Archive for March, 2013

Infographic: Why the Patient-Centered Medical Home Works

March 29th, 2013 by Patricia Donovan

The five key features of the medical home model — patient-centered, comprehensive, coordinated, accessible, committed to quality and safety — are included in this infographic from the Patient-Centered Primary Care Collaborative (PCPCC). It includes definitions for each of these features, sample strategies used by health professionals, employers, and payors, and their collective impact on the health system.

patient-centered medical home

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You may also be interested in this related resource: 2012 Healthcare Benchmarks: The Patient-Centered Medical Home.

Guest Post: Accountable Care Reflects Paradigm Shift from Volume to Value

March 29th, 2013 by Ally C. Evans
Ally C. Evans

Ally C. Evans is an industrial engineer specializing in process and system improvement in healthcare.

In this second in a three-post series on “Accountable Care: The Power of Partnerships,” guest blogger Ally C. Evans, healthcare consultant with Freed Associates, argues that the U.S. volume-based, fragmented healthcare system has to change.

So, volume is a bad thing? Try telling that to a hospital CFO and you’ll quickly realize it’s a hard pill to swallow. The United States’ volume-based, fragmented healthcare system has to change. To that effect, health reform legislation is driving us toward a substantial overhaul of the healthcare delivery system, part of which includes the advent of accountable care, a concept that demands a deliberate rethinking of the way we deliver, coordinate and manage healthcare.

The term ‘Accountable Care Organization’ (ACO) was coined in 2006 by Elliot Fisher of the Dartmouth Institute for Health Policy and Clinical Practice. His idea resonated with policy-makers and lead to the inclusion of ACO provisions in section 3022 of the Affordable Care Act, enacted in March 2010 with final rule in October 2011, under the Shared Savings Program umbrella.

Although the formal introduction of ACOs started with the Medicare-specific Shared Savings Program, the ACO construct provided a new focus for the private sector, which rapidly began experimenting with similar frameworks to constrain costs for commercially insured patients. Through this evolution, ACO has become one of the hottest acronyms in healthcare and most likely has a slightly different definition depending on whom you ask.

In a nutshell, ACOs are formalized, collaborative partnerships between various organizations that agree to be financially accountable for the quality and cost of care for a specific population of patients. This population of patients is typically designated by payor type.

ACOs focus on three core principles:

  1. Provider-led organizations with a strong base of primary care are collectively accountable for quality and total per capita costs across the full continuum of care for a population of patients;
  2. Payments are linked to quality improvements that also reduce overall costs;
  3. Reliable and progressively more sophisticated performance measurements are employed to support improvement and provide confidence that savings are achieved through advances in care.

ACOs have various structures, with most including some combination of physicians, other providers such as hospitals and post-acute services, and payors. Together they are responsible — and receive incentives — for enhancing processes and services across the full continuum of care. The ultimate goal is to change the cost-growth trajectory.

The philosophy of shifting from volume to value-driven care remains consistent across all ACO approaches, due to the shared-savings or shared-risk agreements that are integral to the model. These agreements align high performance (e.g., good outcomes) with financial rewards to encourage providers to maximize efficient utilization of healthcare resources, while providing the most appropriate care for the patient.

Smart ACOs will capitalize on the concept of 'sharing' beyond the financial rewards of success.

High-performing ACO providers will receive a designated percentage share of the cost savings based on performance relative to target thresholds. Smart ACOs will capitalize on this concept of ‘sharing’ beyond the financial rewards of success. ACOs that master the art of clinical and system integration will undoubtedly be able to see greater results more rapidly by leveraging sophisticated processes, systems, technologies and teams to coordinate optimal-quality care both vertically and horizontally within the continuum (See figure above.)

Integrated health systems, or ‘real’ ACOs (i.e. those where the provider partners have pre-existing affiliations) are at a clear advantage here, but what about the ‘virtual’ ACOs (i.e. those comprised of independent providers embarking on new partnerships)? These ACOs need more work on the front end relative to investments of time, energy, and money to design and deploy robust governance systems and infrastructures. This infrastructure is essential to allow for real-time and efficient sharing of patient-health information, information technology resources, decision-making, human resources, research and innovation development and data across all ACO partners.

ACOs that do not invest in this foundational work may struggle later on to implement solutions that rely on integration, and to monitor the impact of those solutions due to poor data systems. As with all projects, the costs incurred trying to fix implementation-gone-wrong will far outweigh any up-front costs involved with detailed set-up.

