Arif Nazir of Signature HealthCare

Though it’s less than a week to go and many colleagues are jittery and restless, I also have seen a feeling of excitement that has been missing for years in the post-acute setting.

The Patient-Driven Payment Model arrives on Oct. 1 and turns on its head the reimbursement philosophies in skilled nursing facilities as the baton of financial intricacies is passed on from therapy teams to nursing teams.

As the Chief Medical Officer of one of the largest post-acute chains, I see many co-workers almost consumed by the hustle and bustle of the transition. It reminds me of childhood days when I used to observe my family running around on the evening before a big holiday, my parents and older siblings taking the brunt of the workload, while asking me to help in a task here and there. 

In my defense, I am playing a key role in this historic transition, for example, informing and educating medical directors and physicians on how the PDPM era will need their support with excellence in timely assessments, documentation and practice of evidence-based medicine. OK, so it’s clear: PDPM impacts SNF providers and practitioner teams, but a question still remains. How does it change the patient experience? Should they and their families be excited, fearful and/or apprehensive, particularly when the “patients” supposedly will drive this new payment model?

One of my friends, a leader on a hospital executive team, recently stated, “Finally, (with PDPM) we are seeing a focus on the patients — making them key to reimbursements will get the job done.” For the moment I nodded my head in superficial agreement, but the comment incited a deep reflection. For example, did previous key reimbursement changes modify behaviors around care? Do humans really respond positively to financial incentives? What does true patient-centered care really look like and will PDPM impact it? And finally, how will PDPM impact the care philosophies of healthcare teams?

We are in an era of healthcare evolution where burnout among healthcare teams is a common thing. The causes are myriad: unfair expectations, electronic medical record hassles, insufficient reimbursements, frivolous lawsuits. Regardless of the reason, we are on the verge of a crisis, with many physicians and nursing teams manifesting depressive symptoms, serious nursing shortages and administrators and managers quitting the post-acute setting due to high levels of stress. Can teams low in spirit truly lead patient-centered care?

In 2017, results of a highly anticipated randomized trial were published and caught everyone with shock. The INTERACT trial failed to show an impact on key quality metrics. In their discussion, the study’s authors provided many explanations. But the one reason that resonated most with me was that the success of any initiative in a complex adaptive system, such as post-acute care, is dependent on the motivation of the healthcare teams. Motivation is a complex concept and is not well studied. I am afraid if we don’t work to understand what sustains and enhances motivation that sincere efforts to improve patient-centered care will fall short.

We do know from credible behavioral science studies that prescriptive structures (both care and regulatory) distract healthcare teams from patient-centered care. Additionally, complex financial incentive programs that rely on metrics that some deem irrelevant or unimportant can further demotivate the team. The more complex financial systems are, the more resources are needed to show “quality” results, making healthcare more expensive and penalizing those who care for the sickest.

I am concerned that PDPM is a complex framework that will consume a lot of energy and resources. I am also concerned that unless we implement strategies to guard against them, the model will add to administrative burdens and dissatisfaction (at least during the ramp-up period). As we implement hundreds of new processes, we must assure we shield our frontline teams against administrative burnout and communicate clearly PDPM’s potential to improve patient-centeredness.

All post-acute health systems should have a robust strategy around patient-centeredness, but more importantly staff-centeredness. Drive: The Surprising Truth About What Motivates Us, an excellent book by Daniel Pink, provides some great frameworks around autonomy, mastery and purpose that can be used to motivate frontline staff and physicians. Healthcare teams need to perceive organizations to be sincerely invested in their professional development, well-being and attainment of their noble purposes.

PDPM while claiming to be “Patient-driven”, if not implemented with care and caution, will be anything but! PDPM’s complex processes, if followed, will no doubt equip SNFs to bill for higher acuity patients, but will care truly improve with it? It falls upon healthcare leaders to assure that patient-centeredness does not get lost as teams get laser-focused on executing PDPM’s new processes. Any loss of patient-centeredness will be accompanied by loss of motivation and engagement of the healthcare team.

PDPM is just a step forward (probably in the right direction) and by no means the destination we sought. Let us move forward with caution, and as we do so, continue our strive for the real PDPM we need for the best patient-centered outcomes—the Purpose-Driven Payment Model.

Arif Nazir, M.D., C.M.D., is Signature HealthCare’s Chief Medical Officer.