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What Should Spiritual Care Be Accountable For?

Much has been made of the changes that are coming to our federal government with the advent of this new administration. And indeed drastic change is here and uncertainty is the watchword of the day. Despite that, most authorities are convinced that some initiatives will not change and this uncertainty also constitutes an opportunity to provide change to the system.

One of the fundamental changes is the conversion of the basic health care payment model from what has been known as fee for service to the one now most often called value-based purchasing. Fee for service is fairly simple. The health care provider delivers a service like a test or treatment and gets paid a set fee. The more service is provided, the more the provider is paid. Value-based purchasing pays for service to the extent it is deemed to be of high quality and, paradoxically, for saving money. This new system comes with many, many unknowns not the least of which is how does quality get defined, who gets to define it, and how is it measured?

The current centerpiece of this change is the Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act (MACRA) passed by Congress with overwhelmingly bipartisan support in 2015. (with now-Secretary Price voting for it). The regulations govern how providers are reimbursed by the federal government- mostly through Medicare Part B. MACRA replaces several value initiatives and payment models mainly with two alternative strategies for raising quality and lowering cost - the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Models (APM).

I have to admit that when I first heard about MACRA and what it involved, my conclusion was that this has to do with provider reimbursement and since chaplains don't get reimbursed, this has nothing to do with us. That conclusion has proved to be completely wrong. The explanation is complicated but basically involves the reality that, in this new system, the provider which could be the hospital or a doctor's group or other, gets paid for delivering quality care and/or an outcome which is cost savings. However, how the outcome is attained is, for the most part, up to the provider. The provider can provide the service any way they choose. Naturally, they will seek to use the most effective and efficient method available. Thus, if the particular service can be provided more effectively and efficiently (i.e. at less cost) by a chaplain, then a chaplain can be hired to provide the service.

A quick description of MIPS and APMs. In MIPS, the provider chooses a number of quality measures to report on from a very long overall list. Many of the measures like patient satisfaction, having advance directives and helping reduce pain, can easily be influenced by chaplaincy care. If chaplaincy care turns out to be the most effective and least costly way of attaining this outcome, the provider may use that method. 

APMs are plans for providing service in which the provider assumes accountability for providing a certain set of services at a certain cost. This set of services may be palliative care or oncology care or pretty much anything. The services are also supposed to be patient-centered. The plans are pre-approved by the government and then any provider can adopt them if they want to.  Various organizations are now submitting plans for approval. Again, as with MIPS, if the inclusion of chaplaincy adds to quality and cost savings, it can be included in the cost that the plan can charge and the services for which it is accountable.

The key to being included in MIPS and especially in an APM is (1) to be able to specify exactly what work your service will do and what outcomes your service will assume accountability for and (2) to be able to precisely price the cost of the work.

So what seems to be the bottom line?  After talking to many people who understand this much better than I do, this is what I understand.

There is an opportunity right now when quality, patient-centered care is the name of the game to demonstrate that chaplaincy adds to both of these goals and can be net cost saving in the process. The outcomes we have always claimed we deliver including patient satisfaction and cost savings are now taken very seriously. Further, a system is coming to a place that will pay for those outcomes.

BUT to take advantage of this opportunity we will have to:

-Rid ourselves of unsubstantiated statements. "We are the best" or "our program works" without data to measure the results against valued health outcomes simply exposes us as a discipline which doesn't understand the values under which the current health care system operates. We must have data to substantiate every claim we make.

-Agree on the outcomes we can be and want to be accountable for. A year ago HCCN put forward a set of evidence-based quality indicators for discussion within the field. To date, no individual or association within the field has engaged that discussion or tested the indicators although the list has been very widely applauded and adopted outside of chaplaincy.

-Be clear what activities we will be accountable for in the service of these indicators.  And we need to agree on how to price what we do. What kind of budget does a hospital need for a professional chaplaincy service and what does that money buy?

Already there is one proposed APM covering end of life care filed for federal consideration that has no mention of spiritual care or chaplaincy. There is another that HCCN is providing input to. However, there is no way of knowing how many others are in process. There will be public comment periods of course but there is real danger that the health care system will move ahead without us even in a time when we have maybe the most clear opportunity in our history to be firmly integrated and paid for.

So what to do?

- Find the table in your institution (and there certainly is one) where these issues are being discussed. We know it is unlikely others will think of us for help here so we need to be there to raise our hand.

- Educate yourself on how your institution currently gets paid and for what and how do they plan to be paid in the future- MIPS vs. APM vs. Accountable Care Org vs. Medicare Advantage vs. Other.

- Think creatively with your chaplaincy colleagues about how you might volunteer chaplaincy to contribute to your institution's plans in this regard. What evidence-based case can you make for adding value to these activities?

There is an unprecedented opportunity here to integrate chaplaincy care and spiritual care into health care and have it reimbursed. However, no one is going to hand it to us. It will only happen if we do the work up front. This work can be done but it will not be easy because it ventures into territory we as a profession have never been in before. 

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