There just are not enough resources to meet all of our health care needs. Despite the success of the Patient Protection and Affordable Care Act (ACA) in decreasing the numbers of uninsured Americans from a high of 18% in 2013 for the 18–65 demographic to 11.4% by the second quarter of 2015, millions of Americans remain without insurance (Obmacarefacts.com, 2016).
 
“The cost of health care continues to rise. U.S. health care spending grew 5.3% in 2014, reaching $3.0 trillion or $9,523 per person. As a share of the nation's Gross Domestic Product, health spending accounted for 17.5% (Centers for Medicare and Medicaid, 2015).
 
According to the Centers for Medicare and Medicaid (CMS), “Health spending is projected to grow at an average rate of 5.8% from 2012-2022, 1.0 percentage point faster than expected average annual growth in the Gross Domestic Product (GDP)” (Centers for Medicare and Medicaid, 2015b).
 
According to the Kaiser Family Fund, “In 2015, spending on Medicare accounted for 15% of the federal budget. Medicare plays a major role in the health care system, accounting for 20% of total national health spending in 2014, 29% of spending on retail sales of prescription drugs, 26% of spending on hospital care, and 23% of spending on physician services.”
 
The Centers for Medicare & Medicaid Services (CMS) is the single largest payer for health care in the United States. Nearly 90 million Americans rely on health care benefits through Medicare, Medicaid, and the State Children's Health Insurance Program (SCHIP) (CMS, 2016b).
 
Regardless of our personal political affiliation we must all agree that our current path is unsustainable.
 
Value-based payment (VBP) strategies are approaches to paying for health care services based on value rather than volume. To understand “value” we must consider both quality and cost. To focus only on one is a dead end. VBP strategies enlist providers of care as partners in accepting the financial risks for care provision. These strategies are also intended to address systematic problems such as large variations in care and costs from one geographic area of the U.S. to another. For example, Dartmouth-Hitchcock (a non-profit academic health center in New England) notes that, “One result of this payment based on volume model is enormous variation in rates of procedures and tests such as imaging and screening. As documented by The Dartmouth Atlas of Health Care, there is a 2.5-fold variation in Medicare spending nationally, even after adjusting for differences in local prices, age, race and underlying health of the population. This geographic variation in spending is unwarranted; patients who live in areas where Medicare spends more per capita are neither sicker than those who live in regions where Medicare spends less, nor do they prefer more care. Perhaps most surprising, they show no evidence of better health outcomes” (Darthmouth-Hitchcock, 2016). 
 
The hospital VBP program is a CMS initiative that awards acute-care hospitals with incentive payments for the quality of care they provide to Medicare beneficiaries (Centers for Medicare and Medicaid, 2015c). CMS rewards hospitals based on:
 
“The quality of care provided to Medicare patients;

• How closely best clinical practices are followed; and
• How well hospitals enhance patients’ experiences of care during hospital stays.”

 
Occupational therapy practitioners have a responsibility, as do all health care professionals, to provide patients the best care possible (i.e. patient centered and occupation-based). We also share responsibility for reasonably controlling costs for our patients, for the organizations for which we work and for society at large. For example, we demonstrate responsible practice when we avoid wasted materials when making a splint. We demonstrate responsible practice by providing the right amount of care to meet a patient’s goals and charge patients in an ethical manner following guidelines and regulations of payers and our organizations. We demonstrate responsible practice when we design occupational therapy programs to prevent unintended negative events such as falls, proactively plan to assure smooth care transitions under bundled-payments or in accountable care organizations (ACOs), and help our patients, our organizations and the system when we take an active role in care management and help to prevent readmissions.
 
The department of Health and Human Services announced that, “it would seek to make 30% of Medicare payments for hospitals and physicians through alternative payment models such as ACOs and bundled payments by the end of 2016, and to make 50% of Medicare payments through APMs by the end of 2018 (Advisory.com, 2016). Recently it was announced that the 30% goal was met ahead of schedule. HHS, CMS and private payers are moving full-steam ahead with the implementation of alternative payment models and value-based purchasing such as bundled-payments.
 
There is a statement that I am quite fond of regarding getting a “seat at the table.” At a fundraising event for Senator Tammy Baldwin of Wisconsin that was held in Houston, the Senator used a version of this statement and noted, “If you don’t have a seat at the table talking with them, they are talking about you.” An attendee politely interrupted Senator Baldwin and noted that, “In Texas we say that if you don’t have a seat at the table, you are on the menu!” Most recently I have learned the importance of a related thought which is, “If you want to keep your seat at the table, you have to understand the conversation!”
 
I am an optimist by nature. No matter how frustrated I become, I almost always rally and think, “What can I do to change course and to direct my future?” I hope that I bring this attitude and optimism to my leadership at MD Anderson Cancer Center and in the profession of occupational therapy. Given the financial challenges faced by the U.S. government including CMS and the challenges that face our health care providers we have to think about what we can do as occupational therapy practitioners to have an impact by understanding the conversation, taking our seat at the table, and making a contribution.
 
What can we do? Here are some initial suggestions that I will edit over time as I think of others or I hear suggestions from others:
 

1. Read and learn. Understand the payment models being introduced such as ACOs and bundled-payments and be able to articulate how they may impact your work setting, your organization and the consumers to whom you provide care.
2. Get aggressively involved at your organization. Volunteer (assertively ask to be a member) for committees and initiatives to streamline care such as early mobilization programs in ICU’s or enhanced recovery strategies for surgical patients).
3. Demonstrate and articulate the distinct value and contribution of occupational therapy practitioners to improving outcomes and limiting costs through efforts such as fall prevention, care coordination, transitions from one care setting to another, medication management and home assessments to help to prevent readmissions.
4. ADVOCATE. If you believe as I do that that achieving the Triple Aim of improving the health of the public, improving health care and providing quality care at a lower cost is critical to our future, then advocate for OTs involvement. In contrast, if you believe that the Triple Aim and VBP structures are partisan schemes the advocate for an alternative. However, I challenge you to present a real alternative, there is no room or time for complaints only!
5. Attend AOTA’s Capital Hill Day and use your voice to speak at the table with your elected representatives (http://www.aota.org/Publications-News/E-Newsletters/Alerts.aspx).

