Archive for April, 2010

Risk-Adjusted Reimbursement in Minnesota

April 26th, 2010 by Patricia Donovan

When it comes to moving the medical home forward -- and funding it -- Minnesota is ahead of the game. The state already has a risk-adjusted reimbursement strategy that reflects the patient's complexity and the time required by the medical home to care for complex patients. This week's Healthcare Business Weekly Update features a podcast from Dr. Jeff Schiff, who describes two key factors that can make care more complex, and presents the business case for creating measurable patient- and family-centered practices. Even a simple gesture like giving the clinic's direct phone number to patients with chronic illness, he says, can have a surprising impact on patient satisfaction and clinic efficiency.

Reform Affecting Reimbursement Levels

April 19th, 2010 by Patricia Donovan

Late last week Congressional and presidential actions postponed to June 1 a scheduled 21.2 percent cut in Medicare physician pay. In this week's Healthcare Business Weekly Update, we feature an AARP survey that finds that one in five Idaho physicians are not accepting new Medicare patients, with one in four refusing new Medicaid patients. This trend is echoed around the country, according to the American Medical Association's reaction to the postponed cut.

Also affecting reimbursement levels are avoidable hospitalizations and readmissions of Medicare patients. That's why more healthcare organizations place case managers at care sites to help coordinate complex care and smooth transitions between care sites. This week we present findings from our 2009 Healthcare Case Management study, with details on case manager case loads, work locations, performance evaluation and effect on utilization.

You'll also hear from Susan Shepard of The Doctors Management Company on the type of patient most at risk for readmission and how a patient's primary physician can contribute to a successful hospital discharge.

Young Invincible’s Health Behaviors

April 16th, 2010 by Jessica Fornarotto

In this day and age, while young adults may believe themselves invincible, their current health behaviors will affect them later in life. This week's issue offers some examples, from the link between adolescent drinking and breast cancer, to the consequences of gaining too much weight during the younger years.

On a positive note though, smoking prevalence among New Hampshire's youth has decreased from 2001.

Technology Backbone for an Evidence-Based Practice

April 16th, 2010 by Melanie Matthews

Registry or electronic health record? Dr. Richard Baron, president and CMO of Greenhouse Internists, defines the roles and limitations of these technologies in the delivery of evidence-based care.

There are four areas of activity to adopt evidence-based principles in a practice: technology, staff, patients and doctors. When it comes to technology, I am a big fan of electronic health records (EHRs). Although it’s not my favorite way to do things, there are organizations doing some of this work using freestanding registries, which are databases that a doctor or a practice might log into and enter data, then use the registries to manipulate those data and generate performance reporting or automated patient outreach.

Many people view registries as a bridge technology. They say EHRs are a big deal for doctors to do and a registry is easier, and that if they could just do registries, then they can do that even in a paper office. That’s true, but the problem with a registry is it tends to be disease-specific. It requires "double entry bookkeeping" — everything that you write in the chart also has to be put into the registry.

It’s better for doctors to move to an EHR model, because then when you write a prescription, it’s already in the registry. When you process the lab report, it’s already in the registry. Everything goes into the database all at once. But that’s a very complicated process to manage in a practice.

To move toward an evidence-based practice, look for aspects of EHR support such as embedded decision support. For example, the EHR knows whether it’s a man or a woman and it knows the age of the patient, so it can make recommendations about preventive care that should be done for somebody in that age group. Of course, that’s more powerful when it’s linked to knowledge of what’s already been done. It’s great to say that the patient is a woman between the ages of 50 and 65 and she needs a mammogram, but it’s even better if the EHR knows whether she’s had a mammogram and can turn off that alert when she doesn’t have it and use it as a reminder of when she does.

You need to use the EHR "intentionally." Most doctors adopting EHRs today are adopting them for the word processing feature of information technology (IT). They’re more interested in the generation of a progress note.

Tuning Up Healthcare Technology

April 12th, 2010 by Melanie Matthews

As payment reforms shift in favor of patient-centered approaches, healthcare organizations are tuning up technologies to support new models of care delivery. In a featured story in this week's Healthcare Business Weekly Update, the president of a five-physician practice offers his take on the health IT necessary to deliver evidence-based care. You'll also learn how the Veterans Affairs' investment in health IT is netting clinical and financial gains, and listen to two healthcare thought leaders on wiring the medical home for efficiency and quality. Contrary to popular belief, it doesn't always require an electronic health record.

Identifying Target Populations for Case Management

April 9th, 2010 by Melanie Matthews

Diane Littlewood, R.N., and Joann Sciandra, R.N., regional managers of case management for health services at Geisinger Health Plan, define targeted populations for case management and initial enrollment steps.

