"In a fee-for-service system, it's very hard to justify expanding psychiatric services," says one expert. "But reducing length of stay is a compelling statistic when you're talking to a hospital administrator."
By the end of July, Johns Hopkins Hospital in Baltimore hopes to have six behavioral health teams working side-by-side with physicians and nurses to help manage the mental health of patients.
The ambitious plan aims to prove that investing in behavioral health specialists is good for patients and the bottom line.
Patrick "Pat" Triplett, MD, clinical director and physician advisor at Johns Hopkins Hospital, says that two months ago, getting a psychiatric consult request during a patient's discharge was common. "We were really only responding to emergencies," he says.
Now, in a pilot program on three general medicine floors, Triplett is part of a three-member behavioral intervention team (BIT) that screens patients for mental and behavioral health shortly after they're admitted.
A leading nonprofit health system is aggressively pursuing a proactive strategy toward mental health care for patients to reduce length of stay and readmissions.
"The goal is to be able to intervene early," Triplett says. "We're in on day one instead of day five."
Triplett is also overseeing the expansion of an additional five BITs at the hospital by the end of July. Currently, the BIT is made up of Triplett, who serves as a half-time psychiatrist for the team, a full-time nurse practitioner and a full-time social worker.
When the BIT program is fully rolled out later this summer, Triplett says the team structures will be similar, but will include two behavioral specialists, either a licensed clinical professional counselor (LCPC) or a social worker with psychiatric expertise.
"Having that psychiatric background is important," Triplett says. "They are able to walk into room and do a psychiatric assessment—to some degree."
The real influence, though, comes from the nurse practitioner.
That was a tip Triplett says he received from Hochang "Ben" Lee, MD, founding director of Yale-New Haven Hospital's Psychological Medicine Research Center psychological.
Lee is a former faculty member at Johns Hopkins Hospital, and co-authored a study showing that a proactive psychiatric consult approach reduced patients' length of stay.
"We're finding that the nurse practitioners having conversations with floor nurses and nurse managers is where the power of the program seems to lie," says Triplett.
"Nurses see the value of it because they really do manage the setting."
BIT in Action
When a patient is admitted, the BIT members swing into action. Patients are screened for active and dormant psychiatric issues, classified into three tiers, and triaged accordingly:
Tier 1: Patients who have debilitating psychiatric symptoms.
Tier 2: Patients with a wide-ranging spectrum of acuity.
Tier 3: Patients with the lowest risk of psychiatric illness interfering with the primary medical diagnosis.
A tiered triage system helps the BIT members know when and how often to confer with the medical team taking care of the patient.
BIT members help with medication management, communication and coordinating care with the hospital's substance abuse services, if needed.
Regardless of how patients are triaged, Triplett says the BIT members consult with the medical team before seeing the patient.
"Context matters," Triplett says. "After we talk to the medical team, we may walk in and say, 'We're from psychiatry, how do you feel your bipolar disorder is being handled?' Sometimes patients do not want someone from psychiatry in their room, and sometimes you pick up things that might not appear in the chart."
It's this psychiatric expertise that helps the most. BIT members notice patient nuances that medical teams may overlook. Triplett says the hallway conversations that ensue are opportunities to educate physicians, nurses and other health care professionals about what a patient is experiencing.
"They're focused on acute medical issues," he says. "They may have heard a snippet of it on floor, but we can explain to them what is happening to the patient from a psychiatric perspective."
Integrating with medical teams has been good so far, says Triplett. The nurses and physicians like the help, especially because BIT members are intervening early and often to prevent sometimes explosive episodes that can delay a patient's discharge or affect their outcome.
"We weren't sure how it would work out," says Triplett. "But they're happy we're here. The only complaints I've received are from the medical floors that we didn't pick."
Measuring the Value of Mental Health
Johns Hopkins Medicine is one of several health systems directing more resources to the mental healthcare of patients.
Commercial retailers also recognize the need for additional resources. Walgreens launched a mental health screening program in May that also offers connections to therapists via video for $60.
Numerous studies show the link between poor health outcomes and common mental illness diagnoses, such as depression, bipolar disorder and schizophrenia.
With hospitals preparing to be on the hook for the total care of patients, not just an episode, leaders are looking for ways to achieve cost reductions through LOS and readmission improvements.
Triplett says that in addition to LOS and readmission reductions, other benchmarks could also be added to determine the effectiveness of early mental healthcare intervention. He says measuring patient and staff safety would be a good indicator of the BIT's impact and suggests looking at nursing and physician satisfaction rates over time.
"If you're providing a service that allows nurses to do the job they're meant to be doing, it may affect nursing turnover," Triplett says.
One of the most difficult benchmarks for mental health initiatives, such as the BIT, is financial.
"In a fee-for-service system, it's very hard to justify expanding psychiatric services," Triplett says. "But reducing length of stay is a compelling statistic when you're talking to a hospital administrator."
In its annual rulemaking proposal aiming to shift hospitals toward a value-based model, Medicare recommends several changes, including one that the American Hospital Association says could undermine efforts to reduce readmissions.
When the Centers for Medicare & Medicaid Services released its proposed rule for the hospital inpatient prospective payment system (IPPS) last week, the American Hospital Association joined a chorus of industry leaders praising the agency's decision to drop the two-midnight rule payment cuts hospitals have endured since 2013.
Not only will CMS discontinue the 0.2% two-midnight rule payment reduction, it will also reimburse hospitals for the cuts with a 0.6% temporary payment increase in 2017. Senior policy associate director for AHA, Priya Bathija, says CMS's proposal is a hard-fought victory.
"This change, in combination with the changes to the outpatient final rule, really is a win for hospitals and Medicare beneficiaries," she says. When determining a patient's status, "hospitals should rely on physician judgment, not a time benchmark."
