Two studies point to the need for a more thoughtful approach to postacute care strategies because readmission rates are simply not improving for some patients.
Hospital and health systems navigating healthcare transformation have no doubt evaluated their approach to postacute care with the hope that its efficient use will help drive down costs. The problem is the lack of standards that exist in the postacute care space.
I've heard concerns from healthcare executives about the variation in quality among skilled nursing facilities, home health agencies, and long-term care hospitals. There is also wide variation in payments to postacute care providers.
Greg Sacks, MD
In last year's report to Congress, the Medicare Payment Advisory Commission (MedPAC) reported that per capita spending on postacute care varied more than any other Medicare-covered service. Yet, it remains one of the fastest-growing areas in healthcare. Between 2001 and 2012, MedPAC reported that it had more than doubled its payments to postacute care providers to $59 billion.
Those combinations of payment and quality variation overshadow the most important part of the postacute care equation—patients. Where is the most appropriate site of postacute care for them?
According to two new studies, it is not at an inpatient facility. UCLA researchers, in a new study published in Medical Care, found that postacute care at an inpatient facility was associated with shorter lengths of stay, but higher 30-day readmission rates.
"It's too big of a leap to say hospitals are sending patients home prematurely, but it points to a pattern," says Greg Sacks, MD, the study's lead investigator.
UCLA researchers analyzed Medicare claims, the local health information, and the American Hospital Association's annual surveys from 2005 to 2008. Out of 112,620 patients spread across 217 hospitals and 39 states, about 40% of patients were discharged to a postacute care setting.
According to the study, 18.6% were sent to inpatient facilities such as skilled nursing, rehab, and longterm care, while 19.9% received home health care.
Richard Iorio, MD
Sacks was surprised by the variability in how hospitals used postacute care. "The extent of the variation was the most surprising," he said. "We adjusted for almost every conceivable variable. We controlled for hospital and patient characteristics, and we looked at the number of postacute care facilities regionally. The most surprising finding was the magnitude of this variation."
Effect on Readmissions
The pattern that UCLA found—higher 30-day readmission rates are associated with postacute care at an inpatient facility—is one that orthopedic surgeons at NYU Langone Medical Center see, too.
"Readmission rates are double for patients who are discharged to postacute facilities rather than home," says Richard Iorio, MD, chief of adult reconstruction and professor of orthopaedic surgery at NYU Langone Medical Center's Hospital for Joint Diseases.
"This difference is seen even when the groups are stratified by medical comorbidities, and has been demonstrated in multiple studies. Going home is best for the patient."
NYU Langone researchers recently revealed what happened to readmission rates when they changed the medical center's postacute care program for Medicare patients who had surgery for cardiac valve replacement, spinal fusion, or major joint replacement in the lower extremities.
Those three procedures are part of the Medicare bundled payment initiative that NYU Langone began participating in three years ago. Since the medical center would be at risk, it looked to control costs by diverting patients away from receiving postacute care at facilities. The rate of discharge to postacute care facilities decreased across all three categories.
It went from 70.5% to 21.1% among cardiac patients. For the orthopedic patients, the discharge rate decreased from 67.6% to 33.5%, and the spinal fusion patients' discharge rate fell to 29.8% from 40%.
Rate of Discharge
(From / To)
Rate of Readmission
Cardiac
70.5%/ 21.1%
stable
Ortho
67.6% / 33.5%
dropped from 8% to 5%
Spinal Fusion
40.0% / 29.8%
stable
Leora Horwitz, MD
"Our main worry was readmissions would go up," says Leora Horwitz, MD, associate professor of population health and director of the NYU Langone's Center for Healthcare Innovation and Delivery Science. Horwitz co-authored the study, which appears in January's issue of JAMA's Internal Medicine.
Instead, readmission rates remained stable for the patients who had cardiac valve replacement and spinal fusion surgeries; however, readmission rates for the orthopedic patients decreased significantly, from 8% to 5%.
"Joints were our biggest success," says Horwitz. "The orthopedic department took this on as a major project. They have implemented aggressive screening for smokers. They screen everyone for smoking before surgery because recovery is worse if you're a smoker. They won't take a smoker unless they go through smoking cessation program. They (patients) have to try to quit."
Joseph Zuckerman, MD
Horwitz also says that the orthopedic surgeons promote weight management, as well. The main lesson is that redirecting postacute care to a home-based setting is better for patients and hospitals as long as there is a comprehensive program in place that puts the patients' needs front and center.
"Patients receive postacute care as part of a comprehensive case program based on diagnosis, which in this case is TJR (total joint replacement)," says Joseph Zuckerman, MD, professor and chairman of the department of orthopaedic surgery at NYU Langone's Hospital for Joint Diseases. "This includes pre-op assessment to determine post-op needs so that each patient's needs are individualized."
There has been anecdotal evidence that 30-day readmission rates can fall when the postacute care is at an SNF, but more data points to home-based care as a better alternative.
"There's a lot of cost to the patient not being home," says Horwitz. "This study is important because the rate of postacute care use has skyrocketed and inpatient postacute care may not be as useful as we think it is."
A joint appearance by leaders from the Centers for Medicare & Medicaid Services and the American Medical Association may signal an important cultural shift in how the two organizations work together over the next few years.
When leaders from the AMA and CMS speak, healthcare leaders listen (usually it's to find out what new regulation CMS is rolling out and what the AMA plans to do about it). But typically the two organizations do not speak together—physicians and hospitals are usually cast as the long-suffering cross bearers of CMS red tape.
That dynamic may be changing.
On Monday, CMS Acting Administrator Andy Slavitt and AMA CEO and EVP, Jim Madara, MD, appeared together at J.P. Morgan's annual Health Care Conference in San Francisco. During their individual remarks and the 20-minute question and answer session that followed, both Slavitt and Madara said they were committed to work together.
Andy Slavitt
"The AMA and CMS share a motivation to empower physicians to deliver higher value care with reduced regulatory burden that frees resources to be put toward patient use," Madara said.
Slavitt recognized the frustration physicians voiced last year about what seemed like a mountain of new regulations and rules. "We have to get the hearts and minds of physicians back," he said.
