Participating in an orthopedic registry reduces some costs, but the expense associated with building and maintaining the technology a registry requires can be huge.
The orthopedic community got its first glance at a four-year data collection effort that, for the first time, marries the national clinical outcomes of a total joint replacement registry with patients' post-operative functionality.
The American Joint Replacement Registry (AJRR) is the primary orthopedic registry that surgeons have been relying on since 2009. That's when the AJRR began collecting information on hip and knee implant devices, and whether or not the surgery was successful.
The newest orthopedic registry, Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) registry, expands the AJRR's definition of success to include the patient's perspective, says David Ayers, MD, chair of the Department of Orthopedics and Physical Rehabilitation at University of Massachusetts Medical School, who is leading the FORCE-TJR registry.
"As long as the implant is in the body, it's considered a success," says Ayers. "We changed that. We can't say that if a joint replacement hasn't been removed then that's a success because what if the patient (still) has incredible pain? We said it needs to be about the patient and not the implant."
The FORCE-TJR registry also measures the same implant information that the AJRR does. In fact, the two registries share information. Hospitals that participate in both the AJRR and FORCE-TJR can streamline the data collection process and submit it once to FORCE-TJR.
"They're not competitive," says Kate Chenok, former executive director of California's Joint Replacement Registry (CJRR), of the AJRR and the FORCE-TJR registry. "They were both started for slightly different reasons. The commonality of all the registries is that they are passionate about patient care."
Multiple joint registries exist besides the AJRR, FORCE-TJR registry, and CJRR. There is a state registry in Michigan, Kaiser Permanente, as well as others that are hospital or practice-specific.
Registry Benefits
It's hard to come up with any drawbacks for these types of registries. They exist in other countries and have driven down medical costs; in other specialties, and registries can offer participating providers with a high-level or microscopic view of comparative clinical outcomes.
For example, the FORCE-TJR registry, which has collected data on 30,000 procedures from organizations in 22 states, found that despite younger patients accounting for more hip and knee replacements, their pain was comparable to what older patients prior to surgery. That's data that destroys assumptions about age.
Ayers says providers can also get practice-to-practice information to compare patients and outcomes, which can prompt changes in protocols that reduce cost and or improve quality.
"It's a very powerful tool because surgeons always want to get better; they always want to improve," says Ayers.
And evidence shows that participating in an orthopedic registry reduces some costs. The CJRR, in its most recent report shows that hospitals that are part of its registry do not have to keep its patients in the hospital as long.
When compared to U.S. average and California averages, the length of stay at a CJRR participating hospital, was shorter for both hip replacements and knee replacements – in some cases by almost two days. The average LOS for a hip replacement in the U.S. was more than four (4.2) days in 2010; in California, it was exactly four days; at a CJRR hospital, it was 2.3 days.
"The benchmarking data that physicians get back isn't information they can get anywhere else," says Chenok. "They're able to see opportunities for improvement."
Barriers to Registries
Despite the importance of the data collected, whether it is specific to implants, patients, or both, funding medical registries has historically been a challenge. The infrastructure costs to building and maintaining the technology a registry requires can be huge.
The FORCE-TJR registry is funded by a $12 million grant from the Agency for Healthcare Research and Quality (AHRQ). The CJRR is funded mainly through the California HealthCare Foundation, but also has financial support from business groups, professional associations, and payers.
"There are a lot of competing resources," says Chenok, who says initial reluctance to join because of potential HIPAA violations, has diminished because the patient's identifying information is not shared.
Another potential barrier that the FORCE-TJR registry has overcome is getting responses from patients, for their outcomes. Ayers says it has an 86% response rate from patients in terms of data completeness. FORCE-TJR registry is patient-centric, and has patients sign a release that allows the registry to follow up with them on pain and functionality at 6 months, 1 year, then annually.
"We don't give up," says Ayers. "Spending time at the front end to educate the patients is key; [we] get not only their home telephone, but also their email address, their cell phone number, their best friend's number, their family's number. We don't give up."
Following the patient also alleviates some of the technology fatigue that causes physicians to complain.
Defining Value vs. Cost
The cost of developing and maintaining a medical registry for orthopedics could also be eventually diminished if value-based reimbursement overtook fee-for-service as the primary way physicians get paid.
Most organizations have their feet in both FFS and some value-based contracts, but the movement away from FFS is not strong enough yet for some organizations to invest in another way to track outcomes, value, and pre- and post-operative patient functionality. But, it's coming, says Ayers.
"The data we collect, which directly measures patient outcome and measures quality, is measuring the numerator of the value equation," says Ayers. "If you don't do this, you can't measure value. This is a toolset that most astute practice leaders understand is going to be essential to thrive."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. They are making a difference in healthcare. This is the story of Rushika Fernandopulle, MD.
