Healthcare Intelligence Network

Physician performance-based reimbursement in the same state can vary widely, as evidenced by this interview with representatives of two Colorado medical home initiatives.

Note: This interview was excerpted from MORE Medical Home Reimbursement Models: ROI from Risk Adjustment, Shared Savings and Multi-Payor Partnership.

HIN: Dr. West, which incentives are built into medical home reimbursement models for Mesa County specialists taking care of a patient whose care is managed by a medical home?

Response: (Dr. David West) The specialists are looked at by specific procedures from our IPA data. Using orthopedic surgeons as an example, maybe we will have a hip replacement, which is done by most orthopedic surgeons in our area, and the orthopedic surgeons’ total cost for doing a hip repair — their hospital fees, medical supply fees and anesthesiologist fees — may all be tabulated. That information is then listed from the most cost-effective doctor to the least cost-effective. This is tricky; it takes much input from the orthopedic surgeons to make it as fair as possible. One orthopedic surgeon at the top of the list may have cost for a total hip replacement that is half of the cost for another surgeon at the bottom of the list.

The reward to that orthopedic surgeon is, when that data is known to all the members of the IPA, they can simply say, “I will send my patients to that orthopedic surgeon because they do it cost-effectively.” It’s an indirect reward, but a substantial one, when these medical home models share worthwhile, important data.

HIN: Ms. Schilz, which health plans participating in the Colorado program are paying a PMPM capitation or sub-capitation, and what is the payment range? Are the payments risk-adjusted in any way?

Response: (Julie Schilz) All of our health plans are paying a PMPM care management fee. We have Anthem, Aetna, CIGNA, Humana and United HealthCare as our private payors, and the Colorado Medicaid program and our safety net insurer CoverColorado.

The ranges for the PMPM are based on the level of NCQA PPC-PCMH that was achieved by the practices: Level 1, Level 2 or Level 3. The thought was, and this was not done through actuarial analysis, if you were performing at Level 1 in NCQA PPC-PCMH, you probably are not implementing as much of the PCMH concept as you would be if you are a Level 3. The ranges are: $3 to $4.50 for a Level 1, $4.50 to $6 for a Level 2 and then $6 to $8 for a Level 3. Some of the health plans may fall inside or outside of these ranges, but that gives you a general idea.

There was no risk adjustment for our private payors. Our Medicaid looked differently at their population, which was an adult population with some more intense needs. CoverColorado made some adjustments in their PMPMs to account for what they felt was to be a higher-risk population.

HIN: What are the challenges evaluating ROI and patient satisfaction in multi-payor programs and how can these be addressed?

Response: (Julie Schilz) There are many challenges. One is that we have 16 practices and 17 sites — anywhere from a single doctor practice to an eight-doctor practice. To build enough patient lives within those practices to get to data that feels statistically significant has been challenging. Because of that, we decided to pool the practices for utilization metrics, such as the ER and hospitalization, and generic e-prescribing use. But we did decide to keep their clinical measures separate; each practice will be evaluated on their own clinical measures.

The other challenge is having multiple payors at the table and making sure that we’re thoughtful in our discussions so that we don’t impact anti-trust considerations. We also want to be thoughtful when it comes to their competition: the components that need to be consistent among all the payors and providers and those that have a little flexibility. For example, when we first started, we thought we would want one standard contract that each health plan would use with each participating pilot practice. We found that this was probably not doable because of each health plan’s systems. We stepped back and asked which components would we want in an addendum or a contract with each practice and handled it that way.

Hudson River Healthcare’s (HRHC) successful strategy for diabetes management begins and ends with the patient, says its chief operations officer Katherine Brieger.

How a patient communicates with their health systems, their providers, their communities, and their families is integral towards their success in managing their diabetes, Brieger says in Healthcare Intelligence Network’s recent webinar, Patient Centered Medical Home: Diabetes Management. But what if the patient comes from a diverse population with challenging problems?

That’s the perspective behind Brieger’s honest, compassionate discussion about HRHC’s Diabetes Collaborative program, which has been in place for over 12 years, and combines attributes from both the Institute for Healthcare Improvement (IHI) and the Wagner Chronic Care Model, to manage diabetic care for more than 3,400 adult patients.

A large percentage of those patients are migrant farmworkers and homeless people, Brieger, also an RD and CDE, says. Care management does work, and getting patients involved in programs is key to their success, she says.

To do this, HRHC implements a patient-centered team approach to treatment, incorporating a full range of clinicians, MDs, (licensed and unlicensed, as in patient care coordinators) LPNs, and case managers to help patients manage their illnesses. Patients are stratified according to severity of health, and self management support and education, including community education days, group visits, and sessions with social/psychiatric workers, dentists, CDEs and RDs, are regularly scheduled to help evaluate and direct the patients.

Opening up access hours for patients, providing language interpretation, and teaching at low literacy levels are also keys to the program’s success, she continues.

