Dr. Justin Liu, MD
Posted on January 23rd, 2017

As healthcare providers in the 21st Century, I find that many organizations and physicians often feel it is an obligation to immediately react to whatever the latest government policy or mandate is.  While it is completely understood that we no longer live in the heyday of medicine where we can order whatever work up we fancy or keep patients hospitalized for however long we want, we still however in theory should all be practicing medicine with the mindset of not forgetting the important age-old oath we all took that explicitly states that there is a definite art to medicine and that we must fight to “apply all measures which are required” for the benefit of the sick.  Some might actually question whether this type of mentality is even possible in today’s constantly changing era of medicine.  Many physicians are forced to believe that we have to sit back and let politicians and hospital administrators decide what’s best for patients.  Like flocks of sheep, we are herded into believing that what we are being instructed to do is clearly the way to go.  Even when certain measures have the potential to be detrimental to our patients’ overall clinical outcomes, many of us mindlessly continue to drink the toxic Kool-Aid and somehow convince ourselves that it actually tastes good. 

When ObamaCare first appeared with the passage of the Affordable Care Act in 2010, it was definitely a huge shake up.  While it had its altruistic goals of providing lower cost health insurance for many, its means for achieving this proved controversial.  Not only were taxes increased and premiums raised for those who already had health insurance, various measures were designed to help the government find ways to perpetuate the program.  Extreme cost cutting initiatives were thereby explored under the umbrella of ObamaCare.  Under the ACA, such things as the Bundled Payments for Care Improvement (BPCI) were created.  BPCI was essentially a test program for the Centers for Medicare and Medicaid Innovation (CMMI) to encourage healthcare systems to learn to provide more efficient care at a lower cost to Medicare.  For those unfamiliar with the initiative, CMMI basically created a system where it would issue bundles of payment for an episode of patient care from acute hospitalization to 90 days after discharge from the acute hospital setting.  Everything from the acute hospital costs to all the associated post-acute care costs (Acute Rehab, SNF, Home Health) were all covered in one big payment bundle.  If the healthcare system’s actual costs for a said episode of care was equal to or greater than its usual baseline average cost for treatment of that type of diagnosis, then CMMI would be able to financially penalize the healthcare system up to 2% of its charges to Medicare.  CMMI seemed to understand that the odds of a healthcare system being able to better itself over recent benchmark numbers that were already quite lean would likely prove impossible.  Unless a healthcare system was bizarrely operating at an extremely wasteful level with a lot of obvious fat to cut out, any system that entered into the BPCI initiative would likely be paying that 2% penalty directly into Medicare’s wallet.  The only problem with the whole bundled payments project for CMMI was that the ACA had provisioned for BPCI not to be actual mandatory law.  Rather it was created as a test initiative that required healthcare systems to electively sign up to participate in.  Given this caveat, what healthcare system in its right mind would voluntarily sign up to test out a program that was designed so that the odds were stacked against them to run the risk of actual financial penalties?  This is where CMMI had a sheer stroke of genius.  It decided to offer healthcare systems that agreed to sign up for the BPCI initiative, the “possibility” of getting a bonus up to 2% if they somehow were able to better their baseline costs for a specific diagnosis.  As unlikely as the odds of this happening would be for most participants, it effectively served as the dangling carrot that CMMI desperately needed.  Despite the Vegas-style odds providers had at actually beating the house and winning real money, CMMI had succeeded in creating the perfect Trojan horse to openly lure healthcare systems into voluntarily signing up to participate in the gamble known as BPCI.
So after its inception, CMMI was able to convince over 500 hospitals across the country to enter into the BPCI test initiative.  While many hospitals initially entered with wide-eyed enthusiasm and hopeful visions of being awarded money back from Medicare, reality quickly set in and proved that this was not going to be the case.  As dreams of financial bonuses rapidly transformed into nightmares of eminent CMMI penalties, healthcare systems across the country panicked to make some drastic changes with their management of patients.  While BPCI may have forced healthcare systems into making these changes, it definitely did not offer any guidelines on what systems could do to help mitigate its odds of being penalized.  Healthcare systems therefore were left to essentially figure things out on their own.  For some sites, they realized that attempts at shaving lengths of stay and reducing the costs of diagnostic testing were not going to prove very fruitful.  They therefore turned to focusing on how to ultimately reduce the costs of post-acute care.  While many systems initially acted on their immediate knee jerk reflex to simply send hospitalized patients with significant functional decline to whatever setting had the lowest daily charges, other systems began realizing that this was not going to help the situation by any means.  They learned that if you send a significantly debilitated patient to a SNF or directly home with home health, a large amount of these patients will be readmitted back to the acute hospital within 90 days or typically sooner.  Costly readmissions obliterated any sort of savings that the healthcare systems initially perceived they were making by sending its patients only to low cost post-acute care options.  Learning from their mistakes, certain healthcare systems have since moved to spending more money upfront on services like Acute Rehab to help the patients achieve a higher level of functional and medical stability so that they can go home and ultimately stay there without the increased risk of a costly readmission.  Nationally, we have seen major academic centers like Johns Hopkins University recently opening up its own onsite Acute Rehab Unit as well as UCLA and Cedars Sinai partnering to open a 138 private room Acute Rehab facility.

