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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.


Making the most of boards’ immersion days’

 

immerse

 

Hospitals & Health Networks looks at how “Immersion Day” gives hospital boards a  very  close-up look at these institutions. This piece focuses on Mission Health, a community hospital system in western North Carolina.

Among the observations:

“Perhaps counter-intuitively, it seems that once board members understand {after participating in Immersion Day} how complicated the delivery of care is today, they come to appreciate even more the skill and expertise of management — and to leave operations to the management team.

“The benefit of immersion for boards seems to be the focus it brings to strategic planning, the experience and authority it gives to board members when they advocate for the system, and the bonding that forms between board and management as both face the stress and rapid change of modern care delivery.’’

“Here are some of the best practices followed by Richard Bock, M.D., of Immersion Advisors in Asheville, N.C., when he conducts an Immersion Day program:

  • “Meets with health system leadership to understand their goals.
  • “Drafts immersion plans tailored to the institution.
  • “Meets with the system’s chief medical officer to refine the plans.
  • “Individualizes standard HIPAA releases and other agreements as needed.
  • “Communicates directly with medical staff and nursing leadership ahead of time.
  • “On Immersion Day, prepares, orients and accompanies participants in all hospital areas.
  • “Conducts debriefings afterward.
  • “Optionally arranges end-of-day discussions with the CEO and other key leaders — particularly valuable for policymaker immersions.”

To read more, please hit this link.

 

mission

The main facility of Mission Health, in Asheville, N.C.

 

 


Julie Rovner: Replacing the ACA: Where there’s a will there’s a way

 

By JULIE ROVNER

Kaiser Health News

Now that the GOP effort to repeal and replace the Affordable Care Act is in limbo, is there a way to make it work better?

Democrats and Republicans don’t agree on much when it comes to the controversial federal health law, but some party leaders from each side of the aisle agree it needs repairs.

“No one ever said the Affordable Care Act was perfect,” said Senate Minority Leader Chuck Schumer (D.-N.Y.) on the Senate floor March 27. “We have ideas to improve it. Hopefully our colleagues on the Republican side do as well.”

A day later, Speaker Paul Ryan (R-Wis.) said, “We all want a system in healthcare where everybody can have access to affordable coverage, where we have more choice and competition.” And several GOP senators have moved away from the party’s long-held call for a total repeal and are offering bills that would amend the measure.

Health-policy analysts say that some of the health law’s marketplace problems could be improved with a bipartisan spirit. Here are some of the possibilities:

Stabilize the Insurance Market

Insurance companies have only a matter of weeks before they must tell the federal government and/or individual states whether they plan to offer coverage in 2018 on the health law’s online marketplaces, which serve customers who don’t get job-based or government insurance.

As of now, many companies say the uncertainty of what the market will look like — or the rules under which they will operate — is making that decision difficult. At least one insurer, Humana, has already said it would not offer coverage.

Two key moves that insurers are looking for from the administration are a promise to continue providing certain subsidies for those with lower incomes and enforcing the requirement for most people to either have insurance or pay a tax penalty.

The subsidies — known as “cost-sharing reductions” — are different than the tax-credit subsidies that many marketplace customers get to help pay their premiums. The cost-sharing subsidies help those with incomes between the poverty line ($20,420 for a family of three) and nearly 2½ times that ($50,400 for that same family) pay their deductibles and other out-of-pocket costs. The House  sued the Obama administration in 2014 for providing the subsidies without a formal congressional appropriation for the money, and a federal judge sided with the lawmakers.

The Obama administration appealed the decision, but if the Trump administration were to drop that appeal, the subsidies would disappear. At a House hearing March 29, Health and Human Services Secretary Tom Price, M.D. would not say what the administration plans to do about the lawsuit or the subsidies.

“I’m a party to that lawsuit and I’m not able to comment,” he said. But Ryan, who is also a party to the suit, said March 30 that he believes the administration should continue paying the subsidies until the lawsuit is resolved.

