Archive for November, 2009

Evaluating the Evidence and Its Relevance to Patients

November 30th, 2009 by Melanie Matthews

Last week, the industry and public reacted strongly to recommendations from two separate groups to delay the starting ages for mammograms and Pap smears and to reduce their frequency. While the recommendations are non-binding for providers and payors, many say they run contrary to traditional medical wisdom supporting aggressive testing and prevention.

The groups’ recommendations were based on a review of evidence and research associated with the screenings. By definition, evidence-based medicine aims to apply the best available evidence gained from the scientific method to medical decision-making, seeking to assess the quality of evidence of the risks and benefits of treatments (including lack of treatment). Evidence-based medicine weighs heavily in healthcare reform proposals. It’s built into the patient-centered medical home model, a requirement for wellness and prevention programs and part of how the government wants to define high-value care: the efficient delivery of high quality, evidence-based, patient-centered care.” Opponents fear that a reliance on evidence-based medicine will lead to healthcare rationing and controversial “death panels.” But most of the time, each provide will have to weigh the value of the science for each patient.

Dr. Richard J. Baron is president and CEO of Greenhouse Internists, a five-doctor practice in Philadelphia that is adopting evidence-based guidelines. Here’s what he said during a recent webinar on Evidence-Based Guidelines in the Medical Home:

“There’s a cognitive shift that doctors have to make. Doctors are trained to see patients one at a time and that’s mostly what we do. It’s the way the reimbursement system pays us. We can think about Mrs. Jones who we saw this morning, but you want doctors to shift to think in terms of rate-based data. Not only did I advise a mammogram to Mrs. Jones this morning, but for all the women I saw between the ages of 50 and 65 last year, how many of them had mammograms? And when you start to get doctors to ask questions like that, they become interested in the results, because their first response when they see things they don’t like is, ‘It’s not my fault if the patients don’t follow through.’

…Also, we need to recall that the evidence base is a broad population evidence base. If a patient is dying of breast cancer, they probably don’t need to worry about getting a colonoscopy even if it’s due. You need to count on the doctors to critically evaluate the evidence and its relevance to this patient. And then perhaps one of the most important things that the doctors do is they start interacting with their own data.”

Providers Leverage ACOs to Boost Reimbursement, Beat Competition

November 24th, 2009 by Melanie Matthews

William DeMarco, president and CEO of DeMarco and Associates, explains the growing appeal of accountable care organizations (ACOs) to providers hoping to increase profits and efficiency while improving care.

We have physicians that are organized into accountable health organizations, also known as accountable care organizations (ACO). The ACO is seen throughout the House version of health reform as well. The ACO can be thought of as a small- to mid-sized group practice that provides services that are tied to benefits or specific specialties in a given community. The ACO normally takes a payment very much like an episodic treatment group (ETG) — a combined or bundled payment. They take that bundled payment and work with it. If they come in under the amount that they’re paid, they get to save some of it, and if they come in over it, then they’re going to lose some of that payment as well.

Another way to look at these ACOs is as a medical group without walls — taking communities where there are onesies and twosies. They just don’t function like a group. They’ll never achieve the economies to scale, and they’re getting into trouble with the combination of both health plans and competing medical groups in the area. Through technology, these small groups can link together and act and think and leverage themselves as a larger group, giving them a reward and also an asset value they didn’t have before. This also allows them to coordinate services virtually between the medical group and the hospital — being able to do everything from scheduling services to obtaining lab tests more rapidly, and doing block lab scheduling for patients so they don’t have to wait for months to get the results.

These large national networks who have been out there for months and months are now starting to combine because a lot of the employers realize, “I can get a better deal if I go directly with top physicians and hospitals in this community with my 4,000 or 5,000 patients and lay it on the line, instead of having my patients be spread over 2,000 or 3,000 physicians in the area who might be part of this other club.” A lot of the third parties are contracting with employers, building these local networks and then building and reporting against guidelines. Employers are looking more for benchmarks than just benefits these days, aggressively negotiating fees and then working with health plans or becoming one.