The AHA challenged the two-midnight rule in federal court along with four state hospital associations (the Greater New York Hospital Association, the Hospital Association of New York State, the New Jersey Hospital Association and the Hospital and Health System Association of Pennsylvania) and four hospital systems (Banner Health, Einstein Healthcare Network, Wake Forest University Baptist Medical Center, and Mount Sinai Hospital).
Bathija says the court still has to determine if CMS met the burden of justifying the 0.2% cuts in the first place. The AHA says CMS has not.
More Payment Adjustments
Another key payment change that Bathija says will impact hospital reimbursement is CMS's plan to increase the amount it has been collecting for coding and documentation overpayments.
Since 2014, CMS has taken 0.8% from hospitals to recoup $11 billion in overages that began in 2008. Fiscal year 2017 is the last year the agency has to finish recovering the overpayments, but CMS says it's short by $5.08 billion. To make up for the shortfall, the agency wants to take 1.5% from hospitals, nearly double the amount it took in previous years.
"We urge CMS to reduce the amount of this cut," Bathija says. "This cut is much larger than we think Congress anticipated."
The AHA also says some of the CMS quality measures meant to improve patient outcomes and quality are unfairly punishing some hospitals. The penalties hospitals incur for excessive readmissions have pressured hospital leaders to develop new protocols, but some factors are out of a hospital's control, according to Akin Demehin, AHA senior associate director.
"There is a growing body of literature that shows a link between socioeconomic conditions and readmission," Demehin says. "We think a socioeconomic adjustment would level the playing field and make it fairer."
The AHA had hoped that CMS would recommend adjusting readmission penalties for hospitals that serve a large number of disadvantaged patients. A report in January by the National Academy of Medicine report heightened awareness of the issue. The report identified five social risk factors that can impact outcome and quality measures, including hospital readmissions.
"Penalty or not, hospitals are focused on readmissions," says Akin. "A lot of the work we've seen across the country relates to transitions in care and making sure discharge instructions are clear. You're seeing hospitals do that across the board, but even those doing an exceptional job are still finding themselves getting penalties."
No Consideration for Socioeconomics
CMS's proposal did not include the socioeconomic adjustments the AHA was hoping to see. Their absence combined with a new recommendation for calculating disproportionate share payments could mean substantial changes for some hospitals. CMS expects to distribute $400 million less in uncompensated care payments next year.
Part of the reason for the decrease stems from fewer uninsured patients. The DSH payment calculation changed to accommodate the increase in insured patients, but the AHA says the reformulation CMS proposes for 2018 "may not be ready for prime time."
According to Bathija, the main point of contention is what's called the S-10 worksheet. It's what CMS wants to use to help calculate DSH payments instead of its current method of counting Medicare, Medicaid, and Supplemental Security Income inpatient days. The AHA concedes that data from the S-10 worksheet could be a more accurate accounting method if some changes were made to it. The problem, says Bathija, is that CMS has not indicated that it changed anything.
"We're analyzing the impact," she says. "We're likely to support it, but we still believe changes are needed."
Quality Reporting Changes
Another proposal that CMS wants to see changed beginning in 2018 affects the hospital-acquired conditions program. There is currently a 1% penalty imposed on the worst performers in a quartile. Demehin says scoring the data that way is misguided because no matter how well a hospital performs, there still has to be a bottom 1%.
"It's a forced distribution," he says. "What CMS is proposing would, instead, allow hospitals to be compared to a mean score. We're doing some analysis to see if it is an improvement worth supporting."
The issue over data collection can seem granular, but the way CMS collects, analyzes and publishes data is a big concern for hospitals. The AHA supports the promise of data from CMS, but is critical of the agency's proposal to fast-track collecting of some clinical quality measures for the Hospital Inpatient Quality Reporting program.
Later this year, hospitals will begin submitting four IPPS clinical quality measures to CMS. Hospitals have a choice of which four measures they will submit in either the third or fourth quarter, and they have had two years to prepare.
In the IPPS 2017 proposal, CMS is bumping up the number of measures to 15. "Reporting on that many so soon is premature," says Demehin. "Hospitals haven't even started the reporting for this year."
Medical specialty societies are pushing back on a CMS proposal that they believe will slow down MACRA's goal of improving cost, quality, and outcomes. "To get this [Medicare claims] data and match it to our clinical data is the golden egg," says one physician leader.
While hospital and physician group leaders focused on the broad implications of MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) at a U.S. House committee hearing Tuesday, medical societies are hoping Congress will pay more attention to a tiny section within the proposed rule that they believe could thwart the healthcare industry's ability improve healthcare quality and cost.
The Physician Clinical Registry Coalition (PCRC), a group of more than 20 medical specialty societies and other physician-led organizations, such as the American Academy of Neurology, Society of Thoracic Surgeons and American College of Emergency Physicians, contends that CMS isn't following the spirit of MACRA that grants access to Medicare claims data.
"We think CMS punted in a way that wasn't consistent with congressional intent," says Rob Portman, who coordinates and represents PCRC.
At issue is valuable Medicare claims data, which qualified clinical data registries were given access to in Section 105(b) of MACRA. Claims data is valuable to medical societies, such as the Society of Thoracic Surgeons (STS), because when it is combined with clinical data, physicians can measure patient care, cost, outcomes, and quality over time.
It gets to the heart of providing value-based care, says Jeffrey Jacobs, MD, FACS, FACC, FCCP, chief of cardiac surgery at Johns Hopkins All Children's Heart Hospital and professor of cardiac surgery at Johns Hopkins University. Jacobs chairs STS's workforce on national databases. He says that even though STS maintains the largest heart surgery database in the world, it has limitations.
"STS collects robust clinical data up until the time of hospital discharge and 30 days after the operation, but Medicare data can tell us if someone's still alive five, 10, or 15 years after an operation," Jacobs says. "It can also tell us how many times they were admitted to the hospital, why, how much it cost, and what medications patients received."
