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PCPs have lost quarterback position on hospital patients’ teams

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Stephen C. Schimpff, M.D., writes in Medical Economics:

There is a crisis in primary care and it’s now flowing over into the hospital when a primary care physician’s (PCP) patient is admitted.

 “No longer cared for by the PCP, the role has largely fallen to the hospitalist. There has been a loss of the long time primary care physician-patient relationship and the trust that comes with time. There has been a frequent loss of satisfactory communication when the patient is admitted and again when discharged. At a time when the patient most wants and needs the comfort of a long-time trusted professional friend, the patient instead is confronted with a stranger at the helm. What has happened to create this state of affairs?”

To read all of his remarks, please hit this link.


For better performance management in bundling

 

The American Hospital Association recommends these steps to support performance management in bundling:

  • “Develop a system to identify patients likely to qualify for bundled episodes early and assess their risk for complications, and track their progress through the bundle episode.
  • “Develop multidisciplinary teams, led by physician champions, in the implementation of standard care processes to reduce variations in care to improve patient outcomes and reduce costs.
  • “Develop a high-functioning discharge planning process.
  • “Enhance data analytics and information sharing capabilities.”

Meanwhile, says a piece in Hospitals & Health Networks, Burlington, Mass.-based Lahey Health has partnered with xG Health Solutions,  in Columbia, Md., to help guide it through its bundled-payment adoption, as well as to provide analysis of CMS data from procedures using bundled payments.

Thus Lahey now knows the analytics of where and when  patients get care within 90-days after discharge,  when patients visit  emergency departments, and whether they’re  readmitted to the hospital other than at Lahey. This information helps to identify patterns the knowledge of which can be used to improve care quality.

The H&HN piece reports:

”{D}ata showed patients participating in the total joint {replacement} bundle were being readmitted with wound infections. After assessing various options, the hospital adopted seven-day dressings, which reduced infections and enhanced patient and staff satisfaction by eliminating multiple dressing changes per day while in-house and associated hospital readmissions post-discharge.”

And:

“One of the keys to success under the bundled-payment model is developing ongoing communication with other providers within the community. Bringing together representatives from the hospital, including physicians, along with home health, acute rehab, and skilled-nursing providers, has helped build trust and understanding of what role each group serves.”

But ”it is critical that physicians have dedicated time to focus on process improvement initiatives under bundled payment.”

To read more, please hit this link.

 


U.S. healthcare: A lot of spending for a few

 

In  a reminder of how  so much of U.S. healthcare resources are spent on a relatively small number of chronically ill people,  and  on older people at the end of life, read a new article in Health Affairs, whose abstract is:

“The distribution of healthcare expenditures remains highly concentrated, but most Americans use few healthcare resources and have low out-of-pocket spending. More than 93 percent of ‘low spenders’ (those in the bottom half of the population) believe they have received all needed care in a timely manner. The low spending by the majority of the population has remained almost unchanged during the thirty-seven-year period examined.”

To read the whole article, please hit this link.


Study: VA hospitals generally do better for patients than civilian ones

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Department of Veterans Affairs hospitals generally outperformed other hospitals in most categories in the quality metrics used in the federal government’s Hospital Compare rankings, write Northwestern University researchers in an article in JAMA Internal Medicine.

Compared with 4,010 non-VA hospitals, the 129 VA institutions had lower 30-day mortality and readmission rates in all categories, and did better in six of nine patient-safety indicators (and no worse in the other three).

However, metrics for  physician and nurse communication, noise, pain management and clinical responsiveness were generally worse in the VA hospitals than in the civilian ones.

To read the JAMA article, please hit this link.


Using hospital-satellite emergency departments to reduce strain on hospitals

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Most hospital emergency departments seem to get busier and more crowded each year, placing ever-greater strains on patients and clinicians. Ricardo Martinez, M.D., suggests that hospital-satellite emergency departments (HSEDs) can offer considerable relief.

He writes in Hospital Impact that they “provide a more distributed access model of emergency care that can be integrated into the healthcare system to relieve the strain on existing EDs and bring emergency care closer to patients.

