News & Updates

Jennifer L. Wiler, MD, MBA; Harold D. Miller; and Nir Harish, MD, MBA
March 08, 2017

The American Journal of Accountable Care. 2017;5(1):51-53

ABSTRACT
The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 encourages the development of physician-focused alternative payment models (APMs). This creates the most significant opportunity in 2 decades to meaningfully redefine how physicians are paid for their services. Whether this results in better care and lower spending, and whether it helps or harms physician practices, will depend heavily on how HHS implements APMs. In this article, we draw on the experience of past and present payment reforms to suggest principles for successfully designing APMs.

Five Principles for Successful APMs

1. Provide the Resources Needed to Deliver Higher-Value Care
An overarching goal of APMs is to slow the growth in healthcare expenditures. However, APMs, which blindly incent decreased utilization of services, can worsen access to care and health outcomes for patients.1 Adding penalties based on quality can protect some patients, but harm others whose care needs fall between the many cracks in current quality measures.

A major weakness in the current fee-for-service (FFS) systems is lack of payment for many high-value services that could address patient needs at lower costs. For example, patient education and self-management support can help patients with chronic disease to avoid hospitalizations, but they are not adequately supported by payers. Similarly, supervised exercise therapy can achieve equal or better outcomes than surgery for many patients with diseases such as peripheral artery disease and joint osteoarthritis, but it is not adequately supported by the current payment systems. A successful APM will give physicians the flexibility and resources they need to deliver higher-value approaches to patient care.
2. Hold Physicians Accountable Only for the Aspects of Cost and Quality They Can Control
A second weakness of traditional FFS payment is that it neither rewards nor penalizes physicians based on the overall cost of treating a patient’s problem or the outcomes achieved. In contrast, capitation payment systems reward physicians for avoiding high-need patients and penalize them for costs they cannot control. The reasons capitation systems were abandoned in the past was not a lack of adequate information technology or quality measures, but rather the inappropriate transfer of full insurance risk to physicians. Many current payment reforms that hold physicians accountable for all spending on their patients create the same problems under a different name.

There is a middle ground between FFS and full-risk global payments.2 In many pilot programs, physicians have demonstrated the willingness and ability to reduce costs and improve quality for the services they both deliver and order if they have the resources needed to do so. A successful APM will hold physicians accountable for aspects of costs and quality they can control (eg, how many tests they order, which procedures they perform, how well they prevent avoidable complications), but not for the things they cannot (eg, the services ordered by other physicians for different health problems, increases in the prices of drugs they prescribe).
3. Improve Payment for Specialty Care, Primary Care, and Inpatient Procedures
Most payment reforms to date have taken 3 forms: primary care medical homes, bundled/episode payments for inpatient procedures, and accountable care organizations (ACOs). Although high-quality primary care, inpatient surgeries, and care coordination are essential to higher-value healthcare, the majority of services are delivered outside of inpatient settings and by specialists, not primary care physicians. Not every acute condition is something that good primary care can prevent, and the mere fact that services are more “coordinated” does not mean they are achieving the highest value.

Although a majority of healthcare spending is associated with a small proportion of patients who have multiple health problems or require very expensive services, most patients receive healthcare services for individual problems. Every patient deserves high-quality, affordable care, and for many patients, that care will be delivered by a specialist in an outpatient setting, not by a primary care physician, a hospital, or a care manager employed by an ACO.

In order to deliver higher-value care, the barriers that specialists face under the current payment system must be removed. Primary care medical homes and surgical episode payments are not readily adaptable to most types of specialty care,3 and it is neither necessary nor desirable to force every patient to be part of a large ACO in order to receive better care. Appropriately designed APMs are needed in every specialty so that all patients can benefit from higher-value care.4
4. Allow Flexibility to Customize Service Delivery Approaches to Local Resources
The significant variation in care delivery within and across regions has been well documented. Much of this variation is avoidable and represents an important opportunity for physicians to improve quality and reduce costs under an APM. However, some of the variation reflects fundamental differences in the resources that communities have available to deliver care. A patient who has an acute stroke may be managed by an internist, neurologist, intensivist, or stroke specialist depending on where that patient lives; similarly, patients with back pain may be managed by internists, physiatrists, pain management specialists, or spine surgeons in different communities. Local regulations, workforce capacity, disease epidemiology, and patient expectations significantly impact how care must be delivered.

To be successful, APMs must allow flexibility in the types of services to be delivered and the types of providers who can deliver those services. Success should be measured based on outcomes, not on adherence to 1-size-fits-all standards for structure or processes, and performance benchmarks must reflect differences in the costs and outcomes that are achievable in rural areas, inner-city communities, and so on.
5. Minimize Administrative Burden
The complexity of current payment models and the systems used to administer them have significantly increased the costs of healthcare in the United States without corresponding improvements in outcomes. APMs represent an opportunity not only to improve care delivery, but to eliminate unnecessary administrative burdens. Just as care delivery should be redesigned to eliminate waste, no administrative requirements should be included in APMs unless the likely benefits will significantly exceed the costs.
Conclusions
By encouraging APMs, MACRA provides an unprecedented opportunity to encourage innovations in care delivery. However, just because a payment model is different does not mean it will be better. The success of APMs will depend heavily on how they are designed and implemented. We believe that these 5 principles can guide the development of APMs that enable better outcomes for patients at a more affordable cost and that physicians can enthusiastically support.
Author Affiliations: Department of Emergency Medicine; University of Colorado School of Medicine (JLW), Aurora, CO; Center for Healthcare Quality and Payment Reform (HDM), Pittsburgh, PA; Department of Emergency Medicine, Robert Wood Johnson Clinical Scholar; Yale School of Medicine (NH), New Haven, CT.

Source of Funding: None.
Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JLW, HM, NH); of the manuscript (JLW, HM, NH); critical revision of the manuscript for important intellectual content (JLW); administrative, technical, or logistic support (JLW); and supervision (JLW).

Send Correspondence to: Jennifer L. Wiler, MD, MBA, Associate Professor, Department of Emergency Medicine, University of Colorado Denver SOM, 12401 E. 17th Ave B-215, Aurora, CO 80045. E-mail: jennifer.wiler@ucdenver.edu.
REFERENCES
1. Grumbach K, Osmond D, Vranizan K, Jaffe D, Bindman AB. Primary care physicians’ experience of financial incentives in managed-care systems. N Engl J Med. 1998;339(21):1516-1521.