Slavitt also announced—to the delight of CIOs and physicians everywhere—that meaningful use is on its way out. He noted that CMS has been working with the AMA to replace it with what Madara called "a more aggregated program."
"Physicians are motivated by patient care and things they believe in," Madara said. "If they're asked to do box-checking on process measures … it really deteriorates the relationship and the system between the physician community and the regulators."
The transition away from fee-for-service payments is on the horizon for CMS. The Department of Health and Human Services announced in 2015 that it is aiming to tie nearly all of its Medicare reimbursement to value and/or quality by 2018. According to Madara, leaders at various physician organizations are aware of this massive change in payment structure, but average physicians are not.
"Rolling this out is probably not the way to go," Madara said. He believes it's up to the AMA to develop a tool that physicians can use to direct patients to the most appropriate care. "The AMA needs to do that."
AMA's Tech Venture
The tool Madara described may be one of the products the AMA's new startup, Health2047, is working on now. The for-profit, C-corporation, is based in San Francisco, and is meant to connect technological innovation with input from physicians to solve practical problems. The AMA is a founding partner of Health2047 and has invested $15 million so far.
Madara said he expects Health2047 to be a "crown jewel" for AMA. "We think having a direct bridge between this database, between content experts, between the physician community, and the tech resources of Silicon Valley [that] will—should—permit a more targeted, optimized, coordinated and rapid-cycle production of solutions."
Initially, Madara said, Health2047 will focus on three business tracks:
Partnerships with emerging or existing products
Co-development an emerging growth company to optimize existing products
Solutions that are a product of the AMA and others
He also said teams with input from engineers and physicians will be "rapid prototyping," products.
CMS praises ACOs, reduces enrollment periods
In addition to bidding MU goodbye, Slavitt also said CMS would reduce the number of special enrollment periods consumers have used to sign up for health insurance through one of the marketplaces. When pressed by the moderator to name a number, he deferred, but hinted it may just be one.
Jim Madara, MD
"We will keep watching this market," Slavitt said, noting that consumers' best chance to sign up for health insurance is within the next few weeks (the deadline is February 15), "unless there is a life event."
Health insurance plans participating in the marketplaces are also going to get some risk adjustment relief. Slavitt said that CMS will give early estimates of risk adjustment calculations to plans. CMS is hosting a conference to discuss the risk adjustment methodology with health plans on March 25th. The combination of reducing special enrollment periods and improving the timeliness of risk calculations is a signal that marketplaces are moving away from the startup stage.
The CMS chief also praised the increase in healthcare organizations participating in the new ACO model, which he termed "NextGen." The Pioneer ACO model, he said, was a training tool. Slavitt is confident that the ACO model is a money-saver, citing that 85% of Pioneer ACOs' quality measures improved. With the addition of 21 NextGen ACOs, he said there are now 475 ACOs; 64 are full risk ACOs. That number is up from 19 in 2015.
Slavitt wants to expand the ACO model to primary care. "We have to be able to make sure that comprehensive primary care works," he said. After that, the next priority is moving bundled payment models beyond surgeries.
Madara's comments, as expected, focused on physicians as key stakeholders who can make or break healthcare transformation, but Slavitt made a pointed effort to credit physicians, too.
"Physicians are drivers," Slavitt said. "Our role is much more minor."
Based on a year's worth of interviewing and listening to physicians, healthcare executives, and patients, these are the top four things physician leaders should be thinking about—and doing—this year.
Instead of looking back at 2015 to analyze the good, the bad, and the ugly of healthcare, I'm taking a forward view and have put together a list of resolutions for physician leaders to consider making in the coming months.
They're based on a year's worth of interviewing physicians, healthcare executives, and patients for this column and for HealthLeaders magazine. I am not a physician, but I talk to a lot of them, and I listen really, really well.
1. Integrate mental health practitioners into primary care practices.
For decades, the mental health needs of patients have played second fiddle to other healthcare concerns. The Patient Protection and Affordable Care Act expanded mental and behavioral health coverage, but it is still not taken as seriously as it should be. Hospital EDs across the country are crowded with patients who are in crisis, and some hospitals are forming strategic alliances.
In New Jersey, five systems have formed the South Jersey Behavioral Health Innovation Collaborative to find a solution that suits patients, physicians, and hospitals.
But where do patients with mental health needs show up first? Their primary care physician's office is often a patient's first stop. In 2007, authors Patricia Robinson and Jeffrey Reiter estimated that 70% of patient visits to a PCP stemmed from a psychological issue. The Agency for Healthcare Research and Quality, which certifies patient-centered medical homes, recognized the mutual benefit of integrating mental health into PCP offices and now it is a PCMH requirement.
Including a mental health practitioner onsite, whether it is daily or a few times a week doesn't have to be disruptive. But, then, it depends on how you measure disruption in your office, which leads to the next resolution suggestion.
2. Aiming for value? Measure for performance and outcomes.
Physicians who are part of larger systems may be rolling their eyes (because they have metric overload) and that's fine. At least you're measuring! I talk to many organizations—large and small—who have big plans to improve patient experience, communication, physician leadership, etc., but don't have a plan to measure their improvement.
Scripps Health, the San Diego–based nonprofit health system, is taking value seriously, and while the large system has considerable resources, its management structure could be a blueprint for other, smaller organizations, too.
The management of Scripps' clinical service lines is done by two people, an administrator and a physician leader. It's an approach that engages all levels of staff and is reducing variations in physicians' offices, which, in turn, reduces wait times and improves patient satisfaction.
The management teams at Scripps have been able to track supply chain costs, patient satisfaction, and prescription refills by measuring what they're trying to improve. Instead of shrugging off this example because of Scripps's resources, consider what small changes in your practice could be easily tracked, measured, and tied to patient outcomes.
3. Embrace transparency.
"Transparency is coming! Get Ready!" You've all heard this, right?
Transparency in healthcare has been in previews for about as long as the new Star Wars movie was before it opened in December. But unlike Star Wars fans physicians feel like they are still waiting for the main event.
