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

January 12th, 2012 by Jessica Papay

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.

Posted in Case Management, Disease Management, Healthcare Administration, Healthcare Trends, Patient-Centered Medical Home, Physician Practices, Transitions in Care | No Comments »

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.

Posted in Accountable Care Organizations, Avoidable ER Use, Case Management, Disease Management, Healthcare Costs, Patient-Centered Medical Home | No Comments »

3 Key Influencers in Improving Medication Adherence

January 4th, 2012 by Patricia Donovan

The big three players in programs to improve medication adherence are the primary care doctor, the pharmacist and the case manager, according to 2011 market research by the Healthcare Intelligence Network. The pharmacist is also being recruited in a big way to assist with these programs, both at the health plan and primary practice levels, according to 162 healthcare organizations that took the survey. Often it is the pharmacist in the patient’s local drugstore that is making the primary contact, frequently with the help of motivational interviewing, and the patients like this.

“The patient feedback is our secret weapon, because it does provide the patients with the opportunity to be able to say, ‘I felt I was heard and understood, my needs were met,’ explains Dr. Janice Pringle of the University of Pittsburgh School of Pharmacy. The university is a collaborator in a pilot that teaches retail pharmacists the principles of motivational interviewing, which they in turn use to screen customers for adherence issues. Other pilot participants are Rite Aid and CECity. “It’s not satisfaction,” she stresses. “A lot of people call it that. Satisfaction is more of a passive, evaluation of the process, where feedback is actually saying how they felt that their needs were met.

The University of Pittsburgh pilot participants are evaluating some of the interim results, she notes. “As a researcher, I’m very, very careful. However, I can say that there is an indication that there are statistically significant changes in adherence for the participating [pharmacy] sites. This will be borne out by our more thorough evaluation in mid-2012. We’ll be comparing not only changes over time amongst the intervention pharmacies, but also comparing to a group of pharmacies that we consider control pharmacies for the same time period and the same metrics.”

Pharmacist motivation and satisfaction with the effort is high, as well. Dr. Pringle shares a comment from one of the pharmacists in the pilot: “We have to do this project. All of us have been trained to work with patients and we have not been able to do that. This is the chance we’ve been looking for to have more contact with our patients and to make a difference in their lives.”

The prevalence of programs to monitor and improve medication adherence has remained steady from 2010 to 2011; this year’s survey identified just a slight uptick in adherence-related interventions. While the big five chronic conditions — ischemic heart disease, diabetes, COPD, asthma and heart failure — are still primary targets for these programs, there is also a move toward targeting individuals with dementia, stroke and osteoporosis.

The value of case managers in improving medication adherence levels is underscored by health plan respondents: 56 percent have given primary responsibility for these programs to case managers. Several future programs will embed case managers in physician practices for this purpose and/or step up case management of patients with chronic illness.

Posted in Case Management, Hospital Readmissions, Medication Management, Patient-Centered Medical Home, Reducing Readmissions, Uncategorized | No Comments »

5 Key Trends for Physicians in 2012

December 12th, 2011 by Cheryl Miller

More than half of today’s physicians believe that healthcare reform will not improve patient care, according to a new trends report from the Physicians Foundation. The changing healthcare landscape is also pushing the majority of physicians to leave primary care practices for hospitals and group practices. These and other trends detailed in this issue.

Children with special healthcare needs are less likely to receive care that meets the criteria for having a medical home, according to a new national report from the Health Resources and Services Administration (HRSA), the first such report on this segment of the population and its counterparts: children without special needs. These children are also being exposed to less than ideal conditions at home; secondhand smoke and poor nutrition are just two situations cited in the report, which based their data on a national survey of more than 90,000 children in the United States.

Depression and diabetes can trigger dementia within three to five years of diagnosis, say researchers from the University of Washington and Kaiser Permanente. Contributors to the study, among the first and largest to date to examine dementia in diabetes patients with and without depression, hope these findings will ultimately slow the advent of dementia.