2. Miller HD. From volume to value: better ways to pay for health care. Health Aff (Millwood). 2009;28(5):1418-1428. doi: 10.1377/hlthaff.28.5.1418.

3. Wiler JL, Beck D, Asplin BR, et al. Episodes of care: is emergency medicine ready? Ann Emerg Med. 2012;59(5):351-357. doi: 10.1016/j.annemergmed.2011.08.020.

4. Miller HD. Win-win-win approaches to healthcare cost control through physician-led payment reform. Clin Gastroenterol Hepatol. 2014;12(3):355-358. doi: 10.1016/j.cgh.2013.12.002.

Original article accessed here.

Hospitals and physician groups across the country are beefing up merit pay for quality and patient satisfaction in their physician compensation plans. But Geisinger Health System is doing something radically different.

The 12-hospital system based in Danville, Pa., did away with physician bonuses altogether this summer and put all of its 1,600 employed doctors on a straight salary.

Geisinger also made the decision to pay each physician at or above the national average whether in primary care or a specialty. “We don’t have below-average doctors so we don’t pay anyone below average,” Geisinger CEO Dr. David Feinberg said.

That Geisinger would abandon a compensation model that previously paid physicians 80% straight salary and a potential 20% performance bonus runs counter to what’s happening with many health systems and physician groups.

Most systems see the emergence of value-based reimbursement, encapsulated in legislation like the Medicare Access and CHIP Reauthorization Act, as requiring the rewarding or penalizing of physicians for performance on quality and patient satisfaction scores.

They are shifting their compensation plans to put more emphasis on attaining those types of benchmarks rather than the old ways of predominantly rewarding throughput.

For example, Crystal Run Healthcare, a 300-physician group based in the lower Hudson Valley community of Middletown, N.Y., today pegs up to 15% of total physician compensation to quality, cost and satisfaction measures, said Dr. Scott Hines, Crystal Run’s chief quality officer and medical director.

That percentage is set to rise to 30% over the next three years because “more and more contracts are being tied to clinical quality and lower costs,” Hines said. He’s seeing the same trend with both government and private payers.

The compensation model at the 1,200-physician Henry Ford Medical Group in Detroit is a little different but similarly aimed at elevating quality and patient satisfaction, said group CEO Dr. William Conway.

The group’s primary-care physicians next year will get a greater portion of their compensation based on how many consumers choose them as their doctor than today’s model, which is predominantly based on the volume of relative value units they perform. RVUs represent a Medicare formula for reimbursing physician services that blends the time it takes to perform a service with the skill level behind that care. A committee of the American Medical Association establishes the relative weights of physician RVUs.

While RVUs determine 66% of pay at Henry Ford today, it becomes a 50/50 split next year between RVUs and patient sign-ups, Conway said. That model also provides an incentive for physicians to perform well on quality and patient satisfaction since consumers will see physicians’ work rated online and can base their selections accordingly, Conway said.

The shift is a response to changes in government reimbursement, not the markets. “It’s about the Medicare payment rate,” Conway said.

Medicare has been coaxing hospital systems and physician groups to organize themselves around taking on more risk for the cost and quality of the care they provide. It’s part of a long process under the Affordable Care Act and MACRA of moving away from fee-for-service to value-based reimbursement.

That philosophy has given rise to advanced alternative payment models. These are Medicare programs that give physicians extra incentives to manage the risk of certain populations or accept bundled payments for targeted procedures rather than paying in the traditional way.

Examples include the Comprehensive End-Stage Renal Disease Care Model and the Medicare Shared Savings Program. To participate, hospital systems and physician groups have developed provider networks, in some cases accountable care organizations, to make sure their patients have access to coordinated services across geography and specialties.

Those organizations are all a little different and offer their physicians different compensation incentives to participate. “If you’ve seen one, you’ve seen one,” Conway said.

Alternative payment models, or APMs, have been exploding in popularity, according to the CMS. From their inception as part of the ACA the four APMs offered by CMS in 2017 now have 359,000 participating clinicians, providing care to 12.3 million Medicare and Medicaid beneficiaries, according to the CMS.

The Next Generation ACO, a model that provides participating doctors even more risk and reward than under the Medicare Shared Savings Program, added 28 groups in 2017 and now has 45, the CMS said.

Looming ahead is the new change agent for physician reimbursement models: MACRA. Though its implementation was recently delayed almost two years until 2018, MACRA establishes two new payment tracks for physicians treating patients holding government-sponsored insurance.

Clinicians in advanced alternative payment models can earn annual bonuses of 5%. But the majority of physicians will participate in the Merit-based Incentive Payment System under MACRA. On that track, physicians can earn plus or minus 4% of reimbursement in 2019, 5% in 2020, 7% in 2021 and 9% in 2022.

While physicians at Geisinger participate in a variety of APMs, the integrated delivery network has gone to straight salary for its employed physicians—rather than an 80/20 mix of salary and merit bonuses. Its physicians don’t need incentives to do the right thing for patients, said Dr. Jaewon Ryu, Geisinger’s chief medical officer.

If they provide quality care in the right setting, Geisinger will do well financially on the 551,000 enrollees in its health plans for whom it takes full risk, Ryu said. And it will qualify to collect the at-risk portion of value-based payment models whether government-sponsored or commercial.

UnityPoint Clinic, with 500 physicians in clinics across Iowa and Illinois, wants 33% of physician compensation by 2020 to be based on the value metrics of patient care, said Keith Seashore, UnityPoint Clinic’s chief financial officer.

Those incentives now constitute 14% of compensation, with 86% of salary measured largely as a function of productivity, he said. UnityPoint Clinic is piloting a compensation model at five locations that will take the entire organization to its 33% goals, Seashore said. In those locations, about 20 physicians and 10 advanced practitioners have 33% of their compensation based on productivity, 33% on straight salary and 33% on the quality, cost and satisfaction variables, he said.

The physicians driving the pilot believe that mix will align better with the additional risk UnityPoint wants under MACRA and the APMs, Seashore said.

