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Healthcare Reform and the Changing Landscape of Occupational Therapy: A Roadmap to Navigate into the Future Gabe Byars, MS, OTR/L
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Healthcare Reform and the Changing Landscape of Occupational Therapy: A Roadmap to Navigate into the Future
Gabe Byars, MS, OTR/L
It is change, continuing change, inevitable change, that is the dominant factor in society today. No sensible decision can be made any longer without taking into account not only the world as it is, but the world as it will be.
Isaac Asimov
GoalUnderstand the changing landscape of healthcare in America and gain a better understanding about potential impacts to the profession of Occupational Therapy
Outline1. Increasing Pressures2. Attempts at Legal Reform3. Impact to Occupational Therapy
Increasing pressures
Demographic changesRising costsPush towards increasing quality
Demographic Changes
Census Bureau, 2008
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 20500%
5%
10%
15%
20%
25%
30%
Older Population by Age: 1900-2050 - Percent 60+, Percent 65+, and 85+
% 60+ % 65+ % 85+
Demographic Changes
DeVol and Bedroussain, 2007
Chronic Disease Prevalence and Cost Projections
Rising Costs
Social Security Advisory Board, 2009
Rising Costs
Squires, 2012
Rising Costs
MedPac, 2012
Increasing Quality
Woolf, et al., 2013
Attempts at Legal Reform
Affordable Care Act
Patient Protection and Affordable Health Care Act (ACA)Passed March 23, 2010Implemented in phases through 2014
Affordable Care ActPublic Opinion Poling on the ACA
Kaiser Family Foundation, 2013a
ACA – Individual Mandate
Most individuals will be required to have health insurance beginning January 1, 2014Tax subsidies for individuals who purchase insurance Penalties for not having coverage Exceptions for financial hardship and religious exceptions
Braveman and Metzler, 2012; AOTA
ACA – Health Insurance Exchanges
ACA – Employer Mandate
Employers will face a penalty for employees who receive tax credits to purchase health insurance
Exception small business, between 2 and 50 employees
Braveman and Metzler, 2012; AOTA
ACA – Medicaid Expansion
Expansion of Medicaid to cover individuals below 133% of poverty level
Optional decision by states
Braveman and Metzler, 2012; AOTA
ACA – Insurance Regulation
Prevent insurers fromDenying coverage for any reasonDenying coverage for pre-existing conditionsRecession of coverageCharging higher premiums based upon health status and gender
Eliminate lifetime limits on coverageAllow young adults to remain on parent’s health insurance until age 26
Braveman and Metzler, 2012; AOTA
ACA – Value Based Purchasing
Reward or penalize hospitals based upon quality of careExample metrics
Percent of heart failure patients given instructions upon discharge about how to take care of themselves.Percent of Catheter- associated urinary tract infection Rate of falls and injuryRate of complications for hip and knee replacement patients30 day death and readmission ratesPatient satisfaction
How responsive hospital staff were to patients' needsHow well caregivers managed patients' pain.How often caregivers explained to patients how to take care of themselves after discharge.
CMS, 2013a
ACA – Trials of new models of payment and treatment
Postacute care bundlingAccountable care organizationsMedical homes
Braveman and Metzler, 2012; AOTA
Other Laws
Functional Limitation ReportingMiddle Class Tax Relief and Job Creation Act of 2012
Therapy ThresholdAmerican Taxpayer Relief Act of 2012
Payment for Hospital Acquired ConditionsIPPS Rule FY 2010
Improvement StandardJimmo vs. Sebelius, 2013
Impact toOccupational Therapy
Impact to Occupational Therapy
Access to Occupational TherapyQuality ImprovementMedical NecessityNecessary Skills for the Future
Access – Decrease in the Uninsured
Kaiser Family Foundation, 2013b
Access – OT as an Essential Benefit
ACA requires ‘benchmarking’ of benefitsEssential benefits:
Ambulatory patient servicesEmergency servicesHospitalizationMaternity and newborn careMental health and substance use disorder services, including behavioral health treatmentPrescription drugsRehabilitative and habilitative services and devicesLaboratory servicesPreventive and wellness services and chronic disease managementPediatric services, including oral and vision care
Metzler, et al., 2012; AOTA
Access – OT as an Essential Benefit
Habilitation:Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
RehabilitationHealth care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
Metzler, et al., 2012; AOTA
Access – OT as an Essential Benefit
Utah Benchmark PlanPublic Employee’s Health Plan: Utah Basic Plus
Benefits:Outpatient Rehabilitation/Habilitation
20 visits per plan yearSkilled Nursing Facility
30 days per plan yearHome Health
30 days per plan yearMental Health Inpatient
30 days per plan yearDurable Medical Equipment
CMS, 2013c
Quality Improvement
Occupational Therapy reimbursement will likely be tied to outcomesOccupational Therapy can play a critical role in improving quality of care and outcomes
Fall preventionPressure ulcer preventionReducing readmissionsPreventative careChronic disease management
QI – Reducing Rehospitilizations
Mor, et al, 2010
QI – Fall Prevention
Bouldin, 2012
Quality Improvement
Arling, et al, 2013
QI – Primary and Preventative Care
New models of careACO, Medical Home, etc.
Chronic Disease Management
Medical Necessity
Providing and documenting medically necessary therapy is even more critical given:
Growth of OT into new settingsRemoval of improvement standardExpansion of fraud prevention and audit measures
Expansion of audits
HMS.org, 2012
Removal of improvement standard
The Jimmo vs. Sebelius settlement agreement on January 24, 2013
coverage of therapy “…does not turn on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care.”
