Archive for January, 2012

EHR No Substitute for Population View Provided by Registries

January 31st, 2012 by Patricia Donovan

The proliferation of EHRs is driving the format and functionality of patient registries today, according to new market research from the Healthcare Intelligence Network.

However, healthcare experts note that EHRs are no substitute for a registry.

“Registry functionality is not always the same as an EMR,” cautions Julie Schilz, manager, IPIP and PCMH for the Colorado Clinical Guidelines Collaborative. “Registry functionality is the ability to understand your patient population and their needs, whether they are being managed against evidence-based guidelines, being able to support outreach to patients who might be falling outside of the guidelines and understand per provider how their patients are being managed against evidence-based guidelines."

The registry is used in a positive way for quality improvement, Schilz notes, not as a stick to suggest that providers and their care team are not managing effectively.

“The registry is utilized to help manage the patient population and understand how, in using the measures as a proxy, the systems that the practices put into place are having the desired impact on patient population for both health and healthcare delivery,” she concludes.

While more than two thirds of 2008 survey respondents favored freestanding database-centered registries, the trend in 2012 is toward registries as a component of an EHR, as reported by one-third of 2011 respondents, or Web-based registries, used by another 29 percent of this year’s respondents.

Registry use has remained constant at about 50 percent since HIN last surveyed the healthcare industry on this topic in 2008.

This year’s analysis also found that registries are used more than three times as often today to generate health alerts and reminders for appointments and preventive services. Only a quarter of 2008 respondents were using registries in this proactive manner. Whether as simple as an Excel® spreadsheet or a module in an EHR, healthcare organizations have warmed to the patient-tracking features and the population-eye view that registries deliver.

“To move primary care forward, you want the care team to begin preparation for visits well in advance of the patient arriving,” adds Michael Erikson, vice president of primary care services for Group Health Cooperative, an organization touted by CMS for its advanced and comprehensive primary care services. “With our EMR, which has registry-like functions within it, we know the care gaps of the patients who are coming for a visit; we see all their HEDIS measures. The team begins, one to three days before visits occur, 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, but we are also responding comprehensively to address any care gaps, whether that be a chronic illness, a preventive need or an acute need.”

Baptist, Geisinger and Banner Among Top Performing Health Systems: Thomson Reuters

January 24th, 2012 by Cheryl Miller

Our congratulations to three frequent contributors to HIN for taking top honors in Thomson Reuters’ annual Best Hospitals list: Banner Health, a leader in ER efficiency, Geisinger Health System, on the forefront of comprehensive primary care, and Baptist Health, a model for bundled payments. These three esteemed health organizations, and 12 others, were singled out from more than 300 organizations for having achieved superior clinical outcomes based on eight metrics that gauge clinical quality and efficiency: mortality, medical complications, patient safety, average length of stay, 30-day mortality rate, 30-day readmission rate, adherence to CMS clinical standards of care, and HCAHPS patient survey score. A full list of the 15 winners can be found in this issue.

At the same time CMS issued its annual report on healthcare spending, showing historically low rates of growth for 2009 and 2010, the HHS has determined that Trustmark Life Insurance Company proposed unreasonable health insurance premium increases in five states, hikes that would affect nearly 10,000 residents. HHS is requiring the insurer to immediately rescind the rates and issue refunds to consumers, or publicly explain their refusal to do so. The ACA requires that insurance companies disclose and justify rate increases over 10 percent. States also have the authority to reject unreasonable premium increases since the passage of the law, to date, 37 states have this authority.

Certified Diabetes Educators and case managers are instrumental in diabetes management, according to the results from our 2011 survey on diabetes management strategies. More than three-quarters of healthcare organizations said they were taking a disease-specific approach to improving health outcomes and self-management in patients and health plan members with diabetes. And the majority of respondents said that weight management was the greatest challenge of managing diabetes. More details can be found in this story, and our complimentary downloadable white paper.

And don’t forget to take our newest survey: Reducing Hospital Readmissions Benchmark Survey. Describe how your organization is working to reduce hospital readmissions for 2012 by taking HIN's third annual survey on this subject by January 31, 2012 and receive an e-summary of the results once they are compiled.

