News & Updates

A new Commonwealth Fund report finds the U.S. has the highest costs and lowest overall performance compared to Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom.

http://www.fiercehealthcare.com/healthcare/when-it-comes-to-healthcare-u-s-once-again-ranks-last-quality-care-compared-to-other

The United States spends more on healthcare than other wealthy nations, yet ranks dead last on equity, access, efficiency, care delivery and healthcare costs.

Despite progress made in providing coverage to previously uninsured Americans via the Affordable Care Act, the latest report from The Commonwealth Fund finds that the United States offers its citizens the least financial protection among the 11 high-income countries surveyed. It is also the only one without universal health insurance coverage.

Indeed, the U.S. has the highest costs and lowest overall performance compared to Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the United Kingdom. The U.S. spent $9,364 per person on healthcare in 2016, compared to $4,094 in the U.K., which ranked first on performance overall.

Forty-four percent of lower income Americans and 26% of higher income U.S. citizens reported financial barriers to care. Remarkably, the report noted, someone with a high income in the U.S. was more likely to report financial barriers to healthcare than a low-income person in the U.K.

“What this report tells us is that despite the substantial gains in coverage and access to care due to the Affordable Care Act, our healthcare system is still not working as well as it could for Americans, and it works especially poorly for those with middle or lower incomes,” Commonwealth Fund President David Blumenthal, M.D., said in an announcement. “The healthcare policies currently being contemplated in Congress would certainly exacerbate these challenges as millions would lose access to health insurance and affordable healthcare.”

This isn’t the first time the U.S. has fared poorly compared to other nations. Since 2004, it has ranked last in every one of six similar reports. This year the Commonwealth Fund added new measures and refined the scoring to give each country an overall score, as well as a score on five specific areas of performance. The new approach ranked the U.K. Australia and the Netherlands as top performers. New Zealand, Norway, Switzerland, Sweden and Germany were in the middle of the pack. Canada and France were near the bottom but performed better than the U.S.

Another recent global report found massive inequity within the United States in terms of access to care and the quality of care provided.

But it’s not impossible for the U.S. to move from last place to first among wealthy countries if it heeds the lessons offered from top performing countries, notes Eric Schneider, M.D., the lead author of the study and senior vice president for policy and research at the Commonwealth Fund, and David Squires, former senior researcher to the president at the Commonwealth Fund, in a piece for The New England Journal of Medicine.

This would mean the U.S. must expand health insurance coverage, such as universal coverage that provides citizens with healthcare they need at little or no cost; invest more in primary care so that it is accessible on nights and weekends; cut down on the administrative paperwork that physicians must complete so they can spend time on providing care; and invest more in social services to reduce healthcare disparities.

“If we are going to be the best, we have to do better for patients,” Schneider said in the announcement. “We are not the U.K., Australia or the Netherlands, and we don’t have to be. Each of those countries follows a different path to top performance. A country that spends as much as we do could be the best in the world. We can adapt what works in other countries and build on our own strengths to achieve a healthcare system that provides affordable, high-quality healthcare for everyone.”

A low-income person, eligible for Medicaid but not enrolled, is hit by a car or a bullet. Gravely injured, she arrives at the hospital unconscious. Thanks to expert, intensive care that lasts for days or weeks, she gradually recovers. Eventually, her health improves to the point where she can complete the paperwork needed to apply for Medicaid.

Such a hospital can be paid today, thanks to Medicaid’s “retroactive eligibility.” Even if the combination of medical problems and bureaucratic delays prevents an application from being filed and completed for several months, Medicaid will cover the care if the patient was eligible when services were provided.

The newest version of the Senate health bill—the Better Care and Reconciliation Act, or BCRA—would end this longstanding feature of the Medicaid program for beneficiaries who are neither elderly nor people with disabilities. If services are received in one calendar month and the application is completed the following month, the hospital would be denied all payment, even if the patient was eligible and the services were both essential and costly.

It does not matter if the state is led by a governor who understands the devastating impact of this change on hospital infrastructure, especially in rural areas where many hospitals are hanging on by a thread. Today, states have the flexibility to seek waivers that limit retroactive eligibility. Under the BCRA, that flexibility would disappear, as states are forced to end retroactive coverage, whether they like it or not.

Almost certainly, this provision would come as a surprise to most senators who are being asked to support the BCRA. It is only one of many unpleasant surprises lurking largely undiscovered throughout the bill.

Following are other selected examples.

A Massive Expansion In Federal Power Over State Budgets
The BCRA grants the federal government startling new power over state Medicaid programs and state budgets. Federal dollars per person would be capped, based on state data about prior spending. But in setting the initial cap for each state, the secretary of Health and Human Services (HHS) could change the amount to rectify what the secretary views as problems in the “quality” of state data. In later years, many states could have their caps adjusted up or down by as much as 2 percent per year. That may sound like a small number, but when applied to billions of federal Medicaid dollars going to a state, it could make or break a state’s entire budget. Medicaid costs triggered by a public health emergency are exempt from the cap, but only if “the Secretary determines that such an exemption would be appropriate.” No statutory limits bound the Secretary’s use of this decision-making authority, which can have an extraordinary fiscal impact on states experiencing an epidemic or other public health crisis.

