Health Care Reform's Triple Aim: Is Physical Therapy Ready for Innovation and Integration?
Coauthored by R. Scott Ward, PT, PhD, APTA president; Paul Rockar, Jr., PT, DPT, MS, APTA vice president and chair of the Public Policy and Advocacy Committee; John Barnes, APTA CEO; and Justin Moore, PT, DPT, APTA vice president of Government Affairs and Payment Advocacy.
Yesterday, a message was sent to association members regarding the recent Board of Directors meeting that references the "Triple Aim" of health care and its influence on policy. We'd like to take this opportunity to further explain the Triple Aim and discuss physical therapy's role in what has become a major focus in the post-health care reform debate.
The Triple Aim originates from the Institute for Healthcare Improvement, a think tank founded by Donald Berwick, MD, in Cambridge, Massachusetts. This philosophy permeated the Centers for Medicare and Medicaid Services (CMS) during Berwick's tenure as its administrator, and is now linked to implementation efforts associated with taking the more than 2,400 pages of health care reform legislation and turning them into volumes of new regulations, programs and federal efforts required to operationalize the Triple Aim. Berwick's tenure ended on December 2, but the Triple Aim is now part of his legacy to reform our health care system.
What is the Triple Aim? To start, it is a proposed solution to our health system's ills. It is well documented that the United States' health care system is the most expensive in the world, disparate in its access, and often doesn't impact or improve one's health status. On November 4, CMS announced that US health care spending growth was 4.0% in 2009, reaching $2.5 trillion in expenditures, or $8,086 per person or 17.6% of the nation's Gross Domestic Product, up from 16.6% in 2008.1 The Triple Aim was outlined in Health Affairs in 2008 as an effort to reverse this trend and simultaneously pursue the 3 objectives of:
- (1) improving the experience of care;
- (2) improving the health of populations; and
- (3) reducing per capita costs of health care.2
The Triple Aim builds upon the 3 goals of the "iron triangle" of health policy, which call for enhanced quality of care, improved access to the right provider at the right time, and reduced health care costs to manage a person's health status.
Can physical therapy achieve the Triple Aim and, if so, how? We believe that we can because the Triple Aim is connected to what we do as physical therapists. The task before us now is delivering this message to policy makers. APTA continues to position and align its organization and priorities to meet the demands of the changing health care landscape, achieve the Triple Aim or contribute our proper role to the Triple Aim for delivery systems, and to demonstrate the essential value of our profession and the services we provide to the public. Connecting these to the health policy environment with which we interact is essential to move the profession forward as a leader in health care delivery. As 2011 comes to a close, there are several critical initiatives ongoing to leverage physical therapists as essential to achieving the Triple Aim.
To improve access, APTA is working to secure a commitment from the new Center for Medicare and Medicaid Innovation (CMMI) to invest in the early access or direct access to physical therapists for musculoskeletal conditions as part of its search for more efficient and effective models of care delivery. APTA's proposal has been submitted and is under consideration by CMMI at this time. Also in this area, APTA saw the completion of a multi-year project on direct access with the publication of an article published in the journal Health Services Research that suggests that "the role of the physician gatekeeper in regard to physical therapy may be unnecessary in many cases." This work by Jane Pendergast, PhD, Stephanie A. Kliethermes, MS, Janet K. Freburger, PT, PhD, and Pamela A. Duffy, PT, PhD, OCS, CPC, should help our state and federal efforts prove the value of direct access to physical therapy in the coming years. APTA also has assembled an issue team led by Roshunda Drummond-Dye, JD, APTA's regulatory and payment counsel, to spearhead our role in integrated models of care delivery. These models, ranging from Accountable Care Organizations (ACOs) to patient centered medical homes, will have key access issues as they become part of our reformed health care system. APTA's work is to demonstrate the value of physical therapy and our role in these models.
To improve quality, APTA hired a full-time policy expert in 2011 to lead the development of a quality work plan and focus on the policy efforts that the federal government is involved in to enhance quality care. This has resulted in a coordinated and consistent approach to position APTA in the quality area and incorporate quality into areas such as a reformed model for payment, the development of a national registry, and health information technology in physical therapy. Just last week, CMS released the updated measures specifications for the Physician Quality Reporting System for the 2012 reporting year, allowing physical therapists to report for an additional individual measure in the 2012-Measure #182: Functional Outcome Assessment. Our work with CMS in this area can be seen each year as physical therapists are included in reporting on new measures.
