When Do We Fully Commit to Opportunities Presented by the Affordable Care Act?

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Thoughts about occupational therapy, interdisciplinary management and living live to its fullest!

When Do We Fully Commit to Opportunities Presented by the Affordable Care Act?

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The last two weekends I presented Keynote Addresses at state occupational therapy conferences in states that have large politically conservative populations (Kansas and Oklahoma). My presentations were on the facts of the Affordable Care Act (the ACA or Obamacare) in terms of the provisions and resulting changes in health care reform and health insurance reform. I also highlighted what I saw as the opportunities and risks for our profession.

In both instances I received praise for my presentation and appreciation from attendees for helping them understand the law (that was nice!). I also heard from audience members who would like to see the ACA repealed. I don't agree with persons who wish to see the act repealed but it is a valid political desire to hold.

Here is a question though.............

At what point do we fully commit to the opportunities presented to our profession in the areas of prevention and wellness, primary care, mental health, Telehealth, accountable care organizations, and as a result of strategies such as bundled payments or the patient centered medical home?

Personally I can't see any scenario that will lead to substantial defunding or repeal of the act in the next three years. The House recently passed a continuing resolution (CR) to keep our government running but defund the ACA. The chance of this working seems very unlikely as even Republican leaders in the Senate don't see it happening. Eighty percent of the act is funded through mandatory and not discretionary funding controlled by the House. The Senate will strip the proposal of the effort to defund the act and send the CR back to the House. The President would certainly veto the act if it got to his desk.

So, assuming it will still be law sometime in November, how long do we wait to fully commit to the opportunities?

Well, there are the Fall 2014 elections. I (completely personal judgment) think the Republicans will maintain control of the House and have a slight chance of gaining control of the Senate. I think the likelihood of gaining a veto-proof majority is nil. If I am missing something here, please point it out.

So assuming that a Presidential veto is near certain until President Obama is out of office, when would be the next chance to overturn the ACA? The presidential election of 2016 with inauguration in 2017? At this point Americans will have experienced the benefits of the ACA for 3 years. They will have worked out any kinks in the health insurance exchanges and millions more Americans will have health insurance. For more than 3 years lifetime caps will have been eliminated. For more than three years Americans with pre-existing conditions will be able to get insurance at the same rates as those without those conditions. For more than 3 years adults between 18 and 26 will have been able to stay on their parent's insurance. For more than 3 years discrimination against women in health insurance rates will have ended. For more than three years.........

If as a profession we wait until there is absolutely no chance of the ACA being repealed before organizing and aggressively pursuing the opportunities under the ACA, who will take our place?

I appreciate the political views of those who oppose the ACA, but Medicare D and Medicare itself as a program were grossly unpopular when first proposed. Will the ACA take a different course?

Am I missing something? When will be long enough to wait before we move full steam ahead on the opportunities that the ACA present to occupational therapy as a profession?

I would love to hear alternative perspectives. 

  • Hi Brent,

    I agree with your analysis that there is low probability of meaningful Senate action this week and even lower probability that the President would sign anything that weakens the current law.  I believe that you are correct in assuming that we will have some continuation of the current plan for the near term.

    The conceptual problem with 'jumping on board' is that there is very little solid evidence of what people would be jumping onto.  Here are some current barriers, all off the top of my head:

    1. Lack of definition of rehabilitation vs. habilitation in most states.

    2. Lack of structural creation of medical homes and primary care models

    3. Lack of structural creation of network providers

    4. Lack of information on actual program costs, which will obviously have an ultimate impact on reimbursement schedules

    5. Lack of any functional plan to get disenfranchised groups to even sign onto the exchanges

    6. Lack of evidence that threat of penalty will drive people into the market

    7. Lack of information about impacts of high deductible plans on non-subsidized families

    8. Lack of planning to solve the 'family problem' that causes families to be non-subsidized if an employer offers insurance that covers a single employee (non-family plan) only.

    9. Lack of impact analysis that contributes to the new 29.5 hour workweek, and the corresponding predicted actions of employers who will 'work less' in order to obtain subsidy.

    10. Lack of understanding that changes to date have been largely non-controversial (stay on parent's plan, remove pre-existing limitation, etc.).  The real mess hits the fan next year.

    Consider this - I make this list from a liberal state that already has a lot of reforms in place and where more is known than as compared to many other states.  In sum, there is still more that we don't know re: structure of actual changes than what we do know.

    How will all or any of this impact the health consumption behaviors of people?  I don't think anyone has that crystal ball, and when people claim to know I tend to view them skeptically.

    I am a business owner, so I look at the landscape here and obviously there is very little for me to make plans about!  All I can see in front of me is a giant mess.  This is not a political statement.  This is an analysis of problems with the law and its implementation on a pragmatic level.