These provisions would give HHS remarkable new leverage over states, which current or future administrations could use to compel state policy changes in any desired direction. The aggressive use of available leverage has been an unfortunate feature of past administrations’ relationships to state Medicaid programs, but it could become substantially more pronounced with the increased federal authority granted by the Senate bill.

Adding To Uncertainties Surrounding State Expenditures
One recurring theme in Medicaid’s history involves state efforts to claim federal matching funds without spending the requisite state dollars. The Senate bill appears to increase this risk. Under Section 207 in the Senate bill, new opportunities emerge for states desperate to counteract the loss of billions of federal dollars. The bill authorizes unprecedented waivers involving federal funding for tax credits that help consumers buy private health insurance. So long as officials complete a form explaining how the waiver’s replacement of federal safeguards would provide an “alternative means” of increasing “access to comprehensive coverage, reducing average premiums, and increasing enrollment,” a state arguably could convert some or all of this federal money into so-called “pass-through” funds that can be used for purposes unrelated to health care. Unlike the Senate bill’s new public health emergency provisions, which require federal audits of state expenditures, states’ use of pass-through dollars has no statutory audit requirement. A state could convert subsidies meant for health insurance to other uses, or simply use the money to close a budget shortfall. As the Congressional Budget Office (CBO) explained about the virtually identical prior version of this section, the Senate health care bill would “substantially reduce the number of people insured” if states “reduced subsidies, received pass-through funds, and used those funds for purposes other than health insurance coverage.”

Medicaid Treatment For Mental Health And Substance Use Disorders
The bill repeals the current requirement that Medicaid programs must cover all “essential health benefits,” including treatment of mental health and substance use disorders. CBO found that, as the per capita limits in the Senate bill grow progressively tighter, federal Medicaid funding would eventually decline by more than a third, compared to current law. States facing such an enormous drop in federal support may see themselves as having no alternative but to cut services classified as optional, which the Senate bill redefines to include mental health and substance abuse treatment.

A Disordered Process
These problems could have been averted had the legislative process followed regular order, with hearings, legislative staff explaining the bill’s provisions, expert testimony, a public markup, and opportunities to address policy and drafting anomalies. Embedded in a measure with underlying policy goals that the authors of this blog post find fundamentally questionable, the picture that emerges is extraordinarily troubling—a legislative effort to divert more than a trillion dollars away from health care for people who are sicker, poorer, older, and indigent, while leaving states with such massive funding deficits and federal leverage that some states may attempt to stem their losses in ways that harm their vulnerable residents even more.

Even people sympathetic to the bill’s core aims, however, have good reason to oppose the Senate making such consequential decisions without taking the elementary legislative steps needed to detect and avoid terrible mistakes. Continuing to shun all the protections of regular order, the Senate appears poised to act on a bill that almost certainly includes additional unpleasant surprises going beyond those discussed here. With legislation that governs one-sixth of the US economy and that directly affects the health and economic security of millions of constituents, Senators are being asked to vote largely in the dark.

About one-quarter of 700 health executives polled in a new survey said they had no value-based reimbursement initiatives planned for 2017.

Health systems are transitioning from a model that emphasizes volume to value, albeit slowly. The escalating cost of care, a lack of standardization in how quality is defined, a disengaged workforce that leads to more medical errors, and a lack of trust and transparency between providers, payers and regulators have impeded their transition, according to a survey global consulting firm EY released Thursday.

Smaller organizations were far more reticent to pursue value-based reimbursement initiatives, some of which include the Medicare shared savings program and variations of accountable care organizations, than larger organizations.
Around two-thirds of the organizations that reported between $100 million and $1 billion in annual revenue were not pursuing value-based initiatives in 2017, while the vast majority of larger firms that have the resources needed to integrate these models into clinical operations had some form of value-based models in place.

“This creates a competitive disadvantage for smaller hospitals, and quite frankly, puts their financial futures, sustainability and corporate existence in jeopardy,” Dr. Yele Aluko, an executive director in the advisory health practice at EY, said in an accompanying report. “Many smaller hospitals and health systems lack the strategic management processes, corporate resources and capabilities to remain competitive in the short term or relevant in the long term.”

Transparency, coordination and communication are essential attributes for any organization striving to transform culture and achieve value-driven care, said Dana Alexander, an executive director in the advisory health practice at EY.

“The industry is beginning to grasp the concept that quality is a driver to reducing costs and that the cost-cutting measures of yesterday were short-term band-aid approaches that did not achieve a sustainable balance of cost and quality,” she said.

Providers are pursuing measures to help reduce medical errors and increase reliability. Morale among the front-line staff must improve to ensure the endeavor to reduce errors is a sustainable one, Aluko said.

“Otherwise, avoidable medical errors will exponentially place patient lives at risk and transformation toward value-driven healthcare will remain nothing but a theoretical conversation,” he said.

The next highest cost-control measures included decreasing unnecessary variation and utilization, increasing patient access to primary and specialist care, and reducing hospital and emergency department use for high-cost patients.

A holistic, cultural shift is needed to fully embrace value-driven care, researchers said. That involves delivering effective care that produces measurable results, increasing transparency to reduce medical waste and redundancy, gauging and improving patient experience—an endeavor 93% of respondents said they are currently undertaking—and making sure employees are engaged and satisfied, they said.