This profile was published in the December, 2014 issue of HealthLeaders magazine.
"One of the rules is we do not bill fee-for-service, period. Big period at the end of that sentence."
As hospitals, health systems, and insurers tinker with payment models that preserve the current fee-for-service reimbursement while preparing for a fee-for-value environment, Rushika Fernandopulle, MD, cofounder and CEO of Cambridge, Massachusetts–based Iora Health, is moving forward with his vision for primary care that puts payment last and patients first.
"Trying to do the right thing for primary care when you're getting paid the wrong way is really hard, if not impossible," says Fernandopulle. His company, Iora Health, works directly with self-insured employers, unions, and health plans to open primary care clinics that do not take patient copays and do not bill fee-for-service. In two years' time, Iora has opened a dozen of these global-payment-only primary care clinics across the country.
Fernandopulle says the company's rapid growth is because self-funded employers who are on the hook for all of their workers' healthcare costs are looking for ways to save money. Iora offers that with a simple demand: Pay a global fee for patients and let us do what we need to do to get and keep them healthy. Recently, insurance companies have been calling, too.
Like many primary care physicians, Fernandopulle bemoans the fee-for-service payment model, saying it gives doctors a perverse incentive to overtreat, overdiagnose, and overlook the root of patients' problems. "All you get paid for are sick visits, and many of the things that are the right thing to do for patients are not doctor sick visits," he says.
Health plans are rolling out accountable care organizations and other shared-savings programs that attempt to give physicians more freedom to take care of patients, but those projects are not widespread. Fernandopulle also says sustaining two payment models is untenable. "What happens in a typical practice is that you might have a few contracts where you can convince people to pay you differently, but the rest of your patients are still being paid for the old way," he says, recounting this exact experience with an early pilot project at a practice in Seattle.
Fernandopulle says the practice ended up having to color-code charts to discern which patients belonged to the plan that paid for value and which didn't. The irony was that the patients had the same needs regardless of their plan, but doctors couldn't take care of them the same way; in a fee-for-service model, if the cost is lower, so is the doctors' income. Fernandopulle also says the administrative burden of managing two systems was overwhelming. "Doing two different things in the same practice … that's just an unholy mess."
So Fernandopulle stopped trying to work with the system. Instead, he does whatever it takes to keep his patients happy and healthy. And he says the data is bearing out his vision.
"Our patient satisfaction is through the roof," says Fernandopulle, who uses Net Promoter Score to measure patient experience and satisfaction. The NPS measurement system has typically been used to measure customer loyalty for retail organizations, but health systems have begun adopting it, too. "Our NPS score is in the 90% range. That's higher than Amazon, Whole Foods, and Trader Joe's. And our outcomes are not a little better, but hugely better. Our practices' impact on downstream spending shows a 50% drop in ER visits and a 12%–15% drop in total spending."
And while Fernandopulle rails against electronic health records and CPT codes, because he believes they exist to help payers and not patients, he acknowledges that in order for his vision to become a mainstream reality, he has to get cooperation from health insurers. Of course, they'll have to play by his rules. "One of the rules is we do not bill fee-for-service, period. Big period at the end of that sentence," he says. "We will not submit codes. Why do they need the codes? Who cares how many visits we do, or how we get there? What they should care about are the outcomes. How we get there is irrelevant."
There are visionaries in healthcare, many of whom are included in this HealthLeaders 20 list, but Fernandopulle is outside of the mainstream, not constraining himself to the existing relationships among patients, doctors, hospitals, and payers. He is building what he believes is a new "operating system" for healthcare, and he's hitting the reset button.
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. They are making a difference in healthcare. This is the story of Lee Aase.
This profile was published in the December, 2014 issue of HealthLeaders magazine.
"What really drove me into it was the way that these tools make communication free and almost effortless."
If Lee Aase, the Mayo Clinic's first social media manager and now director of its four-year-old Center for Social Media, had his way, this profile would probably only be 140 characters, the maximum length of a tweet. But his pioneering work at the Rochester, Minnesota–based healthcare system deserves a longer description.
The Mayo Clinic is, in many ways, a gold standard that healthcare leaders look to when they want to improve clinical quality, patient experience, and medical outcomes. Patients from around the world also put the nonprofit healthcare system on a pedestal for its team-based approach to helping them get better. In the 24/7 world of social media, too, the Mayo Clinic continues to retain its reputation of doing things well.
