The page supplies background on the models, offers videos on collaborative care, and even provides a way for you to join online discussions about this dynamic health care issue.
Linking payment to quality. The fee-for-service model might be doomed, but it's not going out without a fight. Right now, we're in a transitional stage, which means that CMS and private insurers are taking what they believe are incremental steps toward making payment about quality and patient outcomes
The most tangible way this transition is taking shape has to do with what PTs are or will be required to do by way of reporting, and one of the best ways to get a feel for those changes is to familiarize yourself with the steps Medicare is taking. Regardless of whether you bill for services through Medicare, the quality reporting requirements for various settings—acute care, postacute care, and private practice—will give you an idea of the real-world, real-time effects of what is a true paradigm shift in health care. And don't forget: changes adopted by Medicare have a way of being adopted by private insurers later on.
Program integrity. The concept of "program integrity" goes hand in hand with the push for quality and outcomes, and admittedly, it can be a little intimidating. CMS and private insurers are looking for markers that they believe are linked to better outcomes. Guess what that means? That's right, more rules.
Again, CMS plays a big role here. You could try to internalize all the CMS program integrity requirements out there, but why not just audit your practice to see where your policies and procedures may or may not line up? You can access a straightforward self-audit form on APTA's Medicare Claims Audits webpage (it's the first link on the page). After that, get tips and guidance on a wide-range of issues having to do with making your documentation defensible. If you're involved with private insurers, the private insurance webpage is your go-to. For more specifics, focus on your particular practice setting, and connect with resources that will help you see how program integrity is being addressed by the private sector.
This article is a part of APTA's "Profession in Transformation" series. Check it out!