Snowboarder Video As Much About Miracles as Helmet Safety

January 24th, 2012 by Patricia Donovan

Spoiler: This video has a happy ending. But not all athletes participating in extreme sports are so lucky. Last week's tragic death of Canadian freestyle skier Sarah Burke underscores the physical risks these athletes face each time they "strap in."

The fact remains that in 2009, hospital emergency rooms, doctors’ offices, and clinics treated 353,346 injuries related to these winter sports activities, according to a position paper by the American Academy of Orthopedic Surgeons (AAOS). The medical, legal, work loss and pain and suffering costs were more than $9.28 billion.

Know any "shredders" who think helmets aren't cool? You might want to share this video with them.

The newly released film Moving Forward chronicles the recovery to date of Danny Toumarkine, a professional snowboarder from New Hampshire who suffered a traumatic brain injury (TBI) while snowboarding in Montana on a film trip in January 2011. (Full disclosure: My nephew Tom is the human greeting card in the video.) After a grueling year of multiple brain surgeries, physical rehabilitation and sheer determination, Danny was able to return to the slopes to "ride" this month.

Danny wasn't wearing a helmet at the time he was injured, but this video is a convincing argument for the use of "brain buckets" in any type of riding. Sarah Burke was, and there is no indication at this time that equipment played any part in her injury and subsequent death. According to the AAOS position paper, the National Ski Patrol recommends wearing a helmet while skiing or snowboarding:

Studies show that helmets offer considerably less protection for serious head injury to snow riders traveling more than 12-14 mph. Safety and conscientious skiing and riding should be considered the most important factors to prevent injury, while helmets provide a second line of defense against head injuries.

Snowboarders face greater risks, the paper continues:

The 1999 CPSC evaluation of snow skiing and snowboarding-related head injuries found that snow boarders are 30 percent more likely to have a significant head injury than skiers. One of the most common causes of injury is collision with fixed objects, such as trees. More than 40 percent of the annually reported snow skiing and snowboarding-related head injuries could have been prevented or minimized with helmet use.

And even for helmet-wearing athletes, speed is a considerable factor in the severity of a head injury:

The purpose of the helmet is to partially absorb the force and dissipate the energy of blunt trauma in an effort to protect the head. While helmets do not decrease the risk of injury, they can decrease the severity. A study found 15 skull fractures among 27 fatal head injuries. Six of these fractures were depressed, suggesting that protective gear may be of benefit. Several studies in Sweden show that the use of helmets has reduced head injuries by approximately 50 percent.

More detail on Danny's yearlong struggle is chronicled in the Danny is the Bomb blog created by his brother Conor to keep friends and family abreast of Danny's condition, to accept donations for Danny's medical expenses and to raise helmet and TBI awareness in action sports.

Q&A: HRHC Diabetes Collaborative Relies on Tiered Care Management, Registries

January 23rd, 2012 by Jessica Fornarotto

Patient care partners, innovative weight management tactics, patient registries and even telepsychiatry are part of the team approach to diabetes management at Hudson River HealthCare (HRHC) Diabetes Collaborative. The New York-based network of FQHCs finds that tiered care management generates the best outcomes for its patients with diabetes, explains Kathy Brieger, RD, CDE, HRHC’s chief operations officer, prior to her presentation on Diabetes Management in the Medical Home.

HIN: The Hudson River HealthCare (HRHC) Diabetes Coalition uses a patient-centered team approach to manage diabetes in its more than 3400 adult patients with the disease. HIN recently did a survey to find out about disease-focused programs in particular, those that manage diabetes. Our respondents told us that weight management is the most challenging aspect of this disease. Would you concur? If so, how does HRHC address weight management in its population?

(Kathy Brieger): I would agree with this. Weight management is one of the most challenging focuses of this condition. In order to meet this challenge, we’ve had to look at programs from a variety of aspects. We started walking clubs in some communities to encourage physical activity. There’s also a Taking off Pounds Sensibly group, which is a Weight Watchers format but at a lower cost for patients who may be at a low income. We’ve done programs on mindful eating and general ways of looking at portions. We’ve also done a lot of work related to children and preventions. I think this is a big target. We focus on prevention and giving people the options of attending a variety of program formats for weight loss.

HIN: Over the last 12-18 months we’ve seen that case managers are increasingly employed on site, in primary care practices, to assist with the management of chronic illness. Are there any case managers in the HRHC mix?

