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Fitch sees Feds as greatest threat to for-profit hospitals’ earnings

Steward becomes largest for-profit hospital chain


Boston-based Steward Health has become America’s largest for-profit hospital operator. It now owns and operates a total of 36 hospitals in 10 states, with 1,400 physicians and 4,700 physicians in an integrated network.

It reached this status with the completion of  its acquisition of ISASIS Healthcare last week.

Steward Health didn’t disclose the cost of the deal, but Boston Business Journal reported that Medical Properties Trust contributed $1.4 billion of the $1.9 billion purchase of the acquired hospital’s real estate that was in the agreement.

T0 read more, please hit this link.



Senate bill would extend telehealth benefits to several Medicare populations battling chronic illnesses

Telehealth blood-pressure monitor.

Lawmakers and telehealth advocates have lauded  the  U.S. Senate’s passage of bipartisan legislation to extend telehealth benefits to several patient populations battling chronic illnesses.

After another failed attempt to repeal the Affordable Care Act, the Senate has unanimously passed the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017.

The measure would let Medicare Accountable Care Organizations expand the use of telehealth, build broader telehealth benefits into Medicare Advantage plans and expand virtual care for stroke and dialysis patients.

“The CHRONIC Care Act will mean more care at home and less in institutions. It will expand the use of lifesaving technology,” Sen. Ron Wyden (D-Ore.), said on the Senate floor before the vote. “It places a stronger focus on primary care. It gives seniors, however they get Medicare, more tools and options to receive care specifically targeted to address their chronic illnesses and keep them healthy. Those are all important steps forward in updating the Medicare guarantee.”

To read more, please hit this link.


Community health centers anxiously await congressional rescue



For Kaiser Health News

One community health center in New York has frozen hiring. Another in Missouri can’t get a bank loan to expand.

The nation’s 1,400 community health centers are carefully watching expenses in case the financial rescue they hope Congress delivers very soon doesn’t arrive. With four days left in the government’s fiscal year, Congress has not voted on reauthorizing billions of dollars now going to community health centers and other health programs for the 2018 budget year that starts Sunday.

“The anxiety level is increasing on almost a daily basis,” said Dan Hawkins, senior vice president of the National Association of Community Health Centers (NACHC) in Washington, D.C. “There is broad support and agreement in Congress that it should get done, but we are working against a ticking clock and a crowded legislative calendar.”

For the past two weeks, the GOP’s scramble to repeal the Affordable Care Act before the month ends pushed other healthcare matters off the congressional agenda. That effort ended Tuesday when Senate Republicans said they would not seek a vote this week because they lacked enough support to pass the bill.

It’s not clear if lawmakers’ lighter agenda will now leave room for funding health centers or deciding other issues, such as renewing the Children’s Health Insurance Program (CHIP), which also expires Sept. 30. At a hearing Sept. 25,  Senate Finance Committee Chairman Orrin Hatch (R.-Utah) urged his colleagues to work with the Senate’s health committee to settle the matter. NACHC officials privately express optimism that a deal might come later in October if not by Sunday.

Community health centers operate in more than 9,500 locations, serving 27 million people, according to the NACHC. They are the main source of healthcare for many low-income Americans — and the only source of primary care in many underserved areas.

Health centers provide preventive care, counseling, dentistry and primary care to everyone, whether or not they can pay. A sliding fee scale based on income and family size is available to patients without insurance.

In 2015, nearly 1 in 6 Medicaid beneficiaries received health-center services, the Kaiser Family Foundation reported this year. (Kaiser Health News is an editorially independent program of the foundation.)

“The end result is these are people who will be locked out of health care” without new funding, Hawkins said.

Community health centers gained billions of dollars in federal revenue under the ACA, which created a special trust fund to support them from 2011 through 2015. The Community Health Center Fund was extended in 2015 for two years with an additional $3.6 billion annually.

That money represents 70 percent of all federal grants to health centers and about a fifth of their annual revenue. Medicaid reimbursements account for the largest share, about 40 percent.

One beneficiary is Pamela Richardson, a 60-year-old patient of Valley Community Healthcare,in North Hollywood, Calif., who suffers from an iron- absorption disorder called hereditary hemochromatosis. She was unable to get health insurance before Obamacare prohibited insurers from excluding people with preexisting medical conditions. The clinic helped her sign up for coverage through the Medi-Cal expansion.

