#144 Therapy and Value-based Care Models with Dana Strauss

It’s hard to overstate how important it is for OTs and PTs to understand the new value-based care models.

But, let’s be honest—they are an overwhelming and confusing alphabet soup (TEAM, LEAD, GUIDE, ACO REACH), and that’s just the acronyms.

For OTs and PTs, understanding these models will be the difference between being embedded in the healthcare team of the future—where we deliver highly valued care—and falling into obscurity while our patients receive sub-par care.
Luckily, we have a master at demystifying the complex, Dana Strauss, back on the podcast. You’ll learn:

-How to analyze new models
-How to understand your potential role in them
-How to move your career and your organization forward

I know therapists are so busy on the ground, but we can’t afford to miss this one.

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https://otpotential.com/continuing-education/course/therapy-and-value-based-care-models

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Transcript

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SPEAKER_01 0:00

It's hard to overstate how important it is for OTs and PTs to understand the new value-based care payment models that are being piloted here in the United States. But let's be honest, they are an overwhelming and confusing alphabet soup with names like team, lead, guide, ACO reach. And that's just the acronyms. For OTs and PTs, understanding these models will be the difference between being embedded in the healthcare team of the future versus falling into obscurity while our patients receive sub-par care. Luckily, we have a master at demystifying the complex, Dana Strauss, back on the podcast today. You will learn how to analyze value-based care models, how to understand your potential role in them, and lastly, how to move forward your career and your organization. You are going to hear a lot of important information today. So I encourage you to just take it in and we will have a comprehensive blog post attached to this episode for you to reference later. So let's dive in. Welcome to the OT Potential Podcast. I'm your host, Sarah Lyon, OTRL, and I wanted to let you know that this podcast may qualify as continuing education for you. You are probably listening to this podcast on a free podcast platform. But to gain CEU credit, you will need to be a member of the OT Potential Club, our OT Continuing Education platform. You can go to OTPotential.com to learn more. Okay, here we go. As I mentioned at the top, joining us today is Dana Strauss, PTDPT. Dana took her clinical experience as a doctor of physical therapy and expertise in the healthcare continuum and transitioned her career to value-based care and policy analysis and expertise. She believes that the healthcare system can meet everyone's needs better. Her passion is moving towards the optimal patient experience and outcomes wherever an individual is on the spectrum of wellness, illness, injury, chronic care, or serious illness. Dana is optimistic about payer-provider synergistic relationships, making healthcare better for everyone along the care continuum, and is confident that innovative reimagining of the roles and responsibilities of sites of care can lead to higher value and superior quality for all. So without further ado, I will patch Dana into our live studio. Dana, welcome to OT Potential. It's so great to have you. Thanks for having me, Sarah. I'm so glad to be back. I am so thankful you are back. When we have talked about value-based care on the podcast before, my reaction is like, yes, let's move away from being focused on volume from this fee-for-service hamster wheel that we all live in. And can we move to being reimbursed for value? But then you start to look at the details and how many different models there are out there, how just frankly confusing the landscape feels. And I start to feel like, is the juice worth the squeeze to even learn how to take the next step? Like it feels very hard, even though it's something that we want to do. So I'm excited today, one, to just like get a primer from you on what is out there and what exists, but also just to hear like candidly from you like, can we do this? Is it worth it? It feels hard. Should I just sit at home and watch Netflix instead? Or should we do this? Um, so that's where we're going today. But I just want to start with your story again. I know we've talked a little bit about your background in the past, but like you are an example of someone who learned about policy, about payment, and built a career from there. Can you just share with us your story and how you got to where you are today? Sure.

SPEAKER_00 4:11

Um, thanks, Sarah. So uh I will say first that I really followed my curiosity. It should sound more complicated than that, a path that was orchestrated, but it really wasn't. I uh early on, and I mean 1998, early on, when I first started, what we were doing seemed unsustainable. And back then, unsustainable is nothing compared to where we are today, with you know, healthcare spending up 9% per year over the past couple of years projected again for this year. So, in my mind, there was an inevitable shift that would happen. And when the Affordable Care Act came out and the first alternative payment models were announced, I saw this as the direction we had to go and the area that I could develop expertise first as a first mover. And, you know, also figure that as a therapist, I would be unique in that approach. And even now, there are not a lot of experts in value-based care policy therapy or not. So, but I would say, you know, the takeaway is if you believe, as I do, that there is an inevitable move away from fee for service because of its creating massive inflation as part of the results of having a fee for service system, then there are only a few handful of ways that can be solved. And given our political system and how we make laws and change laws and update laws and promulgate regulation, the innovation center is a very special, unique place to do that innovative work. And it becomes the path towards making pieces of these models and then eventually these models permanent through developing the models and even through Congress adopting models eventually.

SPEAKER_01 6:05

I so relate to starting as a therapist and just having this feeling of like, oh, this isn't sustainable. I think part of some of what I am doing is going to get replaced. Like at the time I was picturing it being digitized. As I learn more about therapy, uh, that future makes me uh, I want to say more nervous. Like the like the more I get into therapy, the more I appreciate what happens in the one-to-one person interaction. So even though I believe something needs to change, it's still hard to think about taking the step of learning about the payment models that are out there that CMS, the um Center for Innovation, is putting out. Like they feel far away, they feel obscure, they feel like stuff for people in boardrooms or, like you said, lawmakers. Like they, it's so hard to relate them to our day-to-day as therapists. Um, why do we need to get into those weeds? Why do we need to care about these faraway things that CMS is doing?

