News & Updates

The New York Times has identified three healthcare industry trends and reforms that should survive a repeal of the Affordable Care Act.

A repeal of the Affordable Care Act looms large as President Barack Obama’s time in office winds down, but even a rollback of the healthcare law is unlikely to curb all of the momentum to innovate care delivery and the patient experience.

The ACA ensured that millions of previously uninsured Americans received healthcare coverage, but the Obama administration also pushed for payment reform, a focus on preventive medicine and quality improvements, according to an article from The New York Times, and many of those initiatives are likely to continue.

Here are three healthcare industry trends and reforms that should survive a repeal of the ACA, according to the publication:

A focus on early intervention and community health: The White House under Obama has pushed for greater emphasis on the social determinants of health and has used grants to encourage providers to identify Medicare or Medicaid patients that may have unmet needs, according to the article. Hospital and ER “super-users” are a significant burden on the health system, and many have unmet complex social needs. The health law also pushes providers to meet quality benchmarks, and patients with complex social needs may make those goals harder to reach, according to the article. However, efforts to improve community health are likely to remain even if the law is repealed, the NYT reports.

Alternative payment models: Under the ACA, the Centers for Medicare & Medicaid Services has pushed for payment reform, such as bundled payments for joint replacement surgeries. Though some providers are skeptical about the long-term benefits of some new payment models, according the article, the momentum away from fee-for-service care is unlikely to die with a repeal of the ACA. Industry organizations have called for President-elect Donald Trump to back value-based care, and it’s likely that the transition will continue under his administration.

Emphasis on care coordination: The healthcare law encourages team-based care and better coordination among physicians and other outside agencies that may connect patients to social services. This includes ensuring that patients are connected to primary care at discharge, as patients who most often make repeat hospital visits and incur unneeded costs may have limited access to primary care physicians. One example of success, according to the article, is at Indiana University Health Methodist Hospital in Indianapolis, which sees 12% fewer inpatients than it did in 2013 thanks in part to such initiatives.

Original article can be accessed here.

BY DOUG HOOTEN, MBA AND JONATHAN D. WASHKO, MBA, NREMT-P, AEMD ON JAN 1, 2017

Demonstrating high performance and high value is becoming increasingly important to our evolving healthcare environment and changing community expectations. The financial sustainability—and perhaps even the very survival—of EMS may hinge on our ability to prove the services we provide are valuable.

Defining value in EMS has been relatively elusive, as clinical, operational and fiscal performance measures are often disparate from one system to another. But there are common hallmarks of high performance that any EMS agency can use to demonstrate value to stakeholders.

The Academy of International Mobile Healthcare Integration (AIMHI)—an association of EMS agencies committed to providing high-performance and high-value EMS and mobile healthcare services—is excited to partner with EMS World to produce a yearlong series of articles that will discuss the attributes of high-performance/high-value EMS system design and operations. The series will include topics such as:

• Attributes of high-performance EMS;
• International models of EMS system design;
• Using data to maximize operational efficiency;
• Financial analysis and new economic models;
• IT trends and cybersecurity in EMS;
• Managing a diverse workforce;
• Working with elected and appointed officials;
• Developing stakeholder relationships;
• Case studies and lessons learned in remote deployment centers.

The goal of the series is to assist EMS agencies in creating high-performance EMS processes and help demonstrate value to local community stakeholders.

—Matt Zavadsky, MS-HSA, EMT, Chief Strategic Integration Officer, MedStar Mobile Healthcare, Ft. Worth, TX

EMS systems of today, regardless of their design, face unprecedented challenges. Changing stakeholder expectations and rising financial pressures are driving a need to demonstrate that they provide value. Recent local and national media stories illustrate this shift in expectations and challenge the value equation the EMS profession has used for years.1–7

“Police transport a good bet for shooting victims, study finds”

“Need an ambulance? Why you may not want the more sophisticated version”

“Think the ER is expensive? Look at how much it costs to get there”

“Modesto rejects $1M firefighter paramedic grant”

“Lockport plans to auction off ambulances, cut fire staffing minimum”

“Kalispell voters reject extra taxes for EMS”

“Is the current model for public safety service delivery sustainable?”

EMS agencies that desire to be successful in this rapidly changing environment need to demonstrate value in new ways by delivering high-performance EMS (HPEMS) as the first step to proving high-value EMS (HVEMS). There are generally three main hallmarks of HPEMS: clinical proficiency, operational effectiveness and fiscal efficiency. These hallmarks must be leveraged in a way that balances what is known as the EMS success triad: patient care, employee well-being and long-term financial sustainability. The Academy of International Mobile Healthcare Integration (AIMHI) has articulated several key attributes of a high-performance EMS system that help achieve these three hallmarks:

1. Sole Provider

Clinical proficiency—As a sole provider, an EMS agency will generally be able to maintain a high utilization of the EMTs and paramedics operating within the system. Higher utilization provides the opportunity to refine critical clinical skills such as patient assessment and effective clinical care. Additionally, a single source of quality oversight for all emergency and nonemergency calls helps ensure every provider, regardless of the type of service they provide, shares common credentialing and quality improvement processes.