With such a strong, recognized brand, Mayo could have passed on jumping into social media. The name is so well-known, so well-respected, that it likely would have survived an absence on Facebook and Twitter. But Mayo chose to participate, largely because Aase saw the potential for social media to continue the system's mission of patient engagement and education.
"We're in our 150th year now, and our founders, Dr. Will and Dr. Charlie [brothers William Mayo, MD, and Charles Mayo, MD] had this tradition where one would stay home and one would travel around to teach and learn," says Aase. "They'd bring back best practices and they would take what they were learning to others, so this really isn't all that different. Instead of traveling by plane and by ship, we travel through cyberspace."
Aase arrived at Mayo in 2000, when only 41.5% of U.S. households had Internet access, which was mostly used to send and receive email. Even then, Mayo had an Internet presence, but Aase describes the website, then known as Mayo Health Oasis, as basic, like most early websites. "Back then, it was a consumer health information website; it wasn't interactive, it was, 'We have knowledge that we can share with other people and people come from around the country, around the world to see us in person, and this is a good way to make that more accessible,' " he says.
Aase says like Mayo, he was also an early adopter of technology, buying an Apple IIe and tinkering with computer programming because of the common problems it could solve. "I remember hanging out in my dorm in my first year in college and having to wait for the one phone that was on the floor to be able to make a collect call home," he says. "What really drove me into it was the way that these tools make communication free and almost effortless."
Effortless is how Aase and his 10-member social media team try to make the learning process for physicians, who may be interested in using social media but are skittish because of privacy rules that guard patient identity. "Part of what we do is make it as easy as possible to get engaged," he says.
A doctor's first foray into the Mayo Clinic's social media space—which includes a major presence on YouTube, Facebook, Twitter, and Pinterest—is doing an interview with a simple flip camera that Aase posts to the Mayo Clinic's YouTube channel. "We're asking them to do the same thing they do a dozen times a day as they talk to patients," says Aase. "One of the concerns physicians have about doing media interviews is being taken out of context, or misquoted, and what they really like about the YouTube videos is that we don't have sound bite limits. They find that comforting, and once they've shared their knowledge, it gives us a resource we can put out on the social channels that could be helpful to patients."
The Mayo Clinic's social media presence looms large. The videos on its YouTube channel have received more than 14 million views; in addition, the health system has more than 900,000 followers on Twitter, approximately 543,000 Facebook likes, and some 13,000 followers on Pinterest.
These impressive numbers are due in some measure to Aase's vision, though he gives credit to the Mayo Clinic's President and CEO John Noseworthy, MD, and Chief Administrative Officer and Vice President Emeritus Shirley Weis for supporting the development of the Mayo Clinic Center for Social Media in 2010.
Like Mayo's commitment to sharing best medical practices with peers, the MCCSM is a resource-rich hub for any hospital, healthcare system, or healthcare leader who wants to participate in social media but is unsure how to do so. Aase has established a membership roster for the MCCSM's social media health network that includes 111 organizations, ranging from large academic medical centers such as Vanderbilt University Medical Center to small, independent hospitals such as the 39-bed Yampa Valley Medical Center in Steamboat Springs, Colorado. Members of this social network get access to real-world case studies, tools, classes, and advice from their peers.
"In one sense, we're air cover," says Aase. "Excuse the military term, but organizations would go to their leadership and say, 'Mayo Clinic has a Facebook page.' They are using us as part of their argument to engage in social media. I think that provides some reassurance."
The responsibility of making sure that the Mayo Clinic brand retains its polish as a healthcare and social media leader in a space where there are so many opportunities to stumble is not lost on Aase.
"Just as our founders had this commitment to outreach, we feel both very fortunate and responsible that we want to do it right," says Aase, in just 125 characters with spaces. :-)
Remember patients? They are a driver in healthcare transformation—perhaps the most important one.
The Health IT and Quality Exchange that HealthLeaders Media held in La Jolla, California, last week for CMOs, CIOs, and CMIOs was eye-opening on a number of fronts.
The ideas, successes, and challenges that the gathered healthcare leaders shared in our small group sessions illustrated that changing a workflow or a process isn't nearly as important as changing an organization's focus from physicians and payers to patients.
Don't get me wrong—redesigning work and reengineering processes around efficiencies that are intended to improve patient care are important, too. But retooling inpatient and outpatient processes to put the patient at the center of care (the aim of a patient-centered medical home) isn't as intuitive as it sounds.
The PCMH is often pointed to as one of the ways that primary care can be redesigned around the patient. The path to achieve NCQA status is arduous. Organizations have to demonstrate care coordination with a team-based approach that cares for the patient as a whole person, not just a patient with a medical condition. It requires coordination on many levels from IT tools to basic human resources.