SPEAKER_00 7:17

So, first, I the one thing I would challenge is that this, you know, one-on-one care that we we know is so valuable, we don't have that today. That that's not it, is it's the hamster wheel of volume. And that is the result of there being very few billable codes that really capture the work, the actual work, the interaction, and the eventual output of the therapist patient experience and what those actual visits and um you know are like in any setting, frankly. So, you know, healthcare is being tested through these models because the idea is we are we need to change how healthcare is delivered. But healthcare is really complicated because it's built around strict statutory and regulatory limitations. And so, right, that that means that Congress passed laws. Laws are very hard to modify and change, especially for programs that are among the most popular, like Medicare and Medic and Medicaid. And so to get Congress to make changes very difficult. And the regulatory side also has its limitations because, as let's say, the Center for Medicare and Medicaid Services puts out regulations, it's only within their ability to work within statute that Congress created. So, what CMMI actually has is under section, this is a little technical, but it's 1115A, 1115A of the Social Security Act, Congress granted the Innovation Center the power to waive specific requirements of Medicare and Medicaid. And this allows them to test these innovative payment and service delivery models without being restricted to those really rigid laws that are created by Congress. And so some things can be waived and some things can't. So things that CMMI allows to be waived or allowed to be waived are things like provider reimbursement. So how they're paid, how much they're paid, program benefits. So things like beneficiary cost sharing to incentivize better health outcomes can be put into models. And then scope of services. So allowing different types of providers to provide care in different ways. And but there's other things that can't be waived. So they don't have this limitless authority. The boundaries are being pushed, I think, and they could always be questioned by Congress, who has the authority to have oversight over the innovation center. But there are certain things that they can't do. So they can't waive antitrust statutes or fraud and abuse laws unless there's also safe harbor put into place, which sometimes there are. They can't waive civil rights laws, and then they have budget guardrails. So these models have to either reduce spending while maintaining quality, or they have to improve quality while in without increasing spending. And then if they can in uh not, if they don't increase net spending, they can then be further deployed to either make them become a larger model or a mandatory model or eventually a permanent model. And that's the direction that we're likely to see models go in the future, either made permanent as they get better and better at the versions of these models, and or they will become blueprints for then Congress to be able to develop uh a change with the expertise that CMMI has used, the policy experts at the Innovation Center, before a new law is put together by Congress.

SPEAKER_01 10:54

I have a big picture question I'm going to get to, but let me just uh restate what you said and ask some clarifying questions. So there's this big Center for Medicare and Medicaid, which we're all used to interacting on some level with Medicare. And then there's this little branch off of it called the Center, their Center for Innovation, C M M I, the Center for Medicare and Medicaid intervention. Innovation. Yeah. It's a mouthful. Innovation. Yes, innovation. And they get to pilot new models, new payments. It's a way to get things, I guess, tested more quickly than what lawmakers can do through Congress. So it's a great place. If we're going to direct our effort to understanding the future, we can zoom into the Center for Innovation because that's where it's happening. Okay, so one of my logistical questions is how many models are they piloting at a time? And how long do they pilot something for? Is this something that changes with each administration? So we should not pay attention because it might change soon. How many are there? How long are how long do things get tested for?

SPEAKER_00 12:07

So that's a great question. The first thing to know is that you don't have the level of partisanship in the innovation center like you do in most other parts of government. So when a new administration comes in, if it's, let's say it's the other party and the prior administration is testing certain models, while you may have some tweaking around the edges, or if there's a model that is just started or hasn't started and is really not in the direction that this new administration wants to go in, that could be either shrunk or ended early. But for the vast majority of models, the new administration comes in and they may make some updates because they're they're allowed to do that, or they may, if it's a mandatory program, they will put that through the rulemaking cycle, like the transforming episode accountability model. They will they put that in the um the inpatient payment system rule, the hospital rule. So that goes through comment and then the public can make comments about what they think. But overall, and we've seen Abe Sutton and Liz Fowler, the present and the former head of CMMI, they've been on, I'm calling it the stump, but we've hear them speaking in public. They just put out an article this week in in New England Journal of Medicine. It was an interview, where they're they demonstrate a lot of solidarity that we need to do the kinds of testing that we are, and that there's an acceleration of some of this testing because of AI and technology being able to do some things that are harder to do with only humans. And we'll talk about that a little bit more when we get to access. Now, I didn't count the total number of models before, but there have been like a total of maybe 50 that have been tested or are presently being tested. And I believe there are maybe 12 that have put out and they're not done since this new administration. This administration is also testing, which we're not gonna cover, drug models. So this is the first time we're seeing prescription drug models multiple, the generous model and Medicaid. There's the guard and the guide model, more acronym soup, and really not much for us to follow there. But suffice it to say, yes, there are models of different kinds, which we're gonna talk about. And sometimes there's a lot, too many models to feel like we can wrap our head around them all, but we don't need to. And that's part of what we're gonna touch on.

