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Even worse troubles at Cooper Health System

 

Troubles get more gruesome at southern New Jersey’s corruption-plagued Cooper Health System.


Tense times for hospital CEO’s

 

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Jobless former hospital executive? Severance payments/golden parachutes are a lot higher these days.

Many  hospital chief executives are paying the price of unemployment as the hospital merger mania continues, with, naturally, CEO’s of stand-alone hospitals at the most risk.

One example is Keith Safian, the longtime head of Phelps Memorial Hospital in Sleepy Hollow, N.Y., who lost his job when the hospital joined the larger North Shore-Long Island Jewish Health System in January. Though he remains positive about his future, Safian told Crain’s New York Business:

“There’s a wealth of opportunity [in healthcare]. But not for hospital CEOs.”

Administrative ranks typically feel merger effects more than their clinical counterparts, because as a consultant told Crain’s: “It tends to be the higher-ups where the excess resides.”

 

 


Medicare incentives seen as stingy in first year

 

By JORDAN RAU, for Kaiser Health News

 

Dr. Michael Kitchell initially welcomed the federal government’s new quality incentives for doctors. His medical group in Iowa has always scored better than most in the quality reports that Medicare has provided doctors in recent years, he said.

But when the government launched a new payment system that will soon apply to all physicians who accept Medicare, Kitchell’s McFarland Clinic in Ames didn’t win a bonus. In fact, there are few winners: out of 1,010 large physician groups that the government evaluated, just 14 are getting payment increases this year, according to Medicare. Losers also are scarce. Only 11 groups will be getting reductions for low quality or high spending.

“We performed well, but not enough for the bonus,” said Kitchell, a neurologist. “My sense of disappointment here is really significant. Why even bother?”

Within three years, the Obama administration wants quality of care to be considered in allocating nine of every 10 dollars Medicare pays directly to providers to treat the elderly and disabled. One part of that effort is well underway: revising hospital payments based on excess readmissions, patient satisfaction and other quality measures. Expanding this approach to physicians is touchier, as many are suspicious of the government judging them and reluctant to share performance metrics that Medicare requests.

“Without having any indication that this is improving patient care, they just keep piling on additional requirements,” said Dr. Mark Donnell, an anesthesiologist in Silver City, N.M. Donnell said he only reports a third of the quality measures he is expected to. “So much of what’s done in medicine is only done to meet the requirements,” he said.

The new financial incentive for doctors, called a physician value-based payment modifier, allows the federal government to boost or lower the amount it reimburses doctors based on how they score on quality measures and how much their patients cost Medicare. How doctors rate this year will determine payments for more than 900,000 physicians by 2017.

Medicare is easing doctors into the program, applying it this year only to medical groups with at least 100 health professionals, including doctors, nurses, speech-language pathologists and occupational therapists. Next year the program expands Medicare to groups of 10 or more health professionals. In 2017, all remaining doctors who take Medicare—along with about 360,000 other health professionals—will be included. By early in the next decade, 9 percent of the payments Medicare makes to doctors and other professionals would be at risk under a bill that the House of Representatives passed in March.

The quality metrics used to judge doctors vary by specialty. One test looks at how consistently doctors keep an accurate list of all the drugs patients were taking. Others track the rate of complications after cataract surgery or whether patients received recommended treatments for particular cancers.

There are more than 250 quality measures. Groups and doctors must report a selection —generally nine, which they choose — or else be automatically penalized. This year, 319 large medical groups are having their reimbursements reduced by 1 percent because they did not meet Medicare’s reporting standards.

Physicians who do report their quality data fear the measures are sometimes misguided, usually a hassle and may encourage doctors to avoid poorer and sicker patients, who tend to have more trouble controlling asthma or staying on antidepressants, for instance.

Dr. Leanne Chrisman-Khawam, a primary-care doctor in Cleveland, said many of her patients have difficulty just getting to follow-up appointments, since they must take two or three buses. She said those battling obesity or diabetes are less likely to reform their diets to emphasize fresh foods, which are expensive and less available in poor neighborhoods. “You’re going to link that physician’s payment to that life?” she asked.

Dr. Hamilton Lempert, an emergency room doctor in Cincinnati, criticized one measure that requires him to track how often he follows up with patients with high blood pressure.