Operational effectiveness—A single provider can also maximize operational effectiveness for the system. A patient awaiting transport to a skilled nursing facility from Acme General Hospital can be efficiently transported by the ambulance that just brought a chest pain patient into Acme General’s emergency room. The same unit that transports the patient to the SNF can then be posted to provide temporal or geospatial coverage to that area. Having multiple ambulance providers operating in the same market generally leads to underutilized resources and makes the system less operationally effective.

Fiscal efficiency—The provision of 9-1-1 service is expensive, and the reimbursements more challenging. A sole provider can balance the generally lower-cost, higher-reimbursement nonemergency services to help offset high-cost, low-reimbursement 9-1-1 services. A single layer of utility-like cost structure minimizes the financial impact to the taxpayer and other payers. Further, the operational effectiveness of the sole provider, as explained above, helps reduce the overall cost of the EMS system by preventing multiple infrastructure costs and lower utilization.

2. External Accountability

Clinical proficiency—Holding yourself externally accountable for clinical care helps improve the care provided by identifying areas of potential improvement, coming up with a plan for improvement, implementing the plan and evaluating the results. Some EMS agencies are financially incentivized for demonstrating compliance with scientifically proven clinical bundles of care for conditions such as STEMI, stroke, trauma and hypoglycemia.

Operational effectiveness—External accountability for performance measures like extended response times, unit hour utilization, lost unit hours, employee turnover and mission failures encourages the EMS agency to continually improve these metrics.

Fiscal efficiency—Similarly, reporting and being held accountable for financial measures such as cost per unit hour, cost per call, cost per transport, revenue per transport and revenue per unit hour encourages EMS agencies to improve these measures, as well as benchmark their performance to other similar agencies.

3. Control Center Operations

Clinical proficiency—Controlling your own resources helps ensure your units are appropriately utilized, increasing the clinical proficiency of your field EMTs and paramedics. If another agency is controlling the placement and deployment of your units, it is more difficult to assure appropriate utilization.

Operational effectiveness—As with clinical proficiency, relying on another agency to control your assets may reduce operational effectiveness and make it harder to achieve the correct balance between supply and demand.

Fiscal efficiency—Relinquishing control of your assets to another control center operator may increase costs through less effective asset utilization and lost unit hours.

4. Revenue Maximization

Clinical proficiency—Employing system design and business practices that maximize revenue generation within the EMS system allows the provider greater ability to invest in training, equipment and medical oversight that improves clinical proficiency. For example, FirstPass, a valuable tool for near-real-time clinical quality metrics, requires a significant resource investment. The ability to invest in a system like FirstPass is enhanced when the agency maximizes revenue generation.

Operational effectiveness—The same is true for investing in tools and processes to achieve operational effectiveness. Examples could include an investment in software to predict call volume and locations; dedicated departments that stock, maintain and redeploy ambulances with a high degree of reliability; and sophisticated computer-aided dispatch systems designed to maximize resource utilization.

Fiscal efficiency—Clearly collecting the appropriate fees for the services you provide helps make the system more financially sustainable and could even reduce the tax subsidy burden. This is common in some EMS-based fire agencies that provide nonemergency transfer services as a way to increase revenues.

5. Flexible Production Strategy

Clinical proficiency—Effectively matching supply to demand helps ensure enough EMS resources are on duty to handle larger call volumes while minimizing the number of idle units and amount of nonproductive time. This again helps assure field providers are using their clinical skills regularly to maintain proficiency. It also helps prevent burnout (too many calls per provider) and rustout (too few calls per provider).

Operational effectiveness—Using a flexible production strategy helps maintain a healthy and manageable unit utilization through the day and year, making the system more operationally effective.

Fiscal efficiency—Matching supply to demand improves the financial efficiency of the system by minimizing the expense of excess capacity.

6. Dynamic Resource Management (DRM), System Status Management (SSM)

Clinical proficiency—As with the other attributes, moving resources within the system to cover anticipated demand helps enhance utilization and consequently improve providers’ clinical proficiency. It may also help reduce utilization in high call volume areas and prevent burnout.

Operational effectiveness—Having the right resources in the right locations can significantly improve operational effectiveness. If you know there are high-volume areas in your jurisdiction, dynamically deploying resources from low-volume areas allows for enhanced service delivery.