SPEAKER_01 14:40

I already feel a little encouraged because when I think of looking to CMS or like thinking about trying to move our Congress, I'm like, that feels hopeless. So it's good to know that I can like zoom in on this Center for Innovation and look at what they're doing. But when I think of 50 models and the effort it would take to understand all the things they're doing, that feels overwhelming. I know that you've developed a framework for just kind of understanding the different models. Could you walk me through how I could just look high-level at different models and understand which ones I might want to dive into? Yes, I will absolutely be happy to do that.

SPEAKER_00 15:26

So, the way I would suggest thinking about payment models and how to evaluate payment models is look at the type by who is accountable for the model. So, who's holding accountability for the success of the model? So the first bucket would be the accountable care organization models. Um, we have one that's permanent in statute called the Medicare Shared Savings Program. It's permanent, it is updated every year, and it has a large percentage of uh mostly primary care providers participating, but a lot of health systems and hospitals as well. And then we have uh there have been, we're on generation four of the advanced accountable care organization. So those are models that are taking accountability for a full population of patients, but they are testing more flexibilities and they are allowing for up to 100% financial risk and reward on participants, allowing for a great degree of upside, but also a great risk of downside, which forces this is the key, and you get into more risk and reward, it forces care transformation. In other words, you can't make changes in how you provide care around the edges. You will not succeed. You must transform. And that means caring about proactive outreach, about preventing hospitalizations, you remove transactional care. So then we'll move on to the episodic and condition-specific models. So let's first touch on the acute episodes of care, then we'll do condition-specific. Acute episodes of care, there's a clinical event. So we've tested a bunch of models in this category. And that event, then the accountability is held by what we've seen as either the hospital or provider group specific physician groups. So we've had the bundle payment for care improvement, this the comprehensive care for joint replacement, uh, those different versions. Presently, we have the transforming episode accountability model, the risk and reward is on the hospital and the CJR X model. This is the mandatory, no end to the model. There's no end in sight, which means it can just be turned into law. It has proved it has met the bar over the years when it's been voluntary and when it was tested in small pockets mandatory. So this comprehensive care for joint replacement model on the hospital. So then, if we move on to the next, then we have models that are around a diagnosis. So the accountability in these models, like the guide dementia model or the kidney care choices model, the accountability is held. What we've seen so far is by a physician type or a group that's managing a specific condition that's not primary care. So, for example, people with end-stage renal disease, they very often are seeing their nephrologist all the time and maybe barely touching base with their PCP because their entire health of, you know, going to dialysis, everything is dependent on managing that ESRD. So the kidney model, nephrologists are at risk. In the on, there's an oncology model, the oncologists are at risk. In the guide model, a dementia team is at risk. The fourth and final one. So these are the only four bucketed types that I think physical and occupational therapists need to really be paying attention to, are the novel models. So this is brand new with this administration. Novel models are putting accountability on what I'm calling a novel participant with what they've put in as physician oversight. So, such as a technology tool or a digital health provider. So elevating tech to provider status with the oversight of a physician and testing the ability for technology, the word that they're using very often for one of the models' access is testing its ability to be deflationary. That means to actually reduce spending despite the growth trend that we're seeing. The other thing on the number of years, and then let me stop. Um, and the number of years of models has really changed. It started with the last administration and we're seeing it now again. So the one of the newest ACL models called the long uh long-term enhanced ACO design lead model is a 10-year model. The access model, which is the digital health, I'm framing as a digital health model, is a 10-year model as well. We are starting to see that because part of the reason is five years may not be enough time to demonstrate that high bar that's needed to make a model permanent or to give if Congress wants to write a bill around it, to give the evidence or to extend the model or test it in a mandatory way, because we just don't have enough evidence yet. And part of that, as everyone here knows, healthcare is really hard to change. It requires behavior change on the part of clinicians of all kinds, from hospitals to physicians to therapists to anyone participating. And we need to give that time. Last administration started to realize this the ahead model, don't even worry about it, state-based model. We saw that same thing, an eight-year model. The guide model was a biden model. That's either eight or nine or 10 years, also. So we are seeing this move to this 10-year model, and it's meaningful. The evaluations are tough. They're a difference in difference approach for you researchers out there. It's very hard to show that that high bar of success. So let me stop. Let me stop there.

SPEAKER_01 21:46

I already have a million questions. I think one of the things well, I'm hearing multiple things. One, it's so helpful to think about this framework for these models. Because it's just helping us understand value-based care overall. Like, here's the different ways you can conceive of value-based care and how we can look at uh trying to define value and how the payment could work for it. So it's just worth understanding it so we can understand value-based care. Something that I'm wondering about, which will segue into a question, I promise. Do you feel like most healthcare workers understand these models? Or because I feel like we probably hear this and we're like, what's going on? This is confusing. Does everyone else know? Or are we in a stage right now where lots of people are trying to wrap their head around this and we're just joining a group of people who are all trying to figure it out what this means for organizations? What's your impression there?

