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RUSK REHABILITATION
The Triple Aim – How Physiatry and the
Rehabilitation Team can improve the
patient experience and thrive within
healthcare reform and value based
medicine
Jonathan H. Whiteson, MD, FAAPMR
Assistant Professor, Rehabilitation Medicine
Medical Director, Cardiac and Pulmonary
Rehabilitation
Medical Director, Rusk Outreach and Growth
RUSK Rehabilitation
What is the Tripple Aim?
Improved health
Improved Quality of Care
Reduced Costs
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Health Care Reform is….
Change….. enforced upon us by government agencies
this is HARD!!!!
for…
Health Care Systems / Networks / Institutions
Departments
Individual Practitioners
Health Care Consumers
Don’t forget the Medical Students and Residents…
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The journey of Health Care Reform….
Government agencies set the tone of our industry
Industry viewpoint: expensive / variable outomces / high compliction rate / inptient-centric
Hospital System must: improve efficiencies / work with industry and departments
Departments: embrace grass roots change / clinician training / consumer education
Practitioner: whats your journey – past / present / future?
Have to play an active role in defining HCR ,not just participating in it
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Health care reform is……
a general rubric used for discussing major health policy creation or
changes — for the most part, governmental policy that affects health
care delivery in a given place.
• Health care reform typically attempts to
•Broaden the population that receives health care coverage through
either public sector insurance programs or private sector insurance
companies
•Expand the array of health care providers consumers may choose
among
•Improve the access to health care specialists
•Improve the quality of health care
•Give more care to citizens
•Decrease the cost of health care
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Health Care Reform means…
Different things to different people / settings in the continuum
of care
Conflicting needs / perspectives een within a Department
Allignement critical within the Hospital System
Communication is the key: be at the table
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Health reform includes the following key steps….
• Expand Medicaid to allow more people at the lowest income levels to qualify for
coverage.
• Encourage employers to offer health insurance.
• Provide credits to purchase private health insurance coverage to moderate
income Americans who do not qualify for Medicaid.
• Streamline the purchase of health insurance through the establishment of the
Health Insurance Exchange.
• Strengthen consumer protections and require transparency.
• Impose protections to guard against unreasonable rate increases.
• Encourage primary and preventive care.
• Require most Americans to purchase health insurance.
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What does the Consumer want from Health
Care Reform?
Care that is:
Available
Affordable
Effective
Excellent
Easy to negotiate
Affable
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Healthcare reform issues impacting Physical Medicine
and Rehabilitation….
• Reinstatement of the 75% rule for Inpatient
Rehabilitation?
• Site-Neutral Payments restricting access to
care based on diagnosis, not patients’ clinical
need
• Medicare Bundle Payment Proposals creating
risk of underservice to patients
• Medical Coverage of Outpatient Therapy
Services and Therapy Caps
• Rehabilitative and Habilitative Services and
Devices limiting needed prosthetics and other
needed items like power chairs for patients
RUSK REHABILITATION
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Site Neutral Payments….
The Medicare Payment Advisory Commission (MedPAC), the nonpartisan
government agency that advises Congress on Medicare policy, indicated in 2014
it would recommend:
(1) phasing-in site-neutral payments for inpatient rehabilitation facilities (IRFs)
and skilled nursing facilities (SNFs)
(2) loosening regulatory requirements for IRFs so that they might continue to
provide care to Medicare beneficiaries after their Medicare reimbursement
rates are reduced.
(3) deleting IRF requirements that physicians see patients at least three times per
week and that IRFs provide intensive therapy to patients each day.
i.e. eliminate acute
Inpatient rehab!!!!
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But…
• American Medical Rehabilitation Providers Association Chairman Bruce Gans MedPAC's recommendation "fails to consider the long-term impact of
diverting Medicare beneficiaries into less intensive rehabilitation settings
despite their clinical needs.“
• Hospital outpatient departments treat sicker and poorer patients in need of more
extensive care and resources than do physician offices and patients treated in
outpatient departments have more severe chronic conditions
• Consider at SAR: readmissions / LOS / patient experience
MUST plase patients in appropriate settings: home / AR / SAR…
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Values Based Medicine (and Evidence Based Medicine)
• Values-Based Medicine (VBM) is the theory and practice of effective healthcare decisionmaking for situations in which legitimately different (and hence potentially conflicting)
value perspectives are in play.
• VBM is the values-counterpart of Evidence-Based Medicine, or EBM.
• EBM is a response to the growing complexity of the relevant facts
• VBM is a response to the growing complexity of the relevant values
• VBM emphasizes the importance of good process in the form particularly of improved
clinical practice skills
CONFLICTS – cost vs patient experience
- perception / journey
- cinical outcomes
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Value Based Medicine
•Value = Quality / Cost
•Quality:
•evidence-based standards - transfusion criteria, hospital
acquired pneumonia, pressure ulcer development, central
line associated bacteremia
•LOS - observed/expected - UHC data
•Patient reported data – HCAHPS / Press-Ganey survey
•Cost – laboratory / radiology / drug / LOS-related cost fixed and direct cost as determined by Finance
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Value Based Medicine
Value = Quality / Cost
•Goal – highest quality / lowest cost
•Industry holds you PUBLICLY ACCOUNTABLE
•Don’t lose sight of the patient…
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Shifting the paradigm…..