To reduce costs, APTA continues to seek needed reforms to physical therapy services. As mentioned in yesterday's message to members, APTA is exploring a reformed payment system model, which could include direct billing for physical therapists, and embarking on a regional payment pilot project in the New England area. Also essential to this objective is establishing strong term protection for physical therapy and title protection for the physical therapist. APTA will submit its review of the current status of term and title protection to the 2012 House of Delegates and begin an action plan to improve term and title protection where gaps lie. In addition, we continue to seek policy support through the health service research pipeline to advance our public policy priorities. Work in 2011 began on referral for profit, billing patterns of health care professionals who use the 97000 CPT series (physical medicine and rehabilitation), and bundled payments and the role of physical therapists.
These are just a few of the areas where APTA is working for you and with you to achieve a Triple Aim that advances physical therapy. The key words in health care today are "integration" and "innovation." We are reminded of this daily with announcements such as the following from CMS:
News Alert: The Department of Health and Human Services recently announced the Health Care Innovation Challenge from the CMS Innovation Center, a new initiative designed to test creative ways to deliver high quality medical care and reduce costs across the country. The Challenge will award up to $1 billion in total grants to applicants who can rapidly implement the most compelling new ideas to deliver better health, improved care and lower costs to people enrolled in Medicare, Medicaid and CHIP, particularly those with the highest health care needs.
APTA is a key messenger in this transformation from independent and often fragmented care to more interdependent models. The key message will be the work that physical therapists do daily, our record of compliance, and our value to the health care system in reducing costs while raising the bar on quality. We can have a positive impact on the nation's health-and do so already. Illustrating this by adapting to the current realities of health care and accepting the challenge of innovation and integration will best convey our message.
2011 was a year in which we saw the start of the transformation of our health care system through rules on ACOs, a proposal on the essential benefits program, and payment innovations such as the CMMI bundling project. 2012 promises more transition to a health care system where transparency, accountability, and integration are valued. To deliver the message of physical therapy's role in this transformed health care system that meets the Triple Aim, we need you to participate and build on the successful grassroots efforts and Capitol Hill activities we demonstrated in 2011. It was just 6 months ago when almost 1,000 physical therapists, physical therapist assistants, and students stood in the heat on Capitol Hill ready to share the Triple Aim value proposition that physical therapy is prepared to accept and deliver. We look forward to continuing the momentum in 2012.
Have you thought about your role in achieving the goals of the Triple Aim? Do you see opportunities and challenges to implementing programs in your practice that can improve access and quality and decrease costs? How can APTA's initiatives help support your efforts?
1. Centers for Medicare and Medicaid Services. Historical National Health Expenditure Data. https://www.cms.gov/nationalhealthexpenddata/02_nationalhealthaccountshistorical.asp.
Accessed December 12, 2011.
2. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff. 2008;27(3):759-769.
Sending a Message on Direct Access
Over the past several weeks, we've seen some great coverage of the Health Services Research study supporting direct access to physical therapists. As APTA announced in a recent news release, the study found that direct access to physical therapists is associated with lower costs and fewer visits and suggests that "the role of the physician gatekeeper in regard to physical therapy may be unnecessary in many cases."
Media organizations such as UPI and the Bend Bulletin in Oregon, among others, have published stories on the study. We've also seen APTA members across the country promoting the research on their web sites, blogs and social media channels.
Word about this study is definitely spreading, and we want to continue that trend, so we've developed an online toolkit to assist you in your outreach efforts. The kit contains the resources and information you'll need to get the word out to your local media, legislators, and other important players in health care. Join us in sending a strong message to decision makers that direct access to physical therapists could go a long way toward helping to make health care more affordable and accessible for all.
There's No Place Like Home
Congress is back in session, with many issues of importance to our profession on its docket. But even during the congressional recess in August, many of our members were keeping in touch with their legislators back home - and in some cases inviting them to their practices to provide a firsthand look at the important role physical therapists and physical therapists assistants play in the lives of the American people.
