Today, Dr. Phil talks about the pros and cons of value based purchasing, and prioritising results over productivity. How will value based purchasing in home health turn out?
Hear about OASIS assessments, the difficulties of working with insurances, and get Dr. Phil’s valuable advice, all on today’s episode of The Healthy, Wealthy & Smart Podcast.
More about Dr. Philip Goldsmith
Philip Goldsmith, PT, MSPT, EMT, DScPT, COS-C, is the owner and founder of Goldsmith Therapy Solutions, a provider of high-quality management, consulting, and clinical solutions for home health providers.
Dr. Goldsmith has been a practicing physical therapist for more than twenty years, with experience in home health, skilled nursing, and outpatient orthopedic environments.
Dr. Goldsmith received his BS in Health Studies from Boston University in 1996, his MSPT from Boston University in 1998, and his DScPT from University of Maryland School of Medicine in 2011. Additionally, Dr. Goldsmith has extensive experience in leadership and financial management of small and mid-sized not-for-profit corporations and has won more than $200,000 in grants for public safety organizations with which he is affiliated.
Dr. Goldsmith lives in Hanover, PA, with his wife and son.
Healthy, Wealthy, Smart, Healthcare, Physiotherapy, Results, APTA, Home Health, Value Based Purchasing, Insurances, Advocacy,
To learn more, follow Dr. Phil at:
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Read the Full Transcript Here:
Alright, let's go. Hello, healthy, wealthy and smart. I am Jenna canter here with the Dr. Philip Goldsmith, who we're going to refer to as Dr. Phil, don't you love it? I'm so grateful to have Phil here, because he has a small business owner who runs a business in which he provides Oh, I'm gonna mess this up. And I'm so excited to where he brings stuff to the home health people and they're happy and they smile and say thank you. Without it and I get it.
That's pretty close.
Would you mind summarizing in that perfect sentence you just said a second ago of what it is you're more details on your business, like
elevator speech. It's called Goldsmith Therapy Solutions. And I provide high quality clinical consulting and management services to the home health industry.
I love it. And that's an elevator speech we all need to have you know for each of our own individual businesses, anybody who interviews with me knows I don't spend too much time going into the bio stuff because that will just be in the people can read it and then Wounaan go oh my gosh, I love Dr. Phil, you know, look at this. Wow, incredible. We are going to dive right into the topic which I know nothing about. I'm a cash pay cash based out of network PT working with performers. So I'm going to ask all the base questions to fully understanding the situation so everyone can better get on the on the same page with this apparently, and I I'm, I'm not saying it's not but just for me, it's new, apparently topic that's like a hot topic, and that is value based purchasing in home health. I know nothing about it. So let's talk about what is that? What is the value? What is that
value based purchasing is Medicare's new payment model for certified home health services provided to Medicare party beneficiaries.
Why is that important right now,
because it's different, how Medicare is moving away from the you go do a visit or provide a service and we pay you for a service to a model where they pay you based more on your outcomes, and how good a job you do at taking care of those Medicare beneficiaries that have chosen to avail themselves of your services.
That sounds great to me from a physical therapy standpoint, because that's what we care about. So how was this? Let's start with how this is good. And then we can go how this is potentially something that could get in the way of providing care to people fully. So how is this good?
This is good, because it removes a lot of the artificial drivers that were skewing utilization. Meaning, excuse me until about three years ago. The more visits you the more therapy visits you made, the more money you got. And that was unfortunately driving practice patterns and everybody Medicare, not Medicare kind of agreed. This isn't working. Yeah, yeah. And
because that's about productivity, not about results. Yeah.
Right. And it was it was too much widget counting, and a lot of home health agencies were making a lot of money on providing therapy visits that weren't necessarily necessary. Hmm, Mm hmm. So, you know, the the interim step on the way was this thing called pdgm that we're in now where it's all based on functional states and diagnoses? And that's about it.
Yeah, it's not nothing to push getting them to where we need to get them or to protect them from getting worse. If we're talking about home health. Yes, yes. Okay. Okay. So then let's talk about where this could potentially be problematic.
So the, the concern is, are you comparing apples to apples, meaning they're dividing the agencies up by state by geography and buy large versus small volume, to try to make apples to apples. But the big issue is, this system works literally by robbing Peter to pay Paul, somebody is going to make money. And somebody is going to lose money. So the other people at the other end of the scale can make money.
