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How Aetna, CVS might prosper from merger

Harvard Business School Prof. Leemore Dafny writes in NEJM Catalyst about how the Aetna-CVS merger might pan out. Among her observations:

“With a focus on total costs of care in Aetna’s corporate DNA, {the merged entity}  will aspire to reduce total spending for care (while increasing its own revenues) by redirecting patients to lower-cost sites for certain services, such as infusions or imaging (in which NewCo may have ownership stakes); using its physical convenience and non-visit care technologies to maintain contact with patients requiring closer monitoring, thereby potentially averting ED visits and admissions; and considering combined medical and pharmacy spending.

“Aetna can directly support these objectives by encouraging members to use Minute Clinics, other {merged entity} affiliated providers, CVS pharmacies, and Caremark services — perhaps through favorable cost sharing or more seamless scheduling, billing, and care or product delivery. To the extent that CVS’s physical and digital efforts can lower total costs of care, {the merged entity} can benefit directly from anyone insured by Aetna, and indirectly by sharing in savings with members of self-insured plans. Notably, Aetna is building market share in Medicare Advantage plans, and arguably Medicare Advantage enrollees are the members most likely to appreciate and benefit from frequent, high-touch interactions with CVS pharmacists and nurse practitioners.”

To read her essay, please hit this link.


UVA discharge program for heart patients cuts readmissions

University of Virginia Medical Center, in Charlottesville.
The University of Virginia Health System has a “hospital to home” program for heart patients that’s cutting readmissions. It focuses on the first two weeks after discharge.

The key to the program is an in-hospital clinic staffed by nurse practitioners who reviews post-discharge instructions with patients. it addresses such issues as some patients’ difficulty getting to drugstores and matters connected with low-income and educational status.

Hospitals & Health Networks reports on the UVA program:

“In an effort to reduce readmissions, a patient’s entire care team — doctors, nurses, floor managers, case workers, discharge managers, pharmacists, residents and social workers — visits on the morning of discharge, as on other mornings of the patient’s stay, in a program they call ‘Rounding with Heart.”’

“UVA strives to provide a ‘very clean’ discharge summary that patients can understand easily, with no ambiguities. The discharge nurse reviews discharge instructions with the patient in the presence of a family member.”

“As part of the H2H program, patients are scheduled to visit UVA’s H2H {Heart to Heart} clinic between four and seven days post-discharge. Patients come in for an hour-long appointment to the clinic run by two full-time nurse practitioners who specialize in heart failure. The nurse practitioners also consult on cases with dietitians, genetic counselors, physical and occupational therapists, and social workers.”

“The program was found to reduce mortality at 30 days to 1.8 percent, down from 12.9 percent, and at one year to 15.5 percent, down from 25.6 percent. The average cost of care over the year after was $45,617 for the H2H patients and $101,022 for those not in the program.”

To read more, please hit this link.






Another state widens NPs’ practice authority


South Dakota Gov. Dennis Daugaard, a Republican, has signed a bill that lets nurse practitioners practice independently after completing 1,040 hours of work under physician supervision.

The American Association of Nurse Practitioners reports that South Dakota thus becomes the 22nd state to enact full practice-authority legislation, which lets nurse practitioners provide services without physician supervision.

The organization says the move could save the state $71,000 annually in regulatory costs.

State policymakers are increasingly turning to nurse practitioners and physician assistants to meet the burgeoning demand for primary care.

Healthcare Dive reported: “The  {federal} Health Resources & Services Administration predicted that demand for primary care physicians would grow by 14% over a ten year period from 2010 to 2020. According to these estimates, the healthcare system needs about 241,200 primary care providers to meet that demand. Legislation that lifts restrictions on nurse practitioners could bring that figure down to 6,400.
“There are far more nurse practitioners and physician assistants graduating from training programs than there are primary care physicians. In 2016, there were a total 4,944 medical school graduates matched with primary care residencies. …Meanwhile, 17,900 nurse practitioners graduated from primary care programs in 2015.’’