    We can all HOPE that this will be the smoothest roll out of a program of this size in the history of all governance, but that would quite honestly be foolish.  

    It is absolutely factual that many lawmakers see the current iteration of ACA as an interim program that is designed to stress the current insurance industry into oblivion so that a universal payment system can be created.  This has been stated overtly in many forums and on many occasions.  Based on the rollout of the 2013-2014+ sections of this law I believe this is the intent.

    I am unable to predict what will happen in the next two to three years.  I believe that opportunities will  become evident as some of the above stated issues are resolved or mediated.  However, other challenges in service delivery will become evident and might change practice in ways that we can't yet imagine.  I am not able to predict the cultural tide of this country on this issue because we have never before seen such a fundamental change of a system that is quite literally life and death to the population.  I am fearful that there is a risk of significant social unrest over these issues.

    I don't believe that there is a proactive stance to take other than being prepared to jump in any number of possible directions depending on which floorboards are removed from under our feet at any given time.

    Christopher J. Alterio, Dr.OT, OTR

  • Chris, I appreciate the attention to what we do not know for sure and what we can only guess at. I also appreciate highlighting the challenges.

    My first instinct was to address your concerns point by point, but I don't want to to a "but" response and instead want to post a "AND" response meaning we don't know for sure how things are going to play out AND we can take some active steps now. We do have some pretty good ideas about what is going to be emphasized.

    Here is a non-exhaustive list of ways we can move full steam ahead while adopting the new mantra of management at MD Anderson Cancer Center which is "Adapt and Adjust!"

    I typed the following list in about 15 minutes. This is what I think we CAN reasonably do as a profession, as managers, business owners, and practitioners.

    I hope others comment!

    • Create and promote models of practice for prevention and wellness, share them widely and promote occupational therapy’s involvement in prevention and wellness

    • Create and promote models of involvement in primary care and on primary care teams, share them widely and promote occupational therapy’s involvement in primary care

    • Promote occupational therapy to organizations creating accountable care organizations (ACO’s) and provide specific examples of how occupational therapy can facilitate safe critical transitions and prevent readmissions

    • Target condition specific treatment pathways especially those being investigated in bundled payment trials and develop occupational therapy standards of care that can be shared widely

    • Highlight occupational therapy’s role in managing chronic conditions and multiple chronic conditions including aspects such as medication management, screening for onset of conditions such as early signs of diabetes and train clinicians more effectively in screening and referral to other disciplines

    • Prepare occupational therapy practitioners to give concrete answers to the question, “How does occupational therapy help achieve the triple aim of 1) better health, 2) better health care, 3) and more efficient use of health care dollars

    • Target the population of persons entering the health insurance market and educate them about occupational therapy in the context of ACA implementation

    • Ready ourselves for coverage of habilitation rather than waiting and catching up later, widely educate occupational therapy practitioners who don’t understand the difference between habilitation and rehabilitation and be ready to “pounce” as the situation evolves

    • Advocate aggressively for insurers to adopt the National Association of Insurance Commissioners definition of “habilitation” to promote wider reimbursement and synergize with its use in Medicaid laws

    • Educate our patients, our families, our neighbors, our co-workers and the doorman about health insurance exchanges, the benefits of the ACA (e.g. no exclusion for pre-existing conditions) and challenge myths even if we would prefer the act be repealed

    • Aggressively challenge denials early in the implementation especially in the 10 essential benefit areas and watch closely the definition of “medical necessity” being used.

    • Analyze the impact of  increased numbers of women and children being insured and be ready at the local, state and national level to respond and promote our services

    • Track the CMS innovations site for developments related to our specific practice areas and be ready to respond with models of service

    • Understand this “The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system” and be ready to speak at organizational town halls, local meetings, meetings with our policy makers etc.

    • Prepare for possible changes in mental health coverage, plan NOW for its inclusion as an essential benefit and analyze, strategize and educate so we don’t miss opportunities for involvement

    • Start planning NOW for possible changes in our accreditation standards and/or optional areas of our educational programs to target areas almost assuredly addressed in the next decade  (e.g. Prevention and Primary Care) in real ways

    • Take active leadership roles in the choice of, and development of electronic health records in our institutions, do NOT leave it to all the others and then try and make up ground

    • Recognize that self-management IS self-care and help our practitioners in our organizations and practices understand what that means in the context of the ACA and health insurance reform.

    • Understand coverage for Telehealth in our states and develop specific examples of ethical and effective delivery of occupational therapy through Telehealth.

    • Be a practice specialist if you want, but assume that being an advocacy generalist is the responsibility of every occupational therapy practitioner.

    Sorry for any typos! I was in "flow mode!"

  • Thanks for the list, Brent.  I agree that all of those things need to happen.