Where could you go and give some details on this? Because I'm not really following on on how this could be? Yeah,
Medicare is gonna say, Okay, we're gonna take all of the large volume agencies in the state of Pennsylvania. And we're gonna line them up by the outcomes we've chosen, they haven't told us the outcomes yet.
Deciding what the outcome what outcomes matter,
they are in the process of that now, who are the consulting
So there is what's called a technical expert panel, and we could do that alone. The concept of technical expert panels could be its own podcast, where basically they bring in people in the industry and ask them, What do you think is important? Um, do they pay them? They cover their expenses, do they? Do
they start to get a financial interest to sway certain ways and their responses? Okay, okay.
They're representing their industries. So, you know, they can, I could volunteer to be on a technical expert panel. And my job is to bring the perspective of the physical therapy industry. Hmm. They also do us, you know, these big beltway consulting firms that you hear so much about, and they have policy wonks that work at CMS that do this stuff. A lot of its actuaries accountants and lawyers? Because one of the big rules is this is supposed to be budget neutral, meaning the pot of money doesn't change. It's who gets how much of that pot changes, specifically, the agencies that are the bottom performers, they're going to lose it as much as 5% of their reimbursement, so that the top performing agencies gain 5%. See,
there we go. That's where I think a financial interest could sway what people say, because this could be less money towards their industry. Well, it's problematic,
home health in general. I mean, this is, it's already, you know, you're already getting paid a lump sum for the care of each individual. And that varies based on those clinical and diagnostic factors that that I talked about before. Right. The scuttlebutt is,
I don't, but I just need to highlight that. I know I love that you said scandal, but this is great. That means rumors, love it scuttlebutt, I'm going to start using that every day.
One of the big outcomes they're going to look at is readmission to the hospital, did you keep your patient out of the hospital? Because that costs Medicare more money. And they're gonna look at functional outcomes, like transfers and ambulation. And there may even be a patient satisfaction component because did you know that Medicare mandates patient satisfaction surveys in most settings, you get those annoying Press Ganey surveys? Because Medicare says Thou shalt, and they track those, and those are actually publicly reported data.
That's actually great. I think the patient what their happiness is everything. Yeah, I think that's great. That's, yeah. Okay. Okay.
So it's your secrets here.
So it's it sounds though, like it's a bit of a gamble on where things are going to lie. And what's going to be decided on what these outcome measures are? That sounds like the biggest concern, what are these outcome measures that we're going to be using? Because if we're talking about movement stuff, you
aren't talking about movement stuff. But, you know, they've already established that all of the measures, the outcomes that are going to be looked at are either Oasis based Oasis being the clinical assessment that's done in homecare at a minimum every 60 days. Okay, Mission recertification discharge, hospitalization, return from hospitalization. That standardized assessment gets done. I have
a question about that, actually. And this is just from my own experience, it's a completely different audience that I work with. So when I'm working with my performers, I'm reassessing every single time I work with them. I'm a niche practice, though. I'm, I'm small and keeping it small. And so therefore, they get like real top, you know, I know them inside out what's going on in their lives and stuff, so I can best help them. So that is very, very specific. And and I'm lucky to be in that position. So when you're saying 90 days, that sounds like a long time for like a formal reassessment. I believe in oh, gosh, PT, school, it was it was a matter of like two months. So is it because of the the age where things may take longer to see results? Why it's a 90 day spot? Like, why is that? I'm honestly asking, it's not for judgment, I'm trying to be very transparent on my own bias. So I can learn
that every 60 days, well, every 60 days, that OASIS assessment gets done. However, that doesn't change, that your state Practice Act still applies that you may have to reassess every 30 days or every 10 visits or every 14 days, whatever your state Practice Act says, and Medicare still has the every 10th Visit reassessment requirement in home health, where they expect you to be using objective functional measures, and looking at your plan of care and your goals and saying, Are we getting where we need to be,
which is what we do in physical therapy. That is we're always asking ourselves that question.
Okay. This is more of a you know, it's more of a big picture thing. Yeah. Okay. For example, the emulation question. There's independent, there's independent but needs a one handed device independent but uses a two handed device can walk but need supervision at all times. And then there's a couple of answers for wheelchair bound, or bed bound.
Yeah, I'm not familiar with this, but I'm learning as you're talking about, is there anything about risk of falls because that's like the big a big one.
They look at that from a process measure standpoint, meaning they ask you, did you assess for fall risk, and there's criteria given a multifactorial objective. So really, it's got to be a two pronged thing. They're not looking at the results. They're looking at. Did you do it? Yeah.