Fiscal efficiency—Matching supply to demand is a first step in achieving fiscal efficiency. The second step is to have those resources in the right places. DRM allows moving available resources throughout the system to meet anticipated call volume. Combining a flexible production strategy with DRM has a significant impact on effectively using your on-duty resources.

The EMS Success Triad

The EMS success triad is a philosophy and business compass that can be adopted within any EMS system type, and its importance is highlighted in any HPEMS system. The triad includes a constant balancing of:

Patient care—When we speak of patient care, we must think beyond the clinical aspects of care and also include the value aspects such as patient satisfaction, patient safety, customer service, response time and service reliability, and outcomes.

Employee well-being—EMS is a service business, and service businesses are founded on their people. EMS must acknowledge this and build systems and processes that acknowledge the impacts of lean design on its teams. Issues such as adequate breaks, workload balancing, employee engagement, just culture, trust, employee safety systems, work-life balance, schedules and scheduling, compensation strategies, organizational and mission passion and decision making involvement are just a few areas EMS must work to improve.

Long-term financial sustainability—Every decision made within an EMS organization has a cost that impacts the triad in some fashion. These costs must be accounted for and balanced. Cost is a relative term and not necessarily financial in nature (e.g., impacts on patient care and employee well-being). No matter the type of business structure or operational philosophy an EMS system has, the concept of “no margin, no mission” always applies. Long-term business, financial and other cost impacts must always be kept in check if an EMS system is to remain sustainable.

While not every EMS agency or community will be able to employ all the attributes of HPEMS, we are convinced many EMS providers can use some of these principles to demonstrate the value they bring to their community.

In next month’s column we’ll focus on providing high-value EMS.

About AIMHI

AIMHI represents high-performance emergency medical and mobile healthcare providers in the U.S. and abroad who deliver care to more than six million people over more than 43,000 square miles and responding to nearly a million calls annually.

Formerly known as the Coalition of Advanced Emergency Medical Services (CAEMS), AIMHI changed its name in March 2015 to better reflect its members’ dedication to promoting high-performance ambulance and mobile integrated healthcare systems.

Member organizations include high-performance EMS systems in locations such as Oklahoma City and Tulsa, OK; Fort Worth, TX; Richmond, VA; Pinellas County, FL; Charlotte, NC; Niagara, ON, and the province of Nova Scotia, Canada; New York, NY; Little Rock, AR; Davenport, IA; Three Rivers, IN; and Reno, NV. Find more information on AIMHI at www.aimhi.mobi.

References

1. Avril T. Police transport a good bet for shooting victims, study finds. Philadelphia Inquirer, 2014 Jan 8.

2. Sun LH. Need an ambulance? Why you may not want the more sophisticated version. Washington Post, 2015 Oct 12.

3. Rosenthal E. Think the E.R. Is Expensive? Look at How Much It Costs to Get There. New York Times,2013 Dec 4.

4. Valine K. Modesto rejects $1M firefighter paramedic grant. Modesto Bee, 2016 Oct 5.

5. Prohaska TJ. Lockport plans to auction off ambulances, cut fire staffing minimum. Buffalo News, 2014 Aug 27.

6. Loper B. Kalispell voters reject extra taxes for EMS. Daily Inter Lake.

7. Matarese L. Is the Current Model for Public Safety Service Delivery Sustainable? ICMA Publications.

Doug Hooten, MBA, is the chief executive officer of MedStar Mobile Healthcare in Fort Worth, TX. He has over 37 years of experience in EMS, having served as senior vice president of operations and regional director for American Medical Response, CEO of the Metropolitan Ambulance Service Trust (MAST) in Kansas City, and in a variety of leadership roles with Rural/Metro in South Carolina, Georgia, Ohio and Texas. He has expertise in change management, cost optimization, process improvement and clinical excellence. Doug is the president of AIMHI, serves as a board member for the American Ambulance Association and is a member of the National EMS Advisory Council (NEMSAC). 

Jonathan Washko, MBA, NREMT-P, AEMD, is the assistant vice president for Northwell Health’s Center for EMS and leads numerous innovation efforts to improve patient care, employee well-being and the long-term financial sustainability of EMS systems. He volunteers as a board member with the American Ambulance Association, NAEMT, AIMHI and NYMIHA and also serves as a member of the EMS Compass initiative, working to develop standardized industry measures, as well as an advisor to the Promoting Innovation in EMS (PIE) project. Reach him by e-mail at jwashko@northwell.edu.

Original article can be accessed here.

Bundles of joy are the focus of one of the latest efforts to implement bundled payments.

Seeking to spur widespread adoption of alternative payment models, or APMs, the federally affiliated Health Care Payment Learning and Action Network has set its sights on the high-volume admissions related to maternity and newborn care. Combined maternal and newborn stays represent more than 20 percent of all hospital stays, according to the Agency for Healthcare Research and Quality.