In short, Jacobs says, the databases work best together. And, he says the issue isn't just about data.
"If the government wants to find ways to deliver more cost-effective health care, it would seem to be a no-brainer to allow unfettered access to Medicare data by societies," Jacobs says. "This doesn't just apply to heart surgery, it could apply to neurosurgery or psychiatry."
ResDAC vs. Medical Registries
As far as CMS is concerned, it is granting access to Medicare claims data. In a proposed rule released in February, CMS stated that registries, such as the one maintained by STS, could get Medicare claims data through the Research and Data Assistance Center, known as ResDAC.
It's true that ResDAC is a channel for organizations to get the information in question, but Jacobs and others say ResDAC isn't a true alternative to the Medicare claims data spelled out in MACRA.
"It's difficult to access and the data quality is not as good as it could be," says Jacobs.
Former director of CMS's Center for Medicare Management Jeffrey Rich, MD, agrees. Rich, who is past president of STS and currently serves on the board of directors of Virginia Cardiac Surgery Quality Initiatives (VCSQI), says there are several drawbacks to using data from ResDAC.
"It's cumbersome," he says. "You have to apply, qualify, submit your proposal, ask for the data, then pay a fee. And your file upload capabilities are limited to 50 gigabytes; that's not a lot of data."
In response to CMS's interpretation, Portman wrote a letter on behalf of PCRC pointing out that ResDAC's purpose is for research that uses separate, distinct datasets. MACRA's intent is to link value, cost, quality, and outcomes, which calls for much more dynamic analysis.
"Registries need continuous access to improve the power of their databases," Portman says.
The kind of access that Jacobs and other medical societies want is something that Rich has through VCSQI, a consortium of more than 30 hospitals and cardiac surgery centers in Virginia. The group has worked together since 1996. The 18 VCSQI hospitals share their Medicare claims data with 14 participating cardiac surgical practices.
"Once we get the data back, we do our own aggregation," Rich says. "It's like getting a box of tax receipts at the end of the year to interpret. We hire an IT company, and to do that on annual basis is a quarter of a million dollars. We have a huge infrastructure to do this, but it's really what we need."
By combining Medicare claims data with clinical data, cardiac quality, outcomes, and cost in Virginia have improved. As a result of sharing data, VCSQI developed a standard protocol for reducing post-operative atrial fibrillation. It has also reduced blood transfusions, saving the state at least $44 million. Now the consortium is working on reducing readmissions, Rich says.
"To get this data and match it to our clinical data is the golden egg," he says. "We've proved there is value in doing it, but nobody can do what we do because of the barriers. That's why we pushed Congress hard for access to the data. It's crucial for value-based purchasing."
Hospitals and health systems are relying on partnerships and patients to improve care coordination and build opportunities for sustainable growth in the neuroscience service line.
This article first appeared in the April 2016 issue of HealthLeaders magazine.
While stroke care remains one of the top priorities of the neuroscience service line, there is still plenty of room for growth in this specialty beyond achieving the designation of a primary stroke center. Healthcare executives are looking for ways to improve care coordination for their neuroscience patients.
Some health systems, such as Palo Alto, California–based Stanford Health Care, which is part of Stanford University Medical Center, have thrown out the old siloed playbook and now have all of their outpatient neuroscience services under one roof. Other hospitals, such as the standalone 296-bed Silver Cross Hospital in New Lenox, Illinois, are partnering with larger systems to leverage access to specialty care for patients. Both strategies signal a new chapter for both patients and providers.
Success key No. 1: Centrally locate outpatient services
When Stanford Health Care's new $80 million, five-story Neuroscience Health Center opened on January 11, there were 246 patient appointments on the schedule. For Stanford Health Care executives Frank Longo, MD, PhD, chairman of the department of neurology and neurological sciences, and Alison Kerr, vice president for operations, that first day was a test. Over the course of that first 12-hour day, they would find out if five years of planning, building, and designing a new one-stop shop for outpatient neuroscience services truly met their patients' needs.
"I got an email from a patient who has been to many of our clinics," Longo says. "Her email started off with capital letters: WOW." Longo says the patient wrote that she "couldn't believe" all that the building had to offer.
That wow factor was possible because of 12 patients on the neuroscience patient advisory council who played a major role in the building's design. "They are our subject matter experts; our clinicians are not," Kerr says. "These are people with Parkinson's and patients who have had aneurysms, brain tumors. How can you argue with somebody who has had a stroke that says, 'I'm going to slip and fall on that floor.' You can't argue with someone's day-to-day experience."
The hands-on work of the neuroscience patients led to wider hallways and exam rooms to accommodate electric wheelchairs and additional caregivers who accompany patients to appointments. Lighting and building acoustics were designed to accommodate patients, as well. No detail was left to chance. Picking out the right chairs for the waiting room took an entire day because patients reported that people who have spinal rods can't sit low and need additional support on the seat. "There are some really important things our patients told us that we would not have known," says Kerr. "We would have designed a standard office building with waiting room space."
Paint colors, carpet nap, and lighting were chosen with patients because of their firsthand experience, but it is the new "hallway conversations" and care coordination opportunities that clinicians are most excited about.
The center is meant to be a comprehensive outpatient center that reduces the number of appointments for neuroscience patients by using a team-based approach to care. "The only thing that was in one location before this center was our clinics," Kerr says. "We made our patients seek out our services, but we've flipped that model and now all of us circle the patients in one building."
The new center houses 21 neuroscience subspecialties, imaging, neuro-rehabilitation services, and physical and occupational therapies, which Longo says leads to more collaboration. "One situation we're commonly in is that a patient will have some features of a movement disorder, such as Parkinson's, and some features of a dementia, such as Alzheimer's, and we want to show this to a colleague," Longo says. "I can't describe the patient or tremor over the phone. In the old model, the patient would have to make a separate appointment and come back to our movement disorders clinic. Now I can walk over to one of our eight movement disorder neurologists and say, 'Hey, can you come and eyeball this patient?' Even if it's just for a minute, it's so much more efficient."
