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Robert Whitcomb

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The need for population-health segmentation


An article in Health Affairs asks how to measure and understand the distribution of health metrics across a population.

The authors conclude with these implications for policymakers:

“There exists a clear consensus among healthcare experts around the need for population segmentation in order to measure population health and health equity. However, there is no single way to do this. {T}en population segmentation approaches were considered important by the panel. These results highlight the value of considering the wide range of different population groups that may influence health outcomes.

“The results of this study can help researchers and policymakers prioritize the way they analyze and present population health data. In addition, these results should guide the collection of data. For example, the panel considered socioeconomic status and risk factors to be very important, but administrative datasets collect information on these issues in different ways and according to different definitions. Standardizing the collection of segmentation variables would allow population-wide analysis of the distribution of health.

“Policymakers should also consider using a data-driven approach to identify population segments, rather than a priori defined population groups. Big data and data mining techniques can help quantify the distribution of outcomes in a population and identify the factors driving these differences.”

To read the piece, please hit this link.

N.M. system’s CEO discusses innovations

Presbyterian Hospital

Presbyterian Hospital

Dale Maxwell, who was recently named president and CEO of Presbyterian Healthcare Services, based in Albuquerque, N.M. discussed with Hospitals & Health Networks his system’s innovative initiatives, including its patient-navigation model and its increasing use of telemedicine to treat its far-flung rural population.

He said that the system must grow to be sustainable over the coming years, saying:

“We have two really important initiatives from the growth standpoint right now. One in Santa Fe, where we’re building a medical center to serve the northern part of New Mexico which will open in 2018. Growing outside of New Mexico is also an important strategic option for us. Over the past 30 years, we’ve built expertise and knowledge in integrating the financing of care into the delivery of care; we’re in a great position to export that knowledge and expertise outside of New Mexico and partner with other provider systems to ensure the move toward value-based care and population health. And in North Carolina, we’re partnering with 11 systems to bid on Medicaid as they roll out managed care and move away from a fee-for-service model.”

On the patient-navigation model:

“We started this model in 2010. It came out of the early work of looking at the data and analytics, where patients received care and the overall cost of that care. As we looked at the emergency department, it was a great opportunity to change how care is delivered and be more specific about delivering care in the right place at the right time.

“As patients enter our ED, each one has a medical screening. If the screening determines that the patient is not in an emergency status, the or she is navigated to a more appropriate care setting. That could be a referral to urgent care or a primary care facility.

“The goal is to establish that patient with a primary care physician; then they can begin to manage the patient for future services. It’s taking a very expensive ED visit and translating it into a less costly clinic visit. More importantly, the management of the patient in the long term is going to provide better care to the patient and, overall, decrease the cost of care.”

On the system’s home health care, including palliative services:

” The unique piece of this is that it’s embedded into our patient-centered medical home, similar to other services like behavioral health or pharmacy management services. This aligns the care across the continuum with all of the care teams, so it’s not isolated in any respect.”

On telehealth:

“We have a couple of, I would say, established and successful programs. One is our Telecritical care program. Intensivists here in Albuquerque take care of patients at two of our regional facilities through video. By using the care teams at the point of care and a physician in Albuquerque, we’re able to deliver the necessary care for the patient. He or she receives the highest-quality physicians, is able to stay in the community and doesn’t need to be transferred to a different facility, so that really benefits members.”

To read more, please hit this link.

My unexpected encounters with 2 big ACA foes


For Kaiser Health News


Flying out of Reagan National Airport on Wednesday, I was expecting a short reprieve from the issue that has consumed my work in health journalism for eight years — the Affordable Care Act and, lately, Republican efforts to replace it.

The voyage turned into anything but, with some unexpected close encounters.

Media-accessible Sen. Chuck Grassley (R.-Iowa) keeps his pulse on the news and stays in touch with the public at Reagan National Airport outside Washington, D.C.