As to improving quality, 49% of respondents have initiated quality audits, 31% had implemented physician performance scorecards that include a quality measure and 38% plan to institute facility scorecards.

While it can be costly, providers can better leverage new technologies to improve outcomes and patient experience, researchers said. Only 26% of respondents ranked new technologies as one of their top three priorities for 2017 and only 8% are using patient-centric analytics to improve patient experience.

Anthem Blue Cross Blue Shield of Missouri will no longer cover emergency department services it considers unnecessary, according to St. Louis Public Radio.

The goal of the discretionary ED coverage policy is to direct non-emergent patients to urgent care or primary care physicians to reduce costs and emergency room wait times.

In these nonemergency situations, policyholders could foot the bill if their visit does not meet emergency requirements.

The policy has several exceptions, including if the patient is under 14, the visit occurs on Sunday or there are no urgent care clinics within 15 miles, according to the report.

Similar policies are enacted in Kentucky and Georgia under Anthem-affiliated plans.

“We are looking to expand the policy to other markets, but we have not brought it to other states yet,” Anthem’s Public Relations Director Joyzelle Davis told Becker’s Hospital Review.

Physicians are worried that the policy may cause patients to shy away from seeking care when they need it since there is a threat of receiving large medical bills, according to the report.

In Kentucky, where the policy has been in place since 2015, Ms. Davis said the insurer has only issued denials for a “small percentage” of claims for unnecessary ER use, but the number of members with “repeat avoidable ER claims” has declined.

Last November in Frisco, Candie and Dustin Sandlin entered a Legacy ER & Urgent Care center—a walk-in clinic that also operates as a freestanding emergency center—because the couple’s primary-care physician was unavailable. Candie, experiencing symptoms of a migraine headache, was told by the on-site doctor that a CAT scan was needed to rule out any serious diagnoses.

Candie was reluctant, but agreed to the procedure. Afterward, Dustin says the doctor diagnosed his wife with a headache. The Sandlins returned to Legacy ER & Urgent Care five days later, with Candie still in pain. This time, Dustin says, another doctor suggested she may have vertigo, and ran a blood test to confirm the hunch. Once the diagnosis was confirmed, he says, the doctor could only provide “over-the-counter motion-sickness medicine, because the facility did not have medicine to specifically treat vertigo.” The total bill for the two visits? “$7,000,” Dustin says.

When asked by Dustin in a formal complaint why the bill was so high, he says the facility replied it was because Candie had received a CAT scan and a blood test and that these services were categorized as “emergent,” allowing Legacy to charge freestanding ER prices, without verbally notifying the patient. (Emergent care typically is required in case of a threat of grave disability, or an immediate threat to a patient’s life.)

Later, the Sandlins did recall seeing, in fine print, a reference in Candie’s paperwork to the possibility of some services being “emergent,” which for them meant out-of-network insurance care, carrying a higher price tag. For Dustin, though, a bigger question arose: “Why weren’t patients being notified which medical procedures are classified as urgent care—or emergency services—so they knew the difference?” Legacy didn’t return our calls seeking comment.

The Sandlins aren’t alone in their experience, or in their question. In Frisco alone, freestanding emergency centers owned by Legacy, Code 3 ER & Urgent Care, and other independent operators have attracted more than 10 pages of website reviews. There, patients have complained variously about exorbitant, hidden costs for the treatment of problems ranging from minor injuries to colds.

This is mostly because independently owned urgent care or freestanding emergency centers in general are able to “bait and switch consumers,” Dustin Sandlin alleges. “People are coming in for urgent care—it’s not our goal to go to the ER,” he says. “The transparency of what is and what isn’t considered an ‘emergent’ service determines the price point. There should be a list of services that is distinctly offered, so people are aware. But that list doesn’t exist.”

In Dallas-Fort Worth, according to a national urgent care database, there are at least 45 urgent care centers—26 of which operate as both urgent cares and freestanding ERs. There are more than 490 urgent care centers total in Texas. In addition, there are at least 40 freestanding ERs in North Texas, mostly in middle-to-high income areas, according to the Texas Association of Freestanding Emergency Centers (or TAFEC), and 325 such facilities statewide. Two-thirds of these ERs are independent, while the rest are hospital-operated.

Of course, not everyone believes like the Sandlins that independently operated, freestanding medical facilities are misleading patients. One who doesn’t is Dr. Carrie de Moor, president and CEO of Frisco-based Code 3 Emergency Physicians, and chairman of the American College of Emergency Physicians’ Freestanding Emergency Centers Section. She believes a lack of cooperation between insurance providers and the facilities is what leads to higher-than-expected, out-of-network bills.
In an April commentary for D CEO Healthcare titled “Willing healthcare providers seek fair in-network contracts,” de Moor wrote about the resistance by insurance companies to accepting these facilities as healthcare providers. She describes the facilities as providing expeditious, cost-effective emergency services in a transparent manner.

In an interview, de Moor adds, “I believe having a dual model—both an urgent care and a freestanding emergency center—actually helps us be transparent. We can distinguish if a patient has an emergency or not, and diagnose them on how to treat it.” According to TAFEC, urgent care facilities serve as alternative care options for patients with non-life-threatening injuries or illnesses. Meanwhile, freestanding emergency centers serve as facilities—staffed with 24/7, ER-trained physicians—that treat cases requiring immediate attention.