HCPLAN is a collaborative network of public and private stakeholders working to advance the federal government’s goal that 50 percent of all health care payments will be through alternative payment models by 2018. The network’s clinical episode payment work group has identified maternity care — along with elective joint replacement and coronary artery disease — as a top priority for episode-based payments.

Work group members see plenty of opportunities for improvement in maternity and newborn care. The U.S. cesarean section rate is high — more than 30 percent of births, according to the World Health Organization — despite the expense and potential danger to mom and baby. More than 9 percent of births are pre-term, including many early elective deliveries, which increases the need for neonatal intensive care. The nation’s infant and mortality rates are high, and racial/ethnic disparities for infant outcomes are disturbing.

Geisinger Health Plan has used the bundled-payment approach for maternity care at Geisinger Health System for six years — and with good results, says John B. Bulger, D.O., Geisinger’s chief medical officer for population health. Early elective deliveries almost immediately dropped to zero when the obstetrics department started to focus on processes of care. That resulted in fewer C-sections and reduced NICU use.“It is a win-win-win because the baby is healthier, happier, the mother is healthier and happier, and the population is healthier and happier because it is less costly to the system,” he says.

Geisinger’s perinatal care bundle, available only for low-risk pregnancies, includes all prenatal, labor and delivery, and postpartum care for the mother only; the baby’s care is not covered in the bundle.

Despite Geisinger’s success, its particular approach has not been widely adopted. A handful of payers and health systems are experimenting with maternity care bundles, but most are waiting for somebody else to figure out best practices. The first challenge is the sheer length of the episode.

“We feel pretty strongly that an episode should include prenatal, postpartum and — ideally — 30 days of newborn care,” says Brynn Rubinstein, senior manager for Transform Maternity Care at the Pacific Business Group on Health. “It’s really hard to navigate all of the providers that a woman and baby might see, and all of the other conditions related to pregnancy, or unrelated to pregnancy, and how to include those in the episode.”

Rubinstein, who is working with plans and purchasers to implement the recommendations outlined in HCPLAN’s white paper on maternity care episode payments, says purchasers are tired of the variation in cost and quality of maternity and newborn care.

“While there are many obstacles to navigate, they are all challenges that can be overcome,” she says. “It may take a few years, but they can absolutely be overcome, and we need to start today.”

Original article can be accessed here.

 

Left: Professor Freddie Lippert and the team from Copenhagen EMS, Denmark

Right: Paramedic Students from the Australian Catholic University, Canberra

Brazilian Trauma Surgeon, Dr Rod DeOlivera at the start of his Pan American Trauma Society Observership

FOR IMMEDIATE RELEASE

Contacts:

Rob Lawrence

rlawrence@raaems.org

804 205 2557

Richmond December 19, 2016 — As 2016 draws to a close, the Richmond Ambulance Authority (RAA) is reflecting on one of its busiest years ever, not only in terms of call volume, but also the number of visitors who made their way to Richmond.  In 2016, RAA received international visitors in 16 separate visits from 12 countries on five continents.

RAA takes much pride in being ‘a major stop on the EMS World tour’ and in 2016, welcomed a range of visitors wishing to view RAA operations. Norwegian and Finnish Health ministry members spent time with RAA leadership to compare and contrast data and performance measuring processes.  The entire Norwegian EMS performance monitoring and management system draws some of its roots from RAA’s way of doing business.

One of RAA’s aims as a 501c3, Not for Profit organization is to use its own learning and experience in the pursuit of high performing operational and clinical EMS to raise the bar of global EMS. This was evident in the summer when it hosted the leaders of Rwanda’s (Africa) SAMU Ambulance service for a week’s master class in EMS operations.  SAMU’s Jean Camarade said, “Our time in RAA was a lifetime experience and undoubtedly will have an impact on ongoing quality improvement process of ambulance system in Rwanda. If you are a manager or clinical professional and want to learn from about world class EMS, your next stop should be RAA.”

RAA has also been central to the Pan American Trauma Society Observership program and in 2016 hosted visits from trauma surgeons and medical students from Central and South America for two- to three-week attachments to understand how a high value EMS system operates and take lessons back to assist with EMS development in their own countries. Dr. Rodrigo Gonçalves de Oliveira, a Sao Paulo, Brazil, surgeon said, “It was an amazing experience. The opportunity to learn from the best helps us to identify the gaps on our service, allowing us to propose changes to the entire system.”