The CMS has issued a final rule that will give qualified organizations access to health claims data that can help them identify high quality healthcare providers, or create online tools to help consumers make educated healthcare choices. The final rule makes a number of important changes from the original proposed rule, one of them being that data is less costly than previously thought for qualified entities.

And we wanted to make you aware of our new complimentary e-book on the use of embedded case managers in healthcare, a trend embraced by Geisinger, Aetna, CDPHP, Advocate Physician Partners, Marshfield Clinic, Bon Secours and others. This downloadable e-book provides some early metrics on the emerging trend of placing case managers alongside care teams in physician practices and describes some of the benefits that can result.

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

Posted in Accountable Care Organizations, Affordable Care Act, Avoidable ER Use, Behavioral Health, Healthcare Trends, Patient-Centered Medical Home | No Comments »

Q&A: CDPHP Embedded Case Managers Usher In New Era of Healthcare

November 30th, 2011 by Jessica Papay

From the perspective of the health plan-provider relationship, CDPHP embedded case managers are an example of both parties working together in partnership, explains Lisa Sasko, MA, MBA, director of clinical transformation at CDPHP. Prior to their presentation on The Role of Embedded Case Managers in Clinical Transformation, Sasko, along with Charlene Schlude, director of case management, describe the functions of an embedded case manager, target populations and issues to address prior to embedding a case manager in a practice.

HIN: A news release on the CDPHP physician practice transformation program mentioned that the embedded case managers help practice staff better facilitate medical, behavioral and pharmaceutical services for patients. Can you provide, in more detail, their functions in these areas?

(Charlene Schlude): We have embedded RN case managers that work in the practices and their primary function and role is to assist the physicians and staff in the practice to identify, engage and outreach patients in their practice, whom they believe have many chronic and complex medical issues that may require special coordination of care. The addition of social work, perhaps because there may be some social concerns and financial constraints around having a chronic illness or maybe the loss of a job, help people to engage in a self-management plan. After the case management experience is over, the patients should be able to continue on with the education, adherence techniques, the understanding of their diagnosis and having a list of questions to bring with them to speak to their doctor about regarding their condition. The patient should be empowered and ready to help self-manage their chronic condition on an ongoing basis.

HIN: You mentioned complex patients as targets for the case management program. Are there other target populations, such as by disease state?

(Charlene Schlude): Yes, we target any patient with a complex illness. That could be someone in our commercial product or our self-insured product line; people who may have had a trauma or a catastrophic illness or event. We work closely with our transplant patients because they have significant social and emotional needs as well as medical and pharmaceutical needs. We work with anyone who has a great deal of barriers to self-managing their care, which could be that they have a situation in their home where they’re the caregiver for another patient or another member of their family.

HIN: What are the operational and cultural issues to address before embedding case managers in the practice?

(Charlene Schlude): We found that when we were going into the medical home as embedded case managers, we were going to have to be very flexible and open to the different nuances of each practice. We know that the underlying concepts around medical homes are the transition of the practice so that everyone has an integral part on the team. We knew that we had to be very open to the workflows in the practice. Our case managers are sensitive to that, but they do need to become an integral part of that practice as a member of the team. While they’re employed by the health plan, the message to the practice and to the members is that they are a part of that team and are involved with all of the decisions; they sit in on conferences and talk with the physicians directly. But again, we are being sensitive to the workflows because we did not want to go in and prescribe how things were going to be in one medical home to the other, and say that it had to be consistent.

(Lisa Sasko): From an operational standpoint — from a plan and provider relationship standpoint — some of the issues that were important for us to address, focused on recognizing and working with our practices to recognize that this is a new era of healthcare. We need to work together in partnership. CDPHP is supporting these practices to become these enhanced primary care practices through practice transformation, through the use of consultants, etc. In addition, CDPHP is putting these practices on a new payment model that gets them away from fee-for-service onto a risk-adjusted base capitation, which offers a lucrative, to some degree, bonus potential based on improving quality of care for the members and improving the efficiency of the resources utilized.