We are seeing more physicians who are saying, “I can see the handwriting on the wall. We’re going to have our fees cut again. We’re going to see a lot of these health plans be able to come into the marketplace and start gathering various health plans. What was negotiating with two or three different plans now becomes a gorilla. I’m going to have to figure out whether I am going to have to create my own product or have a very clear alignment with one or two plans to champion my practice.” Because to continue to be on the downside of negotiation for fees and have them increase the number of reports that have to be sent doesn’t make a lot of sense.

Smoking Cessation and Prevention

November 20th, 2009 by Melanie Matthews

In response to the 34th annual Great American Smokeout, this issue of the DM Update is all about smoking — from smoking rates in the U.S. to employer and employee takes on workplace smoking bans to tips on changing unhealthy behaviors.

In addition, learn how the American Cancer Society’s Great American Smokeout can help smokers to quit smoking.

Bundled Payments Demo Shares Savings with Doctors and Patients

November 17th, 2009 by Melanie Matthews

Baptist Health System Chief Development Officer Michael Zucker shares Baptist’s motivation for participating in a CMS pilot on shared or bundled payments — a reimbursement model increasingly mentioned in healthcare reform debates.

There were several components of the CMS Acute Care Episode (ACE). First, there was a competitive bidding process. CMS was focused on one geographic region within the country. They chose the Southwest, which included Texas, Colorado, Oklahoma and New Mexico. These four states fall under the fiscal intermediary TrailBlazer, which administers the Medicare program in this region.

During the competitive bidding process, CMS put out a proposal to providers in the 15 largest metropolitan statistical areas within these four states and sought bids on package pricing or bundled pricing from both the hospitals and the physicians on the targeted cardiac and orthopedic DRGs. CMS was going to select one provider system; that is, the hospitals and physicians who put in the combined bids in each of these metropolitan areas up to the 15 markets that they’ve identified. They didn’t select 15 markets; in fact, CMS only chose five markets in the country to kick off this program.

Another key component of the ACE Demonstration Project was the concept of shared savings. CMS was seeking a lower combined pricing structure from what they would traditionally get under the current Medicare process, which is a DRG basis for the hospital side and the fee schedule arrangements on the physician’s side — or Part A and Part B as we know them. In effect, taking that savings and passing it back on to the Medicare beneficiary is a key differentiator from past demonstration projects. The actual patient or Medicare beneficiary would be allowed to share in that cost savings, but also have an incentive to seek out CMS to find this as a value-based center of excellence.

The bundled payment concept would include both Part A and the Part B components for the hospital where individuals were having any of 28 cardiac and nine orthopedic DRGs. Note that this does not include any outpatient procedures; these are only admissions.

Another key focus for the ACE Demonstration Project was the gainsharing with physicians. And lastly, the beneficiary incentive or the check back to the beneficiary in that shared savings.

To give you an idea of why Baptist Health System pursued the ACE Demonstration Project, I wanted to illustrate the market share in San Antonio and South Texas. The Baptist Health System is a major player in the cardiac arena, having a little over a third of the cardiac market share. We saw the opportunity in that other 65 percent of the market that is undirected and going to other healthcare systems in the area. We have a little more market share on the orthopedic side, but the opportunity there was that 59.9 percent of the marketplace that potentially could move to a Baptist Healthcare System facility.

9 Ways to Curb Healthcare Costs

November 17th, 2009 by Melanie Matthews

While we wait for healthcare reform to clear its next legislative hurdle, the Business Roundtable, an association of CEOs of leading U.S. companies, identifies nine bolder aspects of healthcare reform that could slow the growth of healthcare costs and offer real savings for companies and their employees — by as much as $3,000 per employee in 2019. Their advice shouldn’t be taken lightly; as a group, Business Roundtable’s member companies employ more than 12 million employees, provide health coverage to more than 35 million Americans and report annual revenues of more than $5 trillion.

