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Q&A: Non-Compliance Drives Need for Telephonic Case Management

April 23rd, 2012 by Jessica Papay

Though it emerges in different ways, non-compliance with care plans drives telephonic case management protocols for three distinct populations at Carolina Behavioral Health Alliance (CBHA), explains Jay Hale, its director of quality improvement and clinical operations.

Prior to his presentation on Telephonic Case Management: Protocols for Behavioral Healthcare Patients, Hale defines the distinct groups of behavioral health patients, indicators of non-compliance for each, barriers faced by telephonic case managers, the involvement of PCPs and red flags signaling the need of an in-person visit.

HIN: What is the number one reason behind high levels of inpatient or ER use by the behavioral health population?

(Jay Hale): When we look at the behavioral health population, we’re looking at three different groups of individuals, but with one reason driving all of their care. The three groups are adult mental health, adults with substance abuse issues and children/adolescents, which is generally mental health but can be substance abuse as well. The number one condition that we see is non-compliance with treatment. This comes out in various ways with our mental health population. It comes out as having suicidal thoughts or homicidal thoughts, or other impulsive or dangerous actions that would cause someone to be referred to the ER.

With our substance abuse population, we often see people who stop going to meetings, and/or who stop working with their sponsor and return to the behaviors that they were doing when they were drinking or using, which leads them back to drinking or using. Many of the relapse behaviors lead to using.

Our child/adolescent population is usually a little more complex. Because they don’t have the same control over their environment that adults do, many times they will act out more in either school or home, and that acting out escalates to a point where they’re referred to an ER.

Ultimately, it all comes back to failing to follow through with treatment for various reasons. Many times we begin to get some treatment early on and we get past the crisis, but it’s hard for people to accept that they have a chronic ongoing illness that needs ongoing treatment. Once they start to feel better, they stop or cut back on treatment, but then things begin to deteriorate for them and they don’t catch it until it’s at a crisis point where they’re back in the ER.

HIN: What barriers may a telephonic case manager encounter when contacting someone with a mental health issue? What advice do you give the case managers on establishing rapport during these calls?

(Jay Hale): One big barrier that we see is making sure that we have the member’s correct phone numbers. We want to make sure that we have updated information so that we’re calling the correct people. Another barrier is having the member on the other end trust us enough to accept our help, or accept our support, in their care.

I advise our case managers to work with other people who are working with the member early on. We want to work with the hospital earlier before the person is discharged to get correct contact information and to let the member know that we’re going to be contacting them. We want to be part of that discharge plan and operation, and we want our case management program to be part of that plan as well — a plan that shows that the patient is going to the psychiatrist, or a therapist, and that they’re going to be followed up by us telephonically.

When one of our case managers calls a member to invite them to be part of our program, we want to talk to the member about how the program helps them. We want to emphasize how this is helping them in their recovery for either a mental illness or for a substance abuse episode. With substance abuse individuals, we want to make sure that we are using the language that they are comfortable with in early recovery — language where we’re making sure we’re supporting their recovery program, they’re working their steps, they’re following through with their meetings, etc. We are letting them know that we understand their situation and that we’re supportive of them in their recovery. With mental health individuals, we want to make sure that they feel comfortable with us, that we are understanding their situation, and that we are not here to do counseling. Rather, we are here to support them in their recovery and to help them see the improvements that they’re seeing as they follow through with treatment.

With our child/adolescent population, we’re usually working with the parents. Many parents are appreciative of the support that we can give them as they try to help their child or adolescent do better in school, do better at home and have a more successful life early on. We’re about letting the parent know that we’re not here to blame anyone for any situation that the child is in, but rather, we’re there to support them in having a healthier family and a healthier child.

HIN: How involved is the individual’s primary care provider or any other providers in this process?

(Jay Hale): The member’s providers are a very important part of our program. We want to make sure that the member is going to their sessions, is seeing their psychiatrist or therapist, is going to meetings, etc. We reach out early to those behavioral health providers to let them know the member is involved in the program, that we are not there to be between their relationship — we’re an adjunct to support that ongoing relationship — and to let them know we solicit their support in this service so that the member understands that we’re all working toward one goal. And that one goal is improvement of the member’s care and helping them be and live successfully outside of a hospital environment. One of the things we’re looking at in care management, or case management, is making sure that they’re attending sessions. Behavioral health providers often like to hear that the insurance company is encouraging people to go to sessions rather than limiting sessions. We usually get a lot of support from our providers for what we’re doing.

