Posts Tagged ‘accountable care organization’

Healthcare Business Week in Review: Childhood Obesity, Dual Eligibles, ACOs, Patient Activation Measures

November 1st, 2013 by Cheryl Miller

Last year at this time we watched with disbelief as Hurricane Sandy pummeled our East coastline. Schools closed, power shut down, and Halloween was officially postponed until early November when it was considered safe for children to trick or treat.

Our own town is still recovering from the storm; scarred, vacant houses share the same block as rehabbed homes on stilt-like platforms; trailers double for once elegant restaurants and broken docks and abandoned boats patiently ride the crests of ocean waves.

It was a rocky year for healthcare as well, from an early surge in Medicare ACOs, to the embattled introduction of ACA-mandated health insurance exchanges during a government shutdown.

But many things remained the same; childhood obesity rates continued to climb , as did public health efforts to control it, including counseling and nutritional guidance, according to a new trends report from NCQA. Poverty continued to plague many Americans, particularly dual eligibles, but companies like Wellcare did their best to help them by closing social gaps with health-oriented community connections looking to “give back,” as its vice president of advocacy and community-based programs executive director Pamme Taylor demonstrates in this week’s featured book excerpt.

Organizations like HealthEast and Mercy utilized clinical analytics technologies from Optum to better understand and manage treatment for patients with chronic conditions, and advance performance for its newly formed accountable care organization (ACO).

And doctors’ policies toward accepting new Medicaid patients in the wake of expanded coverage will most likely stay the same, according to a study from Virginia Commonwealth University, Richmond. The decade-plus study found that physicians might be more likely to stop accepting those patients who remain uninsured, however, as our story details.

And lastly, self-management continues to result in better patient outcomes, according to researchers from the Boston Medical Center. Patient activation, or having the knowledge, skills, and confidence needed to manage one’s health, leads to better health following hospital discharge, and lower readmission rates. Screening for patient activation could not only help hospitals identify patients at risk for readmission, but also inform the development of tailored, cost-effective intervention plans.

How did your healthcare organization fare in 2013? And what plans do you have the future? Tell us by completing our ninth annual survey on Healthcare Trends for 2014 and you’ll receive a free executive summary of the results. One respondent will win a training DVD of the “2014 Healthcare Trends and Forecasts” webinar recorded on October 30, 2013.

Deeper Data Dive Improves ACO Performance, Quality

August 1st, 2013 by Jessica Fornarotto

Performance Quality Measurement and Reporting for Accountable Care webinar replay

What started as a closer look at John C. Lincoln Network’s 30-day Medicare readmissions for heart attack, heart failure and pneumonia kicked off a plethora of quality improvements for the Medicare Shared Savings Program, including the hiring of care transition coaches, extension of primary care hours and tightening of key gaps in care.

During HIN’s webinar, Performance Quality Measurement and Reporting for Accountable Care, two experts from JCL shared how their organization modified reporting processes — from workflow changes to customizations within its EMR — to improve performance results during its 2013 reporting year.

For its transition coach program, developed to reduce Medicare 30-day readmissions, JCL hired trained military medics to help recently discharged patients transition more easily from one setting to another, explained Heather Jelonek, chief operating officer for ACOs at JCL.

“These transition coaches go into the hospitals and meet with patients when they are admitted. They get to know the patients, they develop a rapport, and they also start to prepare the patients for discharge.”

After discharge, these coaches follow the patient for a minimum of 30 days to follow up on medical care, monitor blood pressure, explain medications and teach the patient about nutrition with the help of a registered dietician.

A deeper data dive also identified a trend among its Meals on Wheels beneficiaries: 85 percent of these patients were readmitted within 30 days almost always on Friday evenings. The patients did not have enough food to get them through the weekend since Meals on Wheels only delivers during the week.

This program has helped to reduce readmission readmission rates from almost 20 percent to just under 2 percent for those patients receiving Meals on Wheels and became an assessment area for the transitions coaches.

Encouraged, JCL sought to learn what additional data they needed from their system to respond to the reporting requirements for CMS’s 33 quality measures. They determined their course of action for 2012 and the building requirements for 2013. According to Karen Furbush, business consultant for JCL, “we have to continually re-educate each of the practices at the hospital and the ED so that they can continue to remember what’s important. And it’s not just for the ACO measures, but in general for better coordinated care.”

