The "changing health care landscape"—it's an expression that bombards clinicians. The current fee-for-service system of health care delivery in the United States is under fire from Congress, health insurance providers, health care think tanks, consumers, and even health care providers.
What's driving the change? Internal and external forces alike are affecting the future of health care provision and reimbursement: The rising costs of U.S. health care, the lack of affordable health insurance for a significant number of Americans, and the need to demonstrate the functional outcomes of treatment are converging to drive far-reaching transformations in every facet of health care.
Are speech-language pathologists and audiologists ready for a new approach to health care that focuses on quality, value, and functional outcomes? A look back may help clinicians understand and prepare for what lies ahead.
New Ideas? Hardly
Focusing on value and clinical accountability is not new. In "Managing to Care," a 1998 article in the newsletter Front and Center, Edward O'Neil of the Center for the Health Professions at the University of California at San Francisco asked: "Does anyone really desire unmanaged care? That is, care that would be delivered without attention to established guidelines based on empirical evidence, care that is wasteful of resources, or services that fail to meet basic consumer needs. Are we really concerned that a systematic approach to delivering services might affect quality care—care that is based on improving outcomes and holding providers accountable for those outcomes?"
Providers, however, objected to the emphasis on lowering costs and limiting services, and equated more care with better care, arguing that managing care or interfering with the provider-patient relationship led to poor quality. Since then, landmark reports published by the Institute of Medicine in 1999 and 2001 (To Err is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century) negated the argument that health care providers did not need scrutiny and that care should not be "managed." They pointed out lapses in quality and safety across the country, and that despite pockets of spectacular care and technological advances, U.S. services are more expensive than anywhere else in the world—yet lag in quality and safety.
Subsequent studies by the RAND Corporation, the Dartmouth Institute for Health Policy and Clinical Practice, and others demonstrated widespread, unsupported clinical practice variation, care disparities, and lack of evidence for many popular procedures and services. Most recently, in a project initiated by the American Board of Internal Medicine Foundation, nine physician specialty societies—so far—have each identified five tests or procedures that physicians and patients should question. The "Choosing Wisely" campaign encourages physicians and other health professionals to discuss with patients the importance of selecting services that constitute the most appropriate care, based on evidence, for that patient's individual situation.
Today's Calls for Change
Berwick and Hackbarth (2012) acknowledge that the old managed care approaches seemed to be associated politically with the labels "cost-cutting" and "rationing" rather than managing for appropriate care. They contend the answer to the "economically disastrous" course of business-as-usual health care is to cut waste (non-valued-added practices) by keeping services that actually help customers and removing services or processes that do not achieve desired results. Others have also called for change:
- Swensen and colleagues (2010) described health care as a "cottage industry," and recommended implementation of a high-value health care system that "embraces the appropriate use of scientifically informed guidelines, standard practices, teamwork, checklists, and accountability, and welcomes payment for value, not just for volume" (p. e12-2).
- The American College of Physicians issued clinical guidelines on cost-effective care—High-Value, Cost-Conscious Health Care: Concepts for Clinicians to Evaluate the Benefits, Harms, and Costs of Medical Interventions (Owens, Qaseem, Chou, & Shekelle, 2011).
- The Healthcare Financial Management Association (HFMA), a nonprofit membership organization for health care financial management executives, states that "Value is driving a fundamental reorientation of the healthcare system around the quality and cost-effectiveness of care." Its foundation published a substantive paper (Healthcare Financial Management Association Foundation, 2011) that identified the "main culprit" of problems in the current health care system as the fee-for-service system, which "rewards volume over value and does nothing to promote the coordination of care among providers" (p. 10).
- The Institute for Healthcare Improvement, a not-for-profit organization that promotes safe and effective health care, has called for the achievement of the "Triple Aim": improve the health of the population; enhance the patient experience of care (including quality, access, and reliability); and reduce, or at least control, the per capita cost of care.
- The National Quality Strategy, implemented by the Agency for Healthcare Research and Quality (AHRQ), the federal agency leading the effort to improve the quality, safety, efficiency, and effectiveness of health care for all Americans, has established six national priorities, based on objectives similar to the Triple Aim: reducing harm to patients; facilitating more coordination and communication among providers; empowering patients and their caregivers to become more involved in care; implementing evidence-based prevention and treatment plans for common chronic illnesses; promoting healthy behaviors and environments at the community level; and developing and using new delivery models that reduce costs while improving quality.
In its Value Project, HFMA cites the extensive work of Michael Porter (2010), who defines "value" as an equation of quality (a composite of patient outcomes, safety, and experiences in health care settings) and payment (the cost to all purchasers of care). Value, however, is a concept of relative worth—a product's value is increased by improvement in quality or by a reduction of price. In an article on the website of Harvard University's Institute for Strategy and Competitiveness, Porter contends that value should be the goal of the U.S. health care system.
Under value-based health care, risk shifts from those who purchase or finance care to those who provide care. In advice to member organizations, the Health Care Advisory Board (2011), a consulting firm for hospital executives, refers to "health care's accountability moment"—a transfer of responsibility that will challenge every health care organization and professional to achieve higher levels of performance and to "confront disruptive strategic choices about future direction" (p. 3). It will be nearly impossible for providers to avoid the movement toward more performance: quality and efficiency of care, outcomes, and the patient experience.
The passage of the Patient Protection and Accountable Care Act of 2010 (PPACA) began the most recent move to value-based, accountable care. The move will likely continue, regardless of the outcome of the Supreme Court decision on the constitutionality of the Accountable Care Organizations (ACOs), which are networks of hospitals and physicians (and other health professionals) who agree to care for all of the needs of a population of patients (see The ASHA Leader, June 5). The first ACOs were instituted in April 2012, when 27 ACOs began operating, joining 23 "pioneer" ACOs (high-performing health systems already experienced in care coordination and value-based care). Another 150 organizations have applied to begin operations July 1.