Yeah. Is there room for? And this may be you don't know, because this is a bit of mind reading. As far as you know, right now, is there room for measurements for neurological disorders where we know that things may they're going to decline over time? You know, are immune immune? Am I saying the wrong thing? I think he's doing the wrong thing. But is there room for that where they have a health situation where things are going to decline? We know that but we're trying to keep them functioning their best as they're going through their process?
The answer is yes and no. Okay, the questions and answers don't change. What changes is, they can tease out by diagnostic grouping and by what they call risk adjustment, where if your agency has a high population of clients with progressive neurologic disorders, that's the the term in favor now. Okay, thank you, they're going to risk adjust your statistics to reflect that, meaning, we see that you have a larger population of people who probably aren't going to get better. And we're going to do some statistical mumbo jumbo in the background to adjust for that. But that doesn't change the answers that the clinician is using. Okay. There's no, I have to pull a different document because I have a different diagnostic group. There's no, I answer these questions for this diagnosis. And that questions for that diagnosis? Yeah. Yeah, the people who very much a big picture of
the people behind the scenes, I think I know the answer this question, but I'm still going to ask it, the people behind the scenes who will be assessing the the progress progress, and, you know, if it's fitting, looking at the outcome measures and what we need for that patients, are they medical professionals? Are these just people who are trained to work for this company? Who are the Who are these people?
So field clinicians who work with clients answer the oasis for each client, the agency, then submits it electronically to CMS. And the risk adjustment is baked in to the computers at CMS that process all this information.
Also, it's a computer thing. It's all very,
and that's part of the reason the assessment is somewhat limited in big picture. Yes, it's a it's a computer thing. Ah, it's a i. i, maybe maybe not. But it's a lot of higher level statistics. That's way above my head.
Right, right. Yeah. Oh, wow. That's what this is so negative for me to say, but what an easy way as a person in CMS to point away and go, Oh, no, it's the system's. That's what they computed. Like, I can't. I'm like, Who created it? Who designed the code? Fine. We'll look at the code person I need to understand. Okay. Okay. So, I mean, it just sounds a little bit like a trip to Las Vegas, where you studied a little bit. So you know, a bit about gambling, you say, let's say you're very educated about that, and you but it's still gambling? You don't really know. I don't know, I just I,
you know, it's, it's pretty well known how they do the risk adjustment. You know, it's just the statistics of how it's done is pretty high level, but we have a good feel for what they're risk adjusting for and what questions they used to do the risk adjusting.
I mean, do you think the physical and physical therapy industry home health for this, because that's what we're focusing on? Do you think what the way we have things set up now, the way I mean, that's the whole point is to be measuring their outcomes? That is literally what we're doing all the time. Do you think we're pretty safe with this adjustment? If anything, it'll probably be for the better if you're just overall? I mean, because we did the good versus the bad. Where do you think it's, it's gonna turn out for us?
It looks like value based purchasing a home health is going to be a good thing. It is going to reward you for doing your job well, and being aware of your outcomes and delivering good health. Quality physical therapy that drives the outcomes? Yeah, there's going to be, it's going to challenge the physical therapist and the PTA to work at the top of their license and to collaborate with the other professionals. Because some of these measures don't happen in a vacuum for lack of a better term, they don't happen unless you're working as a team, and everybody's on the same page. Yeah. And that's really that interprofessional communication is where the good are gonna be separated from the bad.
Yeah. This isn't my world. Oh, continue,
there's, you know, definitely the agency is going to have to be very aware of their outcomes and their data. And the understanding of that data is going to be huge. Yeah. And I can tell you, that there are consulting firms and companies, and that can look at those outcomes at a clinician level. And they're going to tease out high performing clinicians and low performing clinicians.
Yeah, yeah. Yeah. And I'm assuming that's where the concern is, what is, oh, I'm gonna backtrack to actually what I was originally thinking of asking. What is the hot talk on the streets regarding this? What are the big things that other physical therapists and people in the industry are going like, hey, about it? Or do we already cover those things?
We've covered a lot of it. I think there's a lot of optimism around this. Because the more recent changes over the past couple of years, starting in October 2019 really pulled back on the number of visits. We were seeing clients. And some of that is real. And some of that is artificial. Yeah. And it's gotten me up on my soapbox a number of times, because home health therapists are probably, unfortunately, some of the worst offenders at underdosing strength training. Oh, yeah, you want to get me started? Don't get me started.
Yeah, yeah. So it's, it would force that that push, I would love. It
forces us to understand how to deliver strength training, how to deliver the most the best outcomes we can in in fewer treatments.