HIN: You defined three very different groups. What are some indications or red flags that might arise during a call with a behavioral health client that could mean an in-person visit with a provider is warranted?

(Jay Hale): One of the things we’re looking for is changes in symptoms. Those changes in symptoms, or changes in habits, could be asking the individual at each call about their depression; any type of mania that they may be experiencing, if there’s a history of such. We’re asking about any other psychiatric symptoms that they’re having and asking the member to rate them. Then, we look at our information to see how much of a change that is from the last time we spoke.

If we start to hear about any kind of deterioration, we explore those issues further to see how serious it is — if it’s something that is temporary or something that is more ongoing. We’re also going to be looking for other factors, such as medication compliance. Is the person still following through with their medication? Did they have any difficulty with it? If they have, have they let their provider know they’re having difficulty with those medications? If we start to hear any kind of decompensation when we’re concerned about someone’s safety, or we’re concerned that someone is starting to slide back and return to the more unhealthy behaviors that they had in the beginning, we will make a phone call to that provider to see if we can get an appointment set up for that member to be seen quickly. This way, they can be assessed and changes in treatment can be arranged. Or it could be getting the member back into treatment again if they’ve fallen back or stopped going.

With our substance abuse individuals, often we’re looking for frequency of going to AA meetings, frequency of contact with their sponsor or any kind of irritability, especially over going to meetings. Many times individuals will start to talk about how the meetings are not helping them. We want to help them problem-solve around other things that could help them more and encourage them to start going back to those meetings or start working with that sponsor. If that’s not working, we may help them get in contact with an outpatient therapist who specializes in substance abuse issues to help see if there are other mental health concerns that are driving some of these relapse behaviors.

Posted in Avoidable ER Use, Behavioral Health, Case Management, Health IT, Healthcare Administration, Healthcare Trends, Medication Management, Telehealth & Telemedicine, e-Health | No Comments »

Hospitals Will Spend More on IT, Move Toward ACOs in Near Future

March 14th, 2012 by Jessica Papay

Hospital budgets are on the upswing but cost pressures and changing healthcare models are dictating how hospital leaders are determining their strategic priorities. Sixty-one percent of U.S. hospital executives expect budget increases in 2012, a trend that is expected to continue during the next five years, according to an L.E.K. Consulting Strategic Hospital Priorities Study.

Information technology (IT) is a top area for investment, with 57 percent of hospitals planning to increase their IT spending in this area through 2016, according to the study. During the same time period, one-third of executives are planning to increase spending for large medical devices after several years of delaying medical technology equipment purchases due to financial constraints. Other spending increases during the next five years include facilities (35 percent) and small medical devices (18 percent). Hospital leaders are also willing to pay a premium for disposable products that prevent infections and reduce medical errors — and they expect a 23 percent spending rise in this category.

Most respondents (89 percent) reported increased budgetary pressures during the past year. As a result, 80 percent of hospital administrators continued their aggressive supplier negotiations to better manage costs. Despite their best efforts, there is a concern that rising costs from manufacturers and suppliers, and added costs associated with new regulatory requirements, may raise overall supply costs.

To make the most of their budgets, the study found that 62 percent of hospital executives plan to increase their current Group Purchasing Organization (GPO) use in 2012, up from 52 percent last year. Hospital GPO use is expanding beyond low-cost, high-volume supplies and is increasingly used to purchase higher-priced medical equipment. And smaller hospitals anticipate using GPOs more than larger hospitals because larger hospitals can use their size to negotiate volume discounts with many of their suppliers.

Additionally, many hospital executives are centralizing purchasing to make the most of their buying power, which illustrates a departure from individual physicians taking the lead in procuring key medical products. The development of accountable care organizations (ACO) is also likely to push more centralized purchasing. Currently, less than 20 percent of respondents are pursuing some form of an ACO-like model today. However, 61 percent said they are likely to move toward this model within the next three years.

Other study findings show that a majority of hospital executives (71 percent) are allocating budgets to address operational priorities such as controlling costs, increasing efficiency and improving the profitability of their patient mix. Respondents reported that they are looking for medical device companies to help them address new healthcare insurance reform care and reporting mandates by clearly articulating product cost-benefit value propositions, providing clinical data, sharing risk and offering full solutions.