In addition, Medicare's Value-Based Purchasing program begins in October 2012, when the Centers for Medicare and Medicaid Services (CMS) will withhold 1% of base payments to hospitals. Hospitals can earn back a portion of the 1% by meeting certain quality indicators—processes of care (e.g., discharge instructions for heart failure, primary percutaneous coronary intervention received within 90 minutes of hospital arrival, prophylactic antibiotic received within one hour prior to surgical incision), and patient experience of care (communication with nurses, pain management, communication about medicines, etc.). Hospitals that do not meet expectations will receive reduced payments. By 2017, the total reduction will be 2% of base payments.
CMS also will begin in October 2012 to reduce payments to hospitals by 1% of total Medicare discharges if the hospital has high readmission rates according to a specific formula. Its Hospital-Acquired Payment Limitation, also 1% of discharges, begins in October 2014, and applies to hospitals in the highest quartile of national, risk-adjusted hospital-acquired condition rates.
Finally, the Medicare bundled payments pilot begins October 2013 (episodic payment shared among providers).
All of these initiatives involve performance risk: That is, health care providers and professionals are held accountable for the quality—effectiveness and efficiency—of the care provided.
Just as accountability is not a new concept in the wider health care system, clinical accountability for rehabilitation professionals, including SLPs and audiologists, has been addressed for many years. The May 1983 issue of Seminars in Speech and Language focused on clinical accountability. In that issue, Robert Douglass (1983) advised that each clinician follow a process of continuous review of treatment approaches and activities, in terms of clinical and financial outcomes of care (assessing value), asking: "How do we know, and how do we show, that what we do in therapy makes a difference?" (p. 117).
The era of accountable care offers the opportunity to examine assessment and treatment approaches, the body of knowledge, assumptions, activities, procedures, and conclusions. A previous article on health care reform and speech-language pathology practice (Cornett, 2010) emphasizes the use of the International Classification of Functioning, Disability, and Health (ICF) framework to structure care, answering CMS's long-standing call to demonstrate "significant, practical improvement within a reasonable and generally predicable period of time". Providers can use the ICF to structure clinical care in all venues; its supporters contend that functional status may present a more important roadmap for intervention than the patient's diagnosis (e.g., what does a diagnosis of "stroke" really say about the patient's recovery needs?).
The era of accountable care also offers the opportunity to engage in interprofessional collaboration, teamwork, and communities of practice for care coordination and cross-continuum intervention (see The ASHA Leader, May 15). Interprofessional collaboration will be critical to future success, while also demonstrating SLPs' contributions to achieving desired outcomes at an overall lower cost to the system.
SLPs must have adequate data to determine specifically how their services affect the patient's functional communication skills. When a person has a stroke and loses the ability to spontaneously generate ideas and answer questions, third-party payers ask: What changes in the patient can we expect from speech-language treatment and how long will it take to achieve the functional changes in the patient's communication skills? If a patient has difficulty swallowing, the payers pose questions about services provided by an SLP vs. other health care providers to facilitate a patient's ability to swallow safely.
SLPs and audiologists need to be empowered and equipped with knowledge to adapt effectively to the impending changes in service provision and reimbursement. It is possible that payment for services could be based solely on diagnosis and outcomes, rather than per session. Under that scenario, SLPs need to be able to state with confidence the expected outcomes for a patient given the type and severity of the communication disorder within specific diagnoses. Large data bases facilitate that type of information. Audiologists need data that address the comprehensive benefits of the services that they provide patients.
Clinicians can actively engage to enhance delivery of services in a changing health care landscape by:
- Contributing to the National Outcomes Measurement System (NOMS) and other large- scale outcomes measurement tools (see supplement).
- Following protocols for treatments that have been proven to yield effective clinical outcomes.
- Comfortably and confidently stating the case for speech-language treatment: why treatment makes a difference, for example, and when treatment is not needed or appropriate.
- Using "extenders" in service delivery (speech-language pathology and audiology assistants, for example) to expand patients' functional outcomes and maintenance of skills in their home environments.
- Pursuing connections with accountable care organizations to deliver speech-language services.
As the professional organization representing more than 150,000 members and affiliates, ASHA has supported NOMS since 1997, and is spearheading revisions to the system to enhance its utility. Additionally, ASHA will sponsor a summit in October that will focus on the changing health care landscape. The goals are for invited participants to exchange information and develop specific recommendations that will facilitate members' successful engagement in the new environment; safeguard the professions; advance national databases to inform quality improvement; and drive evidence-based practice. ASHA also is working with federal agencies on alternative reimbursement systems.
Despite many challenges, the future of rehabilitation services may be particularly bright—as part of accountable care, high-cost acute-care services will be minimized, and lower-cost providers and venues of care that emphasize efficient care transitions, care coordination, and functional outcomes are optimized. According to Diaz and Altman (2011), post-acute care has largely been regarded as an "add-on" to the health care system. Now, post-acute care is being recognized as an essential element of the health care equation, requiring active and ongoing communication between acute and post-acute providers to ensure a better understanding of patient needs, better care transitions, and discharge to the most appropriate, lowest cost, post-acute setting. The value of rehabilitation services to the system, however, will ultimately be measured by results, requiring a "relentless focus on providing superior clinical outcomes."
The bottom line? Practitioners must be aware of how to generate the best outcomes to stay competitive. As they compete to work within hospital systems and ACOs, providers must be fully prepared to show they're providing the highest level of quality outcomes at the lowest cost. The future is about competing on quality, with the goal to demonstrate how practioners are making a difference in the lives of those they serve.