Case in point: On August 22, the Chairman of the Health Subcommittee of the House Ways and Means Committee, Rep Wally Herger (R-CA), visited a practice in his home district -- Butte Premier Physical Therapy in Chico, California. This was the first clinic visit for the chairman, whose committee is 1 of 2 key health policy committees in the House of Representatives that play an important role in APTA's legislative issues, including repeal of the therapy cap. Clinic owner Leigh Langerwerf, PT, DPT, led the tour with Herger, who was able to observe the care of 2 patients, while clinic staff described the scope of PT services and discussed APTA's legislative priorities. This grassroots effort represents the importance of a strong collaborative effort between APTA and individual members. Thanks to Leigh Langerwerf for helping to coordinate this important event.
Throughout the August recess, APTA made a concerted effort to increase the number of home district meetings and site visits, and we had an excellent response from our membership and components. We've had 8 sites visits (either completed or scheduled in the near future) and 15 regular visits in congressional offices. It can't be stressed enough how important these visits are for our legislative advocacy efforts.
Thanks to all of our members who opened their clinics and practices to members of Congress in support of APTA's legislative initiatives. We'd love to hear about your experiences on this blog.
Rep Wally Herger (R-CA) (left) with Leigh Langerwerf, PT, DPT.
PT Day on Capitol Hill: Stepping Up to the Plate
Guest post by Karen K. Swisher, PT, MPT, DPT, of California
It's the bottom of the ninth and the bases are loaded. Are we, the profession of physical therapy, going to step up to the plate to be heard? The answer is a resounding YES! YES to the hope of hitting a home run! YES to being heard!
Approximately 1,000 PTs and PTAs said yes to PT Day on Capitol Hill. The event started with a rally on the lawn; all of us facing the Capitol and listening to the National Anthem. Professionals in our association for over 50 and 60 years were recognized. I spoke with those around me and was amazed to find many physical therapy students there to represent our profession. The specific issues at hand are bills that relate to: (1) the balanced budget act of 1997 (repealing the Medicare cap - an arbitrary limit on financial services to PT/OT care without consideration of pathology); (2) adding PT students to the loan forgiveness act if they choose to enter underserved communities via the National Health Services Corps; and (3) the concussion bill that includes PTs in the team of professionals surrounding head injuries to determine safety and timing in return to activity.
As APTA President Scott Ward, PT, PhD, spoke on the first issue I was flooded with emotions remembering back to 1997. Tears streamed down my cheeks as I recalled my own graduation. At the time the balanced budget act of 1997 was implemented, I was a graduating from Old Dominion University's master of physical therapy program. Not only did it rock our profession with a "knee jerk" reaction of laying off PTs, it made it nearly impossible for new grads to get a foot in the door. After searching and interviewing at clinics and hospitals in my area I realized there was a hiring freeze. All I could think was, "ARE YOU KIDDING ME?" I was eager to work and full of excitement only to find I would wait 6 months after graduation to secure a job-and with $35,000 in loans deferred for 6 months (a far cry from the $100,000+ that burden those committed to answering a call today).
During that transition I went to Florida to help my grandparents: my grandfather couldn't drive, and my grandmother was in an acute care facility with a fractured right tibial plateau (NWB for 3-6 months) and a fractured right distal radius, and recently recovering from a left rotator cuff repair a month and a half out. The state-of-the-art facility, which employed 25 professionals (PT, OT, and speech therapists), was preparing to lay off 12 professionals due to the financial burden of the balanced budget act. The need to care for patients in this facility was unchanged. The workforce to do it, however, was obliterated! How could we allow this to occur for the well-being of the patients we serve? This flashback prepared me for the work ahead. We marched as 1,000 strong carrying a message to the legislative body of our nation.
Along with Ryan Johnson, PT, DPT, a new addition to our profession having graduated 3 weeks ago from UCSF, I had the opportunity to meet with Kristen Glenn, who is California Congressman Tom McClintock's health advisor. We spent over 30 minutes discussing health care concerns specific to our profession and the patients we serve. She listened intently and added her thoughts and concerns. We shared stories of our professional experiences and were grateful for her genuine concern. I learned that Ryan followed in the footsteps of his father, a PT for over 30 years. He made it clear as a member of the Board of Directors for the Student Assembly that his voice represented the 15,000 students in our profession. In fact, we represent the field of 210,000 PTs and PTAs in our profession and, more important, the patients in our care.