Some organizations are taking big steps toward transparency in their strategic partnershipsand it's paying off. For example, Illinois Gastroenterology Group partnered with BlueCross BlueShield of Illinois to help patients with inflammatory bowel disease receive care more quickly to reduce patients' visits to EDs.
What helped drive the reduction in ED visits was knowing exactly what care patients were receiving and where. An analysis of data from BCBS-IL revealed what IGG didn't and couldn't know without the payer being transparent about its claims data: Most of the reimbursements were for treating complications, not for the management of patients' conditions. Having access to that information led to actions that helped reduce IGG's patients visits to EDs from 17% to 5%.
Not all payers may be keen to hand out claims information, but other, neutral organizations are acting as a third party and processing claims data so that it is understandable for physician organizations.
4. Meet patients where they are: online.
If you are still not writing a blog, tweeting, or using Facebook, that's OK. It might raise the hackles of your marketing department, but patients are online and there are several options popping up for them that eliminate the need to stay loyal to their primary physician.
Telemedicine took off in 2015. Hospitals invested in it and patients are finally getting it. Now, the question is how can physicians capitalize on it? Some are outsourcing the task, such as MultiCare Health System, based in Tacoma, Washington. Its physicians were skeptical of having another doctor care for their patients, but the tele-docs had to agree to use MultiCare's protocols. The system is measuring performance (see resolution no. 2) based on whether patients were ultimately referred to an in-office visit, quality outcomes, and the length of visit.
The "doc-in-the-box" model that physicians thought would be a fad isn't going away because patients value convenience. Telemedicine is unlikely to fade away for the same reason, and patients are used to managing their lives by their smartphones. The newer models of primary care, such as One Medical Group, know this and patient access to its physicians via email is a given.
As debate about the affirmative action policies at U.S. universities continues, the AAMC is boldly pushing medical schools to improve diversity among their students to reflect the patient populations they will treat.
The American Association of Medical Colleges is one of dozens of organizations that filed an amicus curiae (friend-of-the-court) brief supporting the University of Texas' affirmative action policy that is being challenged in Fisher v. University of Texas at Austin. The U.S. Supreme Court heard oral arguments on the case December 9. The American Medical Association, American Academy of Family Physicians, and other healthcare-related organizations also filed an amicus curiae upholding the AAMC's support of affirmative action.
As SCOTUS cases usually are, the actual issue is narrow (one student is challenging the policy), but the outcome has broad implications for, in this case, race-based college admissions. In medical school, the issue of diversity is more than academic. AAMC President and CEO Darrell Kirch, MD, made it clear in his speech at the AAMC annual meeting in November that in order to improve healthcare quality, diversity on medical school campuses must also improve, saying, "…we must admit medical school classes that reflect the diversity of our communities."
Heidi Chumley, MD
More than half of students enrolled in U.S. medical schools are white, according to the AAMC. At American University of the Caribbean School of Medicine, an international medical school in St. Maarten where 85% of the students are from the U.S., the racial make-up is reversed: 51% of the students are non-white, with large groups of Asian, African-American, and Hispanic students, says Dean Heidi Chumley, MD.
"We have a lot more students from diverse backgrounds, not only in race and ethnicity, but also geographically," Chumley says. "We have students from rural areas and also students who are economically disadvantaged. The key to admitting a class that is diverse is looking at the barriers that are keeping diverse populations out of medicine."
MCAT hurdles
One of the biggest barriers, says Chumley, is the MCAT. The entrance test was revised earlier this year to include a psychological, social, and biological behavior component to gauge students' softer skills.
"Being a good doctor is about more than scientific knowledge," Kirch said in a 2012 statement when the changes were first announced. "It also requires an understanding of people."
Hospital and healthcare system leaders know that the softer skills of physicians, such as bedside manner and communication style, can impact patient experience, satisfaction, and quality. They're spending time and money on leadership classes that teach the very things the new MCAT is gauging before medical students step into their first rotation.
But despite the changes, Chumley says medical schools should look beyond the MCAT scores. "The AAMC has made a big push toward holistic admissions," she says. "But what happens is that the higher the [MCAT] score, the better. When you do that, you select for people who have been privileged, advantaged, and can afford to take MCAT prep courses, which are expensive. It creates an inherent selection bias."
This perspective of bias on standardized tests isn't new, but the AAMC's response to reengineer the test and push for more diversity among medical school students show it is taking the issue seriously.
Chumley, who was previously senior associate dean for medical education at the University of Kansas School of Medicine, says challenging the importance that medical schools place on MCAT scores is controversial. But, she says that capable students are getting rejected. She says at the University of Kansas, she blinded the actual numerical MCAT score of prospective students from the admissions committee and instead gave them a grade range the students scored, such as A, B, and C.
"It drove the admissions committee crazy not to see the exact number," Chumley says. "You couldn't tell the difference between the A and B range; the C range was a higher risk, but there is this whole other group not getting admitted who is perfectly capable. The MCAT affects the diversity of classes."
Chumley says students who score below the mean are prepared for medical school. At AUC, the average MCAT score is equivalent to a pre-2015 two-digit score in the 20 to 29 range, with some students achieving higher scores, but it is still below the mean. "They pass the same tests [at AUC], prepare the same way U.S. medical school students do," she says.
AUC students also do most of their clinical training in the U.S. The school's campus is on a Caribbean island, but to practice medicine there, students have to have a Dutch license, which requires taking the test in Dutch, as well. There are some rotations in the community, however, which helps students from diverse backgrounds connect with each other, says Chumley. The match rate among AUC students is also high. Chumley says 84%–85% of students match on their first try, additional students match on their second try.
AUC graduates are also filling a void in the U.S. healthcare system. About half of AUC alumni return to practice in medically underserved and primary care shortage areas.
"There are not simple answers to improving diversity in medical schools, or people would have done it," Chumley says. "Every search committee group—formal or informal—we pay a lot of attention to who is included. You want to give students glimpses of your intentionality."
Whether physicians who are on probation should be required to disclose their probationary status to patients is a source of debate that's getting hotter in California, where a patient advocacy group is testing the boundaries of transparency.
Two leading patient safety organizations say they support an effort in California to force physicians to disclose their probationary status to patients.
