Moving From Volume-based to Value-based Rehabilitation Care

Moving From Volume-based to Value-based Rehabilitation Care In its National Quality Strategy, the US Department of Health & Human Services’ Centers for Medicare and Medicaid (CMS) has broadly defined its interest in valued-based purchasing (VBP) to achieve the triple aims of better health, better health care, and lower costs.1 As several authors have noted, the best way to achieve these aims in the US health care system through VBP is to measure patient-centered outcomes and to provide incentives toward achieving them.2,3 Or, as Harvey Fineberg, past president of the Institute of Medicine (IOM), has noted, “The only way to know whether the quality of care is improving is to measure performance.”4 To that end, in 2013, CMS began implementing a claims-based data collection strategy designed to gather information on beneficiary condition and function, rehabilitation therapy services provided, and outcomes achieved—otherwise known as G-coding.5 The overall intent of the CMS G-coding system is to provide useful data to CMS on beneficiary function over an episode of therapy services, demonstrate the degree to which functional limitations change as a result of therapy services, and show the relationship between beneficiary function and furnished therapy services over an episode of care. Specifically, the ICD-9 or ICD-10 diagnostic code on the beneficiary claim form would provide CMS with information on the beneficiary's medical condition. G-codes designed by CMS are to be used to identify what is being reported (current status, goals, or discharge status), and severity modifiers are to be used to indicate the extent of severity/complexity of the functional limitation being tracked. The difference between the reported functional status at the start of therapy and the report of functional status at the end of the therapy episode is designed to represent the progress—or lack thereof—that the beneficiary made during the episode.5 Although I believe the intent of the CMS G-code system is laudable, I fear that from a measurement perspective the G-coding system is fatally flawed and needs to be radically overhauled. I further believe that the data collected by therapy providers since 2013 under the CMS G-coding system are essentially uninterpretable and should not be analyzed or used to inform future payment reforms for therapy services provided under the Medicare program. Let me explain my reasoning. The fundamental measurement flaw occurred when CMS designed and implemented the G-coding system for outpatient therapy and failed to specify any measurement method(s) to be used to generate the correct G-code and severity modifiers. Therapists were left to decide for themselves how to select a primary or secondary beneficiary G-code and how to determine functional limitation severity. CMS allows therapists to use a standardized assessment tool, their clinical judgment, the report of the beneficiary, or some combination thereof. CMS has no method for identifying how the G-coding data were collected by outpatient therapists. When the G-coding system was first announced, CMS reasoned that “[r]equiring a specific instrument could create burdens for therapists that would have to be considered in light of any potential improvement in data accuracy, consistency, and appropriateness that such an instrument would generate.“5(p162) What CMS failed to appreciate or acknowledge was that without standardizing how the G-coding data would be collected, the resultant data would be uninterpretable. In creating the G-coding system, CMS did note, however, that they would reconsider this decision in the future and requested public comment on the G-coding approach underway. I believe the time is long overdue to provide CMS with feedback that they need to radically reform the G-coding system. As Porter et al6 have clearly articulated, “Experience in other fields suggests that systematic outcomes measurement is the sine qua non of value improvement,” and “that means committing to measuring a minimum sufficient set of outcomes for every major medical condition—with well-defined methods for their collection and risk adjustment—and then standardizing those sets nationally and globally.” Although CMS has identified the specific functional limitations of importance to the Medicare outpatient therapy program, it has failed to define any specific methods for—and avoided any attempt to standardize—the collection of functional limitations data for the Medicare outpatient therapy program. This decision is especially perplexing when we realize that CMS has standardized the collection of functional outcome data in all other postacute care settings. This decision on the part of CMS has resulted in a major missed opportunity to advance value-based purchasing for the Medicare outpatient therapy program and contributed to providers’ understandable reluctance to embrace G-codes as the basis for determining accountability for the results of the therapy they provide. As the IOM Pathways to Quality Health Care committee noted in their report titled Performance Measurement, “The performance measurement