Posted in Accountable Care Organizations, Affordable Care Act, Health IT, Healthcare Administration, Healthcare Costs, Healthcare Trends, Physician Practices, e-Health | No Comments »

6 Features of CMS’s Redesigned Medicare Summary Notice

March 12th, 2012 by Cheryl Miller

In light of ongoing healthcare reform there is a push for clarity, as several of our stories illustrate this week. Medicare claims forms have been redesigned so that beneficiaries and their caregivers can better understand them, check for important facts and potential fraud. The subject of fraud is particularly timely given the story that has been circulating for the last week involving the arrest of a physician, the office manager of his medical practice, and five owners of home health agencies. They’ve been charged with allegedly participating in a nearly $375 million healthcare fraud scheme involving fraudulent claims for home health services.

When given the option of choosing a high or low cost health plan, consumers will most likely choose the higher cost plan because they associate it with better quality, says a new study funded by the AHRQ. But researchers caution that this isn’t necessarily true: higher costs could be attributed to unnecessary services or inefficiencies. A push is underway to simplify public physician and hospital report cards, and make them clearer for consumers to understand (not unlike the redesigned Medicare claim forms) so consumers can make better informed decisions about their health coverage.

The Robert Wood Johnson Foundation and Group Health Research Institute have launched a new national project intended to shed light on what makes a successful health practice tick. Designed in response to the burgeoning shortage of primary care practices, the project will identify successful practices that improve patient and practice outcomes, and share the information so they can be replicated.

And lastly, a study debunks the long held belief that HIT will improve cost savings by reducing the need for diagnostic testing; instead, the study shows that having computerized access to EHRs in the ambulatory setting could result in a 40 to 70 percent increase in testing.

Don’t forget to take our latest survey: Physician Reimbursement Models. Describe the physician reimbursement models in place at your organization by April 15th and you will receive a free summary of survey results once it is compiled.

These stories and more in this week’s Healthcare Business Weekly Update.

Posted in Affordable Care Act, Avoidable ER Use, Behavioral Health, Consumer-Driven Healthcare, Health IT, Uncategorized, e-Health | No Comments »

CMS to Release Stage 2 Meaningful Use proposals

February 27th, 2012 by Cheryl Miller

CMS and the Office of the National Coordinator for Health IT have just announced proposed regulations for Stage 2 Meaningful Use and Medicare and Medicaid EHR Incentive Programs.

Incorporating recommendations from the Health IT Policy Committee, they stress the need for hospitals and physicians to improve quality and efficiency through HIT. The rules focus on increasing the electronic capturing of health information in a structured format, and increasing the exchange of clinically relevant information between providers of care at so-called “care transitions.”

At this time of writing, some of the new Stage 2 recommendations will include the following: the percentage of orders entered via computerized physician order entry (CPOE) will rise from 30 percent to 60 percent and include medications, labs and radiology; E-prescribing in the emergency department will increase from 40 percent to 60 percent; and recording objectives, such as problem lists, vitals and smoking status will increase from 50 percent to 80 percent.

The proposed Stage 2 regulations will keep some Stage 1 criteria unchanged, revise others, and include new requirements. Once published in the Federal Register, there will be a 60 day comment period; these regulations are expected to be released this summer.

In related news, the use of HIT by hospitals and physicians has more than doubled in the last two years and CMS reports that nearly 2,000 hospitals and more than 41,000 doctors have received $3.1 billion in incentive payments for ensuring meaningful use of health IT, particularly certified EHRs. EHR incentive payments can total as much as $44,000 under the Medicare EHR Incentive Program and $63,750 under the Medicaid EHR Incentive Program.

Want to know the secrets to launching a successful ACO pilot program? Thomson Reuters has published a report showing four key metrics that can predict success; the first metric is the number of attributed members. The others are detailed in this issue.

And unfortunately, there is no secret formula to reducing avoidable hospitalizations; according to a new study from Delta Health Technologies, which was based on data from more than 1,000 homecare agencies across the U.S., while most agencies are taking steps to reduce avoidable hospitalizations, with patient care a strong concern, there was no one magic formula for success in this area. But there were a number of findings on successful hospitalization reduction strategies.

And don’t forget to participate in our latest e-survey: our third annual Healthcare Case Management survey. Participants receive a free, downloadable executive summary of the results once compiled.