Even organizations that are not going after PCMH certification are modeling new care models based on the core PCMH principles.
One of the primary reasons that patient-centered care represents such a culture shift is because the foundation of care that several generations of physicians and patients know is based on a fee-for-service payment system.
That structure inherently puts payers and providers at the center of a patient's care, whether she is coming in for a cold or a colonoscopy. It's transactional, when it needs to be transformational–at least to the patient sitting in the waiting room anxiously awaiting to hear what the lab results mean, or to the patient waiting for a routine physical.
Patient Variations
"There's not just one generic patient out there, and our entire system has been built around our physicians, our nurses, our payers, our practices," says Stephen Moore, MD, CMO and senior vice president for Catholic Health Initiatives, the Englewood, Colorado-based system with more than 90 hospitals in 18 states.
The variation in patients may seem like a barrier to providing patient-centered care because it means giving the patient the right care at the right time for what they need. Those are a lot of conditions for building a care model for all different types of patients, but structures can be built to standardize some systems that gives patients more say in their care.
For example, in 2011 Geisinger Health System developed an online process that allowed patients to check the accuracy of their medication lists before seeing a doctor. Medication reconciliation can be a nightmare for physicians, and it is so important that medication reconciliation is a required measure of Stage 1 Meaningful Use.
A new study measuring the effect of giving patients access to their medical record reveals two important things that should qualm the fears of physicians who are queasy about handing over control to patients. One, medication list accuracy improved and two, patients accessed the online portal to Geisinger, called MyGeisinger, more often.
Many healthcare organizations are banking on portals engaging patients in their own healthcare, though to make it meaningful to the patient, there has to be some level of usefulness.
The Geisinger experiment bears this out. Of the 30% of patients who completed a form offering feedback to the system, 89% requested changes to their medication lists. Geisinger pharmacists did not make changes without reviewing the requested changes and following up with the patient. Over half of the medication request changes were granted.
A positive side benefit to the access Geisinger gave its patients is that engagement with the portal increased. The study's authors found that patients who updated their medication list logged into the MyGeisinger portal 2.3 times as often as an average patient. The study also found the patients who used the portal also used its secure messaging feature more often.
A Step Further
Altering the access a patient has to his or her medical record is being taken one step further at Mosaic Life Care (formerly Heartland Health). Patients there are actually writing their medical history directly into their personal health record. It's a narrative that allows insight to other parts of their life, such as social, economic, etc. challenges, that can have a deep effect on health.
These technologies are tools that get at what patients are looking for from their providers: access. Already and rapidly, retail clinics are filling that space because it's what patients are demanding. Their expectations will continue to rise and disruptive providers will likely continue to emerge, unless your system does something to fill the demand.
Patients are a driver in healthcare transformation, perhaps the most important one, says Moore.
"Our solutions are going to have to be tailored to patients."
It's not only anatomy, but cell biology that distinguishes women's health needs from men's. Leading providers recognize the value of gender-based medicine and strive to educate and empower patients.
This article first appeared in the October 2014 issue of HealthLeaders magazine.
As a population, women have different health and medical needs beyond the ones that present in the bikini zone. For example, women need smaller medical devices for knee replacements because their frames are smaller. Signs of a heart attack are different for women, as well.
The list of gender-specific presentations, diagnoses, and treatments goes on and on, thanks in part to a landmark study from the Institute of Medicine that showed sex differences were not just anatomical but cellular. That research led to a different way of thinking, says Jennifer H. Mieres, MD, FACC, FASNC, FAHSA, senior vice president for the Office of Community and Public Health at North Shore-LIJ Health System, a 17-hospital organization that provides care for 7 million people in an area that includes Long Island, Manhattan, Queens, and Staten Island in New York.
Mieres says presenting the need for gender-specific medical treatment because of the biology of cells rather than the anatomy of a person helps move a physician from skeptic to believer.
Patient engagement at the practice level is identified as a key factor that contributed to the success of a Pioneer ACO in New York.
This week, dozens of healthcare leaders will converge in La Jolla, California, for HealthLeaders Media's inaugural Health IT and Quality Exchange. We have held this type of invitation-only event for CEOs and CFOs for a few years now to glean insight into the challenges of delivering quality care to patients amid a dynamic environment of regulatory change.
This newest event highlights the need—and requirement—to integrate technology into nearly every step of healthcare delivery.
Competing Priorities
Healthcare system leaders are charged with responding to the transformation of healthcare delivery on a number of fronts. Preparing for new payment models, keeping pace with new care partners, and trying to align with the latest health information technology demands all seem to be screaming for priority status.