He added that the changes will be rolled out slowly so that the clinic’s physicians feel comfortable that the data collected for determining compensation are fair and accurate.

CareMore, a Cerritos, Calif.-based clinic operator and health plan for frail seniors, incentivizes its physicians to keep patients out of the hospital, said CEO Dr. Sachin Jain.

Jain, a former adviser to the Obama administration, said CareMore employs 80 “extensivists,” whose job is to track frail patients so they get the medications and care they need at home and in settings outside the hospital.

The physicians, who earn on average about $200,000 annually, can earn an additional 5% to 65% in incentives by managing their patients so that hospitalization is a last resort, Jain said. That might mean making sure a patient has proper food, that they are not being dehydrated by lack of air-conditioning and other items that might fall outside the typical things that doctors are responsible for.

Preventing hospitalization, Jain said, “is one of the purest metrics of clinical success.”

Original article accessed here.

After years of lobbying to repeal and replace the ACA, House Republicans put forth The American Health Care Act on Monday. Here are 10 things to know about the legislation.

1. The AHCA would eliminate the ACA’s individual mandate, or requirement for American adults to enroll in health insurance. Further, the legislation eliminates the tax penalty adults faced if they were not covered. However, the concept of penalties still remains in some form: To encourage people to buy coverage, the AHCA lets insurers charge a 30 percent penalty for those who let their health plans lapse and try to buy a new policy, according to NPR.

2. The AHCA calls for Medicaid expansion to remain in effect through Jan. 1, 2020. This is different from earlier drafts of legislation, which called for an immediate reversal of Medicaid expansion. Thirty-two states, plus Washington, D.C., have opted to expand Medicaid under the ACA. By 2020, the government will “freeze” the expanded programs and restrict funding only to people who were in the program as of then — no added enrollees from that date on. States would keep getting that amount of federal aid for each Medicaid enrollee as long as the enrollee doesn’t lose eligibility for more than a month. There is also a provision in the AHCA that calls for grants of extra Medicaid provider reimbursement funds to go toward states that didn’t expand Medicaid.

3. The AHCA restructures Medicaid’s federal funding to a per-capita cap opposed to the current open-ended federal entitlement, reports Politico. States would receive capped payments based on how many people are enrolled in Medicaid. The plan also calls for more frequent eligibility testing of Medicaid enrollees.

4. The AHCA restructures Americans’ tax credits to buy health insurance. It replaces income-based subsidies under the ACA with refundable, age-based and income-capped tax credits, according to Politico. These credits increase with age, from as low as $2,000 for those under 30 or as high as $4,000 for those over 60. There would be a limit as far as credits for a single household — $14,000 — and subsidies would be eliminated over time for individuals with annual income of $75,000 and for families with annual income of $150,000, according to the report.

5. A few ACA staples roll over in the AHCA. The ACA provision related to pre-existing conditions would remain intact, meaning insurers would not be able to deny coverage or increase prices for people with such conditions, reports Reuters. Also, the AHCA retains provisions allowing adults up to age 26 to maintain coverage through their parents’ health plans, according to the report.

6. The AHCA eliminates the cap on the tax exemption for employer-sponsored insurance. Although earlier drafts of legislation capped the exemption at 90 percent of current premiums, the final version eliminated the proposal, according to Politico. The bill also gets rid of the penalty for businesses that do not offer employees health coverage.

7. The AHCA delays the effective date for the ACA’s Cadillac Tax on costly health plans from 2020 to 2025, according to The Hill. GOP lawmakers are delaying but keeping the tax to make certain their replacement plan will not increase the national deficit after a decade.

8. The AHCA bars federal Medicaid funds or federal family planning grants for Planned Parenthood clinics, according to the report. (Separate from the AHCA, the White House earlier this week extended terms for a compromise to Planned Parenthood by proposing maintained federal funding if the group agrees to discontinue providing abortions, according to ABC News.)

9. The cost of the AHCA is not yet known. The nonpartisan Congressional Budget Office has not yet scored the legislation, which means there is neither a cost estimate for the plan or how many Americans would gain or lose insurance under it.

10. What’s next? The House Ways and Means and Energy and Commerce committees are expected to review the AHCA legislation Wednesday. If the committees approve the measure, the full House could potentially act on it before April 7, according to The New York Times. The measure would then be taken up by the Senate.

Original article can be accessed here.

Because Sunil Budhrani, M.D., has spent about 20 years treating patients in emergency departments, he knows all too well that many people still go to the ED for minor injuries or illnesses.

Budhrani, now the chief medical officer of Innovation Health, is “amazed” that he continues to see patients come to the ED for conditions like cuts, bruises and sore throats, he said in a recent interview.

“Clearly, you come in with symptoms like that, it creates distress for everyone, because you never really want to be in the ER because you’re happy,” he said, noting that such patients often face long wait times.

Often urgent care centers or retail clinics are a better option for many acute, non-life-threatening conditions, according to Budhrani. And more than just patient satisfaction is on the line—if Americans turned to those alternative sites instead of the ED for non-emergency care, it could save $4.4 billion annually, he noted, citing a past study from Health Affairs.

That’s part of why Budhrani spent the early 2000s building out urgent care centers, then later co-founded a telemedicine company. “Much of my career has been focused on, what are the best places for people to obtain their care?” he said.

Now at Innovation Health—the joint venture between Aetna and Inova Health System—Budhrani is leading the organization’s effort to direct patients to the most appropriate care setting.

A new feature of that effort is an illustrated decision tree that helps patients decide whether an urgent care center or ED is the right place to be treated for the symptoms they’re experiencing.

Innovation Health takes a two-pronged approach to sharing such educational materials and messages, Budhrani said: It distributes them to providers as well as directly to members/patients.

“Being that we’re a unique model, of an insurance company half-owned by a major health system or provider, Inova, and by a major insurer, Aetna, we have opportunities to reach our members and providers in a way that most people can’t,” he said.

That means leaders like Budhrani can sit at a table and communicate directly with the medical directors of a major health system like Inova about how to instruct members about the services Innovation Health offers. Innovation Health also reaches out through its contractual relationship with other providers to let them know that it has one of the largest networks of urgent care centers in the region.