RAA has also educated and influenced medical, paramedic and healthcare administration students. Individuals and groups from the Australian Catholic University campuses based in Canberra, Sydney and Brisbane enjoyed their RAA learning experience.  The largest group of visitors every year is from the Masters in Healthcare Administration class from Taiwan’s Kaohsiung Medical University (KMU).  Medical student Maria Jose Jaramillo from Quenca, Ecuador, said, “Every person at Richmond Ambulance Authority taught me something, not only high quality prehospital care, but also team work, kindness and love to every patient they take care of. I consider it one of the best experiences I’ve had by far, and I’ll keep this team forever in my heart.”

RAA’s international visit coordinator, who also began his own RAA career after an international visit from the UK, COO Rob Lawrence said, “We learn as much as we give with every visit and make lifelong friendships with those members of our international RAA family.  Our staff certainly enjoys the opportunity to share their experiences, whether it is a surgeon from Sudan or a student from Sydney.”

As for the full count, RAA received visitors from Australia, Brazil, Chile, Denmark, Ecuador, Finland, India, Japan, Norway, Rwanda, Sudan and Taiwan.

About the Richmond Ambulance Authority
In 1991, the Richmond City Council and the city manager implemented an Emergency Medical Services (EMS) system that placed the patient first and guaranteed its performance to the City’s residents.  Today, the Richmond Ambulance Authority responds to approximately 200 calls per day and transports, on average, 140 patients per day.  RAA’s emergency response times are among the fastest in the nation with ambulances on the scene of life threatening emergencies in less than 8 minutes and 59 seconds in more than 90% of all responses.  RAA is one of only 22 EMS agencies in North America accredited by both the Commission on the Accreditation of Ambulance Services and the National Academies of Emergency Dispatch.  RAA is also a Commonwealth of Virginia Accredited Dispatch Center.  For more information, see www.raaems.org.

The CMS on Wednesday launched two new consumer-oriented websites that publish information about the quality of inpatient rehabilitation facilities and long-term care hospitals, lengthening its list of Compare websites amid a broader push in healthcare to increase transparency about quality and engage patients in their care.

The CMS also said it would update the overall quality star ratings on its Hospital Compare website, by refreshing data derived from patient feedback and from timely and effective care measures. In those star ratings, hospitals are assigned one through five stars, with five representing the highest quality. The CMS will also incorporate five new oncology measures into the Cancer Hospital Reporting Program and add readmissions after coronary artery bypass graft surgery to the Readmissions Reduction Program.

“At the CMS, one of our top priorities is to help individuals make informed healthcare decisions for themselves or their loved ones based on objective measures of quality,” Dr. Patrick Conway, acting principal deputy administrator and chief medical officer for the CMS, and Dr. Kate Goodrich, the director of CMS’ Center for Clinical Standards and Quality, wrote in a blog post Wednesday. Using the CMS’ Compare websites, “individuals can compare the quality of health care providers, facilities, and health plans, highlighting that people have a choice in their care,” they added.

Among healthcare stakeholders and experts, the Compare websites have proved controversial, especially Hospital Compare. Transparency advocates have praised the CMS’ ongoing efforts to publish data and inform consumers, but industry groups have pushed back by questioning the accuracy and precision of these ratings and the methodology behind them.

“I think it’s exciting that the CMS is updating the Hospital Compare website, and I appreciate that they are becoming even more current in the data they’re using to report,” Leah Binder, president and CEO of the Leapfrog Group, said of Wednesday’s updates. “We think consumers can really understand it and use it.”

The new websites on long-term care and inpatient rehabilitation facilities constitute “a breakthrough,” Binder added. “Certainly as the population ages and so many of us worry about our parents and grandparents, this is really helpful.”

In the past, industry groups have vigorously opposed the CMS’ initiatives to publish quality data and have gotten Congress on their side. In July, when the agency published its star ratings for overall hospital quality, the American Hospital Association voiced concerns that “the current ratings scheme unfairly penalizes teaching hospitals and those serving higher numbers of the poor.”

A study published in JAMA in November found that star ratings for hospitals were affected by their locations and surrounding socio-economic conditions.

The new Compare websites for long-term care hospitals and inpatient rehabilitation facilities will report quality measures: the percentage of residents or patients with new or worsened pressure ulcers, and unplanned readmissions, for any reason, within 30 days after discharge.

Original article can be accessed here.

Payment and care delivery innovation have long held bipartisan political support, the Health Care Transformation Task Force said Tuesday.

The Health Care Transformation Task Force called on the incoming Trump administration in a letter sent Tuesday to continue efforts to replace fee-for-service payment models with value-based care.

The task force, which includes patients, payers, providers and purchasers in its ranks, notes in the letter (PDF) that payment and care delivery innovation have long held bipartisan political support, and asked that President-elect Donald Trump, Vice President-elect Mike Pence and leaders in Congress make it clear to the industry that the support will continue.