(Kathy Brieger): This is a key question to diabetes management. We’ve found that a team-based approach to care is really the most effective. We have several team members who help to case-manage the patients. And that includes everyone from a dietician to people called patient care partners. Patient care partners may not have a clinical license, but are trained in motivational interviewing and help to serve as a bridge between the clinical team and the patient. We also have sophisticated, high-level RN care managers who work in a targeted way with patients who have diabetes. Those are usually the patients who have comorbidities and who may have poor control over their diabetes. At Hudson River HealthCare, we look at a team-based approach using different levels of care to get the best outcomes. We find that that really is the most effective.

HIN: The more sophisticated care managers are for the sicker patients with comorbidities. How do you assign patients to the other two levels of management?

(Kathy Brieger): We have some reporting systems because we do have an electronic health record; we use eClinical Works® (ECW). We have different cutoffs for the care manager. We’ve run the registries. For people who have hemoglobin A1Cs of over 8 or 9, the care manager reviews them and she’ll pull off people who may have some of those indicators. Also, the medical providers will tell us, “This person may not have a hemoglobin A1C of over 8 or 9, but they’ve been in and out of the hospital several times.”

Right now, we’re also working with hospitals to get us hospital discharge summaries so we can see if those people who may have some unstable situations that we’re not aware of can be pulled in. For every single person who has diabetes, their care is also managed by the patient care partners. We taught them how to use the registries, how to call people in for group classes and how to send letters out for our programs. These levels are done in a three-tiered approach using the care team so that the patient care partner who is assigned to the care team, the nurse who is assigned to the care team and the provider assigned to the care team would together be able to route or send people to the right place. The bulk of our patients are able to do the low-level patient care part. It’s just the top 15 percent that are having some issues.

HIN: It sounds like registries are important to the program.

(Kathy Brieger): Yes, they are. Over 10 years ago, we started with the Patient Electronic Care System (PECS) as part of the federal government’s move to get a population health underway, but it was a limited standalone registry. And then about three years ago when we became fully electronic, we were able to get our registries and our reports done on all patients with all conditions, and that is valuable. We’ve done a lot of work on training our staff on how to use registries; it’s not so helpful just to have registries; you have to know how to use them.

We’ve tried to use registries as a teaching tool for everyone from even clinical assistants in training all the way up to the providers. They know how they can use it to have more effective team-based care, more effective disease-based focus, and even prevention of things like, “When did you get your mammogram done last?”

HIN: And finally, are there any applications in telehealth, telemedicine or remote monitoring that you are using successfully in the management of diabetes?

(Kathy Brieger): Yes. We’re involved with telemedicine, focusing on telepsychiatry at one site. We have purchased equipment and are right now getting it cabled for six different locations, so that we’ll be able to expand our services in the telemedicine area. We do have some sites that are located in remote areas. We are unable to get some specialists that may help in the management of diabetes. We think telemedicine will be a great resource in improving some access to services that may not be available in some of those remote areas. Even though we’re in New York, people think we have all types of access to specialists, but there are areas where they do not exist, even in New York. We’re looking forward to having that happen.

Gastric Bypass Surgery – Extreme Makeovers for Obese Teens

January 20th, 2012 by Cheryl Miller

It seems that gastric bypass surgery is way more popular than Justin Bieber.

At a time when most teens should be contemplating their friends' latest Facebook post, there's instead a large segment weighing the pros and cons of lap banding versus stomach stapling versus sleeve gastrectomy, the current crop of bariatric surgeries now targeted toward teenagers.

According to a recent New York Times article, 1 to 2 percent of all weight-loss or bariatric operations are on patients under 21, and studies are underway to gauge the outcomes of such surgery on children as young as 12. As stated in the Times:

Allergan®, the maker of the popular Lap-Band, a surgically inserted silicone band that constricts the stomach to make the patient feel full quickly, is seeking permission from the Food and Drug Administration to market it to patients as young as 14, four years younger than is now allowed. Hospitals across the country have opened bariatric centers for adolescents in recent years.

Along with the obesity epidemic in America is an explosion in weight-loss surgery, with about 220,000 operations a year — a sevenfold increase in a decade, costing more than $6 billion a year.

The article follows one obese but otherwise healthy teenager who has adjusted to her weight, but gets stomach banding surgery at her doctor’s advice to prevent future health problems like diabetes. The operation takes about 25 minutes, costs nearly $22,000, and is covered by a state insurance plan for low-income families.