While increased use of Acute Rehab in the post-acute care setting can likely lead to reduced overall usage of the lump sum bundled payment for an episode of care by reducing readmissions, will it ultimately enable healthcare systems to achieve their target costs, avoid CMMI penalties and possibly even collect some Medicare bonus money?...Maybe or maybe not.  Let’s not forget that one of the blatant objectives of the BPCI initiative was to “save Medicare money” rather than have Medicare break even or actually pay money back out to its BPCI participants.  While CMMI won’t make any formal comment on the true success of the program, the 3-year test initiative was supposed to conclude in 2016.  Under the authority of the ACA, CMMI in April 2016 approved a 2-year extension to the program where they stated it would be a chance to obtain “a more robust and rigorous evaluation of the initiative.”  Analysts of BPCI have however reported that Medicare is not truly saving any significant money by improving the efficiency and quality of care, but rather by collecting penalties from the initiative’s 500+ voluntary participants.

While the BPCI initiative extension was approved under the ACA, things have once again taken a dramatic turn with the new era of President Trump and his strong views on ObamaCare.  Shortly after being sworn in on 1/20/17, Donald Trump signed an executive order which first notes the President's intention to seek the "prompt repeal" of the ACA, and says that in the meantime, it is seeking to offer flexibility to states to create a more "free and open healthcare market.”  The order grants authority to the heads of all federal agencies, including the Secretary of Health and Human Services to “waive, defer, grant exemptions from or delay the implementation of any provision or requirement of the Act that would impose a financial burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications."  Analysts now are already predicting that if the ACA is largely repealed, all CMMI provisions like the BPCI Initiative will be entirely eliminated.

In the big picture, where does this leave healthcare providers?  While the principles of BPCI are now unlikely to ever see the light of day as any kind of formal law, should this even really matter?  BPCI or no BPCI…ObamaCare or TrumpCare…We really should be returning back to our core roots and always fighting to do right by the patient regardless of what politicians and administrators are trying to force us to do.

Posted on May 27th, 2016

In the new era of bundled healthcare payments, various healthcare systems nationwide are constantly trying to cut spending. As a direct result of this, we are seeing a massive shift in what care options patients are being directed to when they are not well enough to go immediately home from an acute hospitalization. Skilled Nursing Facilities in particular have seen a massive boom in business growth. This is attributable to the fact that many healthcare systems have been operating under the assumption that Skilled Nursing Facility Rehab is essentially the same as Acute Rehab…so why bother at all with the costlier Acute Rehab option. Despite the tremendous inaccuracy of this assumption, healthcare systems seem to have no issue operating under this mentality due to the perceived cost savings. The true repercussions of these decisions however ultimately comes at the expense of patients.