    However, many of those points are rather stratospheric.  Can we talk about practicing clinicians?  If I am a clinician working in some job somewhere I read these posts and see that I should be doing something.  What are we asking clinicians to do?  Or is this not at the level of clinicians yet?

    There are ACOs and medical home models (allegedly) in my community.  However, in reality I know that these are just large corporate medical multispecialty practices that got grant money and are calling themselves ACOs or whatever.  My local experience with these models is that they focus their marketing around online medical records and coordinated care.  However, these 1-2 groups are just a small drop in the bucket when it comes to the totality of care in the community - most of which (>95%)  is not at all affiliated within these models.

    So on a practical level, what is the average clinician supposed to do?  Should they try to affiliate within this large corporate multispecialty practice?  I would consider doing that, but I know that I can't afford the tribute I would have to pay for the privilege of locating within one of their fancy buildings.

    I know that if I develop my wellness or health promotion practice that if I restrict my referral base to the theoretical ACOs/medical  homes that I will not last out the first three months.

    Also, if the large corporate multispecialty clinic hires an OT or two, what are the other 100 OTs supposed to do?

    I just want to pick single topics at a time because it is easier to have a conversation.   I am interested in knowing what practicing clinicians should be doing and from my vantage point I see a theoretical opportunity for one or 2 OTs to get a job if the large corporate multispecialty clinics decide to take a financial loss and provide this as a service.  

    However, and again from my vantage point, there is absolutely no incentive for these medical homes as they are existing in my community at this moment to take on a service that is virtually guaranteed to lose money.

    An additional disincentive is that no one knows what the coverage will be for hab/rehab services - in a practical and financial sense.

    This is boots on the ground perspective in my community.  I like your ideas of:

    • Create and promote models of practice for prevention and wellness, share them widely and promote occupational therapy’s involvement in prevention and wellness

    • Create and promote models of involvement in primary care and on primary care teams, share them widely and promote occupational therapy’s involvement in primary care

    • Promote occupational therapy to organizations creating accountable care organizations (ACO’s) and provide specific examples of how occupational therapy can facilitate safe critical transitions and prevent readmissions

    • Target condition specific treatment pathways especially those being investigated in bundled payment trials and develop occupational therapy standards of care that can be shared widely

    I honestly just don't know how to do this, and I am a relatively savvy private practitioner who has built a successful business.  I am VERY interested in hearing some real-life stories about how practicing clinicians are making these things happen.

    Christopher J. Alterio, Dr.OT, OTR

  • Brent,

    Thanks for your thoughtful and thought-provoking posting. I really appreciate your comments and those of Chris Alterio. I'd like to share some additional perspectives and, in part, address some of the questions Chris posed at the  end of his most recent response.

    First --in the interests of full disclosure. I personally support the ACA. I have a chronic condition which twice has left me owing a hospital more than what I was making annually-- after insurance (purchased on the private market, with very limited coverages). When the cumulative effects of my condition made it no longer feasible for me to work 8-5, 40 hours/week, I worked a part time position that allowed me to buy into health benefits. When funding ran out, I exhausted COBRA and discovered that the only policy I could purchase on the individual market would cost $1200/month (this was in 2003). I secured a part time teaching position, accepting essentially half time compensation for what amounted to a 30/hour week workload to qualify for health benefits. I exhausted COBRA again when my part time teaching position was eliminated due to lack of funds. For 4 of the past 7 years, I had no health insurance. I'm not stupid and not interested in taking risks with health or finances. But efforts to find coverage resulted in either withdrawing the application when it became clear I would be turned down  or facing a premium for severely restricted coverage (which would not cover my preexisting condition) which was more than half of my gross income. All this with the risk that, if I couldn't identify the dates of every medical encounter I'd had for the past 30 years, the policy could be cancelled as soon as I filed a claim, citing “falsification” of the application for omitting even one of those encounters. All this occurred even though I had not needed treatment for my pre-existing condition since 2003. I got coverage again in 2010 when the first phase of the ACA-- high risk coverage--was implemented. I have a significant premium and a very significant deductible, but with it the assurance that a major health episode will not result in bankruptcy or losing the house.  My state will have one of the most limited exchanges in the country, so I am awaiting October 1st to see what my options are, as the high risk coverage ends December 31st.  For me, the ACA is the chance for those of us who cannot work full time, but can and want to work part time, not to be forced to choose between forgoing appropriate care and thus, risking  catastrophic care, or applying for disability in hopes of --ultimately--obtaining health coverage.

    So clearly, my health consumer experience leads me to be enthusiastic about the ACA. But this also forces me to recognize that it can be challenging for any of us to distinguish between 1) how the ACA may affect one personally as a health care consumer, 2) how the ACA affects one professionally, as an individual practitioner, and the profession as a whole, and 3) how the ACA aligns (or does not align)  with one’s own political persuasions. Brent framed the issue nicely by distinguishing between political viewpoint and professional interests, and it is the latter that I want to address.