That means California doctors may be a litmus test for a new debate about physician transparency. At issue is whether physicians who are on probation should be required to disclose their probationary status to patients.
The Medical Board of California (MBC) rejected a push from the Safe Patient Project, a patient and policy advocacy group backed by Consumer Union, for new physician disclosure requirements, but the MBC is appointing a task force to explore the current disciplinary system. "We are taking this seriously," says Cassandra Hockenson, MBC spokeswoman. "We could have said, 'we do outreach already, thank you.' But we are serious about patient safety. Our mission is consumer protection."
Tejal Gandhi, MD, MPH, CPPS
The task force will have four members, two from the public and two physicians. The members haven't been publicly named yet, but the group will be appointed by the time of MBC's January board meeting, according to Hockenson. "We had a task force for prescription drug abuse and use and we opened it up to stakeholders, so we will very likely open this up, as well," she says. "It's not going to be in a vacuum."
The disciplinary status of physicians and the details that led to sanctions are available online now through most state medical boards. But it isn't convenient and the burden shouldn't be on patients, says Tejal Gandhi, MD, MPH, CPPS, president and CEO of the National Patient Safety Foundation (NPSF). "Ethically, this is the kind of information patients have a right so see and [should not have to] go hunting for," Gandhi says.
NPSF just released a report on patient safety with eight recommendations that address culture, research, and metrics to improve patient safety. A separate NPSF report on transparency released earlier this year, explicitly called for clinicians to tell patients about their "experience, outcomes, and disciplinary history."
Gandhi says patient safety and transparency are intertwined. "I know there are challenges, but the fact that someone is on probation is something patients should know about," she says. "It's fundamental."
Gandhi, who was executive director of quality and safety at Brigham and Women's Hospital in Boston as well as chief quality and safety officer at Partners Healthcare, says one barrier for physicians agreeing to any kind of disclosure requirement is an agreed upon definition for probation.
"It has to be clear what probation means," she says. "There has to be the right way to explain it as well. Is there standard language? It's not the easiest conversation. The board should be providing some standard language and tools."
Guidance Offered
The Safe Patient Project has recommended some guidance on disclosure. It suggests including a paragraph detailing the offense that led to probation, the physician's practice restrictions because of the probation, and directions for contacting MBC for more information about the offense. Safe Patient Project Director Lisa McGiffert applauded MBC's creation of a task force. "We got their attention," she says.
When it comes to whether probationary status at MBC also includes minor physician offenses, such as poor record keeping, McGiffert says that in California, that's likely not the case. "They (MBC) don't hand out probation frivolously," she says. "We think it's disingenuous to claim that doctors are on probation for minor issues. The majority of doctors have no idea how bad these guys are."
McGiffert is no stranger to patient advocacy. She is the consumer liaison to the CDC Healthcare Infection Control Practices Advisory Committee and is a consumer representative on the National Quality Forum's Healthcare-associated Infections Steering Committee.
As of September 2015, about 500 doctors in California were on probation, which is less than 1%. And McGiffert is right. A quick spot check on reveals that the doctors on the list are linked to egregious errors ranging from sexual assault to failing to follow up on patients who eventually died.
'Patients Deserve to Know'
What isn't known, and what the MBC task force can do, says McGiffert, is determine if there are minor offenses among the physicians who are on probation and narrow down the determination of which offenses are so bad that patients should be notified.
The Federation of State Medical Boards does not know if a requirement to disclose probationary status of physicians to patients exists in other states. McGiffert says it does not. "This would set a precedent," she says.
The Leapfrog Group, which monitors hospital safety and transparency for patients, says consumers want this kind of information, and they should get it. "Patients deserve to know," says Erica Mobley, the group's director of communications. "We should never underestimate the intelligence of a consumer. There's no reason why they shouldn't be able use that information to make an informed decision."
The move to disclose errors to patients isn't groundbreaking. The information is online, some organizations, such as Cleveland Clinic, post reports on their quality—both the good and the bad. But telling a patient personally, whether on a form they sign at check-in or in a notice posted on the practice's physical and online site is unprecedented.
Todd Johnson, CEO of HealthLoop, a patient engagement platform provider, says physicians could look to the disclosure rules that govern IT.
"When there's a data breach, we have to report it," Johnson says. "Transparency is a double-edged sword for physicians, but the train has left the station. Medicine is an interesting place to explore this issue of transparency because people are literally putting their lives in someone else's hands."
Physician leadership at nursing homes can substantially reduce costs and improve quality measures, but is a woefully underutilized resource.
A unique ACO partnership has reduced length of stay, readmissions, and costs for Medicare beneficiaries receiving post-acute care at skilled nursing facilities in New Jersey.
How it achieved such improvements relies largely on the influence of physician leadership.
When Poonam Alaigh, MD, was New Jersey's Health and Senior Services Commissioner in 2010, her mother-in-law was diagnosed with a serious illness. Alaigh was able to navigate the fractured healthcare system because of her unique experience as a physician and healthcare executive. But she says she knew other patients and families were unlikely to have someone like her that could steer medical care appropriately.
Poonam Alaigh, MD
That experience led to a sort of personal mission for Alaigh after she left her appointed post in 2011 and says that "taking care of elderly and making sure they have the autonomy and respect they want is my personal and professional mission."
Alaigh drew on her personal connection to her in-laws to help develop the Atlantic Accountable Care Organization, a joint venture developed in 2010 between Atlantic Valley Health System, a Morristown, NJ-based nonprofit health system, and Valley Health System, a 451-bed acute care, nonprofit hospital, based in Ridgewood NJ.
"I work in the nursing home at the VA on the weekends," Alaigh says. "My patients tell me, 'If only we had all those resources.' Those things have inspired me when looking at the post-acute care world."
Focusing on Post-acute Care
Atlantic ACO decided to focus on post-acute care last year with Optimus Healthcare Partners, a clinically integrated network with 500 primary care and specialty physicians.
Thomas Kloos, MD
"Our analysis of data showed a significant regional difference in the post-acute care costs for both our ACO's as compared to national averages," says Thomas Kloos, MD, executive director for Atlantic Management Services Organization, which provides management services to both the Atlantic ACO and Optimus Healthcare Partners.
