THE AFFORDABLE CARE ACT ITS EFFECTS ON RESPIRATORY CARE & SLEEP DEPARTMENTS

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1 THE AFFORDABLE CARE ACT ITS EFFECTS ON RESPIRATORY CARE & SLEEP DEPARTMENTS SHANE KEENE, DHSC, RRT- NPS, CPFT, RPSGT, RST DEPARTMENT HEAD, ANALYTICAL AND DIAGNOSTIC SCIENCES UNIVERSITY OF CINCINNATI

2 Mr. Brian Hobson, COO Bristol Regional Medical Center SPECIAL ACKNOWLEDGMENT Personal interview provided unique prospective on topic as a respiratory therapist, department head, and a hospital administrator.

3 AFFORDABLE CARE ACT The Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA) or "Obamacare The ACA represents the most significant regulatory overhaul of the country's healthcare system since the passage of Medicare and Medicaid in Additional reforms aim to reduce costs and improve healthcare outcomes by shifting the system towards quality over quantity through increased competition, regulation, and incentives to streamline the delivery of healthcare.

4 WHY THE GOVERNMENT WANTS CHANGE The Genesis of the Affordable Care Act : 19% GDP spent on healthcare highest of any other country US healthcare system ranked 37 th of 191 countries Life expectancy ranked 33rd of 191 countries 2 nd only behind Mexico in highest per capita for obesity We spend more than any other country on healthcare yet our quality ranking is 37 th. This is like recruiting the best football players that money can buy and never even making it to the playoffs. Must utilize our resources better and be more accountable for quality outcomes. WORLD HEALTH ORGANIZATION

5 INPATIENT PERSPECTIVE PAYMENT SYSTEM (PPS) Each case is categorized into a Diagnostic Related Group (DRG) The DRG base -payment amount is determined by two primary factors DRG Weight (levels of severity) Market Conditions (payer mix and cost of living in geographical area) The average DRG payment per inpatient in 2013 was $ Example basic DRG with no comorbidities or complications weight 1.0 $ X 1.0 = $ Example basic DRG w/o MCC major complication or comorbidity pulmonary embolus weight $ X = $9875 Example basic DRG w/ MCC major complication and comorbidity pulmonary embolus weight $ X = $

6 MCC- Major Complication/Co-morbidity Reflects the highest level of severity Examples: Respiratory Arrest, Pneumothorax CC Complication/Comorbidity The next level of severity Examples: Diabetes, Hypertension Non-CC Non-Complication Co-morbidity Do not significantly affect severity of illness Example: Eczema

7 CMS will penalize or bonus inpatient facilities based upon 2 factors: 30 day hospital readmission rates counts for 70% of the 1% rate towards DRG bonus or penalty Overall patient satisfaction scores: HCAP s (Hospital Consumer Assessment of Healthcare Providers and Systems) counts for 30% of the 1% rate towards DRG bonus or penalty

8 Current targeted DRG s: Acute Myocardial Infarction Pneumonia Heart failure COPD beginning in October,

9 WHY TARGET? Current Data 30 day readmission rates for specific conditions Heart Failure 26.9% Pneumonia 20.1% COPD 22.6%

10 Three Goals : 1. Generate comparative data among hospitals 2. Create incentives for hospitals to improve quality of care 3. Enhanced accountability and increased transparency HCAPS Survey INITIATIVES- PATIENT- ASSESSMENTINSTRUMENTS/HOSPITALQUALITYINITS/HOSPITALHCAPS.HTML

11 EXAMPLE OF HOSPITAL VALUE BASED PURCHASING CMS.GOV

12 VALUE BASED PURCHASING ROLLOUT % % % % 2017 and subsequent years 2.00 %

13 VALUE BASED PURCHASING TIMELINES Date HCAPS Readmits Total % 0.7 % 1.00 % % % % % 1.05 % 1.50 % % % 1.75 %

14 ACCOUNTABLE CARE ORGANIZATIONS (ACOS) SHARED SAVINGS PROGRAM General Guidelines Must agree to a 3 year contract and Provide benefits to minimally 5,000 Medicare enrollees Must have enough primary care providers to meet enrollee needs Negotiated rate below estimated average rate per capita for Medicare expenditures for services provided Be willing to be graded on outcomes and measures such as Clinical processes and outcomes Patient and caregiver experience of care Utilization (such as rates of hospital admissions for ambulatory care sensitive conditions)

15 RT PROTOCOL DRIVEN HOSPITALS Makes respiratory therapists part of patient care decision making process Decreases response times for patients in need Affords therapists the autonomy to focus on therapies that patients actually need by discontinuing the procedures and medications that are ineffective Increased efficiencies result in better utilization of resources and cost savings Transitions department from treatment driven model to patient center model of care