    Firstly, I think the ACA and the term Obamacare is being used to refer to many shifts in healthcare which are occurring regardless (or outside of) the ACA.  I recently saw a CE program abstract which purported to be about “Obamacare”-yet of the 8 “big changes” identified, 7 of them were Medicare reforms which Centers for Medicare & Medicaid Services has had in the works since as far back as the late 1990s. CMS has been moving toward implementation of value based purchasing for more than a decade. Bundled payment (and the need for case mix management) started back in 1984 with Medicare’s hospital prospective payment system (PPS). CMS, AHRQ, Joint Commission and NCQA have promoted primary care and, subsequently, primary care medical homes for much of the 2000s.  Private insurers pioneered capitated systems in the 1990s. And demographic shifts, not just aging, but chronicity, are forcing reforms in payment systems premised on acuity. While many of these “new” constructs are mentioned in the ACA, they did not originate in the ACA, and in many instances, the ACA simply acknowledges or capitalizes on trends which were well established before 2010. The recent Jimmo settlement, with implications for those with chronic, especially chronic degenerative, conditions—has nothing to do with the ACA yet aligns with the intent.

    Secondly, our professional history suggests that, as a profession, we are slow to recognize and respond to major shifts in healthcare delivery or health care payment, shifts which ultimately have enormous consequence for practice and the profession.   We were slow to recognize the significance of Medicare when it was created, and it was not until ten years later, when we were being left out of benefits, that we endorsed state licensure (a key factor in being included in covered benefits). Nearly 40 years later, we still do not have licensure in every jurisdiction. PL 94-142, the original law that later came to be known as IDEA, became law in 1975, yet it was not until the early-mid 1980s that we began to acknowledge or recognize public schools as a viable practice setting and began to develop resources and revise educational curricula to prepare practitioners for this setting. In that same part of the 1980s, we were all “doom and gloom” about hospital DRGs. Many predicted mass losses of OT jobs. Instead, the implementation of hospital PPS gave rise to post-acute care—rehab, home health and expansion of outpatient care. We’ve gotten so used to post -acute care comprising more than 40% of clinical positions nationally that we forget that, 30 years ago, post acute care as we know it didn’t exist and what did exist included very little OT.

    The consistent themes in this history are a reluctance to explore the possibilities, a tendency to magnify the threats, and a reluctance to act or respond until either forced or until the tide is so strong we have no choice but to follow where others have already blazed trails. So when I consider Brent’s question, my first reaction is, bravo, could we, maybe just this once, be the ones blazing the trails, recognizing and seizing the opportunities, parrying the threats, and demonstrating our value to consumers, payers, and health care organizations? Given the shifts already happening or about to happen which are independent of the ACA, the healthcare world as we know it is going to change—significantly—so can we really afford to wait and see, focused exclusively on the ACA, when there are already seismic changes occurring-many of which align with, but are not dependent upon, the ACA?

    Thirdly, I’d like to respond to Chris’ questions. I am a practitioner. For the past 7 years, my income has been solely dependent on my ability to convince others that my skills and expertise were valuable to them.  Most of my work is contractual. For those 7 years, I have been the only OT in a statewide system supporting primary care Medicaid practices. Twelve years ago, I donated my time to contribute to the planning and grantwriting for an aging in place project that morphed into an outreach program of a federally qualified health center. I’ve been part of the program for nearly 10 years. The grants to cover OT ran out long ago, but OT is still a part of the program and I am being paid because the leadership recognizes that having OT on the team improves outcomes and the overall effectiveness of the team. (I’m also the resident policy wonk so am called upon—often—to analyze or explain Medicare and Medicaid policy in relation to the program services.)   I designed and am currently one of the implementers of a pilot project to reduce Medicaid costs while enhancing functional outcomes among adult enrollees with multiple chronic conditions. As a result, primary care providers who had no idea what OT was a few years ago are now lobbying Medicaid for OT to have a key role in a statewide implementation of the pilot. Another primary care provider—at an FQHC- wants some of my time on chronic pain management project—seeing patients in the health center to address non-somatic approaches to pain management. For 4 years I have been sending her reports on patients, linking what is presented to her in the clinic with the patient’s routines and functional status. Now she wants me on this project and wants to write me into another program based at the clinic. We’ve recently brought on another OT because there is more work on the pilot than I can possibly manage alone. I’m not saying this to boast about me—but it is about how this practitioner thrives by looking for opportunities in policies and in practice models emerging from the shifts mentioned earlier—translating the scope and expertise of OT to the language of the relevant providers and payers so they can connect OT's contribution to key gaps in their services, and then delivering “top of the license” practice any time an opportunity is offered.

