5
Improving Systems of Follow-Up Care: Perspectives on the Roles of Certification, Reimbursement, and Information Management Systems
The fifth session of the workshop explored potential mechanisms for expanding the scope, scale, and sustainability of traumatic brain injury (TBI) follow-up care programs, including the roles of center certification, financial
incentives, and technology platforms. These examples illustrate different types of enabling mechanisms: certification programs can help standardize elements of care and encourage institutional adoption of certification requirements; financial incentives influence how health care programs and systems navigate competing priorities; and technology and data management platforms can assist in data collection, integration, and learning to enhance care. Cross-cutting issues in enhancing learning health systems for TBI, including the roles of information integration and coverage for TBI care and rehabilitation, are areas of ongoing interest to the forum.
APPLYING LESSONS FROM STROKE CENTER CERTIFICATION TO TBI CARE
David Baker, executive vice president for Healthcare Quality Evaluation and Improvement, The Joint Commission, discussed the stroke certification program as a potential model for encouraging a more comprehensive TBI system of care. In 2005, the Brain Attack Coalition (BAC) published a consensus statement describing elements of stroke systems of care that included primary stroke centers, comprehensive stroke centers, and the essential structures and processes of these facilities (Alberts et al., 2005). Guided by BAC-defined criteria, stroke experts partnered with The Joint Commission and the American Heart Association to design a stroke certification. Initially, the certification featured two levels of care: primary and comprehensive. Once the certification program became established, emergency medical system providers nationwide used it in determining triage transportation decision rules, which in turn created a financial driver for hospitals to become certified. Given the lucrative nature of many stroke procedures, he noted, becoming a destination for ambulances transporting suspected stroke patients carried a financial incentive for hospitals. To date, over 1,600 hospitals have attained stroke center certification from The Joint Commission.
The certification system has evolved over time, Baker noted. As experts began to recognize the need for faster treatment, particularly in regions with long transport times, The Joint Commission created an additional stroke certification. The acute stroke-ready hospital certification applies to programs that are able to begin thrombolytic treatment and rapidly transport patients to a higher level of care, a process known colloquially as “drip and ship.” The thrombectomy-capable stroke center certification was created after evidence demonstrated that mechanical thrombectomy for strokes caused by large vessel occlusions dramatically improves outcomes. In addition, The Joint Commission developed a set of process and outcome measures to drive improvement and to prove that stroke centers—particularly comprehensive stroke centers—achieved improved
patient outcomes. Baker outlined numerous lessons learned from the stroke center certification development process that apply to TBI systems of care (see Box 5-1). These lessons may be helpful as the TBI community considers strategies to enhance care and follow-up after TBI, Baker concluded.
THE ROLE OF FINANCIAL INCENTIVES IN TBI FOLLOW-UP CARE
Seth Seabury, director of the Keck-Schaeffer Initiative for Population Health Policy and associate professor in the Department of Pharmaceutical and Health Economics, University of Southern California (USC), discussed how financial factors affect health care access and the role that financial incentives could play in increasing provision of, and access to, TBI followup care. A study from the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) consortium showed that nearly half of TBI patients with Glasgow Coma Scale (GCS) scores of 13–15—indicating a mild TBI—with significant postconcussive symptoms were not seen by a medical practitioner within the first 3 months of injury (Nelson et al., 2019). A person suffering from TBI symptoms might not receive care because of such issues as poor care coordination, lack of awareness of treatment options, techno-
logical hurdles, or insufficient financial incentives for programs that could provide follow-up care. Numerous examples demonstrate the influence of financial incentives on behavior in health care, Seabury said. For instance, research shows that patients are less likely to adhere to prescribed medication regimes when they face greater cost-sharing. Furthermore, Seabury noted, physicians are more likely to accept patients with generous insurance plans and providers direct more resources toward lucrative procedures and treatments. This tendency is evident in the relationship between increases in reimbursement for specific procedures and subsequent increases in frequency of performing those procedures. Given that financial incentives affect behavior throughout the health care system, understanding such incentives can aid in identifying potential solutions to increase rates of TBI follow-up care, he said.
