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.