Is Audiology effected by the Changes or will it be? The basic problem The U.S. has the highest absolute medical expenditures and highest per capita medical expenditures of any nation. The U.S. also has the fastest growing percentage of GNP devoted to the health sector (Schieber, Poullier, & Greenwald, 1992). The rate of medical expenditure growth has accelerated in the last two decades. 1
Growth of Medical expenditures in the United States: 1929-1993 Data source: Health Care Financing Administration http://www.mum.edu/msvs/6195herron1.html http://www.lean.org/shook/displayobject.cfm?o=1274 2
Forces Driving the Change Cost containment Increase Value this has not been accounted for with prior attempts by Centers for Medicare / Medicade (CMS) Increased integrated care getting rid of the silos Patient Protection and Accountable Care Act ACO / health insurance exchanges / Essential benefits How did we get to this point From Beatty Bambur, Ph.D., RN U of Vermont At the turn of the century 1800 to 1900 Hospitals were to get the undesirables off the street health care took place in the homes paid for by bartering in many cases Therefore hospitals could not get patients to come 1929 Baylor hospital started a scheme for pre paid care in the hospital but only Baylor $6 per year for 21 days of care American Hospital Association took up the idea but for all hospitals start of Blue Cross This was opposed by Physicians in general 3
How did we get to this point As the great depression came on Physicians could not get paid so they adopted the concept of pre paid health care hence the AMA started Blue Shield for income protection for MDs With WWII came wage and price controls so employers competed for employees via increasing health care benefits. So by the mid 1950 s what developed was an employee based health care insurance plan fee for service this left out the elderly, the unemployed This led to the development of Medicare / Medicaid (now CMS) led to the development of subspecialty services and tests the more we can bill for the more we can get paid. Cost Containment for Health Care Why does CMS feel cost control is needed? partial indications: Risen 78% since 2000 vs. 20% for salaries Average 9% per year with range of 7% 13% Defensive medicine (malpractice) Unnecessary treatment Inefficient service delivery models Pharmaceuticals End of life care 4
Cost Containment for Health Care CMS started efforts along these lines in the 1970 s Over the decades have introduced different mechanisms to reduce the costs to CMS The largest impact to Audiology (and now SLP since they can bill independently) was introduction of the RVU manner for setting reimbursement schedules 1990 s Cost Containment for Health Care More recently several other mechanisms for reducing cost have been implemented: RAC (Recovery Audit Companies) Duplicate payment analysis Medicare screens for procedures reported together => new, combined procedure CPT codes Re survey and re validation of procedure value under the assumption by Relative Value Scale Update Committee Healthcare Professionals Advisory Committee (RUC HCPAC) that all surveys are inflated Bundled payments under CMS reform Another concept that has been around for a while but not mandated is the concept of Pay for Performance 5
Cost Containment for Health Care Robert Fifer, 6 OCT 2012, Changing Landscape Health Care Summit Bundled payment models de-emphasizes services that increase utilization and cost Initiative by Center for Medicare and Medicaid Innovation Bundled Payments for Care Improvement initiative Working to identify procedure groups to bundle Coincident reporting of CPT codes Grouping of therapy sessions Based on diagnosis rather than procedure(s) Examples: diabetes; cardiac care Initial demonstration operational fall 2012 Cost Containment for Health Care Multiple organizations but especially CMS are recommending and CMS putting into operation going away from Fee for Service model and replacing it with Value Based Purchasing Fee for service: Encourages increased utilization More services => more payment Questions of true medical necessity for increased services 6
Value Based Purchasing From the view point of CMS the global benefits to this approach are: Based on Medicare vision of the right care for every person every time Aligns payment to efficiency and quality of care delivery Rewards providers for measured performance (patient outcomes) Patient centered care focused model Value Value is measured by outputs, not inputs. Value in health care depends on actual patient health outcomes, not the volume of services delivered. More care is not always better care, and shifting the focus from volume to value is a central challenge M. Porter, What is Value in Health Care? NEJM, 2010, 363: 2477 2481 7
Value Value Based Purchasing More specifically it is the concept that this will: Promote evidence based medicine Require clinical and financial accountability across all settings Focus on episodes of care Better coordination of care Payment based on outcomes, not number of sessions (performance based payment) Focus on effectiveness of treatment patient centered but not just for a single event but across the care continuum for the patient medical home 8