To read more, please hit this link



9 ways to cut hospital debt


Meg Bryant, writing for Healthcare Dive, discusses nine ways in which hospitals can reduce debt:

1. “Understand your costs of care. Hospitals make money taking care of patients, so their debt needs to be clinically proportionate to the types of services they provide….If a hospital has large surgery needs, it will require lots of operating rooms, which are expensive to implement and maintain. …. Make sure the capital structure is appropriate to the model of care needed or the risk profile of the patients the hospital treats.”

2. “Improve ICD-10 coding on claims forms. Not coding appropriately and not coding for the proper amount of time the doctor sees the patient or for interactive effects can cause reimbursement rates to plummet….”

3. “Renegotiate rates with insurers. Larger, more prestigious hospitals and health systems are able to extract much higher reimbursement from private payers than less prestigious ones, even in the same geographic area. Hospitals can increase volume and revenues by convincing health plans to increase rates and then direct patients toward the less-expensive hospital.”

4. “Increase efficiencies and productivity. Another thing hospitals can do is make sure nurse practitioners, nurse, LPNs, and other clinicians are operating at the top of their license. {N}urse practitioners can perform many of the tasks a physician does, but at a lower cost of care.”

5. “Manage risk. This is something that all hospitals are having to do under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), but it is also a good way to reduce costs and knock out debt. Focusing on high-risk patients to reduce costly inpatient stays can have a rapid return on the bottom line. Coupling that with narrow networks of high-quality, low-cost physicians may increase referrals from health plans and enhance reimbursement rates.”

6. “Refinance or restructure to cut debt. Hospitals can also work with capital market organizations to see if there are ways to refinance or restructure to reduce the debt burden….”

7. “Divest property.

8. “Reduce ‘bad’ debt. To increase the odds of getting paid, some hospitals are training patient access staff to identify patients who may default on payment and putting in point-of-service payment plans. Some hospitals have also set up space to enroll uninsured patients in Medicaid….”

9. “Join a health system.”  Get  the efficiencies from being in health systems, as opposed to being a single hospital. With a system you have the credit worthiness of the whole system behind you, probably getting you lower interest rates.

To read the entire article, please hit this link.

Not too few physicians but bad distribution, not enough non-physician clinicians

It’s sort of a cliche to say that America has a  dangerous shortage of physicians. But a New York Times story challenges that.

It says, among other things:

“Some people think there’s no shortage at all — just a poor distribution of the doctors we have.”

“Adding data to this argument, the United States has fewer practicing physicians per 1,000 people than 23 of the 28 countries that reported data in 2013 (among nations in the Organization for Economic Cooperation and Development).”

“But there is strong evidence that we are thinking about this the wrong way. In 2014, the Institute of Medicine released a thorough analysis on graduate medical education that argued there was no doctor shortage, and that we didn’t really need to invest more in new physicians.

“The system isn’t undermanned, it said: It’s inefficient. We rely too heavily on physicians and not enough on midlevel practitioners, like physician assistants and nurse practitioners, especially because evidence supports they are just as effective in primary care settings. We don’t account for advances in technology, like telehealth and new drugs and devices that lessen the burden on physician visits to maintain health.”

“And we fail to recognize that what we really have is a distribution problem. Parts of this country have lots of doctors, perhaps too many. These are mostly in cities, especially in cities where it seems desirable to live. The problem is made worse by the ways we reimburse for care. Medicare, for instance, pays more to doctors who live in places that are more expensive. The argument for this is that the cost of living is higher, so reimbursements must be, too. But that also means that doctors can earn more in places where they already might want to live. A result is that many rural areas, and less popular cities, experience more of a doctor shortage than others.”

“The other distribution issue is in specialization. When it comes to generalists, we ranked 24th of 28 countries in doctors per 1,000 people. Specialists are a different story. There, we were 11th. This is an important fact about the American health care system. We sometimes hear that we have too many specialists and too few generalists. That’s not necessarily the case. We have an average number of specialists compared with other advanced countries, and even shortages in some specialties. It’s the ratio of specialists to generalists that’s the problem. …”

To read the full Times story, please hit this link.

The still modest lure of physician unionization


“Strike action” (1879), by Theodor Kittelsen

More physicians are considering joining unions.

