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Mo. hospitals focus on patient poverty in CMS readmissions penalties

May 27, 2016by Robert Whitcomb in Uncategorized tagged , , , , , , , , ,

revolving door

 

By LISA GILLESPIE

For Kaiser Health News

Christian Hospital says its costly difference of opinion with Medicare hinges on how to count the large number of poor people that the St. Louis hospital treats.

Medicare penalizes hospitals that readmit too many patients within 30 days of discharge, and Christian expects to lose almost $600,000 in reimbursements this year, hospital officials said. Christian is one of 14 hospitals in the BJC HealthCare System.

Steven Lipstein, chief executive of BJC, which includes Barnes-Jewish Hospital in St. Louis, said Medicare doesn’t play fair because its formula for setting penalties does not factor in patients with socioeconomic disadvantages — low-income, poor health habits and chronic illnesses for instance — that contribute to repeated hospitalizations.

If Medicare did that, Christian’s penalty would have been $140,000, Lipstein said.

As every hospital executive knows, half a million dollars pays for “a whole lot of nurses.”

In total, hospitals around the country lost $420 million last year under Medicare’s Hospital Readmissions Reduction Program, an initiative of the federal health law that seeks to push hospitals to deliver better patient care.

Since the program began in 2012, “recent trends in readmissions suggest that (it) is having the desired impact,” Health Affairs reported in January.

Hospitals have lobbied Congress and Medicare to change the rules and gained some ground May 18 when Rep. Patrick Tiberi, R-Ohio, introduced a bill in the House to adjust Medicare’s program to account for socioeconomic status. The bill was co-sponsored by Rep. Jim McDermott,  D.-Wash.

Meanwhile, the Missouri Hospital Association is trying to pull public opinion behind it.

This year, the association overhauled its consumer Web site, Focus On Hospitals, to include not only the federal readmissions data, but also each member’s readmissions statistics, adjusted for patients’ Medicaid status and neighborhood poverty rates.

The federal government already adjusts its readmissions data for age, past medical history and other diseases or conditions, and that’s public on Medicare’s Hospital Compare Web site.

The association explains its adjustment methodology in an article on the site. “There is emerging national research that suggest poverty and other community factors increase the likelihood a patient will have an unplanned admission to the hospital within 30 days of discharge,” it states.

The hospital group’s alternative data — Lipstein’s source for how Christian could have reduced its 2015 penalty — comes from a study it commissioned. One finding: Missouri hospitals’ readmissions rates improved by 43 to 88 percent when patients’ poverty levels were considered.

“The question is, has [readjustment] been done in a just and fair way,” Lipstein said. The Missouri Hospital Association “has provided methodology that suggests what the Feds are doing is unfair.”

The controversy over penalties is likely to grow beyond the readmissions question. Federal health officials have announced that they want to shift from paying doctors and hospitals based on the services they provide and move toward a value-based system that encourages a better quality of care and better outcomes while controlling costs.

Medicare bases penalties on readmissions on the care of Medicare patients who were originally hospitalized for one of these five conditions — heart attacks, heart failure, pneumonia, chronic lung problems and elective hip or knee replacements.

This year, Medicare penalized almost half of all hospitals — 2,592 to be exact — for excessive readmissions. More than 500 were fined 1 percent of their Medicare payments, or more, for the fiscal year that will end Sept. 30.

Still, the system harms so-called safety-net hospitals most, said Herb Kuhn, the Missouri Hospital Association’s president.

“Hospitals in difficult neighborhoods are getting worse scores, and those in affluent [ones] are getting better. It’s time to adjust [rates] for the disease of poverty,” he said.

Kuhn’s experience makes him an influential voice on health-policy issues. He was deputy administrator of the Centers for Medicare & Medicaid Services from 2006 to 2009 and before that, director of the agency’s Center for Medicare Management. In April, Kuhn completed a three-year term on the Medicare Payment Advisory Commission, which advises Congress.

The commission proposed an alternative to Medicare’s readmission penalties last year. Others are also studying modifications.

The Centers for Medicare & Medicaid Services has taken a cautious stance, but last year CMS announced it is working with the National Quality Forum, a nonprofit group whose research influences CMS’s quality metrics, on a trial to test socioeconomic risk adjustment.