It’s worth noting that ACO partners may be part of multiple ACOs simultaneously, each focused on a unique population of patients and different participating partners. Some organizations are embarking on both commercial and Medicare-sponsored ACOs; others have multiple commercial ACOs in progress. Although this approach expands potential bandwidth by reaching a larger population of patients, it is likely to dilute their ability to maximize their ‘sharing’ potential within each ACO. Also, as ACO models continue to adapt, particularly in the private sector, each ACO may prescribe different metrics, goals, and therefore, solutions, to ensure success. Clear delineation of priorities across and within ACOs, and alignment of core tactics and timeframes with organization-wide strategy, will be core components of success.

Read Part 1: Why Accountable Care Organizations?

In the final post in the series, Ms. Evans will propose ACOs as a panacea.

Ally C. Evans is an industrial engineer specializing in process and system improvement in healthcare. Most recently, Ally has driven various initiatives in the Accountable Care arena, focusing on the design and implementation of ACO strategy and tactical interventions. She is a consultant with Freed Associates, a California-based healthcare consulting firm. Their work is to provide sustainable solutions that enable healthcare organization to improve patient care services reduce costs and increase operational efficiency.

HIN Disclaimer: The opinions, representations and statements made within this guest article are those of the author and not of the Healthcare Intelligence Network as a whole. Any copyright remains with the author and any liability with regard to infringement of intellectual property rights remain with them. The company accepts no liability for any errors, omissions or representations.

Q&A: Embedded Workplaces, Home Visits Emerging Trends for Case Managers

March 28th, 2013 by Cheryl Miller

As the healthcare industry continues to evolve in the wake of ACA reforms, case managers are taking on more standardized collaborative approaches to care coordination and its changing delivery systems.

Prior to her presentation during a February webinar on The Role of Case Managers in Emerging Care Delivery Models, we talked with Teresa Treiger, RN-BC, MA, CHCQM-CM/TOC, CCM, president, Ascent Care Management, about emerging trends in case management, including embedding case managers at large employer work sites, and the proliferation of home visits.

HIN: What advice do you have for case managers going into embedded workplaces and what are some of the obstacles those already embedded have encountered?

(Teresa Treiger): One of the most important things to keep in mind is that you’re walking into someone else’s territory, where dynamics and relationships are already established. There’s a trust amongst the staff that’s already there.

As a case manager, you need to survey the landscape to figure out how people relate to each other, and then just use good business etiquette, for lack of a better way of expressing it. It doesn’t mean that you change your case management process. Absolutely not. We know case management. But how we relate to the people around us is probably the number one thing.

You will be faced with a situation, without a doubt, that has challenged other people. It could be a difficult patient or a patient that’s labeled as being difficult. And that is where you are going to prove your worth, by leveraging the skills that you have to find out what really is the issue or issues going on, and finding ways of addressing them. You might not be able to solve all of them. But you can address them in a professional way, helping that individual to resolve something, to get a service they haven’t been able to, maybe obtain some equipment or get a community resource hooked up with them. That’s when you start to develop your own currency of trust with the people that you work with, and that’s what’s going to get you firmly ensconced as a part of the team.

HIN: Will we see more case managers called upon to do home based care?

(Teresa Treiger): I think so, for a couple of different reasons. There are already community-based companies that do home care. And (case managers) may be part of or leading the team of lay care workers for these companies, (acting as) main points of contact to their individuals, at least when the client, or a family member has the resources to engage a company like this. These are often for-profit companies that will step in and provide a network of community-based individuals who come in and help for those who don’t qualify for other services.

There’s also the Visiting Nurse Associations (VNAs.) I’m not entirely sure what they’re going to be doing with case managers, but there is definitely an opportunity for them.

Accountable care organizations (ACOs) will also be using case managers that are assigned into a practice, or a group. It doesn’t matter where the patients of that group are, in the hospital, in the skilled nurse facility, at home. That case manager is part of that individual’s team. If the individual is at home, and hopefully most of them will be, they’re going to be helped there. It’s very resource intensive, because not only is the case manager not in the office, where other people may need him or her, there’s travel time, and the issues that go with that. And so while it sounds like a really great plan, the reality is there’s a cost involved, of both money and human resource.

The bottom line is that the Affordable Care Act (ACA) already highlighted community-based care. So the opportunities will be and continue to be out there for case managers to be more involved with their communities at a community level.