Two approaches helped Atlantic ACO understand why its metrics were an outlier. The ACO formed a multidisciplinary group of physicians, social workers, nurses, and others to analyze the data. The ACO also worked with the American Health Care Association (AHCA), the organization that represents more than 11,000 nursing facilities, assisted living facilities, and sub-acute care providers in the United States. ACHA shared data on length of stay, readmission rates, and the percentage of patients discharged back to community.
The collaboration helped Atlantic ACO develop a program that was meaningful to the 89 nursing home providers that are now part of the Atlantic and Optimus post-acute care initiative. "The nursing home partners raised the bar," Alaigh says. "It wasn't top down; it was organic. It met the needs of what they expected and at the same time, [it helped] the changes become sustainable."
New Jersey-area nursing home providers were also invited to the table. It gave them a voice, says Denise Ratcliffe, LNHA, strategic advisor at Christian Health Care Center (CHCC), a nonprofit, full continuum of care facility for seniors that includes short-term and long-term care.
"It's been great to let some guards down and share what's working and what's not," she says.
The Medical Director's Pivotal Role
The improvements that Atlantic ACO has seen are significant. Alaigh says for the first time, there have been two consecutive quarters of cost reduction in post-acute care among Medicare beneficiaries. In the first quarter, cost-per-member decreased by 1.8%, and by the second quarter, costs fell by 3.4%.
"That's huge," says Alaigh.
Ratcliffe says CHCC has seen improvements in some of its measures, too, since becoming part of the ACO. "Our readmission rate was 25%, we are down now, year-to-date, to around 16.6% and have gotten as low as 13%."
Ratcliffe also says that length of stay, previously 28 to 29 days, is now down to 25 days and CHCC is looking for efficiencies to reduce LOS even more. The facility's performance is on par with others in the high performing network.
It's an accolade that the nursing homes try to earn quarterly instead of yearly. Alaigh says the rapid cycle improvement keeps everyone engaged and energized. "This is not, 'my way or the highway,' " she says. Rather, "it's 'all boats rise together.' There are four pillars: evidence-based medicine, clinical operations, physician leadership, and outcome data. The top three quartiles are automatically in the high-performing network."
For facilities that don't make the cut, there is always next quarter, but they can also earn entry by improving significantly, says Alaigh. "We added an improvement score. Out of 89, only 12 haven't made it."
The pillar of physician leadership was added because early on in the development of the post-acute care program, it became clear to Alaigh that medical directors of nursing homes were key to improving metrics, but they weren't as active as they needed to be. "We believe if you're going to be involved in meaningful change, physicians have to take the lead," Alaigh says. "That's why 25% of the (high performance) score is based on how active the physician is in the nursing home."
At CHCC, the medical director is on site five to six days a week, but Ratcliffe says that isn't typically the case. "Many facilities have a medical director who is in once or twice a week. I think that's the biggest challenge as well where we're seeing the biggest improvements."
One of the most unique aspects of the program is that it is open to any nursing facility. Instead of approaching only those that were deemed high performing by the ACOs, Alaigh says she wanted it to be inclusive.
"We went from 61 to 89 facilities who want to participate," says Alaigh. "We wanted to engage with like-minded facilities, who wanted to experiment with change and knew the status quo was not sustainable."
Andeven though the nursing facilities are competitors, Ratcliffe believes there is more focus on working together because of population health goals. Such a broad approach also helps clinical staff who are doing the day-to-day work to better understand their roles in healthcare transformation.
"This program was inclusive to allow our post-acute facilities to develop the quality measures to report on and develop the transformational change processes to improve outcomes and reduce LOS and readmissions," says Kloos.
Physicians are at odds with hospitals over Medicare pay cuts at the same time that doctors' financial ties to medical devices are under the microscope of the U.S. Senate. And the AMA is sounding the alarm on drug ads.
The American Medical Association's penchant for making big announcements during its annual interim meetings continued this week in Atlanta with a call to ban all ads aimed at consumers for prescription drugs and medical devices.
The AMA also reaffirmed its rejection of the proposed mergers of insurers Cigna and Anthem and Humana and Anthem.
Normally, I'd focus all of my attention this week on the AMA's meeting because symbolic and significant policy pronouncements are typically made at these events. But two items that flew under the radar this week caught my attention instead because of their potential financial impact on physicians.
Patrice Harris, MD
First, the practice of physician-owned distributorships, or PODS, in which physicians earn a portion of sales from prescriptions for medical devices, was heavily criticized during a U.S. Senate Finance hearing on Tuesday. The regulatory environment of surgeons using devices they may have a financial stake in, such as orthopedic implants, is not straightforward. Second, the Medicare payment cuts that are part of the budget deal agreed to in October are pitting hospitals against physicians.
Banning Drug and Device Ads
Direct-to-consumer prescription drug and medical device ads are a significant chunk of consumer advertising—just watch any TV show. The AMA wants this to stop. In a statement, Patrice Harris, MD, AMA board chair-elect, said the ads drive up consumer demand for expensive treatments over cheaper, but effective alternatives. "Direct-to-consumer advertising… inflates demand for new and more expensive drugs, even when these drugs may not be appropriate."
Unsurprisingly, Pharmaceutical Research and Manufacturers of America, PhRMA, pushed back immediately on Twitter.
The AMA believes banning drug ads will reduce healthcare spending (because patients won't be demanding specific drugs they may not need) and improve transparency.
I have heard physicians complain about having to give in to patients who heard or read about a new drug. But over and over again, research points out that patients listen to their doctors when they trust them. There are always one or two patients who are insistent, but if a physician is constantly giving into patients' demands for Humira because the ad for it is on heavy rotation in during Law & Order reruns, maybe it is time to for a doctor-patient relationship checkup.
Prescription drug and device advertising is a favorite punching bag, in part, because the commercials are so predictably bad. The ads are also everywhere, as the Washington Post found earlier this year. Kantar Media, a market research firm the Post used to source its findings, reported that drug companies spent $4.5 billion in marketing in 2014, and that the drug companies spent more on marketing than research.