“HSEDs are structurally separate from a hospital, but offer patients emergency services that are equal to or surpass those at hospital-based facilities. The acuity levels for patients seen in HSEDs are similar to those seen at hospital-based EDs as well (broken bones, burns, chest pain, abdominal pain, pulmonary symptoms, head traumas and concussions). In short, when it comes to treatment, there is little to no difference between the two types, but HSEDs have the ability to provide more accessible and a greater value of care.

“Having multiple HSEDs throughout local communities expands access to emergency medical care for more patients, including those who live far from a centralized hospital system. This type of medical delivery system is already implemented with decentralized imaging centers, laboratories and urgent care centers.”

To read more, please hit this link.


Care New England wants Partners to acquire it

 

Rhode Island’s Care New England hospital system wants to be acquired by Greater Boston’s Partners HealthCare, which includes such famed institutions as Massachusetts General Hospital and Brigham and Women’s Hospital.  CNE’s plan is to  sell off Memorial Hospital, in Pawtucket, R.I., as part of being acquired. Ohio-based Prime Healthcare would buy Memorial.

Because of Massachusetts state regulators’ concerns about Partners’ pricing power, that system has found it difficult to expand more in Greater Boston.

CNE’s  current units are:

“Today’s announcement represents the positive results of an extremely careful and deliberate process intended to ensure the best clinical, financial, and strategic direction forward for CNE,” said board Chairman Charles R. Reppucci, in a release. “While we are taking the first steps in this process, we do so with the utmost optimism and dedication to ensuring the successful completion of this affiliation with Partners which represents a unique and compelling opportunity in the advancement of Rhode Island healthcare delivery.”

Care New England has struggled financially in recent years and has  long been wanting to merge with another entity.

The system had  a $68.3 million operating loss in fiscal 2016 and a $1.8 million operating loss in fiscal 2015.

CNE has had a  relationship with Partners since 2009 through a clinical affiliation with Brigham and Women’s Hospital. And McLean Hospital, also owned by Partners, has  sometimes worked with Care New England’s Butler Hospital in behavioral health and research.

How such a merger would affect the Alpert  Medical School at Brown University is unknown. Partners has very close links with the Harvard Medical School.

Presumably the acquisition would involve  big golden parachutes for CNE executives.


CMS seeks to adjust readmission penalties to account for duel-eligibles

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The Centers for Medicare & Medicaid Services wants to adjust penalties in its Hospital Readmissions Reduction Program according to a hospital’s proportion of dual-eligible (Medicare and Medicaid) patients — a move long supported by hospital-industry stakeholders.

The proposed rule would take effect in fiscal 2019. In it, the CMS laid out several approaches  for determining   hospitals’ proportion of dually eligible patients and other key metrics.The change stems from the 21st Century Cures Act,  enacted last December. The law required Medicare to consider patient background when calculating payment reductions to hospitals under the Hospital Readmission Reduction Program, and to adjust those penalties based on the proportion of patients  dually eligible for Medicare and Medicaid.

The  Medicare Payment Advisory Commission has reported that while these dual eligibles constituted 18 percent of beneficiaries they accounted for nearly a third of total Medicare fee-for-service spending in 2012.

To read more, please hit this link.

 


Looking for middle ground on the ACA debate

By EMILY LAZAR

For Kaiser Health News

Joel Hay, a professor at the University of Southern California, describes his political views as “conservative, free market.” But in a counterintuitive twist, his proposal to fix the Affordable Care Act would expand the largest source of public health coverage in the country: Medicaid.

Hay, who specializes in health policy and economics, envisions an Obamacare replacement plan that would scrap health insurance exchanges such as Covered California, which sell subsidized private market plans.

Instead, he would allow people under the age of 65 to buy into Medicaid, called Medi-Cal in California. Their premiums would be based on family income and a surcharge would be assessed on those who are uninsured at the time they apply. That would be intended as an incentive to keep them from buying insurance only when they’re sick. People could acquire coverage regardless of preexisting conditions.\

Under Obamacare, 31 states and the District of Columbia expanded Medicaid, the federal-state health care program for people with low incomes. In doing so, they added more than 11 million people to the rolls, including about 3.7 million in California.