As for its direct-to-member approach, Innovation Health connects with them through channels like mail, postings on social media, local broadcasts and more, Budhrani said. Materials like the new decision tree are also a complement to tools that Aetna has already deployed like the app iTriage, which navigates members to the closest ED or urgent care center after they type in the symptoms they are experiencing.

While the decision tree is relatively new, Innovation Health already has some positive feedback from distributing it to its non-physician leadership team and their families, Budhrani noted. “They found this greatly helpful because it just created in a picture format, a step 1, step 2, step 3 approach to thinking about their symptoms,” he said.
The overarching goal, according to Budhrani, is to drive home the message to members that they can save themselves a lot of time, money and resources if they go to the right place to receive care.

“Frankly, working in the emergency room, there is still a lot of confusion where to go, and the more we can education our members before they actually get sick and before they actually need the urgent care, the better off everyone is,” he said.

Original article can be accessed here.

FORT WORTH, Texas — Her mother’s breathing had become labored in the wee hours of the night, during what would prove to be the Fort Worth woman’s final days living with lung cancer. Distraught, the daughter called 911.

“Her mother was having some pretty severe shortness of breath,” said Tim Gattis, the third paramedic to arrive on scene late last year. “She was certainly working very hard to obtain a breath, and was just not being successful.”

Gattis pulled up in a sports utility vehicle shortly after the ambulance had arrived, and the first two responders were already loading the 64-year-old woman into the back. The daughter was insisting that her mother go straight to the hospital, Gattis said.

But the role of Gattis and other Fort Worth paramedics trained for this type of hospice support — part of a local partnership with VITAS Healthcare, the country’s largest hospice organization — is to spend a longer stretch of time on the scene to determine if the symptoms that triggered the 911 call can be addressed without a trip to the emergency room. MedStar Mobile Healthcare, a governmental agency created to provide ambulance services for Fort Worth and 14 nearby cities, is one of several ambulance providers nationwide that have teamed up with local hospice agencies. The paramedic backup, enthusiasts argue, not only helps more hospice patients remain at home, but also reduces the potential for costlier and likely unnecessary care.

On average, 18 percent of hospice patients go to the emergency room at least once before their death, according to an analysis of Medicare data published last year in the journal Medicare data published last year in the journal Medical Care. Melissa Aldridge, the study’s lead researcher and an associate professor at New York City’s Icahn School of Medicine at Mount Sinai, describes paramedic-hospice partnerships such as Fort Worth’s as “forward-thinking” in promoting better patient care.

Hospices also can financially benefit, she said, since they’re paid a flat rate — typically just under $200 a day — regardless of where their patients are treated. So, any hospital treatment related to the patient’s condition, such as pain stemming from advanced cancer, would come out of that payment, she said. “For [the agencies], it could definitely be worth it, particularly for the one or two outlier families who seem to be using the emergency department fairly heavily during a hospice stay,” Aldridge said.

An Expanding Role
These emerging programs rely upon a new type of emergency responder. Dubbed community paramedics, they can offer a range of in-home care and support for home health patients, frequent 911 callers and others to reduce unnecessary ambulance trips. MedStar’s community paramedicine program had already been launched, when VITAS got in touch.

The Affordable Care Act had been passed, and with it the inclusion of financial penalties for hospitals if their patients return too quickly to the hospital. John Mezo, senior general manager for the Fort Worth region of VITAS, said that since many VITAS patients come from hospital referrals, it’s important that the hospice not become “a big problem for our referral sources,” he said.

So in 2012, Fort Worth’s VITAS program began contracting with MedStar, targeting patients who have been flagged during the hospice admissions process as moderately to highly likely to call 911 or end up in the hospital. (VITAS pays a flat monthly fee to MedStar for each patient enrolled.)

Once signed up, hospice patients calling 911 can be identified through various routes, including their address, name or phone number. Then a community paramedic like Gattis, who is available for home health and other types of calls, including hospice, is dispatched along with the traditional ambulance response, said Matt Zavadsky, MedStar’s chief strategic integration officer. The ambulance provider now contracts with two hospice agencies and is in talks to add others, he said.

In Ventura, Calif., a similar hospice initiative is being piloted through a state agency — part of a larger multicity effort there to study the use of community paramedics. That pilot, which has worked with some 20 hospice agencies since 2015, sends out a community paramedic to any 911 call involving a hospice patient. Also, a large Long Island, N.Y.-based health care system added similar paramedic backup last year for a portion of its hospice patients living in Queens under a grant-funded project.

If any of those nearly 180 patients or their family members calls the 24/7 hospice number with an urgent situation, a community paramedic can be immediately sent, said Jonathan Washko, assistant vice president of emergency medical services for the system, Northwell Health.

It’s “extremely rare” that patients call 911 directly, Washko said, “because we get them help, just as if they would have called 911.”

Navigating Final Days
The uncomfortable truth is that a patient on hospice can develop unsettling and sometimes scary symptoms during their final weeks or days. Secretions can accumulate in the throat, which might sound like choking, even though the patient is not, Mezo said. The patient might suffer a breathing crisis or a seizure.

VITAS stresses that a hospice nurse is available around-the-clock, by phone or to stop by. But family members can understandably be loath to wait for a nurse who might have to drive from an hour away, Mezo said.

“When it’s your loved one there and you’re in charge of them, it’s very frightening,” he said. “If you’ve ever had to call 911, even five minutes waiting on an ambulance seems like an eternity, right?”

For paramedics involved, the work has proven to be challenging and gratifying, requiring a mix of psychology and social work skills along with medicine. “You can’t Google what to do in these situations,” said Ambrose Stevens, a Ventura community paramedic, who has responded to about 40 hospice calls.

By the end of 2016, Ventura paramedics had responded to 258 hospice calls, but paramedics needed to access hospice-provided medications for pain, nausea and other symptoms in fewer than 2 percent of those calls, said Mike Taigman, project manager of Ventura County’s Hospice Community Paramedicine Pilot Project. “Most of what we do is really helping coordinate, talk people down from being upset, helping remind them of what hospice is all about,” he said.