The AMA's statement on banning drug and device ads doesn't hold consequential weight, however. The FDA regulates prescription drug and device ads and any changes to them would have to come from Congress. But as a powerful lobbying group in a presidential election season, the AMA's opinion may get some traction.
Physician-owned distributorships
A U.S. Senate inquiry into physician-owned distributorships (PODs) on Tuesday revealed support for models that include more transparency. Critics of the PODs say surgeons are more likely to overuse medical devices they have a financial stake in while proponents say they encourage innovation.
Finance Chair, Orrin Hatch (R-UT) and ranking Democrat, Ron Wyden (D-OR), held the bipartisan hearing the same week that a federal judge rejected a plea deal from Aria Sabit, MD, a neurosurgeon who was part of a POD and who admitted to performing unnecessary surgeries because of the financial incentives the POD offered him.
Sabit pled guilty and was looking at spending at least nine years in prison, but the judge's rejection means Sabit's sentencing could be even longer.
"POD ownership may affect clinical decision making… is this a conflict of interest that compromises medical judgment?" Hatch asked.
John Steinmann, DO, senior partner and medical director at the Spine and Joint Institute at Redlands Community Hospital says no.
"I don't believe it's powerful enough to change a person's ethics," Steinmann said. "We have, and are met with, a powerful conflict of interest in every patient we see. We are paid, on a back pain patient $100 to recommend a conservative regimen of exercise and safe medication, or we're paid $5,000 to operate on their back."
Steinmann says that instead of the traditional PODs model that is based on manufacturer control over inventory of medical devices, he is part of a POD that uses a "stocking distribution model" that controls inventory through volume purchasing.
Suzie Draper, vice president of business ethics and compliance at Salt Lake City–based Intermountain Healthcare, says the healthcare system revised its policies regarding not only PODs, but also all physician-owned enterprises in May 2013.
Federal investigations into PODs prompted fraud alerts across the industry. Draper says Intermountain is committed to transparency and meeting the letter and spirit of federal guidance about PODs, but also says there are now significant implications when buying medical devices.
She says the field of suppliers is narrower and that there could be a "potential chilling effect" on innovation among physicians at Intermountain who want to design and collaborate.
"We recognize that many of Intermountain's own physicians are in the best position to invent disruptive and innovative technologies, and we hope that this exception will provide a compliant model for those activities," Draper says.
Wyden argues that PODs gave physicians an opportunity to double dip—first, by getting paid by the insurer, then by getting residuals on the devices that were used.
Docs vs. Hospitals in Medicare Payment Cuts
The American Hospital Association is lobbying for a new exemption to Medicare payment cuts that were agreed to in last month's budget.
At issue are the payments to outpatient facilities and ASCs once owned by physicians that hospitals are planning to buy or build but the deals have not yet been finalized.
The higher payment rates hospitals received when they bought a physician-owned practice or ASC expired November 1, when the new budget became law. The AHA says the deals that are in process should be exempt from receiving the lower rate and instead be grandfathered in as existing HOPDs or ASCs.
The American College of Physicians supports the payment cuts. After the budget deal was reached in late October, ACP officials issued a statement calling the new payment policy "a positive step forward." The ACP is one of the largest U.S. physician groups with 143,000 members. It criticized the facility fees that get tacked onto a physician practice when it's acquired by a hospital.
The cuts also have broader support from physicians and physician organizations who are part of the Alliance for Site Neutral Payment Reform. The coalition of payers, and members from physician groups, such as the ACP, the American Academy of Family Physicians, and others, lobbied for site payment neutrality in January, sending a letter to then House Speaker, John Boehner (R-OH). It said: "Reforms must be further designed to stop hospitals' reliance on revenue from HOPD services to fund the delivery of unrelated care services."
So far, the ACP, AAFP and others part of the alliance have been silent on whether the deals in play should be exempt.
Physicians who practice in concierge and direct primary care models have been put on notice by the American College of Physicians, which warns against creating barriers to care, particularly for low-income and minority patients. DPC physicians say the ACP has it all wrong.
New care models, such as direct primary care (DPC) emphasize that the doctor-patient relationship can be a lifeline to physicians who are burned out, stressed out, and thinking about getting out. But the American College of Physicians isn't sold on the idea.
Omar Durani, MD
The ACP's medical practice and quality committee released nine recommendations in the Annals of Internal Medicine for "direct patient contracting practices," an ACP term that lumps DPC, cash-pay, and concierge practices together. Though the recommendations neither endorse nor reject those models, some DPC physicians are upset the models are grouped together in the first place.
"The ACP draft inaccurately lumped concierge/boutique, cash-only and DPC as one entity, and questioned the ethics of such physicians, which we do not agree with," says Omar Durani, MD, a DPC physician. Durani and his partner Howsen Kwan, MD, are about to open their first DPC practice in Dallas next month.
Normally, I don't split hairs over semantics, but in this case, Durani and Kwan have a point. DPC and concierge models are very different. DPC is an offshoot of the well-established concierge practice model. Both types of practices charge patients a fee in exchange for longer appointment times and 24/7 access. Concierge and DPC physicians also have smaller patient panels.
But that is where the similarities end.
Concierge practices are expensive. Their annual fees can run in the thousands of dollars and their patients typically carry traditional health insurance policies. DPC practices charge a monthly fee that can range from $10 to $99 per month and their patients are usually insured by a major medical policy only.
Both models and cash-only practices have a place in patient care because patients are using them. This key variable is often overlooked, and in many ways the DPC model is growing in popularity because it is meeting patients' needs.
The Ethical Case
An overarching theme of the ACP's recommendations concerns the ethics of seeing fewer patients because of the burden it places on other physicians. The ACP is also calling on physicians in these models to see more Medicaid patients and to be advocates for removing barriers to patient care.
Kwan says he and Durani, who met during residency at Parkland Hospital, Dallas County's public hospital, chose a DPC model because of its flexibility to see many types of patients. "We trained at a county hospital and we were still being told, 'You can't order that [test] because it costs too much,' " Kwan says. "This is a way for us to take back control."