16 COPD NAVIGATOR NEED Value Based Purchasing targeted DRG (COPD) COPD third highest cause of death in the United States Pulmonary rehabilitation has been decimated in recent years Very little structured inpatient education for this patient population Medications regiments are becoming increasingly difficult for patients to understand Crucial to the profession for COPD patients to receive the care they need both in and out of the hospital

17 COPD NAVIGATORS Patient advocates, hospital educators, and discharge planners: Upon admission navigator is assigned to the patient Using protocol and COPD Gold guidelines as a guide navigators orders procedures, modifies therapy and medications to fit patient need. Navigators serve as patient advocates getting the patient what they need so they do not get lost in the system During the course of the inpatient stay the patient receives extensive education about their disease and every aspect of how to better manage it AMERICAN ASSOCIATION FOR RESPIRATORY CARE

18 COPD NAVIGATORS (CONT) Navigator plans discharge of patient Orders appropriate therapies Changes home medications to fit patient needs Assesses home care needs and functional capabilities of patient Checks in with patient at regular intervals to assure compliance of medications and therapies Follows up with durable medical equipment and home health providers to coordinate care and actually provide home visits to assess needs AMERICAN ASSOCIATION FOR RESPIRATORY CARE

19 POTENTIAL COPD NAVIGATOR RESULTS Patient actually receives the treatment and access to care they need as an inpatient Inpatient stays are dramatically reduced Readmission rates within 30 days are significantly reduced Patient is provided with the knowledge to take better care of themselves and manage their disease Patient satisfaction is increased Most importantly patients get better faster and are provided the resources to help stay out of the hospital Who Better to Manage COPD than Respiratory Therapists AMERICAN ASSOCIATION FOR RESPIRATORY CARE

20 RECOMMENDATIONS FOR RT Step 1:Educate your department about PPS and VBP Step 2: Do whatever it takes to become a protocol driven department Step 3: If your facility has a high prevalence of COPD patients by all means initiate a COPD Navigator program Step 4: Measure and track what is really important Step 5: Get all of the formal (degree) and informal education (credentials) that you can. The yardstick for the profession is changing!

21 SLEEP CHANGES WITH ACA Cadillac plans - high co-pay and/or high deductible insurance plans promote the usage of Home Sleep Testing (HST) Will reduce the quantity of supplies used by home sleep patients Could increase compliance because patients are agreeing to pay more money up front (vested from the start) Widely accepted now by the health care community that untreated sleep disorders aggravate other comorbidities (i.e., diabetes and heart disease) SLEEP REVIEW

22 HST expansion : HOME SLEEP TESTING (HST) Reached a level of clinical competence with most health care providers and insurance companies Favorable because some insurance companies in the health exchanges are placing caps on diagnostic studies in labs Restless Leg Syndrome and Upper Airway Resistance Syndrome are exploratory at this point and do not currently have clinical acceptance SLEEP REVIEW

23 ORAL APPLIANCE THERAPY Statistically compliance is much better with oral appliance therapy than positive pressure Mild to moderate OSA patients experience comparable results to positive pressure Gaining prominence because of its affordability Very small percentage of dentists have sleep specialty availability is fragmented especially in rural areas SLEEP REVIEW

24 ACO FOR SLEEP Currently a CMS experiment this one sided HMO will most likely be unavoidable in the future Logical partnerships would exist between sleep labs and durable medical equipment providers OSA is not currently listed as a chronic disease nor des it have a DRG modifier makes t logical to be packaged with other comorbidites SLEEP REVIEW

25 RECOMMENDATIONS FOR SLEEP HST is not going away: embrace it and make it work for your lab (your competition will) Look into partnerships with ACOs that make sense Inpatient triggers (STOP BANG questionnaire pre-op, etc) Reallocate your work force (Marketing, HST, follow up, compliance) Be prepared for a shrinking workforce because of technology and reimbursement

26 CHANGE IS NOT ALL BAD For the first time clinicians will be charged with taking care of patients beyond just their hospital stay 5 % reduction in hospital readmissions already (600,00 patients) Forces hospitals to not be complacent (carrot and stick method in now in place) Patient noncompliance is no longer a catch-all for not being accountable Forces continuity of care and enhanced communication Opportunity to change the face of the profession DR. STEPHEN JENKS KEYNOTE ADDRESS 2013 INTERNATIONAL AARC CONGRESS

27 TAKEAWAY We are no longer going to be judged by the number of procedures we perform but by the clinical outcomes of our patients We are moving away from being stereotyped as just treatment jockeys to disease management specialists Patient treatment is moving beyond the walls of the health care facility COPD as a targeted DRG will bring increased recognition to our profession. How we respond will determine our future!

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