One  well-known supporter of unionization is David M. Schwartz, M.D., president of a union local that represents 27 hospitalists at PeaceHealth Sacred Heart Medical Center at RiverBend, in Springfield, Ore.

“The biggest challenge for employed physicians is going to be the realization that they’re no longer part of an autonomous profession,” he told Medscape. “They work for people who no longer respect their autonomy.”

The publication reported that his group “is thought to be the first doctors’ local limited to just one specialty. The National Labor Relations Board now lets “micro-units” of employees to join unions, which could boost the  overall unionization of physicians.  It is easier to sign up a small group, such as hospitalists, than to recruit the entire physician workforce in a hospital.

But don’t expect a  rush of hospital-employed physicians to join unions, although things may change as healthcare’s reimbursement revolution accelerates.

Howard Forman, M.D., a radiologist who teaches healthcare economics at Yale, noted that unhappy employed physicians generally have many jobs they can move to — and hospitals’ C-suites’ knowledge of that would tend to prevent unpopular moves that would lead many physicians to quit.

“A few physicians able to move ‘should provide a meaningful lever to change compensation and work requirements for all,’ ‘ Dr Forman told Medscape. For most doctors to agree to strike, ”the times would have to be more desperate than they are now”.

Still, the move to hire cheaper clinicians such as nurse practitioners and physician assistants to perform many of the tasks traditionally performed by physicians, and especially by internists, pediatricians and hospitalists, may soon reduce  the number of physicians’ greener pastures elsewhere.

To read the Medscape piece, please hit this link.

Lia Spiliotes: Close rural care gaps by boosting nurse practitioners



Rural America lives with layers of demographic and geographic obstacles to health care, and not surprisingly, rural Americans face bigger health challenges than their urban and suburban neighbors. Berkshire County, the second most rural county in Massachusetts, is no different.

More than residents elsewhere in the state, our neighbors and communities struggle with high rates of obesity, cancer, diabetes, cardiovascular disease, mental illness and addiction to smoking and other drugs. The suicide rate in Berkshire County was the highest in the state in 2013, and admissions to mental-health facilities are above the norm.

Berkshire County mirrors other remote rural geographic regions in the nation, where recruiting primary-care providers is an ongoing challenge of economics, retirement, the allure of specialty medicine and big-city compensation. In these areas, the supply of primary-care physicians falls below federal standards. (Kaiser Foundation 2015).

The good news is that the education, experience and quality of physicians and nurse practitioners at Community Health Programs in Berkshire County, where I have been interim CEO since January, is on par with any of the best healthcare organizations in which I have worked in Massachusetts. Equally important is the work we are doing to educate patients about the front-line role that nurse practitioners play in the delivery of high quality primary care. Increasingly, patients understand that nurse practitioners are excellent partners in providing primary care.

National studies have shown that patients assigned to either nurse practitioners or primary-care physicians have comparable health outcomes. More than a dozen states — including Maine, Vermont, New Hampshire and Rhode Island — have long-since passed measures freeing nurse practitioners from physician oversight in treating, diagnosing and prescribing medication to patients.

States that have already done so show fewer emergency-room admissions, improved health status, and better overall healthcare experiences. Yet in Massachusetts, physician organizations have resisted giving nurse practitioners sufficient autonomy to practice to the full extent of their training. We need to maximize the use of nurse practitioners as a vital healthcare resource.

This lack of full practice authority for nurse practitioners has broad implications for healthcare access in Massachusetts, particularly in underserved communities. Competition for primary-care providers is intensifying. Physician salaries at community health centers, which serve mostly lower-income residents, remain 25 to 30 percent below entry-level salaries at many hospitals and private physician practices.

Outdated practices

At rural health centers, which continually struggle to attract providers away from urban areas, the impact is even more profound if nurse practitioners cannot provide the full range of patient care. The health of rural communities is compromised by policies that protect outdated ways of delivering primary care.

The role of nurse practitioners should grow as our health system moves toward the team-oriented, patient-centered care approaches — the foundation of post-Affordable Care Act healthcare delivery. Often referred to as the patient-centered medical home (PCMH), this coordinated model emphasizes a critical shift to staying well, not just getting better.