One strategy that may help reduce the distractions that inevitably arise from such large undertakings is to focus on how each change or redesign in process empowers patients. They are the single entity that binds healthcare's complex and connected issues together.
Improving patients engagement, whether it is getting them to adhere to medication regimens, care plans, or even just following up with a PCP after a hospital stay not only improves outcomes, but could also play a role in improving patient experience.
Improving Outcomes
Keeping patients healthy is the core of a physician's work. That's a no-brainer, but the fee-for-service payment model doesn't give doctors any incentive for healthy patients. Transitioning out of a decades-old reimbursement environment that rewards doctors for the number of patients they see and not the outcomes of the patients is tough.
It's a clinical and cultural shift; however, patient outcomes are a key component to value-based payment systems. With Medicare and commercial accountable care organizations beginning to report on systems that are saving money and sharing in those savings, some leaders are using the momentum to increase their patient engagement strategies, despite the debate over whether these payment models are truly sustainable.
"Patient engagement is one of the differentiators between health systems or physician groups that can deliver quality care," says Kristofer Smith, MD, vice president and medical director of North Shore-LIJ Care Solutions, the health system's care management organization.
Improving Cost
North Shore-LIJ and University Physicians Group are part of the Montefiore ACO, a Pioneer ACO that saved Medicare $24.5 million in 2013. UPG physicians took care of 4,917 of the 25,000 Medicare beneficiaries that participated in the Montefiore ACO, just 5%, but the multi-specialty physician group generated 14% of the total savings.
Smith attributes patient engagement at the practice level as one of the key factors that contributed to the ACO's success.
"The practice has a relationship with the patient, and so as UPG started to get information, they saw gaps and reached out," says Smith. "Patients heard, 'This is your doctor calling,' and to leverage prior relationships, that's a more effective strategy."
To close, or at least, narrow the gaps in care, Medicare ACO participants received reminders about blood draws, vaccines, and other important components to their care. UPG also incorporated the clinical measures as determined by CMS into its electronic health record.
Another gap closed when North Shore-LIJ, in conjunction with UPG, used real-time notification tools with patients.
"We knew when one of the patients was in one of our hospitals," says Smith. "We would arrange to follow up after they were discharged, and we had much higher engagement rates."
Communication is key, says Smith. The upside to that kind of communication is that the person who is engaging with the patient does not always have to be a physician. Front office receptionists, medical assistants, nurse practitioners, navigators, etc., are playing important roles now in physician offices across the country.
Patient Experience
North Shore-LIJ is one of the dozens of health systems that will be joining and leading the discussion around how to leverage technology, leadership, and population health strategies that help empower patients in their own care.
HealthLeaders Media research has shown repeatedly that healthcare leaders believe that improving patient engagement can lead to an uptick in patient experience, which also has downstream implications.
But connecting with patients is still a work in progress. Despite the gains made in the Montefiore ACO, Smith says the system is working on an accurate way to capture the patient's voice.
It will likely be a complicated journey to answer the seemingly simple question, "What do patients want?" But, finding out what a patient needs and how they view the value of their healthcare offers insight into how a patient wants to communicate with a provider. And that answer may unlock other points of connection impact quality and cost, says Smith.
"Patient-centered communication is key. You have to figure out how to elicit information, and if you've explained things in a way they understand. The starting point is care management."
After a three-year legislative battle, physicians and physicians assistants in Tennessee say they are "mutually committed to continuing to improve access to safe and effective patient-centered quality care within an integrated, coordinated, physician-led team."
Doug Springer, MD, FACP, FACG
The Tennessee Medical Association (TMA) and the Tennessee Academy of Physician Assistants (TAPA) are vowing to work together after a years-long divisive legislative battle splintered the relationship between the two organizations.
The split could have permanently damaged an important partnership at a time when midlevel providers, such as PAs, are being leaned on as a possible solution to easing the shortage of primary care physicians.
In 2012, state legislators passed a law, put forth by the TMA, that required a physician to be onsite when a physician assistant) or other mid-level provider administered a spinal injection to patients. PAs had been doing spinal injections without an onsite physician, and felt that the bill limited patient access to pain management therapy.
MDs, represented by the TMA, believed it was a patient safety issue, and after a three-year battle in the legislature, won the argument, but nearly lost a longtime ally. "It was a rancorous fight in the legislature," says TMA President Doug Springer, MD, FACP, FACG.
Leadership at TAPA agrees, and says the issue put the two organizations at odds for too long. TAPA's Executive Director, Katherine Pesut Moffat, says that after the law was passed, the organization approached TMA to find out how to move forward.
"It made us stop and say, 'We need to rethink this conversation and dialogue,' " says Moffat.