Hay believes that the Medicaid expansion was the most successful part of the ACA and contends that the health insurance exchanges have struggled to provide affordable plans with adequate networks in many states.

He said expanding Medicaid further could achieve two important goals: slowing the growing costs of health care, which he said is better achieved by Medicaid than private market plans, and giving all Americans access to at least basic health coverage.

Scrapping the exchanges may not be an easy sell in the Golden State, where Covered California has been lauded as a national model.

Laurel Lucia, director of the health care program at the University of California at Berkeley Center for Labor Research and Education, agrees with Hay that the Medicaid expansion has been a success, but she wonders whether middle class consumers will enroll in Medicaid as readily as private market plans.

California Healthline recently interviewed Hay about his proposal, and Lucia for a contrasting point of view. Their comments, below, have been edited for clarity and length.


 

Joel Hay proposes scrapping the Obamacare exchanges and building on the expansion of Medicaid instead. (Courtesy of Joel Hay)

Q: Can you provide an overview of your Obamacare replacement plan?

It would build on the successful part of the Affordable Care Act, namely the Medicaid expansion that is responsible for the majority of the increased coverage.

This is how it would work: Below some family income threshold that would be yet to be determined, the cost of getting Medicaid would be zero. Above that, there would be premiums based on family income up to some maximum threshold, where the cost would be something like 10 percent of family income.

People would always have an option of opting out into a private plan if one is available to them. But this is a backup for anybody that doesn’t have other options.

This plan focuses on the two biggest problems in American health care. No. 1: Not everyone has health insurance. No. 2: We have the highest health care costs in the world.

Medicaid is a no-frills health plan available in all states. It’s not perfect, but it works. There are certainly access problems, but it seems to do a much better job, even in some of these rural areas where we’re seeing problems with the health insurance exchanges.

Q: In some states, such as California, the exchanges seem to be working reasonably well. Why lump all exchanges in one basket?

There’s a philosophical issue here. Is competition across health plans the best way to get affordable, basic care to everyone?

Among the majority of people that are reasonably well-educated, middle class or better, have good jobs and in fact maybe get their insurance through their jobs, the competition between insurance plans works reasonably well. But when you go further down the income scale, that’s where the competition doesn’t seem to work.

The Obamacare experience thus far backs that up. A lot of people just don’t seem to be able to get a good plan either because the premiums are skyrocketing or because the narrowing of the coverage options they have is prohibitive.

Q: Would your plan require everyone to have health insurance?

There is no mandatory requirement for having health insurance, but there are penalties if you go without coverage. If you don’t sign up during open enrollment, the only option you can get outside of that window would be this Medicaid option. The longer you delayed getting into it, the higher your monthly premiums would be.

Q: Would subsidized health plans still be offered through exchanges?

No. The subsidies to help people buy into Medicaid should be targeted to making sure everybody has access to essential care. The subsidies would be focused on helping low-income people get into a no-frills Medicaid health plan. The subsidies will phase out at some upper income level.

If you’re earning $96,000 for a family of four, hopefully the private market will generate options for you. But if you have no other option, this would be available to your family at a premium of 10 percent of your family income. That’s going to work out to be something like $10,000. That’s a lot of money, but that’s the problem we have.

Q: What do you mean when you say “that’s the problem we have”?

We’ve reached the point in this country where the average cost of health care per capita is over $10,000, whereas the median family income is only $54,000. A median family of 2.6 people is going to see over half of their income going to health care.

We have to consider other options. Medicaid is cheaper. It gets the lowest price for drugs by law and negotiates vigorously to get extremely low prices for medical services, hospitalizations, doctors. If you can get your health care through Medicaid, the cost per every unit of service is lower.

Q: Can the already-stressed Medi-Cal program {California’s Medicaid program} handle millions more enrollees?

