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Money, Money, Money, Money

Posted By Barry J. Jacobs, Tuesday, January 3, 2012

Happy New Year and welcome to a once-in-a-decade opportunity to promote the growth of Medical Family Therapy. On January 1, new Medicare rules for hospital payments took effect and are a veritable game-changer.

In the past, if a 70-year-old man was admitted to a hospital with, say, a COPD exacerbation, he'd be pumped full of steroids and given breathing treatments for 3 days and then sent home; the hospital would be paid by Medicare for those 3 days of intensive care. If, once home, the guy started smoking heavily again and then suffered another COPD exacerbation a week later, he'd be readmitted to the hospital—jocularly called a "bounce-back”--and the hospital would again be paid by Medicare for another 3 days of care. The guy could keep going in and out of the hospital and the hospital could keep reaping the profits from its ultimately futile treatments for up to 100 days a year that the gentleman was hospitalized.

No longer. Under the new regulations, hospitals will not be paid by Medicare for patient re-admissions within 30 days of hospital discharge. That means the hospital will be paid for the first admission for our 70-year-old smoker but for none of the re-admissions thereafter if the guy bounces back too quickly. In other words, hospitals will have to eat the cost of the care it provides—the steroids, the breathing treatments, the food, the linens, etc.--during those bounce-backs. Medicare will no longer incentivize hospitals to provide inadequate care that doesn't keep patients out of hospitals.

This has spooked hospital administrators. Nearly every VP of Clinical Integration in the country is now scrambling to find ways to decrease hospital bounce-backs and thereby save their institutions money. They are looking at "care transitions”—i.e., how to make sure patients follow up with their primary care doctors, get the proper medications, and receive necessary home-based services. They are also turning their attention to something we know is obvious—the conditions in patients' home environments that affect their health.

Here's MedFT's golden opportunity. We have the know-how and techniques to understand the impact that patients' family members have, for example, on treatment compliance and to foster good health habits to keep patients ensconced at home.

For instance, please take a look at this presentation by Carol Levine, MA, a MacArthur Award-winning ethicist, director of the Families and Health Care Project of the United Hospital Fund of New York, and a major figure in the family caregiving movement (as well as a former CFHA conference plenary speaker)-- http://www.uhfnyc.org/publications/880807?tr=y&auid=10030107. The presentation, given during October 2011 at the National Health Policy Forum in Washington, DC, has a simple premise: If we better support all family caregivers in their work with chronically ill patients, then they will keep those patients from being re-hospitalied.

Then consider combining this approach with that of the "hot spotter” or "super-utilizer” emphasis propoundeded by Jeff Brenner, MD, a family physician and plenary speaker at the CFHA Philadelphia conference in 2011. Dr. Brenner has been highly successful using data to identify those patients within Camden, NJ who have the highest health cost expenditures and then lowering their hospital and emergency room usage by providing them with team-based primary care instead. For an eloquent description of Dr. Brenner's work, see this New Yorker magazine profile--http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande

At the Crozer-Keystone Health System in suburban Philadelphia where I work, we are now trying to decrease hospital bounce-backs by using a "super-utilizer” approach that focuses on family factors. For example, we identified a brittle diabetic man who was hospitalized 20 times in 12 months for diabetic complications, creating hospital bills in excess of $500,000. What simple method worked to decrease his rate of hospital re-admissions? We engaged the man's wife and convinced her to provide greater supervision for his diabetic regimen. To cite another example, a middle-aged, somaticizing woman who was frequently hospitalized for syncope ran up hospital and ER bills of over $700,000 over a 5-year period. What changed this pattern for her? We engaged her husband to help us convince the patient that her symptoms were more stress-related than neurologically based.

Money always talks. Under the new Medicare rules, hospitals will quickly get out of the revolving-door, bounce-back business. Working effectively with patients' families will be the key. We hold that key.

 

Barry J. Jacobs, Psy.D. is a clinical psychologist, family therapist and the author of the book, The Emotional Survival Guide for Caregivers—Looking After Yourself and Your Family While Helping an Aging Parent. He is the Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springrfield, PA and has had adjunct faculty positions with the Temple University School of Medicine, University of Pennsylvania School of Nursing and the Institute for Clinical Psychology of Widener University. He is on the board of directors of the Collaborative Family Healthcare Association. He lives with his wife and two children in Swarthmore, PA and maintains a website—www.emotionalsurvivalguide.com.

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Comments on this post...

