October 30, 2012 News

A 'Sea Change' in Health Care Reimbursement

A "sea change" is coming in health care reimbursement, according to a keynote speaker at an ASHA summit on the changing health care landscape, and providers need to be ready for reimbursement based on outcomes, rather than on the sheer volume of services provided.

The changes are inevitable, regardless of who wins the November elections, said David Willis, managing director of The Advisory Board Company, a global health care research and consulting firm, because "no health care proposal argues that the status quo of fee-for-service is okay."

Willis opened "The Changing Health Care Landscape," a three-day summit at the ASHA national office in early October that brought together more than 70 health care administrators, clinical directors, clinicians, researchers, academicians, consultants, and consumer group representatives. The summit focused on how audiology and speech-language pathology might successfully transition from fee-for-service to pay-for-performance and value-based service delivery.

"Our goal was to inform, challenge, and inspire participants to serve as catalysts for change and to help ASHA develop strategic responses to the rapidly changing health care landscape," said Becky Cornett, summit chair and director of fiscal integrity at The Ohio State University Medical Center. "Presenters—selected for their ability to offer significant and specific guidance—offered stellar information and clear advice for participants to consider."

In presentations, plenary sessions, and small- and large-group discussions—some with separate agendas for speech-language pathology and audiology—participants addressed many topics, including value creation, outcomes research and measurement tools, public reporting of quality indicators, patient-reported outcomes and care, clinical decision-making and pathways, and potential changes in academic training programs.

Not What, But How

In his keynote, Willis highlighted four forces that are influencing change: the desire of payers to pay less for better quality care, rising health care costs (approximately 4% annually), growing Medicare rolls, and more patients with chronic, costly conditions.

As a result of these forces, "What's more important than what providers are getting paid is how they're getting paid," Willis said. The "how" will include value-based purchasing that ties payment to quality; bundled payments that reimburse for all services a patient needs for a given diagnosis; and shared savings, which reward providers for providing quality, cost-effective care at lower-than-anticipated rates.

These trends have three implications. "Measurement and transparency are coming, and providers have to prepare for them," he said. "The question is, who's defining quality and value? If you're not defining quality, standards, and payments, someone else will be involved in that conversation."

The need for quality and cost-effectiveness leads to the second implication: "Avoid the tyranny of 'or,'" he said. "If low cost and quality are an either/or proposition, you're in trouble." Providers who improve both at the same time "will win in this market."

The final implication is that "All roads lead to team-based health care," Willis said, an approach that will take "a cultural change that requires providers to step up and take larger roles in the provision of care."

Quality and Cost-Effectiveness

The next presenter, Stephen Swensen, director for quality at the Mayo Clinic, underscored Willis' emphasis on quality and cost-effectiveness. "Quality and productivity/efficiency are not a trade-off," he said in his presentation on patient-centered value creation. "They go hand in hand."

Mayo's Value Creation System focuses on interdisciplinary teamwork and standardization. Practice variation from established guidelines is encouraged only for specific, patient-centered reasons. Improving patient value, Swensen contends, improves financial performance through increased productivity and reduced waste.

The results of this approach, Swensen said, are treatments that promote high reliability and high quality. He gave an example of how this approach would be used for modified barium swallow exams: "What are the best practices, for when, how, and how often?" he said. "I would encourage ASHA to synthesize the research data, gather expert opinion or the most-reasoned approach if data are not available, and to do that in collaboration with other disciplines." A multidisciplinary approach is "more credible and promotes what needs to happen in a multidisciplinary environment."

Christine MacDonnell, managing director of CARF International, an independent, nonprofit accreditor of health and human services, said that the movement toward accountable care is "exciting" because of "the passion that each of us has within to transform and improve the way services are delivered; the will to use accountable systems, measurements, and standards to identify services that add value; and the ability to align with all stakeholders and come together for the people we serve."

Outcomes Research

Carolyn Clancy, director of the Agency for Healthcare Research and Quality (AHRQ), echoed the importance of outcomes research. AHRQ, a federal agency, is charged with improving the quality, safety, efficiency, and effectiveness of health care for all Americans.

"We have a health care system that has fantastic components—trained health professionals, facilities, and technologies," she said, "but the whole is less than the sum of the parts" because of high costs, pervasive quality-of-care problems, variations and inequities in clinical care, uncertainties about best practices, and difficulties translating scientific advances into actual clinical practice and useful information.

Patient-centered outcomes research will help, Clancy said, citing the AHRQ systematic review of tinnitus as an example. "What treatments work for which patients and with what kind of trade-offs?"

Patient-reported outcomes are an important part of this research. "We need to better understand treatment effects over time that are not captured in traditional clinical measures," she said. "They help clinicians design better treatment plans, improve communication, and manage chronic disease," and are already used in many health care disciplines.

"The planning committee has prepared a report for the ASHA Board of Directors, which will determine the next steps," Cornett said. "These may include implementing action plans, developing a variety of education formats, and widely disseminating information in multiple formats." All updates will be posted at the ASHA's Health Care Reform website.

Carol Polovoy, assistant managing editor of The ASHA Leader, can be reached at cpolovoy@asha.org.

cite as: Polovoy, C. (2012, October 30). A 'Sea Change' in Health Care Reimbursement. The ASHA Leader.


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