At Geisinger, our approach to case management is focused on the identification of the high-risk population. Looking at our targeted populations, we focus on heart failure, chronic obstructive pulmonary disease (COPD), the frail elderly and any patient with transition of care. The majority of our case referrals come through at hospital discharge and admissions. Anyone who is identified with a hospitalization and a discharge is automatically a high risk with a risk rank of five. We proactively use our claims system to identify other populations that would require case management. Patients that are at the highest risk — patients with heart failure, COPD, frequent hospitalizations and ER visits — are high risk and we look to enroll them into case management.

Once we have our patients identified, our nurses provide a comprehensive assessment, which comes from our assessments and stratifications. This assessment identifies the driving issue behind the case and where we have to start with this patient to make a difference. We develop an action plan based on the issue. Having a case manager on site gives us the ability to interact with the healthcare team who is managing this patient in our ProvenHealth NavigatorSM site. Our case manager has the ability to sit down with the primary care site doctor and show them the action plan. That primary care site doctor then has the ability to make changes in that plan. It’s comprehensive and collaborative. We have found that our plans work better when the primary care site physician is brought into the plan from the beginning.

We have templates that are built into our documentation pieces that are NCQA-driven and that address the social, physical and behavioral needs and health history of the patient. We develop a patient center plan of care based on their risks and the goals that they have. We’re talking about short- and long-term patient goals as well as how we hope that their health status, and the care that we deliver, will move them to quality care and a good quality of life. We manage those acute care exacerbations with targeted action plans. We’re hoping that if someone has heart failure and needs diuresis, that we don’t have to send them to an ER for that. The sites are set up and the nurses and nursing staff have all been trained so that they are able to start IV’s and give some Lasik™ in the clinic setting. Or, if there is possibly dehydration, they can hydrate someone there instead of sending someone for a long wait in an ER. Our nurses are engaged with community resources and strong relationships with area agencies on aging and different communities — again resources that we tap into frequently.

Monitoring Disease

April 9th, 2010 by Melanie Matthews

In this week's issue, learn about a retail clinic now offering health monitoring services for certain conditions, as well as gender differences in exercise by cardiac patients. You will also discover the risks that diabetes can pose in patients needing cancer surgery.

In addition, get the latest metrics in obesity and weight management by completing our new e-survey by April 30. Tell us what your organization is doing to reduce obesity.

Shared Savings from a Gold Standard Medical Home

April 5th, 2010 by Melanie Matthews

About a year ago, Dr. Atul Gawande, a writer for The New Yorker, put Grand Junction, Colorado's healthcare system on the map when he contrasted its low-cost, high-quality approach with one of the most expensive healthcare systems in the country. Before long, the area was being touted as the gold standard for healthcare; President Obama even held a healthcare town meeting in the region.

During last week's webinar on shared savings in the medical home, hospitalist, family physician and healthcare consultant Dr. David West shared with us some of Grand Junction's cost-effective approaches, including a community-supported non-FQHC clinical safety net clinic providing care for the uninsured. In our featured podcast in this week's Healthcare Business Weekly Update, Dr. West describes how Grand Junction's model might be adapted for use in other areas of the country, and explains the area's secret to keeping Medicare patients out of the hospital.

Also this week, we present the results of our special edition survey on reaction to healthcare reform — the good, the bad and the skeptical. Learn how 124 healthcare organizations feel about the legislation and how they're preparing to survive in healthcare's new frontier.

Shared Savings from a Gold Standard Medical Home

April 5th, 2010 by Melanie Matthews

About a year ago, Dr. Atul Gawande, a writer for The New Yorker, put Grand Junction, Colorado's healthcare system on the map when he contrasted its low-cost, high-quality approach with one of the most expensive healthcare systems in the country. Before long, the area was being touted as the gold standard for healthcare; President Obama even held a healthcare town meeting in the region.

During last week's webinar on shared savings in the medical home, hospitalist, family physician and healthcare consultant Dr. David West shared with us some of Grand Junction's cost-effective approaches, including a community-supported non-FQHC clinical safety net clinic providing care for the uninsured. In our featured podcast in this week's Healthcare Business Weekly Update, Dr. West describes how Grand Junction's model might be adapted for use in other areas of the country, and explains the area's secret to keeping Medicare patients out of the hospital.

Also this week, we present the results of our special edition survey on reaction to healthcare reform — the good, the bad and the skeptical. Learn how 124 healthcare organizations feel about the legislation and how they're preparing to survive in healthcare's new frontier.

4 Ways to Improve Care Delivery in the Medical Home

April 5th, 2010 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 have standard work around demand management — successfully providing same day/next day access to patients.

The second strategy of our PCMH 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.

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 for the 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 diagnosed with 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; we know 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 or an acute need.