“Most everyone’s blood pressure is elevated in the emergency department because they’re anxious,” Lempert said. Another metric encourages testing the heart’s electrical impulses in patients with non-traumatic chest pain, which Lempert said has led emergency rooms to give priority to these cases over more serious ones.

“It’s just very frustrating, the things we have to do to jump through the hoops,” he said.

In their first year doctors are affected by the program, they can choose to forgo bonuses or penalties based on their performance. After that, the program is mandatory. This year, 564 groups opted out, but even if all of them had been included, only 3 percent would have gotten increases and 38 percent would have seen lower payments, mostly for not satisfactorily reporting quality measures, Medicare data show.

Smaller groups and solo practitioners are even less likely to report quality to the government. “The participation rates, even though it’s mandated, are just really low,” said Dr. Alyna Chien, an assistant professor at Harvard Medical School. It’s “a level of analytics that just is not typically built into a doctor’s office.”

Dr. Lisa Bielamowicz, chief medical officer of The Advisory Board, a consulting group, predicted more doctors will start reporting their quality scores when the prospect of fines is greater. “They are not going to motivate until it is absolutely necessary,” she said. “If you look at these small practices, a lot of them just run on a shoestring.”

This year’s assessments of big groups were based on patients seen in 2013. A total of $11 million of the $1.2 billion Medicare pays doctors is being given out as bonuses, which translates to a 5 percent payment increase for those 14 groups getting payment increases this year. That money came from low performers and those that did not report quality measures to Medicare’s satisfaction; they are losing up to 1 percent.

The exact amount any of these groups lose will depend on the number and nature of the services they provide over the year. This year, 268 medical groups were exempted because at least one of their doctors was participating in one of the government’s experiments in providing care differently.

Officials at the Centers for Medicare & Medicaid Services declined to be interviewed about the program but said in a prepared statement that they have been providing all doctors with reports showing their quality and costs. “We hope that this information will provide meaningful and actionable information to physicians so that they may improve the coordination and integration of the healthcare provided to beneficiaries,” the statement said.


Seniors at risk if Calif. coordinated-care program ends

 

This California Healthline asks what happens to frail elderly people if a coordinated-care program ends.


Allures and pitfalls of hospitals becoming insurers

 

Here’s a broad national update on the growing move by providers into the insurance business.

At Premier Health, owned by Catholic Health Initiatives, Mike Maiberger, chief value officer of Premier’s five-hospital system and CEO of its Premier Health Plan, based in Dayton, Ohio, explained  his system’s intentions to Modern Healthcare:

“For us, the insurance business is just a vehicle to cover as many lives as we can in our service area with our population health initiatives.”

Modern Healthcare notes that ”Providers see the financial and quality advantages of controlling premium dollars from beginning to end and steering patients toward their services. It frees them from having to share with insurance companies any savings they generate from improved quality and efficiency.”

But, it can be scary: Once hospitals ”get into product design and pricing and all of the nuanced areas, you can get into trouble reasonably quickly,”  Greg Maddrey, a director at the Chartis Group, a consulting firm, told the magazine.

“As an alternative, some health systems such as UCSF Medical Center in San Francisco are seeking partnerships with insurers,” the publication says.

 

 


Hospital execs’ illogical cost-shifting rhetoric

 

Austin Frakt,  a health economist, goes after the illogic of hospital executives’ assertion that they have to make up reduced reimbursement from Medicaid and Medicare by charging higher prices to insured patients.

”{P}ublic policy that holds or pushes down Medicare and Medicaid prices (or their growth) could put downward pressure on the prices hospitals can charge to all its customers and, in turn, on the premiums we pay to insurers.”

”It’s natural, then, that hospital executives continue to promote the idea of cost shifting. The widespread belief they encourage — that it promotes higher premiums — could foster support for larger public payments. It may be a politically useful argument, but it is an economically flawed one.”


Pitfalls of firing a patient

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This Medical Economics piece look at how to safely and ethically fire a patient. Obviously, there can be big implications for the organizations with which the firing doctors are associated. As the piece notes:

The piece defines “patient abandonment” and explains:

”A myriad of situations might bring about a doctor’s discharge of a patient and termination of the physician-patient relationship. The physician might move, leave the insurance network, or determine that the patient needs the care of a different specialist. The physician also might want to end the relationship due to inappropriate patient conduct such as disruptive or violent behavior; repeatedly missing appointments and/or non-adherence to treatment plans; or refusal to pay for medical services.”