SPEAKER_00 22:55

So you have the early adopters and then the early majority. I would say for the for the if we look at the totality of clinicians across the country, some are not even in the early adoption stage. They haven't moved from, you know, putting their toes in the water. That being said, 50% of PCP practices, physician primary care practices are in the shared savings program. And another, I don't know, maybe another 10% are in the ACO reach program. The sun-setting full risk prime, it's not a primary care program, it's an ACO, a lot of primary care participates. So even for those who participate, I keep using primary care as a good example because they have a lot to gain in these models generally. And so they're some of the most heavy participants. In my experience, a lot of them don't know the details of the models. They have, you know, there are there are folks within the organization that have decided to take the innovation center as part of their and the models as part of their strategy. And so they establish goals and a budget around participating in these models once they they get analyses by usually data companies, they look for where they have opportunity. And then once that's decided by an organization, they'll bring it to the providers. Do all, let's say physicians, PCPs, do they all understand how the models work across the board? No. There are some that are curious and learn about it. So that is basically a call to action to the curious among you, know that it is no different for even those that are participating now. You know, typically they become interested or end up having to practice differently because it's come from leadership that this is a mandate, that this is part of their strategy, their business plan, and they have devoted a focus to some percentage on this because they understand the potential upside. Some of it is, you know, your early adopters truly believe that, and I agree with them, that this is an inevitable and you cannot afford to get left behind, partly because it is complicated and it is a multi-year effort to transform how you deliver care.

SPEAKER_01 25:20

That's really helpful to think about. If we can start learning about this now, we're going to be an early adopter in the therapy space, and we'll likely have um physician counterparts who are looking for therapists to talk to about this. The next thing I want to ask is just like quick wins for how we can be that early adopter. Like, what would you do, or what do you recommend to the curious of how we learn more? We're going to go into the depths into the models in a little bit, but I wanted to give us some quick wins midway through. I do want to add in some questions for the comments. I had a uh one of the questions was can we just like look up who's participating in these models? How do we know if my practice is eligible for one of these models? And can small practices be involved in these models or just large systems? Um, yeah, what are our quick wins uh for midway through this podcast? What can we do to feel good about ourselves? Like we're making progress in understanding this giant frontier.

SPEAKER_00 26:29

I I can first just answer that for any of the CMS models, the so the Center for CMMI is embedded in inside CMS for all intents and purposes, although they have their own budget. Those models post the participants every year as they some sometimes you have participants leave or added, depending on the model. So every year you can look up the participants. Now, there are some, you have to do a little digging to get really specific. So you will see when you look up, you know, if you go on that Medicare shared savings program landing page, you can navigate to the um the participant page and you can download the Excel spreadsheet and you can just look at the list. It'll tell you certain things about that participant. So things like how many years have they been participating, how many contracts in a row have they signed, what was their shared savings the last time or last year. They give you a lot of information. What they don't give you directly is who are the participants. So let's say the ACO is called XYZ ACO in Omaha, Nebraska. You will have to then do a little research, a little desktop research to figure out what is the composition of that accountable care organization. Some are very small. You need a minimum of 5,000 beneficiaries. That could be one physician practice. Um, it could be multiple, it could be a health system, right? And it you could have huge ACOs with full health systems and all the practices involved. So you do a little bit of that research. Same with the innovation center models. It depends how closely they name it to the name of the actual like uh provider themselves, makes it easier. Um, so go ahead. Let me stop and a follow-up to that, or should I go into yeah? No, that's great. Yeah.

SPEAKER_01 28:19

So you can look, you can just look them up. I think lots of them even have like maps. Like once you get to the place, it is pretty accessible. It just takes a little work to look up who's participating in what model. So I can do that. I can dial in on specific models, I can look up who's participating around me. What are some other quick wins I can do just to learn more and stay informed?