Doug Nunamaker, MD
Durani adds that the DPC is a place where the uninsured fit because the prices are affordable ($49 per month, then adjusted for age). "I got to really see what some people have to go through to get medical care," Durani says. "Our goal is to make this a win-win for everyone."
For those who eye DPC models skeptically because the practice model treats fewer patients, consider the patient who is in a traditional practice and gets six to seven minutes with the physician because the physician has to churn through visits just to break even .
"Forcing physicians to see more patients because insurance reimbursements are going down is wrong," Doug Nunamaker, MD, co-founder of Wichita, KS-based, insurance-free AtlasMD, told me.
Now, to be clear, there are other forces that contribute to that model and no physician I talk to is happy about it. But Nunamaker and AtlasMD co-founder Josh Umbehr, also say the DPC practice model is set up to see low-income patients.
Josh Umbehr
"If we take our oath seriously, 'Do No Harm,' that has to mean 'Do No Financial Harm,'" Nunamaker says. He and Umbehr say they've helped patients reduce their financial burden by keeping them out of emergency rooms and managing their medication costs and overall care better.
Qliance Medical Group, in Seattle, is one of the oldest DPC practices that does see Medicaid patients. The six-location practice began in 2007 and grew from seeing individuals only to now providing care to Washington's health insurance exchange members, employers and the state's Medicaid population.
That doesn't answer the ACP's concern, though, which is rightly included because health disparities are a huge problem. But there are some strong indicators that the DPC model of care is more than just a new trend.
Quality Questioned
There is uncertainty about the quality of care in DPC practices. But, frankly, there are big questions about patient quality at every kind of practice. Standardizing processes to improve care goes beyond screening rates and numbers, says Durani.
Erika Bliss, MD
"These quality requirements are randomized decisions," he says. "Just because my A1C panel is dropping, does that mean my patients are better? Does that show the patients are being taken care of?"
These aren't questions only DPC physicians are asking. There are strong arguments for the quality standards being pushed down to physicians; however, Durani recognizes these quality indicators have a place. He says he and Kwan are planning on tracking patients' chronic disease improvement in a certified EHR.
QLiance has stronger data on the quality of care DPC patients receive. In its own study, patients who were in QLiance's DPC practice had fewer visits to the ED, specialists, and radiologists. Erika Bliss, MD, FAAFP, CEO and cofounder of QLiance told me that patient satisfaction rates were also higher.
The ACP is right to eye closely these new models of care that are outside the traditional sphere of practice. But it should also recognize the stark differences among these models of care because patients use them differently. DPC practices are a first wave of care model innovation from primary care physicians who are frustrated but aren't leaving.
"The beauty of the DPC model is that there is no cookie cutter blueprint," says Durani. "It is a fluid model based on the patient population and it is up to the doctor and patients on what constitutes a successful practice. We are here to help the insured, uninsured [and] underinsured discover better health and rethink primary care."
"Half a million people are dead who should not be dead," says a researcher who has identified a steep rise in deaths among middle-aged whites. With data like this, how can physicians not seek out more mental health training to help them understand how to effectively treat patients?
Suicide is among the reasons mortality among middle-aged whites has unexpectedly increased, according to an unsettling report published by a pair of Princeton economists this week. In order for physicians to effectively respond to these patients' needs, they should demand more access to mental health training and resources.
A couple of weeks ago I wrote about the Accreditation Council for Graduate Medical Education's focus on improving mental health resources for residents. The ACGME is holding a national symposium on the subject in a couple of weeks and it could prove to be a turning point in reducing mental health stigma within the physician community.
But the report published this week showing a marked increase in death rates among middle-aged white men points to a need to include more mental health training for physicians to address patients' needs. And a study published last year showed high rates of suicide among elderly white males. "Half a million people are dead who should not be dead," the paper's co-author, Nobel laureate Angus Deaton, said.
According to a study, published in the Proceedings of the National Academy Sciences, (after it was rejected by JAMA and others) increases in drug and alcohol poisonings and suicides "were large enough to drive up all-cause midlife mortality," specifically for whites age 45 to 54. Other causes of death include chronic liver disease and cirrhosis.
The findings are significant because they are limited to middle-aged whites, according to the report. Death rates among blacks and Hispanics continued to fall in these categories. Researchers estimated that 7,000 deaths in 2013 alone could have been avoided.
With data like this, how can physicians not seek out more mental health training to help them understand how to effectively treat patients?
Maria Oquendo, MD, president-elect of the American Psychiatric Association, attributes it to the stigma that persists among physicians about patients who present with mental illness. "There is a belief that psychiatric conditions are not real, and not that big of a deal," she says.
Stigma in Practice
Such thinking is short-sighted particularly because of numerous studies that show mental and physical health are connected. Treating diabetes, for example, without addressing a patient's depression likely decreases the chance of positive outcome.
Oquendo says she believes there is a generational shift in attitude. Younger physicians are more open to talking about mental health, she says, but backward practices in some doctors' offices persist. For example, the PHQ-9, the widely used nine-question depression screener, may be used for patient intake by a PCP or internist; however, Oquendo says doctors will administer it as a PHQ-8.
"They don't want that last question," she says. "It asks a patient whether they are having suicidal thoughts. It sends a message to the clinical staff that it is OK not to talk about this and it misses a population who is at-risk."
Maria Oquendo, MD
The apprehension that physicians have about asking that last question on the PHQ-9 is rooted in fear that once suicide is brought up, the patient will kill him or herself. But Oquendo says physicians don't need to panic.
"It doesn't make people suicidal to ask them about it," she says. "For individuals who are not, they'll comfortably tell you they aren't, but for individuals who are, they may be relieved to have someone to talk to."
Knowing how to talk to a patient is crucial. Oquendo, who is also a professor of clinical psychiatry at Columbia University, director of residency training at the New York State Psychiatric Institute and vice president of the American Foundation for Suicide Prevention (AFSP), stresses thatphysicians in all settings need to have strategies that address what patients need.
"As the health system moves toward having PCPs do more of the work of taking care of psychiatric patients, it will become very important," she says.