But Stephen Mansfield, CEO of Dallas-based Methodist Health System, contends that, in reality, there is little difference between the two. Mansfield says he knows of a few facility owners who “basically turned an urgent care into a freestanding ER, by changing [their] operating hours to be open 24/7, 365 days. They didn’t really change the staffing model, clinics, or equipment. They may add a CAT scan and a small lab. But the main difference is that the facility needed only four more visits a day [to stay in business], since the reimbursement is so much higher” for emergency centers.

With a highly profitable business model, and free rein to plant seeds in higher income areas following the passage of a 2010 Texas licensing law, it’s no wonder that freestanding ERs are proliferating here. “For a private entity investing in private money … there’s not any stipulation that you can’t set up a freestanding ER,” Mansfield says. “We don’t have [certificates-of-need] in Texas. … If you want to put one at an intersection or by a hospital, and you can get the land, you can do it. There is no regulatory body to tell you otherwise.”

While it may be relatively easy to set up shop, de Moor says independent freestanding centers face other obstacles. Her struggle working with insurance providers, for example, prevents her patients from being billed in-network, she says. “We’re trying to get patients to understand their healthcare plans better, and educate them so they know we’re trying our best to be in-network with them,” de Moor says. “ … We’re doing what we can.”

Kevin O’Donnell, managing partner at Dallas-based Healthcare Resources of America, believes patient safety is an additional concern with some of these facilities. “Urgent care centers and freestanding ERs have a lot of limitations on what medical services they can provide,” O’Donnell says. “In a serious emergency like a stroke or heart attack, [patients] won’t get the care they need there. They may be able to stabilize them for the next move—which is a hospital emergency room—but you’re putting their safety at risk, losing time.”

Says Mansfield: “Hospital systems pay millions of dollars every year for specialists to be on-call. If you go to an emergency room there, you’ll have a doctor that can cater to your problem well. At a freestanding ER, you’ll see a doctor with a limited skill set. What ends up happening is an ambulance will take you to a hospital ER. Then you have to pay for two visits, while putting your health at risk.”

Mansfield’s Methodist Health is one of the largest DFW healthcare systems that has yet to contract with any independently operated, freestanding ERs. Other systems have opted to open freestanding emergency centers, sometimes partnering with independent operations.

In a D CEO Healthcare article last year, Barclay Berdan, CEO of Texas Health Resources, said THR decided to partner with the First Choice Emergency Room chain, adding a number of freestanding emergency rooms in order to increase access to care.

As of now, Mansfield says, Methodist has no similar plans. “We believe everything we do either needs to improve quality of care for the patient or lower the cost,” he says. “So far, we’ve had a hard time convincing ourselves that freestanding ERs do that.”

It’s common for emergency care clinicians to order more tests if they suspect the patient may have acute coronary syndrome (ACS). But researchers found that routine testing may increase the use of resources but not necessarily improve the outcomes of patients who come to the ER with chest pain but no other evidence or initial diagnosis of ischemia, according to a new study published in JAMA Internal Medicine.

The retrospective cohort analysis looked at national claims data of more than 925,000 privately insured patients between the ages 18 to 64 years old who came to the ER with chest pain. Weekday patients were more likely to receive testing compared to patients who came to the ER on the weekend. Researchers found that invasive and noninvasive cardiac testing of the relatively young patients didn’t lead to a reduction in subsequent hospital admissions for acute myocardial infarction.

“Our results show that cardiac testing is overused and reinforces the need to evaluate which, if any, patients with chest pain without evidence of ischemia benefit from noninvasive testing,” write lead author Alexander T. Sandhu, M.D., Stanford University Center for Primary Care and Outcomes Research, and the research team.

The findings, according to an accompanying editorial in JAMA, are consistent with a rapidly “expanding evidence that challenges the current paradigm of early noninvasive testing after an ED evaluation for suspected ACS.”

In addition to the costs involved, the noninvasive testing may expose patients to injuries associated with radiation exposure, invasive angiography and cardiac revascularization procedures, Benjamin C. Sun, M.D., Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University and Rita F. Redberg, M.D., Division of Cardiology, University of California–San Francisco, wrote in the commentary.

They agree with researchers that further study is necessary to determine whether there is a benefit to the testing for patients who are at higher risk for ACS.

Accountable care is an important mechanism used by public and private payers to align health care provider payments with efficient care for defined patient populations. Leavitt Partners, in partnership with the Accountable Care Learning Collaborative, tracks the growth and spread of accountable care organizations (ACOs) and other alternative payment models.

Growth Of ACOs
As of the end of the first quarter of 2017, our inventory included 923 active public and private ACOs across the United States, covering more than 32 million lives (Figure 1). The increase of 2.2 million covered lives in the past year means that more than 10 percent of the U.S. population is now covered by an accountable care contract (Note 1).

As the ACO model matures, there is now some turnover, with organizations joining and leaving the model. Since the first quarter of 2016, 138 new ACOs began operation, and 46 ACOs dropped their accountable care contracts, representing a net increase of 92 organizations becoming ACOs, or an 11 percent growth.