But Leah Binder, CEO of the Leapfrog Group, a nonprofit patient safety group, says Medicare’s readmission penalties have pushed hospitals to improve care and adjusting the data for patients’ poverty levels could deter them.

“Hospitals are paid a lot of money. I think they can find a way to handle their readmissions, the way they should have been handling them all along,” Binder said.

Here’s the latest in CMS’s hospital-rating saga

May 19, 2016by Robert Whitcomb in Uncategorized tagged , , , , , , , , , ,

blueribbon

By JORDAN RAU

For Kaiser Health News

Over the past decade, the federal government has publicized 115 different ways to measure medical quality in hospitals, from assessing wait times in emergency rooms and noise levels outside hospital rooms to tracking blood clots in surgical patients. But the latest effort, to combine dozens of metrics into one patient-friendly quality indicator, has proven the most contentious.

The Centers for Medicare & Medicaid Services recently postponed its plan to release the new rating system, which would award one star to the worst-quality facilities and five stars to those with the best marks. The delay came after a majority of members of Congress signed a letter supporting the hospital industry’s concerns.

Hospital leaders who previewed the preliminary rating system say that the formula seems skewed against institutions that treat the poorest or toughest patients, meaning those with complex illnesses. The number of stars would be based on 64 different measures, which are posted on Medicare’s Hospital Compare Web site. The metrics on mortality, readmission, patient experience and patient safety are the most influential, each representing 22 percent of a facility’s rating.

Steven Lipstein, president of BJC HealthCare, a St. Louis-based nonprofit that runs 14 hospitals, said the ones in his organization that earned five stars were smaller, located in affluent areas and handled less complicated cases. “They don’t have comprehensive cancer centers, they don’t have major cardiovascular disease, they don’t have neuro-specialties,” he said.

BJC’s more advanced hospitals did worse, he said. “That’s not surprising when you look inside the ratings and see how they’re built,” he added.

Consumer advocates defend the rating system, saying that while not perfect, it correctly reflects higher rates of problems in some big institutions despite their lofty reputations. They worry that delay and congressional resistance are undermining Medicare’s attempt to help consumers select a hospital based on something more substantive.

“The star ratings hopefully will get quality into that decision-making process,” said Andrew Scholnick, a lobbyist for AARP, the advocacy group for seniors.

Medicare officials initially said they hoped to release the ratings to the public in July. But in a presentation to hospitals and other interested parties on May  12, they did not set a firm date.

Medicare already has made minor tweaks in the formula to calculate the stars, but it remains a tough grader, the presentation shows. If Medicare releases the star ratings in July, nearly half of the 3,658 hospitals being evaluated would be getting three stars, according to Medicare’s preliminary calculations. Just 100 hospitals would receive five stars, while 135 would receive a single star.

Officials indicated they were standing firm in their intention to eventually release the scores. “The Overall Star Rating represents a performance summary designed to facilitate patient and consumer use of Hospital Compare,” the presentation said. Officials plan to update the scores every three months through the end of this year and then twice thereafter.

The broader debate about the government judging hospitals has been going on since Medicare began publishing quality ratings in 2005. But it has intensified since passage of the Affordable Care Act, which instructed Medicare to use quality metrics in setting payments.

Teaching hospitals as a group have tended to fare poorly from some of these financial incentives. This year, for instance, nearly half of major teaching hospitals are losing 1 percent of their Medicare payments because of high rates of infections and surgical complications. Facilities with more low-income patients, who often face difficulties affording medication, following complicated recovery instructions and getting to doctors regularly, typically have higher readmission rates.

Some health care researchers are also skeptical. “If you come out with a rating that says Cleveland Clinic is terrible but podunk hospital in North Carolina, they’re the bomb, there’s a disconnect,” said Ashish K. Jha, a professor at Harvard’s public health school. “If it completely contradicts everything you’ve known, you need to ask yourself, ‘Did I not understand the way hospital care works, or is there a problem with the metric?’”

Medicare’s move toward using star ratings is part of a greater focus on easy-to-grasp composite judgments of hospital quality. The Leapfrog Group, a nonprofit patient-safety group, uses report-card letter grades to characterize hospital safety based on many of the same individual measures as Medicare. Healthgrades, a Denver-based company, judges hospital quality with one, three or five stars. Consumer Reports calculates a safety score on a 100-point scale.