The new center, says Kerr, is poised to handle the growth of its neuroscience ambulatory visits, which has ranged from 15% to 20% per year since 2013 when its patient volume was 35,000 annually. Kerr says neuroscience is on the cusp of an innovation bell curve.
"We understand risk factors for cardiovascular disease, we've got lipids, we've got statins, but we don't understand Alzheimer's," says Kerr. "There is a partnership with our physician and neuro scientists at Stanford, and we eagerly anticipate many new discoveries and treatments."
Stanford's new center also connects patients to cutting-edge research. "When a patient has been affected with a neurological disorder that doesn't have an easy cure, having access to the research is so important, and a traditional clinic space is not built to support research activities for the patients, families, and physicians. We have space dedicated to make research access easy and efficient," says Longo, referring to the Alzheimer's Disease Research Center that is funded by the National Institutes of Health.
Success key No. 2: Partner for specialty care
Stanford Health Care's resources are enviable. Smaller hospitals that have patients with the same needs may not have easy access to an academic medical center or a large, integrated system. One solution is to merge with a larger organization, but Silver Cross Hospital, a 296-staffed-bed community hospital outside of Chicago, has resisted that trend and instead aggressively pursued affiliations with organizations that could bring their expertise to the suburbs.
"We have five partners, and every year we meet with the board to review them," says President and CEO Paul Pawlak.
Silver Cross' journey to tracking down partners began in 2009, with the Rehabilitation Institute of Chicago and rehab services. It was a weakness at Silver Cross, with only 305 patients per year. Now, patient volume is nearly doubled to 604 patients annually, he says.
Pawlak set out to similarly improve Silver Cross' neuroscience service line because he wanted the hospital to be a primary stroke center. Earlier efforts to develop neuroscience in the 1990s fell apart, he says.
Two things happened in 2012 that made a partnership to grow a neuroscience service line possible. First, Silver Cross built a new $365 million hospital in a new location in New Lenox. Second, a neuro-interventional radiologist—Harish Shownkeen, MD, at Cadence Health, which is now part of Northwestern Medicine, the health system that includes 1,500 employed physicians, an academic medical center, and outpatient clinics in metropolitan Chicago—needed space to practice. "Shownkeen reached out to us," Pawlak says.
The partnership between Cadence and Silver Cross meant that Pawlak would build an endovascular neuroradiology lab that would be staffed full-time by Cadence neurointerventional radiologists and neurologists. There are now five neurologists and also three neurointerventional radiologists. "I knew what we were doing was so important to our community," Pawlak says. "It meant that people who were suffering from a stroke didn't have to travel."
Still, the effort was not enough to generate substantial patient volume in the first year. Pawlak says transfer agreements from hospitals were more difficult than expected, and recruiting staff for the new neuro lab at Silver Cross was hard. "We needed to recruit radiology techs with experience working with the brain," he says. "Those people are hard to find, and it took another one and a half years for sustainability."
Given the slow start of the program, financial arrangements of the partnership with Northwest Medicine had to be modified. But, Pawlak says, it reinforced the need to be nimble and adapt. "Each service line is different," he says. "We have to bend and be flexible."
To improve volume, Shownkeen and Ruth Colby, Silver Cross' chief strategy officer and senior vice president of business development, hit the road, visiting emergency departments and neurology groups to show what Silver Cross could now offer. Shownkeen also put together an annual conference offering CME credits. Pawlak says 400–500 people show up. "It's another way of letting the community know what we can do. He is masterful at including other physicians."
The effort is paying off. In its first year of operation, Colby says Silver Cross had 105 patients in its new lab. Volume has now doubled and is continuing to grow. Silver Cross has also since earned primary stroke certification.
Another byproduct of a partnership strategy is that Silver Cross does not employ many physicians. "We only employ 10 doctors," Pawlak says. That approach, he says, attracts the physicians who want to remain independent but still have access to expert programs in the primary hospital.
Colby's advice to hospital executives is straightforward: Know your weaknesses; don't ignore them. "We felt we weren't the best in certain areas, such as oncology, neuroscience, and rehabilitation," she says. "If you can't be the best on your own, then bring someone in."
Oncologists have been the most vocal group opposing CMS's proposal to restructure Part B drug reimbursement because they believe patients have the most to lose—namely access to care.
The backlash against a new Medicare proposal that reduces physician reimbursement for Part B drugs has been swift. Several strongly worded letters were sent to the Centers for Medicare & Medicaid Services protesting the change, including one from more than 60 cancer care groups that represent nearly every state in the country.
Zon has held several leadership positions with American Society of Clinical Oncology (ASCO), one of many cancer organizations that believe restructuring Part B reimbursement from ASP plus 6% to a flat fee of $16.80 plus 2.5% will reduce patient access to cancer care.
Reimbursement Affects Patient Access
National Patient Advocate Foundation CEO Alan Balch, PhD, says the proposal will hit Medicare patients in rural areas. "Most cancer patients are still getting care in a community setting, especially in rural areas," he says. "Cutting reimbursement may mean providers won't take Medicare or they'll sell [their practice] to a hospital, which pushes patients to a setting that is further away."
Transportation is a major concern for the more than 20,000 patients NPAF helps annually, 50% of which are Medicare beneficiaries. Cancer care at a hospital is also more expensive. A Community Oncology Alliance study in 2012 on cost of cancer care by site showed that the cost of chemotherapy treatment in a hospital-owned outpatient office was 34% higher when compared to the same treatment in an independent oncology practice.
Vice President of Texas Oncology, Debra Pratt, MD, says she is equally concerned about the potential impact on cancer patients in rural areas. Texas Oncology has more than 165 community-based cancer clinics in Texas and Oklahoma, some are in rural areas. Pratt calls the CMS proposal a "blunt instrument" with no consideration of oncologists and the cancer community.