Financial Status of TBI Populations
On average, the population of TBI survivors is poorer and has lower levels of health insurance coverage than the general population, said Seabury. People who have experienced a TBI are almost twice as likely to be uninsured (18 percent) than the general population (10 percent) (Seabury et al., 2018). Moreover, TBI survivors are less likely to have private insurance, with 56 percent having private coverage compared to 68 percent of the general population. Whereas 33 percent of Americans have an annual income greater than $50,000, only 26 percent of people with TBI attain income at that level. Seabury acknowledged that these statistics come from the TRACK-TBI study, which was not nationally representative and therefore may not reflect the lived experience of all TBI patients. Nonetheless, these statistics are reflective of much of the adult civilian nonsports population who have experienced TBI.
Seabury noted that the economic disadvantages faced by a significant portion of TBI patients can pose barriers to accessing follow-up care: both lower insurance rates and lower income decrease the likelihood of receiving appropriate care. Researchers explored these access barriers by randomly calling multiple ambulatory care clinics while posing as patients (Asplin et al., 2005). They told the clinics they had been recently discharged from the emergency department (ED) with instructions to receive follow-up care within 1 week. Each clinic was contacted twice by the same researcher, who would claim to have private insurance on one call and claim to have Medicaid or no insurance on the other. Calls placed by the same caller to the same clinic were more likely to result in an appointment within 1 week if the caller claimed to have private insurance versus Medicaid or no insurance. However, callers claiming to be uninsured but able to pay out of pocket in full for the appointment were just as likely to be scheduled for
an appointment as callers with private insurance. This indicates that the likelihood of receiving an appointment is associated with the ability to pay, rather than any contractual obligation with insurers, Seabury noted.
Creating Incentives for TBI Follow-Up Care
Barring the ability to increase the incomes of the TBI patient population, methods for financially incentivizing follow-up care for TBI within existing U.S. health systems could help address gaps, said Seabury. Such incentives often fall under the categories of “value-based care” or “pay-for-performance.” Such care involves financial incentives or disincentives targeting improvement of specific measures of provider performance or health care outcomes. For example, a hospital readmission penalty can serve as a disincentive. Using financial incentives and disincentives to improve rates of TBI follow-up care would entail data collection efforts, such as tracking the care that TBI patients receive and their outcomes. This data collection could be approached by creating quality metrics relevant to TBI follow-up care, such as the percentage of patients discharged from the ED that receive appropriate TBI educational materials, or the percentage of patients with a positive finding on a head computed tomography (CT) scan that receive care from a TBI specialist within 90 days. Currently 30–40 percent of mild TBI patients with a positive CT finding do not see a provider, Seabury noted (Seabury et al., 2018). Such metrics could be tied to financial bonuses or penalties for hospitals or health plans to drive desired behavior change.
Attention to implementation is key to ensuring that financial incentives result in intended changes, said Seabury. Pay-for-performance or value-based purchasing systems do not work effectively unless appropriately designed. Systems implementing financial incentives for quality care need to determine who will be penalized or rewarded based on the quality measures used and to consider in their designs the types of health equity considerations raised during prior sessions of the workshop. Furthermore, the value case and sustainability of existing services needs to be considered, as well as how to make value cases for the uptake of new innovations. Insurance or payer reimbursement is a significant consideration throughout the care system. Seabury pointed to the pharmaceutical industry as an example in which companies have made effective value arguments leading to coverage and reimbursement for drugs with expensive up-front prices.
THE ROLE OF TECHNOLOGY IN OPTIMIZING TBI FOLLOW-UP CARE
David Wright, founder and chief executive officer, Disruptive Innovations, discussed the use of technology platforms to improve the patient
experience and uptake of follow-up care. He used the example of an actual health system that contains over 400 practices, 14 hospitals, more than 9,000 physicians, 8 different electronic health record (EHR) platforms, and hundreds of software applications. The resulting operational inefficiency creates challenges regarding patient access, siloed care, data-driven decision making, care coordination, and quality of care. Technology platforms can help address such issues, supporting development of a health care system in which a patient’s record is not lost during transfers between specialties or practices and promoting better follow-up care, he said. The COVID-19 pandemic also created new demands on health systems and created an opportunity for increased innovation, including in enabling technology platforms. Although many health systems made efforts to use technology to better meet the demands of the pandemic, he said, many of these efforts involved automated patient interfaces that do not provide continuity throughout the patient experience life cycle. However, automation will only increase the use and effectiveness of follow-up care for TBI if it successfully engages patients.
