Archive for August, 2011

Advice for CMS Bundled Payment Participants: Physician Engagement a Must

August 31st, 2011 by Patricia Donovan

Continuous physician engagement and communication is a must in any bundled payment initiative, advises a veteran of the CMS Acute Care Episode (ACE) demonstration project. Organizations have until September 22 to apply for participation in Model 1 of of CMS's newest bundled payments initiative, which seeks to align payments for services delivered across an episode of care, such as heart bypass or hip replacement, rather than paying for services separately.

The application deadline for Models 2,3 and 4 is November 4.

Launched by the Center for Medicare and Medicaid Innovation Center, the program outlines four broad approaches to bundled payments. Providers will have flexibility to determine which episodes of care and which services will be bundled together, making it easier for providers of different sizes and readiness to participate in this initiative.

CMS says bundled payments will give doctors and hospitals new incentives to coordinate care, improve the quality of care and save money for Medicare.

The bundled payments initiative is based on research and previous demonstrations that suggest this approach has tremendous potential, such as the CMS ACE demonstration project. Baptist Health, a five-hospital system in San Antonio, Texas, participated in the ACE demo, which focused on the cardiac and orthopedic diagnosis-related group (DRGs), two of its most frequent and largest cost disease areas.

A major player in the cardiac arena, having a little over a third of the cardiac market share, Baptist Health saw in the ACE demo an opportunity to gain market share, align providers in quality and efficiency efforts, and improve patient satisfaction.

Baptist Health System Chief Development Officer Michael Zucker, FACHE, outlined Baptist's motivation for participation, the key principles of the ACE pilot and the challenges and benefits during a recent webinar on Medical Home Reimbursement: Exploring Bundled Payment Options.

Zucker offered this advice to organizations considering a transition to a bundled payments model:

Continuous physician engagement and communication is a must. No matter how much we’ve communicated, it hasn’t been enough, but it’s getting better. As we get more and more experience with the program, things are becoming more on autopilot. For example, we’ve developed care protocols for each of the DRGs. Initially, physician support of those protocols, even though these were evidence-based and best practice-defined protocols, was highly variable. But the physicians also realized that if they weren’t following the evidence-based protocols, they ran a higher chance of falling outside of the quality metrics.

7 Domains of NCQA Fall ACO Accreditation: Benefits for Early Adopters

August 30th, 2011 by Patricia Donovan

Early adopters of the NCQA ACO accreditation effort launching this fall are eligible for discounted survey fees, online education tools and promotion via NCQA press release. Order the NCQA ACO standards.

NCQA worked with consumer advocates, purchasers and other healthcare and managed care experts to develop seven standards by which it will evaluate Accountable Care Organizations (ACOs). The ACO Accreditation program evaluates organizations in seven domains:

1. ACO Structure and Operations

The organization clearly defines its organizational structure, demonstrates capability to manage resources and aligns provider incentives through payment arrangements and other mechanisms to promote the delivery of efficient and effective care.

2. Access to Needed Providers

The organization has sufficient numbers and types of practitioners and provides timely access to culturally competent healthcare.

3. Patient-Centered Primary Care

The primary care practices within the organization act as medical homes for patients.

4. Care Management

The organization collects, integrates and uses data from various sources for care management, performance reporting and identifying patients for population health programs. The organization provides resources to patients and practitioners to support care management activities.

5. Care Coordination and Transitions

The organization facilitates timely exchange of information between providers, patients and their caregivers to promote safe transitions.

6. Patient Rights and Responsibilities

The organization informs patients about the role of the ACO and its services. It is transparent about its clinical performance and any performance-based financial incentives offered to practitioners.

7. Performance Reporting and Quality Improvement

The organization measures and publically reports performance on clinical quality of care, patient experience and cost measures. The organization identifies opportunities for improvement and brings together providers and stakeholders to collaborate on improvement initiatives.

Warning: Winds of Healthcare Change Ahead

August 29th, 2011 by Cheryl Miller

As we go to press Friday afternoon, Hurricane Irene is threatening to pummel our eastern coastline with winds greater than 80 mph; store shelves have been emptied of bottled water and batteries and anyone searching for a generator is probably out of luck.