The administration has been similarly quiet about how strictly it will enforce the “individual mandate” that requires most people to have health insurance or pay a fine. On his first day in office, President Donald Trump issued an executive order directing federal agencies to “minimize the unwarranted economic and regulatory burdens” of the health law. But other than the IRS backtracking on a plan to enforce the mandate more strongly, little has happened on that front.

Yet those two provisions together — the cost-sharing subsidies and the individual mandate — could result in 25 to 30 percent increases in premiums if they were to disappear, said Andy Slavitt, who oversaw the health law for the final years of the Obama administration. Assuring that the subsidies will remain and the mandate will be enforced “would send a strong signal to (insurance companies) that they should continue to participate in the market,” he added.

Some GOP health policy analysts — including economist Gail Wilensky, who previously ran the Medicare and Medicaid programs — have proposed replacing the individual mandate with penalties for signing up for insurance late, which is what Medicare does. Republicans did that in their proposed replacement bill, by adding a 30 percent premium surcharge to those with a break in coverage longer than two months. But insurance actuaries and the Congressional Budget Office said that might eventually prompt fewer people to enroll because it would encourage healthy people to remain uncovered.

Entice People to Enroll

Getting young and healthy people to sign up for coverage is not just a benefit for them. If there are not enough healthy people in the insurance pool, then premiums rise for everyone, because risk is being spread across a mostly sicker population. And someday even the healthy people will need medical care.

But it takes more than just the requirement for coverage to get people to enroll. Slavitt said it requires a real effort by both federal and state officials to reach people and help them understand that having health insurance is a good thing, even if they are healthy. “What they should be doing is increasing marketing and the outreach budget,” he said. “You’re trying to reach people who are uninsured and are unsure how it all works, and it does take a lot of hand-holding.”

So far, however, the administration’s only move on that front was to cancel ads encouraging people to sign up at the end of the enrollment period that overlapped with Trump’s first days in office. The HHS Inspector General is now investigating the results of this action. Some analysts have estimated canceling the last-minute push lowered enrollment in the exchanges by as much as a half-million people.

Help Offset Insurer Losses

Democratic lawmakers who wrote the Affordable Care Act knew that the market might be hard for insurers to navigate for the first few years, and they built in several programs to help reimburse those who lost money.

Republicans, however, blocked funding for one of the major programs, which was intended to reimburse insurance plans that enrolled sicker-than-average populations for the first three years of the marketplace operations. Republicans called the money “insurer bailouts.” The loss of that money was a major reason for the collapse of many of the nonprofit insurance co-ops created under the law and some other insurance companies said it contributed to their decisions to leave the marketplaces.

Now, however, there are indications that Republicans might support some efforts to provide more funding for insurers.

On March 13, Price sent a letter to governors encouraging them to apply for waivers of the ACA rules in order to make insurance more affordable and available in their states. Among the state innovations singled out in the letter is a “reinsurance” program in Alaska that helps insurers pay for extremely high-cost patients. That plan, said Price, “significantly” offset what was a projected 40 percent premium increase in the state, and might be an option elsewhere under the waivers, which could allow states to get federal funding for such a program.

And the GOP health bill, the American Health Care Act, included $100 billion for a “Patient and State Stability Fund” that states with limited insurer competition could use to lower costs and help encourage insurers to stay in the market.

“They have a potential fix staring them in the face,” said Larry Levitt of the Kaiser Family Foundation of the GOP proposal for a stability fund. “It was a clever mechanism because the states could use it for any of a variety of purposes.” (Kaiser Health News is an editorially independent project of the Foundation.)

Assist Patients With High Out-Of-Pocket Costs

Democrats and Republicans agree that people who buy their own insurance are paying too much out-of-pocket, in premiums as well as deductibles and cost sharing.

Democrats mostly want to increase federal subsidies to help with affordability — something Republicans are not likely to embrace.

But there are other ways to lower consumer spending.

