By JAY HANCOCK (jhancock@kff.org | @JayHancock1)
Kaiser Health News
Obama administration officials have warned that ambitious experiments run by the health law’s $10 billion innovation lab wouldn’t always be successful. Now there is evidence their caution was well placed.
Only a small minority of community groups getting federal reimbursement to reduce expensive hospital readmissions produced significant results compared with those from sites that weren’t part of the $300 million program, according to partial, early results. The closely watched program is one of many tests to control costs and improve care being run by the Center for Medicare and Medicaid Innovation, which was created by the Affordable Care Act.
Dozens of community agencies on aging, from Ventura County, Calif., to southern Maine were offered money to try to ensure that seniors leaving the hospital received care that reduced their chances of being readmitted within a month.
But an early evaluation found that only four groups out of 48 that were studied in the Community-based Care Transition Program significantly cut readmissions compared with those of a control group.
At the same time, 29 groups have either withdrawn from the program or been terminated by the Department of Health and Human Services for failing to achieve targets, agency officials said. The CCTP project, which has grown since the evaluation was done, now has 72 participating sites that administration officials hope will still produce readmission reductions and lessons in post-hospital care in return for the investment.
The evaluation, produced under contract with HHS by consulting firm Econometrica, is one of the first independent analyses of an innovation-lab test to be made public. It is dated May 30, 2014, but was posted on HHS’s Web site Jan. 2.
The 111-page report notwithstanding, experts said it’s too soon to pronounce substantial judgment on CCTP.
“It’s really too early to tell,” said Ellen Lukens, who leads the practice on hospital and post-hospital care at Avalere Health, a consulting firm. “Can you really evaluate this when it’s been such a short period of time?”
A five-year experiment, the program signed its first round of deals with community agencies in late 2011 and its fifth and last round in March 2013. Econometrica’s report covered partial-2012 results from groups participating in the early rounds, including some for which only a few months of data were available. Congress required the lab to closely monitor all tests, which explains the early evaluation, experts said.
One positive note was that “a lot of the sites were able to implement the program very quickly,” Lukens said, adding that later data will give a better idea of CCTP’s effectiveness.
The readmissions result — less than one site in 10 significantly reducing them — “seems kind of wimpy,” said Eric Coleman, a professor at the University of Colorado whose previous work on care for discharged patients influenced the CCTP program. He said he remains optimistic about the tests, however, also noting that the results are early and praising HHS for cutting off nonperforming groups.
“This is really the first glance of the first two waves of the program,” said HHS spokesman Raymond Thorn. “It’s too early to determine whether this model is failing or not. We will have successes.”
CCTP is one of dozens of experiments being run by HHS’s innovation lab, which has a 10-year, $10 billion budget. Preventable readmissions are calculated to cost the Medicare program for seniors $17 billion a year.
Paying community agencies to work with hospitals was thought to be one potential way of reducing them. Rather than getting grants, agencies are paid according to the discharge cases they handle.
The program faces several challenges, experts said. In awarding funding, HHS favored groups working with hospitals with high readmission rates, perhaps making success more difficult.
Plus, numerous groups and hospitals are working to cut readmissions through other means. That increases competition for aging agencies trying to make their mark and raises the difficulty of measuring their results separately from those of other programs.
Readmissions have been dropping nationally since Medicare began penalizing hospitals in late 2012 if they have too many. Some CCTP groups reduced readmissions — but so did comparison hospitals. That means the system improved overall in those areas and money was saved, but statistically the aging agencies did not show up as the critical factor.
Coleman faulted HHS for requiring agencies to file detailed reports on care models and administration rather than letting them focus on the main job.
“If it doesn’t reduce readmissions it’s game over, so why do you want all these process measures?” he said. “If we want these sites to succeed we need to get out of their way.”
Originally more than 100 agencies agreed to participate. But 29, including New York Methodist Hospital and Pennsylvania’s Delaware County Office of Services for the Aging, have withdrawn or didn’t have contracts renewed because they missed readmission-reduction or enrollment targets, HHS said.