“Given the significant industry investment and strong progress to date, we urge the new Administration and Congress to send signals of support and encouragement so this transition can be sustained,” the task force wrote. “This is not the time for policymakers to waiver [sic] or reverse course, which would send a negative message to the industry and chill ongoing transformation efforts.”

The consensus of the task force’s 43 member organizations—which includes six of the 15 largest health systems in the country and big-name payers such as Aetna and Blue Shield of California—is reflected in the letter. As healthcare costs continue to soar, the high expense becomes unsustainable for both businesses in the industry and consumers, they wrote, and the letter offers several key ways the incoming administration can show its commitment to lowering healthcare costs.

The task force’s work is an example of the individual private sector leadership that Trump and Republicans have extolled, they wrote, but despite individual groups working hard to continue transforming care delivery and payment models, progress will be stymied if the Centers for Medicare & Medicaid Services doesn’t also signal that it is on board.

Sustainable value-based payment models are only possible “by aligning private sector and public sector efforts,” according to the letter. Policymakers can remove red tape hindering the private sector to improve this, they wrote, but that alignment is key. In particular, they point to the Center for Medicare & Medicaid Innovation as a source—a public-sector entity that has made great strides in payment and care delivery transformation.

A likely decrease in regulations under Trump and a Republican-controlled Congress may help foster other industry innovation as well.

Original article can be accessed here.

In medical emergencies, patients have few alternatives to calling 911 or rushing to the emergency department for costly care. That’s the status quo, but a growing number of providers, payers and agencies are testing care approaches that help patients in novel and proactive ways.

One of these approaches is mobile, integrated healthcare. Teams made up of a mix of clinicians are available 24/7 to attend to patients’ needs—outside the hospital and in person or by video chat, phone or text message, whether there’s an emergency or not. Evidence suggests this approach can improve patient outcomes and lower costs, although putting it into practice presents considerable challenges.

“There is significant, potentially avoidable cost in most populations, and it can be identified if you choose to look for it,” said Dr. Eric Beck, CEO and president of Evolution Health, a population health management company that managed such a program in Florida. A preliminary study of that program, carried out among members of a Medicare Advantage PPO, was recently published by Beck and other researchers in the Journal of Health Economics and Outcomes Research.

The study showed a 19% decrease in monthly emergency room costs per patient and a 21% decrease in emergency department utilization among the roughly 1,000 patients enrolled in the model, compared to a control group. Patients also appeared to be more engaged and active in managing their health. A larger, forthcoming study will include 60,000 patients.

The program in Florida began with specifying high-risk, high-cost patients for whom interventions would most likely have an impact. The patients in the study represented between 9% and 12% of the entire Medicare Advantage membership and more than half of its costs.

Those patients received planned and unplanned care from physicians, nurses, paramedics, pharmacists, social workers and other providers. A patient with a chronic illness, for instance, would have a care plan that included coaching, appointment follow-ups and medication adherence through home visits and weekly phone calls.

Such regular contact is supposed to help patients manage chronic diseases by ensuring they receive timely preventive care. And if they do have emergencies, they can call the team.

Previous studies have suggested that as many as 27% of all emergency department visits could be handled safely at sites such as urgent-care centers, with annual savings estimated at $4.4 billion. From 2009 to 2010, people over the age of 65 made 19.6 million visits to emergency departments, or 15% of all such visits, despite making up 13% of the overall population.

The National Association of Emergency Medical Technicians has described mobile integrated healthcare and community paramedicine as an innovation with “the potential to transform EMS” into “a value-based mobile healthcare provider that is fully integrated” with healthcare and social services. The association estimated in 2014 that 103 EMS agencies had such programs with more agencies developing them.

For hospitals and health systems, these programs require considerable amounts of time, resources and energy to build. Having the right financial incentives and revenue models are key. For the growing number of providers moving into bundled payment programs and other CMS demonstration projects that hold them financially accountable for patient outcomes, a mobile, integrated program might prove particularly appealing.

“It’s not for organizations that aren’t strategically interested in making an investment to do that at scale,” Beck said.

Another challenge is preparing personnel and training clinicians.

“How do you bring together a team?” Beck said. “How do you take paramedics and nurses and physicians, and how do you prepare them for virtual, mobile, 24/7 delivery? It’s a new mental model that needs to be familiar to the patient but to the clinician as well.”

Original article can be accessed here.

A visit from a primary care clinician that focuses on following up on treatment plans after a patient’s discharge from a hospital stay lowers the risk of readmission.

A study by Kaiser Permanente found that tailored post-hospital visits lowered readmissions for Medicare Advantage patients. The 20-minute visits are scheduled for patients while they are still in the hospital and focus specifically on follow-up treatment plans, according to the study published in JAMA Internal Medicine. In contrast, regular outpatient visits by a primary care clinician may focus on routine care and not cover specific issues related to the recent hospitalization.