    For better or worse, the implementation of the ACA is really state-based. Every state is different. New York and Texas do not have a homegrown Medicaid managed care and care management system such as the one in North Carolina. Not every ACO is a Geisinger or Cleveland or Mayo. I appreciate Chris' comment about why an ACO might bring on a "money liosing" service. But--the shift to VBP is already occurring. We're moving to a model where every service is a cost, payment is based on panel size or case mix severity and it will be up to every one of us to demonstrate that our product (in outcomes and efficiiencies) is commensurate with, or exceeds, our cost. So much of our thinking is premised on fee for service (unit=revenue) -we need to recognize that that model is going away--and Medicare, not the ACA, is the leading driver of the extinction. Yes, the devil is in the details, but we cannot let details that are still to emerge paralyze us from seizing the opportunities. Isn't it preferable to be involved in defining or refining the details rather than being buffeted by them once they are set in policy at all levels?  I think of the ACA as putting the spotlight on unmet needs in our healthcare system. If we as OTs recognize and understand those needs, can connect the dots between our expertise and those needs (at every level where we have the opportunity to influence), and address those needs effectively (singly or as part of a team), we will deliver real value to patients, payers and the public  . . . since we are all, ultimately, the payer.

    Carol Siebert, MS, OTR/L, FAOTA

  • Carol, thanks so much for your comments and perspective.

    I think there are concrete things that every practitioner, manager, business owner, educator, researcher and student can do right now to be preparing to act if not actually acting! I am going to do some one topic posts to highlight them. Here is an article on Accountable Care Organizations that points out that 428 hospitals have already signed up to become an ACO and that 14 percent of the population is already being served by one (and may not even know it).

    One concrete thing everyone in our profession can do is read and understand 1) what is an ACO? 2) How many ACO's are in my state? 3) Do I or anyone I know work in an ACO? 4) What is the impact on a hospital of becoming and AC0? and 5) What are the drivers that will be pushing organizational leadership toward certain approaches and where can OT fit in?

    Example, for me, I work at a National Cancer Institute designated hospital and we are not yet being impacted by the ACA or ACO's but our organization is not waiting. Leadership is anticipating that the ACO system or some version of it will expand and organizations like ours, children's hospitals and free standing rehabilitation hospitals will likely have to work in to the system some how. I am attending every meeting I can to keep track of what is going on with the "regionalization" strategies in my area. I have submitted a proposal to our administrative fellow program to get a fellow to help me do some data analysis on providers in the Houston suburbs and I am brainstorming with other directors about what is coming down the pike.........

    This article points out that ACO's are not the "end game" but they are likely to be around long enough for us to be able to talk the talk and participate as leaders!

    Adapt and adjust....be proactive, learn now and be ready to act!


  • Here is a next specific topic, the “habilitation” part of the “rehabilitation and habilitation” essential benefit of the ACA.

    There are some specific things that are “boots on the ground” included in the ACA that I would do now depending what setting we are discussing. For example, if I worked in a hospital that was already part of an accountable care organization I would have information on the role that occupational therapy practitioners play in facilitating safe “critical” transitions such as going home. I would address falls prevention, medication management, equipment and home assessment and anything else we can do to prevent readmissions. I would get this information in front of any organizational decision maker who would look at it, I would volunteer for committees that put me next to decision makers and I would attend every town hall and open meeting and ask a question that leads into the role that all health professions can play.

    In other areas, it is a little more tentative and the “thing” we can right now is become educated, analyze the evolving information, strategize and educate! This way we are ready to pounce when opportunities present themselves AND to advocate, advocate, advocate!

    For example, the future of habilitative care under the ACA is far from certain, but sitting back for a few years and waiting to see how it all plays out is a losing strategy. This is especially true during the first few years when decisions will be made and appealed at the state level.

    The following link is to an article that provides some background information on habilitation and its importance and uncertainty for children with disabilities:


    It is important for every practitioner to be aware of the NAIC definition of disability. Read it and think about what habilitation means in YOUR practice setting. Be able to give specific examples of habilitation across the lifespan! (This is something every practitioner can do NOW!)

    National Association of Insurance Commissioners’ Definition of Habilitation

    “Habilitation Services – 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.”

    Next, we each should search and read about Essential Health Benefits Including habilitation on line and become familiar with the range of organizations invested in helping to define habilitation. For example, The Arc is an organization focused on persons with intellectual and developmental disabilities that has a large vested interest in habilitation and rehabilitation.

    There is a helpful page to read here:


    This document from the Habilitation Benefits Coalition is always very informative:


    Check out this section of the AOTA Website frequently for information on ACA implementation and advocacy including essential health benefits:


    Adapt and adjust! :-)

  • Thanks for your comments Carol.  New York has a rather well developed Medicaid managed care program and it is universally shunned by providers.  The primary reason why is because the managed care programs (up until now) have limited benefits severely and created a 'lower class' of coverage that causes providers to turn away Medicaid managed care participants.