Both organizations met frequently over the last year and last week produced a joint statement:
"We, the Tennessee Medical Association and the Tennessee Academy of Physician Assistants, are mutually committed to continuing to improve access to safe and effective, patient-centered quality care within an integrated, coordinated, physician-led team."
The working relationship between MDs and PAs isn't one that has room for much contention. And knowing that professional organizations have the ability to set the tone for communication at the provider level, both TMA and TAPA leadership say sending out the joint statement reset the relationship and expectations.
"This joint statement is a giant first step," says Springer. "It's a message that it's time to focus on the future, not a rehash of the past."
Future of PAs
The first PAs began practicing alongside MDs in the mid-1960s. Their number has been increasing year over year for more than a decade. According the National Commission on Certification of Physician Assistants (NCCPA), at the end of 2003, there are 43,000 certified PAs in the U.S. That has grown to 100,000 this year, and projections are for more than 125,000 by 2018.
The reason for the exponential growth is the same reason the profession began in the first place: There is a shortage of primary care physicians. The longtime working partnership is one reason that physicians are comfortable with PAs in their practice, says Springer.
"The PAs have been an incredibly important part of medical practices," he says.
There are more than 1,400 certified PAs in Tennessee. They work under the supervision of a physician, with the power to prescribe, see, and diagnose patients. PAs are trained alongside medical students, taking pre-med classes, and spending time in clinical rotations. In practice, PAs function as team members with physicians as team leaders.
This staffing model, in many ways, is what hospital and health systems are working toward now, and this focus on team-based care is another reason the growth prospects for PAs is strong.
Removing Barriers
Despite the strong tenor of cooperation between the TMA and TAPA, PAs still have to work to secure their place on the medical team, and this potential tension exists in other states besides Tennessee.
While PAs have similar powers in all 50 states, plus the District of Columbia, there are still some barriers to PAs working at the top of their license. The National Governor's Association, seeing the potential for PAs to help relieve access issues, recently issued a 15-page whitepaper with several recommendations for states to encourage the use of PAs in medical practices. Among them:
Increase clinical training opportunities for PAs
Review legal definition of provider to make sure it includes PAs
Develop financial incentives for PAs to work in medically underserved areas
Moffat says TAPA is focused on knocking down similar roadblocks in Tennessee.
"We are making sure that there are no barriers to PAs practicing at the top of their license, and at the highest level of their training," she says.
Patient Satisfaction
According to the American Academy of Physician Assistants (AAPA), their survey shows patients are ready for PAs to treat them. In fact, some states, such as New York, have models of care that allow PAs to be the primary care provider in a patient-centered medical home.
According to the AAPA's survey, 92% of 1,500 adults surveyed reported that access was better at a practice with a PA. From Moffat's perspective, it reinforces what physicians who utilize PAs tell TAPA.
"From member physicians, we hear, 'I love my PAs, they are trained to approach medicine like us.' "
An overwhelming number of practices surveyed say Medicare's quality reporting programs have a negative or significant negative impact on practice resources. They also say the programs negatively impact efficiency, morale, and staff time.
A new survey of physician practices shows a high rate of dissatisfaction with several Medicare programs that are meant to improve quality and cost.
The Medical Group Management Association (MGMA), representing more than 33,000 executives and administrators of medical practices, surveyed more than 1,000 medical groups in October to assess how three quality reporting programs under Medicare Part B are affecting patient care and processes.
The Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VBPM), and Meaningful Use EHR incentives (MU-EHR) are supposed to work in tandem to improve the quality and cost of patient care. But many providers who responded to MGMA's survey say the programs are not helping their organizations achieve those goals.
'Arcane' and 'Duplicative' Rules "Medicare has lost its focus with its physician quality reporting programs," said Anders Gilberg, MGMA senior vice president of government affairs, in a statement earlier this week. "Each program has its own set of arcane and duplicative rules which force physician practices to divert resources away from patient care."
An overwhelming number of practices (76%) responded that Medicare's quality reporting programs had a negative or significant negative impact on practice resources. Providers also report that the programs negatively impact efficiency, morale, and staff time.
At issue is the administrative burden that is detracting from patient care without gaining any real value, says Louis Goodman, Ph.D., president of the Physicians Foundation, a nonprofit group focused on helping physicians understand their changing roles because of healthcare reform. Goodman is also EVP and CEO of the Texas Medical Association.
"One of the major complaints that physicians have is that they find themselves looking at a screen to make sure they meet all the requirements in the record," says Goodman.
"The doctors I talk to tell me that a small portion of the medical record is very helpful because so much of it is devoted to meeting HIPAA and other regulatory requirements that it really doesn't have an impact on their ability to see the patient or quality."