"The natural consequences of this will be that Medicare patients will not have access, there will be further hospitalization, and increases to the cost of care," Pratt says.
The CMS proposal to change Part B drug reimbursement is described by the agency as budget-neutral. Some critics have charged that the current reimbursement model gives physicians an incentive to choose drugs with higher costs. But Zon says most oncologists are following clinical care pathways to do what's best for their patients. Plus, she says, the current model doesn't pay enough now.
"We are already in a situation where Medicare was not keeping up with the cost of drugs," Zon says. "ASP plus 6% was never updated quickly enough for physicians, and the sequester (2%) really made it ASP plus 4%. It's some desperate attempt to try and control drug costs. The problem is we have done nothing to cause the cost of drugs to escalate."
Independent oncologists also say there isn't a level playing field between them and hospitals. "[Hospitals] have bigger discounts on drugs," Pratt says.
The debate over drug costs is at a near-tipping point. Two studies out this month point to double-digit cost increases and billions of dollars wasted. The costs impact Medicare beneficiaries, too. Zon's practice has hired financial counselors to help patients figure out how to afford treatment. "It's taking a personal toll on them," Zon says. "Patients are coming in crying."
Cancer Treatment Outlook
What's gotten lost in the debate over adequate reimbursement, say Zon and Pratt, is that patients with cancer are living longer in part because of better drug treatments. ASCO's State of Cancer Care in America: 2016 report celebrates some of those advancements but also warns that access to care in rural areas is a critical issue.
"It came out of nowhere," says Robin Zon, MD, FACP, vice president at Indiana-based Michiana Hematology Oncology.
According to the report, only 5.6% of oncologists practice in rural areas—where 11% of cancer patients live. "In the last decade, there's been wonderful advancement," she says. "The eye is on the wrong ball. We need comprehensive payment reform. Don't make the doctors carry the burden of the rising drug costs when we had nothing to do with it."
Other organizations believe CMS's proposed payment change is an end-run around Congress. Community Oncology Alliance Executive Director Ted Okon questions why CMS is using the Center for Medicare & Medicaid Innovation to test a new payment model.
"This is using the mandate that Congress gave CMS in creating and funding CMMI," Okon says. "That allows CMS to use CMMI to overturn any law dealing with Medicare that Congress has made. We're testing a mandatory national initiative. That's flat-out wrong."
COA has taken an aggressive stance against the proposal. It has threatened legal and legislative action to stop the proposal from moving forward. Okon says the reimbursement changes are at cross purposes with the Oncology Care Model, CMMI's model that's been three years in the making. Its aim is to improve cost, care coordination, and quality by using performance-based incentives.
"It's designed to address the clinical side of care and give practices the opportunity to improve, but we've been waiting for four months to find out which practices and payers are going to get to participate," Okon says. "I suspect the reason that's been delayed is because of this [new proposal]."
Other specialists are also against the policy change, include rheumatologists and gastroenterologists. The American College of Rheumatology issued a statement criticizing a Medicare reimbursement rate that is already too low.
"It is our hope that the proposed payment methodology changes would not exacerbate the existing access problem and force more patients to receive biologic therapies in the hospital setting, where they will be faced with higher copayments, more expensive facility fees, longer travel times, and administration of complex therapies without the supervision of their rheumatologists."
Competition from hospitals and health systems forces private practices to focus on efficiency and patient experience.
A group of Mid-Atlantic orthopedic practices joined forces two years ago to retain their independence amid market forces that were driving health systems to grow by acquisition. Now, The Centers for Advanced Orthopaedics (CAO) is bigger and preparing for price transparency, bundled payments, and giving patients the "Four Seasons" experience.
"2016 is the year of doing things we want to do," says CAO President Nicholas Grosso, MD.
CAO grew from 128 physicians in 2014 to 150 physicians and 50 locations in 2016. Grosso calls the growth "incremental," but to other independent physicians who are trying to figure out a way to stay in business without selling to a hospital or health system, CAO's growth represents a reason to be optimistic.
Christopher Raffo, MD, is with Maryland Orthopedic Specialists, a two-location, three-person practice that was one of the first groups to sign up with CAO in 2014. He says CAO's buying power as a group of nearly 130 physicians immediately began to see "significant savings."
"There is a cost to join [CAO]. Physicians were upset we had to pay money every year to be part of this organization," Raffo says. "But in our practice, we saved more on the group malpractice policy than it cost to join the group."
Raffo says revenues are stronger too. The major benefits, however, are elusive to small practices because of their size. For example, CAO is examining claims data to prepare for initiating bundled payment projects with insurers.
"That's the most exciting thing," Raffo says. "We're trying to be proactive. It gives us an opportunity to positively affect changes in healthcare so we aren't stuck with somebody else's model."
Raffo says that kind of project wouldn't be possible in a standalone, private practice of three physicians. He credits Grosso as a visionary who can break through the inertia that comes with large groups of physicians.
Grosso says his leadership style is democratic. He points to one number that shows the CAO model is working: Zero. That's the number of physicians who've dropped out. "No one has quit us," he says. "Like any organization with 150 orthopedic surgeons, there are certain physicians who aren't agreeable to everything but we communicate so it doesn't come across as top-down. I've gotten calls for advice on how to do what we've done."
Betting on Patient Experience
CAO's structure—a joint corporation—allows physicians' offices to stay independent but enjoy economies of scale. In 2014, the branding of CAO wasn't a top priority, but Grosso says it is now because the practices are competing with large hospital systems. "John Hopkins, MedStar, they are trying to develop these vertical networks," Grosso says. "Hospitals get an orthopedic group to sign up and nothing changes except for the hospital rates. We're setting ourselves apart."