Wright remarked that technology can be used to create a patient experience that features a consistent context across interactions, is personalized to a person’s needs and progress, and enables communication with a provider 24 hours a day, 7 days a week via the individual’s preferred mode of communication. He noted that Amazon, Walgreens, and other retailers are building patient experience spaces within the cloud environment, and customers will likely interact with such systems because they have been designed for ease of use. At the onset of the COVID-19 pandemic, Disruptive Innovations created a patient experience optimization module that considers the people, process, technology, and methodology surrounding the patient experience life cycle throughout the continuum of care, and this type of module has potential application to TBI care (see Box 5-2). Wright noted that cross-training and properly implementing knowledge management programs can also expand the ability of care coordinators to operate beyond one specialty.
DISCUSSION
Tolu Oyesanya, Duke University School of Nursing, moderated the discussion and posed an opening question on key strategies related to scalability, reimbursement, and innovation to improve TBI care and followup. Subsequent topics arose in response to comments and questions from participants.
Strategies for Improving TBI Follow-Up Care
In response to Oyesanya’s question, Baker highlighted the need for multiple strategies, including (1) data collection to establish that interventions are effective, (2) use of data and effective interventions to drive payer recognition, and (3) development of a certification program to enable value-based purchasing. Seabury emphasized that the creation of systems to collect data on a wide patient population would inform which patients require the most intervention after TBI and which interventions are most effective. Such data strengthen the case for payment reimbursement. Whereas
medical claims data are helpful for making such a case for other disease states, TBI claims data are extremely limited and are therefore insufficient for this purpose, he said. Furthermore, important information on TBI outcomes involves people’s functioning in areas that are not captured within the health care system, such as employment, education, and quality of life. Given that medical spending does not fully illustrate the ramifications of TBI, the creation of a broader data system that considers patient-reported outcomes and other aspects of recovery could be valuable in generating the evidence for improved TBI care. Wright remarked that segmentation between clinical operations and information technology is common, generating a lack of synergy between practice and data collection, and this is another challenge in creating enhanced data collection and analysis systems for addressing TBI.
Insurance Considerations in TBI Care
Flaura Winston, Children’s Hospital of Philadelphia, remarked that when a TBI is caused by a car crash, auto insurance is responsible for associated medical care payments, rather than health insurance. Given that car crashes are the second leading cause of TBI, this feature may diminish the visibility of TBI care within the health insurance industry. This payer aspect differentiates TBI from stroke, in that stroke is only characterized as a medical problem. Seabury acknowledged that auto insurance companies lack incentives to consider the long-term consequences of TBI, as the person injured in a car crash is often not the policy holder. This fuels interest in closing the claim as quickly as possible. He noted that workers’ compensation is another type of insurance responsible for TBI claims, and TRACK-TBI data indicate that 20 percent of TBI patients experience long-term employment consequences (Nelson et al., 2019). As a result, longer-term relationships are typically involved with workers’ compensation claimants. Physician involvement can also help to support a smooth return-to-work process for TBI survivors, including through provision of information and instructions for patients, their families, or employers addressing potential symptoms and accommodations relevant to this transition. Although many health insurance companies do not adopt a long-term perspective in addressing chronic disease, they tend to recognize the possibility of cost offsets, he said. Thus, the health insurance industry is more likely to consider the cost of a potential hospital readmission than are auto or casualty insurers.
Baker summarized that this issue can be framed in terms of the entities that stand to benefit the most from good patient outcomes. Employers may benefit most, but they are not necessarily directly paying for care. The risk of hospital readmission is lower for TBI than for some conditions, and this
lessens the motivation for health insurers to prioritize readmission rates via coverage for excellent care when less expensive options are available. Bundled payments are a method of increasing coverage for follow-up care, but are unlikely to be adequate. Using technology to enable data collection can maximize efficiency of care, he suggested.
Seabury remarked that some TBI outcomes carry expenses beyond acute care that are relevant to health plans. For instance, depression, substance abuse, and other potential associated conditions are costly. However, the medical billing codes for these conditions do not indicate the connection to a person’s TBI, and thus additional research is needed to identify such connections. Baker stated that this type of data would likely be effective in driving insurance coverage of improved TBI care. Oyesanya asked whether insurance billing codes currently allow for reimbursement of care management and transition services. Surendra Barshikar, University of Texas at Southwestern Medical Center, commented that charges are possible for tasks that are not face to face, such as extended phone calls or preparing letters, and insurance reimbursement varies for these types of charges.