CMS set up PQRS as a quality check, by having physicians and physician practices report on different measure sets. This year, CMS adopted 287 measures in 25 measures groups to address some gaps.
But physician organizations such as the American Medical Association, the Physicians Foundation, and others have long complained about the PQRS requirements, particularly because CMS will be looking at data collected in 2013 to assess penalties or incentives in 2015.
Providers have had some access to their progress on quality measures that CMS is using, but essentially, any progress that organizations made in 2014 over 2013 will not count.
While PQRS has been a pay-for-reporting program, VBPM is a pay-for-value program with penalties or incentives beginning next year. VBPM initially applies to provider groups with 100 or more eligible professionals. It will eventually cover more and smaller provider groups by 2017.
In 2013, provider groups that were going to start being judged had to tell CMS which one of the three PQRS reporting methods it would use to avoid an automatic 1% penalty to payments in 2015.
The way CMS is determining the value modifier—upward, downward, or neutral—is by comparing performance measures of provider groups to the average of the previous year. CMS calls this "quality tiering." It isn't mandatory to participate in quality tiering until 2016.
Physicians: Give Us More Flexibility Provider groups who opted out for 2015, will receive a neutral modifier, which won't have an impact on their payments from Medicare. To assess whether a provider group gets a ding or a bump—or nothing—Medicare will use the quality data that was collected in the PQRS from 2013, as well as cost data from traditional Medicare fee for service claims.
There is one caveat: The modifier does not apply to eligible provider groups that are taking part in CMS's Medicare Shared Savings Program or its Pioneer Accountable Care Organization program, or that are part of the Comprehensive Primary Care initiative.
CMS is under some pressure to respond to the complaints about PQRS, VBPM, and MU-EHR. In addition to MGMA's survey results, last week, the AMA sent a letter to CMS Administrator Marilyn Tavenner asking to align the programs.
Among the AMA's recommendations: giving more flexibility to organizations attempting to meet meaningful use requirements. In its letter to Tavenner, the AMA ask for CMS for a 50% threshold for incurring a penalty, and a 75% threshold for earning an incentive in MU stages 1 and 2, as well as expanding hardship exemptions for some physicians, and requiring that doctor meet only 10 measures under MU stage 3.
All three programs begin penalizing providers in 2015, and the AMA argues that the combined penalties could amount to potentially an 11% reduction in Medicare payments by 2017.
"If the physicians meet the protocol and standards for one quality program, they should be deemed successful for all," said Robert Wah, MD, AMA President.
While residents of the city are getting back to their normal routines in the wake of an Ebola scare, it may take a while for Texas Health Presbyterian Hospital to recover.
The fallout from Ebola is hitting Arlington-based Texas Health Resources in its pocketbook.
Last week, Moody's Investor Service downgraded the hospital system's long term debt rating outlook to developing from positive. The shift in the rating action was directly tied to concerns about litigation related to Ebola cases, according to Moody's report.
"The developing outlook reflects the uncertainty on the system's long term financial performance, impact on financial resources and litigation risk following recent cases of Ebola at one of the system's flagship facilities."
Despite the change, THR's Aa3 and Aa3/VMIG1 ratings remain the same. Presbyterian Hospital Dallas, the site where Ebola became a real health threat in the U.S., accounted for 13% of the system's net patient revenues in 2013.
New financial disclosures from THR show that revenue, ED visits, surgeries, and the daily hospital census at its Dallas hospital all fell beginning October 1, just a few days after Ebola patient Thomas Eric Duncan was admitted.
In addition to the financial hit, any new Ebola cases that hit Dallas will no longer be routed to THR's Presbyterian Hospital Dallas.
Venue Shift
Texas Governor Rick Perry announced earlier this week that patients presenting with Ebola in Dallas and surrounding areas will be treated at Methodist Campus for Continuing Care, which is part of the Dallas-based Methodist Health System, a six-hospital nonprofit system.
Parkland Hospital and UT Southwestern Medical Center are providing resources to Methodist, including manpower, personal protective equipment, and laboratory equipment. The new Ebola Treatment and Infectious Disease Bio Containment Facility will take up an entire floor at the campus, which is located in Richardson, a suburb of Dallas and less than 10 miles away from THR's Presbyterian Dallas hospital.
A second Ebola treatment facility will be located in Galveston at the University of Texas Medical Branch there. Dallas County Judge Clay Jenkins cited healthcare worker fatigue at THR as a reason to send future Ebola patients to another hospital.
In a statement, THR offered a somewhat unemotional response to the news that they would no longer be where Ebola patients would come for treatment.