One change implemented immediately was the addition of a new message within EPIC, an ADT inbasket message that alerts the primary care physician (PCP) to schedule a follow-up visit within seven days. The PCP then reviews the message and forwards it to the medical assistant (MA) to schedule the visit. This change helped to meet one of the ACO quality measure as well as the transitional care management incentive.

Realizing that enhancements were needed for quality reporting, JCL added additional logic to its patient health questionnaire for future fall risk, aspirin usage and a depression scale. JCL also has ACO patient navigators who analyze reports to determine which patients were missing required measurement values and then schedule those patients by the end of the year as needed, noted Ms. Furbush. “We learned how to get the information out and quickly assess who hasn’t had the influenza or pneumococcal shots, or […] a mammography or a colorectal screening. We wanted to go out and capture that information as quickly as possible because we still had three months left to be able to find that information, whether it was in a previous system or if it was in our current EMR,” explains Furbush.

“We immediately tried to get on the phone to start scheduling these appointments, working through all the things that we need to do for the ACO, as well as just bringing the patient into the EMR completely,” Furbush continued.

Furbush also started a weekly ACO quality reporting call to discuss a group of measures to see what kind of challenges were being faced and what was being implemented. JCL also hosted two EPIC-specific subset calls to learn how everyone was using EPIC.

Once JCL received its patient sample from CMS, it sent samples to each practice. According to Furbush, “We said [to the practices] this is what CMS said this person happens to be associated with. There are 15 categories and CMS will provide a rank of one to 616, one being the highest. You have to report on 411. We had to let them know where the patients ranked for each of the disease states and that we needed information back from them if we couldn’t get it from the EMR.”

JCL continues to struggle with integration opportunities. According to Jelonek, “This includes talking to other communities and looking at HIEs as we’re making an acquisition of a new practice or signing a new community physician onto the ACO. In other words, bringing everybody to the table so that we’re all speaking the same language.”

Infographic: Spotlight on Embedded Case Management

January 28th, 2013 by Jackie Lyons

Case managers working inside patient-centered medical homes and accountable care organizations are taking on larger roles in primary care. About half of healthcare organizations embed or co-locate case managers at points of care, according to a new market research by HIN.

Thinking about adding a case manager to a primary care team? Assembling case manager criteria and finding the right practice are just a few steps that should be taken before embedding a case manager. This new infographic from the Healthcare Intelligence Network outlines top sites for ECMs, tools, protocols and workflows and typical duties of ECMs, drawing from responses from our 2012 Trends in Embedded Case Management survey.

Among the data points presented in this infographic are:

  • Top care sites for ECMs, such as primary care practices and clinics;
  • Ten steps to take before embedding a case manager;
  • Top ECM protocols, such as teaching patients to self-manage their health; and
  • Typical duties of an ECM, including medication management and reducing readmissions.

We invite you to embed this infographic on your own Web site using the code that appears beneath it. Also, share it via your social media channels. A deeper dive into the latest trends in case management is reflected in 2012 Healthcare Benchmarks: Embedded Case Management.

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Q&A: Integrated Health Coaching Brightens Total Healthcare Picture of Population

November 21st, 2012 by Jessica Fornarotto

To determine the coachee’s values, the health coach listens to achieve empathy and understanding, which demands that they have a sense of an individual value, says Kelly Merriman, vice president of service delivery at HealthFitness.

Prior to their presentations during a September webinar on Integrated Health Coaching: The Next Generation in Health Behavior Change Management, Merriman and Dr. Dennis Richling, chief medical and wellness officer at HealthFitness, discussed HealthFitness’ transition to a population health management focus, why HealthFitness’ coaches target the chronic disease population and a new coaching tool called appreciative inquiry.

HIN: How has HealthFitness’ shift from a disease management to a population health management focus meshed with the industry’s post-reform models of care, for instance the patient-centered medical home (PCMH) and the accountable care organization (ACO)?

(Dr. Dennis Richling): HealthFitness has had a population health management focus for many years and we see that many of the same principals that we use in our approach are included in ACOs and in medical home models.