Posted in Accountable Care Organizations, Avoidable ER Use, Case Management, Health IT, Healthcare Costs, Uncategorized, e-Health | No Comments »

Q&A: HRHC Diabetes Collaborative Relies on Tiered Care Management, Registries

January 23rd, 2012 by Jessica Papay

Patient care partners, innovative weight management tactics, patient registries and even telepsychiatry are part of the team approach to diabetes management at Hudson River HealthCare (HRHC) Diabetes Collaborative. The New York-based network of FQHCs finds that tiered care management generates the best outcomes for its patients with diabetes, explains Kathy Brieger, RD, CDE, HRHC’s chief operations officer, prior to her presentation on Diabetes Management in the Medical Home.

HIN: The Hudson River HealthCare (HRHC) Diabetes Coalition uses a patient-centered team approach to manage diabetes in its more than 3400 adult patients with the disease. HIN recently did a survey to find out about disease-focused programs in particular, those that manage diabetes. Our respondents told us that weight management is the most challenging aspect of this disease. Would you concur? If so, how does HRHC address weight management in its population?

(Kathy Brieger): I would agree with this. Weight management is one of the most challenging focuses of this condition. In order to meet this challenge, we’ve had to look at programs from a variety of aspects. We started walking clubs in some communities to encourage physical activity. There’s also a Taking off Pounds Sensibly group, which is a Weight Watchers format but at a lower cost for patients who may be at a low income. We’ve done programs on mindful eating and general ways of looking at portions. We’ve also done a lot of work related to children and preventions. I think this is a big target. We focus on prevention and giving people the options of attending a variety of program formats for weight loss.

HIN: Over the last 12-18 months we’ve seen that case managers are increasingly employed on site, in primary care practices, to assist with the management of chronic illness. Are there any case managers in the HRHC mix?

(Kathy Brieger): This is a key question to diabetes management. We’ve found that a team-based approach to care is really the most effective. We have several team members who help to case-manage the patients. And that includes everyone from a dietician to people called patient care partners. Patient care partners may not have a clinical license, but are trained in motivational interviewing and help to serve as a bridge between the clinical team and the patient. We also have sophisticated, high-level RN care managers who work in a targeted way with patients who have diabetes. Those are usually the patients who have comorbidities and who may have poor control over their diabetes. At Hudson River HealthCare, we look at a team-based approach using different levels of care to get the best outcomes. We find that that really is the most effective.

HIN: The more sophisticated care managers are for the sicker patients with comorbidities. How do you assign patients to the other two levels of management?

(Kathy Brieger): We have some reporting systems because we do have an electronic health record; we use eClinical Works® (ECW). We have different cutoffs for the care manager. We’ve run the registries. For people who have hemoglobin A1Cs of over 8 or 9, the care manager reviews them and she’ll pull off people who may have some of those indicators. Also, the medical providers will tell us, “This person may not have a hemoglobin A1C of over 8 or 9, but they’ve been in and out of the hospital several times.”

Right now, we’re also working with hospitals to get us hospital discharge summaries so we can see if those people who may have some unstable situations that we’re not aware of can be pulled in. For every single person who has diabetes, their care is also managed by the patient care partners. We taught them how to use the registries, how to call people in for group classes and how to send letters out for our programs. These levels are done in a three-tiered approach using the care team so that the patient care partner who is assigned to the care team, the nurse who is assigned to the care team and the provider assigned to the care team would together be able to route or send people to the right place. The bulk of our patients are able to do the low-level patient care part. It’s just the top 15 percent that are having some issues.

HIN: It sounds like registries are important to the program.

(Kathy Brieger): Yes, they are. Over 10 years ago, we started with the Patient Electronic Care System (PECS) as part of the federal government’s move to get a population health underway, but it was a limited standalone registry. And then about three years ago when we became fully electronic, we were able to get our registries and our reports done on all patients with all conditions, and that is valuable. We’ve done a lot of work on training our staff on how to use registries; it’s not so helpful just to have registries; you have to know how to use them.

We’ve tried to use registries as a teaching tool for everyone from even clinical assistants in training all the way up to the providers. They know how they can use it to have more effective team-based care, more effective disease-based focus, and even prevention of things like, “When did you get your mammogram done last?”

HIN: And finally, are there any applications in telehealth, telemedicine or remote monitoring that you are using successfully in the management of diabetes?