Over the same period, the number of contracts has grown by 166, as many ACOs have expanded the number of accountable care contracts in which they participate (Figure 2). These ACO contracts span diverse types of health insurers (Figure 3). Commercial contracts represent a plurality of all contracts (715) and a majority of covered lives (59 percent), while Medicare contracts represent 563 contracts but only 29 percent of covered lives. Medicaid accounts for 88 contracts and 12 percent of covered lives. On average, commercial ACO contracts tend to cover more lives (about 26,700 per contract) than Medicare contracts (about 16,800 per contract). The pace of growth in contracts has been similar for all payer types.

While the most populous states have the most ACOs, these organizations continue to expand around the country and exist in all 50 states; Washington, D.C.; and Puerto Rico (Figure 4). When examined at a hospital referral region (HRR) level (Figure 5), the strongest ACO growth has occurred in metropolitan areas. However, there are still 15 HRRs that are not served by an ACO.

The percent of the population estimated to be covered by an ACO varies significantly by state (Figure 6). Two largely rural states (Wyoming and West Virginia) have less than 2 percent of their population covered, while two states (Rhode Island and Maine) now have over 30 percent of their populations covered. Interestingly, the most populous states (California, Texas, Florida, New York, and Pennsylvania) have a lower percent of lives covered than the national average, despite having some of the highest counts of ACOs.

Figure 7 shows the estimated percent of the population covered by an ACO at the HRR level. Growth in ACO lives has varied substantially by market, with some markets in every region of the country now having ACO penetration of over 30 percent. Neighboring HRRs in the same state can have vastly different levels of penetration.

Growth Of Other Alternative Payment Models
While ACOs are an important alternative payment model (APM), other APMs with accountability for person- or episode-level outcomes and costs are also expanding. Specifically, there is growth of the APMs labeled category 3 and 4 of the Health Care Payment Learning and Action Network (LAN) framework, which, in addition to shared-savings and shared-risk ACOs, include episode-based models and partially- and fully-capitated payments for patient populations. These trends have been reinforced by passage of the Medicare Access and CHIP Reauthorization Act (MACRA), which contains new incentives for many physicians to join APMs.

Figure 8 summarizes information from the Centers for Medicare and Medicaid Services (CMS) on the number of organizations participating in different types of Medicare APMs, categorizing them by model type. Although fewer providers participate in ACOs than in any other type of APM, the majority of dollars paid through APMs flow through the ACO-based models that cover patients’ total cost of care. Together, these APMs represented over 30 percent of Medicare payments in 2016. While Medicare is the most prevalent sponsor of APMs, state Medicaid plans and commercial payers are also expanding a range of APMs. The LAN 2016 APM Measurement Effort found that in 2016, 25 percent of health care dollars were in category 3 and 4 payment models for commercial plans, Medicare Advantage, and Medicaid.

Looking Forward
A variety of factors will influence the growth of ACOs and APMs over the coming years.

Policy Environment
Since the start of the new Congress and the President’s inauguration, there have been ongoing legislative deliberations on the future of the Affordable Care Act. The proposals have generally focused on different methods to provide health insurance coverage, but there is relative bipartisan agreement on the need to support reforms in health care payment to improve value in care delivery. The American Health Care Act, as passed by the House of Representatives, did not seek to change any of the payment and delivery reforms for Medicare and Medicaid, continuing the Center for Medicare and Medicaid Innovation (CMMI). Consistent with concerns raised by Health and Human Services Secretary Tom Price about mandatory APMs, the Trump Administration has delayed mandatory bundled payment programs. However, the administration has otherwise continued the drive toward payment and delivery reforms for Medicare and Medicaid, and private plans in commercial, Medicare Advantage, and Medicaid managed care markets are continuing to implement APMs.

Whether payment reform accelerates or moves in new directions will be influenced by further administrative and legislative actions. To the extent MACRA is implemented on schedule, payment reform is likely to accelerate. While CMS provided physicians with administrative relief from Merit-Based Incentive Payment System (MIPS) penalties in 2017, in the absence of further delays, physicians must decide whether to report under MIPS or try to participate in an APM to avoid penalties in 2018. As Medicare Shared Savings Program (MSSP) Track 1 participants are not eligible for the MACRA advanced APM bonus, it is likely that more organizations will move toward greater risk sharing arrangements, such as the new MSSP track 1+, MSSP track 3, Next Generation model, or other advanced APMs. The expanding Comprehensive Primary Care Plus program (CPC+) also counts as an advanced APM for primary care providers, and CMS has indicated that it aims to make additional APM options available for specialized care in the coming months.

A Need For More Evidence
To accelerate progress with ACOs, there is a need for more evidence about which models produce the best results for organizations with different circumstances and characteristics, whether rural or urban, large or small, or physician- or hospital-led. To date, there is evidence that a wide range of ACOs can improve measured quality, but fewer ACOs have successfully combined quality improvement with significant spending trend reductions. Given the challenges of reforming care delivery to improve outcomes and lower spending, there is an increasingly urgent need for better evidence about what has worked for the variety of ACOs that have succeeded.
Changes In Bundled Episode Payment Models

Under bundled episode payments providers receive a predetermined amount for all the care related to a specific condition, such as a knee replacement, over a specified time period. Bundles provide a financial incentive to manage efficiently a patient’s treatment throughout the entire episode of care across multiple providers, giving providers flexibility in the resources they use during the episode. While bundles encourage and support providers to deliver care for the episode more efficiently, they could also create incentives for the delivery of more bundles. There is a need for evidence to evaluate the impact of episode bundles on overall spending and quality.

