Medicare wants to push $26 billion dollars in risk onto America's private health care providers.
Are you ready?
The timeline is 2010 - just over six months from now.
The risk is in managing the 'episode of care' rather than the patient visit.
The 'episode of care' is gaining traction as an alternative payment model designed to stem Medicare spending increases due greater 'per person' use of the system, not just more users.
What is the episode of care?
For instance, a patient goes into the hospital to get her knee replaced, she stays two days, sees three doctors and gets discharged with home health PT for two weeks - then she gets sent to outpatient PT for one month. All costs, including the pre-hospitalization exam and imaging studies would be 'bundled' into one flat rate.
The current payment model is mainly fee for service during a patient visit - you do the work, you bill for it and you get paid. Fee for service risk is borne almost entirely by Medicare - the private practice or hospital provider only has the risk that not enough patients will show up to cover rent, utilities, salary, etc.
The current administration's budget proposal recommends the 'episode of care' that pays acute care hospitals a single payment for all services connected with a single episode of care, such as a total knee replacement.
This new version of the episode of care as the acute care hospital as 'the banker' - doling out payments to providers down the chain: doctors, surgeons, home health agencies and independent physical therapists.
Surgeons are currently paid using the episode of care model for surgeries.
Physical therapy is considered 'ancillary service' (I hate that term) which is not currently bundled with the surgeon's service.
Some of the details are described in the President's budget proposal, this APTA response letter to Senator Max Baucus (D-MT) and in other sources.
Where does risk come from?
Hospital risk is mainly from re-admissions within 30 days of discharge.
Private practice physical therapy risk comes from visit outliers that use more therapy visits than expected.
How can physical therapists manage "Episode Risk"?
Outpatient facilities are judged on functional outcomes - rated by the therapist or self-reported by the patient.
What can you do to improve your patients' functional outcomes?
- Ask your patients about medication compliance (especially use of prescription inhalers for COPD patients).
- Screen each patient for medical pathology (eg: DVT, depression, elevated fear-avoidance beliefs).
- Provide standardized functional outcomes.
- Treat pain early - don't use the emergency room for medication refills.
Other than providing high-quality, patient-centered care I don't feel qualified to evaluate the risks in contracting with acute care hospitals, accepting a fixed payment and bearing the cost if the patient takes 20 visits to get better instead of 10 visits.
Are you ready?