Once Richardson was covered, she received long-delayed primary care, which revealed she had “scary high” blood pressure and a lump in one breast (which proved benign). “When you don’t have insurance you don’t get breast exams. You don’t have Pap smears,” she told a KHN reporter earlier this year. “I wish people had a little more patience with Obamacare. Once you get what’s wrong with you under control, the cost would come down.”

California has by far the most federally funded health centers and they serve 6.2 million Californians, according to CaliforniaHealth+ Advocates, which represents state clinics. They have received over $1.6 billion from 2011 through 2016 from the Community Health Center Fund, more than any other state, the Congressional Research Service reported in January.

If health centers receive no new funds for 2018, the ensuing financial crunch would cost 51,000 jobs, force the centers to close 2,800 locations and cause 9 million people to lose healthcare services, according to a budget document that the Health and Human Services Department gave Congress in July.

Uncertainty about what Congress will do now is already causing problems. Hawkins said his members call him and his staff every day, fretting about employment contracts, lease agreements and equipment rentals that run past Oct. 1.

Neighborhood Health in Nashville, Tenn., has federal grant money that will carry it through Jan. 31, but CEO Mary Bufwack said some of her 180 staff members live paycheck to paycheck and are getting nervous about Neighborhood’s stability.

Bufwack is worried the health center won’t receive money it needs to replace a clinic, a project now being planned.

She fears that a new doctor she recruited to join Neighborhood next June will take another job before she can get his signature on an employment contract. And she doesn’t want to do that until she’s sure about her budget.

Mostly, she worries that whatever Congress gives her will be only for one year.

“We’re already worried about next Sept. 30,” Bufwack said.

Future hospitals to go to patients


Photo by Oxyman

Anders Wold,  CEO of GE Healthcare Clinical Care Solutions,  writes in Med City News about how the hospital of the future will go to patients. Among his observations:

“{H}ealthcare is breaking down traditional hospital walls, and it’s not just the developed world leading this disruption. Indeed, the healthcare model for billions of people in the developing world has always been different. Lacking the massive and complicated hospital infrastructure of other regions, medical care in many parts of the world travels to the patient in the form of a visit from a local doctor or a stop at a rural clinic.

“This ‘last mile of care’ – where the hospital finds the patient, not the other way around – is made possible as medical innovation across the globe becomes increasingly mobile, digital, personal and accessible.”

“While most acute care will continue to take place inside brick-and-mortar medical facilities, future generations will likely receive care virtually, and participate in their own care to greater degrees. For instance, subtle stick-on monitors that look like digital Band-Aids are being developed right now to help doctors remotely monitor key vital signs, from heart rate and blood pressure to sweat and oxygen levels.”

To read his full essay, please hit this link.

Progressives, conservatives on future healthcare steps

Kent Bottles, M.D., talks with healthcare analysts to see what might next, afterthe collapse of the Graham-Cassidy. Dr. Bottles is a lecturer at the Thomas Jefferson University School of Population Health, in Philadelphia, and chief medical officer of PYA Analytics.  He writes that Congress is unlikely to take on healthcare in the next few months. But it’s worth  looking at the healthcare agendas of progressives and conservatives going forward.

He writes in Hospital Impact:

“Progressives are committed to protecting the Affordable Care Act and extending healthcare coverage to all Americans. There is not consensus about how to accomplish this goal:

  • “Some are advocating for ‘Midlife Medicare,’ which would be open to citizens ages 50 to 64.”
  • “Sen. Brian Schatz (D.-Hawaii), has proposed a bill that would extend the Medicaid program to all who wanted to seek coverage under that program.”
  • “Sen. Bernie Sanders (I.-Vt.)  has garnered support from many mainstream Democratic senators for a ‘Medicare for all’ measure.”
  • “Others think that expanding Medicaid, providing coverage for immigrants, fixing the ACA family glitch and extending CHIP are the best ways to go.”

“Since many conservatives do not think the federal government should play any role in healthcare, opposition to the ACA is easier than coming up with a replacement solution. Leading conservative experts do not agree on what to do next:

  • “Michael Cannon of the Cato Institute still thinks repealing the ACA is the only way to go.”
  • “Avik Roy of the Foundation for Research on Equal Opportunity would favor a system similar to Switzerland’s with universal coverage through private insurance and subsidization, but no individual mandate, per the article.”
  • “Doug Holtz-Eakin of the American Action Forum would focus on changing the delivery system to decrease cost and not concentrate on insurance coverage.”
  • “Sen. Ted Cruz (R.-Texas) has proposed allowing insurers to sell non-ACA-compliant plans in any given state as long as they sell at least one ACA-compliant plan there.”