    As a specific example, here is the approximate reimbursement for across several managed care products for a one hour outpatient occupational therapy visit in WNY:

    Medisource (Independent Health): $26

    Univera managed care: $24

    Fidelis: $21

    Compared to straight Medicaid: $59

    You can see why providers turn away patients who are participating in Medicaid managed care products.  This is just OT; the pattern is the same across primary and specialty care.

    Additionally, this year NYS instituted a 20 visit limit for outpatient services for rehabilitation (each service 20 visits).  That limit is waived for children, adults with developmental disorders, TBI, and some other specific settings that apparently had a good lobby.

    I have been trying to determine if Medicaid in general or Medicaid Managed Care products will have to be ACA compliant.  From the best I can tell they will have to be compliant but the guidance is lacking.  I am concerned because if there is an influx of Medicaid eligible people into the system, and if the system then demands a different (higher) benefit level than what is currently present, that there will be continued price pressures to keep reimbursements low.

    As we have already seem, that will just mean that there will be a two tiered delivery system - providers will be happy to take on commercial insurance lines but will avoid managed care and ACA plans like the plague.

    Here is the interest part though: these insurance companies that are participating as managed care intermediaries will also offer commercial plans (mostly).  Here is the approximate reimbursement schedule for one hour OT visit if someone has a commercial insurance product:

    Independent health (commercial): $47

    Univera (commercial): $54

    Fidelis (doesn't offer a commercial product line at this time).

    So you can see that the exact same insurance company will have rates that can almost double between what they will pay for commercial lines vs. Medicaid lines.  That is the two tiered system I refer to: one for people with commercial insurance and another for people with government insurance.

    The concern I have in all this is that almost NOTHING has been published about the scope of actual benefits, the reimbursement rates, or anything at all and we are just three months away from launch.

    State Medicaid programs are in disaster mode all over the country.  The NY State program is so broken that the Office for the Medicaid Inspector General is currently shaking down day treatment programs for adults who have developmental disabilities and making them repay millions of dollars because of paperwork and technical problems with regulatory compliance.  Can you imagine that we are in such a desperate place that the State is actually rolling our most vulnerable citizens for their Medicaid dimes back?

    I am generally aware that North Caroline Medicaid is also in tatters - and NC just just lost their chief policy wonk to land what will unquestionably be a less stressful position in the private sector.

    She had good reason to leave, because by my best understanding NC was planning to go the same route that NY did with commercial insurance running the Medicaid program -and as you can see above it has not worked out so well.  I still don't know how it will all intersect with ACA.  If anyone has any of that information I would love to have it.

    I don't intend to sound negative - it is just that with so little information and with so much uncertainty it feels so difficult to even try to imagine creating a new product line for a new system with new reimbursements - all of which is functionally unknown at this time.  

    If there were answers I would like to find them - but I am acutely aware that I know just about as much as anyone else at this point in time - and that does not bolster my confidence.

    Christopher J. Alterio, Dr.OT, OTR

  • As a follow up to my post, here is an interesting summary of this issue that I found from the Robert Wood Johnson Foundation, which I hope people will perceive as a policy analysis piece and not as a political piece.  This report does a nice job of providing more detail to the issues I was referring to.

    It seems that so often these days it is hard to have this conversation without people looking through their political lens, and as I stated above I am trying to approach this pragmatically and not with any political intention.

    The report can be found at www.rwjf.org/.../rwjf406305

    (Are State Medicaid Managed Care Programs Ready for 2014: A Review of Eight States)

    Christopher J. Alterio, Dr.OT, OTR

  • I have downloaded the report you shared Christopher and trying to find time to read it. Been a hectic last week with a 2 day BPPC meeting and now the Joint Commission is here!

    Here is an update on ACO development from today's "The Advisory Board" daily briefing.......charting rapid growth in the number of ACO's.


  • Thanks for that link; I liked the chart that showed where the various pilots are located.

    There has not been a lot of press about the ACO drop out rate, but it seems that this is something to consider because it is a real issue.  By my reading, some think it matters and others don't think it is a big deal at all.  This leads me to believe that those groups that were not successful with the model didn't like the revenue losses.  

    What interests me is that it is win-win for CMS.  Either groups save CMS money and are 'successful' or they lose money and have to pay money back to CMS.  

    Where are the quality metrics in this equation?  Did we actually improve real care, or are we just saving money?

    I have a large philosophical concern with the way that our system creates and re-creates models that have us more focused on the financial transaction than on the needs of an individual.  Somehow, 'good' health care is being defined as 'less expensive' health care.  That may be true in some or even many situations, but it is not universally true.