— Photo by Phil Galewitz

Awaiting my flight and in search of any outlet to plug in my phone, I recognized Sen. Chuck Grassley heading back to his home state of Iowa. Always one of the more media-accessible senators, he didn’t hesitate to chat when my reporter’s instincts kicked in to curbside him with some questions on the ACA repeal. It was Grassley who initially helped turn the public tide against Obamacare when he (wrongly) claimed the legislation had “death panels.”

Grassley, 83, chairman of the Senate Judiciary Committee and one of longest-serving members of Congress, told me the GOP leadership bill — the American Health Care Act — doesn’t go far enough to help older Americans, those ages 55-64, get coverage.

He said a plan is circulating in the Senate to extend more government subsidies to help this age group, which a recent report by the non-partisan Congressional Budget Office (CBO) noted would be hit particularly hard.

But, reflecting Republican divisions, he acknowledged that subsidies — even if directed at low-income Baby Boomers — would be tricky given opposition from conservatives such as House Freedom Caucus Chairman Mark Meadows (R.-N.C.). Much of the party’s hard right is opposed to subsidies, including former presidential candidate Ted Cruz.

Then Grassley moved on to two points on which his party is united. He said the Republicans must deal with Obamacare before it adjourns for Easter/Passover recess on April 6. That’s because Republicans still must leave time to deal with tax reform and infrastructure bill before summer break. “It’s now or never,” he said.

I asked if he would support any GOP bill, even if it increased cost for some Americans or led to more joining the ranks of uninsured. Grassley grew a bit angry. “Anything is better than Obamacare and what we have now,” he said with his outstretched fingers nearly touching me.

This is a common but increasingly contentious talking point in GOP circles. The CBO report found that 24 million more Americans would lose coverage under the GOP plan by 2026.

No sooner had I shaken hands with the senator and boarded my American Airlines flight to South Florida, I spotted none other than Sen. Ted Cruz, himself, the conservative fireball from Texas, sitting in the row ahead of me. I watched the flight crew comp his glass of red wine — I paid $7 for my Sam Adams beer — and hesitated to disturb him in flight as he played a basketball-themed game on his tablet.

But once landed, I couldn’t resist introducing myself as a reporter. I told him I had just read his op-ed in The Wall Street Journal explaining his own opposition to the GOP leadership plan, and the need to freeze Medicaid expansion immediately rather than by 2020 and provide tax credits only for working Americans to help them get health coverage.

Sen. Ted Cruz (R-Texas) flies coach — in the row that offers extra legroom — on a March 15 flight to South Florida.

— Phil Galewitz photo

As we deplaned in West Palm Beach, Cruz told me that he didn’t think Medicaid should help non-disabled adults because it would give them an incentive not to work and would make them dependent on government handouts. He said Medicaid was meant to help children, pregnant women and the disabled — and money spent to help others would take away from those who were more deserving.

He noted that states that expanded Medicaid have long waits for care for disabled Medicaid beneficiaries needing home and community-based care. I cover Medicaid and felt compelled to point out that the longest Medicaid waiting lists were in states that did not expand Medicaid.

Cruz, 46, mentioned that he wants the federal government to offer straight lump-sum grants to states for Medicaid — different from today’s open-ended federal funding and the GOP leadership’s plan that ties funding to the number of patients enrolled.

He said a block grant would give states more motivation to “innovate” to find ways to provide care for less money. I asked how states would innovate during times of economic downturns. “States have faced tough times before and would find a way,” he said.

Cruz, who was in Florida for a conference, discussed Obamacare changes in a thoughtful and mild manner that I did not expect, given the prevailing tone in Washington, D.C., these days.

As we searched for our rides, after midnight, outside the terminal, he took my business card.

My close encounters with two influential voices in the Republican Senate during one journey underlined the deep divisions the party faces as it seeks to replace the ACA.

It was time to put Obamacare to bed — at least for the night.