The competitive edge Grosso is betting on is patient experience. He wants patients to have a "Four Seasons" experience in every CAO practice. A third-party group is using time-tested techniques to help physicians reach CAO's patient experience goals. Patients are surveyed about details from parking to lighting and wait times, something that remains a challenge. Grosso has immediate access to the patient experience results down to individual physicians. Additional efforts to brand individual practices as divisions of CAO will also set the practice apart from health systems, says Grosso.
Price transparency is a major advantage that Grosso and Raffo say could become a game changer when competing with hospitals for orthopedic patients. The hospital-owned outpatient groups that can still tack on facility fees (for now) can mean higher costs for patients.
"We'll be able to compete very well," Grosso says. "The price of a knee replacement at a surgery center is 60% to 70% less than hospitals."
CAO is also making sure that its quality outcomes are top-notch, which Raffo says is another benefit of belonging to a large group of independent, but like-minded practices. "We're really in our infancy as a company," he says. "The primary goal was survival because health systems are growing like crazy and we're trying to protect the private practice model. It's been great."
For a group that was founded on the principles of staying independent, CAO's branding, patient experience and bundling initiatives may seem counterintuitive. Gross says it's not; instead it is the reality of where healthcare is headed.
"Independence has stayed the same," Grosso says. "But we always knew we'd have to become unified as a group. We have to do that quicker because the change of pace happened quicker."
There are major hurdles facing the survival of private practices. CAO's growth and aggressive plans for the future offer a promising direction for physicians like Raffo, who says he was "all in" from the beginning.
"There's an interesting paradox in medicine right now," Raffo says. "If you talk to the residents, they are told by the health systems that educate them that private practice is an endangered species. I think the opposite. Private practice is alive and well and it will be the most efficient cost form of healthcare."
Consumers' reliance on technology to answer ordinary questions is a driving force in healthcare, and physicians at Virginia's Bon Secours Health System are giving the initiative to provide virtual visits high marks.
In less than three months, more than 4,000 patients in Virginia have signed up for virtual visits with primary care providers at Bon Secours Health System.
Telemedicine isn't new for the nonprofit Catholic health system headquartered in Maryland. It's been in the system's hospitals, but the new service was specifically developed to address the rise in consumerism, says Louise Edwards, senior manager for business development and planning for BSHSI.
"It's the natural evolution that we respond to changing expectations of consumers," Edwards says.
A total of 15 BSHSI primary care providers, which include a combination of physicians, medical assistants, and certified nurse practitioners, provide virtual care to patients during regular office hours, 7AM to 8AM. After hours and on the weekend calls are handled by American Well, a third-party telemedicine provider.
The health system's employees were the first group to test the platform, and Edwards says about 2,000 employees signed up in the first two weeks. Within 11 days, virtual visits were available to residents in Virginia, one of six states where the health system operates.
By April 1, the $49 virtual visits will expand to Kentucky and portions of West Virginia and Ohio. "It's in our strategic plan; that's how important it is," she says. "The future of healthcare is going there."
Virginia is one of eight states the American Telemedicine Association awarded a composite grade of "A" in a report last month. Like most technological innovations, the speed of implementation is outpacing regulation and demand. A major barrier to telemedicine is that each state makes its own regulations, but sheer demand for access may ultimately remove that hurdle.
Identify Physician Champions
Currently, virtual visits are only available with primary care providers, but Herbert Cummings, COO of Bon Secours Medical Virginia Medical Group, says phase two will include specialists.
"We're floating ideas now to cardiologists and neurologists," Cummings says. "Instead of being prescriptive, we're asking, 'How could this assist you?' We believe creativity is going to come from physicians."
The use of telemedicine, whether in emergency departments or in doctors' offices, is growing significantly. The criticism it receives for being merely transactional is hollow. Consumers already flock to retail clinics for minor issues. And patient demand for virtual visits isn't likely to slow down because physicians think it disrupts care coordination.
BSHSI's aggressive schedule to expand to other states signals it is willing to work with the new ways patients engage with technology.
"It's important to make sure we are accessible to patients in many different forms," Cummings says. "We have retail clinics staffed by NPs [and] telemedicine provides another opportunity for patients to see us. We think it's going to resonate with patients who self-seek, let an illness play itself out, or patients who may use the ED for something minor."
Cummings says he strategically thought about which doctors could be the prototype for virtual care. "We identified physicians who were open-minded and tech-savvy," Cummings says. "They weren't afraid of it and they were going to be our best ambassadors. They would also provide a sense of confidence in patients who were also using this for the first time."
Cummings also says he looked for physicians new to BSHSI because they are on a fixed compensation.
The setup for providers is pretty simple. Each one has an iPhone, iPad, and desktop computer
designated for virtual visits. Two to three employed providers are available at all times. Edwards says they log on and off in-between their regular office visits so that someone is always available.
Patient Experience is the Driving Metric
Out of the 4,203 patients who've pre-registered, either by the system's app or the desktop version, 300 have used it. That might seem like a low number, but both Edwards and Cummings say that's because the service is so new. Plus, they aren't looking to increase volume—yet—instead, they are measuring the program's success based on patient experience.
"We had a couple of hiccups in the beginning," says Edwards. "The Internet connection that the provider has is critical. You don't want something slow because video feed can be affected."
BSHSI also had to train physicians about small details that can make a big difference, such as where to look in the camera, and how to set volume control. The technical bumps were quickly alleviated, says Edwards.
"So far, patients rate the visits a 4.94 out of 5 and they rate providers just as high, a 4.74 out of 5," she says.
While Cummings says the goal is not "visit volume," he does believe that virtual visits will eventually a new normal at BSHSI.
"Our focus is on patient experience," he says. "A future goal is one of every four visits to be performed virtually. For new physicians, I think this will be a standard part of their onboarding."
There is likely no clear winner in the fight between hospital and physician groups who are weighing in on Medicare's new site-neutral payment policy that goes into effect next year.
Hospitals with newly acquired and almost-built physician practices located off of the main campus are hoping a congressional committee will put the brakes on payment cuts that are slated to take effect in January 2017.