SPEAKER_00 28:44

So the the first, if you're just going to choose a couple of you know, quick wins that you can keep up with. The the primary source is going to be where the information is first deployed. So when I was first starting this, I wanted to, because I try to be an overachiever, I wanted to be the first to know about things, right? So that I could report back, analyze what I thought the opportunity was in a model. The only way to do that is to sign up for the listserv. So you go on the CMS Innovation Center website, you sign up for their general listserv, which will give you new announcements, for example. So if a new model comes out, you can't yet sign up for that new model. You, the innovation center is going to send out an announcement. They will also send things like an evaluation of model performance for a model that you're following or that you know you may be participating in or you're interested in. And you can start to get a feel for how what success looks like in models. And they honestly do a great job of making simple fact sheets, a visual. So even if you're a beginner in reading this stuff, they appreciate that. And I think they've gotten better and better over the years. So the CMS Innovation Center listserv, there's also, you know, things like the Innovation Insights dashboard, which you you can look up and if you wanted to check that out. And then CMS also does open door forums, which you would be made aware of if you're signing up to the listserves. I would also definitely suggest the Medicare Shared Savings Program, the biggest ACO by far, is a CMS program, not Innovation Center. So you want to go specifically to sign up for updates on MSSP, which is part of the physician fee schedule rule. I'll make one quick side note and go right back. I want everyone to hear this because it's super important in fee for service. The Abe Sutton, the director of the innovation center, keeps reminding the public that he is putting value-based care and fee for service through the advanced primary care management codes. This is a bundle of codes that rather than tracking minutes on things like care management and RPM and similar types of codes, you can just bill the once-a-month fee, right? So there's a specific code for each of the different bundles. And they keep adding to these bundles since they were started by, oh, by the way, the Biden administration. So this administration under Abe Sutton has been adding. And I suspect, don't know, I'm just taking a wild guess, that when we see the physician fee schedule come out, we're going to see the APCM codes be be added to made bigger. They want, they want practices providers to get experience in delivering a bucket of services without thinking about the volume that of minutes or units that they're documenting and seeing how that plays out over time. So getting Dak. So that's MSSP. And then I, if it was choosing one other place for you to subscribe, it would be Health Affairs, Forefront, and Health Affairs Insider. If you only want one, start with Forefront. They give very deep dive commentary, often even by policymakers that are in right now are going to publish through Health Affairs. It is that highly regarded. Um, they do, they do an amazing job, and researchers and others publish to Health Affairs to get messages and commentary out there. There's a host of other, you know, to Kaiser Family Foundation would be the other. Again, both of these nonpartisan. This is just giving information and summaries and some deep dives. And then the one other bucket, there's value-based care coalitions, if you're really interested in this, Accountable for Health, the National Association of ACOs, healthcare transformation task force, large coalitions of very varying different types of providers. And when I say providers, I use that term to mean it could be hospital, it could be home health, it could be physician practice, it could be occupational therapists. It is those who are on the journey and want to advocate for good policy around value-based care. They come together as a multidisciplinary team. And boy, do we need more therapy groups participating in these, in these types of organizations. And then, of course, APTA, AOTA, the updates that they put out might not be as in-depth or as comprehensive as you're going to get in other venues, but it's a good place to start for sure.

SPEAKER_01 33:35

I can totally attest to the value of signing up for these listservs. Like I hope everyone gets on CMM, CMS. You sign up for their mailing list, and there's then there's like 50 things you can follow, and you click CMMI, and you start getting like weekly emails, and you feel like the biggest insider because some of them just feel like personal emails from uh some of the leaders, and then you get nice reports and you really start to learn the language. I truly think that is like the lowest hanging fruit for all of us is just to be uh on a listserv, which we can all do that. It's very satisfying. You feel like you're in the club. So I hope everyone takes that action step. I want to circle back to this general framework and kind of the buckets of the models and talk through them just a little bit more, and then we'll circle back to more action steps for people. Um, but I want to start us start with ACOs. I think that's probably the most familiar term for people. I think give me again just a primer on an ACO and what the value of therapy might be in that model, what our pitch might be to an ACO.

SPEAKER_00 34:59

So an accountable care organization is a group of healthcare professionals that come together, they create an organization, the the accountable care organization, and they decide together that they are going to commit to taking steps to improve quality, and that is defined different ways, and reduce total cost of care. And I what I want to dive just a bit into is what is total cost of care? Because that term is used so easily as if everybody just understands what it is. Total cost of care means all of when it comes to Medicare, traditional Medicare, all parts A and B spending that an individual has over the course of a year. So in the case of a very complex patient, if you think about right, someone has COPD and heart failure, diabetes, your most complex patients oftentimes are what the ACO may do some focusing on because they want to try to get their help them get their conditions under control to prevent hospitalizations and that whole inpatient suite of time that is very costly and often leads to repeat cycles of that, right? So the other thing accountable care organizations, so these groups of providers will do is upstream outreach on the preventive side. So they will make sure, and it's part of the quality metrics, they will make sure that all of the members, those patients that are part of their practice, they're all getting their whatever the recommended schedule is for their preventive testing. So things like breast cancer screening and colon cancer screening, and they're getting their immunizations. They part of the quality measures in the Medicare program in ACOs are really around did you make sure this got done, which is a process measure. Um, and then they'll also look at, depending on the model, things that should improve in quality because you did some of these proactive quality things. So you kind of have this barbell approach. Accountable care organizations will work on the upstream, the outreach, making sure the those who have maybe some rising risk are getting in to see their providers. And then you have management of the most complex, the ones who use the most, you know, the 80-20 rule, 20% of patients use 80% of the resources. So if you are trying to manage total spend, you have to concentrate on some of the more frail and complex beneficiaries. The where we'll go more into this later, but where therapists can play a role is, you know, therapists' skill set and expertise is not well captured in most of the participants in accountable care organizations. So while they may focus on chronic care management of diseases, they don't have a lot of levers to pull to try to manage things like the ability to remain independent at home and the type of functional impairments that lead to decompensation and hospitalizations. They don't do a lot around musculoskeletal condition management. And what happens is those patients end up in specialty care and in advanced testing. So the value that therapists can bring is we are the more conservative and highly evidenced types of clinicians that can partner with these practices and these systems that are participating and help avoid some of that to use the word again, avoidable, some of that avoidable utilization by medical specialists and help to prevent the high cost acute conditions and our ability to build that therapeutic alliance with patients to help engage them in managing their care and improving their function. These are the values that um the value that therapists can bring that right now, I have not seen a whole lot of that of therapy groups participating directly in accountable care organizations.