I believe we hit a home run! We were heard! We fostered a new relationship with our congressmen out of the concern for the PT profession and the patients we serve. Many physical therapy professionals concluded the same experience. As Katherine Sullivan, an APTA House of Delegates representative for the Neurology Section, noted of the final motion brought before the House, "PTs are committed to a society where people of all ages live healthy, active, and productive lives with optimal function." As a first-time delegate of the House of Delegates, I felt that this final day of a 5-day stint was a life-changing experience in my career. It was the "cardiac paddles" I needed to erect a spirit of hope and a commitment to change. We can no longer proceed along the same path if the path is not the one that will allow us to arrive at our final destination! Please rise to be heard! At any level - city, state, or national - one voice can be the catalyst to change.
Karen K. Swisher, PT, MPT, DPT (right), with Ryan Johnson, PT, DPT, and Kristen Glenn
PT Day on Capitol Hill: Found the Purpose
Guest post by Mickie Hucke, PT, JD, of Washington
As I stood on the lawn in front of the Capitol listening to a beautiful trio sing "The Star-Spangled Banner" I was filled with excitement and a sense of purpose mixed with a little trepidation about the day to come. I am a middle-aged member who attended the national legislative rally for my first time Thursday, and the whole experience exceeded my expectations. What made me do it? The encouragement of my association and a sense that health care is at a pivotal point. APTA President Scott Ward put it well when he said that we do not have a government run by representation, we have a government run by those who participate in the representative process. That rang true for me because I have always felt that what we learn in PT school and in continuing education is not enough; if we don't take care to have a voice and exert a presence then we will be legislated out of the ability to be effective and use the knowledge and skills that we have.
My saga started back in my local chapter (Washington) where I was recruited for our Legislative Committee and then became legislative chair several years ago. I had planned and attended many local legislative days at my state capitol but never flew across the country to attend the national rally. I changed jobs and then re-established my commitment to chapter governance by getting elected as the Practice Panel director, but there was still this thing called House of Delegates and the national scene that would take a bigger commitment of time and resources. Last fall I took the step and ran for a delegate position to bring my personal education and involvement to a different level. That brought me to the right place at the right time for my first national rally.
Issues around Medicare, health care reform, and reimbursement changes have been moving at a faster pace, and I realized that our profession stood at a crossroads. My nonmember PT friends back home didn't seem to see the same train on the tracks that I was watching. I saw the ACOs coming, the RACs coming, and Medicare's sky falling! I felt that we could either choose to mutely stand by and accept whatever happens or we could take some control and shape our destiny into one with exciting possibilities. After being one of the thousand APTA representatives standing shoulder-to-shoulder in the intense humid heat of Washington, DC, I now feel certain that we have a lot of good people who do see the train and are working hard to keep the train on the best track for our profession and our patients. A PTA friend of mine encouraged me, saying I would find rich debate in the House of Delegates, and the experience at the Capitol would live up to my expectations. She was right (thank you, Cathleen).
Since Washington is so far from the Capitol it really takes a commitment to attend our national legislative day. I did not realize how much support I would get from my colleagues and association. APTA rolled into action, and my national staff turned a daunting task into a few e-mail clicks beyond my ordinary travel plans. The APTA staff had training for us the night before, maps, written instructions, glossy handouts, and pre-scheduled appointments. Although the heat was stifling at times we were able to get out of the sun because there were rest areas and strategies that kept us inside as much as possible. I saw a lot of APTA staff standing outside in the heat organizing the bus drop-off/pick-up process with smiles, clear instructions, and encouragement. More than once I heard staff telling groups of us how important the mission was; one of them told me that the way we connected as individual constituents was more powerful than a whole year's work for our staffers.
When we got into the meeting rooms I noticed that each one of the legislative assistants that I saw was interested in our story. The level of expertise varied and I found myself speaking to one legislative assistant on topics that seemed new to him. He took notes, took my card, and asked if he could e-mail me for more information in the future. He really meant it!
At my senators' offices, larger groups coordinated who could best tell stories that connected with our legislative agenda: repeal the Medicare cap, add physical therapists to the list for loan forgiveness via the National Health Services Corps, and support national legislation on concussion management that recognized physical therapists amongst qualified practitioners in this arena. Each visit we were asked to individually identify ourselves, our hometown, and practice locations. The senators had legislative assistants who knew about past participation as co-sponsors. One expressed that the senator had simply been so busy last year that she did not prioritize it and did not sign on, but our presence indicated that the cap is still a big issue. They took copious notes and seemed to gain a new understanding of the student loan repayment situation as a result of our visit. Yes, we can open doors and we can be heard at the national level. The future will tell us how successful we have been, but at least I know that I lived up to Scott Ward's call to participate. We will not go down silently.