Medicare hopes that a star rating from the government will carry even more credibility.

“People need this information now,” Scholnick said. “Trying to wait until everyone’s 100 percent happy with everything just delays it further than it needs to be.”

Study links patient-centric care and stronger hospital finances

May 12, 2016by Robert Whitcomb in Uncategorized tagged ,

 

Patient-centric care may well improve the operating margins and revenues of hospitals, says this Accenture study.

The report studied six years of hospital margin data reported for the Centers for Medicare & Medicaid Services and compared it with patient experiences recorded in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The analysis found that hospitals that performed the best on HCAHPS had net margins  an average of 50 percent higher than those with average ratings. The correlation between higher margins and positive patient experiences was recorded across all types of hospitals.

 

Senators urge delay in star standards release

April 12, 2016by Robert Whitcomb in Uncategorized tagged ,

 

The Centers for Medicare & Medicaid Services is  scheduled to reveal overall star ratings for hospital quality on April 21, but 60 senators have urged the agency to delay the release amid concerns about allegedly incomplete and misleading data. It is unknown how much of this call for delay is due to political pressures from hospitals in the senators’ home states.

In a letter to Acting CMS Administrator Andy Slavitt, the senators say that flawed quality measures can cause wide variations between CMS’s quality ratings and other reports.

The senators added: “It is clear that additional time is necessary for hospitals and stakeholders to thoroughly review the data and understand the impact of the current methodology to ensure the validity and accuracy of the information before it is publicly released,” the letter states.

They also expressed concerns that the ratings methodology didn’t properly include providers that treat low-income or disadvantaged patients.

 

The star ratings and the methodology used for them have long been a source of controversy.

Hospitals trying to revamp care via community health workers

April 11, 2016by Robert Whitcomb in Uncategorized tagged , , , , , , ,

 

By SHAFALI LUTHRA

For Kaiser Health News

BALTIMORE

Donnie Missouri, 58, doesn’t have medical training. He started his health career in the linens department in Johns Hopkins Hospital. Now, he works on the front lines — one of the hospital’s non-medical workers who reaches out to patients who doctors think are at risk of suffering setbacks that will force them to return.

One recent day at the end of March, he visited Vincent Berry, a 28-year-old man who’s paralyzed from the waist down, a condition resulting from a years-ago gunshot wound after a drug deal went sour. Berry’s doing well medically, but he lives with his aging grandmother, in the upstairs bedroom of a narrow apartment where he relies on help from friends and family to be able to leave. Missouri has been trying to help him secure independent, wheelchair-accessible housing that will make it possible for him go to school or pursue other activities that might move his life forward.

Right now, “I can’t get out and go to school every day,” Berry said, adding that he just tries to make the best of everything. “I just — I know I want to be in a house. It doesn’t have to be the best house.”

Missouri’s goal is to connect people like Berry with resources like housing, transportation and other government benefits — factors that influence health but aren’t the doctor’s focus.

What’s Missouri’s secret? It’s a combination, he says, of building rapport, meeting patients at home and, most importantly, understanding the challenges — medical and not — his neighbors face.  “You have to know your community,” he said of the East Baltimore neighborhood where he lives and works. “If you don’t … it ain’t going to work.”

What Missouri does is hardly a novel concept. For decades, community health workers have tried to fill the system’s gaps. Often hired by the local health department, they take on diverse public health initiatives — running diabetes or nutrition education programs, counseling patients to stick to their medication regimens or teaching new mothers about vaccinations.

But now, hospitals across the country are turning to them in a bid to revamp patient care. They are using these aides to strengthen their relationships with patients and surrounding neighborhoods — improving the community’s health and, along the way, their own finances.

Part of it is spurred by the 2010 federal health reform, which introduced a number of changes in how Medicare pays hospitals.

Similar efforts are underway on the state level, through Medicaid payments and health insurance regulations. Health insurers, too, are starting to show interest in figuring out how they might pay for these services.

“We need to do things differently than what we had been before,” said Ken Fawcett, a physician and the vice president of the community health worker initiative at Spectrum Health in Grand Rapids, Mich. “People are starting to recognize there are non-health care related variables that have a profound impact.”

Challenges persist, though, in figuring out how to finance community health worker programs and regulate the growing workforce.