Recently, we took a new look at disease management, which traditionally has been a stand-alone service, largely focused on patient self-care issues separate from lifestyle coaching interventions. In our new model, health behaviors across the entire risk continuum are dealt with in a person-centric way, rather than a disease-centered approach. That of course aligns with some of the principles of the post-reform models of care, like the medical home, and even to some degree with ACOs, which are attempting to be responsible for the total healthcare picture of a population.

HIN: In your company’s three-tiered coaching across the continuum approach, where do most of the coaching candidates fall?

(Dr. Dennis Richling): In every population you find different numbers, but in a typical employer, we see that the greatest opportunity for coaching is in those individuals who have behaviors that can lead to chronic disease. A good example of an ideal candidate for our coaching program is a 40-year-old manager working 50 hours a week. His blood pressure isn’t high, his cholesterol is slightly elevated and he’s a little overweight. He doesn’t exercise regularly and while he tries to watch his fats, he isn’t eating the most healthy diet because he hasn’t figured out how to balance his work schedule and his family life, and being 40. He’s also at risk for chronic disease. If he adopts more healthy behaviors, he can avoid developing a chronic disease.

Then there are those who already have a chronic disease like diabetes or coronary artery disease. This is about 10-20 percent of a population, depending on the population we’re looking at. Instead of putting all of them into nurse coaching, like traditional disease management, we determine through claims and a short assessment if the disease is well managed. In our experience, about three-quarters of those with chronic disease are taking their medicines and managing their diseases relatively well, though, they still need help with the underlying lifestyle issues that led to the chronic disease.

Those individuals are matched with an advanced practice coach (APC) who understands their underlying chronic disease issues, but will work with them to achieve goals that they want to work on, like losing weight or exercising regularly. By far the smallest group is those with the newly diagnosed or uncontrolled chronic disease. We match them with nurse coaches who can most effectively work with their self-management approaches, with making sure that they follow their medication and care plans that the physicians have prescribed.

HIN: In tailoring a coaching program to the individual, how does a coach determine the coachee’s values?

(Kelly Merriman): We call it ‘listening until you don’t exist.’ Most people listen to get information or because they enjoy the process of exchanging perspectives. Our coaches listen to achieve empathy and understanding, which demands that they have a sense of an individual value. For example, Michelle is 46 years old and is significantly overweight. And because of her weight, she’s a pre-diabetic. She told her coach that she was ready to make a change. She knew her weight wasn’t only impacting her health, but also her self-esteem. Michelle’s coach listened and learned that she took pride in being a pillar of support for family and friends, that ‘never let them see you sweat’ mentality, which meant she was holding in her fears of being overwhelmed at times.

Imagine if a coach reflected back thoughtfully and said, “I’m hearing, Michelle, that you take pride in caring for others, that you value being competent and having others rely on you for support. And sometimes when things get to be a little too much, you overlook your own health.” Once a coach finds those values, they’ve got something to work with to promote hope and inspiration. It’s what we call motivation.

HIN: Could you provide some details on appreciative inquiry and perhaps describe a scenario in which a coach might employ this tool?

(Kelly Merriman): All too often when people want to change a behavior, they tend to focus on all the negatives. All the attention goes to focusing on what’s broken. That focus can hold a participant back from achieving their goal. Our coaches use appreciative inquiry to focus on the participant’s strengths instead. The appreciative inquiry approach deliberately seeks to discover that person’s exceptionality, through their unique gifts, strengths and qualities. We listen with intent to appreciate who they are during the early coaching interactions and then envision how they want their life to be.

Appreciative inquiry has low resistance as an approach to change because it builds upon the person’s positive core, the things that they already have going for them. It assumes that tapping into their positive experiences and strengths are useful in discovering their intrinsic motivation to change and development. This immediately shows the coach and the participant that they have faith in the ability to make a positive change.

As an example, let’s look at Michelle again. We want to appreciate what she’s got going for her and use that to help her to envision what her future may be. Michelle is overweight, pre-diabetic and feeling overwhelmed. Her coach learned that she’s committed to her health, takes pride in being a pillar of support for her family and friends and is organized and creative. Instead of focusing immediately on fixing what’s broken, that she eats too much between meals and doesn’t exercise enough, her coach focuses on envisioning Michelle’s idea of health, one that honors her strengths and her values. In this case, Michelle’s vision of health may be using her creativity and strengths of purpose to take care of her own self as well as the people she loves. She’ll make healthy choices, will see the results, and have the freedom to live the life she wants.

