There has been a lot of recent chatter regarding the Alternative Payment System (APS) proposed by the APTA for the reimbursement of Outpatient Services. This model of reimbursement would supposedly move payment for outpatient therapy services from the current fee-for-service, procedural-based payment system to a per-session system. This mode would account for the severity of a patient’s condition and intensity of therapist services required in a session. While this proposal sounds idealistic, there has most definitely been some opposition from some key players in the game.
In addition to the APS, the Centers for Medicare and Medicare Services (CMS) has proposed a Value-Based Payment model for the 2016 Home Health Prospective Payment System. I have provided an outline the “simple” adjustments as analyzed by the APTA here:
Payment Policy. Taking into account all the policy changes, CMS estimates that overall Medicare payments to home health agencies will be reduced by $350 million or 1.8% in 2016 compared with 2015. This decrease reflects a 2.9% market-basket update and 0.6 percentage point cut for productivity, which is mandated by the Affordable Care Act. The rule also includes a 1.72% cut in each of 2016 and 2017 to account for estimated case mix growth 2012-2014, which the agency believes is unrelated to patient acuity, and a scheduled -2.5% rebasing adjustment, the third of a 4-year phase-in. In addition, the proposed 2016 national, standardized 60-day episode payment rate would be $2,938.37. If a home health agency (HHA) does not submit the required quality data, that rate would drop by 2% to $2,880.92.
Home Health Quality Reporting Program. CMS will add 1 standardized cross-setting measure to the Home Health Quality Reporting Program for 2015, as required by the IMPACT Act of 2014. The law requires HHAs, skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals to submit standardized patient assessment data and standardized data on quality measures and recourse use. The proposed new measure, the National Quality Forum (NQF)-endorsed measure: Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678), addresses changes in skin integrity. Also new for 2016, all HHAs will need to submit both admission and discharge OASIS assessments for at least 70% of all patients whose episodes of care occurred during the reporting period starting July 1, 2015. The threshold will increase by 10% in each of 2016 and 2017 to reach 90%.
So I pose a question to you: “How the *%^& have we allowed our model of reimbursement to become so complex and confusing?” Seriously. We need to diligently work towards a model that simplifies, well, everything. I do not believe procedural-based reimbursement encourages the best practice. I personally think it’s absurd and leads to an over-utilization of services due to ridiculous productivity standards set by some employers.
So whats the solution?
Here’s my proposal—it’s a start (payers #cms #highmark #cigna #unitedhealthcare #UPMC—and PTs—let’s start talking…to each other):
1. PT Evaluation – Flat Rate Reimbursement. Let’s say: $150 (account for regional differences)
2. PT Visits/Reassessments/Discharges – Flat Rate Reimbursement. Let’s say: $100 (account for regional differences)
3. Number of Visits – This tends to be where things get more complicated. I would recommend a flat rate of visits per patient per year (many payers already do this). Let’s say 20 visits per calendar year. To incentivize a patient to stick with a health plan, the payer would allow these visits to carry over year-over-year until a visit limit is met.
While models of risk stratification exist, and many propose these for determining length of care, research is limited on this. By limiting the number of visits per year, the payer can risk adjust, the patient can be involved in decisions on utilization of services and the provider can maintains a level of ease knowing an industry standard.
So I ask the readers…why can’t something as simple as above be utilized? Let’s talk…