SPEAKER_01 39:34

So uh I want to move on to the others too, but I want to linger on this one. So would this look like I'm in a hospital setting, my hospital is part of an accountable care organization as a therapy department, knowing that they're a part of an ACO. We now have new levers to go to leadership and talk about things like, oh, we would love to get more physician referrals earlier for back pain, for sleep. In the past, honestly, those conversations were hard because of the hospitals. Like, we make more money when they go to our surgery department. Like they are we're not listening to therapists. Uh, we did not have like a voice, but being in this ACO, if we understand it, means that you're more likely to be listened to. Is that true?

SPEAKER_00 40:31

It is with a caveat. And you're just gonna get the realistic perspective from someone who's done this on the ground and then has been working on this ever since. The level of engagement of the hospital and the health system is going to depend on how well integrated they are with the ACO and how much of their whole health systems business is dependent on the value-based care portion. So, where there are levers to pull in the hospital that are not going to directly impact the fee for service side of the hospital in an obvious way, that's where we have the ease, and it's important to know that because it's reality of business. That's where you have the chance to step up and kind of learn these levers and approach leadership with these opportunities. So you made some great call-outs. Things like under getting more in-depth with patients about the amount of help they have at home that may have been lacking before, and making sure when that patient is transitioned out of the hospital, let's say they're going to home, that the patient and their care partners, their loved ones, understand the importance of, let's say it is they need more help than they have right now, ensuring that you have educated them about why. It is things like making sure the transition to whatever side of care has the perspective of the therapist, which is not always well captured right now, to that handoff is becoming more and more important, let's say between hospital and let's say skilled nursing facility, when therapists, as part of that transfer document, can share how that patient has progressed and what you, as the therapist, see as their therapy prognosis and what your plans would be if you were managing that patient. That is valuable information that is becoming more and more important and prioritized, especially when other parts of the system are engaged in the program. It also means things like a patient who's being discharged home without home health. You know that they need follow-up, let's say with occupational therapy to address an ADL issue. And maybe there isn't a skilled nursing need, but you know that that patient will have a better outcome. And you think about total cost of care, if their, let's say their ADL impairments are addressed through occupational therapy under, let's say, Med be in the home or to an outpatient occupational therapy clinic. And then, you know, where you can kind of track the activities that you can do these things, most of them, without usually even asking permission, right? You're just adding to the quality of the transition for the patient. Also making sure patients have an appointment with their primary care physician in the ACO. That ACO needs to get back to tracking that patient. And if you can provide a handoff, you can't imagine how valuable and helpful that is. So that the team that's been helping this patient can jump back in. So great call out. And um, I hope that helps give a little bit of a picture to this.

SPEAKER_01 43:56

Yeah, we really have to get into the details of understanding. How our organization is functioning. The flow of the money honestly feels like the big lever. Someone in the comments asked, How do we show or advocate for our value? My gut answer to that is money. That's how I've seen uh OTs and PTs get on maternity wards, which is the most like emotional, like that's so emotional to me needing that. But at the bot, at the end of the day, their argument came down to money. Like we are going to save money to this hospital system by providing therapy after uh delivery. Uh is that your gut reaction? Is we need to understand the money of it.

SPEAKER_00 44:40

You do. And so something like hospital mobility, which the first reaction is mobility therapy. A lot of times it takes the therapy department to embrace and try to elevate. So it usually takes leadership in the therapy department to understand the opportunity. So quickly, if a hospital mobility program is in place and patients who come in, let's say that are ambulatory, if they're just kept on bad rest, the chances are they're going to get worse in their function and they're going to need ongoing care they wouldn't have needed if they were mobilized. That where there are some really rich, wonderfully executed mobility programs across the country. While they may be designed and um and built out with therapy as a large part of that team of the development of the program, a lot of times it's it's mobilizing via a nurse's aide. It could be a physical or occupational therapy aide that's doing some of that mobilization, advocating for the skill that therapists have and where they're consulting clinicians versus just the checking the box of we had the therapist come in, knowing the difference and how where you can make an impact by understanding what recovery looks like for a certain patient. Working in a hospital setting, it can't, you can feel like you're in a silo. But as you think about where was this patient really before, what has happened to them, you can start to piece together what is the future going to potentially look like from a rehab and a and a movement and independence prognosis standpoint. That is a way to better deploy resources that also lines up perfectly with accountable care organization goals, which are not to have to discharge to other inpatient settings. They want to get patients home as often as they possibly can when it's appropriate. So I'm glad we deep we dove into that a bit. Yes, yes. Very specific, tangible example.

SPEAKER_01 46:47

Yeah. Uh that's ACOs. That's probably the biggest bucket. I want to move really quickly through the next two buckets. And I want to give out a shout out to the blog post that you put together where we have all these models in this really nice table uh for people to explore. And hopefully it helps you like quickly find which models you might be interested in diving deeper into. In one of the columns, I'm going to say out loud, I want to add a link like directly to where you can see the participants in those models just to shortcut people through that information. But let's just spend two minutes. I know that's not enough time talking about two of the buckets, about the episodes of care and space condition-specific models and what therapists need to know about those and the value we we might bring to them.

