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The decline of clinical network management offerings


According to a new report by Chilmark Research, fewer companies are offering clinical network management (CNM) solutions.

Those that do have such solutions have moved from a “build it and they will come” approach to the question “can it help and at what cost?” Chilmark says.

Healthcare Dive summarizes the report’s conclusions: “Provider organizations will develop CMN capability if it supports broader business or clinical goals such as Accountable Care Organizations, quality improvement programs, population health management or referrals management.’’

The report notes that the CMS’s focus on advanced payment (valued-based) models will further push providers to invest in technology to improve data interoperability and allow coordinated care among different provider networks.

With more and more provider mergers and other partnerships, the need for networks to easily communicate with each another grows. So EHR vendors  support more open platforms for data sharing. But widespread standards are needed for interoperability to reach the goals set by providers, regulators and policymakers.

To read the Chilmark report, please hit this link.

To read the Healthcare Dive analysis, please hit this link.


Focus on high-cost patients is challenged


The mantra for the last few years among many healthcare policymakers has been the need to focus on high-cost patients when looking at ways to slow  healthcare costs. But in an article in the New England Journal of Medicine, the authors argue for taking a broader approach, especially for those in such relatively new payment models as Accountable Care Organizations.

J. Michael McWilliams, M.D., a professor of health policy and medicine at Harvard Medical School, and Aaron L. Schwartz, Ph.D., a health economist at Harvard, write that more care coordination is essential and say that because system-wide changes may have varying cost structures, focusing on a specific patient  group might not be very effective in cutting overall system costs.

Among examples  they give of areas for cost-cutting not involving a patient-group-centered approach, they suggest developing  preferred networks of specialists or e-consulting systems that reduce unneeded referrals. They also said that providers could launch decision-support programs to cut the number 0f unneeded tests or prescriptions and improve triage to divert patients from emergency departments to outpatient clinics.

 To read their article, please hit this link.

Psychological safety and physician teams

Jessica Wisdom, Ph.D., and Henry Wei, M.D.,   writing about a project they did at  Google, discuss the importance of psychological safety in physician teams.

They note at the start that “Physicians may enter training drawn to the autonomy of medicine, but effective health care delivery — particularly in the era of Accountable Care Organizations and patient-centered medical homes — will likely be driven by effective teams, not individuals working solo.”

“But what is the secret to creating an effective team? Over two years, Google conducted 200+ interviews and a series of analyses of over 250 attributes to understand what drives team performance. What emerges is not the who, but the how: the attributes of the team members matter less than how the members interact, structure their work, and view their contributions.”

“For healthcare, this may mean that individual clinicians’ technical excellence is necessary, but insufficient to improve team-driven patient outcomes.”

“We’ve learned that there are five key dynamics that set successful teams apart from other teams at Google:

  1. Psychological safety: Can team members take risks by sharing ideas and suggestions without feeling insecure or embarrassed? Do team members feel supported, or do they feel as if other team members try to undermine them deliberately?
  2. “Dependability: Can each team member count on the others to perform their job tasks effectively? When team members ask one another for something to be done, will it be? Can they depend on fellow teammates when they need help?
  3. “Structure & clarity: Are roles, responsibilities, and individual accountability on the team clear?
  4. “Meaning of work: Is the team working toward a goal that is personally important for each member? Does work give team members a sense of personal and professional fulfillment?
  5. “Impact of work: Does the team fundamentally believe that the work they’re doing matters? Do they feel their work matters for a higher-order goal?”

“It may surprise people to learn that psychological safety is the most important of these five dynamics by far. In fact, it’s the underpinning of the other four.”

In their piece, they outline six steps to improve team performance and psychological safety

To read their piece, please hit this link.


CIGNA head touts ACOs


David Cordani, CEO of the giant CIGNA insuror, says its health plans under the Affordable Care Act work best when they are connected with the networks of physicians and hospitals  in Accountable Care Organizations, The Hartford Courant reported.

He wouldn’t comment on what might happen next as the Republicans start the process of killing the ACA

To read The Courant’s article, please hit this link.

Vermont’s all-payer healthcare hopes


The Vermont State Seal in a stained glass window in the State House.

Governing magazine has looked at Vermont’s development of  an all-payer healthcare system, which CMG has reported on before.