Medicaid in almost every state and many private health plans now cover bariatric surgery, often more readily than diet or exercise plans. In fact, braces cost more than bariatric surgery. Federally funded bariatric surgery is a relatively new phenomenon; Medicare first endorsed paying for bariatric surgery in 2006. And Medicaid approved funding of it in 2004.

Gastric surgery is the latest surgical quick fix for teenagers who should be navigating the convoluted hallways of high school adolescence instead of surgery options. These surgeries constrict the stomach so that even eating a slice of pizza with friends, while not condoned in excess, could cause problems.

This, despite reports that show that U.S. obesity rates decreased last year from 26.6 percent in 2010 to 26.1 percent in 2011, according to a report based on the Gallup-Healthways Well-Being Index. Researchers said the decline was due in part to more Americans saying they were a normal weight in 2011.

This small decrease is significant, says Gallup researchers, because:

The cost of obesity is so high that even this small improvement has the potential to save the American economy a significant amount of money. A December 2010 analysis by the Society of Actuaries estimates that the total cost of obesity to the U.S. economy has climbed as high as $270 billion. Gallup's own analysis finds that obesity and related chronic health issues cost businesses alone upward of $150 billion annually. But with more than one in four adults still obese, the nation has a long way to go to achieve lasting change.

We recently reported that CMS is now offering free preventive obesity counseling to seniors with a BMI greater than or equal to 30 kg/m2. As the Times reports, Allergan is targeting children at this threshold of obesity as candidates for the Lap-Band surgery.

And that’s a lot of children. According to a recent survey from the National Health and Nutrition Examination, nearly one-fifth of U.S. children and adolescents are obese.

It’s hard not to wonder when preventive education and old-fashioned dieting and exercise were replaced with surgical quick fixes like stomach stapling. Instead of paying for these surgeries, we need to finance education programs for the young so they don’t become one of the three American adults expected to have diabetes by the year 2030.

Timeline to ICD-10: BCBS Michigan Approach is Business-Driven

January 19th, 2012 by Patricia Donovan

In its third year of ICD-10 work, BCBS of Michigan sees the project as business-driven, not solely an IT initiative. Early on, the Blues plan realized the ICD-10 transition affected nearly all aspects of its business, explained Dennis Winkler, BCBSM's ICD-10 technical program director, in this week's webinar on Mapping the Way to ICD-10 Readiness.

One of the first steps in the project was determining how and where it was using codes, Winkler continued. The challenge was then determining how to associate or map ICD-10 diagnosis codes to the proper diagnostic category, and then validate the mappings for professional claims. Faced with more than 70,000 ICD-10 codes, BCBSM focused its work on codes with discrepancies and high-impact codes.

After identifying discrepancies — when an ICD-10 code points to more than one ICD-9 category — BCBSM enlisted five ICD-10-certified coders and a legion of doctors and nurses to help resolve code discrepancies.

The result of their efforts was "BCBSM Blue GEMs" — the payor's own customized database of general equivalence mappings (GEMs) whose life span would end when CMS stops updating GEMS. The company is willing to share BCBS Blue GEMS with interested entities who wish to model its approach, provided a formal request is submitted.

The BCBSM Blue GEMS will be loaded into an ICD-10 encyclopedia, an enterprise-wide tool that will become "the single source of truth" on ICD-10 as well as a baseline for annual updates, Winkler said.

Winkler also predicted that the issue of ICD-10 neutrality — which occurs when neither the claims acceptance rate, the number or rate of inquiries, the rate of electronic claims or claims reimbursement amounts are affected — will continue to be a hot topic for 2012. Winkler defined the four challenges of neutrality as well as its six targeted dimensions, emphasizing that BCBSM has a reliable process for each of these six dimensions.

A successful transition to ICD-10 will require different levels of collaboration from payers, providers, medical societies and state agencies to get the job done, followed by "testing, testing and more testing."

Low Healthcare Spending Linked to Poor Economy, Low Utilization

January 16th, 2012 by Cheryl Miller

The United States’ spending on healthcare increased by just 3.8 and 3.9 percent in both 2009 and 2010 respectively; these figures represent the lowest rate of increase in the entire 51 year history of the National Health Expenditures (NHE.) Analysts point fingers at the poor economy and low unemployment numbers, causing many Americans to skimp on medical care. A breakdown of the report is included in this issue.