These top business leaders suggest nine reforms to the U.S. healthcare system that would help curb costs:

  1. Delivery system reforms, such as value-based purchasing;
  2. Innovation centers that identify alternative methods of provider reimbursement;
  3. Accountable care organizations that realign financial incentives to improve the quality and the value of the care delivered;
  4. Financial penalties for failing to avoid preventable hospital readmissions;
  5. Increased individual accountability for healthcare spending decisions, including health reimbursement arrangements and health savings accounts;
  6. Cost and quality of care data that is easier for patients and providers to access and use;
  7. Elimination of sharp regional variations in practice patterns;
  8. Promote wellness and prevention programs and expand financial incentives to participate in specific programs to reduce lifestyle-related illness; and
  9. Insurance market reforms that promote competition and choice.

A featured story in this week’s Healthcare Business Weekly Update provides an example of realigned financial incentives. Baptist Health System explains its rationale for participating in a CMS pilot of bundled payments, in which savings are shared with providers and patients.

Conversely, the Business Roundtable identified several conditions that could increase healthcare costs: delayed or watered-down
cost-saving efforts; failure to implement a strong individual mandate to minimize cost increases in health insurance exchange plans; increases in cost of healthcare to individuals from changes to consumer spending accounts or other actions that discourage consumer-engaged decision-making; and cost-shifting to the private sector.

Risk Factors for Cancers

November 13th, 2009 by Melanie Matthews

Excess body fat and high cholesterol are risk factors for certain types of cancers, as explained in this week’s DM Update.

Learn when a bedside visit is warranted for the frail elderly, and how an osteoporosis prevention plan can help reduce the national rate of hip fractures.

House Health Reform Bill Heavy on Prevention

November 9th, 2009 by Melanie Matthews

The health reform bill that passed by a slim margin in the House on Saturday is still a long way from being law. However, it’s worth noting the bill’s huge focus on “high-value healthcare,” defined in the House bill as “the efficient delivery of high quality, evidence-based, patient-centered care.” The word “value” is mentioned 112 times in the 1,990-page document. Getting more ink is “prevention,” which appears 226 times — as in diabetes prevention, obesity prevention, prevention of alcohol and substance abuse, suicide prevention, and many other programs aimed at improving the overall health status of the nation.

Speaking of health status, Mississippi has one of the nation’s highest obesity rates, along with high rates of diabetes, poverty and medical need. The Mississippi Health First Collaborative announced last week by CMS wants to change those statistics by improving care for patients with diabetes in that state. The non-traditional approach profiled in this issue of the Healthcare Business Weekly Update will deliver diabetes self-management education in community centers and senior centers instead of the usual healthcare settings. Partnering in the collaborative are community groups, health experts, faith-based organizations, housing providers, healthcare providers and others to reach the insured and uninsured across the state.

Poorly managed, uncontrolled diabetes leads to many serious and costly complications. Health First can learn a great deal from Community Care Plan of Eastern North Carolina, which began establishing medical homes for diabetics in its Medicaid population in 2000. Case managers embedded in primary practices called enrollees, sent out information on community support groups, diabetes health fairs and medications — even went to patients’ homes and taught them one-on-one how to test glucose levels and do a foot exam. An external program evaluation by the Cecil G. Sheps Center for Health Services Research estimated a $2.1 million savings from that diabetes program.

In a recent podcast, Community’s nurse case manager Roberta Burgess described the provider and patient education aspects of the diabetes medical home program.

COPD Awareness

November 6th, 2009 by Melanie Matthews

According to the National Heart, Lung and Blood Institute, Americans’ awareness of COPD is rising. Unfortunately, understanding of COPD is not. Discover more on COPD awareness and treatability as well as the surprising effects of hope on the chronically ill in this week’s issue of the DM Update.

You’ll also learn about new policy recommendations for improving medication adherence.

4 Ways to Improve Care Delivery in the Medical Home

November 5th, 2009 by Melanie Matthews

Michael Erikson, vice president of primary care services for Group Health Cooperative, shares four strategies that dramatically improved care delivery in Group Health’s successful medical home pilot.