For example, Sabrina Corlette of Georgetown University’s Center on Health Insurance Reforms, calls for “smarter, not skimpier benefit design.” One way to do that is to set federal rules to push insurers that offer coverage with high deductibles to add more benefits that would be available without paying thousands of dollars first, like a few trips to the doctor or urgent care center or a few prescriptions. She writes that could keep people from dropping coverage because they feel they are not getting any value for their premiums. And if those mostly healthy people feel they are getting benefits they might use, they are more likely to continue to purchase coverage, thus reducing premiums for everyone.

Another potential way to lower insurance costs is to lower health care costs. Even if there are multiple competing insurers in an area, if there’s one dominant hospital system, it can pretty much charge whatever it wants.

“There’s no other price in the U.S. economy that’s growing as fast as a hospital price,” said Bob Kocher, a former Obama administration health official now at the venture capital firm Venrock. And in areas with not much hospital competition, “prices are 30 to 50 percent higher for everything.”

But how to get hospital prices down is almost as hard as regulating insurance. Kocher said one way would be for federal regulators to be more discriminating about approving hospital mergers, which tend to give hospitals more negotiating power over insurers.

More controversial would be to require hospitals that dominate their markets “to just accept Medicare prices” from marketplace insurers, Kocher suggested. While that would tend to bring prices down, it’s not likely to fly with free-market Republicans.


5 takeaways from the AHCA collapse

 

Billy Wynne, writing in Health Affairs, presents five lessons from the failed launch of the American Health Care Act:

They are:

“Nothing is inevitable”

“There’s a difference between making a political statement and enacting real policy. The latter is invariably complex and time-consuming, creating vulnerabilities and pitfalls both known and unknown at the outset. While a cornerstone of tried and true policymaking is to leverage the ‘strategy of inevitability’—more than seven years ago, the ACA campaign itself vigorously deployed just such a strategy—the underlying premise of that strategy is always inherently false.’’

“Stakeholders matter’’

“Virtually every hospital and hospital group, every physician group, nurses, patient groups representing the young, old, disease-stricken, and disabled, and many others fervently opposed AHCA. They added analysis of AHCA’s impact on them, as governors did regarding its impact on their states. At the end of the day, this was simply a bad bill. Stakeholders figured it out and acted when it counted.’’

‘’Ultimately, on the day AHCA was originally supposed to get its final House vote, a Quinnipiac University poll came out showing only 17 percent of the public supported the bill, while 56 percent opposed it, a startling gap rarely seen in any bona fide political polling.’’

“The ACA stole most of  the good conservative ideas’’

‘’While it was lambasted by Republicans as the manifestation of a Marxist dystopia, the truth of the ACA is that it is a very moderate law. …As Health Policy Counsel to then-Finance Committee Chairman Max Baucus in the prelude to President Obama’s election, I know the pains he took to build bipartisan consensus. In 2008, he negotiated with Republican counterparts on reforming the market for small businesses, in what became the SHOP Act component of the ACA (drawing from legislation originally co-led by Republican Olympia Snowe). He convened an all-day, fully bipartisan Prepare to Launch summit to query experts and debate ideas. He released a series of white papers that laid out detailed policies he believed could gain bipartisan support (welcomed by the conservative Heritage Foundation as ‘a starting point for serious discussion’). And all of that was before President Obama was elected.”

‘’The centerpiece of the ACA became tax credits for the purchase of commercial—not government—health insurance, with a tax-driven mandate that everyone take responsibility for buying in. This had been the linchpin of numerous Republican health reform proposals prior to that time. While Medicaid expansion was also included, it took on a greater role only because that is a less costly way to expand coverage, and Democrats were utterly committed to ensuring the bill did not increase the deficit.”

‘’Other key conservative ideas were embedded in the law as well. Numerous new payment reforms were instituted to drive efficiency and lower costs; states were allowed to pool their markets (though notably none have yet); price and value transparency was instituted so consumers could compare their coverage options side-by-side; emphasis was placed on prevention and community health centers; states were free to run their own exchanges and establish their own essential health benefits; dozens of new program integrity and oversight protections were instituted.’’

