It’s an exciting time to be the new Chief Medical Officer of a rehabilitation hospital. Healthcare payment and delivery reform is accelerating and the role of rehabilitation within new delivery models is being defined. As healthcare costs increase, payers are experimenting with new payment models that reward value, rather than volume, and are encouraging providers to participate in healthcare networks that manage the health of a large numbers of patients, using innovative ways to provide care. Ironically, the basic principles being used to drive healthcare reform are the same ones that I learned from the nurses and therapists when I began work at Helen Hayes Hospital more than 30 years ago – putting the patient’s goals first and using a team approach to achieve meaningful health outcomes. However, what’s new is that payers are relying on data to measure and reward value. The challenge going forward will be how to remain true to the ideals of patient-centric, team-based care within the reality that payment for providing rehabilitation care is becoming more complex.
Value in healthcare incorporates measures of quality, cost, and satisfaction. In plain English for a particular patient, this translates to “Am I receiving personalized care that is efficient and helps me improve in a way that matters?” To a healthcare payer like Medicare, value can be interpreted as “is the population of patients treated receiving care that is efficient, safe, and effective over time?” Determining whether a hospital, such as HHH, is providing high value care requires not only asking individual patients, but also measuring and analyzing the outcomes that are important for patients and payers. For years, we have been measuring and tracking our patients’ gains in physical function and independence over time, and have compared favorably to other facilities, with significantly better efficiency in many programs compared to regional and national averages. More recently we have been looking at medical outcomes, such as readmission to acute care hospitals during rehabilitation or after discharge, again with much better outcomes compared to similar facilities. Our safety of care outcomes, such as how often patients develop a pressure ulcer while they are treated here, if they develop urinary tract infections related to bladder catheters, or if they have an injury related to a fall, are also outstanding. Finally, we track and respond to patient satisfaction surveys, concentrating on fixing the issues that matters most to our patients and their families.
So, if we’re so good, what’s the challenge? Post-acute care (i.e. inpatient, sub-acute or outpatient rehabilitation and visiting nurse services) accounts for a large percentage of the cost of care for many diseases and procedures, and how that care is delivered varies across the country. Medicare and other payers have developed demonstration projects to bundle payment for certain conditions such as joint replacement, heart failure, or elective heart surgery, in order to reduce disparities and cost. That means that the payment for care over time, such as 30 or 90 days after an event, is bundled into one payment, regardless of what services are provided and in what setting. The most simple, but perhaps not most value based, way to approach this would be to move all patients who are treated in a more expensive level of care to a less expensive one. This might mean treating patients at home with outpatient services, rather than in an inpatient or sub-acute rehabilitation facility. For some, this may be appropriate; for others, this may not, resulting in slower recovery, injuries, or emergency room visits. The challenge with bundled payment models will be to determine which patients are appropriate for which level of care, provide that care efficiently, and track outcomes over time in order to improve how care is delivered. It will also mean that facilities and community providers communicate well to transition patients safely among levels of care, use valid, reliable tools to measure outcomes, and work together to track and improve these outcomes over time.
To make a meaningful impact on the health and rehabilitation of patients we serve, those of us in leadership positions at HHH must continue to promote efficient, patient-centric care, track meaningful outcomes, and reach out to hospitals, providers, and payers to work with them to provide an appropriate level of care for patients with rehabilitation needs, regardless of their complexity. Although it will not be easy, I know that there is a strong team at HHH beside me to get this done.
Marjorie L King, MD, FACC, FAACVPR
Chief Medical Officer