Episode bundled payments may help address one weakness of population-based payment models, namely that many clinicians—such as surgeons or other specialists—can have an important impact on quality and costs for specialized groups of patients, but are not well-positioned to help manage the total care of a population. Bundled payment models therefore provide a vehicle for involving more clinicians in APMs. As noted, MACRA provides an additional incentive for clinicians to participate in episode bundled payments with downside financial risk (such as the Comprehensive Joint Replacement program) by allowing them to qualify for the advanced APM bonus.

For many clinicians, though, there are no existing Medicare APMs that cover the services for which they are responsible. To address this challenge, MACRA authorized the creation of the Physician Focused Payment Model Technical Advisory Committee (PTAC), charged with recommending potential APMs to CMS for piloting and adoption. To date, many of the submissions to PTAC have focused on specialized care, reflecting the interest in such models.
Balancing Multiple Payment Models

Going forward, there is potential value in expanding the range of accountable payment models, to give all providers more support and incentives to implement reforms in care. Indeed, different types of APMs may complement and reinforce each other. However, the expansion of multiple payment models has raised concerns about how they interact.

As APMs spread, more health care organizations are operating under multiple APMs. One common overlap is the use of bundled episode payments for specific services within an ACO arrangement. This could be a positive combination: evidence suggests that bundles improve efficiency within a defined episode, while ACOs can help improve population health and lower overall spending. For example, a joint replacement bundle could support the orthopedic surgeon to coordinate care for the episode and provide an efficient, high-quality intervention, while the ACO program would encourage the broader organization to address the patient’s disease progression through primary care and care coordination, and ensure the patient only receives the surgery when necessary.

However, there are challenges with operating both models for the same patient, such as how to attribute cost savings within the organization or across an ACO and specialist group, if different provider organizations are involved in care for a given patient. To avoid over-burdening physicians, it is essential to ensure that providers have aligned, non-competing interests and to minimize the administrative burden of multiple payment models. Alignment within Medicare payment models is important, but greater alignment of payment models across payers, including Medicaid and commercial payers, should ensure that incentives from multiple APMs are reinforcing and do not create additional burdens.
Supporting Providers To Succeed In Payment Reforms

As APMs become widespread, it is increasingly critical to their sustainability that providers have the competencies they need to succeed. The assumption behind accountable care is that paying providers differently will provide an incentive to deliver care differently, resulting in better outcomes and lower costs. However, if providers are not confident about what to do differently, these goals will not be achieved. Further, if providers are uncertain about how to succeed, and payment reforms are not implemented efficiently, there will be increased pressure for delaying or minimizing payment reforms, compromising efforts to improve care and lower costs. For payment reform to be successful, providers must collectively experiment with new models, evaluate the effectiveness of different approaches, develop and share best practices, and commit to constant learning and improvement.

Conclusion
Alternative payment models that feature increasing accountability for improving patient care and lowering costs continue to expand. Their impact will likely grow as providers are subject to greater risk and develop the competencies to succeed. But, the payment model is not an end in itself. To achieve better value across the American health care system, more progress is needed to refine and align alternative payment models, and to help all types of health care providers develop the capabilities needed to succeed in them.

By most accounts, the federal government’s five-year campaign to stem the tide of hospital readmissions has been a success.

The number of Medicare beneficiaries making a U-turn within 30 days of being discharged has been on a downward slope ever since reimbursement dollars were at risk under the Hospital Readmission Reduction Program. For example, readmission rates for Medicare beneficiaries suffering congestive heart failure averaged 22% from 2011 to 2014, down from 24.5% from 2005 to 2008, according to a Kaiser Family Foundation analysis of CMS data. Readmissions for pneumonia patients fell from 18.2% to 16.9% during the same period.

A good thing for patients, reducing readmissions has also helped cut spending. As recently as 2011, all-cause readmissions cost the nation $41 billion, according to a 2014 Agency for Healthcare Research and Quality report. Medicare’s tab alone was $26 billion annually, $17 billion of which was attributable to avoidable rehospitalizations. By 2014, Medicare spending on readmissions fell by $9 billion.

While improvements were made during the first three years of the readmissions program, concern is mounting that momentum has stalled. There’s been no more than 0.1% reduction on average between 2013 to mid-2016, according to a December 2016 JAMA study.

“It kind of surprised us,” said Dr. Nihar Desai, a cardiologist at Yale New Haven (Conn.) Health System, and lead author of the study, which showed the link between financial penalties for readmissions and improved results.

The Medicare Payment Advisory Commission estimated that 12% of Medicare readmissions in 2011 were avoidable, and that of the 10% of hospitals who were the worst performers, 15% were avoidable. If that’s true, that would suggest most hospitals that went from 22% readmissions for a certain condition to 20% already achieved 75% of what is possible.

The reasons for the plateau are complicated, said 
Dr. Steve Jencks, whose research was instrumental in helping create the readmissions program. For starters, the number of conditions measured has grown from three—heart attacks, heart failure and pneumonia—to six with the addition of chronic lung disease, coronary artery bypass graft surgery, and hip and knee replacements. Hospitals haven’t had as much time to work on the new measures. But, he said, it may also be because after making initial improvements, hospitals are going to have to dig a little deeper to get the next level, and it may take longer to see results.