Offering The Option
Patients or their family members can still insist on going to the emergency room, and sometimes they do. Of the 287 patients enrolled in Fort Worth’s program for the first five years — all of whom had been prescreened as highly likely to go to the hospital — just 20 percent, or about 58 patients, were transported, according to MedStar data. In Ventura, ambulance transports for hospice patients calling 911 also have declined — from 80 percent shortly before the program’s start to 37 percent from August 2015 through December 2016, according to data provided by Taigman.

That difficult night in Fort Worth, Gattis put the VITAS nurse on speaker as they talked to the daughter about ways to keep her mother more comfortable at home. The daughter agreed to hold off on ambulance transport and see if anti-anxiety medication and morphine would ease her mother’s breathing struggles.

Within a half-hour, Gattis said, it was apparent that the medicine was helping. “She was feeling better to the point that she could eat a little bit of a sandwich.”

Gattis stayed for more than an hour until the hospice nurse arrived. The woman died several days later in her own bed.

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation. Coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.

Article can be accessed here.

The bill was expected Feb. 27 after a congressional recess, but was leaked to Politico and published Friday.

Most of the reconciliation bill is simply a more detailed version of the policy brief revealed last week — it would repeal Medicaid expansion, a host of taxes and dismantle current cost-sharing subsidies under the ACA — and replace those items with a number of proposals that have been popular with Republicans.

Here are the five most important details to know about the proposal, as reported by Politico.

1. The main revenue generator behind the bill is a cap on tax exclusion for employer-sponsored health insurance. The bill repeals a number of taxes and tax increases installed under the ACA including the medical device tax and health insurance tax, among others. In place of these taxes, the bill caps the amount employers can contribute tax-free to employees’ health plans. Benefits that exceed the 90th percentile of current premiums would be taxed, according to Politico. If that sounds familiar, that’s because the cap is similar to the ACA’s Cadillac tax on luxury employer-sponsored health plans, which was a 40 percent excise tax paid for by insurers. The unpopular tax was delayed due to opposition from companies and labor unions that would have had the costs passed down to them.

“Capping the exclusion is the same thing [as the Cadillac tax], but it’s a much more direct hit on companies and consumers,” Russell Sullivan, a partner at McGuireWoods and one of the principal drafters of the Cadillac tax, told Becker’s Hospital Review. Both the cap on employer exclusion and the Cadillac tax would put downward pressure on prices by discouraging overuse of healthcare services, which is common with generous health plans. Also similar to the Cadillac tax, the proposal will likely face opposition from businesses and labor unions, according to Mr. Sullivan. “This expands the battlefield,” he said.

2. The bill would roll back Medicaid expansion. Of course, states would have the option to continue with the expansion, but they would no longer receive enhanced federal funding to do so, which could make the option impossible financially. The bill lays out a proposal to instead cap federal Medicaid funding based on how many people qualify by state. However, to help offset the repeal of Medicaid expansion, the bill would restore cuts made to Medicare disproportionate share hospital payments under the ACA. The healthcare reform law reduced DSH payments presuming coverage would increase and the need for uncompensated care would decrease, particularly with Medicaid expansion.

3. The bill would also repeal the individual mandate and the premium subsidies. Instead of tying subsidies to income, they would be linked to age. Tax credits would start at $2,000 for people under age 30. They increase in steps of $500 per decade of life, reaching $4,000 for people over age 60. In the absence of the mandates, the bill would encourage people to maintain coverage by allowing payers to penalize beneficiaries for any lapses in coverage by increasing future premiums by 30 percent. It would also encourage more young, healthy people to buy health plans by increasing the age rating band tied to insurance plans from 3:1 to 5:1, according to Politico. This means insurers can charge older beneficiaries up to five times as much as younger beneficiaries for the same plan. Currently this ratio is limited at 3:1 under the ACA.

4. The bill also offers more detail on plans to help subsidize the cost of covering more expensive enrollees, such as those with pre-existing conditions. It would allot $100 billion in state innovation grants, which can be used in a number of ways at a state’s discretion to help offset the costs of high-cost patients. One option is the money could be used to reinstate high-risk pools for people with pre-existing conditions.
5. This bill is not finalized. The leaked version is still unnamed and unnumbered and considered a discussion draft. A number of issues are still disputed among Republicans. Representatives who held town halls about the ACA are finding their views are not as simple as for or against, The New York Times reported earlier this week. Leadership may also oppose certain elements. For example, Politico reported HHS Secretary Tom Price, MD, would want the subsidies to be lowered from the current proposal. Congress plans to take up discussion again next week when they return from recess.

Article can be accessed here.

In 2007, USA Today called Houston a city in crisis when it came to healthcare. Houston had among the worst wait times in the country for emergency care, and 40 to 50 percent of visitors to emergency departments really just needed primary care, which the area also had a severe shortage of. Ambulance diversions were common.

More recent research found that similarly high numbers of nonemergency calls to 9-1-1 were for primary care-related issues.

The Texas city, the fourth-largest municipality in the U.S., also had a perception problem with emergency medical services delivered through the Fire Department.

“Our fire trucks are capable of giving the same care as an ambulance,” Dr. Michael Gonzalez, deputy medical director for the Houston Fire Department, said at HIMSS17 in Orlando, Florida. But, he noted, people feel like there has been a mistake if a fire truck shows up when they call an ambulance, and sometimes demand an actual ambulance. That further ties up scarce resources.

“We are not built to handle primary care issues,” Gonzalez said. The Fire Department, as well as area EDs, can certainly deal with primary care on an episodic basis, but emergency physicians simply are not in a position to follow up with patients to address chronic health issues.

Since late 2015, telemedicine for ambulance-based triage has greatly alleviated several of the problems, HIMSS attendees heard Tuesday.

A program called ETHAN — for Emergency Tele-Health and Navigation — outfits emergency medical technicians with 4G-enabled tablets that connect to 9-1-1 services, the University of Texas Health Science Center, a nurse help line, a network of primary care clinics (for the purpose of getting people into medical homes) and even to a taxi service for transportation.

“We’re prepaying taxi vouchers on the premise that a Yellow Cab is a lot less expensive than an ambulance,” James Langabeer, professor of clinical informatics at the University of Texas, said during a joint presentation with Gonzalez.