Yeah, how to get trust, motivation.
really gotta understand you've got to be a high performing clinician, yeah. To survive in this market. Yeah, because a home health agency literally cannot afford to have lower performing clinicians that can't deliver the outcomes. Yeah. And a lower number of visits.
Yeah. Yeah. Absolutely. Absolutely. I definitely get that. So I I mean, I'm all about the outcomes. I've had people a different dance physical therapists asked me about how I do my outcomes and it really does depend on my patient and everything but I have a very I have a special circumstance you know, like I'm very lucky to have this niche that I have. i There are from an outpatient not out push out. Yeah. Out not outpatient. Wait, I'm getting so confused. Ortho. From an ortho standpoint, I'm calling because I'm not, I'm not home health. So I'm just like trying to get back to my my world. There are definitely I'm gonna choose my words specifically. So if you are a person who does own a clinic, that sees a lot of patience, you are a mill, there is no way to paint that there is a reason why there is a name for that. That's like saying, I, you know, I was you know, born from two Jewish parents and I grew up I have my Bar Mitzvah and then and like, I still observe Passover, and then be saying, I don't I'm not Jewish. Like what? Like, no, I'm Jewish, you know. It's very weird comparison. But whatever. That's what I chose. And I'll go with it. We
get to the point of mills.
I've always thought that the it was because of the problem with insurance and reimbursement and it's one of those like chicken or the egg kind of thing. What happened first, which I use in defense for any clinic. I'm like, hey, they're trying to figure out how to get reimbursed but at the same time, does in this horrible circle of terrible reimbursement trying to communicate what you did and everything, and people are trying to make money, which is fine, it's okay to want to make money Hello. Is
we as a profession do wrong to allow an industry to devalue our services like that?
It's because when trying to guess this is me, because I'm not a network. So, but from what I've seen, it's it's clinics trying, they're doing their best to report what they're doing. They outcomes with the patients, while at the same time speaking the language that the insurances say, they will reimburse. And then also these insurances saying they're going to reimburse, but they're not actually reimbursing, then there are administrative staff calling over and over again, fighting to get those reimbursements, you know, getting better at that. So that's why you have certain people working on the at the front desk, and then and so then they increase the number of patients during that time, because while they're gambling per patient on honestly, this is how I look at it for a patient on getting that reimbursement. Through, you know, the paperwork we've we've been trained to do to report outcome measures and everything. They're not they're not getting paid for it. They're fighting to get paid even on the basic level. So I think, but I don't know what happened first if insurance happened first, or, and, or the, you know, provision of the services, and they decided for it to be a lot of people that's the chicken or the egg thing. I mean, I'm sure somebody could look up the history, but I think that's where people just say, Oh, the healthcare system is messed up needs to be fixed. I, that's where I kind of lean back on to kind of be fair to everyone. Not that there has to be a middle ground. But I mean, that is kind of the truth. If I owned a big business, you're constantly you're like, Okay, I've hired this, these EMR systems, you know, we're we're gonna track and write down things. I hope this is the right system. Okay, this one's not working. Let's do a new one. And then you have your clinicians going, Ah, dang it, we have a new one, I have to readjust. But it's because we're trying to do it. Honestly, we're trying to do it legally. And then insurances just go, now, we're just not gonna reimburse you, we're not gonna explain why. And we're gonna be difficult to get in contact with to discuss and figure things out. So I don't know it's a random tangent, I'm sure people will go be like, Jenna said something wrong. I'm not the person to attack here. I'm just speaking. If you have problems, go talk to the insurance companies and figure it out if you already know how it works. But that's kind of how I look at it being problematic in the Ortho world specifically, because there is a lot of measuring of my brain out there. There's a lot of measuring of what was the word that we use, the more patients you see.
Counting widgets, counting widgets.
It happens, it does happen at the larger clinics. But yeah, can you I mean, I'm not saying I'm not saying I'm not saying I agree with it. But also, can you blame on? You know, like,
you started this to make money. I get that, you
know, but, but I mean, what I am in the business to hear, I mean, that's what I'm doing my own thing, is it easy to do what I'm doing, is it easy to get the patient Oh, my God. But that's I that's where I put my energy where I put my energy. But I feel like what is happening in the home house, like, Oh, my God, this is hilarious, full circle, but I'm going to connect it, it's going to be amazing. Feel like the Home Health what you're doing with pushing that pushing forth. The outcomes, I would love that I would, but I would love to actually be that not than just saying that. We love their beat. Let's make it all about the outcomes. And honestly, I feel like that's what we've been trying to do the whole time. It's just people aren't. insurances aren't saying there aren't following through with it, what they say they're going to reimburse, they say, We can reimburse up to this amount. It doesn't mean anything. It's horrible. So I would love there to be fixing in that way.