AHA: Anthem-Cigna merger would hurt move to value-based reimbursement


The American Hospital Association (AHA) is urging a federal appeals court to uphold a district court decision that has blocked Anthem’s proposed $54 billion acquisition of Cigna.

The organization asserted that the combined company would reduce innovation in the health-insurance market when it’s most needed to continue shifting healthcare away from the fee-for-service model toward value-based care.

“Anthem has been less willing than Cigna to innovate and develop value-based reimbursement systems,” the AHA wrote.

Anthem has said that it is “committed to completing this value-creating merger either through a successful appeal or through settlement with the new leadership at the Department of Justice.”

However, the AHA contended that value-based reimbursement models “depend critically on the willingness of payers to experiment, innovate, and collaborate with hospitals and physicians to develop new payment methodologies that go beyond the old fee-for-service system.” And there is “substantial evidence that underscores Cigna’s particular reliance {as opposed to Anthem’s} ‘upon innovation to compete,’” the AHA added.

AHA’s brief comes days after the Department of Justice, several states and the District of Columbia also urged the appeals court to maintain the lower court’s blocking of the agreement. There is “overwhelming evidence – uncontested by Anthem on appeal” that the merger would raise prices to consumers and shrink innovation among insurers, and that “showed Anthem had no real plan to achieve” the medical-cost savings it asserted that the combined company would create.

To read the AHA’s argument please hit this link.



Judge explains shift to reject big Ill. merger



Advocate Lutheran General Hospital, Park Ridge, Ill., part of Advocate Health Care.

U.S. District Court Judge Jorge Alonso has explained in a new court filing why he  switched from siding with two large Chicago suburban health systems that wanted to merge to favoring antitrust regulators that have fought the proposed merger.

The reversal, announced March 7 , stopped  the proposed marriage between Advocate Health Care of Downers Grove, the largest hospital network in Illinois, and Evanston-based NorthShore University HealthSystem. Such a merger  would have created the nation’s 11th largest nonprofit hospital system.

Basically, Judge  Alonso’s decision was that if he let the systems merge, it might have been harder to break them up later and “recreate pre-merger competition.”

Read Judge Alonso’s decision here.

Read  a Modern Healthcare article on this here.

Four tips for clinical documentation improvement

Jonathan Elion, M.D., a cardiologist and associate professor of medicine at Brown University, has four tips for clinical documentation improvement in ambulatory settings.

They are:

  • “Define the exact patient and visit categories that you think merit inclusion in a CDI workflow.
  • “Determine how these patients can be identified by information in the HIS {hospital information system} and its associated electronic messages.
  • “Make sure that you can define your facility’s use of account numbers in open or recurring visits.
  • “Be specific about what you want to accomplish and how you will measure your progress.”

To read more, please hit this link.

Mayo to cherry-pick patients with private insurance


The Minneapolis Star Tribune reports that Mayo Clinic’s chief executive recently told his staff to prioritize patients with commercial insurance over those with Medicaid or Medicare when possible.

The announcement came during a speech Mayo CEO John Noseworthy, M.D., gave to employees. Mayo stressed that the announcement refers  to cases where patients may be able to receive comparable care elsewhere, and that the prestigious hospital system still uses medical need as the primary factor in its decision-making.

Mayo cited an estimated $1.8 billion in unpaid Medicare services and an increased number of Medicaid patients across the organization in 2016 as reasons for its move.

“We need to balance requests from these patients with their specific needs—if it’s necessary for them to come to Mayo—as well as the needs of commercial paying patients,” said Karl Oestreich, Mayo’s spokesman.

Dr. Noseworthy said a recent 3.7 percent increase in Medicaid patients was a “tipping point” for Mayo.

“If we don’t grow the commercially insured patients, we won’t have income at the end of the year to pay our staff, pay the pensions, and so on so we’re looking for a really mild or modest change of a couple percentage points to shift that balance.”

To read more, please hit this link.

Will GOP health bill cut nonprofit hospitals’ outreach to their communities?