CMS, 2013b
Medical Necessity Services provided are of the level of complexity and sophistication, or the patient shall be such, that services required can be safely and effectively performed only by a qualified therapist. It is not medically necessary for a qualified professional to perform or supervise maintenance programs that do not require the professional skills of a qualified professional. These situations include:
Services related to activities for the general good and welfare of patients (i.e., general exercises to promote overall fitness and flexibility).Repetitive exercises to maintain gait or maintain strength and endurance, and assisted walking such as that provided in support for feeble or unstable patients.Range of motion and passive exercises that are not related to restoration of a specific loss of function, but are useful in maintaining range of motion in paralyzed extremities.Maintenance therapies after the patient has achieved therapeutic goals or for patients who show no further meaningful progress and should become patient- or caregiver-directed.
CMS Transmittal 63, 2006
Necessary skills for the future
Communication with all stakeholdersFunctioning as a consultantFlexibility and creativity in role of OTAdvocacy for patient needsPolitical and social advocacyCourage to forge a new path
Final thoughts…
Change is inevitable. Change for the better is a full-time job.
Adlai Stevenson
Thank you
Dr. Mark Hyder, PT, DPT, RAC-CTSteve Newton, OT
ReferencesAmerican Occupational Therapy Association. Ad Hoc Committee Presentation on Health Care Reform Implementation. Retrieved from: http://www.aota.org/en/Advocacy-Policy/Health-Care-Reform/Ad-
Hoc.aspx
Administration on Aging. 2011. A profile of older Americans: 2011, US Department of Health and Human Services.
Arling, G., Cooke, V., Lewis, T., Perkins, A., Grabowski , D.C., and Abrahamson, K. 2013. Minnesota's Provider-Initiated Approach Yields Care Quality Gains At Participating Nursing Homes. Health Affairs, 32 (9):1631-1638
Braveman, B., and Metzler, C.A. 2012. Health Care Reform Implementation and Occupational Therapy. American Journal of Occupational Therapy, 66(1), 11-14.
Bouldin, E.D. 2012. Falls among adult patients hospitalized in the US: Prevalence and Trends. Presented at American Geriatrics Society Annual Scientific Conference. Retrieved at: http://www.americangeriatrics.org/files/documents/annual_meeting/2012/handouts/saturday/S1045-5508_Erin_LD_Bouldin.pdf
Census Bureau, 2008. Census 2008 national projections, issued August 14, 2008 , Retrieved from: http://www.census.gov/population/www/projections/2008projections.html
Center for Medicare Studies. 2006. CMS Transmittal 63. Retrieved from: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r63bp.pdf Center for Medicare Studies.2013.Hospital Value Based Purchasing. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based-purchasing
Center for Medicare Studies. 2013a. Hospital Value Based Purchasing. Retrieved from: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based-purchasing
Center for Medicare Studies. 2013b. Jimmo v. Sebelius Settlement Agreement Fact Sheet. Retrieved from: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&ved=0CC4QFjAA&url=http%3A%2F%2Fwww.cms.gov%2FMedicare%2FMedicare-Fee-for-Service-Payment%2FSNFPPS%2FDownloads%2FJimmo-FactSheet.pdf&ei=eitOUt2fKoua9QTwtIHACA&usg=AFQjCNG0eiBQB8OAyHd7xYcvj-VcCHmvyg&sig2=v4GniTS3uZdoN3F1R_RR8Q&bvm=bv.53537100,d.eWU
Center for Medicare Studies. 2013c. Utah Essential Health Benefit Benchmark Plan. Retrieved from: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&ved=0CC4QFjAA&url=http%3A%2F%2Fwww.cms.gov%2FCCIIO%2FResources%2FData-Resources%2FDownloads%2Futah-ehb-benchmark-plan.pdf&ei=m_ZNUsSONsnlrQHP3oHIAw&usg=AFQjCNGNy47rRoLG3Bv9_JnH4UtFWa25dA&sig2=sN_JQbONedZsK7hKssQPkA&bvm=bv.53537100,d.aWM
DeVol, R., and Bedroussain, A. 2007. An Unhealthy America: The economic burden of chronic disease. Milken Institute.
HMS.org. 2012. FY2012 Medicare RAC Recoveries Exceeded $2 Billion. Retrieved from: http://www.hms.com/fy2012-medicare-rac-recoveries-exceed-2-billion/
Kaiser Family Foundation, 2013a. http://kff.org/interactive/health-tracking-poll-exploring-the-publics-views-on-the-affordable-care-act-aca/
Kaiser Family Foundation, 2013a. http://kff.org/interactive/zooming-in-health-reform-medicaid-uninsured-local-level/
Metzler, C., Tomlinson, J., Nanof,. T., Hitchon, J., 2012. What is Essential in the Essential Health Benefits and Will Occupational Therapy Benefit?. American Journal of Occupational Therapy. 66(40), 389-394.
Mor, V., Intrator, O., Feng, Z., and Grabowski, D. 2010. The revolving door of rehospitilization from skilled nursing facilities. Health Affairs, 29(1), 57-64.
Social Security Advisory Board. 2009. The unsustainable cost of health care.
Squires, D. 2012. Explaining High Health Care Spending in the United States: An International Comparison of Supply, Utilization, Prices, and Quality, The Commonwealth Fund.
Woolf, S.H., and Aaron, L. 2013. US Health in International perspective: Shorter Lives, Poorer Health. National Academies Press.