How It’s Done

Preliminary research suggests health systems are seeing returns on these investments. Patients stay healthier. Fewer are readmitted. That reduces how much expensive, often-not-profitable care hospitals need to give, yielding a financial payoff.

“Because of this new policy environment, health care systems are going to be held accountable” for people’s health, said Shreya Kangovi, an assistant professor at the University of Pennsylvania’s Perelman School of Medicine, who directs its center for community health workers.

The American Hospital Association doesn’t systematically track how many health systems have launched community health worker programs. It’s becoming “much more common,” said Ken Anderson, chief operating officer of the hospital trade group’s Health Research and Education Trust. “This area of interest seems to be very much front and center for hospitals.”

Community health workers are often uniquely positioned to help their clients — the hospital patients.

Frequently, workers have had similar life experiences — maybe addiction, navigating the criminal justice system or simply facing difficulties gaining access to care or other neighborhood’s challenges — so they can connect with patients in ways doctors and nurses don’t, said Scott Berkowitz, Johns Hopkins’ senior medical director for accountable care.

For Missouri, that’s invaluable. When visiting patients, he avoids business clothes that might render him unapproachable, opting for a shirt and lanyard showing he’s from Hopkins, but also jeans and brown walking shoes. He jokes with Berry’s grandmother, and recognizes his dog. After fist-bumping Berry goodbye — they’ll check in later by phone, they confirm — he can cross the street to his next client, a woman with substance abuse problems. He’s a recovering addict himself.

How do programs work? Take the University of Pennsylvania’s Perelman School. Community health workers — who are full-time hospital employees — are assigned patients. They assess patients’ needs and develop relationships spanning months. An early study of the program found patients who participate are less likely to keep returning to the hospital and have better outcomes.

Penn is betting these efforts will ultimately mean savings, so it’s investing upfront: funding the program through its own operating expenses. Some health systems are using grants from private foundations or the federal Centers for Medicare & Medicaid Services to get started. New York Presbyterian Hospital, affiliated with Columbia University, started its community health worker pilot a decade ago, using grant funding. Since then, program leaders have convinced the hospital not only to pay for the program but to expand it, citing healthier, more satisfied patients.

Hopkins got a federal grant from the Center for Medicare & Medicaid Innovation to launch its program in 2012. The funding is ending this year, but it is planning to continue anyway.

In Maryland, the state has taken steps to reform hospital payments — rewarding health systems for keeping patients healthy enough that they don’t need hospital treatment. That adds financial incentives for Hopkins and other hospitals, encouraging them to use strategies such as outreach by community health workers.

Federal policies also add appeal. The University of Maryland Medical Center, in West Baltimore, for instance, started its community health worker project last year after it was penalized by Medicare for failing to meet national standards regarding how many patients it readmitted within 30 days of discharge.

The hospital’s seen readmissions drop by about half, said Zina Kendell, the program’s manager, but the program doesn’t save enough to offset the cost of running it. Still, the hospital is looking into expanding it, said Charles Callahan, vice president for  population health. “We have a model we believe in,” Kendell said.

Meanwhile, state and federal regulators are grappling with how to set standards for community health workers’ training and certification.

More than 20 states have instituted regulations or created oversight committees, according to Sharon Moffatt, interim executive director of the Association of State and Territorial Health Officials.

But there’s no consensus on the best level of scrutiny for community health workers.

Take background checks, an idea that “comes up all the time,” said Carl Rush, who heads the Project on Community Health Worker Policy & Practice at the Institute for Health Policy at the University of Texas Health Science Center at Houston.

Though well-intentioned, that standard can be counterproductive, he said. “There is a legitimate argument to be made that people who have exposure with the corrections system or criminal justice generally are better-equipped to work with people” coming through community programs.

Institutions like Penn and Hopkins train workers before sending them into the field. But Missouri, the Hopkins community health worker, said knowing the city, its resources and residents matters most.

“A lot of people sit in their office and talk about how they’re all about community,” he said. “[But] when’s the last time you got into it and found out how your community works?”