Posted in Case Management, Disease Management, Healthcare Administration, Patient-Centered Medical Home, Physician Practices, Transitions in Care | No Comments »

Mini Medical Homes Open Door to Disease-Based Patient-Centered Care

November 22nd, 2011 by Patricia Donovan

Call it Medical Homes 2.0: disease-specific ‘mini’ medical homes for high-risk, high cost patients with chronic diseases.

“We do see a trend right now with the medical home; especially in the Medicare area where the patient is assessed up front,” noted Steve T. Valentine during HIN’s eighth annual healthcare industry forecast. This approach generally focuses on but is not limited to the ‘big five’ chronic diseases: ischemic heart disease, diabetes, COPD, asthma and heart failure, Valentine said.

“For example, let’s just pick diabetics and move them into their own mini medical home. They would have a multidisciplinary team focused around those complex patients,” said the president of The Camden Group. “We see that as a bigger change that’s beginning to come. This model does help with throughput in terms of primary care in the medical home.

“A focus on population management and delivering superior value become critical strategies as we begin to move forward,” Valentine predicted during the healthcare publisher’s annual industry forecast.

The disease-specific approach is gaining followers as the industry navigates away from a fee-for-service environment toward a more evidence-based, protocol-driven approach that rewards not only clinical outcomes but an organization’s ability to deliver value-based healthcare.

HealthCare Partners Medical Group of California, which is experiencing its lowest hospital readmission rates in its history, uses a predictive modeling tool, a dollar tool predictor, and a hierarchical condition categories (HCC) or HCC-like modeling tool to risk-stratify their patients before placing them in the medical home that best suits their needs, explains Dr. Stuart Levine, corporate medical director.

This could be hospice and palliative care, or a home care program where teams of physicians, nurse practitioners, case managers and social workers take care of chronically frail patients at home, meeting all of their needs, Dr. Levine said.

HealthCarePartners also has a medical home program for patients with end-stage renal disease (ESRD). “All patients are seen at the dialysis center, and that’s where their medical home is. They no longer come into offices. They are seen by nurse practitioners with backup nephrologists.

“They’re not only getting their renal disease managed, but way more importantly, they’re getting all their primary care needs met.”

Some diabetes-focused medical homes are being constructed with a little help from corporate sponsors. The GE Foundation recently awarded a $3M grant to establish a Care Management Medical Home Center for 10,000 Miami Dade patients suffering from chronic diabetes and its costly and debilitating side effects. The grant is part of the GE Foundation’s Developing Health initiative.

The grant will enable Health Choice Network of Florida and its seven participating health centers to provide a centralized model staffed with medical professionals who will assist the health center teams in providing high quality, effective and efficient care management services that will decrease costly hospitalizations and emergency room visits.

In addition to the new jobs the funding will add, the center will leverage existing data warehouse infrastructure and electronic medical records to deploy real-time disease-specific patient panels, identify health trends and expects to improve diabetic patient outcomes by 10 to 20 percent in the first year.

The Camden (N.J.) Coalition of Healthcare Providers and the Cooper Foundation will receive $3.45 million over five years from the Bristol-Meyers Squibb Foundation to strengthen community-based components of its Camden Citywide Diabetes Collaborative care model by focusing on patient self-management, education and support, care coordination, food access and physical activity programs, and behavioral health and community engagement activities in order to bend the curve of the diabetes burden and healthcare costs in the city.

One of the goals of the diabetes collaborative is to Increase the capacity of community-based, primary care practices to provide comprehensive, proactive care to their patients with diabetes.

The Camden collaborative was one of eight organizations to receive grants from the Bristol-Meyers Squibb Foundation grants.