Healthcare, too, is preparing for the winds of change as reform laws descend upon it, and many preparations are being made in its wake. HHS just announced it is awarding $40 million in grants to identify and enroll children eligible for Medicaid and the Children's Health Insurance Program (CHIP). The two-year grants are authorized under the Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009, and part of the administration’s push to ensure all eligible children.

In a move to address shifting reimbursement plans, CMS is proposing four bundled payment plan models. These models are designed to align payments for services delivered during an episode of care, rather than paying for services separately. This new initiative will give providers the flexibility to determine which episodes of care and which services will be bundled together. Read more about this proposal in this week's Healthcare Business Weekly Update.

And lastly, nearly one of every 10 mid-sized or big employers might stop offering health coverage to workers after insurance exchanges begin operating in 2014, states a recent survey from Towers Watson. The survey, which involved more than 1200 companies, says that the companies are willing to risk the ensuing fees and tax headaches that could arise with such a move. Last year, the average annual health insurance premium for employer-sponsored family coverage was $13,770 per worker, with companies picking up most of that tab,
according to the Kaiser Family Foundation and Health Research and Educational Trust. That cost has more than doubled since 2000.

But survey officials stress that these results aren’t written in stone, and that employers could change their minds given all the unresolved variables, not unlike the hurricane headed our way. We’ll just have to see what path the storm takes.

Video: Evolution of Embedded Case Managers

August 24th, 2011 by Patricia Donovan

They're called case managers, nurse navigators, or something else, and they're showing up in primary care practices, hospital emergency rooms, and even long-term care facilities. We've watched with interest the emerging trend of the colocated healthcare case manager and created a video that presents the latest industry benchmarks on this population health management strategy as well as a look at how Geisinger Health System, Bon Secours Health System and others are colocating case managers at points of care.

While the practice is relatively new, these organizations are reporting dramatic reductions in hospital readmissions, length of stay and patient cycle times, among other benefits. We invite readers to share how an on-premise case manager is affecting care delivery and healthcare spend.

U-M’s Care Strategies Save Medicare $22 Million, Demonstrate ACO Benefits

August 22nd, 2011 by Cheryl Miller

Improving preventive and chronic care helped the University of Michigan (U-M) to save Medicare more than $22 million during a five-year Physician Group Practice Demonstration (PGPD), which was designed to show the potential benefits of ACOs. A new transitional care program assisting patients with hospital discharge and follow-up was one of the ways the health system successfully achieved savings.

HHS has awarded $185 million in grants to 13 states and the District of Columbia to help them establish new state-based health insurance
marketplaces. The agency is hoping that individuals, families and small businesses will be able to use the exchanges to purchase private health insurance beginning in 2014.

And lastly, don’t forget to participate in our second annual survey on medication adherence. You'll receive a free executive summary of the survey results once they are compiled. To take the survey, please click here.

These issues and more in this week's Healthcare Business Weekly Update.

Less is More When it Comes to Healthcare

August 19th, 2011 by Cheryl Miller

Less is more, at least when it comes to certain medical procedures.

That was the conclusion of a recent study by the American Heart Association (AHA) and reported here in a recent issue of Healthcare Business Weekly Update. Researchers compared the use of drug-eluting stents (DES) in 2004-06 to 2007, when their use decreased by nearly 25 percent. Using data from the Evaluation of Drug-Eluting Stents and Ischemic Events registry, the study found that limiting the use of DES did not increase the risk of death or heart attack, and only slightly raised the need for repeat angioplasty procedures. In fact, because the stents were reserved for use on higher risk patients, healthcare costs were reduced by an average of $410 per patient. When multiplied by the estimated 1 million angioplasty procedures performed annually, the United States is able to save nearly 400 million a year.

A recent story in Newsweek corroborates this research, and suggests that the use of DES weren’t the only medical procedures being overused. The article goes on to state that some common tests and procedures aren’t just expensive, but can do more harm than good.

“There are many areas of medicine where not testing, not imaging, and not treating actually result in better health outcomes,” says Dr. Rita Redberg, professor of medicine at the University of California, San Francisco, and editor of the Archives of Internal Medicine.