Infographic: The Digital Diagnosis

March 28th, 2013 by Patricia Donovan

The digital age is redefining healthcare and many factors are driving this medical revolution. This infographic from MDG Advertising shows that patients are now much more digitally active in their healthcare. Research reveals that 72 percent of U.S. adults have gone online to seek healthcare information in the last year, while one-third have searched the Web to figure out certain medical issues. The graphic shows that women are more inclined to seek health answers online and that more than 55 percent of medical Web searches are about specific diseases, 43 percent are related to medical treatments, and that weight loss and health coverage each account for one-quarter of Web inquiries.

It also points out that patients are coming together on social media sites to form communities for sharing their experiences, resources, and research. As a result, 40 percent of patients have posted comments about personal health experiences and 30 percent have consulted online reviews of healthcare services.

digital diagnosis

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You may also be interested in this related resource: 31 1/2 Essentials for Running Your Medical Practice.

Infographic: Employers Commit to Wellness Despite Economic Hard Times

March 27th, 2013 by Patricia Donovan

87 percent of global employers believe it’s their role to manage worker health, according to the latest report from Buck Consultants. Employers cite their commitment to promoting health and wellness as a business strategy and show continued desire to expand health promotion initiatives.

The report, “Working Well: A Global Survey of Health Promotion and Workplace Wellness Strategies” found that employers, regardless of location, identified improving worker productivity and reducing presenteeism as one of their top wellness program objectives. As health promotion takes its place as a top consideration among drivers of profitability and performance, an increasing number of organizations recognize their role in managing employee health — 87 percent in 2012 vs. 75 percent in 2010.

Employers and wellness

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You may also be interested in this related resource: Health and Wellness Incentives: Positioning for Outcome-Based Rewards.

Are Accountable Care Organizations Improving Population Health?

March 27th, 2013 by Cheryl Miller

What does the phrase ‘improving population health’ really mean? And are ACOs truly designed to improve it?

Researchers from Weill Cornell recently tackled these questions in a thought provoking piece featured this week, questions that need to be addressed in order to formulate effective healthcare and social service policy.

At issue is the widespread use of the phrase population health tied to ACOs, and whether ACOs actually have the incentives or the tools to improve the health of the entire community in which they are located, or whether they are just responsible for improving medical care for their own population of patients.

To read more on this discussion, click here.

In another story about improving healthcare, notably the issues of access, quality and cost, the Robert Wood Johnson Foundation (RWJF) has launched a $3 million initiative with the AARP to implement the Institute of Medicine’s (IOM) evidence-based recommendations on the future of nursing. The foundation will provide states with the support they need to build a more highly educated, diverse nursing workforce that will improve health outcomes for patients, families and communities.

Another effort to decrease healthcare costs is presented in a study from Brigham and Women’s Hospital and CVS Caremark, published in the American Journal of Medicine. Patients with coronary artery disease (CAD) who are medication adherent can save the healthcare system up to $868 per patient per year. Researchers found a consistent trend toward improvement in coronary artery-related events, mortality, readmissions, and costs among those patients who most adhered to their medication regimens.

In other more cost-related news, a collaborative of 333 hospitals intent on improving costs and care have saved $9.1 billion and 92,000 deaths since 2008 by replicating the performances of top performing hospitals, according to Premier Healthcare Alliance’s QUEST™ collaborative.

If hospitals nationwide followed QUEST’s™ lead, they could save 950,000 lives and approximately $93 billion over the next five years, officials said.

And don’t forget to take our new survey, Managing Care Transitions in 2013. Proper management of a transition in care — the process by which an individual’s care moves from one health setting to another, such as from hospital or ER to home, or from SNF to hospital — has the potential to dramatically hasten that person’s return to optimal health, as well as reduce the likelihood of a return ER visit or readmission. The quality of transitional care is also shaping up to be a critical factor in value-based reimbursement, as federal and private payors ask patients to rate the quality of the transitional care they receive.

Please share your organization’s efforts to improve care transitions by completing HIN’s third qualitative survey on this topic by Friday, April 12, and we’ll send you a free executive summary of the compiled results.

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

Infographic: Stay Out of CMS Penalty Box for PQRS and eRX

March 26th, 2013 by Patricia Donovan

Unless healthcare organizations take certain key steps this year, their Medicare reimbursement level in 2015 could be cut 2 percent or more. That’s because among other areas, the CMS Physician Quality Reporting System (PQRS) and ePrescribing (eRX) programs are shifting from bonus to penalty programs to insure compliance.