Wanda Filer, MD, FAAFP
But physician groups are fighting equally hard to get the cuts expanded.
At issue is the site-neutral payment policy that was part of last year's budget agreement. A tiny section that was tacked on to the budget during negotiations makes big changes to how some hospital outpatient departments are paid.
It primarily affects off-campus physician practices that hospitals bought or built after November 2, 2015. Instead of a higher reimbursement rate because of being associated with a hospital, those practices are slated to receive the same payment as physicians who are in stand-alone offices.
There are a few caveats. The cuts do not apply to physician practices that are located on a hospital's campus, emergency departments, critical access hospitals, rural health clinics, federally qualified health clinics, and other outpatient departments.
The House energy and commerce committee is weighing the impact of the payment cuts, accepting public comment through Friday.
"It's not a good stewardship of federal dollars to pay more for the exact same services," says Wanda Filer, MD, FAAFP, president of the American Academy of Family Physicians.
In a Feb. 11 letter to House energy and commerce committee members, the AAFP noted that physicians should get reimbursed for patient care no matter the site of service.
"There is an element of fairness in this whole process," Filer says. "I've worked in both scenarios (independent and hospital-owned) and services are frequently the same."
But there are significant differences beyond a new hospital sign on the door, says Lawrence Vernaglia, partner and chair of the health care industry team at Foley & Lardner. Physician offices that are either built from the ground up or acquired by a hospital have to meet a number of regulations before they can qualify as an off-campus HOPD. The narrative that nothing changes but the name is "not true" Vernaglia says.
"All regulations need to be met," Vernaglia says. "We have provider-based rules for nursing, infection control, dietary counseling. HOPDs can provide a hospital-level of care."
That level of care is what the American Hospital Association also points to as an example of the difference between HOPDs and stand-alone physician offices. The AHA sent its own letter to the committee as well as put its members on high alert to send feedback about the site-neutral payment impact.
"Hospitals are different," says Erik Rasmussen, AHA's vice president of legislative affairs. "We are open 24-hours a day and provide all the services people come to a hospital for. If you pay hospitals physician office rates, you are going to get physician office-level service."
Off-campus HOPDs can do some things that standalone physician offices can't, such as provide outpatient psychiatric services that are beyond the scope of incorporating behavioral health into primary care practices. The AHA also says that higher reimbursement rates collected at off-campus HOPDs offsets the cost of caring for sicker and poorer patients.
Erik Rasmussen
Filer says there may be some differences between the site locations, but hospitals remain at an advantage because of their deep pockets.
"Family physicians get paid for taking care of people for little or no pay, too," Filer says. "The difference is we don't raise money from donors and we don't have charitable foundations."
Congressional Intervention
It's unclear which way the house committee is leaning on the issue. The AAFP is calling for the site neutrality payments to be expanded. As of now, the payment cuts only affect off-campus HOPD sites that were acquired after Nov. 2, 2015. AAFP calls that a loophole and wants the date expanded. It's also promoting site neutrality for all facilities.
That idea has broad support from decision makers who see site neutrality as a way to reduce health care costs. But stripping out the facility fee an off-campus HOPD can charge for the same service at another doctor's office down the road isn't a cost-savings, says Vernaglia.
"This is a cost-shifting exercise," he says. "A hospital's overhead is still a hospital's overhead, and hospitals will have to make up the cost somewhere else… patients and payers."
The issue also has hospital CEOs in a bind. Plans that were drawn up, ground that's been broken for new builds, and people who've been hired are all in a holding pattern. "More than a few projects are on hold," Vernaglia says.
But physicians are in a bind, too. They are hearing complaints from patients and they are struggling to give them an explanation, according to Filer.
"Some members sold their practices and patients come in and say things to them," she says. "They give the same service, but now the cost to the patient is higher."
For all of the doomsday pronouncements about the end of the independent medical practice, one solo practitioner in Texas is bullish on his prospects.
Joseph Valenti, MD, is the founding senior partner for an independent OB/GYN practice that is growing instead of shrinking.
His strategy so far has been to grow by acquiring solo practices that are no longer financially viable. It contradicts the trend of hospitals buying up independent practices, and Valenti says his growth is intentional.
Joseph Valenti, MD
"I would like to help other doctors stay independent," Valenti says. "Right now, it's very difficult, but I believe that if physicians remained independent, it would probably mean better quality and cost less."
Valenti believes that maintaining an independent practice is sustainable with the right tools, such as technology, an organized approach to billing and collections, and negotiating with insurers. He says negotiating skills can save money, but they also cue insurers into business practices that are ready for a value-based environment.
"Physicians who are practicing cost-effective medicine aren't leveraging it," Valenti says. "You need to have data to report to insurers. For example, our midwives have a low C-section rate. When we take that to an insurer, that's a lot of savings: time-off saved, morbidity saved. Insurers are interested in that."
Failure to collect data that shows the quality and outcomes at an independent practice is a problem, but isn't surprising, says Lisa Enright, senior vice president and director of the healthcare practice banking group at Citizens Bank.
"Business acumen depends on the practice," Enright says.
Valenti's expertise did not come from an MBA. It came from on-the-job training when he opened his practice in 2001. Now, 15 years later, Valenti's practice has grown to include six physicians, three nurse practitioners, three certified nurse midwives, and three locations. The lessons he learned in the first year of business are ones he still practices today.
"You have to have be willing to negotiate," Valenti says. "A lot of things need to be shopped and negotiated: supplies, your lease, insurance contracts. And I didn't pay myself for the first four to six months."
Another vital component to managing an independent physician practice is cash flow management, says Enright.
Negotiate and Collect
"Cash flow impacts the ability of the practice to invest in technology and staff that are key to long-term sustainability. The disconnect is when they don't see, 'If I manage what I do really well, it will set me up in the future.'"
