Congress and presidential administrations over the last 20 years have slowly moved forward with Medicare value-based health care purchasing initiatives (that is, paying for results, not volume of tests, procedures, or services, regardless of quality or outcomes achieved). These initiatives were bolstered and extended with the recent passage of major health care reform legislation: the Patient Protection and Affordable Care Act (PPACA, P.L. 111-148) and the Health Care and Education Reconciliation Act (P.L. 111-152). As sections of the law and accompanying regulations are implemented during the next few years, the ways in which hospitals, physicians, and non-physician health care professionals operate and practice will change in fundamental ways.

The chief research officer (Roades, 2009) of the Advisory Board Company, a provider of comprehensive performance improvement services to the health care and education sectors, outlines common areas of change in health care reform:

• Hospitals and other health care providers will see increased risk to revenue growth as the system transitions to outcomes-focused payment and an emphasis on operating efficiency.
• Bundled payments will reduce specialty care.
• Rewards in primary care practice will focus on coordination, chronic disease management, and population health.
• Total cost management will supplant fee-for-service incentives.
• New regulatory frameworks and entities will emerge.

Milliman's Health Care Reform Briefing further contends that "restructuring the payment system can motivate providers to perform, and payers and patients to pay for, only those procedures consistent with the best evidence and the needs of the patient. A system driven by results allows clinicians time to focus on the treatment delivered rather than the quantity of services provided" (Shreve, 2009, p. 2).

For many years, the Centers for Medicare and Medicaid Services (CMS) has indicated that rehabilitation goals must focus on "functional" outcomes, and that "there must be an expectation that the patient's condition will improve significantly in a reasonable and generally predictable period of time," as stated in Chapter 15 of the Medicare Benefit Policy Manual.

CMS also has encouraged use of the ASHA National Outcomes Measurement System (NOMS) Functional Communication Measures (FCMs) to assess functional progress and outcomes; CMS now endorses NOMS as an official registry for the reporting of outcome data to Medicare.

However, the determination of a patient's significant, practical improvement within a specified time period largely has been the purview of the health care professionals responsible for treating that patient. Now, however, professional self-scrutiny is called for by CMS' recovery audit contractor (RAC) and other Medicare auditing programs, Medicaid, and commercial payers, as well as by provisions in the new PPACA that call for additional auditing, different payment structures (such as bundling), and the conclusions of comparative-effectiveness research. This scrutiny is required in the ongoing effort to answer Douglass' (1983, p. 117) question: "How do we know, and how do we show, that what we do in therapy makes a difference?" 

Enter the ICF Framework

The International Classification of Functioning, Disability, and Health (ICF; World Health Organization, 2001) is a standardized classification of health and health-related domains from individual and societal perspectives, according to health conditions (body functions and structures, activity, and participation) and contextual factors (characteristics of the individual and environment that affect the individual's ability to function in society). These personal and environmental factors may serve as barriers or enhancements to individual performance and participation (see sidebar on p. 15). Although the ICF classifications are not used for coding or billing health care services in the United States, the ICF provides a valuable framework for structuring clinical care to address increasing demands for efficiently achieving functional outcomes.

The professional community has long discussed the application of the ICF to speech-language pathology services. ASHA incorporated the ICF framework into the Scope of Practice for the Profession of Speech-Language Pathology (ASHA, 2007) and the Preferred Practice Patterns for Speech-Language Pathology (ASHA, 2004). ASHA has a web page featuring the ICF and at least two professional journal issues have been devoted to the ICF framework [see Seminars in Speech and Language (Vol. 28, No. 4, 2007) and the International Journal of Speech-Language Pathology (Vol. 10, Nos. 1–2, 2008)].

Putting the ICF Framework into Practice 

Although the ICF is not a model of care, it does provide a framework for structuring care to focus on
function (activity and participation) within a range of communicative contexts. According to Palmetto GBA Medicare (the Part A/B Medicare administrative contractor for eight states), using the ICF to structure clinical care allows for:

• Enhanced decision support
• Identification of care pathways
• Coordination of care
• Education
• Continuous quality improvement

A transcript, presentation, and case scenarios for the module Going Beyond Diagnosis: The Value of ICF are available online (search "Going Beyond Diagnosis Series").

Nickola Wolf Nelson contributed to our knowledge of focusing on functional outcomes in her article "Seven Habits of Highly Effective Change Agents (with apologies to Stephen Covey): Focusing on the Needs of School-Age Students" (Nelson, 1996). She confided that her personal paradigm shift occurred when she "stopped looking at the purpose of speech-language services as fixing deficits and began to see it as assisting individuals to meet their needs" (p. 12). Nelson outlined seven habits associated with the change process that serve to illustrate use of the ICF framework:

• Expect change to occur.
• Expect to work for change as part of a system.
• Ask others what changes are needed.
• Think about how a successful outcome will look.
• Consider the steps between where you are and where you want to be.
• Take the first (or next) step with the goal in focus.
• Measure change and celebrate it when it happens.
• Nelson also posed four key questions that clarify how the ICF framework can be used to structure care for speech-language pathologists:
• What does the individual's communicative context require?
• What does the individual currently do in that context?
• What might the individual do differently to increase communicative success in the future?
• How might the context (environment) be modified to increase success?

Success in the Years Ahead 

Donald Berwick, President Obama's newly appointed CMS administrator, warns of "ill-considered autonomy" among health care professionals (Berwick, 2002). For example, as payment mechanisms are bundled (one payment shared by acute and post-acute programs and/or between hospitals and physicians and other professionals), clinicians will be chosen for the "bundle" who can produce results efficiently and who can perform collaboratively. Professionals who insist on "autonomy" and say that their services inherently "take longer" will likely not be chosen to participate. Instead of distancing ourselves from other health care professionals or seeking to increase a patient's number of "visits" with little accountability for communicative outcomes, now is the time to engage in coordination of care with other clinicians to effect change in patients' activities and participation. It is hoped that most SLPs will accept the increased scrutiny and challenges associated with health care reform and will work closely with others to achieve desired health care outcomes—our consensus goal.