The mini medical home approach is not limited to the big five chronic diseases. Last week, Priority Health and Cancer and Hematology Centers of West Michigan (CHCWM) announced their intention to jointly explore an innovative oncology patient-centered medical home. The goal of the oncology medical home is to integrate and coordinate the many office visits, medical professionals, high-tech services and care decisions encountered by cancer patients to help streamline their care while ensuring better outcomes, Priority Health said in a press release.

“This project is a natural evolution of our extensive experience with medical homes,” said John Fox, M.D., Priority Health’s associate vice president of medical affairs. “Cancer patients experience complex medical needs and rely on an extensive network of interdisciplinary healthcare specialists. Having a medical home can ensure cancer patients receive optimal care.”

Both organizations have agreed to payment reforms and care enhancements. Under this new model, oncologists will be paid a care management fee and will share in savings resulting from reductions in emergency room visits, imaging and hospitalizations. Current fee structures pay physicians based on the costs of drugs administered, which results in higher payments for more costly drugs, not necessarily the physician’s time, expertise or resource utilization.

The care management fee will go directly for patient support services, such as end-of-life and financial counseling, case management, medication therapy management, survivorship programs and social work services.

Posted in Avoidable ER Use, Bundled Payments, Disease Management, Patient-Centered Medical Home, Physician Practices, Reducing Readmissions | No Comments »

More MGMA Highlights: Changing Where and How Healthcare Is Delivered

October 27th, 2011 by Patricia Donovan

The only way to revamp the existing healthcare system is to “change the places and the ways in which we deliver care,” advised Eric Dishman, Intel Fellow and director of health innovation and policy, during Tuesday’s opening session of the MGMA 2011 annual conference.

To illustrate, Dishman held aloft a small computer about the size of a pedometer that Intel gave to homebound elderly to wear. The computer generated data on their gait, information the scientific community can use to better understand how to prevent falls in this population, he explained during “Changing Practices: Home- and Community-Based Care Technologies for Independent Living.”

It’s just one of the ways Intel is studying the entire “human” system to better design the technologies to support their care, Dishman said.

Out in the conference exhibit hall, home monitoring technology by Alere supports the shift in care delivery locations that Dishman is proposing. The technology allows patients who take the anticoagulant Warfarin to test PT/INR levels regularly. Keeping PT/INR levels within a safe range can help individuals to avoid serious complications such as bleeding or stroke.

“These rapid and real-time diagnostic tests in home allow for more frequent testing, which provides additional data,” explained Clint Brown, Alere home monitoring national business director. “We can catch an INR drifting out of range, which is the essence of preventive care.”

By helping to reduce risk and adverse events, the technology helps to reduce the likelihood of readmissions, Brown added, “while contributing to the efficiency conversation.”

Patient portals were also part of the efficiency conversation at the conference, since they help to optimize EHR use, enhance patient engagement and clinical information exchange and shift some care management tasks to the patients themselves — everything from making appointments to paying bills to reviewing lab results. Most EHRs have a portal component that can be activated.

The conference’s Healthcare Innovations Pavilion featured a case study Tuesday on patient portal use, co-presented by Intuit and St. Vincent Medical Group. The 34-site, 150-physician multispecialty group launched the portal in May, explained Patti Ballman, St. Vincent’s director of operations, but is already experiencing improved patient flow, a decrease in telephone calls and an ability to see more patients.

The portal, which the medical group has branded “MySV,” positions the group well for the patient engagement requirement of meaningful use, but that wasn’t the primary driver for portal implementation, noted Ballman.

“We wanted to improve the care experience for the patients in the office. The online portal allows us to focus more on the patients who are in front of us rather than the ones on the phone.”

Physician practices considering the use of a patient portal should start collecting patients’ e-mails now to make the launch easier, Ballman recommended.

Portals are just one of the technologies that are helping physician practices to improve collections by providing a more private transaction. Another is automated voice messaging, contributes Marc Tumminello, vice president of healthcare practice sales for Televox, another exhibitor at the conference.