The city that never sleeps could be getting just what the doctor ordered: expanded care facilities. Cigna and Weill Cornell Physician Organization have launched Manhattan's first ACO between a health plan and a physician organization, in order to meet the
IHI’s aims to improve health outcomes, lower total medical costs and increase patient satisfaction. Crucial to the program’s success will be the utilization of RNs, employed by Weill Cornell, who will serve as clinical care coordinators and help patients with chronic
conditions to navigate their healthcare system. They will use patient-specific data provided by Cigna to identify patients being discharged from the hospital who might be at-risk for readmission, as well as patients who may be overdue for important health screenings or who may have skipped a prescription refill.

Job-hunting smokers beware: Geisinger Health Systems has joined the list of healthcare systems that will no longer hire smokers. As of February 1st, job applicants will be screened for nicotine as part of the company’s routine drug test. Cigarettes, smokeless tobacco, even nicotine patches and gum will prevent an otherwise eligible candidate
from being hired; however, applicants will be given a chance to reapply for the job in six months’ time if they take advantage of the company’s smoking cessation resources and can quit smoking in that time. Non-nicotine hiring practices are currently legal in 20 states, including Pennsylvania, where Geisinger is based.

And Google’s Flu Trends Tool is proving to be a successful warning system for hospital EDs. Researchers from John Hopkins noted in a 21 month study that the rise in Internet searches directly correlated to a rise in ER patients with flu-like symptoms; the study was particularly effective when noting the surge in searches for flu symptoms and the
number of children entering the pediatric ER. In the past EDs, hospitals and other healthcare providers have relied on CDC flu case reports provided during flu season, October to May, as a key way to track outbreaks. The Google tool collects and provides data on flu search topics on a daily basis. While the medical and science community has
generally accepted flu search activity as a good indicator of impending sickness, this study, detailed in this issue, is the first of its kind to show the relationship between the data and an increase in ER activity.

These stories and more in this week's issue of the Healthcare Business Weekly Update.

Meet Wellness Coach Christy LeMire: Educating Parents About Nutrition

January 13th, 2012 by Jessica Fornarotto

Here we take an inside look at a wellness coach, the choices made on the road to success, and the challenges ahead.

Christy LeMire, certified holistic health coach and owner of Waterside Wellness.

HIN: What was your first job out of college and how did you get into health coaching?

Christy LeMire: For my first job out of college I was an assistant director for an early childhood education center in Roxbury, MA. I believe this experience planted the seed for wanting to work with people on a personal level and help children and families. I often spent time listening to single parents’ struggles to find balance juggling work and caring for their children. I also noticed the food limitations in the school regarding quantity and quality, and how it affected the children's behavior, which made me concerned.

Have you received any health coaching certifications? If so, please list these certifications.

I am certified as a holistic health coach by the Institute of Integrative Nutrition and SUNY Purchase College. I will also become board certified as a holistic health practitioner by the American Association of Drugless Practitioners this year.

Has there been a defining moment in your career? Perhaps when you knew you were on the right road?

There have been many reassuring moments. Above all, seeing people start to value their bodies and their health through the education they receive in my program has been the most rewarding. It proves that a support system focused on the specific health of an individual does make a difference in their life and that health coaches are needed in our communities.

In brief, describe your organization.

Waterside Wellness offers personalized nutrition, wellness and lifestyle counseling. I tailor my program based on the particular needs and desires of my clients. We work together to determine their health goals and I support them to achieve those goals in realistic, enjoyable ways. Education is also a big part of my practice. I believe the more informed we are about how food and lifestyle affects our health and future, the better choices we make and the more satisfying those decisions are.

What are two or three important concepts or rules that you follow in health coaching?

  • Bio-individuality --- no one diet or way of living works for everyone.

  • Making changes step-by-step allows for sustainable healthy practices.

  • Food is not the only thing feeding us; our careers, relationships, exercise and spirituality all contribute to our health.

What is the single-most successful thing that your company is doing now?

I currently offer a health coaching program designed specifically for brides-to-be who are looking to loose weight, manage time and stress, and start their marriage off as their most beautiful, healthy self. I find this is something all brides want and often need support in achieving while planning for their big day. It is also an opportunity to support women throughout changing times in their lives when they need support the most. Brides turn into wives who often turn into mothers. Finding balance between career and family can be challenging. Many women feel the need to be a "superwoman" and a little support and encouragement goes a long way.