Infographic: ACO Activity Assessment Tracks Launch of Accountable Care Organizations

August 17th, 2012 by Patricia Donovan

Click image for ACO metrics and benchmarks.

Check out this new HIN infographic depicting the rapid evolution of the ACO as a bona fide healthcare delivery model.

We’ve discovered infographics, a creative and visual way of conveying the latest healthcare benchmarks we’ve identified. Our e-mailboxes seem to be full of infographics lately, and we have to admit they’re a fun alternative to plain old pie charts and bar graphs. So we are creating a few ourselves, based on data from our healthcare benchmark surveys, and you’ll be seeing them here.

If you’re as new to infographics as we are, there’s one thing you should know: infographics can be LONG. So you usually have to click on it to display the entire image. For example, click on the colorful red image above to enlarge it, and learn about ACO challenges, benefits and locations, metrics to measure ACO success and time needed for ACO implementation.

Scroll down this detailed image to find out who’s running the ACOs, what the industry has to say about accountable care, whether your ACO should be wired with an EHR, and prognostications about the future of ACOs.

If this infographic piques your interest and you’d like to review all of the data that went into the making of it, check out 2012 Healthcare Benchmarks: Accountable Care Organizations

Like the infographic? Then share a comment, and while you’re at it, let us know of any healthcare infographics that catch your eye. We’ll share the best ones here.

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New Video Documents ACO Activity: Accountable Care Doubles in Last Year

July 17th, 2012 by Patricia Donovan

Along with bundled payments, the accountable care organization would be the healthcare model to watch in 2012, predicted healthcare consultant Steven T. Valentine late last fall.

And as this new ACO video from the Healthcare Intelligence Network can attest, The Camden Group president knew what he was talking about. According to 200 healthcare companies who took the HIN ACO survey in May, participation in accountable care organizations doubled in the last year.

The survey also found that today’s ACO is leaner and more efficient, with more physicians at the helm than hospitals and less time necessary to get the ACO up and running.

For the uninitiated, ACOs create integrated delivery systems that encourage teams of physicians, hospitals and other providers to collaboratively coordinate care for ACO members. Built into the ACO model is a business opportunity: provide a focal point of care while attaining health and cost containment goals.

The bundled payment method referenced by Valentine refers to the practice of aligning payments for services delivered across episodes of care or “bundled” care.

Narrated by HIN COO and Executive VP Melanie Matthews, HIN’s second annual ACO analysis delves into ACO administration, size, and the model’s impact on healthcare utilization and care delivery. And in case you missed Valentine’s forecast last fall, his comments are included here.

If you prefer to read an executive summary of the survey results, download it here. A more detailed analysis is available in the HIN bookstore.

Federally Funded Clinics as Effective as Private Practices on Most Quality Measures

July 17th, 2012 by Cheryl Miller

Federally qualified health centers (FQHC) and their “look-alikes” are as effective as primary care practices, and better on some quality measures, according to a new study from the University of California, San Francisco. Because they serve the poor and uninsured, there have been concerns that they provide less effective care because they are serving more medically and socially complex patients. Researchers refute this, and the clinics will receive $11 billion from the federal government to expand their operations in the wake of anticipated primary care shortages as an estimated 32 million people seek healthcare under the ACA.

Family and primary care physicians could receive as much as 7 percent increases in payments under a proposed ruling from the CMS. The ruling is Intended to help primary care doctors improve patient care and lower healthcare costs long term by helping to transition patients back into the community following a hospitalization or SNF stay. If passed, CMS will make separate payments to a patient’s community physician or practitioner to coordinate the patient’s care after they are discharged.

More good news for primary care: of the 89 new ACOs selected to participate in the Medicare Shared Saving Program (MSSP), half are physician-driven, serving fewer than 10,000 beneficiaries, demonstrating that smaller organizations are interested in operating as ACOs. This correlates to our research, conducted in March 2012, that found that physician-led ACOs were the most common.

