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;
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:
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.
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.
The opinions expressed in my blog are personal and neither represent the views of my employer nor any organization.