It is probably a fair assumption that very few people in the US do not have strong feelings about the recent presidential election spanning pretty much the whole spectrum of human emotion. However, whether we are in deep mourning or jubilant celebration, it behooves us to attend to business.
While the consensus I am hearing from people deeply involved in health care policy and funding is that the changes in health care are not apt to be as cataclysmic as both candidates predicted if the other was elected, there will be new changes in what already was a fast-changing health care industry. There will also be a continuation of some of the changes already in progress. These changes, both new and continuing, do not need to be negative for spiritual care. Like all times of turmoil, the situation provides both opportunities and dangers. But the changes are all coming fast- some even before Mr. Trump takes office.
The trick for everyone in health care, including chaplains, will be to negotiate this uncharted territory while simultaneously avoiding the grave dangers and taking advantage of opportunities. It won't always be obvious which is which.
While a lot is up in the air, a couple of issues seem to be clear to most experts. First, the new administration along with a Republican Congress is likely to double down on reducing the growth in health care costs, mostly by tightening Medicare reimbursement even further. The Advisory Board, maybe the most respected think tank in health care has said, "This means providers have to maintain a relentless focus on taking excess cost out of their systems, eliminating unwarranted clinical variation, and rationalizing their fixed cost footprints." Cost containment is not news. However, it is clear that the pressure is only going to intensify. We should expect that no one is safe- including chaplaincy and Clinical Pastoral Education. The key word here I think is "excess". How is a hospital going to determine what is excess? I think the answer is in what seems to be the next issue.
The Medicare Access and CHIP Reauthorization Act (MACRA) passed Congress with huge bipartisan majorities in 2015. Because of the bipartisan support and because it supports many Republican positions (unlike the ACA), it is expected to survive and maybe largely intact. The final rule implementing MACRA was recently released and is becoming generally known as the Quality Payment Program (QPP). The key word here is "quality". QPP might well be translated as "we are only going to pay for quality." How is quality going to be defined? Most likely, quality will be that which serves cost reduction (i.e. reduction of excess costs) and/or better medical outcomes (i.e. reduction of clinical variation which also cuts costs). This is where the movement to payment for value and away from fee for service that is already in full swing meets the new administration agenda for cost reduction. This is why QPP largely stays.
So what about chaplaincy? Put simply, the pressure on clinical chaplaincy and chaplaincy training to demonstrate the value to the institution is likely to ramp up significantly as institutions delve into every corner of their operation to cut costs and increase value. Chaplaincy, along with all other programs and services that cannot show the data to demonstrate their value as defined above, will run an increasing risk of being deemed "excess cost". The good news is that many providers of all disciplines see opportunities in QPP for chaplaincy and social work to contribute value by documenting the cost saving of what we are often already doing in the service of certain quality metrics, and thus actually increase our footprint. In other words, inactivity on the value issue is a real threat, but proactivity can make this a significant opportunity.
To learn more about this important topic, chaplains should listen to the free webinar, Update on MACRA Quality Payment Program: What Palliative Care Providers Should Do Now” sponsored by the National Coalition for Hospice and Palliative Care, the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association, and Health Care Chaplaincy Network. The webinar will be held on Tuesday, November 29 from 12:30 – 2:00 p.m. Eastern Time. Register for free at https://attendee.gotowebinar.com/register/9179586563428946948
So how does chaplaincy demonstrate its value? One course that is out of the question now is trying to get chaplaincy directly reimbursed for any service. Even in the current administration and certainly in the next any attempt to increase classes of providers or newly billable services will be seen as adding costs when all efforts are on reducing costs. Further, as we know, health care is increasingly a team game funded by bundled payments that are headed lower if anything. In a team game, demonstrating the contribution of any single player becomes difficult.
However, there is a way. The paradigm is in research such as that done by Tracy Balboni and her team that has demonstrated that meeting spiritual needs at the end of life, which is what patients want, also reduces the use of aggressive care such as ICU stays and thus reduces costs. The next step is to demonstrate that this effect is larger and may be delivered more reliably when the team has a certified chaplain on board to lead the effort.
So what should chaplains be doing now?
Listen to the webinar on the 29th.
If you don't know already, educate yourself about how quality programs work. At least learn the language so you can participate in the conversation. Many institutions offer introductory courses for employees for free.
Get involved in the discussions in your institutions about what quality metrics your institution is going to report in the QPP. Many will need to start reporting in 2017. A good number of the options could be advanced by chaplain participation.
Investigate what quality initiatives are ongoing or anticipated in your institution and be creative and proactive in making the case for how what the chaplains do contributes to these. When those initiatives succeed, patients will likely be better served and the role for spiritual care will be enhanced.
I firmly believe that, if we are aggressive and strategic, we can not only negotiate this new health care environment without serious damage, but we can genuinely emerge with spiritual care and chaplaincy more firmly integrated than ever before into health care. I strongly believe we can do it without selling the soul of our profession and compromising our historic relationship to patients in the process. However, there is no time to lose.