More than 80 percent of Medicare providers will face penalties for failing to meet quality thresholds if current performance trends continue. This infographic from Medical Billing highlights these changes and what healthcare entitities need to do to protect their practices.

PQRS and eRX penalties

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You may also be interested in this related resource: Avoiding the Readmissions Penalty Zone: Population Health Management for High-Risk Populations.

Payment Bundling Requires Suspension of FFS State of Mind

March 25th, 2013 by Patricia Donovan
payment bundling shared savings

Webinar Replay: Moving Forward with Payment Bundling

Four hundred healthcare providers — about a tenth of all hospitals in the United States — can’t be wrong, can they?

That’s the number signed on to participate in a Medicare payment bundling pilot run by CMS, their biggest payor. And while it’s too early to know if the reimbursement concept will stick, one thing’s for certain, noted Jay Sultan during a recent webinar on Moving Forward with Payment Bundling: there’s a growing body of proof that the payment model works.

As an example, Sultan, associate vice president and chief product portfolio architect for TriZetto® shared some data from California’s Hoag Orthopedic Institute, formerly two surgical groups who have collaborated in a bundled payment model and “reengineered every aspect of care, from beginning to end, significantly lowering its common cost structure.” In one proof point shared by Sultan, Hoag reduced infection rates for knee replacements to 0.1 percent, significantly below the national 2 percent average, Sultan explained during the advice-filled session. The savings per avoided infection is about $60,000, he said.

While the federal payor has yet to report, early feedback from CMS’s recently concluded ACE bundled payment demo is largely positive in terms of revenue for participating payors, hospitals, physicians — even the patients in the pilot received a rebate from CMS, he added.

Based on Sultan’s own research, he is “not aware of any prospective payment, bundled payment program that was not beneficial for the providers, the payor and the members.” He contrasted prospective payments with retrospective payments, which he characterized as similar to fee-for-service (FFS) but with the possibility of receiving a bonus afterward.

There is a place for both payment types, but prospective does a better job of transforming care, Sultan noted.

Sultan went on to outline the general challenges for both payors and providers of crafting an episodic payment program, which could take up to 12 months. A strong analytics framework for both health plan and provider use is essential. What is also required is a mind shift on the part of entities unused to working together and sharing data, who need to realize that “under payment bundles, the provider and the payor have an opportunity to collaborate, instead of competing against each other in a zero sum way.”

For payors, some prickly areas early on might include provider contracting, claims administration, and impact on member responsibility.

Providers, for their part, must become adept at managing risk. Providers “need to be able to get the data, to develop analytics, and to develop methods for collaborating with each other — including the fact that some providers are going to lose,” he emphasized.

Sultan offered a wealth of advice for each entity contemplating a shift to bundled payments. For all stakeholders, what will be required is a paradigm shift away from FFS, the foundation for much of the industry’s day in, day out day out operations. “We measure our utilization by it, we evaluate our quality by it, we do all these things based on fee-for-service.

“When you change that, whether you’re changing it for shared savings ACOs, moving from FFS to capitation, or going from FFS to payment bundling, it has profound impacts throughout the entire organization.”

Sultan provides more advice on bundled payments, from two key factors to keep in mind when trying to engage physicians in the model to the major decision facing primary care now that CMS has introduced bundled payments for care coordination tasks, in this expanded interview.

Infographic: The Future of HealthTech

March 25th, 2013 by Patricia Donovan

Whether through exercise, healthy eating habits, or routine checkups, daily healthcare decisions have a direct impact on the future of healthcare investing. With the demand for quality healthcare steadily rising, innovations in healthtech are encouraging investors to take a closer look at the role this sector will play in the future of healthcare, as shown in this infographic from SecondMarkets. The infographic depicts consumer demand for healthtech, which cities are hotspots for healthtech investing, and more.

Future of HealthTech

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You may also be interested in this related resource: Electronic Health Records: Strategies for Long-Term Success.

Infographic: Weight of the Union 2013

March 22nd, 2013 by Patricia Donovan

Weight of the Union 2013, an infographic from Anytime Health, examines the macro-implications of obesity on the nation’s health. This graphic not only defines the program, but suggests a treatment program to reverse this unhealthy trend, including the recruitment of food and beverage brands to make and market healthier products and the increased access to locally grown food in restaurants and supermarkets.

Weight of the Union 2013

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You may also be interested in this related resource: 38 Disease Management Metrics: Population Health Benchmarks to Drive Accountable Care.