“Using automated reminders for accounts receivable is far less costly than call centers,” noted Tumminello. “Practices can also build in the option to speak to a live person. Giving the patients various payment options reduces the potential embarrassment of this transaction.”

Phreesia, which calls itself “The Patient Check-in Company,” puts this transaction back in the waiting room by building payment options into the self check-in process. Patients can check themselves in on the company’s bright orange portable tablets, then render their co-pay or outstanding balance by swiping their credit card on the side of the tablet. The technology verifies eligibility, and also offers customized disease management education at the end of each transaction.

Patients have been receptive to this technology, notes Phreesia representative Katie Ray, who was demonstrating the tablet. “Patients are used to self-service in other aspects of their lives; why not in healthcare?”

On the clinical side, several presenters described how they are embedding case managers in the primary care practice. In separate sessions, both Advocate Physician Partners (APP) and Marshfield Clinic said they have embedded case managers in physician practices in the last year.

Sixty colocated outpatient case managers were added to APP’s clinical integration program in early 2011, explained Dr. Mark Shields, senior medical director and vice president of medical management for Advocate Physician Partners and Advocate Health Care. “They will focus on the sickest 2 to 3 percent of our population.”

Marshfield Clinic has embedded 55 nurse care coordinators in its 35 NCQA-recognized level III patient-centered medical homes, explained Dr. Theodore Praxel, medical director of quality improvement and care management. On average, the nurse care coordinators have been working for about six months in the practices, which have been very positive about this addition to the care team.

Watch this blog for more detail on these hot topics for practices — as well some innovative strategies for coping with HIPAA compliance, physician shortages, acquisition, decreased reimbursements and other challenges.

Posted in Affordable Care Act, Case Management, Healthcare Costs, Healthcare Quality Ratings, Patient-Centered Medical Home, Physician Practices, e-Health | No Comments »

MGMA 2011: Monday’s Highlights

October 24th, 2011 by Patricia Donovan

The world’s best managers are most productive when they play to their strengths and neutralize and manage around weaknesses, reports Marcus Buckingham, today’s keynote speaker. Buckingham is an independent consultant and author of several books on strengths in the workplace.

It’s a concept physician practice leaders might want to keep in mind when engaging staff in the new technology, care delivery systems and reimbursement models that are part of a value-based healthcare system.

Not surprisingly, the accountable care organization (ACO) delivery model is getting a lot of attention at this year’s conference. “The ACO time frame is short and the learning curve steep for organizations that enter the ACO field late,” notes Deborah Walker Keegan, president of Medical Practice Dimensions, during a session on the structure, operations and financial strategies of ACOs. “The ACO train has left the station.” In the room of about 300 people, only three or four raised their hands to indicate they were already participating in an ACO.

Keegan explained the four flavors of ACOs currently in demonstration or pilot form, setting the stage for Bruce Johnson’s explanation of ACO models available to practices interested in pursuing the model. Johnson, JD, MPA, a partner and shareholder in Polsinelli Shughart, Denver, described the final ACO rule released last week by CMS as “kinder and gentler.”

How to prepare for the ACO experience? Practices should begin to innovate so that they can demonstrate accountable care, recommends Walker Keegan. These innovations should begin with expanding patient access through the use of patient portals, expanding the role of the nurse, anticipating needs, and rejecting the sequential visit as “historical.”

Patient portals are also useful in streamlining workflows in the use of EHRs, notes Ron Anderson, who led a session on optimizing EHR and practice management workflows to improve efficiency and the bottom line. While about half of the room’s participants are already using EHRs, none felt they were optimizing them.

Anderson encourages practices to have all active users involved in analyzing and revamping workflows when the EHR is introduced. “Don’t just ask them for support; demand involvement.”

Staff should be trained on new equipment and programs first, before the physicians, he suggests.