“Tom Price is now the most important person in healthcare”

“While the Trump Administration has some more thinking to do before it commits to letting our health care system crash and burn, via sabotage or neglect, it certainly has that power. The locus of that power is the Department of Health and Human Services and its Secretary, former Republican Congressman Tom Price, M.D., a former orthopedic surgeon.

‘’As we have already seen, simple maneuvers like pulling publicity for HealthCare.gov and creating an aura of uncertainty can adversely impact insurance enrollment. Payment and delivery system reforms, intended to lower costs and improve quality, have been halted in their tracks. Governors have been informed that they are now freer to impose premiums and increase cost-sharing for Medicaid enrollees.

“As destabilizing as these changes are, they pale in comparison to some of the more nuclear options Secretary Price has at his disposal to wreak havoc on health care. Perhaps the foremost of these, and the one readily accessible at any moment, is the option to refrain from defending the cost-sharing subsidies.”

.

“Bipartisanship is still possible’’

“While not as expedient or gratifying to the inner ideologue inside us all, the long, frustrating work of compromise is the only viable path forward.

‘’There is a lot of lower-hanging fruit and we should give AHCA credit for bringing some of those to people’s attention. Insurers have now made clear what they think will help stabilize markets and perhaps make them more competitive, including funding risk corridor and reinsurance programs. Meanwhile, several start-up health plans are eyeing a wide array of markets where competition is limited and ripe for a lower-cost competitor. Some have faced obstacles at the state-level, undoubtedly due in part to the objections of entrenched interests. Can a Price-led HHS help open up these markets?’’

 


Can/should bedside manner be measured and reported?

bedside

In a NEJM Catalyst piece, Paul Rosen, M.D., looks at attempts to measure  and report physicians’ bedside manner. Among his remarks:

“Is there common ground between patient and physician perspectives? When approaching an encounter with a patient, the physician goal typically is to make the correct diagnosis and provide an evidence-based, efficacious treatment plan.”

“Consumer surveys show that patients value the correct diagnosis, a proper treatment plan, and the doctor’s medical knowledge. However, patients also value whether the doctor treats them with respect and dignity, listens and cares, takes time, and takes them seriously. The ideal patient experience merges excellent medical care, high-quality outcomes, compassion, and empathy that address the emotional needs of patients. Can physicians deliver all these things given the other constraints of practicing modern-day medicine?”

“Research demonstrating the correlation between service and quality is mixed. Some studies find a correlation between service and medical outcomes, yet other reports show no linkage between patient experience and outcomes, and some show a negative correlation. Study in this area, and the controversy, is ongoing.”

“The more cynical among physicians feel that the patient experience movement is just another cottage industry within medicine that enables consulting companies to thrive, while detracting from the real practice of medicine. It has become another charged administrative issue and another bully club for administrators to use against their doctors. The fact that many physician bonuses depend on the results of these survey scores drives further embitterment.”

Still, “many industries improve their performance when their data are shared transparently. Health systems, too, that are posting their patient satisfaction data on the Internet are seeing improvement in their scores and comments.”

To read  more, please hit this link.

 


Trump’s CMS pushes back against bundled payments

knee

The CMS has delayed the expansion of a major bundled- payment pilot, Comprehensive Care for Joint Replacement, and implementation of its bundled-payment initiatives for cardiac care to Oct. 1, 2017, from July 1, according to an interim final rule posted to the Federal Register. It also again delayed the effective date of a final rule detailing the  implementation process  for CJR and other bundled-payment programs, to May 20, 2017 from March 21.

The agency is considering delaying  implementation of all bundled-payment initiatives even further, until 2018.

Modern Healthcare speculated that the Trump administration’s “move to delay these initiatives raises questions about the future of government initiatives to usher healthcare out of fee-for-service operations and into a new age of value-based payment.”

The new secretary of health and human services is Tom Price, M.D., who had a very lucrative career as an orthopedic surgeon and has been a major investor in some medical companies. CMS ultimately reports to him and President Trump.