For Kaiser Health News

For the past six years, Mardi Chadwick has run a violence prevention program at Boston’s Brigham and Women’s Hospital. The program’s goal is to address broader, community-based health issues and social problems that make people ill or prone to repeated injury from gunshots, stabbings or environmental causes.

In Chadwick’s view, this endeavor — almost from its inception — made a big difference in nearby neighborhoods. But its profile in the eyes of hospital administrators got a boost from an Affordable Care Act provision that required nonprofit hospitals to conduct triennial assessments of local health needs and devise strategies, updated yearly, to address them. Falling short would trigger a financial penalty.

“Everyone, all of a sudden, cares about the social determinants of health,” she said. “Our expertise is being brought in. … We have a bigger seat at the table.”

But will programs like this one continue to get such attention? As the GOP-controlled Congress works to scrap Obamacare, the answer is uncertain.

Requiring this “community health needs assessment” was part of a broader package of rules included in the health law to ensure that nonprofit hospitals justify the tax exemption they receive. Another directive was that these facilities establish public, written policies about financial assistance available for medically necessary and emergency care and that they comply with limits on what patients who qualify for the aid can be charged.

These requirements add to the ongoing controversy about whether all nonprofit hospitals do enough to deserve a tax break. People on one side of the issue view the assessment rule, for instance, as an undue, unfunded burden while others say it doesn’t do enough. So far, though, the community health assessment requirement hasn’t exactly been a hot topic in the repeal-and-replace debate and was not addressed by the House Republicans’ health plan unveiled March 6.

Sen. Chuck Grassley (R.-Iowa), who has long urged that more scrutiny be applied to nonprofit hospitals’ tax status, championed the provision. His spokeswoman said he will continue to advocate that it remains in effect in whatever new health policy plans emerge. Regardless, the financial uncertainty of any overhaul of the health law could undermine some hospitals’ efforts.

The decades-old nonprofit tax status, granted by the Internal Revenue Service to institutions that meet the “community benefit” standard, spares hospitals from paying federal taxes and is collectively worth billions of dollars. Nonprofit hospitals have generally cited the uncompensated or “charity” care they provide, as well as initiatives they undertake to promote public health, as sufficient proof that they earn their tax exemption. But for-profit hospitals, which do pay taxes, cry foul, saying they make similar contributions.

The new requirements overall were meant to hold nonprofits to a higher standard — and penalize those that didn’t deliver. Under the law, hospitals that fail to complete the assessment and implementation strategy face a $50,000 fine — which can seem small next to their overall operating budgets. But down the line, the penalties can accumulate and ultimately could jeopardize their valuable tax exemption.

Meanwhile, federal data show that as recently as 2011 nonprofit hospitals targeted less than 10 percent of their operating expenses to benefit the community — this includes charity care, unreimbursed costs from Medicaid and other government programs and medical research and education. Less than 1 percent went to community health improvement services like Chadwick’s.

Advocates hoped the health law would change this. The idea was to push nonprofit hospitals to invest more in public health initiatives that do not directly earn them money — giving such programs more value on the balance sheet. But it’s hard to gauge whether that’s happened.

“You can find hospitals that have done this. But … are we seeing a real shift in the hospital community? Or are these a few hospitals that are outliers?” said Gary Young, director of the Center for Health Policy and Healthcare Research at Northeastern University. “We’ve asked them to make a sea change in how they’re doing things. And that can’t happen overnight.”


Part of the problem, analysts say, is that the underlying idea — reaching into the community to help people navigate the social and economic factors that can influence health — goes beyond what hospitals have traditionally viewed as their mission. Despite the potential for long-term payoff, administrators tend to focus on the immediate questions: How many beds are full? What medical services are being provided? How are they doing with their operating budget?

“It’s a new world out there in terms of the hospital not being the center of the universe,” said Lawrence Massa, president of the Minnesota Hospital Association, the state’s hospital trade group, which has been tracking hospital response to the health assessment requirement.

