An emergency medicine physician recounts her personal experience with stuttering to advocate for more compassion, training, and equitable treatment of patients who have a disability.
When physicians are faced with caring for a patient with a disability, they may be overlooking the most important aspect of treatment: respect for the patient.
Leana Wen, MD
It's ironic that physicians contribute to the inadequate treatment of people with mental and/or physical disabilities because the doctor's office is often where disabilities are initially diagnosed, or at least cared for, and there is some patient expectation that behaviors, such as avoiding eye contact, will not be encountered.
An essay published in this month's issue of Health Affairs, Leana Wen, MD,director of patient-centered care researchand assistant professor of emergency medicine at the George Washington University School of Medicine and Health Sciences, recounts her personal experience with stuttering to advocate for more compassion, training, and equitable treatment of patients who have a disability.
Wen spoke with me about the additional challenges patients face when they have a disability and what physicians can do to overcome their fears of caring for someone who is physically and or mentally disabled.
HLM: In your essay, you write that it wasn't until the end of medical school that you decided to be open about stuttering. What led to that decision?
Wen: Of course I knew that I stuttered, but I thought that if I were open about it, that people would see me as incompetent and not able to perform, and I wouldn't be able to realize my dream of being a doctor, so I hid it.
Usually, I would say nothing about it at all. It wasn't until I was a medical student that I realized I needed and sought treatment for it. Speaking up about stuttering is something my speech therapist and I talked about.
HLM:What did it feel like to speak up for yourself, once you decided to be open about your stuttering?
Wen: One of the first times I did was when I was a medical student. Somebody was brought into the emergency room for a suspected stroke because the triage nurse said, "He can't speak." I saw what she meant, he was really struggling to speak.
But his behavior I knew well, and in fact, he wasn't having a stroke. He was there for something totally unrelated, like abdominal pain, but because he was having trouble getting out his words, the providers thought he was having a stroke.
It was so frightening for me to admit that I stuttered, but it was such a breath of fresh air because I was able to help a patient.
HLM: You advocate for the Association of American Medical Colleges, the Accreditation Council for Graduation Medical Education, and others to incorporate caring for people with disabilities into curriculum. What can physicians and other medical staff do to ensure the equitable treatment of patients with a disability?
Wen: It's being able to first address people with disabilities with appropriate language, then showing respect and having some understanding of the difficulties and challenges of the disability, but getting beyond the disabilities to treat the patients.
Often providers will see a patient in a wheelchair and think, "This is going to be a difficult patient," and won't undress them, or will delay seeing them. These are things that as physicians we would normally do.
Providers have a tendency to say, "This is going to take a lot more time, and we don't have time to talk, so we're just going to order a bunch of tests." If a patient doesn't speak English, we don't say that we won't see them. We get them an interpreter and help them. Why don't we treat patients with disabilities this way?
HLM: What kind of training would help physicians and medical staff?
Wen: There was a study done that 25% of offices don't even see patients with disabilities. It takes others pointing out that disparities exist.
I am also a firm believer that things have to be continually fostered. That behavior has to be modeled in residency. It can be taught. I strongly believe that.
There are wide variations in training. We learn about treatments that may benefit many, but nearly 20% of the population has a physical or mental disability, and many medical schools don't have anything about treating patients with a disability.
Part of it is time, another part of it is that this softer side of medicine is getting lost in technology. We've gotten so far away from what it means to be healers.
I think role modeling is key. I don't think it happens organically. You can give people all these statistics, but they're not really going to know the impact… we have to be very conscious that we are addressing the needs of people with disabilities. It's not just talking about people with disabilities, but we have to be conscious about what we're doing.
The AMA opposes the reclassification of hydrocodone combination products, but placing tighter prescribing rules on drugs such as Vicodin and oxycodone sends a strong message to physicians about the drugs' high potential for abuse.
The combination of a new federal law placing stricter requirements on prescription drugs containing hydrocodone and a new statement criticizing the effectiveness of long-term use of opioids, such as hydrocodone, for chronic pain may be a one-two punch in the battle to reduce deaths and addictions to these powerful and easily accessed painkillers.
Beginning October 6, hydrocodone combination products (HCPs), such as Vicodin, will be reclassified as schedule II drugs. Vicodin joins methamphetamine, methodone, oxycodone, and others drugs in this classification, which falls under more restrictive prescribing rules because they are all defined as having a "high potential for abuse."
Hydrocodone by itself is already listed as a schedule II drug. The new law applies to hydrocodone combo drugs that are used to manage pain, which are the most prescribed opioids in the U.S. HCPs are also one of the most abused prescription drugs.