The problem is that “in otherwise healthy people,” screenings can lead to false positives, and cascading tests and procedures for possible problems that might have been harmless, or gone away on their own, the article says.

From PSA tests for prostate cancer (which more than 20 million U.S. men undergo every year) to surgery for chronic back pain to simple antiobiotics for sinus infection, a remarkable number and variety of tests and treatments are now proving either harmful or only as helpful as a placebo.

The article doesn’t dismiss the benefits of progressive medicine; instead, it lists the procedures that have saved lives and eased suffering for millions:

Screening tests like mammograms...can lead to early treatment of breast cancer, especially for women with hereditary risk or a strong family history of the disease. For cancer patients who report back pain, MRIs can prove invaluable for spotting tumors that have metastasized to the bones, allowing doctors to intervene before it’s too late. The years between 1980 and 2004 saw a 50 percent decline in the death rate from coronary heart disease thanks to better treatments and drugs that reduce cholesterol and blood pressure. At least 7,300 lives are saved every year thanks to colonoscopies.

But the flip side is that procedures are being overprescribed, like colonoscopies for the elderly, which can often harm them, and CT scans for the injured. A study published by John Hopkins noted the rise in MRIs and CT use in emergency departments over a 10 year period, from 1998 to 2007. The Hopkins team found that patients with injury-related conditions were three times more likely to get a CT or MRI scan in 2007 than they were in 1998. But the team also found that diagnosis of life-threatening conditions, such as a cervical spine fracture or liver laceration, rose only slightly.

Part of the problem is compensation: according to the Newsweek article, Medicare pays physicians more than $100 million a year for screening colonoscopies; still other procedures, like angioplasty, bypass surgery and stenting are not improving cardiac patients’ lives; but instead costing Medicare more than $1.6 billion a year.

The solution? The study published by the AHA didn’t directly identify which patients are the best candidates for DES, although other studies are currently underway using similar patient registries to address it. And research shows that low risk heart patients can benefit more from noninvasive treatments like drugs (beta blockers, cholesterol-lowering statins, and aspirin), exercise, and a healthy diet.

With the push for reducing healthcare costs while improving care, it’s an issue that will most probably continue to be explored.

Adults’ Top 10 Health Concerns for Kids

August 17th, 2011 by Jessica Fornarotto

Adults rate drug abuse and childhood obesity as the top health concerns for kids in their communities, according to the fifth annual survey of the top 10 health concerns for kids conducted by the University of Michigan C.S. Mott Children’s Hospital National Poll on Children’s Health.

In May 2011, the poll asked adults to rate 23 different health concerns for children living in their communities. The top 10 overall health concerns for U.S. children in 2011 and the percentage of adults who rate each item as a “big problem” are the following:

  1. Childhood obesity: 33 percent
  2. Drug abuse: 33 percent
  3. Smoking and tobacco use: 25 percent
  4. Teen pregnancy: 24 percent
  5. Bullying: 24 percent
  6. Internet safety: 23 percent
  7. Stress: 22 percent
  8. Alcohol abuse: 20 percent
  9. Driving accidents: 20 percent
  10. Sexting: 20 percent

The poll also found that adults’ perceptions of top health problems for children in their own communities differ by race/ethnicity. The poll found that for both blacks and Hispanics, drug abuse was their top health concern, at 44 and 49 percent, respectively. However, drug abuse for white populations came in second at 28 percent, while childhood obesity came in first at 30 percent. Meanwhile, 44 percent of both blacks and Hispanics chose childhood obesity as their concern. When ranking smoking and tobacco use, 36 percent of blacks and 22 percent of whites both ranked this issue at number three, and 35 percent of Hispanics ranked it at number eight.

According to Matthew Davis, MD, director of the poll and associate professor in the Child Health Evaluation and Research Unit at the U-M Medical School, “The perception of drug abuse as a big problem matches recent national data showing increasing use of marijuana and other drugs by U.S. teens. Meanwhile, although obesity remains atop the list of child health concerns for the fourth straight year, the level of public concern has declined over the last few years in our poll. This may be a warning to public health officials, because it indicates how the public is hearing national messages that previous increases in children’s obesity rates have recently leveled off.”

