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January 27, 2011 Volume VII, No. 29

HIN Communications Editor Jessica Papay

Dear Healthcare Intelligence Network Client,

A recent study has found that Medicare may not cover all preventive services. Read this week's issue to find out more about this coverage gap. Also, we present new data on heart patients and the effect of an obese patient's race on counseling sessions with physicians.

Your colleague in the business of healthcare,
Jessica Papay
Editor, Disease Management Update

This week's DM news:

Table of Contents

  1. Medication Adherence
  2. Weight Counseling & Race
  3. Physician-Owned ACOs
  4. Medication Therapy Management Effectiveness
  5. 5 Risk Factors in Care Transitions
  6. 2010 Reducing Readmissions Benchmarks
  7. Medicare & Prevention Services
  8. Healthcare Case Management in 2011

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Decrease in Medication Adherence for Heart Attack Patients with Low Levels of Kidney Function

Among older adults with a recent heart attack (myocardial infarction), those with lower levels of kidney function are less likely to take their medications as prescribed, according to a study in the Clinical Journal of the American Society of Nephrology (CJASN).

The researchers studied 2,103 patients aged 65 or older with a recent heart attack. Pharmacy insurance claims records were used to determine the percentage of days that patients actually had their prescribed medications. The results showed low long-term adherence rates for three major classes of heart medications: angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (ACEIs/ARBs), beta-blockers and statin drugs. Over three years' follow-up, the patients had their prescribed drugs for only 50 to 60 percent of the time. For ACEIs/ARBs and beta-blockers, medication adherence was significantly lower for patients who had lower levels of kidney function at the beginning of the study. Adherence to statin drugs was not significantly related to kidney function.

"Since poor medication adherence increases the risk of hospitalization and death, it is important to understand the scope of the problem," explain the researchers. In a previous study in the same group of patients, the researchers found low medication adherence rates within the first 90 days after heart attack. "In the current study, we wanted to extend these findings to examine long-term outpatient medication adherence, particularly in patients with kidney dysfunction, who are at high risk for recurrent heart attacks but who have not been studied extensively to date. Future strategies to improve medication adherence and clinical outcomes will need to pay special attention to this high-risk population."

The study had some important limitations. For instance, since medication adherence was measured using insurance claims data, the researchers were unable to determine why patients weren't following their prescriptions. "The medication may have been purposely discontinued by the treating physician due to unwanted side effects," said the researchers.

To learn more about this research, please visit:

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Does Race Play Role in Weight-Related Counseling of Obese Patients?

When it comes to advising obese patients, blacks receive less weight reduction and exercise counseling from physicians than their white counterparts, according to a study from Johns Hopkins Bloomberg School of Public Health. Researchers examined the impact of patient and doctor race concordance on weight-related counseling.

Researchers analyzed National Ambulatory Medical Care Surveys (NAMCS) from 2005-2007, a nationally representative cross-sectional survey of physician office visits, among individuals ages 20 years and older. Using a sample size of 2,231 visits of black and white obese patients to their black and white physicians from the specialties of general/family practice and general internal medicine, the researchers examined the relationship between doctor-patient race concordance and weight-related counseling (measured as weight reduction, diet/nutrition and exercise counseling). Logistic regression was used to model the outcome variables of interest. In addition, tests were used to statistically compare whether physicians of each race provided counseling at different rates for obese patients of different races.

"Contrary to our expectations, we did not observe a positive association between patient-physician race concordance and weight-related counseling," said the researchers. "Rather, black obese patients seeing white doctors were less likely to receive exercise counseling than white obese patients seeing white doctors. We also found that black obese patients seeing black doctors were less likely to receive weight reduction counseling than white obese patients seeing black doctors. This suggests that regardless of the physician’s race, black obese patients receive less weight-related counseling than white obese patients. Our findings could be due to a number of factors such as negative physician perspectives toward black patients or a lack of sensitivity to the underlying levels of obesity risk for black patients as compared to white patients."

"Previous studies have shown disparities in the proportion of black obese adults informed by physicians that they were overweight compared to white obese adults," said the researchers. "We now also see that black patients are receiving different medical counseling as well. Further research is needed to understand how to improve obese patient counseling, particularly among the black population."

Obesity is defined as having a BMI greater than or equal to 30 kg/m2 and is an important risk factor for mortality and morbidity. In the U.S., blacks are disproportionately affected by obesity and are at an increased risk for a number of chronic diseases associated with obesity, such as cardiovascular disease, hypertension and diabetes.