To read more, please hit this link.


Four tips for clinical documentation improvement

Jonathan Elion, M.D., a cardiologist and associate professor of medicine at Brown University, has four tips for clinical documentation improvement in ambulatory settings.

They are:

  • “Define the exact patient and visit categories that you think merit inclusion in a CDI workflow.
  • “Determine how these patients can be identified by information in the HIS {hospital information system} and its associated electronic messages.
  • “Make sure that you can define your facility’s use of account numbers in open or recurring visits.
  • “Be specific about what you want to accomplish and how you will measure your progress.”

To read more, please hit this link.



Providers complain about lack of guidance on ‘observation’ status

 

Modern Healthcare reports that  providers say that the lack of guidance from CMS about a new rule mandating that hospitals notify Medicare patients why they are receiving “observation” care could cause hospitals to lose billing privileges and patients.
Beneficiaries must spend three consecutive nights as admitted patients in a hospital  for Medicare to cover subsequent skilled-nursing facility costs; observation days don’t count.

The publication reported that  as of March 8 hospitals had to begin “giving out the notices, which alert patients that they received observation care rather than being admitted as an inpatient. CMS estimates as many as 1.4 million beneficiaries will receive the notices every year, and they are meant to cut down on the surprise bills observation patients tend to receive.”

“The CMS requires hospitals to give patients a reason for their observation status, but the CMS has declined repeated requests from hospitals to suggest language that providers should use. Providers are concerned that the vague instructions put them at risk of auditor citations.”

“The stakes are huge in that without guidance from CMS, each auditing organization is left only with their personal interpretation if a hospital is in compliance or not,” Ronald Hirsch, M.D., a vice president at R1 Physician Advisory Services, a consulting firm on billing matters for providers, told Modern Healthcare.

The publication added that a CMS spokesman declined to comment on the issue, but pointed to an FAQ document on the agency’s Web site “that encourages providers to use their clinical judgment when writing the notices and make them ‘reasonably understandable’ to the beneficiary.”

To read more, please hit this link.

 

 


Should standards be lowered for safety-net hospitals?

 

The federal government sometimes withholds money from safety-net hospitals because they fail to meet certain standards.

A piece in governing.com asks whether those standards should, at least in some cases, be lowered.

Penalties “handed down by CMS are part of the Affordable Care Act {and} are meant to motivate hospitals to correct procedures so as to avoid patient safety violations. But the problem with these penalties, some health policy experts say, is that they don’t take into account the particular challenges that individual hospitals face.”

“Most of the penalized hospitals take care of the poorest and sickest,” Ashish Jha,  M.D., a  Harvard professor who focuses on patient safety, told the news service.

“Jha and others argue that CMS should add a risk adjustment factor. Until then, safety-net and academic-centered hospitals {with the most challenging patients} will continue to get slapped with the most penalties.”

“Adding to the hospitals’ exasperation is the fact that there is little information about whether the penalties have actually improved health outcomes.”

To read the piece, please hit this link.

 


How MACRA will fail

napolean

Napoleon’s Retreat From Moscow.

David L. Keller, M.D., a California internist, writes that the Medicare Access and CHIP Reauthorization Act (MACRA) will fail. In a piece in Medical Economics he writes:

“The last thing doctors need is another set of distracting bureaucratic measures to be satisfied before we can attend directly to the patient’s needs. CMS is rushing to implement MACRA, despite the heavy burden this will place on physicians and their patients. MACRA will supposedly improve the quality of medical care while decreasing its cost and increasing the amount of information that doctors collect from their patients and report to CMS. 

“MACRA will, inevitably, fail on all counts: It will increase the cost of medical care, degrade the quality of care and it will clog patient charts with even more of the useless and distracting ‘junk’ information that already litters patient charts and records, due to prior mandates by CMS. 

“CMS can save American physicians (and their patients) a great deal of stress and expense by postponing the implementation of MACRA and reopening the question of whether it is needed at all. ”

To read his article, please hit this link.


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