It’s better than what has been demonstrated in the private health insurance exchanges under Obamacare. In Medicaid, people may have to travel long distances for specialty care, although some of those things can be overcome with telemedicine and other mechanisms. But we’ve seen pretty much a collapse of the private markets to handle people in rural, hard-to-reach places. Yet Medicaid has provided care to people in every state, including in every one of these remote access areas. It’s not perfect. Rural health care access is never going to be perfect.

Q: You have mentioned block grant funding of Medicaid as part of your proposal. That is what Congressional Republicans have been pushing to reduce federal spending on the program. How can you do that and significantly expand Medicaid at the same time?

I certainly wouldn’t want to hang the whole program on whether or not it’s block-granted. The argument in favor of block granting is if you give a certain amount of money per-capita to the states, it’s up to them to allocate the resources efficiently and effectively to provide the highest quality of care. If you continue with the current funding approach for Medicaid, the states have 50 percent or less of the responsibility for how the dollars are spent and so they’re not going to work as effectively to control costs and quality.

Some people on the far right want to actually destroy Medicaid. They think by block granting Medicaid, they can eventually make it go away. That’s not my goal here. My goal is to provide sufficient federal funds to make this thing work.

Q: Have you discussed this idea with any lawmakers?

I’m just beginning. What I see so far is that everybody is so polarized, that there really isn’t any movement in the middle. I’ve presented this to left-wing academics, and they say what they want to do is push through single payer, even if it’s only in California. They’re just not interested in compromise. I’m sure the same would be true of Tea Party Republicans.

No Death Spiral In Obamacare Exchanges

From Laurel Lucia, University of California at Berkeley Center for Labor Research and Education, health care program director

I agree with the conclusion that the Medicaid expansion has been working really well, especially in California. It’s true that Medicaid costs are lower than the costs to cover an equivalent population with private insurance and that Medicaid costs have been growing more slowly than costs in private insurance.

Q: What do you think of Professor Hay’s idea?

But I disagree with the premise that the individual market components of the ACA are failing. In California, the individual market reforms and subsidies have been working very well, and nationally I’d say they’re mostly working.

In California, we’ve had very high enrollment and we still have significant competition in the individual market. The vast majority of Californians have a choice of at least three insurers through Covered California.

Nationally, millions of people have been newly insured as a result of the individual market subsidies under the ACA. And affordability has improved significantly for low- and middle-income people who don’t have job-based coverage and need to rely on the individual market.

Both nationally and in California, I would not say that the individual market is in a death spiral.

Q: Aren’t there places where premiums have skyrocketed and choices have decreased?

There are places in the United States where much more plan choice is needed. We need to build on the Affordable Care Act reforms in the individual market to ensure greater choices and greater competition, rather than starting from scratch.

Q: It doesn’t seem like the current Congressional leadership wants to build on the ACA.

If there’s bipartisan will to make the ACA work better in terms of the individual market, it’s very possible to do with some policy changes. And in some places, like California, it is already working well.

Q: So why not end subsidized private plans and allow people to buy into Medicaid instead?

It’s an interesting idea to expand upon Medicaid. There is a question of whether middle-class consumers would enroll at the same rate in a Medicaid-type plan as they do in private insurance.

The provider networks in Medicaid are often quite different than those in plans offered through Covered California. Some consumers may be less likely to enroll in Medi-Cal if they have a strong attachment to their provider and that provider is not in the Medi-Cal network or isn’t accepting new Medi-Cal patients.

Q: Would middle-class consumers be less likely to sign up for Medicaid because of a perception or stigma that it’s just for poor people?

I just don’t know how Californians or Americans at higher income levels would perceive a new program like this that builds upon Medicaid.

If you were going to expand Medicaid to a broader population, you would want to make sure that it is adequately funded. One part of Professor Hay’s proposal would fund Medicaid through block grants, which would actually do just the opposite.

Most research has indicated that block-grant funding for Medicaid would result in substantial cuts to federal Medicaid spending over time without resulting in better cost efficiency. The loss of federal funding would force states to make difficult decisions like cutting eligibility, cutting benefits or implementing enrollment caps.