And I think someday Medicare will come around to a value driven system for outpatient therapies. And until Medicare does, nobody else will mean, Medicare very much still drives that bus.
Yeah. Wow. I never realized that. That's yeah. How do you know how do you I mean, honestly, asking, How do you know that they're the ones driving the bus?
Because most of the private insurance is based their policies on payment on what Medicare does,
because they're so huge. Yes. Mm hmm. Oh, gosh. Not saying it. It's easy to say there's no easy road.
That's where all the that's the root of all the CPT codes and everything else. Medicare needed a common terminology to wash claims through a computer to pay people. Let's boil everything down to a five character code.
Right, right, right. Wow. Huh? She's What a hot mess. It just gives me a headache thinking about all of it. I don't like it. It makes I need cake. Or pizza. Oh, not chocolate though. My dad loves chocolate cake. Are you a chocolate cake person?
I am a chocolate person head on.
We only put like chocolate cake is so different from chocolate bars come on.
Yes. But they both have their merits
F No. Disagree? Absolutely not. All right, if you are a person that if you would handle your stress from chocolate cake, just as much as chocolate bars. Okay, your team Dr. Phil. If you're like No, chocolate, just chocolate actual chocolate, your team? Jenna. I'm interested to see if there's going to be any written debate on this or discussions I'm sure there already has, which is why you were meeting Dr. Phil was like, let's do this topic. And like, I don't know anything about this, which is good. I think it's good because then I get to learn everybody else who listens gets to learn. And oh, I'm going to just say this just because I am not a fan of meanness. Don't attack either of us in this discussion. If that's in your if that's in, if that's in your intention in in hearing this and your response, oh, just at this as a message just for you get out of here. Well, we got to be better together, we need to be able to have these discussions, talk about it, totally fine to speak on your concerns about it or all that stuff. But we're just attacking each other that is not helping out the patients at large. This is about the people we serve. So we're discussing this to see what's going on to better understand what's going on. If you are in an estate, you are close to somebody who is in legislature, the then do talk to them, or see if there's a pre written letter from a PTA right now regarding this through their app, if you're in a PTA member or see if you can get a hold of that letter through a friend or something or I'm sure it's honestly on their webpage for you to easily access to advocate sending a letter to fight this or fight for it, whatever it is, because there's there's positives and negatives and everything. I mean, sometimes there's you know, it's leaning one way, obviously, but we got to just take action. If you want to see something you got it don't just reply on here take action. Well, I just gave so many different messages and one thing at the end, but that's okay, I'm fine with it. Any last words you want to say on this matter that you that we haven't covered? Dr. Phil?
I think the take homes are twofold. You just said the first one. You've got to be involved in advocacy if you want to see change. Second, value based purchasing, like we're talking about it today is just in the home health arena right now. It is what Medicare wants to bring across the board across all settings. And, you know, they don't they want to get away from fee for service. They want to get away from ID to units. If they're x and a unit. If they're X, a unit of East M and A unit of manual therapy and you need to pay me for it. They want to know a client walked in your clinic with this problem. They had these issues that we're able to quantify. And at the end of it, the client left our clinic and the issues were gone and here's how we've quantified it. That's what they want to be able to pay you for. And if you can't be excellent with that. You're not going to have a successful practice 510 years from now.
Thank you. Thank you so much. Where can people they wanted to get in contact with you Where can they connect with you on either social media or email?
I am P gold PT on Twitter. I do have a personal Facebook. I am not fancy or cool enough to have Instagram or Tik Tok or any of those. I have LinkedIn. My email is Easy it's P gold email@example.com. The other place that's really easy to find me is if you go to a PTA home health.org on the leadership page, you'll find my name. Currently the treasurer of APGA Home Health formerly known as the Home Health section. And in two weeks in two days I become the President
didn't say that at the beginning. I was like, I wonder if you want me to and you didn't say bring it and bring it out? So yes, this is a person. This is a person who's very involved with fighting and spin keeping on top of what's going on for home health. So thank you so much, Dr. Phil, for coming on for your name. I love just saying Dr. Phil over and over again. And just sending you the biggest hug from afar. We got a meet at a conference recently and you are a gem. Thank you so much, and everyone send love to Dr. Phil for for his time.