Researchers reviewed the electronic health records of more than 71,000 Medicare Advantage patients discharged from 14 Kaiser Permanente hospitals from 2011 to 2014. The study found patients who had one or more visits within seven days of being discharged home were 12% to 24% less likely to be readmitted to the hospital than those who did not have an outpatient visit from a clinician.

Patients who had a visit tailored to address their post-discharge treatment plans—called a POSH visit—were 28% less likely to experience readmission.

“Although any primary care clinician outpatient visit appeared to reduce readmission risk compared to no outpatient visit, the POSH visit provides the added benefit of the care team being alerted to, and therefore better prepared to address, patients’ post-discharge needs,” Ernest Shen, Ph.D., research scientist biostatistician at the Kaiser Permanente Southern California Department of Research & Evaluation, said in an announcement.

The POSH visits focused on a patient’s immediate post-discharge needs and allowed the clinicians to assess the person’s clinical status, determine if more intensive treatment was needed, follow-up on test results and referrals, review medications and provide patient and family education.

The research is important as one analysis projected more than half of U.S. hospitals would be penalized for excessive 30-day readmission rates this year, with Medicare withholding more than half a billion in payments.

Original article can be accessed here.

Shares in Lewisville-based Adeptus Health took a major hit Wednesday after the nation’s largest operator of freestanding emergency rooms reported an $11.7 million loss in the third quarter.

The loss was attributed to high fixed costs that resulted in continued decline in patient volumes at facilities that are not hospital-affiliated. Adeptus refers to those facilities as non-hospital outpatient departments.

The company also surprised analysts by disclosing it needed to secure $27.5 million in emergency financing from investors.

Adeptus shares fell about 3 percent to $26.87 a share on Tuesday, but tanked on Wednesday. It closed down 68 percent to $8.60 a share.

The company’s low patient volume was coupled by billing and collection issues, and expenses associated with opening three new hospitals, which are planned for the end of the year.

Leadership admitted frustration during a call with analysts after the market closed Tuesday.

“Let me be clear, third quarter results were disappointing and are not acceptable operating results,” chief financial officer Frank Williams told analysts. “While our business is currently underperforming, we have put in place plans … that will allow us to correct this underperformance.”

Analysts were less optimistic, describing it as a “distressed situation” and noting that without emergency financing Adeptus has enough cash to fund just two additional quarters of operations. Volume dips and cost scrutiny could hamper any possibility of aggressive expansion, noted equity analyst Brian Tanquilut said in his report on Wednesday.

Cedrick Dark, an emergency medicine physician at the Baylor College of Medicine in Houston who also works in hospital-affiliated freestanding ERs, said the freestanding model will continue to face challenges, but not just with low volumes.

“Facility fees” designed to help freestanding ERs cover their overhead are a major concern for patients who show up for medical issues that could be handled at urgent care.  “They’re getting emergency room sized bills,” Dark said.

Freestanding ERs must provide access to doctors, lab testing, nurses, radiologists, and other staff all day, every day.

“It’s not cheap to do,” he said. “The facility fee helps pay for all that. Without it, the model’s not going to financially be viable.”

The proliferation of freestanding emergency facilities in the U.S. also has increasingly been met with criticism by health policy researchers.

They worry that locations are cropping up in wealthy communities and may not be regulated by the same standard that has prevented hospitals from dumping people who cannot afford to pay. Patients have also complained about their confusion over whether services are covered by insurance.

Operators of the facilities, on the other hand, call it an industry of demand. They argue the facilities provide a convenient alternative to affluent patients who do not want to wait in crowded hospital emergency rooms.

Adeptus operates more than 90 freestanding emergency rooms in the United States. In Texas, where growth has been the fastest, Adeptus runs First Choice Emergency Room locations in Dallas-Fort Worth, Austin, San Antonio and Houston.

Patients who are willing to pay higher prices provide the greatest revenue per visit given the company’s high fixed cost model, Williams said.

“Our predominantly fixed cost model has a fairly direct impact on our bottom line,” he told analysts.

The biggest impact was in Houston, its largest market. The company reported “a decline of approximately 2,000 mainly lucrative commercial patients quarter over quarter.” Over 15,200 patients were seen in Adeptus ERs in that market in the third quarter, and the majority of the facilities there became affiliated with hospitals in October.

Other markets that experienced drops in volumes were San Antonio, where 2,578 patients were seen in the third quarter, and Austin, which had a patient volume of 2,644. “These are small markets and less significant to the bottom line,” Williams said. “But still an impact in excess of $2 million for the combined markets.”