Following several years of slowing growth, global spending on pharmaceuticals could reach nearly $1.2 trillion by 2016, according to a report from the IMS Institute for Healthcare Informatics. Studies indicate that the market for drugs will nearly double by 2016, reaching $1.2 trillion compared with about $956 billion in 2011, an annual growth rate of 3 to 6 percent. Suggested factors for the growth are volume increases in the pharmerging markets and an uptick in spending in developed nations.

Looking for new ideas on cost reductions in the ER? We present several stories on this topic, from Mina Chang’s detailed pre-ER interventions, to those presented in our blog post on the nonelderly Medicaid’s use of ER.

It’s not too late to participate in our survey on asthma management. Describe your organization’s efforts to manage asthma in your population by July 27, 2012 and you’ll receive a free e-summary of the survey results once it is compiled

Are Payment Tides Turning for Primary Care?

July 16th, 2012 by Patricia Donovan
Primary Care Pay

Value-Based Payments

Several indicators this month point to more dollars flowing into primary care offices, either in the form of higher provider salaries, increased reimbursement, or both. And new market data finds physicians leading the majority of accountable care organizations (ACO).

A study released last week by Medical Group Management Association found that median pay for primary care physicians (PCPs) grew 5 percent last year to $212,840, capping a five-year increase of 16.7 percent from 2007 to 2011. While an actual PCP paycheck pales next to a specialist’s, of note is MGMA’s finding that PCP compensation grew at a faster rate than specialist pay over the last five years.

The reimbursement stage is being set for patient-centered care delivery models like the patient-centered medical home and the ACO that put a premium on care coordination, with many payors offering a combination of traditional fee for service (FFS) payment topped off with a care coordination fee, with possibly a little shared savings thrown in to sweeten the payment pot.

Sixty-one percent of respondents to the sixth annual HIN 2012 Patient-Centered Medical Home survey reported they operate under an FFS plus care coordination fee model.

And earlier this month, CMS proposed payment increases for family physicians of approximately 7 percent and for other practitioners providing primary care services of between 3 and 5 percent. As it has in other initiatives resulting from healthcare reform, the proposed rule offers additional financial incentives for care coordinated during critical transitions in care, such as when a patient is discharged from the hospital:

For 2013, CMS is proposing for the first time to explicitly pay for the care required to help a patient transition back to the community following a discharge from a hospital or nursing facility. The proposals calls for CMS to make a separate payment to a patient’s community physician or practitioner to coordinate the patient’s care in the 30 days following a hospital or skilled nursing facility stay.

Dr. Carrie Nelson, medical director of special projects for Advocate Physician Partners (APP), lauds CMS’s proposal. “It’s a long time coming that that kind of recognition has translated into reimbursement for primary care physicians,” notes Dr. Nelson, a family physician herself. “I know first-hand the amount of work that goes into making sure your patients aren’t falling through the cracks and getting the care they need in an efficient manner, especially after a hospitalization or major clinical situation.”

However, it’s critical that those dollars given to primary care for care coordination actually go toward that function, Dr. Nelson cautioned, and that quality measures are established in parallel with this funding. “There’s a risk that these funds could be seen as ‘new money,’ she said. “I think primary care feels undervalued and underpaid, and there is some validity to that. But at the same time, reimbursement for care coordination may not translate into actual care coordination unless there are some quality measures associated with that in order to make sure that the dollars go toward the purpose for which they were intended.”

With eight years of clinical integration (CI) under its belt, involving more than 4,000 physicians and 10 hospitals, APP can speak from experience. Its nationally recognized CI effort has achieved record performance in almost all measured areas, resulting in improved patient outcomes and significant cost savings. The CI program laid the groundwork for a value-based payment contract between APP and Blue Cross Blue Shield of Illinois. Dr. Nelson will share lessons learned from contract implementation during a July 18, 2012 webinar, Bending the Cost Curve with a Commercial Value-Based Payment Contract.

Healthcare 80/20 Law Saves Consumers Over $1 Billion

June 25th, 2012 by Cheryl Miller

Consumers should check their mailboxes this August

Insurance policy holders just might have some extra spending money this summer.