“Is this the bottom, is what people are asking, and if not, what is the next set of strategies?” said Nancy Foster, vice president for patient safety at the American Hospital Association, adding that experts may have reached the limits of scientific knowledge on how to reduce readmissions.

The Hospital Readmission Reduction Program was a significant part of the Affordable Care Act’s efforts to not only control costs, but push providers to improve outcomes. The first round of penalties for high rates of readmissions took hold in 2012, with roughly 2,000 hospitals collectively taking a $290 million hit. Penalties could total $528 million in 2017, according to the Kaiser Family Foundation.

The penalties have worked, Desai’s study strongly suggests. Improvements were rapid for hospitals that learned in 2010 that they were likely to be penalized for targeted conditions, with declines of 1.3 to 1.72 points a year over the next two years on average. Compare that with improvements of about 0.8 points in non-target conditions.

At hospitals that were already below average—where improvements were happening faster than the others before the readmission program’s existence—conditions that weren’t targeted declined about 0.54% a year, and there was no significant decline in the targeted conditions.

“Our data should suggest places that were not penalized seemed to have conducted broad readmission initiatives that reduced readmissions for everyone,” Desai said.

Hospitals tackled the issue in both treatment—trying to standardize best practices to avoid complications—and by beefing up discharge planning and care coordination.

Renown Health, a not-for-profit health system that serves a 17-county region in northern Nevada and northeastern California, benefited from $9.8 million in grant money the Center for Medicare and Medicaid Innovation awarded to the Regional Emergency Medical Services Authority to incorporate paramedics into a care-coordination program in hopes of improving services for patients at home. During in-home visits, paramedics go over the patient’s discharge plan, provide education and medication reconciliation and reinforce the importance of follow-up appointments. The program saved $9.6 million over three years and Renown decided to keep funding it after the grant ended.

Joanne Scillia, Renown’s vice president of population health management, said the paramedic program saw Medicaid and Medicare Advantage patients, and delivered consistent reductions in readmissions for patients with congestive heart failure, chronic obstructive pulmonary disease and heart attacks.

Care-management teams at Renown also call recently discharged patients and check that home health aides or Meals on Wheels is on the way. Nurses also ask how patients are feeling and about lingering symptoms.

Renown, which is an accountable care organization, tracks all-cause readmissions by all payers and looks at the figures non-risk-adjusted. From April 2016 through March, 11.38% were readmitted within 30 days, and the system’s goal is 10.32% by a year from now. In heart attacks, Renown is below the goal, and within a tenth of a percentage point for pneumonia. COPD rates stand at 18.03% with a goal of 14.84%; with heart failure, the rate is 18.57% and the target is 16.82%.

“Although we’re doing well by national statistics, we don’t want to rest on our laurels,” Scillia said. “Our CEO, Tony Slonim, is involved in this, and he’s driving this for the organization.”

In federal fiscal 2017, Renown’s two hospitals in Reno, Nev., were assessed penalties. Renown Regional Medical Center owed 0.31% in penalties, and South Meadows Medical Center owed just 0.03% in penalties, according to a Kaiser Health News analysis of CMS data.

At the 1,500-bed Yale New Haven system, efforts to curb readmissions are continually evolving.

Dr. Ohm Deshpande, director of utilization review and clinical redesign for the system, said the first initiative they tried was to email each attending physician who had a patient return within 30 days and ask if there were specific interventions that could have been done.

“We found only 2.5% to 5% of those emails resulted in a clear process miss or mistake,” he said. “That was just not super helpful.”

Then Yale asked some of the highest-performing inpatient care managers or discharge planners to become transitional care managers, with a 70-100 person caseload, straddling inpatient and outpatient delivery.

Yale also focused on improving charts while the patient was still in the hospital. Previously, clinicians didn’t have a clear picture of which patients may have had heart failure or COPD because a DRG wasn’t assigned until three to five days after discharge. Now, nurses who review charts are assigning a working DRG within 48 hours of the patient’s arrival.

“Clinical documentation is to maximize payment, given the care given,” Deshpande said. “What we’ve found is it has huge effects on our quality scores as well.”

National Quality Forum CEO Dr. Shantanu Agrawal said hospitals have plucked the low-hanging fruit.

Deshpande described one such initiative, where Yale has invested a lot of effort, but not yet moved the needle. The health system discovered that patients transferred to a skilled-nursing facility were the most likely to return within 30 days. There was also a large degree of variability in the readmissions depending on skilled-nursing facility.

At one nursing home, Deshpande said, 45% of patients returned within 30 days. So Yale used a combination of measures—CMS star ratings, how responsive the facility was to coordinating with Yale, and internal data on readmissions—to identify preferred providers. Overall, the nursing homes that are not recommended by Yale have readmission rates 24% higher than the preferred group.

The proportion of patients who go to the preferred nursing homes has not increased, even though Yale has asked transitional-care nurses to suggest those facilities.

For fiscal 2017, Yale’s penalty is 1.91% of its Medicare reimbursement, Kaiser Health News reported , still well below the 3% maximum, but the highest in the state of Connecticut.

