The Centers for Medicaid & Medicaid Services will not let Boston-based Partners HealthCare resubmit paperwork for 19-bed Nantucket (Mass.) Cottage Hospital that, if it had been filed correctly, would have resulted in higher Medicare payments to hospitals across Massachusetts
CMS’ decision to deny Partners’s resubmission request was included in CMS’s Inpatient Prospective Payment Systems rule. CMS refused to allow the corrections because the hospital missed the original submission deadline.
Becker’s Hospital Review reports: “Under hospital payment rules, Medicare is required to reimburse employee wages at urban hospitals at the baseline set at rural hospitals in the state. Nantucket Cottage Hospital typically sets the floor for wages at hospitals across Massachusetts because it is the only rural hospital in the state.”
“Last year, the Nantucket-based hospital provided data that underestimated its wages, dragging down payments for the entire state. Partners identified the errors in mid- to late March, and sent corrected numbers April 5, almost two months after the deadline for submitting corrections.”
Partners HealthCare, trying to prevent steep declines in Medicare payments to its Massachusetts hospitals, is urgently urging CMS to use corrected data that the Boston-based system submitted for 19-bed Nantucket (Mass.) Cottage Hospital.
As Becker’s Hospital Review notes: “Under hospital payment rules, Medicare is required to reimburse employee wages at urban hospitals at the baseline set at rural hospitals in the state. Nantucket Cottage Hospital typically sets the floor for wages at hospitals across Massachusetts because it is the only rural hospital in the state. However, that isn’t the case this year.”
“Consultants hired by Partners made several errors in the data Nantucket Cottage Hospital submitted to Medicare. The errors reduced the hourly wage rate by overestimating hours and failing to include enough overtime pay and high-paid physician hours. Due to the mistakes, Massachusetts hospitals could lose a total of $160 million in Medicare funding next year. ”
In a sign of the rapidly growing importance of population health, Boston-based Partners HealthCare and its insurer, Neighborhood Health Plan, have created a new position: vice president for population-health finance.
Douglas Thompson will be the first executive to oversee population-health finance operations for both Partners and NHP. He is to provide leadership on care integration and in promoting new population-health models, including payment mechanisms and investments.
Mr. Thompson has been chief financial officer for Neighborhood Health Plan since 2014, a position he will retain in addition to his new job.
Partners HealthCare, whose properties include Massachusetts General Hospital and Brigham and Women’s Hospital, is stepping up efforts to commercialize research done at its labs and hospitals. Its latest tactic, reports The Boston Globe, is to offer as much as $1 million in grants (up to $100,000 each) for employees “who come up with promising ideas for new drugs, devices and other inventions that have the potential to improve patient care.”
“The grants are open not just to researchers, but to anyone in Partners’ workforce of 64,000 who has a good idea. The small sum is intended to help early-stage ideas get off the ground,” the paper reported.
“This funding is aimed at making an even stronger connection between the innovative ideas within our healthcare system and Boston’s biotech and life-sciences industry, which can bring those ideas to life,” Anne Klibanski, M.D., chief academic officer, said.
Now that Massachusetts officials have stopped Partners HealthCare from growing further in Massachusetts, at least for now, there’s been talk about decoupling the chain’s two flagship hospitals: Massachusetts General and Brigham and Women’s.
Perhaps, Joan Vennochi, writing in The Boston Globe, ruminates, the two world-famous Harvard-affiliated teaching hospitals, which compete with each other even though they are in the same company, can “grow more as independent entities than they can under Partners.”
The MGH-Brigham alliance under Partners did not merge the assets of the two hospitals, which remain financially independent.
David F. Torchiana, M.D., a cardiac surgeon and the chief executive of Partners, said of the idea of breaking up Partners that it “crossed my mind,” although it “takes a lot to dissolve a 2o-year relationship.”
He added later: “It would be disastrous if we did it now.”
It bears noting that the MGH-Brigham alliance did not merge the assets of the two hospitals, which still compete with each other and remain financially independent.
The Partners HealthCare institution was $53 million short of its budget in the fiscal year that ended Sept. 30. Part of this was connected to unexpected costs of its EHR transition.