Medical Home Model Robert Fifer, 6 OCT 2012, Changing Landscape Health Care Summit MedPAC and others continually push to have primary care physicians better compensated to improve care coordination Medicare Physician Fee Schedule adjusted to respond Primary care physician becomes medical manager All referrals will go through PCP Different from gate keeper concept of HMOs PCP paid to coordinate and manage all care of that patient AUD & Value Based Purchasing Since audiology is still classified as a diagnostic practice only the issues facing SLP starting over the next 12 months are not as severe The potential biggest impact will be working to identify procedure groups to bundle such as the changes in immittance testing and vestibular testing 2 years ago One could envision further efforts along these lines. So in effect paying for a group of diagnostic procedures with a single payment the group of procedures is to result in diagnostic AND functional information. 9
AUD & SLP Effecting both in this concept of paying for performance and outcomes is to have the medical community take a collective responsibility for the quality of care via coordination of care for an individual patient (interprofessional practice) Increased productivity and decreased cost structure are intended and rationally expected consequences of higher quality. Swensen et al. The Mayo Clinic Value Creation System. Am J of Medical Quality 27 (1) 2012 How Does one code for Outcome Another phase of the overall change in the healthcare landscape (timing of these changes is likely not coincidence) is the change to ICD 10 coding October 1, 2013 To International Classification of Diseases, 9 th Revision, Clinical Modification ICD 10 CM ICD 9 CM approximately 18,000 codes ICD 10 CM approximately 160,000 available codes provides more flexibility for adding new codes. Provides for coding to the level of functional impairment especially when involved with the International Classification of Functioning, Disability & Health (ICF) this could be used for coding level of severity 10
Accountable Care Organizations Typically would consist of primary care physicians, specialists and a hospital. Built on the concept of the Medical Home CMS is pushing for increased reimbursements for PCP for providing coordinated care and therefore reducing the reimbursements to specialists Other specialty diagnostic and therapy services could be within the ACO or contract out. The ACOs via coordinated patient care would be a method of increasing quality and decreasing cost Shared Savings with a bundled payment to the ACO The shared savings payments would be the incentive to create the ACOs Essential Health Care Benefits The ACO has to be able to provide what has been determined as Basic Essential Health Care Benefits the insurance that you obtain through the insurance exchanges have to have these as benefits as a base. ambulatory patient services emergency services hospitalization Maternity and newborn care mental health and substance use disorder services including behavioral health treatment prescription drugs rehabilitative and habilitative services and devices laboratory services; preventive and wellness services chronic disease management pediatric services including oral and vision care AUD services are not within the listed benefits not likely to be included individually in the ACO structure What is needed to make AUD essential Via evidence based data must show that the services, diagnostic and therapeutic, make a significant difference in the outcomes of the patients AND does so in a cost efficient manner i.e. must be able to demonstrate your Value. 11
Essential Health Care Benefits What do we currently do that can make us unique and essential that will get us invited to the table: Diagnostic services interpretation of Hearing and vestibular/balance studies on routine patients?? But on special populations Determination of functional impact and therapeutic services again on routine patients?? But on special populations Prevention and Wellness Industrial hearing screening and recommendation programs Preventing hearing loss in children Dangerous Decibels Program Infant hearing screening and early intervention programs Falls prevention programs with PT and OT Education of other healthcare workers impact of hearing loss in consultations ototoxic drugs on hearing & VESTIBULAR In the relationship between untreated hearing loss in elderly & dementia Where From Here? AUD has stated feeling the impact of the changes and will continue to notice these changes The Health Care Summit in OCT 2012 by all the AUD organizations with SLP ultimately identified 3 key areas of change needed NOW: Changes in education of: our peers as to what has and is changing; our training programs in the manner in which we teach the students to think about what they do with patient and the mechanisms as to how they will be reimbursed; A primary focus on increasing interprofessional education assuming this leads to increase in IPP Development of a National data base repository for outcomes measures for mining to determine Best practice and supporting our contention that we bring value added services to the patients but start first with what outcomes are needed for what purposes Rebranding the professions of AUD and SLP so other recognize the breadth and depth of our scope of practice and understand what Value we add. 12