    In the for-profit context the opposite is true: 'more expensive' health care is 'good' health care.  That isn't exactly the best model either, obviously, and you don't need to look any further than the Medicare Part B system to see how broken it is.

    It just feels to me like our system keeps swinging the bat and missing.  I recall the days where we attempted to de-program care providers from diagnosis-leading identifiers (the 'hip' in room 224, or the 'cva' who has an outpatient appointment).  Now I notice that I have to de-program those identifiers a little less and now I spend my time pushing back against people referring to their 'Med Bs' or some other insurance designation.

    I think that designation-by-payor-type is a little more insidious and damaging to our mentalities and care.  It also does not serve our ethics at all - and actually that is a rather large issue that needs to be tackled at some point.

    When we place anything other than the person requiring care in the front of our thought process, our outcomes for actual health are more likely to elude us.

    I have a small hope that eventually we will get this right.  And to be absolutely clear, the 'we' I am referring to is society - I don't believe that this is a unique OT problem.

    Christopher J. Alterio, Dr.OT, OTR

  • One concrete thing that all occupational therapy practitioners can be doing as health care reform implementation is shaking out is to assume responsibility for "environmental scanning."

    I get daily emails from "The Advisory Board Company" and here is a story on two large employers (Walmart and Loews) who have entered into a bundled payment arrangement.

    "The companies joined the Pacific Business Group on Health (PBGH) Negotiating Alliance to create the Employers Centers for Excellence Network, which will offer no-cost knee- and hip-replacement surgeries for more than 1.5 million employees and their dependents at:

       Johns Hopkins Bayview Medical Center in Baltimore;

       Kaiser Permanente Orange County Irvine Medical Center in Irvine, Calif.;

       Mercy Hospital in Springfield, Mo.; and

       Virginia Mason Medical Center in Seattle."

    If I were an OT practitioner at any of these organizations I would want to be sure and be on the ball with best practice standards of care for patients with these diagnoses!


    Here is a bundled payment tracker from the Advisory Board;


  • Brent,

    Does it concern you at all that bundled methodologies remove the primary focus of institutions from providing care and instead focuses on methodologies for cost control?

    Specifically, administrators who are not caregivers will be looking at their margins and deciding how to provide services in the least costly way possible so that they are eligible for even higher payouts when they receive their retroactive bundle reconciliation.

    I suspect that the fail-safe is supposed to be 'patient outcomes' but as we see all around us - someone determines what they want their outcomes to say and they will find a metric that will comply!

    There are additional problems with this concept, chief among them being a very faulty logical assumption that all episodes of care can be assumed to be equal, or perhaps close to equal.  This issue in particular is astonishing to me.  As a clinician, I know that every time someone has a Colles fracture that it is not the same Colles fracture.  There may be standard protocol for intervention, but what about individual differences?  What about the fact that some people have better healing than others, or that someone may have an diagnosed or undiagnosed condition that impacts their recovery, or that someone will be compliant with their care and someone else won't, or that someone will accidentally hold the dog leash with the injured extremity and someone else won't, etc etc.  How does one make average assumptions about chaotic human systems?

    In simple terms, health is governed by non-linear dynamics and is not cleanly predictable.

    We already have a model that might indicate concerns about applying a standardized model of investment to a theoretically unitary population: it is called public education.  We have not been so successful with standardized investment and curricular protocol to what is actually a tremendously diverse universe of children who all have complex developmental and social factors that impact their outcomes.  

    I know that health care and education are vastly different from each other; but the concept of applying population-level decision making upon individual complex human systems is the same.  It does not work well.

    Will it save money or improve outcomes?  I have some doubts.

    There is undeniable need to reform payment systems.  I am an advocate for reforms that promote cost controls and competition in local markets where local providers know their local population.  I am an advocate for reforms that reduce the need to practice defensive medicine.  I am an advocate for studying wellness initiatives that would hopefully reduce incidence of unhealthy behavioral choices.  

    When I need my knee replacement at some indeterminate time in the future, I don't want to be shipped off like cattle to some clinic far from my home because someone has made the determination that it would be 'best' for 'me.'

    Christopher J. Alterio, Dr.OT, OTR

  • Chris,

    I have some professional reflections and some personal/political reflections. I am going to post them separately to keep the thoughts clearer and to hopefully illustrate how I think about these complex issues given that what I think and want personally is seldom what I need to respond to professionally.

    My (off the top of my head) professional reflections on your questions and concerns about bundled payment structures are as follows:  

    Let us imagine two different scenarios and outcomes:

    The first a positive one where cost control is achieved and accountability is shifted more to providers who respond by standardizing care, reducing unwarranted variation and improving outcomes. The second a negative one in which providers react by limiting care, focusing more on dollars than quality and patients suffer.