STAT reported that the EHR transition — part of an Epic implementation across 10 Boston-based Partners HealthCare hospitals — “cost Brigham $27 million more than its $47 million cost estimation,” reported Becker’s Hospital Review.
The hospital cited improperly coded patient visits that led to lower reimbursements from insurers, estimated at $13.5 million of the $27 million in excess costs. “The other half came from reduced patient volume this past summer in an attempt to avoid miscoding,” reported Becker’s
A doctor’s training hasn’t historically focused on sensitivity. And too often while juggling heavy workloads and high stress, they can be viewed as brusque, condescending or inconsiderate.
A 2011 study, for instance, found barely more than half of recently hospitalized patients said they experienced compassion when getting health care, despite widespread agreement among doctors and patients that kindness is valuable and important.
But payment initiatives and increasing patient expectations are slowly forcing changes, encouraging doctors to be better listeners and more sensitive to patients’ needs.
“We train people to ask the question, ‘What’s the matter?’ We train toward diagnosis,” said Martha Hayward, who leads public and patient engagement efforts at the Institute for Healthcare Improvement, a Massachusetts-based nonprofit. “We don’t train toward lifestyle understanding.”
Many medical centers across the country are striving to improve doctors’ bedside manner. Even some physicians in private practice are working to improve.
Much of the motivation is financial. Under the 2010 health law, Medicare payments to hospitals can be affected by patient satisfaction surveys.
The trend is also fueled by consumer demand. As patients pick up an increasing share of the cost of care, they’re becoming more particular about quality and experience and choosing doctors accordingly.
The University of Michigan, the Cleveland Clinic and some Catholic health systems are among medical systems experimenting with techniques to encourage physicians to be more responsive, said Tim Vogus, an associate professor of management at Vanderbilt University who has researched the relationship between compassion initiatives and patient satisfaction scores.
His research found that hospitals that promote compassion – especially with rewards — are more likely to have higher patient satisfaction scores.
Partners HealthCare in Massachusetts and medical schools such as Duke are requiring some residents to take courses to help them be empathetic and offering training to practicing physicians. Other medical organizations encourage physicians to put personal details about patients in their medical charts so they can bond over topics like hobbies or sports teams. Some urge doctors to send handwritten follow-up notes to patients and their families, according to a survey of 35 health systems published this March by the Schwartz Center, a Massachusetts nonprofit that promotes compassion in health care.
Small gestures, like a follow-up phone call from a doctor, go a long way, said Matthew Taylor, 57. After his daughter was prescribed new medication for her anxiety and depression, the doctor called to check up on her.
“That [the doctor’s office] considered it important — even if it’s only taking 30 seconds or a minute of time to say, ‘Are things going well? Is there anything we need to be concerned about?’ — shows that they’re paying attention to things they need to be doing,” said Taylor, who lives in Mount Airy, Md. “It’s not out of sight, out of mind.”
Such small behavioral modifications aren’t “a panacea,” the Schwartz Center researchers noted in their paper. But they can improve patient experience.
Recognizing Doctors’ Efforts
Doctors working in hospitals are at the forefront of the efforts, often because of the patient surveys’ effects on Medicare payments. But health staffers also need to know how patients view them, so they can figure out what actually works, experts said. At the Cleveland Clinic, employees get a quarterly report that includes feedback from patients’ reviews, said Adrienne Boissy, chief experience officer. If they do things patients dislike, they’ll find out and can adjust.
“If you really don’t get any feedback on your ability to communicate or be empathic,” she said, “you won’t think you have a problem.”
At the University of Rochester Medical Center in upstate New York, doctors who demonstrate compassion are recognized in monthly notes the department head sends out to the hospital’s faculty. Those notes are often based on patient evaluations, which mention, for instance, listening well, spending extra time at a bedside and answering questions in ways the patient can understand.
“These practices are pretty simple things – recognizing people publicly for giving especially compassionate care,” Vogus said. And they can pay off in higher patient satisfaction.
At Rochester, physicians can get coaching. Other doctors watch them practice and work one-on-one with them to help them talk to patients. After shadowing, the coach might talk the doctor through interactions that could have been more thoughtful; then, depending on the critique, they might role-play scenarios based on that conversation.
