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N.J. ACO’s success linked to PCMHs, nurse coordination


Results have varied a lot across America for Medicare Accountable Care Organizations in their efforts to  save money and improve clinical outcomes. One that has done well is a New Jersey Medicare ACO that saved money and boosted care for two years in a row  while focusing on high-risk patients, says a study published in the American Journal of Managed Care.

The Hackensack Alliance Accountable Care Organization  had fewer readmissions and admissions and lower emergency department use, compared to a similar ACO group.  The organization also had far more patient office visits, which improved outcomes across the board, particularly for patients with chronic conditions.

The ACO reported shared savings of $5.6 million in the first year and $2.8 million in the second year.

The authors cited two big things for the successes:

  • An initial requirement that its physician practices be certified as patient-centered medical homes (PCMHs), which meant that physicians  understood what is required within a value-based care system.
  • Nurse  coordination  for patients at high risk for readmissions.

The authors of the study wrote: “We should emphasize that we do not change physician practice, we change physician behavior. By creating the appropriate interventions, we eliminate waste in our bloated healthcare system. We learn to address patient needs better. Although we are still good at disease management, we learn how to perform health management better from the PCMH model.”

To read the study, please hit this link.

CMS/AHIP come up with new quality measures


The Centers for Medicare & Medicaid Services (CMS) and America’s Health Insurance Plans (AHIP), the main private-health-insurance lobbying group, have unveiled new  sets of core measures for quality care.

The Core Quality Measures is a collaboration to design and implement a standard set of metrics across payers so that providers who have been forced to report different quality metrics on a payer-by-payer basis get their administrative burdens reduced as CMS and private payers move to  a common system.

The seven new measure sets include metrics for Accountable Care Organizations/patient-centered medical homes, primary-care cardiology, gastroenterology, HIV/hepatitis C, medical oncology, orthopedics, obstetrics and gynecology.

The announcement is a  step in the transition from the traditional fee-for-service model.  Fierce HealthPayer noted: “While improved quality of care provides an attractive philosophical underpinning for a value-based care model, it’s very difficult for practices to take pragmatic steps toward improving their quality of care without knowing how payers define quality and, more importantly, how they intend to measure it.”

Healthcare quality is more than audit results

Fred N. Pelzman, M.D., the New York writer and internist, writes in MedPage Today:

“The Institute of Medicine’s report ‘Vital Signs: Core Metrics for Health and Healthcare Progress’ from the Committee on Core Metrics for Better Health at Lower Cost, attempts to define such a set of metrics we need to measure to ensure that we are taking the best care of each individual patient, each group of patients, and each population that we are providing care for.”


But, he warns, “All of these checkboxes, audits, database reviews, lead, in more cases than not, to us paying lip service, checking a box, testifying that we have reconciled meds or counseled a patient on healthy lifestyles, come up with a plan for weight loss, ensured that they will definitely take their medicines. Quality is more than audit results and patient satisfaction scores.

“We risk catering our care to the measured outcome, rather than to true quality and what is best for patients….

“As we build up patient-centered medical homes, Accountable Care Organizations, and other models of care, we need to continuously ensure that we are not being overwhelmed with mindless tasks that add no benefit to our patients, that by default cause us to click a box to get through our day’s work….”



Hope and anxiety from new Medicare law


Physicians are generally happy, or at least relieved, about the new Medicare payment reforms, which assure them of higher reimbursements from the Feds.

Some worry that the drive to federally standardize treatment-outcomes measurements will put undue  record-keeping pressure on them. And, yes, it’s often difficult to measure outcomes, and what about uncooperative patients?

But, of course, the drive to fee for value from fee for service is already well underway, if far too complicated because of the turgid role of the insurance companies.

The new law seems sure to speed the absorption of physician groups into hospital systems where  big back offices and economies of scale make it easier to  measure and record outcomes.  And it will be a big stimulus for expansion of Accountable Care Organizations and patient-centered medical homes.


Cutting waste: Advancing beyond the ACO


Modern Healthcare reported that “Chapin White, a senior policy researcher at the RAND Corp., pointed to the historic slowdown in Medicare costs as one of the most important trends in healthcare spending. But he also pointed out that the spending reductions have been achieved largely through rate cuts to providers rather than widespread adoption of risk-based payment systems. ‘ACO’s are really tinkering on the edges of the big picture of Medicare spending,’ White said.”Patient Centered Medical Homes and bundled payments are two other approaches  to avoid rewarding providers for quantity of care instead of quality.

”Kristen Miranda, vice president for strategic partnerships and innovation at Blue Shield California, said the changing payment landscape is resulting in some strange bedfellows….she cited the not-for-profit insurer’s partnership with competitor Anthem Blue Cross to launch the $80 million California Integrated Data Exchange as evidence of unique collaborations aimed at creating a more efficient healthcare system.”

Some argue that ”paying doctors more for services provided at hospitals than they get paid for the same care delivered in an office is driving up costs and driving consolidation. ‘The site-of-service differential has to go,’ said Simeon Schwartz, CEO of New York’s WESTMED Medical Group,” Modern Healthcare reported.

The PCMH and/or the ACO route?

Should physician groups become  patient-centered medical homes (PCMH) and/or affiliate with  Accountable Care Organizations? 

This Medical Economics article provides some guidance.

 “Because the PCMH and ACO share common goals of lowering costs and improving patient outcomes, physicians often think of them interchangeably. But they differ in that a PCMH is an approach to care for an individual practice, whereas an ACO is a method of reimbursing a network of providers. ‘Basically, the PCMH is a care delivery mechanism, while the ACO is a payment mechanism,’ explains David Gans, FACMPE, senior industry affairs fellow with the Medical Group Management Association (MGMA).”’

Trying to address overcrowding at a big E.D.


In what might or might not be some useful ideas for other big urban hospitals, two New York officials have released a report on overcrowding in the emergency department of huge and prestigious New York Presbyterian Hospital, in  northern Manhattan.

Federal healthcare regulators said 5 percent of the hospital’s E.D. patients leave before  medical professionals see them — compared with the national average of 2 percent. That might not seem like  much of a difference, but given  the huge population that runs through Presbyterian, it means a lot of untreated and/or irritated customers. Of course, given the location, a lot of these patients have no insurance and chronic illness. They’re heavy duty.

Among the suggested improvements: increased staffing, improved patient privacy, ”better access to urgent-care centers, and inclusive partnerships with community health providers and professionals,” reports WCBS. It should be noted that some politicians pushing these reforms see Presbyterian as an opportunity to create more local jobs, for which the politicians would take credit.

We at CMG have been in that E.D. (or E.R. as we instinctively first call it as pushback to certain commercials on TV)  and so suspect that many, perhaps a majority, of patients there would do better going to urgent-care facilities, including  Federally Qualified Health Centers, if there were enough of them. And most need patient-centered medical homes.




Enhanced medical homes for kids seen to improve outcomes


An article in JAMA concludes:

Among high-risk children with chronic illness, an enhanced medical home that provided comprehensive care to promote prompt effective care vs usual care reduced serious illnesses and costs.”

The aim of the study was to find out “whether an enhanced medical home providing comprehensive care prevents serious illness (death, intensive care unit [ICU] admission, or hospital stay >7 days) and/or reduces costs among children with chronic illness.”

The study’s authors had noted that regular “Patient-centered medical homes have not been shown to reduce adverse outcomes or costs in adults or children with chronic illness.”



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