Geisinger, Dartmouth-Hitchcock in CMS PGP Transition Demo

August 15th, 2011 by Cheryl Miller

Congratulations to all CMS PGP Demonstration participants, especially Geisinger Health Systems and Dartmouth-Hitchcock, both of whom have shared their strategies for population health management with HIN.

Early on in the PGP demo, DH targeted patients with CHF, CAD, and diabetes; it then developed two 'super registries' to monitor both chronic disease markers and preventive care needs in its population. It created training for new roles for nurses and case managers, focusing on health coaching, motivational interviewing and bridging care across transitions. DH then created reports comparing its MDs' performance with those of their peers. In the end, they received about $13 million in shared savings from CMS.

Says Barbara Walters, senior medical director, "What did we do to make a difference? It was our admission rate, cost of care for CHF patients and our clinical quality compared to the comparison group. We didn't even realize it but we had created a medical home, which is a very important cornerstone for all of this."

And Geisinger achieved 100 percent on the PGP program's quality measures, the only one of the 10 organizations to do so for the last four years of the demonstration. "By focusing on improving quality, we were able to reduce the total costs of treating Medicare beneficiaries. Our costs at Geisinger rose only 1.4 percent, compared to the typical 4 to 6 percent increase observed nationwide," said Thomas Graf, M.D., associate chief medical officer, Population Health; chairman, community practice, Geisinger Health System.

We look forward to charting the progress of all of the organizations involved in the transitional program.

You can read more about this and other healthcare issues in this week's Healthcare Business Weekly Update.

Bon Secours Models Nurse Navigators On Geisinger Embedded Case Managers

August 12th, 2011 by Patricia Donovan

Bon Secours Health System has put its own spin on the embedded case manager at the center of Geisinger's Proven Health Navigator model, adding home-grown care improvement tools and retooled workflows to support Bon Secours RN Nurse Navigators.

VP and Chief Clinical Officer Robert Fortini described the rollout of the Bon Secours Clinical Transformation project and the central role of the nurse navigator during an August 10 webinar on Embedded Case Management.

A premier goal of the team-based project is to "provide more care to more people," Fortini explained, adding that the new system of care is capable of doubling the capacity of a typical practice with a panel of 2,000 patients. Using the principles of division of labor, the project encourages staff members to practice at top of license and puts clinical tasks in the hands of someone most able to help. Often, this will be the RN nurse navigator — a case manager embedded in a physician practice. Bon Secours is also exploring the use of virtual case managers for its remotely located practices.

Support tools include a home-grown online database of community resources that nurse navigators can consult when assisting patients; a patient severity index developed in-house that determines a patient's likelihood of being readmitted to the hospital; and daily hospital discharge reports generated by registries that fuel follow-up calls from nurse navigators.

An important new workflow is the daily "huddle" — a 5- to 10-minute meeting during which all staff members will review the cycle of patients due to come through the door that day.

While the program is still in its infancy, Fortini expects that the team approach in general and embedded RN case managers in particular will substantially curb 30-day readmissions. He said Bon Secours has also noted improvements in patient cycle times and the hourly rate of completed nurse navigator patient calls, as well as spikes in efficiency, capacity and staff satisfaction.

Listen to an interview with Robert Fortini.

The Nurse’s Contribution to Discharge Planning

August 10th, 2011 by Cheryl Miller

Johns Hopkins' nurses play an essential role in the discharge planning process, explains Chad Boult, MD, MPH, MBA, professor of public health, medicine & nursing and director of the Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health.

Question: What's the role of the nurse in discharge planning for the comorbid population?

Response: In our model, the nurse doesn't do the discharge planning. There are some transitional care models where the nurse does do it and every hospital has to have a discharge planner, but we rely on the discharge planner to make the plan. Our nurse interacts with the discharge planner to make sure that they know everything they need to know about the patient for whom they're making the plan. Most discharge planners have no idea of the patient's home circumstances. However, our nurse has been to the home and makes sure the planners know the capabilities at home and tries to ensure that a good plan is made. Importantly, our nurses visit the home the day of or day after discharge. That's when the opportunity is greatest to resolve the confusion that's almost always going on in patients who have complicated problems, have had their medications adjusted and then are sent home.