Coaching changes doctors’ behavior, said Susan McDaniel, a psychologist who directs Rochester’s coaching program. “They’re exhibiting skills that they weren’t exhibiting before.”
It’s hard to say whether factors like age make a difference, she said. Some older doctors are less enthusiastic about changing their ways, but often, they “know better how important good communication is, because of their years of experience,” McDaniel said. Younger doctors are likelier to have had some kind of communication training in medical school, but that doesn’t necessarily mean they’re always better at talking to patients.
“I don’t think I’ve ever in my medical career – this included medical school – had somebody observe me to this degree,” said Jonathan Friedberg, Rochester’s chief of hematology and oncology, who participated in the program. He has since noticed small changes, he said, in how he interacts with patients. The exchanges have become less rote and routine, and more of a conversation.
Improving Health
If patients feel their doctors genuinely care, experts said, they’re more likely to take medications and comply with recommendations.
“Empathic care is a real intervention that has impact on patients’ adherence, whether they’ll come back to see the doctor or just skip town and go untreated,” said Stephen Post, who directs the Center for Medical Humanities, Compassionate Care and Bioethics at Stony Brook University in New York. And listening more carefully could lead physicians to pick up cues and details they might otherwise miss, and consequently prescribe better treatments.
When that thoughtfulness is absent, patients can be turned off. Harvest Moon, 42, who lives Grand Prairie, Texas, found a new doctor condescending and dismissive during a visit in August. She was so upset she forgot to ask about the problem that brought her in and left reluctant to get follow-up care.
“I was feeling obstinate,” she said. “It was almost a way to get back at him.”
When talking with a patient, doctors need to do more than just run through a list of questions. “It’s important to train physicians not to just ask about a patient’s medical history and medications but to make a meaningful inquiry,” Post said.
Doctors can easily forget to listen, Boissy said. Even in her own experience, she’s seen doctors who don’t introduce themselves when they walk into the exam room – a small gesture, but one that helps establish trust and gets patients to open up.
“It’s not that they don’t care. There’s a depth of caring,” she said. “But they forget.”
As The Globe notes “if the merger can be completed, it would reshape the state’s health care industry, creating a system of eight hospitals across Eastern Massachusetts that would rival the {not-for-profit} Partners network of 10 and {for-profit} Steward Health Care System’s nine.”
It also poses a threat to nearby, Rhode Island-based CVS, whose drugstores are rapidly adding urgent-care centers. The prestige of Partners’ famous hospitals may take some business away from CVS’s urgent-care centers, which it calls MinuteClinics. It may also lighten the load a bit in some area hospitals’ emergency rooms.
Partners is late to urgent care in Massachusetts. Steward Health Care System, Beth Israel Deaconess Medical Center, Lahey Health, and others are already in the business, either directly or with partners, The Boston Globe reports.
But, The Globe reports, “Partners has advantages in its size and reputation. It is the parent of 10 hospitals, including Massachusetts General and Brigham and Women’s, and has 6,000 doctors, the largest network in the state. It also is planning more urgent care locations than most of its competitors.”
“This is more than a pilot for us,” said Dr. Gregg S. Meyer, chief clinical officer of Partners, told The Globe. “These are meant to be extensions of availability and convenience for patients. We know we are not always as available as possible for our patients.”
As The Boston Globe notes: “Tufts … straddles the ground between an elite academic medical center and a safety net hospital. Tufts surgeons, for example, perform more heart transplants than at any other hospital in the state. Still, about 60 percent of its patients are covered by … Medicare and Medicaid, a higher portion than at many other hospitals.”
“If Tufts fails to grow, it risks losing business to larger systems that can serve more patients and use their market clout to extract higher payments from insurers.
The Globe says: “Tufts executives say the end of the BMC talks underscores that the hospital’s future lies beyond Boston, where they will seek to link up with other hospitals and expand their network of doctors. They point to the merger with Lowell General as a model.”
How about a merger with Providence-based Lifespan? Or does Partners HealthCare want that for itself?
“Our goal is not to be a big megamedical center in downtown Boston that would require pulling patients into Boston to basically fill the beds. Our goal is to be a nimble, small, academic medical center that works in partnership with the community,” Michael Wagner, M.D., told The Globe.
