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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

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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

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Goal

Understand the changing landscape of healthcare in America and gain a better understanding about potential impacts to the profession of Occupational Therapy

Outline

  • Increasing Pressures
  • Attempts at Legal Reform
  • Impact to Occupational Therapy
increasing pressures1
Increasing pressures
  • Demographic changes
  • Rising costs
  • Push towards increasing quality
demographic changes
Demographic Changes

Census Bureau, 2008

demographic changes1
Demographic Changes

Chronic Disease Prevalence and Cost Projections

DeVol and Bedroussain, 2007

rising costs
Rising Costs

Social Security Advisory Board, 2009

rising costs1
Rising Costs

Squires, 2012

rising costs2
Rising Costs

MedPac, 2012

increasing q uality
Increasing Quality

Woolf, et al., 2013

affordable care act
Affordable Care Act
  • Patient Protection and Affordable Health Care Act(ACA)
  • Passed March 23, 2010
  • Implemented in phases through 2014
affordable care act1
Affordable Care Act

Public Opinion Poling on the ACA

Kaiser Family Foundation, 2013a

aca individual mandate
ACA – Individual Mandate
  • Most individuals will be required to have health insurance beginning January 1, 2014
  • Tax subsidies for individuals who purchase insurance
  • Penalties for not having coverage
  • Exceptions for financial hardship and religious exceptions

Braveman and Metzler, 2012; AOTA

aca employer mandate
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
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
ACA – Insurance Regulation
  • Prevent insurers from
    • Denying coverage for any reason
    • Denying coverage for pre-existing conditions
    • Recession of coverage
    • Charging higher premiums based upon health status and gender
  • Eliminate lifetime limits on coverage
  • Allow young adults to remain on parent’s health insurance until age 26

Braveman and Metzler, 2012; AOTA

aca value based purchasing
ACA – Value Based Purchasing
  • Reward or penalize hospitals based upon quality of care
  • Example 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 injury
    • Rate of complications for hip and knee replacement patients
    • 30 day death and readmission rates
    • Patient satisfaction
      • How responsive hospital staff were to patients' needs
      • How 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
ACA – Trials of new models of payment and treatment
  • Postacute care bundling
  • Accountable care organizations
  • Medical homes

Braveman and Metzler, 2012; AOTA

other laws
Other Laws
  • Functional Limitation Reporting
    • Middle Class Tax Relief and Job Creation Act of 2012
  • Therapy Threshold
    • American Taxpayer Relief Act of 2012
  • Payment for Hospital Acquired Conditions
    • IPPS Rule FY 2010
  • Improvement Standard
    • Jimmo vs. Sebelius, 2013
impact to occupational therapy1
Impact to Occupational Therapy
  • Access to Occupational Therapy
  • Quality Improvement
  • Medical Necessity
  • Necessary Skills for the Future
access decrease in the uninsured
Access – Decrease in the Uninsured

Kaiser Family Foundation, 2013b

access ot as an essential benefit
Access – OT as an Essential Benefit
  • ACA requires ‘benchmarking’ of benefits
  • Essential benefits:
    • 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 and chronic disease management
    • Pediatric services, including oral and vision care

Metzler, et al., 2012; AOTA

access ot as an essential benefit1
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.
  • Rehabilitation
    • Health 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 benefit2
Access – OT as an Essential Benefit
  • Utah Benchmark Plan
    • Public Employee’s Health Plan: Utah Basic Plus
  • Benefits:
    • Outpatient Rehabilitation/Habilitation
      • 20 visits per plan year
    • Skilled Nursing Facility
      • 30 days per plan year
    • Home Health
      • 30 days per plan year
    • Mental Health Inpatient
      • 30 days per plan year
    • Durable Medical Equipment

CMS, 2013c

quality improvement
Quality Improvement
  • Occupational Therapy reimbursement will likely be tied to outcomes
  • Occupational Therapy can play a critical role in improving quality of care and outcomes
    • Fall prevention
    • Pressure ulcer prevention
    • Reducing readmissions
    • Preventative care
    • Chronic disease management
quality improvement1
Quality Improvement

Arling, et al, 2013

qi primary and preventative care
QI – Primary and Preventative Care
  • New models of care
    • ACO, Medical Home, etc.
  • Chronic Disease Management
medical necessity
Medical Necessity
  • Providing and documenting medically necessary therapy is even more critical given:
    • Growth of OT into new settings
    • Removal of improvement standard
    • Expansion of fraud prevention and audit measures
expansion of audits
Expansion of audits

HMS.org, 2012

removal of improvement standard
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 necessity1
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
Necessary skills for the future
  • Communication with all stakeholders
  • Functioning as a consultant
  • Flexibility and creativity in role of OT
  • Advocacy for patient needs
  • Political and social advocacy
  • Courage to forge a new path
thank you
Thank you

Dr. Mark Hyder, PT, DPT, RAC-CT

Steve Newton, OT

references
References

American 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.