The third quarter results were a significant change from the previous quarter, when Adeptus saw operating revenue increase 12 percent to $100.2 million, which it attributed to its affiliations with hospitals. Operating revenue in the third quarter was $85.4 million.

On Tuesday, the company again noted positive results from hospital-affiliated outpatient departments. Patient volume rose 39.3 percent at hospital-affiliated emergency departments and dropped 19.1 percent at those that were not.

Adeptus has been seeking partnerships to bolster hospital relationships.

Texas Health Resources

Texas Health Resources, an Arlington-based health system, began rebranding 31 of Adeptus’ North Texas freestanding emergency facilities and one hospital with its logo in September.

ER volumes in the Dallas-Fort Worth market in the third quarter topped 37,000 patients. Chief operating officer Graham Cherrington said the THR affiliation has “already been a positive impetus.”

Adeptus has opened 21 new freestanding ERs and two hospitals this year alone, and has plans to add three more. That would bring its total to 104 ERs, most of which will be hospital-affiliated.

It also plans to open hospitals in Denver, Houston and Colorado Springs by the end of the year.

In light of the disappointing quarter, Adeptus leadership plans to focus on affiliating facilities with hospitals that do not have those relationships. It also plans to address issues with billing and collections, and scale back on expansion.

The company went public in June 2014 at $23.30 a share. Its share price peaked at $115.68 in September 2015.

Original article can be accessed here.

More than 1,600 hospitals will see bonuses from Medicare in 2017 under the Hospital Value-Based Purchasing program, according to federal data released Tuesday. The number earning positive pay adjustments is about 200 fewer than last year.

The program affects some 3,000 hospitals, which are penalized or rewarded based on how well they perform on certain quality measures. A hospital’s performance is assessed in comparison to its peers’ and to its own performance over time.

The results are “somewhat concerning,” said Francois de Brantes, executive director of the Health Care Incentives Improvement Institute. One reason was the fact that fewer hospitals are being rewarded. Another was hospitals’ lack of movement in rankings.

Search the results:

Search by hospital and location to see the bonuses and penalties for 2017 compared with 2016.

The payment increases add up to about $1.8 billion for 2017. To create the pool for the bonuses, the CMS imposed a 2% reduction to base DRG payments for hospitals paid under the Inpatient Prospective Payment System. Medicare redistributes that money to hospitals based on their performance on patient surveys and quality and efficiency measures. They earn two scores—one for achievement and another for improvement.

For about half of the hospitals in the program, the changes to base DRG payments will be minimal, in the range of 0.5 to -0.5%. The highest performing hospital will receive an increase slightly more than 4%, while the lowest performing hospital’s payment will be cut 1.83%, CMS said.

The number of hospitals whose payments were docked grew from 1,236 in 2016 to 1,343 in 2017, according to a Modern Healthcare analysis of the data. Last year, 59% of hospitals received bonus payments; this year 55% did.

More than half of the 2,879 hospitals in the program both years will see lower payment adjustments in 2017 than in 2016. Payments improved for 1,388 of those hospitals.

About 1,250 hospitals earned bonuses both years and 875 were hit with penalties both years. By comparison, 437 hospitals that earned bonuses last year were docked in 2017, and 315 hospital penalized in the last round will receive bonuses next year.

The Hospital Value-Based Purchasing Program contains inherent design flaws, de Brantes said. As a “tournament-style” program in which hospitals are stacked up against each other, they don’t know how they’ll perform until the very end of the tournament. “It’s not as if you have a specific target,” he said. “You could meet that target, but if everyone meets that target, you’re still in the middle of the pack.”

The Hospital Value-Based Purchasing program went into effect in October 2012. It was established under the Affordable Care Act as one of many initiatives to pay for healthcare on the basis of quality, not quantity.

The Inpatient Prospective Payment System excludes specialty hospitals such as psychiatric institutions, oncology centers and pediatric facilities; hospitals that do not have a minimum number of cases; and hospitals that don’t participate in the Hospital Inpatient Quality Reporting Program.

The CMS also announced several changes to the program for fiscal 2018. The four domains on which hospitals are scored—clinical care; patient- and caregiver-centered experience and care coordination; safety; and efficiency and cost reduction—will be weighted equally. The program previously allotted 30% to clinical care and 20% to safety.

For 2018, the CMS also removed two measures from clinical care and added a care transition dimension.

The results show “how progress on quality can be accelerated when pay-for-performance programs reward both achievement and improvement,” said Nancy Foster, the American Hospital Association’s vice president of quality and patient safety policy. “However, CMS must continue to refine the program to ensure that it effectively drives quality forward for hospitals and the patients they serve,” she added, including ensuring its measures prioritize areas with the greatest impact on patient care.

Original Article can be accessed here.