In this approach, the publication says,  ”{i}nstead of billing doctors for each service they provide, insurers in Vermont will now give them a fixed sum each month, along with bonuses for keeping patients healthy. (Doctors can also pay penalties for adverse health effects, like having a high number of patients getting readmitted to the hospital within 30 days.) The hope is to eliminate unnecessary procedures, reduce costs and elicit more positive health outcomes.”

“In the 1970s, a dozen or so states tried all-payer systems for their hospitals. Except for Maryland, they all eventually shifted back to the standard fee-for-service because there was little evidence that all-payer was actually reducing overall health-care spending.”

“All of those states, however, only applied all-payer to hospitals — leaving out a large portion of health-care providers and limiting its potential impact.”

“Vermont’s system will cover all providers — hospitals, primary care, specialists, urgent care clinics, you name it. And instead of the state paying the providers their monthly fixed sum, it will be up to accountable care organizations (ACOs), which are groups of providers that have the same goals as all-payer: to reduce spending by rewarding better, not more, care.”

But there will be big challenges to making this work.

To read the Governing piece, please hit this link.

Nursing homes stressed as move to value-based reimbursement intensifies

In a new report, Stackpole Associates has commented on and summarized  data  that the nursing-home industry has been avoiding for several years.
Of particular interest to Cambridge Management Group is the effect on nursing homes of moving from volume to value, since CMG has been spending a lot of time in helping clients do that in recent years.
 Among Stackpole’s observations:

“Declining demand in long-term care markets is not a popular topic, but the inaugural SNF {skilled nursing facility} report from the National Investment Center for Seniors Housing & Care (NIC) clearly shows this trend. The occupancy rates in long-term care markets have been dropping, and in the SNF category, occupancy fell from just under 85% in October 2011 to 82.8% in December 2015, according to NIC. The decline in occupancy in this specific long-term care market would have been worse if owners and operators had not been removing capacity (taking beds off-line) from the system progressively over the same period of time. When both the number of beds is declining, and occupancy is decreasing, how can this be described as anything but a late mature, early declining market?”

“The biggest single factor in the decline in demand in the long-term care markets is the Demographic Dip or Birth Dearth. Demographics are like gravity; you can learn to work with it, but you can’t deny it.”

We at CMG take issue with part of Stackpole’s  remarks below. The implication  that nursing homes will only be available for rich people is not correct.    Strong skilled nursing facilities are emerging in the Medicaid sector.

“Compounding the challenges of declining long-term care markets, are the initiatives by CMS and … managed care organizations to reduce utilization, and ‘squeeze out’ margin in the sector. The transition from volume-based payments to value-based payments through such mechanisms as Accountable Care Organizations (ACOs) and Bundled Payment for Care Improvement (BPCI) are laudable and needed, but these will have devastating effects on the sector. The shift from volume to value will benefit the strongest (i.e., SNFs with the best quality payor mix) and disproportionately hurt SNFs serving the most vulnerable populations in our society. As intermediaries and value-based payment initiatives reduce utilization, and margin from the sector, the weakest will be forced to either close or merge with other, bigger and stronger systems.”


A Swedish model for coordinating care of elderly people with complex needs


Images of Jönköping County.

A case study published by the Commonwealth Fund discusses Sweden’s “Esther Model” of caring for elderly patients with complex needs.

The authors note, by way of introduction:

“Elderly patients with complex care needs may receive services from multiple specialists, as well as primary care physicians. In addition, they may visit emergency departments, have frequent hospitalizations and post-hospital rehabilitations, and receive long-term care services at their home or in nursing facilities. Jönköping County, in Sweden ,focused on improving care coordination and the experiences of elderly patients through the ‘Esther Model.”‘

“The Esther model began in the late 1990s, originally as a three-year project. Founder Mats Bojestig, then head of the medical department of Höglandet Hospital, in Nässjö, used the negative experiences of an elderly patient, known as ‘Esther,’ as inspiration.”

As for its value as an example for America, the researchers write:

“The Esther Model developed as a voluntary collaborative effort in a small region that allowed for face-to-face meetings among all care-providing organizations. It is difficult to envision the model exported in its entirety to more complex settings. Nevertheless, many of its strategies are applicable well beyond a subregion of a Swedish county. In fact, cousins of the Esther approach are now operating elsewhere in Sweden, and replication is occurring in locations in other countries as well.