Education Shortfalls
Most suicide prevention strategies are learned informally. Psychiatrist and AFSP Chief Medical Officer, Christine Moutier, MD, says when she was a resident she had "maybe one or two hours" of lectures about psychiatric emergencies. Most residents do not even get that much. Instead, the skills are learned on-the-fly, usually in the emergency department.
"That's half of what you see in the ER," Moutier says. "What I think happens is people see it so often in clinical practice, that they assume their responses are based in education but the reality is there is a whole science behind evidence-based practice for working with suicidal people or even people who are at-risk. That is what is missing in the curriculum."
The Suicide Risk Assessment form is time-tested and used in some settings, but other suicide prevention protocols are newer, such as the Collaborative Assessment and Management of Suicidality (CAMS). This treatment approach, says Moutier, is showing positive results among veterans.
Christine Moutier, MD
In addition to improving curriculum for residents, Oquendo also wants education and training improved for licensed clinical social workers (LCSWs), who are being plugged into physician practices to improve patients' access to mental health services. Oquendo believes LCSWs are an important part of improving access, but wants them to be trained in risk assessment and diagnosis.
There are suicide prevention strategies and training available to physicians now. Both Moutier and Oquendo say that letting a patient talk is important. What you say back to them is equally important.
"We say, 'Don't get into debates about life or minimizing their problem," says Moutier. "Calling their thoughts 'selfish' is so wrong and for so long we've known that. What happens is the person gets into a mindset more often than not that they feel they are such a burden to everyone else in their life that suicide becomes an even more logical optional to them."
Resources
Suicide is a public health problem that is preventable. The AFSP has embarked on a nationwide training effort for not only physicians, but anyone, to take part in Mental Health First Aid. The concept is similar to common first aid techniques. It's an eight-hour training course that teaches how to recognize and respond to signs of a behavior change that could indicate mental health deterioration and/or a mental health crisis.
"Nine out 10 Americans value mental health on an equal level of physical health," says Moutier. "I sometimes feel like my colleagues are, in a way, stuck in an older time. Out in the larger public, that's really changing. Physicians should be the leaders of this kind of communication with their patients."
Both the APA and AFSP have several resources for suicide prevention as well as practice guidelines.
If you are in crisis, call the national suicide prevention number, 1-800-273-8255.
Despite the burdens of running a family practice, when hospitals and health systems offer a buyout, the decision to sell or stay solo is a tough one, says one New Jersey doctor who see himself at a crossroads.
Fifty-eight-year old Gerard Faugno, MD, is a board-certified family physician facing a decision that many other solo practitioners are also asking themselves: stay independent or sell?
"I've called my own shots all these years," Lyndhurst, NJ-based Faugno says. "I like the autonomy, but I sit here in my office year after year looking at my bills and looking at my income trying to make it work. I'm at a crossroads."
What's perplexing Faugno is whether he should wait for insurers to develop more alternative payment models or let someone else worry about the future.
Faugno recently finished up his first year in an insurer's alternative payment program. "I have 1,100 patients in a PCMH model with Blue Cross Blue Shield," he says. "I was in the top 10% of quality measures, so I got a pretty sizeable bonus, which was nice."
The quality and utilization targets BCBS set were easy to meet Faugno says. They included mammogram screenings, diabetes management, and colonoscopy rates. The insurer even helped fund a nurse to help Faugno manage collecting and reporting the data.
As long as the benchmarks and manpower to meet them continue, Faugno says remaining a solo practitioner is a possibility. But it's the uncertain future of whether alternative payment models can fully replace the traditional fee-for-service system that has him thinking about partnering or selling.
"For small group practices, these models are happening slowly," says Dave Harris, partner for PwC's health sector. PwC issued a recent report on the slow pace of alternative payment adoption. "The chief proponents of APMs (alternative payment models) are large employers and the federal government—the true purchasers of healthcare."
Consumers Rule Harris says hospitals are hesitant of abandoning the fee-for-service payment model because that ultimately means they'll get fewer admissions. Instead of viewing healthcare transformation through the lens of what hospitals and health systems want, Harris believes it is the consumer who will play the biggest role in healthcare over the next 10 years.
"Consumers didn't have resources at their fingertips to make healthcare decisions. They had to rely heavily on physicians," says Harris. "But that is completely changed today with social media."
Faugno says he responded to what patients wanted by expanding his office hours. "I used to work 60 hours a week," Faugno says. "I increased it to 70 hours a week in the spring, working from 7AM to 8PM during the week and opening on Saturday until noon."
The extra hours also helped Faugno bridge the widening gap between cost and income. It's at a tipping point now, which is another reason he's considering selling the practice.
"The overhead is going to outstrip the incremental increases," he says. "Up until now I have always been able to do something about it. My kids are going to college and I'm worried. I'm selling my house. It's hard to whine because we make more than most people, but I am making the same amount I did 15 years ago. That's hard to see."
Faugno estimates he has 7,000 patients in his system—an attractive number to two hospitals currently courting him. One offer, Faugno says, is a complete buyout. He would be an employee and receive annual bonuses. The other offer is from a health system and is similar. Faugno says he also attended a presentation about concierge medicine, but that turned him off.
"I spent all these years trying to be accessible," he says. "The doctor who was presenting this [model] talked about how he told his patients about the transition. He said he told them, 'I didn't leave you, you left me.' Wow. I can't imagine doing that happily."
Concierge medicine does get criticism, but there are hybrids of the model that don't cost patients thousands of dollars a year. New models of payment, whether driven by employers, the federal government or patients, will continue to emerge as long as alternative payment models leave physicians in limbo.
Not Pessimistic "This is a sea change in how the healthcare industry thinks," says Harris. "The driver right now is cost. When you look at other consumerism movements, like cars, cost was also the initial factor. Then came quality, safety, and reliability. I think the same thing will happen with healthcare."
How long can physicians hold on? Faugno says he would gladly sign up for another insurer's payment program that rewarded him for meeting quality benchmarks.
"I'm in a better place than I was a year ago," Faugno says. "I don't feel pessimistic. I think every year I get better and I get more satisfaction. I've never sat looking at every nickel and dime. That changed a couple of years ago, but that's not because of me. That's the industry."