Before I traveled to Washington, DC, I read a lot of posts from colleagues claiming that the only issue before us was reimbursement. After this trip I know that the debate is about far more than reimbursement, AND it is about reimbursement. We are at a pivotal point for physical therapy, and I think about the pioneers who came before us. By participating in our national legislative efforts I feel that I am joining in historical times. The future of our profession is in our hands and I am more positive about all the issues that we face because we face them together and with a united voice. Tonight I will sleep well, knowing that I participated-finally.
Advocacy in Action
If you need encouragement to attend APTA's PT Day on Capitol Hill, June 8-9, look no farther than a recent example of successful grassroots advocacy by one of our chapters. Our Alabama colleagues proved there really is strength in numbers when – shortly after their PT Legislative Day & Rally on April 26 – direct access legislation in Alabama, Senate Bill 361, moved forward in the state’s Senate Health Committee with amendments proposed by the chapter.
Approximately 300 physical therapists, physical therapist assistants and students had converged on the Alabama state legislature in Montgomery to rally in support of SB 361 and the House's version of the legislation, HB 202. Before the rally, participants met personally with their statehouse representatives and state senators – educating them the on the importance of direct access for state residents. Many of the physical therapy students explained to their legislators that they would potentially leave the state following graduation given that Alabama is 1 of only 2 states left that has no form of direct access.
These personal visits really do make a difference, which is why we need you to come to Washington, DC, next month to advocate for your profession with members of the U.S. Congress. This year, PT Day on Capitol Hill replaces APTA's annual Federal Advocacy Forum to run in conjunction with APTA's Annual Conference & Exposition (PT 2011). PT Day on Capitol Hill takes place over two days, with events at National Harbor, MD, and on Capitol Hill in Washington, DC.
Let's look to our Alabama colleagues as an example. Together, we can make a difference. As your colleagues who were interviewed for the video below have said, "If we don't speak up for ourselves on Capitol Hill, who will?"
Hope to see you next month!
Protecting Our Players
Concussion management has become big news lately as the professional sporting leagues deal with the issue and its effects on their players. A recent study has found, not surprisingly, that concussions in the National Hockey League may be getting more severe; Major League Baseball has adopted new concussion guidelines; and the National Football League will be requiring sideline concussion tests this fall, assuming there is a 2011 season.
These are all major steps in the right direction - not only for the players themselves, but also for the millions of student athletes across the country who look toward professional players as role models. But more needs to be done to protect our young athletes from the often devastating effects of head injuries, and the state of Iowa recently made one giant leap toward making athletic activity safer for our children.
A new groundbreaking law permits student athletes in Iowa to be evaluated by physical therapists to determine when it is safe to 'return to play' following a hit, fall, or other incident in order to reduce the risk of a concussion or other brain injuries. Signed April 7 by Gov Terry Branstad, SF 367 requires that a student be immediately removed from participation in an activity when a concussion is suspected, and must be evaluated by a physical therapist or other licensed health care provider trained in the evaluation and management of concussions and other brain injuries. The health care provider must provide written clearance for the student to return to activity.
Kudos to Iowa Physical Therapy Association (IPTA) President Blake A. Hardy, PT, DPT, OCS, and IPTA members whose grassroots lobbying efforts helped ensure that student athletes with head injuries will continue to have access to physical therapists. So far, similar legislation has been introduced in more than 35 states and enacted in 15 in an effort to reduce the risk of concussions or other brain injuries sustained in community and school sports or other extracurricular interscholastic activities. The Iowa law is the first to specifically allow student athletes to receive clearance to return to activity from a licensed physical therapist. Legislation in Vermont also includes physical therapists as health care providers who can make similar decisions, but the bill is awaiting passage. As we know, physical therapists are well trained in evaluation and treatment of balance and vestibular disorders and are appropriate participants in return-to-play decisions.
APTA is working to make certain that physical therapists and other qualified health care providers are included in similar legislation in other states to ensure that there is access and collaboration across a broad range of providers on this important public safety issue.
What are your thoughts on this issue? How might physical therapists best help ameliorate this public health concern? How is this issue being addressed in your state?