Do you see a trend or path that you have to lock onto for 2012?

Obesity and diabetes in children is more present than ever, mostly because of fast-food diets and sedentary lifestyles. It is predicted that many of today's parents will outlive their children. I want to do my part in helping this issue by working with parents and making nutrition education accessible to schools.

What is the most satisfying thing about being a health coach?

Seeing clients find a renewed energy, positive outlook and achieve results toward their health goals is extremely satisfying. We are in control of our bodies and our happiness. We just need to be reminded sometimes.

Where did you grow up?

I grew up in a small town in Vermont where being active outdoors and eating home cooked meals with my family were big parts of my life.

What college did you attend? Is there a moment from that time that stands out?

I attended Emerson College. Trying to balance classes, homework, internships, work and eating healthy on a tight budget stands out as a challenge. Thinking back to that time helps me keep things in perspective and reminds me that people often have hectic lives, and expectations need to be simplistic and realistic when it comes to beginning to incorporate positive change.

Are you married? Do you have children?

I am married to my high school sweetheart. We look forward to having children when the time is right.

What is your favorite hobby and how did it develop in your life?

Regular yoga practice came into my life a couple of years ago as a way to relieve stress. Now, I can't live without it. I also enjoy capturing emotion and natural beauty through photography.

Is there a book you recently read or movie you saw that you would recommend?

The documentary, "Discover the Gift," is a film about self-discovery and living a life you love. I think it will resonate well with anyone who is feeling lost in their life, career, or spiritual practice and in need of inspiration.

Any additional comments?

I invite you to visit my Web site and follow my blog for healthy tips, recipes and inspiration. You can also follow me on Facebook and Twitter. I offer free consultations for those interested in discussing their health goals and learning more about how a health coach can support them in achieving health and happiness.

Q&A: How Aetna Redefines Case Management for Medicare Population

January 12th, 2012 by Jessica Fornarotto

The purpose of case management is care completion, states Dr. Randall Krakauer, Aetna’s Medicare medical director. Prior to his presentation on Demonstrating the Value of the Embedded Case Manager for the Medicare Population, Dr Krakauer discussed in detail the purpose of case management, the act of combining the capabilities of the physician and the health plan to create something new, and the enhanced patient experience that results from the medical home partnership between Aetna and Emory Healthcare.

HIN: What is the purpose of case management?

(Dr. Randall Krakauer): The purpose of case management is to assist members in the management of their own health. Case managers provide advice and assistance to make sure that patients understand what they need to do and that their questions are answered to engage their own risk factors and manage them better. Case managers help members to engage their own chronic conditions and to manage them more properly, and to better navigate the healthcare system to their own benefit.

HIN: What is care management at the provider level?

(Dr. Randall Krakauer): Better care management would involve the provision of additional resources at the provider level. This includes data (which may not be available to a provider) and longitudinal contact. Providers generally assume and accept responsibility for management of their own patients’ illnesses. They don’t always have all the data, however, and they sometimes don’t have the outreach for longitudinal follow-up case ability. For example, they don’t always know what other physicians are doing. They don’t always know what other medications are being prescribed. Patients get lost in follow-up. Patients don’t always follow instructions or fill their own prescriptions. They leave a physician’s office and don’t necessarily understand the instructions as well as they should. The purpose of case management is care completion. When a physician sees a patient in the hospital and writes a set of orders, he has a very high level of confidence that this will all get done. That’s not the case with outpatients seen in the office. The purpose of case management is to improve the ability to manage the cases in that milieu.

HIN: How can the capabilities and skill sets of the health plan be combined with those of the provider to create something greater than the sum of its parts?

(Dr. Randall Krakauer): The health plans generally engage in case management and disease management for a population that they identify through their own means or algorithms. They try to coordinate and collaborate with physicians’ offices to whatever extent is possible, frequently by telephone. Physicians are likewise trying to manage their own patients and this includes incoming calls and occasionally outgoing calls, plus other types of contact. They each have information and data that the other may lack. The physician has knowledge of the case, the family and the milieu that the health plan lacks. The health plan has claims information, its own process and transaction data for the individual case, and also global information on outcomes for the provider’s patients in general. We also have an expertise in longitudinal case management and the ability to provide people who will, with experience, outreach to members in between office visits.