Because weight loss is the most challenging aspect of diabetes management, HRHC offers innovative weight management programs like walking clubs, diet programs, mindful eating, and prevention services, Brieger continues.

Certified Diabetes Educators (CDE) are crucial to patient care, says Brieger, who is a CDE; as are case managers. And registries are an important element of the program; “It’s not enough to have a registry, but to know how to use it,” she says. Even telepsychiatry is used in remote areas lacking specialists, Brieger says, contrary to what people might think of New York’s densely populated area; “we have a lot of remote areas,” she says. Continuity and follow up are also key, medications are issued electronically; high risk patients are followed closely, and nurse care managers are implemented for the most complex patients.

To promote quality and continuity, site quality reports are sent out each month, and every nine months sites are visited by site teams.

Brieger shares other elements of the Diabetes Collaborative Program, including:

But basically, it all begins and ends with the patient, Brieger concludes. Taking in the patient as a whole, and instilling a level of trust into the relationship, is what gets the best results.

Our congratulations to three frequent contributors to HIN for taking top honors in Thomson Reuters’ annual Best Hospitals list: Banner Health, a leader in ER efficiency, Geisinger Health System, on the forefront of comprehensive primary care, and Baptist Health, a model for bundled payments. These three esteemed health organizations, and 12 others, were singled out from more than 300 organizations for having achieved superior clinical outcomes based on eight metrics that gauge clinical quality and efficiency: mortality, medical complications, patient safety, average length of stay, 30-day mortality rate, 30-day readmission rate, adherence to CMS clinical standards of care, and HCAHPS patient survey score. A full list of the 15 winners can be found in this issue.

At the same time CMS issued its annual report on healthcare spending, showing historically low rates of growth for 2009 and 2010, the HHS has determined that Trustmark Life Insurance Company proposed unreasonable health insurance premium increases in five states, hikes that would affect nearly 10,000 residents. HHS is requiring the insurer to immediately rescind the rates and issue refunds to consumers, or publicly explain their refusal to do so. The ACA requires that insurance companies disclose and justify rate increases over 10 percent. States also have the authority to reject unreasonable premium increases since the passage of the law, to date, 37 states have this authority.

Certified Diabetes Educators and case managers are instrumental in diabetes management, according to the results from our 2011 survey on diabetes management strategies. More than three-quarters of healthcare organizations said they were taking a disease-specific approach to improving health outcomes and self-management in patients and health plan members with diabetes. And the majority of respondents said that weight management was the greatest challenge of managing diabetes. More details can be found in this story, and our complimentary downloadable white paper.

And don’t forget to take our newest survey: Reducing Hospital Readmissions Benchmark Survey. Describe how your organization is working to reduce hospital readmissions for 2012 by taking HIN’s third annual survey on this subject by January 31, 2012 and receive an e-summary of the results once they are compiled.

It seems that gastric bypass surgery is way more popular than Justin Bieber.

At a time when most teens should be contemplating their friends’ latest Facebook post, there’s instead a large segment weighing the pros and cons of lap banding versus stomach stapling versus sleeve gastrectomy, the current crop of bariatric surgeries now targeted toward teenagers.

According to a recent New York Times article, 1 to 2 percent of all weight-loss or bariatric operations are on patients under 21, and studies are underway to gauge the outcomes of such surgery on children as young as 12. As stated in the Times:

Allergan®, the maker of the popular Lap-Band, a surgically inserted silicone band that constricts the stomach to make the patient feel full quickly, is seeking permission from the Food and Drug Administration to market it to patients as young as 14, four years younger than is now allowed. Hospitals across the country have opened bariatric centers for adolescents in recent years.

Along with the obesity epidemic in America is an explosion in weight-loss surgery, with about 220,000 operations a year — a sevenfold increase in a decade, costing more than $6 billion a year.

The article follows one obese but otherwise healthy teenager who has adjusted to her weight, but gets stomach banding surgery at her doctor’s advice to prevent future health problems like diabetes. The operation takes about 25 minutes, costs nearly $22,000, and is covered by a state insurance plan for low-income families.

Medicaid in almost every state and many private health plans now cover bariatric surgery, often more readily than diet or exercise plans. In fact, braces cost more than bariatric surgery. Federally funded bariatric surgery is a relatively new phenomenon; Medicare first endorsed paying for bariatric surgery in 2006. And Medicaid approved funding of it in 2004.

Gastric surgery is the latest surgical quick fix for teenagers who should be navigating the convoluted hallways of high school adolescence instead of surgery options. These surgeries constrict the stomach so that even eating a slice of pizza with friends, while not condoned in excess, could cause problems.

This, despite reports that show that U.S. obesity rates decreased last year from 26.6 percent in 2010 to 26.1 percent in 2011, according to a report based on the Gallup-Healthways Well-Being Index. Researchers said the decline was due in part to more Americans saying they were a normal weight in 2011.