This disconnect is all too common, according to Valenti, who recently took over the practice of a solo practitioner because the practice's overhead was running at 90% and was unsustainable.
"They were collecting 48% of billed charges," he says. "We collect 57%. Everything is running on an incredibly tight margin. That can be the difference between staying open and not staying open."
Many physician practices are closing. In 2014, The Physicians Foundation found in its biennial survey of physicians that solo and independent practices were declining. That's no real surprise. Hospitals have been on a buying spree in recent years to secure their market share. In Texas, where Valenti's practice is located, those pressures are the same but he is confident that there is room for independent physicians.
"The system is leveraged against the small practice," he says. "You have to have great billing and collections practices so that it allows for administrative work."
The administrative burden for physicians is enormous, especially for primary care physicians because of the numerous quality reports they are required to do. Valenti, who is a Physicians Foundation board member, says if legislators want evidenced-based medicine, then they should have to practice evidenced-based regulation.
"If I am spending a ton of time away from patients answering all your quality questions, I'm not improving patient care," he says. "How much is too much? I don't know the answer to that question, but I think we're there."
So do a lot of other physicians. Burnout is on the rise, according to Medscape's 2016 Lifestyle Report. One of their biggest complaints is "too many administrative tasks," according the report as well as longer hours and spending more time on a computer.
Developing a strong, independent practice is admittedly hard work, but it may also be a way to stave off burnout, with either the right investment in technology and staff or a partner.
"A lot of doctors are good at being doctors, but are not skilled at being small business owners," Valenti says. "It's very difficult."
Healthcare executives believe the neuroscience service line is primed for delivering better and more coordinated care. OSF HealthCare, Carilion Clinic, and Stanford Health are making big investments in patient-centric facilities and state-of-the-art equipment.
Neuroscience may be a clinical mainstay at hospitals and health systems, but new technologies are helping to reinvigorate the service line. So are the possibilities to improve care coordination for some of the most medically complex patients.
Funding for neuroscience initiatives got a big boost from the federal budget signed into law in December. Both the National Institutes of Health and the National Science Foundation will see more money for neuroscience research, but hospitals and health systems are also investing in neuroscience because of patients' needs.
For example, Peoria, IL-based OSF Saint Francis Medical Center, a 609-bed tertiary teaching center that is the largest of OSF HealthCare's 11 acute care facilities, and the Illinois Neurological Institute just unveiled a new intraoperative MRI (iMRI).
Frank Longo MD, PhD
It's only the second hospital in Illinois to have the technology, which lets surgeons better identify and see tumors as they are operating. And Carilion Clinic, a nonprofit integrated delivery health system in Roanoke-VA, recently opened a $32 million, 116,000-square-foot Institute for Orthopaedics and Neurosciences.
One of the most significant investments in neuroscience is in Palo Alto, CA at Stanford Health Care, the integrated health system that includes a highly regarded academic medical center. It built a five-story Neuroscience Health Center, which opened in January.
The center includes a full autonomic lab, which includes four EEG's, two EMG's, EKG, TCD, utlrasound, and two tilt rooms. It's the first and only such lab on the West Coast, according to Alison Kerr, vice president of operations for Stanford Health Care. "Most outpatient centers might do EEGs and EMGs, but they won't offer all," Kerr says. "We have the full complement of all the diagnostic testing, everything our patients need. We are really trying to accommodate them."
Now all outpatient services for neurology patients are under one roof. Instead of doubling back for a separate lab, rehab, or therapy appointment, patients can have multiple appointments on the same day, in the same building. Prior to the new center, the clinics were the only thing that were in one place for patients.
The central locality of rehab, infusion, and other services will make a huge difference to patients and their families, says Frank Longo MD, PhD, department chairman of neurology and neurological sciences, who was part of the center's planning team.
"These are scary diseases and frightening situations." Longo says. "When a person is in that situation, it is extremely important that they are confident they are getting the best [care] that exists. For doctors and nurses, they are also facing some very challenging clinical situations, and they need to feel they are in the most supportive environment they could be."
Gary Steinberg, MD, PhD
Planning for the center began five years ago with Kerr, who oversees the inpatient and outpatient side of Stanford's neurology service line, as well as Longo and Gary Steinberg, MD, PhD, neurosurgery chair and founder of the Stanford Stroke Center. "We really got everybody in the room to talk about clinical care, basic science, and research, because we have an advantage of being on the Stanford University campus," Kerr says.
"Neuroscience touches everything, especially as we look to the future of imaging."
When planning started, Kerr said she based neuroscience growth projections at 10%, but the reality is that neuroscience has experienced tremendous growth and Kerr expects appointments to get filled quickly. "I think physicians would say we are at the beginning of the bell curve," says Kerr about neuroscience.
Nurse practitioners take the complexity out of the process for patients, following them from discharge to outpatient. Once patients need outpatient services, NPs coordinate their visit by order tests and imaging in advance. "We've really designed this building around what our patients need," Kerr says.
What they needed, Kerr and other executives found, was assurance that every detail mattered—from flooring to lighting to seating. "As we were designing our space, we had a neuroscience patient advisory council," she says. "We had 12 people on our committee, and they were brutal at times, but they were our subject matter experts."
Kerry says patients showed them how narrow hallways, small exam rooms, and even carpet nap interfered with wheelchairs. Low seating in the waiting room wasn't comfortable for patients who had spinal rods, and dimmers were needed on the lights in infusion rooms for headache patients.
In addition to the more comfortable space that Stanford hopes will improve patients' experience, neurologists and the clinical care staff are also expecting that the space will improve care coordination.
Longo says he is excited to be able to "curbside" with colleagues when one of his patients has a tremor that isn't easily explained over the phone. Details or questions about testing can also be taken care of in a hallway conversation instead of a follow-up appointment that may be cumbersome for patients.
"The physicians providing the care will be in much better sync," Longo says.
