Patient reported outcome measures began as a way to measure change in research studies. Measures are now included in the majority of clinical care. Value is gained from using these measures if the components within the measurement tool are truly relevant to the patient. These measures provide a glimpse into a patient's perception of her current situation.
In January of 2013, Centers for Medicare and Medicaid services began requiring clinicians providing therapy services to report on outcomes via functional limitation reporting and severity code modifiers. Five years ago the majority of the rehabilitation industry scrambled to understand patient reported outcome measures and how to determine functional limitations.
What has happened in the last 5 years?
From 5 years ago to today: what's the trend?
I'd like to think about trends within a framework of who is using outcomes management data. What has changed within five areas: payer, organization, clinician, mentorship and patient sectors?
Centers for Medicare and Medicaid Services moved from functional limitation and severity code modifiers to actually requiring the reporting of functional outcome measures. Physical therapists became eligible clinicians for reporting all patient outcomes via the Merit-Based Incentive Payment System (MIPS). If participating in the program, all patient outcomes are required to be reported. For physical therapists, the measures listed in the final rule included measures created by Focus On Therapeutic Outcomes. Incentives will actually begin to be related to the final outcomes achieved. Another aspect within MIPS included a defined completion rate. A research study analyzing 2014 indicated that less than 50% of patients did not have interim or discharge data. MIPS requires a level of 60% completeness in outcomes data. The federal payer trend moved from sticking its toes into the water to requiring full participation for eligible clinicians who exceed low threshold requirements.I believe the trend will probably lead to bundled payment for commonly treated conditions with an expectation of the final outcome. Via MIPS the payer now has defined results of care compared to predicted outcomes along with the cost of that care. This data may jump start bundled payments for rehabilitative services. If this were to happen, hopefully the payer would be able to categorize subscribers as very healthy, average health, and poor health so that the subscribers are adequately tiered for the bundled payment.
Performance Defined Bundled Payments
Every state has multiple payers. I am unable to share trends outside of the federal payment system due to the inability to clearly substantiate an actual trend. I can speak about the largest private payer in Michigan: Blue Cross Blue Shield (BCBSM). If I recall, BCBSM contracted Landmark in 2008 to categorize physical therapists based on their outcomes. The program continues today with eviCore at the helm in determining utilization categorization of physical therapists. To this date, utilization categorization separates physical therapists who practice in a private practice from those in a hospital setting. Although the program suggests "outcomes," the process discludes the final result of care. The primary components involved in determining clinician categorization include number of visits and cost of care. Although the utilization categorization includes a risk adjustment process, the defining variables seem to be gender, age and a loose categorization of the type of care and body part. Due to lack of transparency, the risk adjustment factors and impact remain private. None of the patient factors that actually affect clinical outcomes play a role in the process. The reconsideration process for utilization category ignores the cost of care provided and downstream savings. The whole program places attention on the number of visits provided to the patient. The goal of the program focuses on elimination of physical therapists who provide the worst outcomes (based on number of visits). BCBSM desires the program to be expanded to require prior authorization prior to providing any treatments to all BCBSM subscribers.
The trend occurring in Michigan with BCBSM indicates less and less visits are being provided to subscribers. This will lead to minimal positive functional outcomes and an actual increase in cost because patients will hop to a new provider to attain desired gains. The disconnect in care that requires a new initial evaluation and new rehabilitation providers will increase the long term cost of care.
In the last five years, the outcomes management software industry growth requires organizations to delve into specific needs. The diversity in the available options affects decisions. All the products can track outcomes. Outcomes management has expanded to include far more than just tracking outcomes. Are time and efficiency for completing the assessments factors? Science progression now includes measures designed specifically for computer adaption testing. Will the organization choose to value legacy tools (measurements originally designed to be completed via paper and pencil) or computer adaptive testing? Is it more important for the organization to initially know the likelihood of failure to progress? Is it more important for the organization to know the average outcome for specific categories of patients? Does the organization desire a risk adjustment process with an immediate predicted outcome? Does the organization need an option with a Qualified Clinical Data Registry? Which has more value: a stand alone product or a product designed as an optional electronic medical record subscription?
Over the years, the trend indicates most products include a risk adjustment process. Because of this trend, in my opinion, it is no longer good enough to check a box that risk adjustment happens. Savvy organizations ask how much variance is explained through the risk adjustment process. In order for an apples to apples comparison to happen, the risk adjustment process takes into account differences. In healthcare it is very unlikely that 100% of variance will be explained. The current processes take into account patient factors related to health. The range of variance explained probably comprises a spectrum from 5-40%. In time our industry may learn the impact of social determinants of health on outcomes. If social determinants affect clinical outcomes, the risk adjustment process will incorporate new variables potentially tagged with zip codes. The last factor that may require attention in the future includes the clinician. Certain clinician factors may impact outcomes. Incorporating these factors into the risk adjustment process may improve the explanation of variance.