Block-grant funding would not only threaten Medicaid coverage for existing enrollees, but it would also be especially harmful if you were considering expanding the Medicaid population at the same time.

Q: What can be done to moderate health care cost growth, if not through Medicaid?

Cost containment is an important next step in federal health policy and state policy as well. Costs are growing too rapidly, not just in the individual market but also in job-based coverage, but those are trends that started well before the ACA.

They’re not due to the ACA. In fact, since the ACA, private insurance premiums have grown at a slower rate.

But we do need more focus on slowing the rate of cost growth. I think a lot of the barrier there is political. There have been a lot of solutions proposed to reduce costs, for example allowing Medicare to negotiate with drug companies on drug prices. And often Congress doesn’t want to take on the drug industry or the hospital industry or other aspects of the health care industry to reduce costs.

 


Geisinger develops a ‘nursing bundle’ to improve care

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Geisinger Health System has developed a “nursing bundle” to improve and streamline care.

The big nonprofit Pennsylvania/New Jersey system said, in a NEJM Catalyst article:

“Our goal was to develop and adopt a consistent ‘nursing bundle’ across all of our sites. A bundle, as defined by the Institute for Healthcare Improvement, is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices — generally three to five — that, when performed collectively, consistently, and reliably, have been proven to improve patient outcomes. This definition allowed us to focus on the most critical elements of the bundle.”

“We created a team comprising chief nursing officers (CNOs) and key nursing leaders across the system. This team identified evidence-based practices that were proven to provide the best experiential and clinical care outcomes. Each CNO was charged with vetting the best practices and eventual nursing bundle plan with managers and frontline registered nurses. This process assured support, buy-in, and input from all levels within the organization.”

Its lessons so far:

  • “Executive leadership must make patient experience a strategic priority via goal-setting, day-to-day behaviors, and culture.
  • “It is just as important to train the top leadership as to train frontline employees.
  • “Monitoring performance is essential. Ongoing results and progress, monthly and quarterly, are shared with our board, our CEO, all levels of leadership, and fellow employees to track performance and celebrate successes.
  • “We are improving our performance by adding other tools, such as an inpatient welcome letter that helps set expectations by educating patients on the nursing bundle elements and providing photos and contact information for the nursing leaders in each department.”

To read the whole NEJM piece, please hit this link.

 


Why Spectrum Health won award for community health

 

Here’s a look at Spectrum Health’s Healthier Communities Department. It has five sections: its School Health Program; its Partnership Health Care Programs, which provide free or discounted medical care to vulnerable local urban populations;  its Community Partnership Programs for Healthy Food; its Community Partnership Programs to Create Healthy Lifestyles, and its Core Health, a chronic-disease management program for at-risk area residents.

Spectrum Health is a not-for-profit, integrated, managed care  organization based in Grand Rapids, Mich. Spectrum  subsidiaries include hospitals, treatment facilities, urgent-care facilities, as well as physician practices.

In recognition of Healthier Communities’ two decades of outreach services for underserved Western Michigan residents, Spectrum Health was awarded the 2016 Foster G. McGaw Prize for Excellence in Community Service. As the 31st recipient of the prize, sponsored by the Baxter International Foundation, the American Hospital Association and its nonprofit affiliate, the Health Research & Educational Trust,  Spectrum will get $100,000 to expand on its community health efforts.

“Since 1997, Spectrum Health’s Healthier Communities has built the infrastructure, resources, community-based programs and services to reach the people who need care the most,” says John O’Brien, chairman of the Foster G. McGaw Prize Committee. “Through impactful alliances with community organizations, Spectrum Health has shown incredible perseverance, patience and a vision to dramatically improve the health of individuals in their community and reduce health care costs.”

Healthier Communities started 20 years ago with a focus on reducing infant mortality and disparities in maternal-infant health; improving children’s health, and preventing and managing chronic disease among those living in its 13-county service area. Spectrum Health spends $6.8 million each year in the department.

To read more, please hit this link.

 

 


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