    My reaction starts by thinking of a question which is, “As an occupational therapy practitioner, manager and advocate do I react any differently in the short term knowing that either of these extremes, or something in the middle may play out over the next 5 years?”

    My answer is probably not. I am going to think through the impact of the continued trend toward capitated payment, per diems, bundled payments and discounts on my organization and promote OT as a cost saver and contributor to improved outcomes, fewer readmissions and fewer complications. I am going to work to influence decisions in my sphere of control to benefit our patients and my organization.

    There are many things about our health care system I do not like and whenever I can I advocate for change in my organization, in my city, in my state and nationally. At the same time I am working for change I work as hard as I can to act proactively as a manager and advocate for the profession. I want to be ahead of the curve in guiding my department to be ready to respond to changes in our systems.

    One of my favorite quotes is from Wayne Gretzky, NHL player and coach. The paraphrased quote is “I skate to where the puck is going to be, not where it has been.”

    In this case I am assuming that bundled payments will become more common in the near future whether I have concerns about them or not. My job is to figure out where I need to be in order to be ready for puck?

  • Chris,

    In the personal/political realm here are some quick (also pretty off the top of my head) reactions:

    1. Sure continued shifts toward per diem, per episode or capitated payment concern me; but my first comment to myself (out loud) was “That is what we do every day in a hospital now anyway!”  We deal with several forms of lmited payment now and have been for a long-time (e.g. DRG’s, limited coverage determinations etc.).

    2. I am more concerned about the growth in the percentage of health care spending as a percentage of our GDP (16.4% in 2011 but projected to increase to 22% by 2038) than I am about bundled payments as a cost control mechanism.

    3. I am more concerned about 15.7% of Americans who were uninsured in 2012.

    4. Personally I am more concerned about people like my partner who works hard every day but does not qualify for employer provided insurance and due to societal discrimination cannot be added to my health policy.

    5. I am less concerned about someone covered by an employer provided insurance who needs a knee replacement being told where to get it for no out of pocket costs than being told they are on their own unless they can pay for it.

    6. The care givers AND the administrators I come across every day at my hospital work very hard to provide excellent care AND at the lowest cost. It is not that I think that payment does not affect quality;  I think it does in the long haul and in the long haul we have to figure out how to use our limited resources most effectively. However, I do not think that any administrator is getting up tomorrow and approaching their work any differently than they did today. I report to a Vice President for example who is ALL about quality and patients first (and he is a JD/MBA!).

    7. In the specific case of the Walmart-Loews example,  why assume that this is a bad financial deal for the hospitals? The providers are not being forced into these situations and I guess worked hard to win this agreement from two large employers who represent a bunch of “covered lives.” HMO’s and PPO’s have been around for a long-time……..

    I think my personal reflections bring me to the same place as my professional reflections. Change the things that I don't like whenever I can and be smart about how to take proactive action even when something is beyond my influence.


  • I think that a large contributing factor to why I am in private practice is because I bore rather easily when other people have the puck or when it is careening around the rink.  I think I am rather adroit with knowing where the puck is going, but rather than just skate to its likely destination I always hope that I might have some impact on its vectored path if I speak up about where I think it should be going.  That might be naive.  Also, sometimes I like to be the one in charge of the puck, so to speak.

    I have no illusions about impacting anything by bantering on a blog, but maybe if enough people talk about it we can eventually locate ourselves within positions of influence or influence someone who is in a position so that we can make a difference.  

    In general, I don't like the idea that other people are in positions of influence and that we have to try to skate around in response to the decisions that others make.  Maybe it is part of that 'powerful' thing that I think we should be attempting to achieve.

    These reimbursement schemes are all just pilot programs.  They may stick and they may not.  I think it is ok to have opinions for or against them as they are developed and I think we should speak up.  As a person who has also seen reimbursement schemes come and go I am sure you can probably appreciate why I have some cynicism.  I don't think we can point to our current delivery and reimbursement system and find ourselves saying, "WOW!  We really got it right with this methodology!"  Usually I hear the opposite, with clinicians finding more and more burden from the payment system.

    Actually, one of the primary drivers of my cynicism is watching how reimbursement schemes are now driving practice in long term care contexts.  It is beyond the level of simple disagreement; actually I think that it is probably immoral.  That is my opinion based on observations and certainly there are exceptions.

    I think my bottom line concern is that we should be working for health care systems and not health reimbursement systems.  I don't expect that we will ever be like Doc Baker from Little House on the Prairie, bartering chickens or a fixed roof for an appendectomy, but I feel very uncomfortable with the way things are currently being set up where care is actually a cost driver and not the point of the transaction.

    Christopher J. Alterio, Dr.OT, OTR