Down the hall, Dr. Farzad Mostashari, National Coordinator for Health Information Technology, answered a range of questions on meaningful use, whether quality measures could be “harmonized” across all federal quality initiatives, health information exchanges (HIE) and patient ID cards.

Inroads have been made on some of the protocols and standards for HIE, but the business case and privacy, security and trust requirements must still be defined, he said.

Down in the Innovation Pavilion, I heard how one DO is using a smartphone app for e-prescribing developed by NaviNet. Leonard Sukienik, DO, Primary Care Solutions, said he uses the app on his iPhone and iPad during the patient visit. Because the app provides a full picture of the patient’s compliance, its use “opens the door to a lot of conversations we as physicians need to start having.”

Far from being upset that they weren’t being handed a paper copy of the prescription, his patients were thrilled that the prescription was sent directly to the pharmacy. (He can still print out a paper copy for the patient, as well as generate “care messaging” tailored to the patient’s needs.)

Posted in Accountable Care Organizations, Patient-Centered Medical Home, Physician Practices | No Comments »

ACO Final Rule Accompanied by Advance Payments for Care Coordination Tools

October 24th, 2011 by Cheryl Miller

The anxiously awaited final rule on accountable care organizations (ACOs) for Medicare beneficiaries is finally out. Based on the more than 1300 comments CMS received on its proposed ACO ruling first released in March, this new rule will make it easier to establish ACOs by providing organizations with additional funding for support tools, such as new staff or information technology systems. Under this new initiative, the Advanced Payment Model, these payments would be recovered from any future shared savings.

The second initiative, the Medicare Shared Savings Program, will provide incentives for healthcare providers who agree to work together and become accountable for coordinating care for patients. Participants who meet certain quality standards based upon, among other measures, patient outcomes and care coordination among the provider team, may share in savings they achieve for the Medicare program. Both initiatives launched on October 20th.

The United States earned low marks in healthcare access and affordability in the Commonwealth Fund’s third annual scorecard report. According to the report, the nation received a 64 out of a possible 100 when compared to best performers. Among the findings that contributed to the score were the percentage of overweight or obese children (32 percent), the number of prescription errors among elderly Medicare beneficiaries (one out of four) and the percentage of adults that reported not having a primary care provider in 2008 (44 percent).

Despite the low scores in key quality indicators, the United States is doing something right in the area of heart failure (HF) care. New research from the Yale School of Medicine shows that hospitalization rates for HF dropped by 30 percent from 1998 to 2008. One year mortality rates also dropped slightly during this period. HF ranks as the most frequent cause of hospitalization and re-hospitalization among older Americans, with related costs estimated at $39.2 billion in 2010.

In other news, 46 percent of physician practices do not meet NCQA standards for medical homes. The news, from a recent University of Michigan-led study, found that while larger, multi-specialty practice groups can more easily meet the standards, one in nine Americans receive healthcare from smaller, often solo practices. Researchers recommend initiatives to help these smaller practices team up with larger organizations to establish more medical homes.

More than 50 percent of physicians and hospitals are looking at ways to team up, a trend that is causing medical malpractice concerns. Aon’s 12th annual Hospital and Physician Professional Liability Benchmark Analysis states that healthcare systems will face significant risk management challenges associated with integrated physician-hospital arrangements. The study details the growth of integrated self-insurance strategies and highlights the challenges faced by systems as they pursue the cost of risk savings.

And lastly, what are you doing to staunch the flow and expense of avoidable emergency department use? Describe your efforts in this area by October 31 and you will receive a free executive summary of results from this second annual survey. These stories and more in this week’s issue of Healthcare Business Weekly Update.

