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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.


Employers focusing more on the patient experience


A new survey from the National Business Group on Health, an employers organization, has found, in Healthcare Dive’s paraphrase:

  • “Twenty-one percent of respondents plan to encourage use of accountable care organizations and another 26% are considering offering them.
  • “More than half (54%) will offer health centers either on site or nearby.
  • “Nearly nine in 10 (88%) plan to use centers of excellence for specified procedures like transplants or orthopedic surgery to take advantage of bundled payments and other alternative payment models.
  • “Close to 40% employ some type of value-based benefit design that rewards employees for managing chronic conditions or seeking more cost-effective care.’’

“One of the interesting findings from the survey is that employers are focused on enhancing the employee experience,” Brian Marcotte, president and CEO of NBGH said in a written statement. “For example, there is a big increase in the number of employers offering decision support, concierge services and tools to help employees navigate the healthcare system.”

The surveyors found that 66 percent of employers will offer medical-decision support and second-opinion services by 2018, up from 47 percent this year, and 36 percent will offer high-touch concierge services.

To read the survey results, please hit this link.

To read Healthcare Dive’s commentary on it, please hit this link.



What’s needed for future bundled-payment success


A piece in JAMA looks at what would be needed in future expansion of bundled-payments programs.

The authors consider such things as extending bundle durations to a year; the role of bundled-payments programs outside the hospital, especially as efforts intensify to reduce readmissions, and ensuring that Accountable Care Organizations and bundles are adequately integrated and coordinated by aligning incentives and sharing information on shared patients.

The authors conclude

“Expansion of bundled payment for episodes of care is under way. The 3 key innovations in the next generation of bundled payment models (extending the duration of the bundles, expanding the accountable entities beyond hospitals, and integrating bundled payments with global budget models within ACOs) could better align episode-based payment with population health and offer a smoother path to global budgets. Testing bundles nested within overarching collective accountability through bundle-ACO integration is particularly promising. There will be ample opportunity to inform bundle design based on findings from voluntary and mandatory Centers for Medicare & Medicaid Services programs and private insurer initiatives. Innovations in bundled payment design could increase their attractiveness to commercial and public payers alike in the pursuit of higher-value care.”

To read the whole article, please hit this link.

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.

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