In addition, care for higher-risk patients with chronic needs, who account for so much of our overall healthcare spending, is better managed. In states that have lifted restrictions on nurse practitioners, early data show a reduction in ER admission rates, improvements in residents’ health status and increased patient satisfaction.

The time has come for the Massachusetts legislature to pass House Bill 1996/Senate Bill 1207. The bills, which draw upon guidelines developed by the Institute of Medicine, would remove barriers preventing nurse practitioners and certified registered nurse anesthetists from practicing to the full extent of their training. The bill also ensures that Massachusetts can meet workforce demands, address gaps in access to care and adopt new care models tied to healthcare delivery and payment reforms.

According to the National Council of State Legislatures, of the 2,050 rural U.S. counties, 77 percent are designated as health- professional-shortage areas. Around 4,000 additional primary- care practitioners are needed to meet current rural healthcare needs. There is no single fix to meeting the health needs of rural Americans, but by elevating the role of nurse practitioners, we believe we can begin to close the gap.

Lia Spiliotes, a Cambridge Management Group partner and senior adviser, is interim chief executive officer of Community Health Programs, the Federally Qualified Health Network in Berkshire County, and serves on the board of the Massachusetts League of Community Health Centers. This piece first ran in The Berkshire Eagle.


The controversial role of NPs and PAs



Nurse practitioner at U.S. naval base in Japan.

This article from Physicians Practice looks at the expanding but controversial status of nurse practitioners and physician assistants in U.S. healthcare.

Regulators and insurers seek to boost their role as part of an effort to curb costs  and expand healthcare access in the world’s most expensive healthcare system. But many physicians think that these nonphysician clinicians are inadequately trained for expanded roles and fear that they will cut into physicians’ incomes.

Florida House’s ambitious healthcare package


The Florida House has passed a healthcare package that, as nicely summarized by The Miami Herald:

  • Sets rules for telemedicine that let out-of-state physicians use technology to serve patients in Florida.
  • Lets  people contract directly with physicians to pay for primary care without involving insurance companies. Those choosing this option would still need to have some  health coverage under the Affordable Care Act.
  • Giving advanced registered nurse practitioners and physicians’ assistants the right to prescribe narcotics and other drugs.
  • Creating new recovery centers that can care for patients for 72 hours after surgery and extending the time  that patients can stay at ambulatory surgical centers to 24 hours.
  • Sets sweeping price-transparency requirements to ease patients’ shopping for non-emergency coverage.
  • Creates new recovery centers that can care for patients for 72 hours after surgery and extends the time patients can stay at ambulatory surgical centers to 24 hours.
  • Seeks to to protect consumers from “balance billing,” in which physicians directly bill patients for services not covered by insurance, which often happens when hospitals contract with outside physicians.

NPs making slow headway to widen scope of practice


Nurse practitioners are making inroads in some states in getting more clinical authority but are still blocked in some states by physician groups fearing that giving nonphysician clinicians a wider scope of practice would cut into the income of  doctors, who remain by far the highest paid in the world.

Advanced nurse practitioners  have been fighting for years for the right to write prescriptions  and  operate practices without an agreement with a physician.

The pressure to expand the scope of nurse practitioners’ practice has intensified with studies saying that many millions of Americans live in areas with primary-care physician shortages.

A wider scope of practice would include, for instance, letting nurse practitioners diagnose patients, order tests, complete death certificates and initiate involuntary psychiatric commitment for unstable patients without a supervisory relationship with a physician.

Modern Healthcare says that “Physicians say advanced nurse practitioners can help alleviate the primary-care shortage, but only if they are a part of a coordinated team led by a doctor. ”
Robert Wergin, M.D., chairman of the American Academy of Family Physicians told the publication:

“What we’re for is team-based care where it’s the right provider, the right care at the right time. Everyone contributes to the care, but we’re not necessarily interchangeable.”

“Independent practice and team-based care take healthcare delivery in two very different directions,” an American Medical Association spokeswoman added. “One approach would further compartmentalize and fragment healthcare delivery, while team-based care fosters greater integration and coordination.”


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