To read more, please hit this link.




New EHR system lets rural health system boost population-health oversight


Hospitals & Health Networks reports on how Coteau des Prairies Health Care System, in South Dakota,  improved its population-health capabilities by fixing its EHR system

The 25-bed acute care system, based in Sisseton, had  “limited staff, burdensome administrative tasks and low satisfaction among providers and patients,” H&HN reported. But a new CEO, Michael Coyle,  started by bringing on a new leadership team and looking at various departments.

“His team asked staff and one another a number of questions: Are there standard operational procedures? Did patients trust the staff? What was the culture like at Coteau des Prairies? And did everyone in the system smile?

“During their review, Coyle and his team heard concerns again and again about the electronic health record system in place. One member of the staff went as far as to describe it as a ‘rock pile,’ Coyle said. He discovered that the EHR wasn’t set up correctly and wasn’t being used by any providers, and that the data didn’t exist.”

Within six months, Coteau des Prairies had a new EHR.

“Coteau des Prairies now has 100 percent physician usage of its EHR, a percentage that Coyle says he has not achieved in any system he’s worked at before. Provider trust has also improved. Many of the clinicians travel to multiple clinics, and the new system allows for records to be readily accessed across locations.

“The data collected by the new EHR have created a picture of the health needs of the population served by Coteau des Prairies. If any condition is 30 percent higher than the system’s average, Coyle and his team re-evaluate how they’re allocating physician hours across the system.”

To read more, please hit this link.

How some poor communities improved healthcare


The Commonwealth Fund looked at a few U.S. communities that have made progress on a majority of healthcare indicators included in the Commonwealth Fund’s latest “Scorecard on Local Health System Performance.  Interestingly, half were in regions where poverty rates exceed the national average.

It looked at how, for example:

  • “Stockton, the northern California city that filed for bankruptcy after the 2008 housing crash, managed to reduce avoidable hospitalizations, emergency department visits, and readmissions.
  • “Pueblo, a Colorado city where nearly half of the population lives below the poverty line, promotes shared accountability for solving problems.
  • “Paducah, in rural western Kentucky, leveraged Medicaid expansion to meet the primary care needs of newly insured low-income residents.
  • “Akron, Ohio, in the nation’s Rust Belt, has been tackling obesity, infant mortality, and opioid addiction.”

To read more, please hit this link.

Anthem directs imaging exams to independent centers


Looking through an MRI scanner.


For Kaiser Health News

Tightening the screws on pricey imaging exams, health insurer Anthem will no longer allow many patients to get MRIs or CT scans at hospital-owned, outpatient facilities, requiring them to use independent imaging centers instead.

Anthem says the change is aimed at providing high-quality, safe care while reducing medical costs.

But critics say that imposing a blanket rule that gives preference to freestanding imaging centers is at odds with promoting quality and will lead to fragmented care for patients.

“To achieve true value, you have to have high-quality care at a good price,” said Leah Binder, president and CEO of the Leapfrog Group, a nonprofit organization that advocates for improved safety and quality at hospitals. “Anthem would be better off judging the quality of these [imaging] diagnoses” regardless of where they’re provided and setting payment accordingly, she said.

Imaging tests are generally subject to preapproval by Anthem to confirm that they’re medically necessary. Under the new policy, AIM Specialty Health, an Anthem subsidiary, will also evaluate where they should be performed. Doctors who request non-emergency outpatient MRI or CT scans that can be done at an independent imaging center rather than one owned by the hospital will be given a list of centers eligible for patient referrals.

The policy doesn’t apply to mammograms or X-rays.

In rural areas that lack at least two other non-hospital imaging centers, hospital outpatient tests will still be approved.

The new policy could save Anthem enrollees hundreds of dollars per exam, said Lori McLaughlin, Anthem’s communications director.

“There are huge cost disparities for imaging services, depending on where members receive their diagnostic tests,” she said. “Members can save close to $1,000 out-of-pocket for some imaging services for those who haven’t met their deductible and up to $200 for those whose plans require only a copay.”