Communication Approaches to Expanding TBI Follow-Up Care
In response to a question about coordination between physicians, researchers, and other stakeholders regarding clinical informatics, Wright replied that his company has historically collaborated primarily with chief information officers and chief technology officers of health care organizations. However, in recent years they have increased collaboration with chief medical officers and chief health information officers. These leaders are more active in decisions surrounding follow-up care and have greater medical expertise. In some cases, such officers are currently practicing medicine and therefore have a vested interest in ensuring a successful rollout of the health information technology.
Oyesanya asked Baker for strategies on communicating the importance of TBI follow-up care from his experience with the proliferation of comprehensive stroke centers. Baker emphasized the importance of communicating gaps in current TBI care and the effects these gaps have on outcomes. Communication efforts should target payers, such as state Medicaid programs, he suggested. Furthermore, public awareness efforts are needed to establish a shared understanding of the serious nature of TBI and its potential consequences.
Social Determinants of Health Considerations
Wright highlighted progress in leveraging artificial intelligence (AI)based communication to combat language barriers for individuals. How-
ever, such technology is in the early phases within the health care industry, he said. He is currently working on integrating AI with the EHR to maximize the capabilities of this communication technology. Noting advancements made in recent months in AI algorithms and large language models, he predicted that this area will provide tremendous benefit for people with limited English proficiency within the United States and around the world. Seabury shared that a colleague at USC conducted a large demonstration project via a Center for Medicare and Medicaid Innovation grant that placed Spanish-speaking pharmacists in clinics with predominantly Hispanic patient populations (USC, 2012). The project resulted in better patient adherence to medication regimens and improved outcomes. However, the expense of a full-time pharmacist is substantial, and therefore cost-effective approaches to overcoming language barriers could potentially result in improved outcomes for greater numbers of patients.
Baker maintained that financial cost remains one of the largest barriers to follow-up care. Even smaller copayment amounts can be outside the budgets of individuals with limited income. Moreover, the number of uninsured individuals is likely to increase as some Medicaid expansion programs end. Transportation is another major barrier to accessing care, he noted. Although telehealth and digital health approaches can ameliorate this need, broadband access is not universal. Such considerations need to be integrated into program designs for TBI. For instance, connecting with federally qualified health centers that extend into the community can help to address inequities associated with transportation barriers.
Seabury highlighted the concerns that although pay-for-performance systems can serve as a mechanism for expanding follow-up care services, they may also exacerbate health disparities. Equity considerations are not typically featured in the design of these systems, and therefore better-resourced facilities treating wealthier patients are likely to demonstrate higher levels of performance. It is important to recognize that a system designed in the absence of equity considerations may thereby increase the resource gap between health care settings, he said.
Ramifications of Digital Health
Given the growing market of prescription digital therapeutics, a participant asked about payment considerations for prescription digital health for services such as cognitive behavioral therapy or symptom-tracking apps. Wright responded that such technology is most successfully deployed via mobile apps or other digital mediums connected to workflows within a health care organization’s EHR. He added that direct-to-consumer systems, such as those providing ketamine treatment to the public, are outside of his purview. Seabury noted that although direct-to-consumer platforms
raise numerous concerns, they may increase patient access and they may be particularly effective for health concerns patients are embarrassed to raise with their doctors. New innovations entering the market will compete with existing services for health care spending dollars, he reflected. This competition for resources makes the need for value studies and cost-effectiveness research all the more pressing. Wright provided the example of a company that is currently expanding by approximately 200 percent month over month by prescribing medications for behavioral health or psychiatric conditions that general practitioners are not typically well-versed in. Digital health companies offload this service provision through revenue-sharing agreements with primary care physicians.
Baker highlighted that hybrid models of digital behavioral health care services combine online tools with physician services, and these models have been studied via randomized controlled trials for over a decade. Whereas freestanding online tools may be designed to drive business and generate maximum revenue, hybrid or digitally enabled care models can be designed to achieve the best possible outcome at the lowest cost. Migrating from fee-for-service models to bundled payments and using new types of hybrid models that integrate face-to-face, digital, and telephone communications is one potential avenue to improve outcomes following conditions such as TBI while decreasing costs.
This page intentionally left blank.