Posted in Accountable Care Organizations, Affordable Care Act, Avoidable ER Use, Health IT, Healthcare Administration, Healthcare Costs, Healthcare Quality Ratings, Healthcare Trends, Hospital Readmissions, Patient-Centered Medical Home, Physician Practices, Reducing Readmissions, Uncategorized | No Comments »

Q&A: How to Survive and Thrive Under Bundled Payments

October 14th, 2011 by Patricia Donovan

Time in the trenches with Acute Care Episode (ACE) pilot participants qualifies Jim Reilly to comment on CMS’s latest Bundled Payments initiative specifically and bundled payment trends in general. The managing partner of TRG Healthcare Solutions shares three lessons CMS learned from the ACE pilot and more in this interview with the Healthcare Intelligence Network (HIN).

(This interview was conducted in advance of Reilly’s presentation on “Evaluating the Bundled Payment CMS Initiative — Legal, Financial, and Clinical Considerations,” an October 19, 2011 HIN webinar.)

HIN: To begin with, what did CMS learn from the ACE Pilot and how is that influencing its newest payment initiative?

Mr. Reilly: First, CMS learned that episodic payments or bundled pricing is a very effective way to incentivize hospitals and physicians to work closer together. They firmly believe combining the fees for an episodic period will lead to better coordinated care, not only between hospitals and physicians but across different specialties, to work together for optimal outcomes. They also learned that it will save CMS money. Through their bundled pricing experience in the past, this has led to lower rates that CMS pays for providers. And they also feel, finally, that it’s going to improve beneficiary health and outcomes. So it’s something that they’re investing in and moving forward with aggressively nationally.

HIN: ACE Pilot participant Baptist Health System, one of the companies that you worked with, refers to its ‘Hallmark moment’ of distributing gainshare checks to participating physicians. What are some other benefits of participation for health systems?

Mr. Reilly: Physician alignment is number one. The level of collaboration has truly increased within that health system. That then drives a greater focus on quality metrics and service metrics — not only the cost side, but also a different level of engagement in trying to move those important cardiovascular and orthopedic metrics in this case. That’s been a great benefit to the health system.

The health system is also benefitting from this experience because CMS is not the only payor that’s going to be adopting bundled payments as a way to pay for care. There will be other payors outside of CMS — outside national payors that will be active in bundled pricing. And a system like Baptist Health is well positioned to take advantage of that as well.

HIN: And finally, our fifth annual survey on the patient-centered medical home (PCMH) found that 9 percent of respondents have already begun experimenting with bundled payments. From your perspective, is this an adequate representation of the marketplace? Where do you think this trend is going?

Mr. Reilly: I don’t think it’s an adequate representation. Sometimes in this industry, we’re a little bit slow to move and be as innovative as we should be. The trend here, particularly with specialties like cardiovascular services and orthopedic services, is definitely more toward acceptance of risk in contracting with Medicare and other payors. You’ll see a great deal of activity beyond CMS, with other payors following suit.

And in order to succeed in that environment, we need more providers out there becoming clinically integrated — not only for the acute care episode, but for post-acute care services, so that we can survive and thrive under bundled payment for CMS. And other payors are going to adopt this. This current CMS bundled pricing initiative is going to escalate to other providers out there moving forward in this direction.

HIN: To follow up on that, could you define ‘clinical integration’ and explain why that needs to happen first?

Mr. Reilly: Certainly. The care process requires multiple caregivers and providers to get the optimal outcome and service. And today many times, we have competing interests among doctors and hospitals. We’ve got physicians that are dealing with challenges of running private practices; sometimes that takes away from collaborating in what is the optimal episode in amounts and levels of care provided for patients.

Once we move into alternative payment methodologies such as bundled payments, it breaks down some of those barriers. We’ve got surgeons and cardiologists and anesthesiologists and radiologists and consultants working more in a united way to ensure that that patient is getting optimal care and efficient care. That’s clinical integration.

Posted in Accountable Care Organizations, Bundled Payments, Healthcare Administration, Healthcare Costs, Patient-Centered Medical Home, Physician Practices, Reducing Readmissions | No Comments »

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