The ETHAN system has allowed Houston EMS to offer mobile integrated healthcare, as defined by the National Association of Emergency Medical Technicians.

EMS telemedicine has been around in at least a rudimentary fashion since the 1970s, but Langabeer noted that it has not been widespread or comprehensive. “We’re using ours in a much broader way as an intervention for primary care-related incidents,” he said.

Firefighters and EMTs access ETHAN on tablets they had already been carrying. On the other end of the line is the nurse call center as well as a team of board-certified physicians in the Houston area.

The Fire Department has a partnership with the local health information exchange to pull in patient records from area hospitals so EMTs and the clinicians on the other end have at least some history on many patients they serve. These elements of ETHAN, Gonzalez said, have helped avoid repeat callers to 9-1-1 by getting people — many of whom had not seen a primary care physician in years — into medical homes so they can receive ongoing care to prevent future emergencies.

Fire Department crews have full leeway to decide whether to transport each patient they visit to a hospital ED or to lean on ETHAN for an alternative disposition, Gonzalez said.

Preliminary results of the program, as detailed in a paper published in December in the Journal of Telemedicine and Telecare, have been encouraging. With ETHAN, ambulances and fire trucks are back in service and ready to take on a new case a median of 39 minutes after being dispatched. Prior to the introduction of the telehealth program, it took a median of 83 minutes to get a vehicle back in service.

At the baseline, 74 percent of people for whom EMS was dispatched ended up being transported to an ED. That declined to 67 percent in the first year after ETHAN went live.

Patient satisfaction with Houston EMS actually ticked up slightly with ETHAN, to 88 percent from a baseline of 87 percent. And the city saved money at an annual rate of $928,000, based on the average savings of $2,468 per ED visit avoided.

Original article can be accessed here.

No one can predict the future of health care under a new administration or predict precisely when and how the Affordable Care Act’s (ACA) successor will become the new law of the land. We don’t know how stakeholders—including consumers—will be affected, or how far the regulatory changes will reach. In times like this, it’s tempting to sit back and wait until the direction is clear.

But that could be a mistake. The industry should not become paralyzed in the face of uncertainty. Now is the time to focus on the things that are and will continue to be critically important. It’s the time to focus on what I like to call the four “Cs” of health care: cost, customers, clinical quality, and consolidation. Regardless of what comes down from Washington, these fundamental elements will continue to be central and perhaps even more important to health care effectiveness and efficiency at the local, regional, and national levels.

Cost. The cost of care remains a pressing concern for providers. Questions persist about reimbursements, payment structures, and investment demands. Costs can’t just be tweaked around the edges; health care organizations need creative, meaningful solutions. Fortunately, there’s no need to start from scratch; leading providers are looking to other industries for proven ideas.

Effective cost containment tools and processes are available now. Think enabling the supply chain with digital, digitizing the finance function, and employing robotic process automation where it makes sense. Solutions such as these can help rein in an organization’s fixed-costs and support scalability. Providers need to be more aggressive about deploying them in the health care space.

Customers. It’s likely a growing share of medical care and coverage costs will be borne by the individual, a trend that started under the ACA. A recent study by the Health Care Cost Institute (HCCI) showed that individuals’ 2015 annual out-of-pocket costs increased to an average of $813, a 3-percent increase. The HCCI also found that 53 percent of customer health spending can now be comparison shopped.

As people grow more price sensitive and knowledgeable, they are likely to seek out more affordable medical options and those options which meet a broader set of needs including service expectations, access, and convenience. Meeting these demands will require providers to be more nimble and attentive to customers’ growing demands and changing needs to stay competitive.

Health care providers can learn a lot by studying customer-centric industry sectors, such as retail, financial services, and travel/hospitality. These types of businesses remain relevant to consumers by gathering insights on customer behaviors and perceptions and using them forge productive relationships. These industries have engaged with customers in ways health care sectors historically have not; their lessons can be instructive.

Clinical quality. The opportunity to improve outcomes, reduce variations in care, and establish better reimbursement models is central to the push for quality-based standards and practices. Providers should scrutinize their clinical quality and care models and introduce ways to reduce duplicative procedures, hospital readmissions, and mortality and morbidity rates. Organizations should look to drive continuous performance improvement in this area by building the foundational infrastructure necessary to drive quality performance across the enterprise holistically versus too intense of a focus on specific metrics.
Consolidation. Consolidation, while more speculative, could be one answer to addressing cost, customers, and clinical quality issues. Partnerships are forming in ways we couldn’t have fully imagined a decade ago, whether provider/provider, providers developing formal agreements with health plans, retailers, or more unique collaborations with outside players. Stakeholders in the provider space should actively pursue arrangements, perhaps even unorthodox ones that advance their interests.

Challenging, complicated work lies ahead. Winning health care organizations will not wait; they will continue driving toward higher-quality, lower-cost patient care while the Trump administration and Congress discuss a replacement for the ACA.
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About the Author
David is a principal in Deloitte Consulting LLP’s Life Sciences and Health Care practice. He leads Deloitte’s Customer Transformation initiatives for the health care provider sector, and his work has focused on enhancing core operations in the revenue cycle, driving performance improvement through operating model transformation and growing the business through mergers & acquisitions all with an eye towards creating a more patient-centric, consumer-oriented delivery system.

Original article accessed here.

More and more, physicians and health systems are treating patients less and less. But it’s not about “rationing” care or cutting expenses. It’s about rethinking old, outmoded practices to achieve more-effective, evidence-based “right care.”
Take, for example, getting people reinvigorated, out of bed and home faster after major surgery.

At Kaiser Permanente’s health plan in Northern California, members who’re slated for total joint replacement are now required to attend a two-hour pre-op class where they’re thoroughly briefed on what to expect — and what’s expected from them — before, during and after the procedure. They even get to pass around a sample of the hardware they’ll soon be wearing.

Three weeks later they get a telephone call from a nurse practitioner to review the instructions and schedule a blood test and an electrocardiogram. Chest X-rays are no longer routine. Ten days before the procedure they meet with the surgeon for a final OK. Joint replacement is elective, they’re reminded — and they have a shared responsibility to heal as quickly as possible.