SPEAKER_00 47:39

So those two buckets are episodes of care and condition-specific models. The episodes of care, again, important takeaway in terms of what we've tested so far. Episodes have been acute episodes. So something that's an event, and something new that is either hospital or hospital outpatient department based, that then triggers accountability for what happens after the hospitalization through a time period, 30 or 90 days is what we have seen. There are therapy is crucial in making sure that that patient who's in the hospital is set up for the best, most efficient, and good outcome over the course of that time period. Understanding that if more money is spent than anticipated by the model for an episode, the hospital itself, when it comes to the transforming episode accountability model, is at risk. So additional spending more than predicted means the hospital has to pay CMS back. They do not want to have to do that. And therapy helps establish a mobilization program in the hospital, and they are key in determining the most appropriate next site of care, understanding that patient's total picture and condition. And then on the condition-specific side, that's where we're talking about models like oncology models, kidney models, the dementia model. And if you keep in mind that the role of therapists is often to plug in where there's really gaps in managing a patient's success in life, for lack of a better word. So for a dementia patient who is struggling to remain home, challenges with caregivers, and being able to keep that home environment right for them, therapists are the ideal participant in that care team to help ensure that that patient can remain home as long as possible. Once they're in an inpatient site of care permanently, they're no longer in the model. On the oncology care side, it can be really hard for oncology patients to remain well enough to stay home and to keep their function up. So the role of the therapist, if you imagine, in that scenario to help prevent the functional decline of patients that leads to complications and they end up hospitalized. So I don't want to take up too much time. So we have time for QA.

SPEAKER_01 50:16

Yeah, that's perfect. I can see people looking at those models and diving deeper based on their own uh therapy expertise. Like some of our expertise might just lend itself, like dementia or um falls uh to understanding those different models. I also want to spend just two minutes on, which is not enough time, on the novel models that are out there, which the ones you've said so far I can wrap my mind around. And then novel models, I have to stretch a little bit farther. Can you explain them to me in two minutes?

SPEAKER_00 50:51

So yep. Okay. The why there's two essentially the wiser model, wasteful and end up in wasteful and inappropriate spending reduction. Essentially, it's prior authorization for surgical interventions that are often done rather than conservative treatment. So we should be embracing this. It's adding a little bit more prior auth for a finite, I think it's 17 sets of surgical conditions that we know are done on this wide, variable lens without good out necessarily any better, sometimes worse outcomes. It's having some challenges in Congress right now because of overlapping with prior authorization conversations in MA. So we'll leave it at that. But in that case, the tech company is doing the prior auth first with AI, if they are going to approve it. And if they don't approve it, then it goes to a clinician of the same type who does the review to decide whether or not to approve it. Going on to the access model, again, the tech, it's not specifically calling out tech, but there's no other way to make the numbers work than if a digital health company essentially participates. And this the access model is reimbursing for ongoing engagements with a patient. Patients can go to access organizations directly without any referrals and without a copay. It looks like they're going to waive all the co-pays. There, you can have any Medicare patient interacting on a daily basis with these tech tools. The idea is to not replace medical care, but to help patients stay engaged in managing chronic conditions. It is meant to replace things like RPM, RTM, and some other things that we don't necessarily love as therapists. It's supposed to be deflationary. So by ongoing engagement with a patient over the course of time, one to two years, they are making a big bet that it's going to change the trajectory of chronic care management. It's a big bet, and we have to see what happens on it. So I hope I got it in there.

SPEAKER_01 53:06

That's perfect and just by itself tells me why it's so important to be paying attention to these models because there's things that could be truly transformational or could fail, and we have to be uh tracking how they're going. I want to hear from you. If you were back early in your career, you're listening to this webinar, you're a practicing therapist. What do you do with this information? Um, I want to say I know there are PTs who are interfacing with ACOs. Uh, we know an OT in North Dakota who's interfacing with one of these models. I'm going to try to have, I'm going to challenge myself to have therapists from each of these four models like buckets on the podcast so I can hear what they did and we can hear real life stories. But in our hypothetical world where you're a practicing therapist right now hearing this webinar, what would you do?