This small decrease is significant, says Gallup researchers, because:

The cost of obesity is so high that even this small improvement has the potential to save the American economy a significant amount of money. A December 2010 analysis by the Society of Actuaries estimates that the total cost of obesity to the U.S. economy has climbed as high as $270 billion. Gallup’s own analysis finds that obesity and related chronic health issues cost businesses alone upward of $150 billion annually. But with more than one in four adults still obese, the nation has a long way to go to achieve lasting change.

We recently reported that CMS is now offering free preventive obesity counseling to seniors with a BMI greater than or equal to 30 kg/m2. As the Times reports, Allergan is targeting children at this threshold of obesity as candidates for the Lap-Band surgery.

And that’s a lot of children. According to a recent survey from the National Health and Nutrition Examination, nearly one-fifth of U.S. children and adolescents are obese.

It’s hard not to wonder when preventive education and old-fashioned dieting and exercise were replaced with surgical quick fixes like stomach stapling. Instead of paying for these surgeries, we need to finance education programs for the young so they don’t become one of the three American adults expected to have diabetes by the year 2030.

The United States’ spending on healthcare increased by just 3.8 and 3.9 percent in both 2009 and 2010 respectively; these figures represent the lowest rate of increase in the entire 51 year history of the National Health Expenditures (NHE.) Analysts point fingers at the poor economy and low unemployment numbers, causing many Americans to skimp on medical care. A breakdown of the report is included in this issue.

The city that never sleeps could be getting just what the doctor ordered: expanded care facilities. Cigna and Weill Cornell Physician Organization have launched Manhattan’s first ACO between a health plan and a physician organization, in order to meet the
IHI’s aims to improve health outcomes, lower total medical costs and increase patient satisfaction. Crucial to the program’s success will be the utilization of RNs, employed by Weill Cornell, who will serve as clinical care coordinators and help patients with chronic
conditions to navigate their healthcare system. They will use patient-specific data provided by Cigna to identify patients being discharged from the hospital who might be at-risk for readmission, as well as patients who may be overdue for important health screenings or who may have skipped a prescription refill.

Job-hunting smokers beware: Geisinger Health Systems has joined the list of healthcare systems that will no longer hire smokers. As of February 1st, job applicants will be screened for nicotine as part of the company’s routine drug test. Cigarettes, smokeless tobacco, even nicotine patches and gum will prevent an otherwise eligible candidate
from being hired; however, applicants will be given a chance to reapply for the job in six months’ time if they take advantage of the company’s smoking cessation resources and can quit smoking in that time. Non-nicotine hiring practices are currently legal in 20 states, including Pennsylvania, where Geisinger is based.

And Google’s Flu Trends Tool is proving to be a successful warning system for hospital EDs. Researchers from John Hopkins noted in a 21 month study that the rise in Internet searches directly correlated to a rise in ER patients with flu-like symptoms; the study was particularly effective when noting the surge in searches for flu symptoms and the
number of children entering the pediatric ER. In the past EDs, hospitals and other healthcare providers have relied on CDC flu case reports provided during flu season, October to May, as a key way to track outbreaks. The Google tool collects and provides data on flu search topics on a daily basis. While the medical and science community has
generally accepted flu search activity as a good indicator of impending sickness, this study, detailed in this issue, is the first of its kind to show the relationship between the data and an increase in ER activity.

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

It’s a new year, time to ring out the old, ring in the new, and reassess existing notions that, like some of those old sweaters, just don’t fit anymore.

For example, a new study from the Yale School of Medicine suggests that previously used ways to assess hospital quality might be in question. Until now hospitals, health insurers and patients measured hospital quality on the number of patient deaths during hospitalization. New research reveals that this measure could be misleading given that some hospitals keep their patients for a shorter time due to patient transfers, and that these hospitals are being favored. The study suggests an alternative approach: measuring patient deaths over a period of 30 days of admission, even after they have left the hospital. This finding could have wide implications as quality measures take on more importance in the healthcare industry.

And an international study suggests that the U.S. healthcare system can be modified to decrease readmission rates, showing that up to one third of heart attack readmssions might be preventable. The study of more than 5700 heart patients in the United States, Canada, Australia, New Zealand, and 13 European countries showed that readmissions may be preventable because rates are nearly one-third lower in other countries.

The HHS finalized its core set of Health Care Quality Measures for Medicaid-eligible adults; it comprises six major categories, among them prevention and health promotion, management of acute conditions, and availability of care. Healthcare providers and
insurers can use these measures to track care delivery among adults enrolled in Medicaid, as well as monitor and improve quality. More details can be found in this issue.

And lastly, a new initiative welcomes an old friend: Dr. Janice Pringle, a valued contributor on medication adherence, has been named an Innovation Advisor;
she is one of 73 selected for this initiative from CMS, designed to improve healthcare for patients. She and others will test new models of care delivery, form partnerships with local organizations to drive delivery system reform, and improve their own health systems.

This and more in this week’s issue of the Healthcare Business Weekly Update.