(Kathy Brieger): Yes. We’re involved with telemedicine, focusing on telepsychiatry at one site. We have purchased equipment and are right now getting it cabled for six different locations, so that we’ll be able to expand our services in the telemedicine area. We do have some sites that are located in remote areas. We are unable to get some specialists that may help in the management of diabetes. We think telemedicine will be a great resource in improving some access to services that may not be available in some of those remote areas. Even though we’re in New York, people think we have all types of access to specialists, but there are areas where they do not exist, even in New York. We’re looking forward to having that happen.

Posted in Case Management, Disease Management, Health IT, Patient-Centered Medical Home, Telehealth & Telemedicine, Wellness/Prevention, e-Health | No Comments »

Timeline to ICD-10: BCBS Michigan Approach is Business-Driven

January 19th, 2012 by Patricia Donovan

In its third year of ICD-10 work, BCBS of Michigan sees the project as business-driven, not solely an IT initiative. Early on, the Blues plan realized the ICD-10 transition affected nearly all aspects of its business, explained Dennis Winkler, BCBSM’s ICD-10 technical program director, in this week’s webinar on Mapping the Way to ICD-10 Readiness.

One of the first steps in the project was determining how and where it was using codes, Winkler continued. The challenge was then determining how to associate or map ICD-10 diagnosis codes to the proper diagnostic category, and then validate the mappings for professional claims. Faced with more than 70,000 ICD-10 codes, BCBSM focused its work on codes with discrepancies and high-impact codes.

After identifying discrepancies — when an ICD-10 code points to more than one ICD-9 category — BCBSM enlisted five ICD-10-certified coders and a legion of doctors and nurses to help resolve code discrepancies.

The result of their efforts was “BCBSM Blue GEMs” — the payor’s own customized database of general equivalence mappings (GEMs) whose life span would end when CMS stops updating GEMS. The company is willing to share BCBS Blue GEMS with interested entities who wish to model its approach, provided a formal request is submitted.

The BCBSM Blue GEMS will be loaded into an ICD-10 encyclopedia, an enterprise-wide tool that will become “the single source of truth” on ICD-10 as well as a baseline for annual updates, Winkler said.

Winkler also predicted that the issue of ICD-10 neutrality — which occurs when neither the claims acceptance rate, the number or rate of inquiries, the rate of electronic claims or claims reimbursement amounts are affected — will continue to be a hot topic for 2012. Winkler defined the four challenges of neutrality as well as its six targeted dimensions, emphasizing that BCBSM has a reliable process for each of these six dimensions.

A successful transition to ICD-10 will require different levels of collaboration from payers, providers, medical societies and state agencies to get the job done, followed by “testing, testing and more testing.”

Posted in Health IT, Healthcare Administration, Healthcare Costs | No Comments »

Hospital Initiative, GE-Microsoft Collaboration Target Healthcare-Acquired Conditions

December 19th, 2011 by Cheryl Miller

Hospitals are the targets of two of our stories this week: an initiative and collaboration both aimed at reducing the millions of preventable injuries and complications arising from hospital-acquired infections (HAI.) Ironically, this refuge for the sick is making people sicker; in the United States alone, an estimated 1.7 million HAIs occur annually, resulting in $35 billion in additional healthcare costs, and the loss of nearly 100,000 lives. As we reported in an earlier story this year, a University of Maryland report found that nearly half of the hospital rooms of patients who tested positive for a multi-drug resistant bacteria were contaminated with the bacteria.

In response to this, hospitals across the country will now have the resources and support to reduce HAIs: the HHS has launched a new initiative called the Hospital Engagement Network. Part of the Partnership for Patients initiative, a nationwide public-private collaboration to improve healthcare, $218 million will be awarded to 26 state, regional, national, and hospital system organizations to help develop learning collaboratives for hospitals and provide a wide array of initiatives and activities to improve patient safety.

And a new collaboration between GE Healthcare and Microsoft is tackling this problem by pulling together data from disparate IT systems and identifying those patients most at risk for a given HAI. Hopefully their solutions will enable healthcare organizations to more effectively deploy their resources and deliver better care at lower costs.

And on a local level, a new ER unit designed solely for seniors is in place in HIN’s backyard, at New Jersey’s Monmouth Medical Center. To ease the increasingly complex needs of those 65 and up, the unit has special age-related features like wall sconces with dimmers and floor lighting to prevent falls. More in this issue.