Demands for Explanation of Variance and Improved Risk Adjustment Process
The current outcomes management system software solely uses patient reported outcome measures. These assessments bring to light a patient's perspective. Although there is value in a patient's perspective, a perspective alone does not always tell the full story. The future of outcomes management will expand to include physical performance data. Patients are wearing devices that have the ability to inform about number of steps and physical activity. Researchers are figuring out ways to measure vibrations in the home via floor sensors to capture changes in gait and falls. Some wearable sensors include accelerometers and gyroscopes to provide specific information about speed and orientation. The future will merge the patient's perspective and data from wearable sensors or external devices capturing performance.
Incorporating Wearable Sensor Data into Outcomes Management
In the clinical world, historically "subjective" focused on the responses to clinical questions. Clinicians would evaluate the subjective and objective findings to determine a diagnosis. Consideration of the strength of the objective tests (sensitivity and specificity) influenced the clinicians' level of confidence with the diagnosis. Evidence based practice or evidence informed practice became a priority to ensure a high level of quality of care. When the payer sector required outcome measures, the clinical sector initially focused on meeting the requirement. In some cases, the trend resided at a low level of going through the motions to meet regulations. In other cases, those who realized future payments would be dependent upon results began including the patient reported outcome measures within the clinical picture. Patient reported outcome measures were viewed to be valid and just as relevant as the typical subjective and objective information.
The extra piece of data, patient perspective, allowed clinicians to create care plans that were more individualized than what subjective and objective information provided. The patient's perspective included details into how the patient was feeling about her current situation. Clinicians used the information to formulate communication strategies to minimize fear and anxiety, to determine frequency of treatment and to address specific activities that were problematic via graded exposure. Frequent reassessment gave insight into the patient's response shift either positively or negatively. Clinicians improved their decisions on when to end an episode of care because they were armed with outcomes data.
When clinicians began truly incorporating patient reported outcome measures into practice, clinicians learned that a significant portion of their value included managing a patient's perceptions.
Significant Value in Managing Patient Perspectives
The future for clinicians will include determining the appropriate frequency of in-person sessions. Because clinicians are now including the patient's perspective during the evaluation process and intermittently to assess response shifts, clinicians will have more options when providing care. Clinicians will consider the intensity of the required services. Clinicians will determine if a patient requires in-office visits or if an app and telerehabilitation will be sufficient to improve the patient's condition. More and more time will be spent analyzing data to insure the patient is progressing as would be expected. Data will include patient reported outcome measures, wearable sensor data, and performance based data.
Telerehabilitation and Data Analysis
Professional development remained important over the last five years. Gurus, charismatic individuals and clinicians with years of experience continued to play a role in the learning process. The overall focus revolved around techniques: what techniques and how to perform the specific intervention. Clinicians either traveled or subscribed for online courses. Learning experience were typically outsourced.
The future will rely heavily on performance based evidence: that of the individual clinician and that of the educator. Mentorship opportunities will more easily arise in-house. Two factors will improve the mentorship experience: outcomes data and the ability to self-reflect. A mentor armed with outcomes data and a mentee adequately self-reflecting will impact the individual's professional development. The learning and growing will become very specific.
Because data provides accurate insight into performance, the situation may also flip-flop. A mentee can absolutely be a mentor to another individual. The mentee has both strengths and weaknesses. In one situation, the clinician may be a mentee, yet in a different situation the mentor.
Performance Based Evidence for Mentorship
Over the last five years, the patient experience changed to include patient reported outcome measures and satisfaction surveys. Consultations and evaluations were not solely dependent upon in-person assessments. Patients were using their computer and mobile devices in preparation for in-office visits. Patient reported outcome measures tracked change.
The data from outcomes management systems touched communities. Patients had opportunities to choose providers based on data. Because of increased cost sharing in most health care plans, patients began shopping prior to initiating services. With the inclusion of outcomes data, patients could learn both the estimated cost of care along with the projected results from services.
Estimated Cost AND Expected Results of Care
Outcomes management has changed over the last five years. An impact occurred in all touch points: patient, payers and providers. The overall trend indicates more and more data driven decisions: clinically, educationally and financially.
Until next time,