“The problems that the Esther model addresses certainly exist in the United States, where the care chain involves multiple provider organizations and payers with conflicting financial incentives. Establishing Esther or a similar model in the U.S. might be most feasible in places where single organizations are responsible for multiple levels of care or where hospitals serve reasonably well-defined geographic regions. Mechanisms that consolidate economic and medical responsibilities for patients, like accountable care organizations, would likely facilitate adoption of the model, as would financial incentives that deter practices that are harmful to patients and wasteful of resources, like unnecessary hospital readmissions. Adoption also might be aided by continuing to survey patients and caregivers about the care they are receiving.”

To read the (fascinating) study, please hit this link.

CMS to let providers set pace to move to value-based payments


The tortoise and the hare.

The Centers for Medicare & Medicaid Services has  announced that it   will let providers choose the level and speed at which they comply with the new payment-reform model  that emphasizes the medical value/outcomes of patient care over the volume of procedures. In the current, predominately “fee for service” system, the more procedures that providers order, the more they get paid. That is one reason that America’s physicians are by far the highest paid in the world.

Healthcare industry stakeholders have put the CMS under intense pressure  to ease implementation of the Medicare Access and CHIP Reauthorization Act, which is set to start Jan. 1, 2017. Two months ago, CMS Acting Administrator Andy Slavitt said the agency was considering delaying the start date.

And so eligible physicians and other clinicians next year will be given four options to comply with  such new payment schemes such as the Merit-based Incentive Payment System (MIPS) or an alternative payment model (APM), such as Accountable Care Organizations.

Modern Healthcare reported that under MIPS, physician payments “will be based on a compilation of quality measures and the use of electronic health records. About 90 percent of physicians are expected to pursue MIPS because a qualifying APM requires a hefty amount of risk.

“In the first option offered Sept. 8, any data reported will allow providers to avoid a negative payment adjustment. The goal is to ease providers into broader participation in the following two years, ” the publication reported.

The second option lets providers  submit data for a reduced number of days. “This means their first performance period could begin later than Jan. 1 and that practice could still qualify for a small payment if it submits data on how the practice is using technology and how it’s improving,” Modern Healthcare reported.

The third option is for practices that are ready to go in 2017.

To read the Modern Healthcare story, please hit this link.



Study: Non-ACO hospitals sometimes do better than ACO ones


A  study in the American Journal of Managed Care indicates that hospitals that participate in an Accountable Care Organization don’t necessarily  perform better that non-ACO peers in all Medicare value-based programs.

Here are three key study findings, as summarized by Becker’s Hospital Review.

1. “Between 2013 and 2016, hospitals in ACOs performed better than non-ACO hospitals in CMS’s Hospital Readmissions Reduction Program by a factor of 0.72.

2. ”During the same period, non-ACO hospitals outperformed hospital ACOs in Hospital Value-Based Purchasing and Hospital-Acquired Condition Reduction programs by a statistical significance factor of 0.001. When researchers adjusted for specific hospital attributes, such as number of beds, ownership and teaching status, non-ACO hospitals fared better by a factor of 0.62 for the HVBP program and 0.28 for the HACR program.

3. ”’Despite similar goals, hospital participation in an ACO is not correlated with improved performance in all Medicare VBP programs,’ the study concluded.”

To read the American Journal of Managed Care study, please hit this link. To read the Becker’s summary, please this link.

Burwell calls Fort Dodge, Iowa, community-health model


Downtown Fort Dodge.

Sylvia Burwell, the U.S. secretary of health and human services, has hailed Fort Dodge, Iowa (pop. 25,000), as a model for improving community health.

That’s in large part because Fort Dodge’s branch of the Des Moines, Iowa-based UnityPoint Health System also hosts one of the first Accountable Care Organizations in the country. The ACO work that healthcare providers have done in Fort Dodge makes it one of the nation’s best examples of how to improve health while curbing costs.

The Des Moines Register reports that Ms. Burwell visited Fort Dodge on July 14 to hear local physicians, nurses and patients about successes in healthcare. “We know that folks are depending on us to make more progress on affordability and on quality. I’m here to visit today one of the great models of people accelerating the change that the rest of the nation needs to do,” the paper reported.

The Register said  that  Fort Dodge’s ACO is particularly  unusual among other early ones because it has  at least broken even financially. Ms. Burwell cited the  collaboration among healthcare providers and a range of community agencies for the success.

For the full article from The Register, please hit this link.

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