"As the first U.S. hospital to face the challenge of both diagnosing and treating Ebola patients, Texas Health Presbyterian Hospital Dallas will continue to share our learnings with health officials at all levels of government, our fellow hospitals and the broader health care community."
As a resident of Dallas, a city that will now forever be synonymous with ground zero for the Ebola outbreak in the U.S., I can say that some of the fear and panic that was playing out on our television screens with hourly updates has subsided.
Local Drama
While the drama played out nationally and internationally, Dallas area residents were privy to press conferences with the CDC and constant video streams from the hospital and two local residences. It was not the same as watching CNN or the other national news networks.
We were watching our healthcare workers, our mayor, and other leaders attempt to calm the city down. Even as a seasoned reporter who knows better than to succumb to unfounded fear and panic, I could see how quickly and easily the two emotions could overwhelm you to a standstill.
The city and its residents are moving again, guardedly.
The first wave of people being monitored for Ebola because of their contact with Duncan were given a clean bill of health on Monday; no new infections have been reported in a week, and one of the infected nurses, Nina Pham, has been upgraded from fair to good. So far, there is no official word on the condition of Amber Vinson, the second nurse who also tested positive for Ebola, though her family says the hospital has told them Vinson no longer has Ebola.
But while residents of the city are getting back to their normal routines, it may take a while before THR and its employees can, especially with the financial news this week. Its Dallas hospital campus is no longer diverting ambulances from away from its emergency department. That is the most significant sign that the hospital is returning to regular operations.
And a nurse I know who works at Presby, as it is known to locals, told me that the workers are rallying behind the hospital leaders and are not upset with the guidance they received to care for Duncan.
A nurse's union has been sharply critical of THR's care of Duncan, citing piles of medical waste and improperly protected nurses. THR issued a point-by-point rebuttal of the union's suggestions, and a number of nurses from Presby held a news conference on Monday citing their confidence in THR and its leadership.
Reaction and Fallout
It's hard to tell what the fallout will be at Texas Health Resources because of its missteps in the handling of the first Ebola case in the U.S. The hospital's leadership has acknowledged its mistakes in both a congressional hearing on its response as well as a full page letter to the communitythat was published in Sunday's newspapers, signed by newly-minted CEO Barclay Berdan.
"Although we had begun our Ebola preparedness activities, our training and education programs had not been fully deployed before the virus struck."
THR may be shouldering most of the blame, but the hospital shouldn't be the only target. In an audio webcast from the New England Journal of Medicine, Arjun Srinivasan, MD, associate director for Healthcare Associated Infection Prevention Programs in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention, acknowledged that all the initial guidance it gave hospitals personal protective equipment to protect healthcare workers from contracting Ebola was based on the outbreak in Africa.
"Training on the use of protective equipment is not something that we have focused on previously in U.S. hospitals," says Srinivasan.
The CDC has since updated its guidance to U.S. hospitals for donning and doffing personal protective equipment, and using respirators or masks when caring for an Ebola patient, as well as other precautions.
Srinivasan says that all U.S. hospitals have to be able to respond to an Ebola threat, though he agrees with those who have called for designating a smaller number of hospital facilities as Ebola treatment centers.
While THR struggles to rebound from the public perception of its mistakes with Ebola, healthcare peers who are in the very complicated business of treating infectious disease, have more compassion.
Dennis Deruelle, MD, FHM, an infectious disease doctor who is also the national medical director of acute services for IPC The Hospitalist Company, says the Ebola virus arriving in the U.S. should be a wake-up call to all hospitals to do a better job at managing the spread of other infections.
"We have to vigilant about infection control," says Deruelle. "We're not as vigilant about gowning and gloving. It's not a stretch to say we haven't been vigilant."
Leading providers now focus on educating and empowering women about the unique healthcare needs they have.
This article appears in the October 2014 issue of HealthLeaders magazine.
As a population, women have different health and medical needs beyond the ones that present in the bikini zone. For example, women need smaller medical devices for knee replacements because their frames are smaller. Signs of a heart attack are different for women, as well.
The list of gender-specific presentations, diagnoses, and treatments goes on and on, thanks in part to a landmark study from the Institute of Medicine that showed sex differences were not just anatomical but cellular. That research led to a different way of thinking, says Jennifer H. Mieres, MD, FACC, FASNC, FAHSA, senior vice president for the Office of Community and Public Health at North Shore-LIJ Health System, a 17-hospital organization that provides care for 7 million people in an area that includes Long Island, Manhattan, Queens, and Staten Island in New York.
Mieres says presenting the need for gender-specific medical treatment because of the biology of cells rather than the anatomy of a person helps move a physician from skeptic to believer.