Hospital imaging is indeed pricier than imaging at freestanding centers. Average prices for MRI and CT scans ranged from 70 percent to 149 percent higher at hospitals, according to an analysis by the Healthcare Financial Management Association, a membership group for health care finance professionals.

But price isn’t the only important variable, and the perception that all imaging studies conducted by qualified providers generally yield comparable results is wrong, Binder said. A study published last year in The Spine Journal, for example, found that when a patient “secret shopper” with low back pain received MRIs at 10 imaging centers, each center reported different findings. Some missed a problem they should have found, while others detected nonexistent problems.

The Anthem policy applies to 4.5 million enrollees in individual and group plans in 13 of the 14 states in which Anthem operates, according to McLaughlin. (Self-funded employers that pay their employees’ claims directly are exempt but can incorporate it if they wish.) The insurer began phasing in the changes in July and expects to finish by March. New Hampshire is the only state without an implementation date, McLaughlin said.

This is Anthem’s second coverage change this year attracting attention. Earlier, the company came under fire for a new policy under which it will no longer pay for emergency department visits that it determines after the fact weren’t emergencies. That decision raised concerns it could discourage people who might need emergency treatment from  seeking care.

Patient advocates and health care providers have also expressed concerns about the new imaging rule’s potential impact on patients.

Cancer patients who often are being treated at cancer centers within hospitals would feel the effect, noted Dr. J. Leonard Lichtenfeld, deputy chief medical officer for the American Cancer Society.

“They have to go to a new outpatient facility, get the film, get it read and transmitted back to the cancer center,” Lichtenfeld said. If, as often happens, the hospital and the imaging center’s computer systems don’t talk to each other, the patient may have to bring the results back to the doctor on a CD. “For that patient who’s in a lot of stress to begin with, it adds another level of stress,” he said.

Dr. Vijay Rao, chair of the department of radiology at Thomas Jefferson University in Philadelphia, said the Anthem policy will create extra effort for hospital radiologists on a patient’s care team, who will need to review and possibly redo the imaging center’s work. Further, relying on a patient to transport the scan so that it can be put into the hospital’s electronic medical record system “leaves lots of room for error,” she said.

Anthem isn’t the only insurer trying to find a way around hospitals’ steeper outpatient imaging costs, said Lea Halim, a senior consultant at the Advisory Board, a health care research and consulting company. The Medicare program is taking steps as well, although its approach doesn’t directly influence patient care in the same way.

In recent years, hospitals have been snapping up independent physician practices, outpatient imaging and testing facilities and then charging Medicare higher hospital outpatient fees for their services. In a bid to equalize payments, in January the Medicare program reduced by 50 percent the amount it pays some hospital-owned outpatient facilities, including imaging centers, that are located away from a hospital’s campus. A further reduction is proposed for 2018.

“So Medicare is doing something that’s in a way very similar to what Anthem’s doing,” Halim said.

4 elements in engaging independent physicians in networks

Jeffrey I. Lasker, M.D., principal consultant of Vision Healthcare Consulting,
discusses four key factors in engaging independent physicians in a network setting. They are, he writes in a NEJM Catalyst blog entry:

“Culture: Fostering a culture of quality involves, above all, respecting physicians’ professional values of self-direction, excellence, and putting patients first — often the drivers of physician behavior and engagement. This respect must be genuine and pervasive. Changing the culture is critical.”

“Trust: Establishing trust is critical for setting expectations in change management. In any kind of organization, you have to develop personal relationships with people to gain their trust. If you’re going to make this work in a network of independent physicians, a lot of relationship building has to happen. To do this, I spent time with physicians in their organizations. I probably knew 300–400 doctors on a first-name basis, and they knew me. If something went wrong, they would call me or others in the organization. They felt that they could be heard, and that what they said mattered.”

“Decision-Making: To support physicians’ values, you must engage them in everything that is done across the network, starting with creating a shared vision and the principles and policies that follow. The majority of our board members were community physicians, and while they mostly focused on high-level strategy, they helped set the principles upon which the organization did business, down to the committee level. There were many times when really tough financial decisions had to be made.”

“Local Infrastructure: To be a successful physician network, you must expect structure and processes at all levels, especially within affiliated practices and local care organizations, because most of the necessary work happens locally. We required each practice and local care organization to have its own structure (such as regular practice meetings), establish a quality improvement team, and appoint a medical director to serve as a liaison with the network. It sounds basic, but if the local infrastructure is not there, you’re toast.”

To read his whole piece, please hit this link.

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