Call management was a necessary underpinning of our patient-centered medical home (PCMH). Prior to the work on our medical home pilot program, our delivery system was only about 9 percent capable of taking a call from a patient into our primary care practices and resolving that in the first call. For those patients whose call could not be resolved, it often took hours to days to get their answer to a simple question. Currently, all 26 medical centers can answer that patient’s call 80 percent of the time the first time they call, and no patient waits longer than 45 minutes for an answer to their clinical question. It was also necessary for us to deliver access. We had to continue what we learned in 2005. We couldn’t drop the ball on that. Patients still need to come in for visits. We now have standard work around demand management — providing same day/next day access to patients and we’re being successful on that front.

The second strategy of our PCMH I alluded to in my introductory comment, and that was to proactively use virtual medicine, which is secured messaging on the phone to substantially improve care planning and connection with patients. We now have no less than two standard phone visits per day per physician, every day of the week. Patients can request and book a phone visit with their physician. Physicians can also request that the patient have a phone visit if there are lab results that need to be followed up on that require a direct conversation. We also wanted to use secure messaging for those patients who are activated on MyGroupHealth, which is our Web-enabled interaction with our patients. It’s a secure Web site that is connected to their electronic medical record (EMR). They have a view of their EMR as well as e-mail correspondence to and from the physician, and become a part of that ongoing medical record. It was a way for the physician in the medical group to do much more proactive planning with patients.

Prior to our medical home pilot, virtual medicine was reactive; when patients e-mailed us with questions, we would answer. In our medical home pilot the medical group converted that and began to be proactive. In other words, the patient who would have a visit and start on a new medicine on a Monday or a Tuesday would receive a secured message from their physician two to three days after that visit asking how they were doing on their new medicines. Were they having any side effects? Were there any lingering questions that were not answered in the visit? By having the care teams actively reach out to the patient, it reduced unnecessary calls to the care team and unnecessary visits. It enabled the medical group to move from 20-plus visits a day down to 14 visits a day in our pilot clinic, a strategy that is now moving as we spread across all the delivery system.

The next strategy is chronic disease management (DM). You want a primary care system that is uniquely capable of dealing with many of the chronic illnesses. We have standard work elements for the care team around your five core ambulatory-sensitive care conditions: diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), coronary artery disease (CAD), hypertension and asthma. The care teams have standard processes for working with patients around those chronic illnesses. It is what drove part of the cost neutrality of our medical home pilot in one year that moves to a cost positive or cost reduction in the two-year study.

Next, in order to move primary care forward, the care team should begin preparation for visits well in advance of the patient arriving. With our EMR and its registry-like functions, we know the care gaps of the patients who are coming for a visit; all their HEDIS measures. One to three days before visits occur, the team begins to look for any of those care gaps, so that when a patient arrives for a visit, not only are we responding to their acute need, we’re also responding comprehensively to address any care gaps, whether that be a chronic illness, a preventive need as well as their acute needs.

A Medical Home By Any Other Name…

November 2nd, 2009 by Melanie Matthews

CMS’s shelving last week of its widely anticipated Medicare Medical Home Demonstration (MMHD) elicited a strong response from our community. Citing language in pending legislation that would repeal the MMHD and replace it with a similar pilot, CMS reiterated its support for multi-payor pilots like the 2010 Multi-Payor Advanced Primary Care Initiative (MAPCI) Practice Demonstration, described in the Sept. 21 Healthcare Business Weekly Update. HHS equates the advanced primary care model with the medical home.

Many questions surround CMS’s shift in focus, including the rationale for a new label for the medical home model when the current one is widely accepted and understood. When asked about CMS’s decision during last week’s Healthcare Trends in 2010: Marketplace and Health Reform Drivers webinar, healthcare consultant William DeMarco said that a focus on accountable care organizations (ACOs) — networks of primary care physicians, one or more hospitals and subspecialists that provide patient-centered care — will likely replace a lot of discussion of the medical home. “There must be 10 different varieties of medical homes,” said DeMarco. “CMS is likely looking for a more stringent definition of the ACO. The original demo project did not include a discussion of bundled services, not only for providers but for hospitals and other services. That’s something CMS needs to do in order to make it work.”

Healthcare consultant and blogger Vince Kuraitis does a great job of analyzing the CMS announcement, the future of Medicare and the rise of the MAPCI in a recent e-CareManagement blog post.