Shepherd Center Readies as the Affordable Care Act Rolls Out

This year, the top priority for Shepherd Center’s President and CEO, Gary Ulicny, Ph.D., will be determining the ultimate form and impact of health care reform on Shepherd Center, its patients and rehabilitation medicine in general.

Q: Let’s start with the good news. What positives might come from this legislation?

A: There are some good things for our patients. First, insurers will no longer be able to deny coverage to someone based on a pre-existing condition. Second, there won’t be lifetime limits on health benefits. For people recovering from something like spinal cord injury (SCI), this is a big deal. In some cases, there are million dollar lifetime caps imposed, and it’s not unusual for people with high-level quadriplegia to use close to half of that on their acute care only. Then they have a lifetime of health needs to contend with. So the ability to keep your insurance and the portability of that, those changes are very positive.

Q: What are some of the challenges or unknowns?

A: The problem with the Affordable Care Act is that it’s not really health care reform; it is about finding ways to provide insurance coverage to more people. Traditionally, insurance carriers try to reduce or minimize their losses by weeding out people who would be high-cost patients. The inability to do this could create some much higher costs.

Although there are a number of alternatives out there, including expansion of Medicaid and the creation of insurance exchanges run by the state or the federal government, these programs may not really provide greater access. For example, they might have a $1,500 limit on durable medical equipment, which won’t even come close to paying for a $15,000 to $18,000 power wheelchair. The lowest-cost health insurance exchange will only pay 60 percent of medical costs. Yet someone’s bill at Shepherd Center could easily total $100,000. What are we going to do? Chase this family that has just gone through a catastrophic injury to get them to pay us $40,000? That’s just crazy, and unfortunately, we may not be able to admit some of those people into our rehabilitation program.

So it goes back to what’s going to be covered. Will the focus be on high-quality care?

Q: In what other ways might the legislation impact Shepherd Center?

A: Depending upon how it is implemented, it could have major effects on how we operate. The biggest change is the move away from fee-for-service reimbursement to value-based purchasing, and we embrace that approach. The issue for us will be whether value-based purchasing – which will more than likely take the form of bundled payments – will be adequate to fully rehabilitate someone with a catastrophic injury. These payments are often based on data from rehabilitation programs caring for 60- to 70-year-old people with a spinal cord injury for an average 18-day stay versus our unique, considerably younger patient population, many of whom are often here for more like 40 days on average.

So, as a specialty hospital that treats a very small minority of acute-care hospital patients, we must figure out how we fit into the overall system and the impact we will experience from the creation of accountable care organizations. How do we improve our value to large and small health care systems so they will include us in their continuum of care?

Q: What is Shepherd Center doing to address these challenges?

A: As always, our focus is on providing the best possible care we can and making sure folks are covered. I have been in Washington, D.C., several times and convened a group of 20 different professional associations, including physical and occupational therapists, and we developed guidelines for essential benefits.

The reality is it’s a bit of a moving target. We are doing everything we can to ensure our programs and services will be covered at an adequate rate. Our strategy is to provide the best possible care we can for the best possible price. We’re working to become more efficient – not by cutting care, but by identifying which care seems to be working the best and doing more of that. So you can look at a patient fee structure in two ways:  You can cut a bunch of costs or identify evidence-based practices that show if you do this, you’re going to get a better outcome. The latter is really our strategy.

The electronic medical record system we are implementing this year will help by allowing us to link the cost of care with outcomes to see what practices really work and in which type of patients.

Q: What, if anything, do you think patients can do in anticipation of these changes?

A: Get involved and be informed.

I saw a bumper sticker that other day that said, “I love ObamaCare.” I thought, “Well that’s great, but no one knows really what ObamaCare is.” House Minority Leader Nancy Pelosi said first we have to pass this bill, and then we’ll see what’s in it, so the majority of people have no idea what it will mean. If you ask the average person on the street, “Do you know that you’re going to be able to buy insurance in this exchange, but you’re going to be responsible for 40 percent of the bill?”, they likely don’t. But they need to educate themselves about what’s out there. There are some good things in this bill, and then there are some things that we just have no idea what the effect will be.