process should include audits to ensure the measures themselves are sufficiently accurate and reliable to yield credible data. The measurement process should also be streamlined to improve its value while reducing its costs. Its results should be open and available to all stakeholders.”7 Reams of G-coding data have been collected and sent to CMS on claims forms; however, without knowing how the data were collected and whether the resultant information is accurate and reliable, we can have no confidence in the meaning or usefulness of that information. Clinicians and Medicare beneficiaries are right to be concerned about how such data might be inappropriately used by regulators and payers. In my judgment, the full potential of VBP initiatives such as the one that CMS desires for outpatient therapy services cannot be realized without a credible, integrated outcome measurement system that is purposeful, comprehensive, efficient, and transparent—and that yields accurate and reliable information. Porter et al6 have discussed what they see as the major reasons why we in the United States have had such difficulty arriving at a credible system of outcome performance assessment. Some of these reasons may be relevant and useful to think about as we attempt to improve outcome measures in the rehabilitation field. First, Porter et al note that we have allowed “quality” to be overly defined as compliance with evidence-based guidelines, rather than as improvement in desired outcomes. He argues that process measures are of less value to patients and don’t differentiate well among providers—nor does adhering to practice guidelines matter a great deal for outcomes achieved. Second, they believe that much outcome measurement has occurred within professional disciplines and specialties, which has not improved the overall care and outcome of a patient. He argues for generic, broadly applicable outcome measures over the condition or body-part functional measures that are highly prevalent in rehabilitation. Third, they highlight that efforts at outcomes measurement have overwhelmingly focused on a patient's clinical state (eg, survival) and on “objective” outcomes readily captured by laboratory tests—and have not sufficiently focused on more “subjective” outcomes, such as patient functional status. I don’t think this is a major issue in rehabilitation where assessment of patient function has been a central feature of our clinical and research culture. Finally, Porter and colleagues note that progress on outcomes measurement has been retarded by allowing each profession or organization to reinvent the wheel, tweaking existing measures or inventing tools of its own. This has led to a patchwork of measures and definitions used by providers, organizations, payers, and individual clinicians, thus greatly complicating our ability to make outcome comparisons across patients, providers, and organizations. The CMS G-coding system, in my view, has exacerbated the challenges Porter et al outline through its “let a thousand flowers bloom” approach to functional limitation assessment in outpatient therapy provided under the Medicare program. I believe the path forward for outpatient therapy under the Medicare program is obvious: Providers, advocacy and advisory groups, and CMS have to reach agreement on a minimum set of functional outcomes for the major important conditions seen in outpatient therapy, with rigorous definitions and assessment methods defined, along with clearly specified risk adjustment procedures for analysis and interpretation. What is less clear is whether the parties involved have the will—and courage—to make the difficult decisions needed to reach such a consensus. It is only then that systems like the CMS G-coding system will yield meaningful data on the value of therapy services provided to Medicare beneficiaries and provide a solid foundation for future VBP. References 1. About the National Quality Strategy. Agency for Healthcare Research and Quality website . http://www.ahrq.gov/workingforquality/about/index.html. Accessed October 3, 2017. PubMed PubMed  2. Porter M. A strategy for health care reform—toward a value-based system. New Engl J Med . 2009; 361( 2): 109– 112. Google Scholar CrossRef Search ADS PubMed  3. VanLare J, Conway P. Value-based purchasing—national programs to move from volume to value. New Engl J Med . 2012; 367( 4): 292– 295. Google Scholar CrossRef Search ADS PubMed  4. Fineberg H. Forward. In: Schroeder S, ed. Performance Measurement: Accelerating Improvement. Washington, DC: The National  Academy Press; 2006: xiii. 5. US Department of Health & Human Services Centers for Medicare and Medicaid. Part II. Vol. 77 ( 146): 156– 179, Washington DC, July 30, 2012. 6. Porter M, Larsson S, Lee T. Standardizing patient outcomes measurement. New Engl J Med . 2016; 374( 6): 504. Google Scholar CrossRef Search ADS PubMed  7. Schroeder S, ed. Executive summary. Performance Measurement: Accelerating Improvement . Washington, DC; The National Academy Press; 2006: 3. © 2017 American Physical Therapy Association http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Physical Therapy Oxford University Press