According to the HHS, insurance companies that don’t meet the 80/20 healthcare rule of spending, which requires them to spend at least 80 percent of consumers’ premium dollars on medical care and quality improvement, and the remainder on administrative costs, must provide their policyholders a rebate for as much as $151 no later than Aug. 1, 2012. Consumers can expect a notice from their insurance company informing them of the 80/20 rule, whether their company met the standard, and, if not, how much of the difference between what the insurer did or did not spend on medical care and quality improvement will be returned to them.

Eligible healthcare organizations have already been reimbursed by the government for adopting EHRs for meaningful use. In fact, the CMS met its goal of getting 100,000 organizations on board with its EHR incentive program three months earlier than planned: more than 110,000 eligible healthcare professionals and over 2,400 eligible hospitals have received over $5.7 billion in payments as of the end of May. The end of 2012 was the original target goal. Officials hope the increasing use of EHRs will provide better patient care, cut down on paperwork, and eliminate duplicate screenings and tests.

Pharmacists could help manage the country’s healthcare costs if the results of a new study from Walgreens prove fruitful. Walgreens pharmacists trained over 4,500 patients starting self-injectable diabetes medication for the first time on appropriate injection technique, side effect management and the importance of adherence to therapy. Pharmacists also provided a follow-up assessment at the patients’ next refill meeting. Initial results showed that patients who received two counseling sessions with a pharmacist were 24 percent more adherent after 90 days and had an additional eight days of therapy compared to a usual care control group.

Employers, too, are looking for ways to keep their costs down, with employee healthcare plans a prime target. A study from J.D. Power and Associates reveals that almost 50 percent of employers might pursue alternate methods of employee healthcare coverage, including defined contributions, vouchers and exchange purchasing. A smaller percentage of fully insured and self-funded employers said they might discontinue sponsoring employee coverage completely. Details in this issue.

And lastly, we have a new survey on asthma management. Asthma drives a lot of healthcare utilization — half a million hospitalizations and nearly 2 million emergency department visits in 2009 alone. We invite you to share how your organization is managing asthma in the populations you serve by July 27, 2012. In return, we’ll e-mail you an executive summary of trends in asthma management.

All this and more in this week’s Healthcare Business Weekly Update.

New Market Data: ACOs Can Survive a Supreme Court Challenge

June 15th, 2012 by Patricia Donovan

The accountable care organization, the number of which has doubled in the last year, is here to stay, no matter how the nation’s highest court rules on healthcare reform legislation.

So say two-thirds of respondents to the second annual survey on ACO activity conducted by the Healthcare Intelligence Network.

The nation’s highest court is expected to release its opinion on the Patient Protection and Affordable Care Act (PPACA) before the end of this month. But the majority of healthcare organizations responding to the ACO survey said the accountable care model is robust enough to survive a Supreme Court challenge.

Almost a third of this year’s respondents — 31 percent — participate in an ACO, up from 14 percent in 2011. 200 healthcare companies completed the second annual survey, which also tracked trends in ACO size, administration, lead time, and early results.

“These results make it clear that the healthcare industry is prepared to go forth with accountable care, whether or not the U.S. Supreme Court upholds PPACA,” notes Melanie Matthews, HIN executive vice president and chief operating officer. “Even though many ACOs are still in their infancy, the accountable care model is already driving improvements in care coordination and a decline in hospital readmissions for patients cared for by an accountable care organization.”

Other data highlights from the survey include the following:

  • Just over half of responding ACOs participate in the CMS Shared Savings program, an ACO for Medicare beneficiaries.
  • Physician-led ACOs are the most common, with a quarter of 2012 respondents reporting physician administration of their ACO. In contrast, the number of ACOs with a hospital at the helm has dropped dramatically, from 32 percent in 2011 to around 5 percent.
  • The typical ACO is smaller in 2012, as the number of active ACOs with 100 to 500 physicians dropped almost 50 percent in the last 12 months. One-third of current ACOs have between 1 and 100 physicians participating.
  • Staff management and buy-in is the greatest challenge organizations must overcome during ACO creation, say 21 percent of respondents.
  • Organizations have become more efficient in ACO creation: 41 percent say it took less than a year to launch the ACO, up from 25 percent in 2011.

Download a complimentary executive summary of ACO survey results.