In other news, a new study shows that disease registries can improve health outcomes and save the United States billions of dollars. Research on 13 registries in five countries, including the United States and Sweden, shows that these tools are becoming even more important under healthcare reform as payments for care are linked to effective treatments. According to our 2011 Survey on patient registries, 68 percent of respondents are using registries to improve care quality.

And lastly, a new report from Deloitte reveals that the majority of physicians do not think that PPACA will reduce costs by increasing efficiency, and they are predicting a continued shortage in primary care physicians as they seek administrative roles in health plans, hospitals and other settings.

These stories and more, in this week’s issue of Healthcare Business Weekly Update.

Posted in Accountable Care Organizations, Affordable Care Act, Avoidable ER Use, Disease Management, Health IT, Healthcare Administration, Healthcare Costs, Healthcare Trends, Hospital Readmissions, Transitions in Care, Uncategorized | No Comments »

Got an Idea? CMS Offers $1 Billion in Health Care Innovation Challenge

November 28th, 2011 by Cheryl Miller

The CMS continues to reward innovation in healthcare; the latest initiative, the New Health Care Innovation Challenge, plans to award up to $1 billion in grant money to organizations that come up with creative ways to deliver healthcare, improve care and lower costs. The agency will take notice of projects that can be up and running within six months and that can hire, train and deploy workers rapidly. Funded by the PPACA, it’s a push for both creative healthcare solutions and increased healthcare job opportunities in as short amount of time as possible, contrary to the Innovation Advisors initiative launched in October, which seeks healthcare solutions over a year long, labor intensive period. All segments of the healthcare industry are encouraged to apply for the Innovation Challenge; December 19th is the cut off date for LOIs.

A quick, innovative, effective solution is also needed to alter the latest statistics on diabetes furnished by the IDF on World Diabetes Day (November 14th): studies show that one adult in 10 will have diabetes by 2030. Far too many are already afflicted with the preventable disease, including 78,000 children suffering with type 1; this despite the fact that the greatest number of diabetics fall within 40 to 59 years of age. The IDF is hoping that continued international awareness of this problem will help; and the agency is in the midst of a five-year campaign to promote diabetes education and prevention programs. Ironically, the CMS cited one health system that worked with community partners to decrease the risk of diabetes with nutrition programs as inspiration for its Healthcare Challenge initiative. Food for thought.

Another area of concern is the number of seniors receiving the wrong medication during their home healthcare visits. The Journal of General Medicine recently published a study stating that nearly 40 percent of patients 65 and over are prescribed potentially inappropriate medications (PIMs) at rates three times higher that patients who visit a medical office. Some of the blame can be placed on our fragmented healthcare system, researchers said: home health-based patients see multiple physicians who don’t communicate with each other, resulting in the wrong medication. Perhaps most troubling about this study is that the majority of these patients are taking 11 medications on average, and nearly half of them are taking at least one PIM, researchers say.

And lastly, one quick fix that should boost care access for patients: a new clinical affiliation between CVS Minute Clinics and Emory Healthcare. The stand alone clinics are open seven days a week in select areas throughout metropolitan Atlanta and have nurse practitioners on hand to administer wellness and preventive services and tend to common family illnesses. Patients who need care not provided at the clinics will be referred to Emory Healthcare. Both CVS and Emory hope to streamline the process with the use of EMR systems. These stories and more in this week’s issue of Healthcare Business Weekly Update.

Posted in Accountable Care Organizations, Avoidable ER Use, Bundled Payments, Disease Management, Health IT, Healthcare Costs, Healthcare Trends, Hospital Readmissions, Uncategorized, Wellness/Prevention | No Comments »

ACO Final Rule Accompanied by Advance Payments for Care Coordination Tools

October 24th, 2011 by Cheryl Miller

The anxiously awaited final rule on accountable care organizations (ACOs) for Medicare beneficiaries is finally out. Based on the more than 1300 comments CMS received on its proposed ACO ruling first released in March, this new rule will make it easier to establish ACOs by providing organizations with additional funding for support tools, such as new staff or information technology systems. Under this new initiative, the Advanced Payment Model, these payments would be recovered from any future shared savings.