 
There are many tables in health care organizations and in communities all around the United States and with over 200,000 occupational therapy practitioners and students there are many opportunities for us to demonstrate our understanding of value and the distinct value that we contribute.
 
References:
 
Advisory.com. (2016). HHS just hit a big value-based payment milestone. Here’s what happens next. Online at: https://www.advisory.com/daily-briefing/2016/03/04/obama-administration-reaches-2016-value-based-payments-goal.
 
Centers for Medicare and Medicaid. (2015). National health expenditure data. Online at: https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html
 
Centers for Medicare and Medicaid. (2015b).  https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/downloads/proj2012.pdf.
 
Centers for Medicare and Medicaid. (2015c). Hospital value-based purchasing. Online at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf).
 
Obamacarefacts.com. (2016). Obamacare enrollment numbers. Online at: http://obamacarefacts.com/sign-ups/obamacare-enrollment-numbers/.
 
Centers for Medicare and Medicaid. (2016b). CMS Roadmaps Overview. Online at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/downloads/RoadmapOverview_OEA_1-16.pdf.
 
Dartmouth-Hitchcock.(2016).Online at: http://www.dartmouth-hitchcock.org/about_dh/what_is_value_based_care.html.
 

I received a message from a colleague asking me to reconsider this blog post and to "reconsider categorizing conversations about occupational therapy the same way that you are categorizing conversations about race relations and gender issues." I like to think that I am always open to feedback and to making an effort to being more clear if there is the potential that I have been misunderstood (or if I have just NOT been clear) so I have edited the post (8/5/16).

More and more often these days I hear a type of response to sharing an opinion (particularly in social media exchanges) that is a total deflection of any issue being put forward for consideration. It is a type of response that ignores the speaker and their message and sends the tacit or sometimes the blunt message that “What you have to say does not matter, because here is what is truly important to me.”
 
If you follow me on Facebook, Twitter, my blog or OTConnections to some extent (I am not cross posting everything on OTConnections) there is no surprise that in social issues and health care policy I have liberal leanings. I am a strong supporter of social justice issues, global health care and equal rights. For this reason I immediately tuned in to one social example of the “what about me” political response when the “Black Lives Matter” movement was met with a retort of “All Lives Matter.” To me it is a tone-deaf, racially insensitive retort that responds to an imagined “only” that is not said (i.e. “only Black Lives Matter). I wrote on the day after the murder of Dallas Policemen, “It is possible to be equally incensed by the systemic racism present in our society, our justice system and our system of law enforcement AND the senseless murder of police officers. We don't have to choose.”
 
Recently posts on Twitter celebrating June as GLBT Pride month and a #GayPrideDay were met with a retort of “heterosexualprideday.” The posters of the hash tag vehemently advocating that if Gays, Lesbians and Transgendered persons could have a day to celebrate their pride than what was wrong with heterosexual persons having a pride day? Of course this tone-deaf, insensitive response ignores the reason that GLBT Pride Celebrations exist; which is a long history of discrimination, hate and violence targeted against the GLBT community. The retort of #heterosexualprideday ignores the fact that most heterosexuals have never had to experience the discrimination, violence and hate targeted to the GLBT community and therefore might be sensitive enough to realize they do not need a “heterosexual pride day.”
 
I am going to totally skip over the idea of things like responding to Black Pride Month with a White Pride Month.
 
In the occupational therapy world the “what about me” response can take a couple of variations. These interchanges are different than the examples above that concern racism and homophobia and related more to the interaction of colleagues. Just yesterday my comments on the value and need for occupational therapy practitioners to advocate for a “seat at the table” to promote OT as part of a response to bundled payments by CMS as one value-based strategy was met with (and I am paraphrasing) “but valued-based payments are partisan schemes and we need to advocate to kick over the table and defend against the status quo!” This response is tone-deaf and falls into the “but what about me” category because there was no recognition that bundled payments are a value-based strategy going into effect RIGHT NOW AS WE SPEAK and that whether you believe they are a partisan scheme or not, advocacy against them as a strategy is unlikely to change the impact on occupational therapy practice in the short-term.
 
Now to be fully transparent, I support the trial of value-based payment strategies and especially bundled-payments as a means of achieving the Triple Aim of improving health, improving healthcare and decreasing costs. There just are not enough resources to go around. Still, I have never discouraged someone from advocating against value-based payment and would never respond to a post from a colleague suggesting that we should advocate against value-based payments by saying, “but no, I want you to talk about this instead!”
 
Another common form of the “what about me” retort in occupational therapy is anytime that someone writes about a new practice idea, “emerging practice” or a new role that an occupational therapy practitioner can adopt and the immediate retort is “But is THAT occupational therapy?” More and more often I am saying in reply, “I’m not sure I care; sometimes “Is that occupational therapy?” is an important question but often it is not.”
 
So this blog post falls a little in the “rant” category so I hope that readers will not parse my words one by one and focus on the big picture. Can we care about multiple things at the same time and isn’t it a little more helpful to respond by acknowledging that a friend or colleague cares about or is excited about an idea before you rush in and say, “Yeah, but this is what I really want to talk about?”