The Physiatrist and rehabilitation team can show value by:
•Improving the patient experience
•Improving patient outcomes
•Decreasing hospital length of stay and readmissions
•Reducing hospital costs
•Decreasing the need for post acute services
•Developing innovative programs that help maximize revenue
while creating new career paths for Physiatrists in the face of
healthcare reform
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Shifting the paradigm…..
Improved Health
Improved Quality of Care
Reduced Costs
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Rehabilitation Medicine is a major ‘player’ in every aspect of
patient care….
• ICU early mobilization
• Bundle Payment Initiative
• Rehab Continuum
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ICU early mobilization
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ICU care – where were we…?
• What was the coordination of clinical care?
• Management of Delirium - Sleep / wake cycles – Sedation – Pain?
• What was the clinical care culture?
• What was the culture of mobilization?
• Frequency and duration of rehabilitation treatments?
• Longitudinal perspective and VBM considerations?
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Review of the literature…
Early Physical Medicine and Rehabilitation for Patients With Acute Respiratory
Failure: A Quality Improvement Project. Archives PM&R 2010, Volume 91, Issue 4,
Pages 536–542
ICU Early Physical Rehab Program • CCM • Volume 41 • Number 3 • March 2013
PT for the Critically Ill in the ICU • CCM • Volume 41 • Number 6 • June 2013
•
Decreased Length of Stay:
ICU
Floor Bed
•
Improved Functional Independence
•
More Discharges to Home
•
Fewer Vent Days
•
Less ill Effects of Bed Rest- e.g., Strength and ROM
•
Lower Incidence and Duration of Delirium
•
Less frequent Use of Sedation/Medications
•
Lower Average Direct Costs (e.g., medical surgical supplies, pharmaceutical
supplies, housekeeping, food expenses, RN salaries)
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Rusk Rehabilitation ICU early mobilization – changes…
• Create a collaborative team – driven by PM&R
• Reduce deep sedation and delirium in patients in the ICU, reintroduce ‘normal’
sleep / wake cycles, adequately manage pain – all to support more effective and
earlier mobilization
• Establish a clinical care culture beyond survival
• Establish a mobility culture beyond the bed and rehabilitation team
• Establish the culture of early mobilization
• Create a ‘beyond the horizon’ perspective and support VBM initiatives
• Administration buy-in
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Early Rehabilitation in the ICU – A Performance
Improvement Project
• Comparison Group – consisted of 123 ICU
patients
• Pilot Group – consisted of 160 similar ICU
patients
• Intervention – Provided average of 60 minutes of
interdisciplinary therapy per day to include PT, OT,
SLP.
• Services were offered to Medical ICU and
Surgical ICU at NYU Langone Medical Center
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The value and outcomes from early rehabilitation in
the ICU
• Reduced ICU length of stay by
0.93 days – 20%
LOS
• Reduced Med-Surg bed length of
stay by 1.9 days – 30%
LOS
$
• Reduced average direct cost per
day by 12%
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Clinical Outcomes for Early Rehabilitation in ICU
• Patients discharged home with or without services
increased from 59% to 76% (up by 17%)
• Patients discharged home without services
increased from 18% to 40% (up by 22%)
• Patients discharged to:
• Acute rehab decreased from 24% to 13%
• Sub-acute decreased from 6% to 1%
• Nursing home decreased from
10% to 6%
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Estimated Cost Savings from Early Rehabilitation in ICU
$1.4M Annually (540 patients) when pilot
group was compared to the comparison group after inclusion
of rehabilitation labor costs using avg. costs per day
*This excludes additional hospital revenue with backfill of ICU beds
resulting from reduced LOS and improved throughput
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ICU early mobilization next steps…
• Administration approved conversion of pilot staff to permanent positions
• Academic Presentation – Poster and Podium presentation: Early Mobilization
in the Medical and Surgical Intensive Care Units: A Performance Improvement
Project. Johns Hopkins Critical Care Rehabilitation Conference
• Academic Publication - Early Rehabilitation in the Medical and Surgical
Intensive Care Units for Patients With and Without Mechanical Ventilation: An
Inter-professional Performance Improvement Project – submitted, pending
acceptance
• Development of rehabilitation pilot on Medicine floors comparing daily rehab
care with current model
• UHC Conference Presentation - upcoming
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Bundled Payment Initiative
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Bundled Payment Initiative
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Bundled Payment Initiative
Where we were
NOT Value Based Medicine!
everyone gets paid
piece-meal
duplication
poor efficiency
high cost
poor outcomes
limited accountabilty
litte attention to patient experience
Where we need to be
Value Based Medicine
one payment for episode of care
coordinated
lean care
excellent outcomes
full accountability
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Bundled Payment Initiative…
• AKA: episode-based payment, episode payment, episode-of-care payment,
case rate, evidence-based case rate, global bundled payment, global
payment, package pricing, or packaged pricing
• …defined as: the reimbursement of health care providers (such as hospitals
and physicians) "on the basis of expected costs for clinically-defined episodes
of care."
