Outpatient rehabilitation network affects value, bottom line

Providing quality health care while watching the bottom line is the eternal balancing act for managed care organizations. Outpatient rehabilitation - an often-neglected area - stands to significantly impact quality and the bottom line.

Outpatient physical therapy is a critical part of treatment for the costliest illnesses - heart disease, stroke and cancer. Rehabilitation therapists not only help prevent accidents that lead to costly inpatient stays and surgeries, they also improve chronic conditions, such as arthritis, back pain and osteoporosis that affect mobility and workplace productivity.

Defining quality in rehab services

In addition to demonstrating that its providers give effective and efficient treatment, a network must have quality control and use review mechanisms in place to ensure that treatment matches the patient's needs and produces the desired outcomes. Quality also includes other areas of the network, such as ease of access to treatment for patients and favorable contracted rates and reimbursement structure for payers.

To ensure that your rehabilitation services are delivering optimum value and quality, consider the following questions:

Do providers participate in an outcomes program?

With the emergence of outcomes programs for rehabilitation therapy, health plan executives can get objective evidence of improvement in a patient's function and can compare providers' performance against national benchmarks.

However, not all outcomes programs are created equal. When evaluating outcomes programs, look for the following:

1) Objectivity. Consider an outside organization as opposed to a rehab network to ensure true objectivity.

2) Scientific validation. The program should be based on extensive research and a large database of outpatient rehab practices.

3) Focus on improvement as well as use. Measuring use of services is important, but a program must also assess the level of improvement for patients, as well as the efficiency of care and value of services given by providers.

The patient satisfaction survey is another tool for payers to evaluate providers. Rehab networks that regularly collect satisfaction surveys from patients across the country are able to quantify the quality and integrity of their providers for payers.

Is broad geographic coverage available?

Rehabilitation services should offer broad geographic coverage for patients to easily locate therapists near work or homes via a toll-free number or network website.

Services should include physical therapy, occupational therapy, speech/language therapy, hand therapy, and pediatric therapy as well as therapists who specialize in areas such as workers' compensation injuries, ergonomic assessment, and geriatrics.

Are contracted rates and reimbursement structure aligned with your goals?

A network must be able to offer affordable rehab services with reimbursement options including negotiated fee-for-service, case rates and capitation to meet the needs of the individual health plan. For capitated programs, case management should be provided by experienced rehabilitation therapists to ensure that patients receive appropriate, medically necessary outpatient treatment. Special software for managing capitated contracts is helpful to verify patient eligibility, benefits and co-payments, and to process claims.

Are providers held to high practice standards?

Therapists should meet strict membership criteria and stringent credentialing requirements, ideally exceeding state licensing requirements and surpassing those required by accrediting bodies such as the National Commission for Quality Assurance (NCQA) for physicians in managed care plans.

Providers should have all relevant licenses, Medicare certification, and continuing education requirements. The network should also enforce strict ratios of clinical support staff to therapists: no more than a 2:1 ratio of aides and assistants to licensed therapists for patient-related tasks.

Who handles provider credentialing?

If the rehab network handles the credentialing process of its therapists, payers avoid the high costs of this process. The network should perform on-site inspections to guarantee that professional standards for documentation, equipment, safety, efficiency and staff courtesy comply with guidelines.