With the recent increased channeling of stroke patients to Skilled Nursing Facilities, the American Heart Association/American Stroke Association (AHA/ASA) has recently issued official guidelines for the first time on rehabilitation after stroke. Published in Stroke on May 4, 2016, the post-stroke guidelines call for intensive, multidisciplinary inpatient Acute Rehab treatment. These AHA/ASA guidelines have already been wholeheartedly endorsed by the American Academy of Neurology, American Academy of Physical Medicine and Rehabilitation, American Physical Therapy Association, American Occupational Therapy Association, American Society of Neurorehabilitation and the American Congress of Rehabilitation Medicine.

Up till now, the AHA/ASA had previously been more focused on the medical management of acute stroke. The AHA/ASA however felt it needed to formally issue new guidelines since it has found clinically significant level 1A evidence that inpatient Acute Rehab has a very clear, beneficial impact on clinical outcomes. The AHA/ASA also has come to the realization that many professionals involved in stroke care may not have been aware of this before. Through publication of detailed guidelines, the AHA/ASA is trying to encourage greater efforts to help make these beneficial interventions happen on a more global level.

The AHA/ASA Stroke Rehab guidelines specifically state that a multidisciplinary team effort is required and this is most easily delivered at an inpatient Acute Rehab facility. Given this, the new guidelines recommend that patients should be admitted to such a facility after a stroke. Based on a mixture of evidence and consensus, the foremost recommendation with Level 1A evidence includes the following:

• Inpatient rehabilitation facilities produce better outcomes than nursing homes.

Dr. Carolee Winstein, the lead author of the guidelines has explained that patients would receive at least 3 hours each day of specific rehabilitation tailored to their needs by a dedicated coordinated team of professionals. This would include physical therapy, occupational therapy, speech therapy, medical management, and a visit from a social worker, whereas at a nursing home the intensity of rehabilitation is normally lower and there is less of an emphasis on recovery, with the focus more on maintenance and medical management.

Dr. Winstein further comments, "There is considerable evidence that patients benefit from the team approach in a facility that understands the importance of rehabilitation during the early period after a stroke. So if relatives are trying to decide what type of establishment would be best for aftercare for a patient following a stroke, then they should choose an inpatient rehabilitation facility if possible.”

The guidelines however point out that 2006 Medicare data showed that only 58% of stroke patients were referred to any post-acute care. Through its new guidelines, the AHA/ASA hopes to educate patients, medical providers and healthcare systems to help promote increased utilization of inpatient Acute Rehab facilities as the recommended standard of care for post-stroke rehabilitation.

by Justin Liu, MD on February 29th, 2016

    Regardless of the healthcare system I have been the director at, it seems that there is always a shroud of mystery when clinicians try to decipher what exactly Inpatient Acute Rehab is all about.  The most common conclusion that I have encountered is that Acute Rehab is essentially just like a Skilled Nursing Facility.

    While Acute Rehab may accept similar patients as SNFs, the differences between the two are quite profound.  Without delving into a novel about this, my goal in this short column is to hopefully shed some light on Rehab and how it can potentially benefit the patients you encounter.

    First things first.  Who is appropriate for Acute Rehab?  As many of you have probably guessed, the large majority of Rehab patients are those affected by neurologic and orthopedic conditions.  These typically include stroke, brain tumors, traumatic brain injury, spinal cord injury, Parkinson’s exacerbation, Multiple Sclerosis exacerbation, Guillain-Barre Syndrome, hip/pelvic fractures, limb amputations and spinal stenosis requiring decompressive spinal surgery.  CMS mandates that all Rehab Units must have at least 60% of their admitted patients fall into what is deemed an “appropriate” Rehab diagnosis.  While most physicians are aware of the more conventional patient diagnoses that can be referred to Acute Rehab, most are often unaware that Rehab Units are allowed to have up to 40% of their total admissions accommodate more atypical diagnoses.  These patients are the ones who have sustained acute functional decline due to their recent medical issues.  Regardless of whether the medical issues are cardiac, pulmonary, infectious, etc...CMS has a diagnosis category known as “Debility” to classify patients that have sustained acute functional decline due to recent medical complexity.  While we don’t exactly have carte blanche to take every single patient that is admitted to the hospital, the Debility diagnosis does allow Rehab Units to have much more flexibility with whom they can consider accepting.

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