At the class, they’re given a bag of goodies including brochures, checklists and pre-op instructions (e.g., discontinue nonsteroidal anti-inflammatory drugs and vitamins 10 days beforehand, no solid food within eight hours of the surgery, clear liquids OK until two hours before the procedure, and brush teeth for five full minutes on the morning of the surgery). There’s also a recommendation to wash with an acne cleansing bar the week before surgery (to eliminate a bacterium resistant to the usual antibiotics), a packet of antiseptic skin wipes to supplement the pre-op shower at home, two 4-ounce carbohydrate “sports fuel” juice packs to be drunk on the way to the hospital, and a spirometer to exercise the lungs after surgery to prevent pneumonia.

For most patients, anesthesia will be epidural not general. There’ll be no urinary catheter. And they’ll be coaxed to get up and head down a hallway (with a walker) as soon as feeling returns to their legs.

Best of all, they can usually expect to go home that same day.

Enhanced surgical recovery
This remarkably pared-down and systematized hip replacement protocol at Kaiser is the fruit of a major re-examination, undertaken in December 2013, of all surgical practices in its Northern California region.

“We drilled down to the evidence base and found that while we were doing what we thought the evidence supported, it really wasn’t always there,” says Stephen Parodi, M.D., associate executive director of Permanente Medical Group.
For example, he notes: “Surgery is a stressful physiological event. If you think about it, it’s kind of like running a marathon.” Nevertheless, surgery patients were always forbidden solid food and most fluids after midnight … “something,” Parodi observes, “no one would be told before running a marathon.”

In fact, the restriction was an administrative artifact, the researchers concluded. There’s no evidence-based risk to patients to allow them to drink Gatorade two hours before an operation; it’s not only safe, it prevents dehydration.
Based on the literature review, Parodi continues, teams of doctors, nurses, nutritionists and physical therapists working in two surgical units set about collaboratively designing protocols that would improve patient outcomes in their specialties as measured by “control of pain, adequate nutrition, time to being more mobile, faster recovery and time in hospital.” What was dubbed the Enhanced Recovery After Surgery program started with two complex procedures, colorectal surgery and hip fracture repair.

Over the next six months, says Parodi, the surgical teams hashed out: “What’s practical? How are [implementing these changes suggested by the literature] going to really work?’ They actually got very excited about it.”

Patients too played a major role as the redesign process unfolded, Parodi adds. “We asked, ‘Was the experience better or not? How can we make it better?’ We put together a calendar that would tell them what to expect and empower them to participate in their own care.”

By June 2014, new workflows had been plotted, piloted and tested. The teams had also specified exactly how Kaiser’s electronic health record system should incorporate updated prompts and best-practice alerts. Simple one-click ordering and order-change capabilities were built in. (For example, says Parodi, a doctor who prescribes an acid-suppressing antihistamine for an inpatient will see a warning that it has recently been found to promote Clostridium difficile infection; one corrective click spares the patient a potential hospital-acquired bout of diarrhea.)

“We try to make it easy for people to do the right thing,” Parodi says.

The ERAS model for colon and hip fracture surgery was introduced throughout Kaiser’s Northern California region in August 2015. Proof of success was documented by December of that year. From an average inpatient stay of eight days after a colon procedure, patients were (and are) being discharged in 5½ to six days, Parodi reports. Postsurgical stays after hip fracture repair have been reduced by a day or more. The rate of postsurgical complications has been pared as much as 17 percent.

With improved attention to nutrition before and after surgery (patients are immediately given gum to chew or hard candy to suck to aid in digestion of a soft meal soon after they leave the operating room), a sharp cutback in the amount of opiates used for pain control (relying on effective nonopiate drugs) and emphasis on early mobility, reports Parodi, patients experience “less nausea, so they’re able to eat sooner than they could in the past; they’re no longer delirious or sleepy after surgery, so they’re able to get up and walk sooner; and as a result, they recover faster and are able to go home.”

“It’s just night and day compared with what it used to be,” observes surgeon Efren Rosas, M.D.

In 2016, the ERAS model was expanded to include hip replacement and cesarean sections, and rolled out to all 21 Northern California Kaiser hospitals. This year will see its adaptation and adoption for every surgical procedure in the nine-state system’s Southern California, Hawaii and Pacific Northwest facilities.

Right care
Even as health care reform has led to reimbursement of doctors and hospitals based on the value rather than the volume of their services, evidence has mounted that “too much medicine happens too often,” to quote an editorial in JAMA Internal Medicine. Indeed, three out of four American physicians say that ordering an unnecessary test or procedure is commonplace in medical practice and a serious problem — yet they confess to doing it themselves on average once a week.

Why? To mollify patients. Out of habit. Failure to keep abreast of evolving evidence on effectiveness. Fear of malpractice judgments. And because, as the JAMA Internal Medicine editorial suggests, “in the United States, there is a deeply held cultural belief that more health care is better and that earlier is better, beliefs that [have been] strongly reinforced by financial and legal incentives.”

But the ground has shifted. Nationwide, progress is underway to discourage obsolete and useless — if not harmful — interventions. Under the rubric of “less is more,” physicians and hospitals are sharply curtailing antibiotic prescriptions (to counter the dangerous increase in resistant strains) and potentially addictive opioids; limiting patient exposure to diagnostic radiation; shortening in-patient stays with their risk of hospital-acquired infection and physical and mental atrophy; eliminating nonessential screenings that can lead to harmful overtreatment … all while achieving better outcomes at lower costs.

Near Boston, the nonprofit Lown Institute has been a catalyst with its sponsorship of the RightCare Alliance, a nationwide health professional’s network dedicated to “transforming the culture of medicine and building a health care system that is affordable, effective, personal and just.”

With Lown Institute backing, the British medical journal The Lancet last month launched its five-part “Right Care” series — articles investigating worldwide medical underuse and overuse as exemplified by inappropriate knee replacements (34 percent in the United States), inappropriate hysterectomies (20 percent in Taiwan), excessive C-section rates (6.6 million performed without medical justification worldwide) and millions of premature births that could have been prevented by a simple steroid prescription.

For its part, under the rubric “A Teachable Moment,” JAMA Internal Medicine now includes in each issue a detailed analysis of a circumstance in which an ineffectual test or medical procedure was ordered, what best practice counsels instead and why.