Desai’s paper speculated that improvements stalled after the first penalties were levied because executives realized the size of the penalty was smaller than it would cost to try to address the issue. “It was much, much smaller than they were expecting,” Desai said. But he said he doesn’t believe it’s politically feasible to make the penalty bite more. “The American Hospital Association and other groups have really, really been firm in their opposition to this. Even the current program, they were strongly opposed to. The idea of going up is really not viable at all.”

The AHA’s Foster suggested that stiffer penalties would actually drive up readmissions. “It would take away the resources to do this coordination, which would be sad,” she said, adding that the hospital group will continue to advocate for a formula that takes a patient’s socio-economic status into consideration.

As policymakers, researchers and providers assess the ongoing effectiveness of the readmissions program, they’ll likely have to overcome a cultural hurdle as well—keeping people motivated. Deshpande said Yale lost ground on heart failure even as pneumonia and heart attack readmissions improved.

“I don’t think we have had the same urgency that we did at that time,” he said, referring to 2012 and 2013. “I think it’s because we haven’t found an easy intervention.”

Original article can be accessed here.

At the Middletown, Ohio fire department, calls for actual fires are rare. These days the station responds to more calls for drug overdoses — four to five a day on average.

Firefighter Bryan Oliver goes on a lot of these runs. Oliver and his team administer Naloxone and then perform CPR. He says they may treat the same patient for multiple overdoses, sometimes in the same day.

“Anybody you talk to who does this job will tell you it’s frustrating and you put that to the side because you have a job to do,” he says.

Opioid overdoses continue to rise and for many cities and towns, the epidemic is starting to affect their bottom line. Middleton, population 48,791, has already seen nearly 600 overdoses this year — that’s more than it saw in all of 2016.

Now Middletown city councilman Dan Picard has made a startling proposal. He’s suggested a three strikes rule: overdose two times and the third time medics may not respond. If overdoses continue at this rate, Picard says they won’t be able to afford to provide emergency services.

“If we don’t do anything the city’s going to run out of money,” he says.

Each dose of Naloxone, an overdose reversal drug, cost about $36 and, depending on the potency of the opioid, one patient may require several doses. The department estimates it will spend up to $90,000 on Naloxone this year —that’s 50 percent more than their entire budget for all the medications aboard their ambulances.

Picard says that’s not the only cost. He calculates that each overdose run cost the city $1,104. He counts the wear on the ambulance, the cost of drugs and the medics’ time.

Original article can be accessed here.

In St. Louis, a woman who struggled with heart disease sometimes had so much trouble managing her breathing that she couldn’t even take out the trash. When that happened, she did what many Americans do: She called 911.

Christian Hospital began working with her via the paramedics who visited her home whenever she called for help. When the community provider, just outside St. Louis, conducted its initial assessment, providers realized she needed ongoing care and a solid plan, including education and working with her primary care physician, to help stabilize her breathing.

Jennifer Cordia, Christian Hospital’s chief nurse executive and vice president of patient care services, says the patient called the hospital recently to let staff know how well she was doing. She’s now able to leave her house, walk comfortably — and take out her own garbage.

“She just went to her first Cardinals baseball game,” Cordia says. “She was so excited. She had never been to one.”

Many hospitals like Christian struggle with overutilization of their emergency departments. Often, underinsured or uninsured patients use these services as de facto primary care. After taking a closer look at the numbers, the hospital discovered that 48 percent of its ED visits and 40 percent of emergency medical services visits were nonemergent — that is, nonacute situations that would have been better handled in an office setting. It was determined to find a solution.

“We really got a team of people together and identified the problem. We realized quickly that we needed to provide the right care, at the right cost, at the right place,” says Cordia. “The right place was our first focus.”

That was in summer 2013. The team began to work with the 911 dispatcher to identify patients who needed something other than the emergency care that 911 provides. By training community paramedics to assess patients, they were able to navigate those patients to what they called an access center. In early 2014, they opened two such centers, with coordinators who could help provide the type of care that patients needed.

“What we realized is that we needed to understand why patients were coming to the ED in the first place,” says Cordia. “So we asked them, individually.” What they found was that people generally weren’t using community resources that already existed and were funded — and sometimes the reason was that they simply didn’t know those resources existed.

Cordia emphasizes that access coordinators do more than simply point people to those assets. “Our access coordinators have made and cultivated relationships with community resources in the past three years,” she says. “We literally walk with the patient as we help them get through the barriers to access care.”

The Community Health Access Program that formed as the result of Christian Hospital’s efforts has transformed the lives of many patients. In the three years since starting CHAP, Christian Hospital has connected over 9,000 patients to needed resources.

Most recently the hospital has focused its efforts on patients who are high utilizers of the 911 system and the ED, like the aforementioned Cardinals fan, helping them get the care they need. Another CHAP patient, Shirlie Anderson, has congestive heart failure that landed her in the ED several times. She says of her experience: “They were excellent, very helpful, very cheerful. Just awesome.”

The team would come to Anderson’s home once a week and take her vitals. She says they helped her tweak the timing of a medication she takes to regulate her blood pressure, which is now under much better control, allowing her to continue to stay out of the ED. “They said, ‘Shirlie, take the medication as soon as you know your blood pressure is up.’ To this day I couldn’t tell you why I was waiting.” For her, this simple adjustment made all the difference.