”Physicians must avoid discriminatory practices that are prohibited by law, including refusing to treat or discharge of a patient based upon the patient’s race, nationality, religion, age, sex or sexual orientation.”


At least 2 big reasons for provider-payer disputes

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Herewith a look at how value-based payments and greater price transparency play roles in creating and intensifying provider-payer disputes.

But Becker’s Hospital Review also notes that “The rising tide of health system consolidation may also fuel the trend of provider-payer disputes … because hospitals that join larger systems wield significantly more purchasing power than their standalone counterparts.”


Pushing indigent mentally ill into outpatient treatment

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Early Persian psychiatric treatment.

The Sacramento Bee reports that Sacramento County will spend ”$16 million this year on hospital costs for the severely mentally ill, almost three times more than originally budgeted for care at area hospitals.’

Experts link much of the increase to the greater number of patients showing up because of the expansion of California’s Medicaid program (Medi-Cal) under the Affordable Care Act.

So that jurisdiction, as are many in America, are looking at placing more emphasis on community-based outpatient treatment and less on hospital beds. This suggests more of a focus at improving  other factors besides direct psychiatric care — such as housing and transportati0n — that also affect health and whose shortages drive up medical costs by driving the mentally ill to hospital emergency departments.

“The plan, expected within three months, will include services that help the mentally ill before they reach a full-blown crisis, alternatives for those in a crisis and better assessments to avoid unnecessary hospitalizations,”  The Bee reported.

“Preliminary estimates peg the cost of those services at around $9 million a year, much of which would be offset by federal and state funds and reduced hospitalization costs.”

This is common-sensical. However, at the same time, there’s growing opinion that there should be a revival of hospitals to care for the most severely mentally for the long-term — in the case of some patients, for the rest of their lives. The deinstitutionalization movement has gone too far for some patients and their exhausted families.

The Bee noted that “Efforts to relieve pressure on emergency rooms have led to more psychiatric hospital stays, according to a county staff report.” Not exactly a fiscal triumph for the payers.

The Mental Health Improvement Coalition, which includes area hospitals and nonprofits, said: “The system of behavioral healthcare is fundamentally broken. People in crisis have little option other than to access services through hospital emergency room departments, which are the least conducive environments for behavioral health patients to become well and receive appropriate services.”

 


50 years of Medicare: Personal histories

 

Physicians, including a former CMS administrator, talk about their experiences  dealing with Medicare and look at its future in a MedPage Today series.

Here are remarks by a couple of  the physicians:

Michael Ellis,  M.D., an ENT surgeon connected with Tulane University School of Medicine: “I think Medicare has worked well overall, providing adequate access for good reimbursement. The problem comes from the Medicare allowable charge of 80% of the doctor’s fee, with the doctor having to bill the patient or supplemental insurance for the remainder, which is a lot of paperwork. And for the dually-eligible, we get nothing for Medicaid. The good side is that Medicare is less hassle to deal with than commercial insurers, now that the program here doesn’t require pre-authorization anymore.

“Now there’s talk about paying for quality, as if we have adequate quality measures, which we don’t, and with a big push toward bundled payments, with hospitals divvying up the proceeds.”

“I think more patient knowledge of costs would help, but public information right now about real costs and not just charges is difficult to come by.”

And Peter Hollmann,  M.D.,  chief medical officer of University Medicine, in Providence: “A Medicare Level 4 visit has a fair range of complexity, and this is the area where geriatricians work. So, while the law of averages sort of works out for most physicians, if you’re working at the skewed end, like most geriatricians, there is more marked inequity in reimbursement. Also, because they’re working largely for one insurer, Medicare, geriatricians can’t cost shift among insurers like some other physicians can.

“In general, it will be difficult to address everything that should be for the more complicated patients. Quality measures may prove difficult because there’s no methodology as yet for evaluating individual physicians with any accuracy, and it’s especially difficult with geriatricians, who deal with a wide variety of cases. But it’s a good thing Medicare is looking at quality initiatives; it’s been behind some private insurers moving in this direction.”

 

 


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