Warning to hospitals on CMS joint-replacement rules

April 8, 2016by Robert Whitcomb in Uncategorized tagged , , , ,

 

hip

A new analysis by Avalere Health discussed in MedPage Today warns that most hospitals involved in Medicare’s new hip- and knee-replacement model would suffer financial penalties if they failed to cut care costs.
“Historically, hospitals focused on what’s happening within the four walls of their institution,” said Josh Seidman of Avalere Health, but much of patients’ costs occur after a procedure is completed and the Centers for Medicare & Medicaid Services (CMS) recognizes this.

In July, 2015, CMS announced the Comprehensive Care for Joint Replacement (CJR) model, which orders 800 hospitals in 67 metropolitan areas to bundle payments for joint replacements in the lower extremities over a 90-day “episode of care.” Avalere estimates that 60 percent of hospitals would face penalties under the new model. The new rule is a “wake up call” for hospitals who had adopted a wait-and-see approach to payment reform, Seidman  said.
Unlike past demonstrations, which were voluntary, hospitals in these randomly chosen regions must adhere to the new program and its rules.

Using  the CMS Public Use File, Mr. Seidman compared hospitals’ current costs across the full spectrum of care and projected where hospitals would rank using the benchmarks set by the new rule.

MedPage reported that “Some hospitals have prepared for changes in payment by developing new or deeper relationships with post-acute care providers, by focusing on both patient and information flow across the care continuum and by creating new ways to improve care management, Seidman noted.”

Using data to help home healthcare workers

March 9, 2016by Robert Whitcomb in Uncategorized tagged ,

By JULIE APPLEBY

For Kaiser Health News

BALTIMORE

There is little in Ruby’s life that is easy. Nearly blind and unable to walk more than a step or two, the 39-year-old struggles to raise three sons while dealing with a daunting array of health conditions, from diabetes that recently landed her in the hospital to pain from bulging spinal disks.

Without support, odds are she’ll end up back in a hospital. But Ruby, who asked that her last name not be used to protect her family’s privacy, is part of a growing effort to reduce those odds by arming home care aides and other non-medical workers with the power of data.

On a recent Monday, health coach Nhaomie Douyon visited Ruby in the small, rented two-story row house where she lives with her children. Douyon works for the Coordinating Center, a Maryland-based nonprofit that helps organize medical and social needs for clients like Ruby, who live in designated medically underserved areas.

The two chatted in the living room, where a couch and chairs share the space with a bed. White curtains obscure the view outside, where small groups of young people cluster on front steps and some homes have boarded-up windows. Douyon, 28, came equipped with a tablet loaded with a software program that uses predictive analytics to generate patient-specific questions.

The software was developed by Care at Hand, a privately held firm that is among a small but growing number of companies touting products they say can help spot potential medical problems before they require hospitalization. The software was created for use by non-medical workers like Douyon and home-care aides who care for millions of elderly, ill or disabled people.

Skeptics note that there are few studies confirming whether the technology accurately predicts problems, prevents hospitalizations or saves money. Still, the business has attracted the attention of venture capitalists and may lead to more healthcare applications for consumers.

Was Ruby having trouble paying for her medications? Did she feel nauseous? Were her ankles more swollen today? Those were some of the 15 questions the program that Douyon’s agency uses generated for Ruby.
“It’s like bringing a pocket nurse Chris with you,” said Douyon, who is also studying for a master’s degree in public health and has previously worked for groups doing health outreach in Ghana and Haiti. When she typed in Ruby’s answer that her ankles and legs were definitely more swollen, it triggered an alert to the nurse manager back at her office.

Within a few minutes, nurse Chris Parsons called from the Coordinating Center’s headquarters, asked more questions and directed the pair to contact Ruby’s doctor’s office for medicine that might help. Try to elevate your feet, she told Ruby, and go to the emergency room if the swelling gets worse.

“It doesn’t just go through medical questions but asks about resources they might need and helps us pick up on certain red flags or the barriers they face,” she said of the tablet.

Another firm, eCaring, is aimed more squarely at home-care aides and their agencies. The company’s software allows aides to note a patient’s well-being hour by hour, using colorful icons, such as a toothbrush for recording personal-care activities and a happy or sad face for documenting their mental state. It, too, uses the information to predict which patients might be at high risk and send an alert back to a care manager.

“It’s a portrait of what is going on in the home,” said Robert Herzog, CEO and founder of eCaring, a privately held firm that has contracted with home-care agencies in New York to use its software programs. “It transforms the home from a black box into a data-rich environment.”