"a middle ground" between fee-for-service reimbursement (in which
providers are paid for each service rendered to a patient) and capitation (in
which providers are paid a "lump sum" per patient regardless of how many
services the patient receives).
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Services that can be included under each model
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the risks for embracing new payment models as they
evolve is worth the opportunity to identify what
works and influence future policy
“The bleeding edge and cutting edge are the same
place”
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Bundled Payment Initiatives
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Bundled Payment Initiatives
• Dept. of Rehabilitation Medicine involved since earliest planning stages of
bundled pilot
• Departmental Chairman / Departmental Administration / Physiatry Specialists
• Hospital Administration and Finance negotiate bundle model and
reimbursement $$$s
Preferred providers:
home health care agencies
acute rehab centers
sub-acute rehab centers
LTACs
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Bundled Payment Initiatives
•Hospital Culture Change
staff education
patient / family centered language
default disposition – home
•Care Coordination Team
Social Worker
Care Management
•Rehab Team
Physiatrist
PT / OT
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Bundled Payment Initiatives
• Total joint - elective: 90 day
• Pre-surgical PT or OT home visits
• Rapid Rehab – POD zero
• ‘Front-loaded’ home care services
• Sub-acute joint replacement program
• Outpatient transition
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Bundled Payment Initiatives
• Total joint – emergency / fractures: 90 days
• Older / increased comorbidities – poorer outcomes from subacute rehab than
acute rehab – LOS / readmissions
• Enhanced value (quality/cost) of acute rehab – skill / monitoring / intensity
• Spine – New surgical techniques associated with unanticipated increased
expenditures
• Dropped from bundle – cost increased – unable to achieve targeted savings
despite decreases in LOS and readmissions
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Bundled Payment Initiatives
• Cardiac Valve: 90 days
• ICU early mobilization
• implementation of twice daily PT and once daily OT sessions
• default disposition - home with services (as indicated)
• inpatient acute and sub-acute inpatient cardiac rehab programs
• outpatient transition
• Change for TAVR… separate DRG created
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The Importance of Care Coordination and the role of the
Physiatrist in the Bundled Payment Initiative
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With Bundling, the Physiatrist ….
Enforces best practices / standardization of pathways,
workflows, and order sets
Improves communication between surgical / medical
team and the patient
Ensures follow-up after care transitions
Optimizes Patient Expectations and Outcomes
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Value Based Management – Changing care delivery while
improving quality through bundled payment initiatives
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Bundled Payment Initiatives – what’s new…
Comprehensive Care for Joint Replacement Model (CCJR)
• 2013
400,000 Medicare THR / TKR
• Significant variation in care:
• Infection
• Implant failure
• Expense ranged $16K - $33K
• DRG 469/470
90 day
5 year demonstration
mandatory
• 75 metropolitan areas with urban population > 50,000
• Evaluated annually with repayments to M’care or additional payments from M’care
• Submission date September 8th 2015
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Bundled Payment Initiatives
• What else…?
• Inflexibility of DRGs
• Myriad of rules
• Communication / feedback with Medicare
• Gain sharing
• Whats next…?
• Medical DRGs
• CABG 10/1
• Cancer
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The Rehabilitation Continuum
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The Rehabilitation Continuum
• Rehabilitation Medicine
•Exemplifies Value Based Medicine
•Patient centered collaborative practice method
•ICU early mobilization
•Bundled payment initiatives (efficiency)
•Key role in care transitions
•Inpatient rehabilitation remains viable – redefine criteria for acute and
sub-acute
•Home care agencies open to input
•Collaborative outpatient programs potentially offer greatest growth
opportunities – value in prevention of readmissions
•Wellness (maintenance) programs to maintain care continuum
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Rehabilitation Medicine – Some lessons learned…
• Physiatrists and the rehabilitation team MUST play an important role in
care redesign
• Enhancing rehabilitation services (Rapid Rehab) during acute hospital
phase is related to decreased LOS
• Advancing clinical relationships with post acute partners expands
influence with care delivery
• Our patients are experiencing improved care through enhanced
coordination
• Well-coordinated care is better for our patients and results in reduced
costs
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Rehabilitation Medicine – Some lessons learned…
Achieving desired goals of health care reform (triple aim) and providing
opportunities for physiatrists to redefine themselves and remain important and
viable going forward.
Considerations for the Future:
expansion of the bundle initiative
enhanced rehabilitation intensity throughout acute care hospitalization
EBM integrated into VBM
e.g. the science of readmissions
growth of ambulatory services
wellness programs in community
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The Triple Aim
Improved Health
Improved Quality of Care
Reduced Costs
Thank you!!!
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