According to the Centers for Disease Control and Prevention, more than half of deaths caused by drug overdoses involved prescription drugs, and 74% of the time, the drug associated with the overdose was an opioid painkiller.
The reclassification of HCPs into the more restrictive class of schedule II controlled substances is a direct result of the overdose deaths left behind in states like West Virginia, which has one of the highest rates of prescription drug overdose.
Andrew Kolodny, MD, president of Physicians for Responsible Opioid Prescribing (PROP), and chief medical officer for Phoenix House, a drug and alcohol addiction organization in 13 states calls the new classification a hard fought victory for patients.
"We are very strongly in support of this change," says Kolodny. "It's probably the single most important intervention on the federal level we can do to bring this crisis under control."
The new rule affects how much and how often HCPs can be prescribed. For example, prescriptions can no longer be called or faxed in by a physician, except in emergency situations that allow for a 72-hour supply. Written prescriptions are required in all cases, even emergencies. Doctors must follow up with a written prescription after the emergency script has been phoned in for fulfillment.
Another effect that will be immediately felt (and complained about) is that prescription refills prior to October 6 may not be honored. There are provisions that allow for refills that were issued prior to the effective date, but the American Medical Association is warning that some insurance companies may not pay for the refills, and that states with stricter schedule II laws may not be able to fill prescriptions written before October 6.
"We're concerned a patient will show up at a pharmacy with a legitimate prescription and that the pharmacist won't fill it, and the patient may not be able to get to their doctor immediately to get a written prescription," says Andrew Gurman, MD, speaker of the AMA's House of Delegates and an independent orthopedic hand surgeon in Pennsylvania.
"[Prescriptions] are supposed to be honored for six months, but we're not sure all states will allow that," says Gurman.
The AMA opposed the change because of unintended consequences such as the scenario Gurman describes. He also says the reclassification of HCPs places a burden on patients if they have to travel to see a physician.
"I am a hand surgeon, and in some cases, I'm the only one for 100 miles," he says. "This may put me in a situation where I prescribe more pills. I don't want to do that."
The reason Gurman believes that he may put more pills in circulation than he's comfortable with is because of the strict no refill requirement, except in certain circumstances that allow for a physician to write multiple prescriptions that total 90-days.
"My practice is to write a prescription with one refill, so what do I do? Prescribe with no refill or write multiple prescriptions with no refill dates? We're very concerned about the opioid epidemic in this country, but this rule is an attempt to solve it from the supply side. We favor a multi-pronged approach."
The AMA believes solving the problem requires funding for the treatment of addiction, patient and physician education, and an increase in what are called "takeback" programs that offer opportunities for people to safely dispose of unused and expired prescription medications.
While PROP and the AMA are on opposite sides of the fence on their support of the reclassification, the American Academy of Neurology recently released a position paper on the effectiveness of opioids for chronic pain.
Using opioids to manage pain long term is controversial because the drugs are highly addictive and have been believed to be effective at reducing acute pain. No one disagrees that opioids are addictive, but there is dispute over their long-term effectiveness.
In the paper the AAN released this week, author Gary Franklin, MD, MPH, a research professor of environmental and occupation health sciences at the University of Washington, concluded that "there is no substantial evidence for maintenance of pain relief or improved function over long periods of time without incurring serious risk of overdose, dependence, or addiction."
A New England Journal of Medicine study made similar conclusions more than 10 years ago, yet it didn't curb prescribing patterns. That is what PROP and Zolodny hope this new classification will do.
"The change will be a burden for pharmacists, pharmacies, and some doctors," says Kolodny.
"The paperwork to track it is very burdensome. It's also a headache for the physician. Opioids are an essential class of medicine for end of life care and they're very good for acute pain for a few days, but the incorrect scheduling has led to massive overprescribing. We have to prevent new people from getting addicted. It sends a strong message to the medical community to rein it in."
The practice of colocating a mental health provider in a primary care setting is being eclipsed by a new model that calls for fully integrating the disciplines.
This article first appeared in the September 2014 issue of HealthLeaders magazine.
Ten years ago, Cambridge Health Alliance, an integrated safety-net health system and teaching hospital for Harvard and Tufts medical schools, based in Cambridge, Massachusetts, believed the best way it could help its primary care providers with their patients' mental health issues was by colocating a mental health provider inside CHA's primary care practices.