Combining the capabilities of the physician and the health plan can create something greater than the sum of its parts; that is, the physicians can identify cases better that could be in need of case management. Physicians, in collaborating with case managers, can give case managers instructions on types of follow-ups that are necessary. Case managers can provide physicians with information, transactions, etc. For example, “This patient left your office. What has happened that you should know about that requires your attention?” Or, “Your heart failure patient has put on a kilogram and a half of weight in one week.” “This prescription was not filled.” It is this interchange, exchange and collaboration that has the potential for creating something that is better.

HIN: Aetna recently announced a partnership with Emory Healthcare and a patient-centered primary care program that will use embedded case managers. You were quoted as saying that this medical home partnership would improve the patient experience. Can you describe how this will happen?

(Dr. Randall Krakauer): In collaborating with the Emory physicians and their staff, we will be able to keep in contact with our members, and/or their patients, when they leave the office to answer questions, to follow up on health issues, to follow up on prevention issues, to follow up on management issues, to bring issues that arise to the attention of the physicians, etc. Once again, we cannot create the milieu of an inpatient patient experience for someone who has gone home. We can try to improve the completion factor, the ability to complete the care that is ordered and provide feedback and information on the results of this care.

Two Medical Home Approaches Behind $1 Billion in N.C. Medicaid Savings

January 9th, 2012 by Patricia Donovan

Aggressive care management and preventive care saved North Carolina Medicaid nearly $1 billion over four years, according to a new analysis by Milliman Inc., a national healthcare consulting firm.

This latest report of savings in the Tar Heel State from patient-centered medical homes (PCMH) links the cost reductions to reduced hospital admissions, readmissions and emergency room visits, many of which are avoided when patient care is managed more efficiently.

The savings update was announced in a press release this week by the office of the state's office governor, Bev. Perdue.

To provide medical homes, the state continues to partner with the Community Care of North Carolina (CCNC), a nonprofit group of local healthcare provider networks that provide and coordinate care for Medicaid recipients. The 14 regional CCNC networks since 1998 have pooled their resources for technological and administrative purposes, which not only saves operational costs but also provides opportunities for cooperation and collaboration throughout the networks.

With financial support from The Commonwealth Fund, CCNC has created a 16-module toolkit on constructing a medical home approach for vulnerable and high-cost populations.

The modules span everything from program development and rollout to IT support and informatics to establishing a network pharmacist program. There are also modules dedicated to a pregnancy medical home, integration of behavioral health and other populations.

CCNC has also created a workbook and resources for organizations pursuing recognition as a patient-centered medical home.

The Milliman report found that the key to the success of medical homes approach is a strong emphasis on preventative care, and aggressive care management. Although the cost of frequent office visits and treatment of newly diagnosed conditions adds to program costs initially, the reduction of emergency room visits and hospital admissions, as well as capturing of efficiencies and improving quality of care, results in significant savings and better health for the recipient.

The report by the San Diego-based accounting firm examined the impact of the state’s support for primary care medical homes – a system to coordinate healthcare for Medicaid recipients. Milliman’s report, which was required by the General Assembly, found that recipients with a medical home get better care and consumed fewer Medicaid resources than those who lack a medical home. From fiscal year 2007-2010, N.C. Medicaid avoided spending $984 million by having 1.1 million of its members enrolled into medical homes. In just the last two fiscal years of the study – 2009 and 2010 - $677 million was saved.

As N.C. Medicaid enrolled higher numbers of its members into a CCNC medical home, Milliman found annual savings increased—$103 million in fiscal year 2007 (July 1, 2006-June 30, 2007); $204 million in FY 2008; $295 million in FY 2009; and $382 million in FY 2010.

Milliman also reported that N.C. Medicaid is on a successful path to decrease cost by enrolling aged, blind or disabled (ABD) members into a medical home. Those Medicaid populations are generally the least healthy overall and costliest to treat. Enrollment into medical homes initially would add to the cost of caring for them but pays off in the long term. Indeed, Milliman found that in FY 2006, medical home enrollment of ABD populations cost the state an additional $82 million. But by FY 2010, enrollment of ABD Medicaid recipients into medical homes had paid off with the state avoiding $53 million in costs.