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Trump changes linked to worrisome decline in ACO partcipation

From FierceHealthcare:

“Some Accountable Care Organization (ACO) groups are worried that a dip in participation this year could be the start of a worrisome trend due to major changes made to the program by the Trump administration.

“The Centers for Medicare & Medicaid Services (CMS) announced Wednesday that 518 ACOs are part of the program as of July 1, a decline from 561 ACOs that participated in 2018. The new data have the National Association of ACOs (NAACOS) worried about whether the decline is an anomaly or the start of a trend thanks to major changes to the Medicare Shared Savings Program (MSSP).

“CMS Administrator Seema Verma wrote in a blog post on Health Affairs Wednesday that CMS approved 206 ACOs to start July 1 and that 41 of them are new to the program. The number of new entrants is below the normal rate of more than 100 ACOs that have signed up each year since the program started seven years ago.”

To read the whole article, please hit this link.

Millennials embrace nursing



For Kaiser Health News

The days are long past when the only career doors that readily opened to young women were those marked teacher, secretary or nurse. Yet young adults who are part of the millennial generation are nearly twice as likely as Baby Boomers were to choose the nursing profession, according to a recent study.

These young people, born between 1982 and 2000, are also 60 percent more likely to become registered nurses than the Gen X’ers who were born between 1965 and 1981.

What gives?

“There’s no perfect answer,” said David Auerbach, an external adjunct faculty member at Montana State University’s College of Nursing and the lead author of the study, which was published this month in Health Affairs. The trend could be associated with economic factors, he said. Millennials came of age during a period of deep economic uncertainty with the Great Recession, which began in 2007, and the nursing profession generally offers stable earnings and low unemployment.

In addition, researchers have teased out generational characteristics that might make nursing more attractive to Millennials.

“These people are looking for more meaningful work and work that they care about,” Auerbach said.

One thing that hasn’t changed since the 1950s: Nursing is still dominated by women. In 2017, women made up at least 83 percent of registered nurses and licensed practical nurses, according to data from the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

For the study, researchers analyzed Census Bureau data on 429,585 registered nurses from 1979 to 2015. The study excluded data on advanced practice nurses.

The study found that the number of new entrants into the field has plateaued in recent years. Still, the millennial generation’s embrace of the nursing profession should nearly compensate for the retirement of baby boomer nurses over the next dozen years and may help avert shortages, according to the researchers.

Many factors will influence whether the supply of nurses is adequate in coming years. The healthcare needs of an aging population is only one of them.

“The growth in Accountable Care Organizations and alternative-payment models is probably the biggest factor,” Auerbach said. For example, as hospitals move away from fee-for-service medicine toward models that pay based on quality and cost-effectiveness, nurses’ roles may shift, and fewer of them may be needed in hospital settings as inpatient care declines.


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.

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