Randall Reitz says...
Posted Tuesday, January 3, 2012
Barry,

I believe that this post hits at the heart of the future of collaborative care. Our field will only enter the sustainable mainstream of healthcare after we have moved away from paying for our services through fee-for-service. The strongest case we can make is that collaborative care enhances a healthcaresystem's ability to meet quality standards in a P4P, PCMH, or ACO environment. The changes in Medicare rules are a perfect example of this. Hospitals don't want to bill Medicare for our services (nor will they be very successful in their attempts to do so), however, they will be very motivated to support service lines that assist them in avoiding fees or lost revenues that Medicare will increasingly hold them accountable to.
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Jennifer Hodgson says...
Posted Tuesday, January 3, 2012
Barry ....I am not sure how healthcare got so far away from the context of the patient but we have and therefore we have lost our way. We need the chance to look at how patients heal and study the systemic factors to their health and wellbeing. Sadly, some of the physical consequences to living a hard life are really secondary to the pain and sadness at the surface. The family can be the exacerbator of stress and relief. The family can also be exhausted by the patient's unwillingness to change or lifetime of abusive behavior toward self and/or others. Working with families is messy and difficult to study but we need better instruments to measure change systemically. In the literature, families are often seen as risk factors to patient change and studied as such. If we can help hospitals to see that employing family therapists can help families to better manage the stress and challenge of a biopsychosocial (and spiritual) illness, we may see recividism rates decline. To do the studies we need the access. To get the access we need to be able to bill. To be able to bill we need to stop fighting one another at the gates of Congress. When it really becomes about the health of patients and families, and not politics, we will see change occur. Currently, licensed marriage and family therapists cannot bill Medicare. However, data by Russ Crane, PhD is showing family therapists have competitive data. We need Russ to write a blog!
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Jackie M. Williams Reade says...
Posted Wednesday, January 4, 2012
I agree with all of the above. I am excited about the changes proposed regarding increased home care and patient transition programs in order to comply to this new rule. I have already seen discussions about increased integrated care here at my institution in response. Obviously, our billing status is a major issue, but our involvement in communicating about a patient's psychosocial needs on an interdisciplinary team would greatly increase the success of patient transition from hospital to home which would reduce readmission.
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Rosalind M. Laraway says...
Posted Wednesday, January 4, 2012
I find it encouraging to be involved in the development of protocols and strategies to reduce hospital readmissions such as those described by Barry. As an MFT with 20 yrs experience in medical mental health in both ambulatory and inpatient care, from my vantage point it certainly seems like this development by Medicare in placing the impetus for prevention of rehospitalizations on the medical system is truly revolutionary. Further, the fact that a MFT is specifically invited to the table in terms of redesigning hospital care does indicate a growing understanding of the integration of mental health (inclusive of family systems) and medical care that is necessary for healing and improved/stabalized medical status. Money motivates, and this trend may prove to be a strong shift of focus for the better. I do hope so!
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Barry J. Jacobs says...
Posted Wednesday, January 4, 2012
Randall, Jennifer and Rosalind--Your comments are wonderful. I'm in full agreement with Jennifer that the health system did lose touch (probably due to past cost-saving measures) with the patient and family contexts of care. But it's also clear that the current efforts to cut healthcare costs are forcing hospitals and health systems to grapple with understanding patients within their home contexts as a way of decreasing re-hospitalizations. I tend to agree with Randall that giving MedFTs the capability to bill fee-for-service won't be necessary for health systems to recognize the financial benefit of having family experts on the care transition team. It will, as always, come down to the evidence that we generate. Can we prove that MedFTs will cut down on re-admission rates? If so, we have tremendous economic value. They'll be buying us up like hotcakes.
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Margaret K. Peterson says...
Posted Wednesday, January 4, 2012
Anything that helps support family caregivers is a good thing. I do worry, though, about possible down sides in promoting MedFT as a way for health systems to defend themselves against dysfunctional poor people and government policies that are more stick than carrot. Will there be a way to transition from this view and use of MedFT to one that sees MedFT (or other ways of conceptualizing and providing collaborative and integrative care) as an integral element of caring well for patients and families in general?
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Randall Reitz says...
Posted Wednesday, January 4, 2012
If I were from Philly I'd prefer that the healthcare system buy me up like a Tastykake.
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Barry J. Jacobs says...
Posted Thursday, January 5, 2012
A Butterscotch Krimpet Tastykake, more than likely. I agree with Margaret's point that MedFT should be valued as a healing art. But the cynic in me says that money will dictate whether or not health systems embrace family-centered care.
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Peter Y. Fifield says...
Posted Thursday, January 5, 2012
In my perfect world the BHS:PCP ration would be more like 5:1 than the current 1:5. I'll take a Little Debbie Zebra Cake please.
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Margaret K. Peterson says...
Posted Saturday, January 7, 2012
I'm not sure that's your inner cynic talking, Barry--probably more like your inner realist. My inner idealist is resonating with Peter's suggestion of a 5:1 BHS:PCP ratio...
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Barry J. Jacobs says...
Posted Saturday, January 7, 2012
I'm not sure I like that ratio either. I'm not of the belief that we need nearly that many behaviorists so much as we need mental health- and family-savvy healthcare professionals of all stripes. That means giving away what we know to others so that we all become more family-centered. And Little Debbie is a saccharine-y substitute for real Philly fare.
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