SPEAKER_00 54:08

So, first, driving home the point, there are various forces at play, new insurgents in healthcare that are going to come in and try to disrupt with let's see how successful they are at we quote incumbents is the term you may hear thrown around, the way we've always done things. They look at things from different lenses. So, again, imploring on you to think about how could I disrupt myself? How could my organization disrupt itself? And how might an outside entity that is not baked in the way we do things, how might they come up with ways to disrupt us? So, for every clinician, no matter what your role, I encourage you to learn the vocabulary. Learn what the acronyms and the major models that we cover today, learn what they mean. Learn how a patient becomes attributed to a model. How does a patient end up in a model? How do benchmarks work? So, how does the money work? How is money shared? How do you become successful? Um, and then, you know, find out what models your employer potentially or you may be touching right now because of your geography. So we talked about before those interactive maps. You can go in your in your location and see the models that are active. And that knowing the types of participants, you can figure out who's participating. Be the first to know who signs agreements to join the lead model, the long-term enhanced ACO design model. It's intended to bring in some brand new providers and giving them some upfront funding and support and a bit better benchmark financial term that means it makes it a little easier for them to be successful. And volunteer for work that drives model performance, even if you are not actively engaged in the model at all. So things like, you know, falls, fall screenings, like thinking about what might prevent a readmission, doing really strong discharge planning, or I like to say transition planning, um, you know, functional outcome collection, those types of things. And if you're in a setting that's actively participating or leadership is interested in becoming involved, if let's say it's your health system, get involved. Don't expect to get anything from it as a staff member first, but you I did it for years before I was able to, I don't want to exaggerate, but a number several years before I benefited in my career, you have to put the work in up front and then go sign up for those alerts. And if you're a manager or a director or you're a leader, try to think about what is the internal data story you could tell that shows how your organization or your entity or your um your team, how do they contribute to avoiding high cost care, either on the more prevention side or the preventing readmission side, or helping patients manage their chronic conditions. Maybe it's outreaching to the PCP if you're an outpatient because they're in an ACO and you're going to share your perspectives on that patient. And then, you know, if I'm a manager or director, I would begin to think about learning what a preferred provider is in these models and how might you suggest or who might you reach out to to begin the conversation about becoming a preferred provider, which can be a contractual agreement with financial upside, depending on how you structure it. And then even if participants aren't quite ready for you, you're starting to plant seeds. And then for owners and for the profession writ large, you know, we really need to be thinking about pursuing contracting and models, um, making sure the profession sees these opportunities while networks are forming, things like post-acute networks. In uh in the ACO lead model that's coming up in January. There are episodes, fall risk episodes are the first type of chronic care episodes ever being embedded into an ACL model. And it calls out PTs, OTs, nurses as members of the team for this longitudinal chronic care episode of false prevention. And they also have the same preferred provider relationships. And then when you see RFIs request for information, where CMMI wants the public, wants participants or providers to give feedback about model ideas or questions, respond to them. There is no wrong answer. Even if you were to bring an idea to your um to your supervisor, for example, about how you might want to respond and why it might be good for your company. So again, looking, you know, who's attributed potentially to the ACOs around you, knowing if your hospital is in the team model, knowing if there's a post-acute care strategy for those hospitalized patients. Um, are you tracking functional outcomes? Think about that. And definitely learn about this upcoming lead model, the MSSP model, the team model, and and the ones that we highlight in the blog, in that table that Sarah pointed out, really important to check those out from my from where I sit.

SPEAKER_01 59:41

There's so much to learn. It honestly feels exciting to me. It also, I have this sense of wow, back in the day, both of you and I stepped into therapy and we're like, oh, this isn't sustainable. Something needs to change. Part of that was high-value therapy isn't being delivered a lot of the time. We're in these therapy mills, this hamster wheel. And the reality is that is getting disrupted. It will not exist in the future. And we right now are in this window of opportunity where either we can disrupt ourselves, we can come up with what a better version looks like, or someone who does not understand patient care, does not understand the therapy process, is going to come in and try to disrupt us. And there are a lot of the players like that out there. So my takeaway is we're at a window of opportunity, and um it's a really important time to reimagine what therapy can be. What's your takeaway from this conversation?

SPEAKER_00 1:00:48

I mean, I, you know, I love the quote: what you want is on the other side of fear. And by fear, I really mean change. Change is hard. And for those of us practicing for decades, man, it's hard to imagine our day-to-day looking different. But if you think about what you wish was better and what the possibilities are, it can be really exciting. Once you start to learn about the models that are out there and the ways you can show your value, you will build momentum and get more and more excited about it. And the thing about enthusiasm and passion about things is it's infectious. I really use the passionate and enthusiastic attitude to drive interest in my own organizations before I was in the policy space for a full-time job. All of those years of working to drive through passion, it creates momentum with those around you. And there are folks like you that are in this audience that are like that and just embrace that. Take the first step, search for free webinars and YouTube videos, read blogs, and and just start to just start to learn a little at a time. And you will not regret it when you think back about hearing this and the things you learn at first.

SPEAKER_01 1:02:04

It's so fun to think about being curious, you using our passion and just closing our eyes and imagining what's possible. And Dana, you just inspire us to do those three things. And you provide so much information during this conversation. We also have this blog post called How OTs and PTs Can Win in Value-Based Care that will outline a lot of this for people to dig deeper. I just want to thank you though for walking us through the information and most importantly for inspiring us. Thank you so much for the time today.

SPEAKER_00 1:02:36

I'm so grateful to share my excitement and knowledge with your um audience, Sarah. It's always a pleasure.

SPEAKER_01 1:02:46

Thank you for joining us on the OT Potential podcast. To earn one hour of AOTA approved continuing education for your time today, you will need to sign in or sign up at OTpotential.com. Once you're in the OT Potential Club, you will find a five-questioned post-course quiz connected to this episode. When you pass the quiz with a score of 75% or higher, you will be able to download a PDF certificate that certifies your completion of this course. Okay, I want to thank you for joining us today, and we'll see you next time.