Initially, they found the money nonprofit hospitals put toward “community needs” went up after the assessment requirement: from about $355 million in 2011 to $459 million in 2013, according to an analysis by the association. (The needs assessment requirement took effect in between, for the tax year starting after March 2012.) But the increase leveled off in 2014 — the most recent year for which data are available.

Massa’s conclusion: Caring for the health of people before they come into the hospital is unfamiliar territory. Not everyone took naturally to it. “We saw some communities that embraced this, and did a nice job. … In other communities, there’s been friction between public health and the acute setting — and lack of understanding.”

With continued time and sustained emphasis, that could have changed, said Sara Rosenbaum, a professor of health law and policy at George Washington University.

But now? Even if the community benefit requirements remain intact, she and others fear this accountability effort could take a hit. Repeal of the health care law is likely to create fresh financial challenges for hospitals. For instance, although the House GOP’s American Health Care Act would restore some of the uncompensated-care funding cuts hospitals absorbed under the ACA, the coverage changes proposed in Republicans’ plan could mean tens of millions more uninsured people.

That scenario, policy experts and trade groups say, would increase the amount of free care nonprofit hospitals provide, creating new budget pressures that could lead them to tamp down on efforts to promote community health work.

“We could be right back in a situation where there is a fair amount of charity care, and that could become a large component of how hospitals are justifying their nonprofit status,” said Ken Fawcett, a physician who runs a community health worker initiative at Spectrum Health in Grand Rapids, Mich.

Meanwhile, the health assessment’s impact has been evident at Boston-based Massachusetts General Hospital. There, administrators used it to devise an intervention strategy around drug abuse — partnering, for instance, with local schools and community organizations, and hiring former addicts to help patients navigate recovery.

“There’s no question the Affordable Care Act required us to bump up our game,” said Joan Quinlan, its vice president for community health. If people lose coverage, she added, hospitals will increasingly argue that’s enough reason for a tax break. It could stifle efforts to promote more substantial community benefit.

“If the ranks of the uninsured or underinsured grow, then charity care will increase. And the ability to do some of these more creative downstream efforts will be hampered,” she said. “There might be heightened awareness. But if there aren’t resources to address them, it’s going to be hard.”


Shift to value-based care must include medical training


The new  emphasis on value-based care, managing populations and chronic diseases means that medical education must be reimagined.

A panel of physicians gathered during a morning session at the SXSW Conference  in Austin to discuss the need to redesign medical curriculum. That starts with a realization that “the competencies physicians need to be good healthcare providers and leaders are different now than they were 10 or 20 years ago,” said Susan Cox, M.D., executive vice dean for academics, chair, department of medical education, Dell Medical School, at the University of Texas at Austin.

Among the needed changes:

  • More and more patients need to know how much something will cost and physicians must provide them with this information, including offering them information on finding cheaper treatments.
  • Medical students need to be educated   about health insurance, underinsured versus uninsured, co-pays, and co-insurance and must be able to inform  patients on comparative values.
  • The students need to embrace shared decision-making. Greater interaction between providers and patients is required to adequately manage  conditions.
  • Finally,  much more emphasis should be placed on  training future physicians to address the  broad-based health challenges of their communities, including working with social-service and other nonmedical organizations.

To read a piece on this in Hospitals & Health Networks, please hit this link.

Tips for redesigning alternative payment model


An article in the American Journal of Accountable Care sets forth some principles for successful redesign of alternative payment models, based on past and current payment reforms. The idea, of course, is to achieve better care and lower spending and make physicians’ lives easier.

Three of the suggestions are:


Focus more resources  on higher-value care.  The fee-for-service system does not address the lack of payment for many high-value services that could address patient needs at lower costs. These would include payers supporting patient education and self-management support for patients with chronic conditions  in order to avoid hospitalizations/rehospitalizations.

Hold physicians accountable only for the cost and quality  matters they can control.

Reduce administrative cost and regulatory burdens.


To read the article, please hit this link.

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