The second initiative, the Medicare Shared Savings Program, will provide incentives for healthcare providers who agree to work together and become accountable for coordinating care for patients. Participants who meet certain quality standards based upon, among other measures, patient outcomes and care coordination among the provider team, may share in savings they achieve for the Medicare program. Both initiatives launched on October 20th.

The United States earned low marks in healthcare access and affordability in the Commonwealth Fund’s third annual scorecard report. According to the report, the nation received a 64 out of a possible 100 when compared to best performers. Among the findings that contributed to the score were the percentage of overweight or obese children (32 percent), the number of prescription errors among elderly Medicare beneficiaries (one out of four) and the percentage of adults that reported not having a primary care provider in 2008 (44 percent).

Despite the low scores in key quality indicators, the United States is doing something right in the area of heart failure (HF) care. New research from the Yale School of Medicine shows that hospitalization rates for HF dropped by 30 percent from 1998 to 2008. One year mortality rates also dropped slightly during this period. HF ranks as the most frequent cause of hospitalization and re-hospitalization among older Americans, with related costs estimated at $39.2 billion in 2010.

In other news, 46 percent of physician practices do not meet NCQA standards for medical homes. The news, from a recent University of Michigan-led study, found that while larger, multi-specialty practice groups can more easily meet the standards, one in nine Americans receive healthcare from smaller, often solo practices. Researchers recommend initiatives to help these smaller practices team up with larger organizations to establish more medical homes.

More than 50 percent of physicians and hospitals are looking at ways to team up, a trend that is causing medical malpractice concerns. Aon’s 12th annual Hospital and Physician Professional Liability Benchmark Analysis states that healthcare systems will face significant risk management challenges associated with integrated physician-hospital arrangements. The study details the growth of integrated self-insurance strategies and highlights the challenges faced by systems as they pursue the cost of risk savings.

And lastly, what are you doing to staunch the flow and expense of avoidable emergency department use? Describe your efforts in this area by October 31 and you will receive a free executive summary of results from this second annual survey. These stories and more in this week’s issue of Healthcare Business Weekly Update.

Posted in Accountable Care Organizations, Affordable Care Act, Avoidable ER Use, Health IT, Healthcare Administration, Healthcare Costs, Healthcare Quality Ratings, Healthcare Trends, Hospital Readmissions, Patient-Centered Medical Home, Physician Practices, Reducing Readmissions, Uncategorized | No Comments »

CMS Seeks Innovation Advisors

October 24th, 2011 by Cheryl Miller

CMS has rolled out a lot of solid initiatives this year; now the latest, the Innovation Advisors program.

The CMS Innovation Center is looking to recruit up to 200 healthcare professionals, including clinicians, allied health professionals and health administrators, to test and refine new models of healthcare delivery for Medicare, Medicaid and CHIP beneficiaries. Program officials hope to deepen skills that will drive improvements to patient care and reduce costs. 

Those who are selected for the program will have to commit up to 10 hours a week for the first six months of the program attending on site and remote sessions to expand their skills and knowledge. The rest of the year-long program will be spent implementing what they learned in their organizations and communities.

Participants will be asked to:

  • Support the Innovation Center in testing new models of care delivery.
  • Utilize their knowledge and skills in their home organization or area in pursuit of the three-part aim of improving health, improving care, and lowering costs through continuous improvement.
  • Work with other local organizations or groups in driving delivery system reform.
  • Develop new ideas or innovations for possible testing of diffusion by the Innovation Center.
  • Build durable skill in system improvement throughout their area or region.

    • This initiative is just one of a number of efforts proposed by CMS this year; to date, more than 5,000 organizations have joined the Partnership for Patients and pledged to reduce hospital-acquired conditions and improve transitions in care.  The Bundled Payments for Care Improvement initiative will give providers flexibility to work together to coordinate care for patients over the course of a single episode of an illness.  The Comprehensive Primary Care Initiative will allow CMS and other payers, such as employer-based health plans, to align strategies designed to strengthen primary care services delivered to Medicare beneficiaries.

    Applications for the Innovation Advisors program are due on November 15, 2011.  Applications will be reviewed and Innovation Advisors will be notified of their selection by mid-December 2011. 

    More information, including a fact sheet, frequently asked questions, application and terms and conditions can be found here.

    Posted in Accountable Care Organizations, Affordable Care Act, Bundled Payments, Health IT, Healthcare Costs, Healthcare Trends, Uncategorized | No Comments »

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