Moving From Volume-based to Value-based Rehabilitation Care

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American Physical Therapy Association
Copyright
© 2017 American Physical Therapy Association
ISSN
0031-9023
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1538-6724
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10.1093/ptj/pzx112
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Abstract

In its National Quality Strategy, the US Department of Health & Human Services’ Centers for Medicare and Medicaid (CMS) has broadly defined its interest in valued-based purchasing (VBP) to achieve the triple aims of better health, better health care, and lower costs.1 As several authors have noted, the best way to achieve these aims in the US health care system through VBP is to measure patient-centered outcomes and to provide incentives toward achieving them.2,3 Or, as Harvey Fineberg, past president of the Institute of Medicine (IOM), has noted, “The only way to know whether the quality of care is improving is to measure performance.”4 To that end, in 2013, CMS began implementing a claims-based data collection strategy designed to gather information on beneficiary condition and function, rehabilitation therapy services provided, and outcomes achieved—otherwise known as G-coding.5 The overall intent of the CMS G-coding system is to provide useful data to CMS on beneficiary function over an episode of therapy services, demonstrate the degree to which functional limitations change as a result of therapy services, and show the relationship between beneficiary function and furnished therapy services over an episode of care. Specifically, the ICD-9 or ICD-10 diagnostic code on the beneficiary claim form would provide CMS with information on the beneficiary's medical condition. G-codes designed by CMS are to be used to identify what is being reported (current status, goals, or discharge status), and severity modifiers are to be used to indicate the extent of severity/complexity of the functional limitation being tracked. The difference between the reported functional status at the start of therapy and the report of functional status at the end of the therapy episode is designed to represent the progress—or lack thereof—that the beneficiary made during the episode.5 Although I believe the intent of the CMS G-code system is laudable, I fear that from a measurement perspective the G-coding system is fatally flawed and needs to be radically overhauled. I further believe that the data collected by therapy providers since 2013 under the CMS G-coding system are essentially uninterpretable and should not be analyzed or used to inform future payment reforms for therapy services provided under the Medicare program. Let me explain my reasoning. The fundamental measurement flaw occurred when CMS designed and implemented the G-coding system for outpatient therapy and failed to specify any measurement method(s) to be used to generate the correct G-code and severity modifiers. Therapists were left to decide for themselves how to select a primary or secondary beneficiary G-code and how to determine functional limitation severity. CMS allows therapists to use a standardized assessment tool, their clinical judgment, the report of the beneficiary, or some combination thereof. CMS has no method for identifying how the G-coding data were collected by outpatient therapists. When the G-coding system was first announced, CMS reasoned that “[r]equiring a specific instrument could create burdens for therapists that would have to be considered in light of any potential improvement in data accuracy, consistency, and appropriateness that such an instrument would generate.“5(p162) What CMS failed to appreciate or acknowledge was that without standardizing how the G-coding data would be collected, the resultant data would be uninterpretable. In creating the G-coding system, CMS did note, however, that they would reconsider this decision in the future and requested public comment on the G-coding approach underway. I believe the time is long overdue to provide CMS with feedback that they need to radically reform the G-coding system. As Porter et al6 have clearly articulated, “Experience in other fields suggests that systematic outcomes measurement is the sine qua non of value improvement,” and “that means committing to measuring a minimum sufficient set of outcomes for every major medical condition—with well-defined methods for their collection and risk adjustment—and then standardizing those sets nationally and globally.” Although CMS has identified the specific functional limitations of importance to the Medicare outpatient therapy program, it has failed to define any specific methods for—and avoided any attempt to standardize—the collection of functional limitations data for the Medicare outpatient therapy program. This decision is especially perplexing when we realize that CMS has standardized the collection of functional outcome data in all other postacute care settings. This decision on the part of CMS has resulted in a major missed opportunity to advance value-based purchasing for the Medicare outpatient therapy program and contributed to providers’ understandable reluctance to embrace G-codes as the basis for determining accountability for the results of the therapy they provide. As