To learn more about this research, please visit:

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Successful Positioning of Physician-Owned ACOs

Even though the specifics of Medicare's Shared Savings Program have yet to be defined, physician organizations can still position themselves to achieve cost savings through an independent accountable care organization (ACO), notes Jeffrey R. Ruggiero, Esq., a partner in the law firm of Arnold & Porter LLP, who is advising the Queens County Medical Society on the launch of one of New York State's largest physician ACOs. Ruggiero describes the advantages of a physician-run ACO as well as some of the regulatory, compliance and operational factors to consider prior to ACO launch.

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Measuring Effectiveness of Medication Therapy Management

This week's expert is Beth Chester, PharmD., MPH, BCPS, senior director of clinical pharmacy services and quality for Kaiser Permanente Colorado.

Question: What tools and measures do you use to determine the effectiveness of the medication therapy management (MTM) program?

Response: One of the reasons that HEDIS measures are attractive to an organization like ours is that it is something that the organization already cares about. Therefore, it is one way to align the services that we introduce. By introducing or providing certain services, we impact these metrics that we know the organization cares about; keep in mind the things they are already measuring that you can impact. We look at some measures of productivity in some of the services and we also evaluate unwarranted variability between clinicians. In cardiac care, for example, we know what the blood pressure achievement rates for each pharmacist are. Therefore, we can identify outliers on either the very high or low end and work with those individuals to see if the variation is unwarranted or if they have a particularly challenging patient skewing the results. Those are other metrics we look at, including HEDIS, some individual clinician metrics and metrics that may be related to that particular service. We are always interested in demonstrating the value we have to the organization, whether that be through quality of care or economic indicators. We track physician’s time saved, so when we have interventions or opportunities that we feel save physician time, we try to quantify those.

For more information on medication therapy management, please visit:

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Top 5 Risk Factors in Care Transitions

Tighter management of transitions in care can help to close care gaps and reduce rehospitalizations, ER visits and medication errors. We wanted to see the top risk factors that are considered when evaluating individuals for care transition management.

Click here to view the chart.

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2010 Performance Benchmarks in Reducing Readmissions

This white paper summarizes the top strategies, program components, staffing requirements, targeted conditions and populations and results from readmission reduction efforts by 90 healthcare organizations in response to the Healthcare Intelligence Network’s second annual Reducing Readmissions e-survey conducted in December 2010.

To download this complimentary white paper, please visit:

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Medicare Covers Only Fraction of Recommended Prevention Services

A significant gap exists between a government-commissioned task force's recommendations on preventive health services older Americans should receive and Medicare coverage for those services, a new UCLA-led study has found. But the researchers say the new healthcare reform law should be able to help mend the disconnect. In particular, there is a need to improve coordination between assessing risk for certain illnesses and providing the tests and follow-up medical services recommended by the U.S. Preventive Services Task Force (USPSTF). The USPSTF is an independent expert panel appointed by the federal government to review and recommend various screenings and preventive healthcare procedures.

The study examined how well the USPSTF's recommendations were aligned with Medicare coverage before implementation of healthcare reform in January 2011. The researchers looked at recommended services (those rated "A" or "B"), as well as services the task force didn't recommend (rated "D"). They then divided Medicare coverage for those services into two delivery components: preventive coordination, which includes risk assessment and arranging for appropriate services; and preventive services, which include testing as well as counseling. A-rated services for adults over 65 included screenings for cervical cancer, colon cancer, high blood pressure, lipid disorders (for men and women, each listed separately) and tobacco. B-rated services included screenings for abdominal aortic aneurysm, alcohol (including counseling), breast cancer genetic risk, depression, diabetes, obesity (including counseling) and osteoporosis, as well as breast cancer mammographies and counseling on healthy diets.

The researchers found that of these 15 recommended preventive interventions, only one — abdominal aortic aneurysms — was fully covered by Medicare for both coordination and service. Most of the rest received either partial funding for one component and full funding for the other, or only partial funding for each. Alarmingly, the researchers say, there continues to be a lack of Medicare coverage for obesity and nutritional services, both of which are recommended by the USPSTF and which are important for maintaining good health.

In addition, researchers found that Medicare reimbursed clinicians for 44 percent of non-recommended, D-rated services, spending valuable tax dollars on unsupported healthcare. These services included screening for cervical cancer in women who no longer needed screening, screenings for ovarian cancer and colon cancer in those older than 85 and heart disease screenings for those at lower risk.

To learn more about this research, please visit:

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Healthcare Case Management in 2011

Targeted case manager interventions across the healthcare continuum are generating significant ROI and positive clinical outcomes resulting from more effective care coordination and reduced health resource consumption. Complete HIN's second annual Survey of the Month on Healthcare Case Management by January 31, 2011 and receive a free executive summary of the compiled results. Your responses will be kept strictly confidential.

To participate in this survey and receive its results, please visit:

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