The health-law innovation program also includes Accountable Care Organizations to cut costs and improve care quality; tests giving more resources to primary-care doctors to coordinate care; and innovation awards for promising models to improve Medicare efficiency.
Administration officials like to compare the lab to a venture-capital fund, in which many investments are expected to fail but a few succeed spectacularly. Many Republicans think it’s a waste.
As Pierre Bogacz, managing director at HFA Partners, told Modern Healthcare, the situation makes hospitals “better-suited for a 10- to 15-year bank loan {for information technology} than for a bond issuance with a 30-year amortization schedule {for new building projects.”
Fierce Healthcare cites as an example the University of Minnesota’s new Ambulatory Care Center, which ”’eschews traditional offices in favor of a choice of different work settings that include ‘places where various providers and caregivers can interact,”’ says a recent Healthcare Design Magazine article.
But how much time in their already long days do these groups to have in which to “interact” more?
Fierce Healthcare reports: ”These ‘collaboration spaces,’ in the center of each clinic and intended to host interactions with patients, are in contrast to the ‘touchdown spaces’ that line the perimeter of the building and provide a place for staff to engage in more focused work outside of clinic hours, the article states.”
And the Gates Vascular Institute, in Buffalo, N.Y., has what it calls “collision zones” outside of operating rooms and laboratories that encourage doctors and researchers to sit down and compare notes, FierceHealthcare previously reported. ”Another innovative design idea comes from Owensboro Health Regional Hospital, in Kentucky, which renovated to place its heart center and operating rooms on the floor directly above the emergency department to speed up patient transfers.”
But many workers find that they don’t like open office space because of the noise and lack of privacy. Indeed, we suspect that most people, from the broom pusher on up, would prefer private offices.
In any event, the new focus on outpatient care makes a lot of sense, given how healthcare in general and reimbursement in particular are going.
It’s interesting that population-health management is still so low considering the inexorable move to risk contracts. The execs are just trying to get through the year, and many will be retired by the time that risk contracts became the major game in town.
Within financial challenges, hospital CEOs ranked Medicaid reimbursement, bad debt and decreasing inpatient volume as their top concerns.
Perhaps surprisingly, Fierce Healthcare noted, “Of all financial concerns, emergency department (ED) overuse was ranked lowest, despite reports that the implementation of the Affordable Care Act has led to an influx of ED visits.”
This might be a growth area.
The Affordable Care Act raised the financial incentives that employers can offer workers for participating in workplace wellness programs and achieving measureable results. People talk about the Nanny State but this is also about the Nanny Company seeking to cuts its insurance costs.
“Wellness-or-else is the trend,” workplace consultant Jon Robison of Salveo Partners told Reuters.
Reuters also noted that “Incentives typically take the form of cash payments or reductions in employee deductibles. Penalties include higher premiums and lower company contributions for out-of-pocket health costs.”
Still, as Reuters notes, “But there is almost no evidence that workplace wellness programs significantly reduce those costs. That’s why the financial penalties are so important to companies, critics and researchers say. They boost corporate profits by levying fines that outweigh any savings from wellness programs.”
“There seems little question that you can make wellness programs save money with high enough penalties that essentially shift more healthcare costs to workers,” said health policy expert Larry Levitt of the Kaiser Family Foundation.
“Thicket of the Mind” (archival inkjet print), by TERRY GIPS, in his show at Galatea Fine Art, Boston, Feb. 4-28.
He says, in his gallery notes:
I have been making art about tangled complexities; the process is like playing a
game of chess between order and chaos, knowing and not knowing, remembering and
forgetting. I sometimes use grids to structure the chaos, wildness and randomness
found in nature. And I take notice of the parallels between these natural entanglements
and those of the mind and the brain and hope that perhaps through these images I
can catch a glimpse of the 500 trillion synapses, and the dendrites, axons, and
nodes in my brain and nervous system.
Thirteen percent of all U.S. health systems now offer insurance in one or more market.
The report says that special circumstances explain the success of the few health systems that have succeeded — such as Intermountain Healthcare, Geisinger and the University of Pittsburgh Medical Center.