the IOM Pathways to Quality Health Care committee noted in their report titled Performance Measurement, “The performance measurement process should include audits to ensure the measures themselves are sufficiently accurate and reliable to yield credible data. The measurement process should also be streamlined to improve its value while reducing its costs. Its results should be open and available to all stakeholders.”7 Reams of G-coding data have been collected and sent to CMS on claims forms; however, without knowing how the data were collected and whether the resultant information is accurate and reliable, we can have no confidence in the meaning or usefulness of that information. Clinicians and Medicare beneficiaries are right to be concerned about how such data might be inappropriately used by regulators and payers. In my judgment, the full potential of VBP initiatives such as the one that CMS desires for outpatient therapy services cannot be realized without a credible, integrated outcome measurement system that is purposeful, comprehensive, efficient, and transparent—and that yields accurate and reliable information. Porter et al6 have discussed what they see as the major reasons why we in the United States have had such difficulty arriving at a credible system of outcome performance assessment. Some of these reasons may be relevant and useful to think about as we attempt to improve outcome measures in the rehabilitation field. First, Porter et al note that we have allowed “quality” to be overly defined as compliance with evidence-based guidelines, rather than as improvement in desired outcomes. He argues that process measures are of less value to patients and don’t differentiate well among providers—nor does adhering to practice guidelines matter a great deal for outcomes achieved. Second, they believe that much outcome measurement has occurred within professional disciplines and specialties, which has not improved the overall care and outcome of a patient. He argues for generic, broadly applicable outcome measures over the condition or body-part functional measures that are highly prevalent in rehabilitation. Third, they highlight that efforts at outcomes measurement have overwhelmingly focused on a patient's clinical state (eg, survival) and on “objective” outcomes readily captured by laboratory tests—and have not sufficiently focused on more “subjective” outcomes, such as patient functional status. I don’t think this is a major issue in rehabilitation where assessment of patient function has been a central feature of our clinical and research culture. Finally, Porter and colleagues note that progress on outcomes measurement has been retarded by allowing each profession or organization to reinvent the wheel, tweaking existing measures or inventing tools of its own. This has led to a patchwork of measures and definitions used by providers, organizations, payers, and individual clinicians, thus greatly complicating our ability to make outcome comparisons across patients, providers, and organizations. The CMS G-coding system, in my view, has exacerbated the challenges Porter et al outline through its “let a thousand flowers bloom” approach to functional limitation assessment in outpatient therapy provided under the Medicare program. I believe the path forward for outpatient therapy under the Medicare program is obvious: Providers, advocacy and advisory groups, and CMS have to reach agreement on a minimum set of functional outcomes for the major important conditions seen in outpatient therapy, with rigorous definitions and assessment methods defined, along with clearly specified risk adjustment procedures for analysis and interpretation. What is less clear is whether the parties involved have the will—and courage—to make the difficult decisions needed to reach such a consensus. It is only then that systems like the CMS G-coding system will yield meaningful data on the value of therapy services provided to Medicare beneficiaries and provide a solid foundation for future VBP. References 1. About the National Quality Strategy. Agency for Healthcare Research and Quality website . http://www.ahrq.gov/workingforquality/about/index.html. Accessed October 3, 2017. PubMed PubMed  2. Porter M. A strategy for health care reform—toward a value-based system. New Engl J Med . 2009; 361( 2): 109– 112. Google Scholar CrossRef Search ADS PubMed  3. VanLare J, Conway P. Value-based purchasing—national programs to move from volume to value. New Engl J Med . 2012; 367( 4): 292– 295. Google Scholar CrossRef Search ADS PubMed  4. Fineberg H. Forward. In: Schroeder S, ed. Performance Measurement: Accelerating Improvement. Washington, DC: The National  Academy Press; 2006: xiii. 5. US Department of Health & Human Services Centers for Medicare and Medicaid. Part II. Vol. 77 ( 146): 156– 179, Washington DC, July 30, 2012. 6. Porter M, Larsson S, Lee T. Standardizing patient outcomes measurement. New Engl J Med . 2016; 374( 6): 504. Google Scholar CrossRef Search ADS PubMed  7. Schroeder S, ed. Executive summary. Performance Measurement: Accelerating Improvement . Washington, DC; The National Academy Press; 2006: 3. © 2017 American Physical Therapy Association

Journal

Physical TherapyOxford University Press

Published: Jan 1, 2018

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