Better choices
Prominent in this movement is the Choosing Wisely campaign launched in 2012 by the ABIM Foundation and Consumer Reports, in cooperation with more than 75 medical specialty societies (representing over 1 million doctors, nurses, physical therapists and dentists) and 100 consumer, employer and patient organizations. Each specialty has documented and agreed on a set of interventions that physicians often misapply but should avoid and that their patients should decline.

Spurred by the Choosing Wisely recommendations, many of which have been incorporated into Wikipedia articles, 14 participating U.S. health systems have adopted strategies that have resulted, according to ABIM Foundation Executive Vice President and Chief Operating Officer Daniel Wolfson, in:
• A 36 percent reduction in the use of antibiotics and a 26 percent reduction in Pap smears (by changing the recommended frequency from one year to an evidence-based three years) by physicians at the Group Health Cooperative in Seattle.
• A 73 percent reduction in preoperative CT and MRI tests, and a 42 percent reduction in presurgical lab tests ordered at Los Angeles County Department of Health Services hospitals (the nation’s second-largest medical safety net).
• A 55 percent reduction in antibiotic use at Detroit’s Henry Ford Health System.

“What the Choosing Wisely campaign has done is to increase the conversation about why less is sometimes better,” says Wolfson. “We’ve given people an antidote for thinking we’re talking about rationing or ‘death panels.’

“For hospitals and health systems, Choosing Wisely engages physicians in ways I think quality improvement efforts in the past have not.” he says. “Physicians identify with their own specialty societies, and if they see recommendations from people they trust and respect, they’re more likely to feel ownership rather than that something is being imposed by administration. It’s more of a bottom-up approach.”

Now, he says: “We’ve pivoted from getting awareness and buy-in to turning to institutional implementation. From here on, it’s really up to the delivery systems.”

David Ollier Weber is a principal of The Kila Springs Group in Placerville, Calif., and a regular contributor to H&HN Daily.

The opinions expressed by the author do not necessarily reflect the policy of the American Hospital Association.

Original article accessed here.

Audio file at the link below…

https://www.marketplace.org/2017/02/16/world/ambulance-service-texas-delivers-home-care

For more than a decade, John Farris traveled through the streets of Fort Worth, Texas, working 911 calls. As a paramedic for MedStar, he would ask himself: Could he prevent these 911 calls in the first place?

It’s a question that went against the very business model of MedStar until recently — a question most emergency medical services companies don’t talk about, because the more trips to the hospital, the more money the company makes. But it still mattered to Farris. So, sometimes, after stabilizing a patient in the back of the ambulance, he’d try to squeeze in a conversation about nutrition or hydration.

“I’d be lucky if I got 10 minutes to talk with them,” he said.

Now, he gets a full hour with five patients each day.

Traditionally, ambulance crews arrive with sirens blaring, ready to rush someone to the hospital. In Fort Worth, some paramedics are doing the opposite: scheduling visits to treat patients in their homes.

This idea — what’s called mobile integrated health care — is gaining traction as a way for hospitals to save money.

Farris still works for MedStar. He still carries a bag with a CPR kit and gauze and gloves, but he rides in a four-door sedan, not an ambulance. Farris is what’s called a community paramedic.

It’s his job to see the trickiest patients, the so-called “frequent flyers” who keep landing back in the emergency room. Since the Affordable Care Act, the government penalizes hospitals for re-admissions. So these patients are costing hospitals across the country hundreds of millions of dollars. Farris is trying to figure out why they keep returning.

Today’s second stop is at Sandra Guevara’s apartment in Fort Worth. It’s dark, and the black curtains are closed. Guevara, who is in her early 30s, sits on her couch wrapped in a Dallas Cowboys blanket while she gets her blood pressure taken.

Last year, Guevara went to the emergency department more than 20 times, occasionally needing a ventilator to breathe.

“My asthma has been going on since I was 14 years old,” she said. “My anxiety triggers it when I go places, so I tend to shelter myself and stay home all the time.”

Guevara is on Medicaid, so she generally doesn’t have to pay the more than $1,000 each visit might cost. But those visits are something the government, hospitals and especially Guevara want to avoid.

“I don’t like going to the ER,” she said. “Especially when they put me in a little bitty room. I’ll start crying and shaking and everything. I can’t deal with it.”

Farris said from the perspective of the doctor in the emergency room, patients like Guevara can be labeled noncompliant. They’re sometimes seen as patients who won’t follow medical orders. But he said if you spend time getting to understand the situation, that’s not usually the case.

“The mental health needs that [Guevara] has, tied in with her asthma, tied in with her allergic asthma, tied in with her clotting factor, all of this stuff together, even her dehydration, all of it together is combining factors to make her worse.

And every time she was out of the hospital she was back in a couple of days,” Farris said.

He’s helped Guevara modify her diet, convinced her to drink more water and consistently take her medication. He also made sure her doctors know what’s going on and connected her to a psychiatrist. Next visit, they plan to tackle one of her fears and take a short walk outside.

Taking walks with patients, talking to them about their fears, setting up social services like Meals on Wheels, is a major shift in emergency medicine.

When MedStar started enrolling patients for its mobile integrated health care program in 2009, it was one of the first in the country. Today, there are more than 260 similar programs.

Dr. Darrin D’Agostino, associate dean of community medicine at UNT Health Science Center, said early studies show pairing frequent hospital users with community paramedics can save money by preventing re-admissions in the long run.

“Some programs are actually showing decreases of 80 to 90 percent re-admission because the services that are needed are things that are not necessary provided by the physician,” D’Agostino said.

That includes things like making sure a patient has the right medicine — and calling the electricity provider to pay a bill and keep the lights on.
MedStar reports saving $17,000 per patient over a three-year period. The challenge, D’Agostino said, is securing initial funding. Right now, most emergency services are paid for ferrying patients to the hospital.

Since MedStar’s community paramedicine program is paid for by hospitals and health providers trying to save costs, it’s not clear if it would be affected by changes to the Affordable Care Act. The company is counting on a continued focus on the quality of care — and cost-cutting — no matter what happens with the ACA. It just helped publish a textbook on how to provide home care that’s now available nationwide.