Other firms, such as Honor in California and Hometeam in New York, offer more consumer-directed services, such as apps that home-care aides use to log their daily observations. The companies have each drawn low, double-digit million dollar funding from well-known venture capitalists, including Marc Andreessen, a cofounder of the Silicon Valley venture-capital firm Andreesen Horowitz, Yelp co-founder and CEO Jeremy Stoppelman, and emerging technology investor Lux Capital. The apps help families hire and schedule home-care aides, and then keep the family informed about how mom is doing with texts, pictures and updates on daily activities.

One big question is who will pay for the technology? Agencies using programs aimed at consumers can build the cost into their home-care services, charging consumers more than agencies that didn’t use the technology. Herzog at eCaring says that his firm pays for the tablets and gets a low-cost data package for internet use — which the tablets require — from Verizon. It then builds those costs into its contracts with hospitals or insurers. The Coordinating Center, which uses Care at Hand in Baltimore and other locations in Maryland, similarly builds those costs into its contracts. It also receives grant money from the state and other agencies for its care coordination efforts.

Thomas Scully, the former top administrator at the Centers for Medicare & Medicaid Services and now a a lawyer who advises clients on healthcare issues and a general partner in a private investment firm, said the idea behind these firms is good. But, he added, their growth potential may be limited because the expense of the tablets and software will make the home-care services more expensive. “All of this is part of the answer, but it has to show economic savings,” said Scully.

CMS: Ahead of pay-for-performance goal

March 4, 2016by Robert Whitcomb in Uncategorized tagged , , , ,

 

Obama administration officials said Thursday  that they were almost a year ahead of their target to change how Medicare pays hundreds of billions of dollars to providers each year.

The Centers for Medicare &  Medicaid Services has sought to make  30 percent of its payments to clinicians and hospitals  be on the basis of the quality of care they provide, rather than the quantity, by the end of 2016, with the aim of hitting 50 percent by 2018.

Patrick Conway, M.D., the chief  CMS medical officer,  said Thursday that the 30 percent goal had been met as of January 2016. The agency estimated  that about  $117 billion out of a projected $380 billion  in Medicare fee-for-service payments for the year were going to providers  participating in pay-for-performance programs.

Article: Physicians, not payers, should develop cancer-care ‘pathways’

February 10, 2016by Robert Whitcomb in Uncategorized tagged , ,

 

path

This piece in JAMA Oncology says that physicians — not payers — should be in charge of designing cancer-care “pathways” to save money and, hopefully, improve care.

Payers are  looking to cancer care to test payment-reform initiatives.

Blase N. Polite, M.D., Ray D. Page, D.O.,  and Chadi Nabhan, M.D. noted mounting evidence that using oncology pathways can reduce spending on chemotherapy patients.

But they argued that clinicians, not payers, should be in charge of developing oncology pathways while noting that a completely unregulated pathway environment would be ”ineffective at best and unnecessarily burdensome at worst.”

Thus they propose the creation of flexible criteria similar to what the Centers for Medicare & Medicaid Services uses for its Qualified Clinical Data Registry Reporting, with various stakeholders–including payers, physicians and patient advocates–determining  criteria. If a pathway meets threshold criteria, all public and private payers would be required to accept it.

 

Restore hospitals’ continuity of care

January 27, 2016by Robert Whitcomb in Uncategorized tagged , ,

 

redflag

Murray Epstein, M.D., writes that it’s time to restore continuity of care in U.S. hospitals.

“I wish to unfurl a red flag, a challenge to the legions of bureaucrats who hover under the umbrella of the Centers for Medicare & Medicaid Services and other agencies governed by the Department of Health and Human Services. Rather than focusing on electronic medical records, and expending hundreds of hours honing and refining penalties and dictums for physicians who have transgressed for slight ‘errors,’ I recommend that you expend time and energy developing a viable algorithm that is readily comprehended for ensuring continuity of clinical care.

“When a patient is asked to name his or her physician in charge, and the response is a blank stare, a deafening silence, or a long list of names, we must recognize that the patient care model currently espoused is broken, and no ACGME dictate will resolve this problem. I suggest that we reach out to the Institute of Medicine, which I regard with great esteem, to become involved and prioritize this problem as one of the key issues to solve in an accelerated timeline.”

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