The mental health providers, either psychologists or licensed clinical social workers, spent 10%–20% of their time among CHA's 15 primary care offices. With this shared resource across the practices, CHA's primary doctors had someone who could take care of their patients' mental health needs.
At the time, colocation was seen as a win-win situation, not only at CHA, but at other health systems. The hope was that colocation would solve the frequent problem that pops up with patients who have mental health needs: poor follow-up—that is, patients who seek initial help from their family doctor, yet never make it to a mental healthcare provider despite being referred to one.
With colocation, primary care physicians had someone to refer patients to quickly, often down the hall or next door, and patients could return to the familiar setting of their primary care office for mental health help, thereby reducing the stigma often associated with mental illness. While CHA found some benefits from the colocation model, it turned out to be a short-term fix for the long-term issue of mental health.
The rise of consumerism and the arrival of quality surveys for physician practices means doctors will have to pay more attention to patient relationships. Providers can be choosy, but so can patients.
When I am sick, even if it is just a minor cold, I am cranky. My husband could regale you with tales of my despondency and general bad attitude when I do not feel 100%. I, too, have the dirt on him, on my son, and well, nearly everyone in my family. You likely know exactly what I am talking about.
So I empathize with physicians and nurses because they see us at our worst. Not only are we going to them for the magic pharmaceutical to knock out a nasty bug or manage a chronic condition, but we also go to them expecting some sign that they care about us. Hearing, "I hope you feel better," from not just the doctor, but also the nurse and receptionist, can go a long way in building loyalty to a particular practice.
Individualized attention may be an unrealistic patient expectation, especially with the limited amount of time doctors have with patients, but it's a reality. Add the additional wrinkle of social media, and one bad interaction could lead to a ding in a practice's reputation, its market share, and eventually, its revenue, via lost reimbursements.
Data collection for CG-CAHPS, the clinician and group practice version of HCAHPS, the quality survey that the Centers for Medicare & Medicaid Services uses to measure patient satisfaction, began this year for practices with 100+ eligible medical professionals who participate in the physician quality reporting system (PQRS).
Patient responses could begin impacting reimbursement in 2015. By 2016, it's expected that reporting on patient satisfaction at practices will be mandatory for groups with 25+ medical practitioners, and that up to 4% of reimbursement will be at risk. A final CMS rule on that is expected later this year.
Forward-thinking physician groups have already begun training everyone, from the front office receptionist to the lab tech, on communication techniques that contribute to a positive patient experience.
"There's an increased awareness of how things should go," says Laura Palmer, FACMPE, senior industry analyst for MGMA, an organization that represents 30,000 medical practice administrators and executives. "Patients have more invested because they're paying more of the bill."
Palmer says CG-CAHPS is not putting as much pressure on physicians as social media channels are, such as Facebook and Twitter or consumer rating and review sites such as Yelp, and Angie's List.
"Physicians are not automatically happy with being in that environment [social media]," she says. "We coach them and want them to respond to comments. We tell physicians, 'Any feedback you get is relevant and worth investigating.' "
Knowing that they will be graded on their customer service, some physician groups are also turning to third-party survey groups, such as Press Ganey, the South Bend, IN-based consulting group specializing in improving patient satisfaction.
Palmer says surveying patients is a common practice, but another challenge physician practices face now that they didn't previously, besides the ubiquitous and instant social media feedback, is that there are more patients.
"There are lots of challenging situations in offices," says Palmer. "We've got new people entering the healthcare system, and maybe their expectation of care is based on their ER visits, if that's the primary place the patients sought care before now."
Handling Complaints
An oft-quoted study from the mid-90s estimates that "difficult" patients make up 15–30% of a physician's panel in primary care. There are myriad characteristics that will push a patient into the "difficult" category, such as drug-seeking behavior, rude and/or harmful behavior, but what about the patient who is not easily satisfied? Or just a personality mismatch? Do you cut them loose?
Thomas H. Lee, MD, a practicing internist and cardiologist employed by Boston-based Brigham and Women's Physicians Organization, says it's a complicated question he's faced twice in his 35 years of practicing medicine.
"These are relationships that are analogous to marriage. You don't bring up divorce every time you have a disagreement," he says.
In both cases, Lee ended up keeping the patient, but each patient presented a different scenario. One patient made "insulting, sexist" remarks about a colleague of Lee's who happened to be Lee's wife. The patient apologized and both moved forward with a doctor-patient relationship.
The other patient represents a more complicated, but not uncommon scenario. This patient believed she was allergic to generic drugs (she was not), and refused to take medicine she was prescribed. Lee wrote about his experience for the Annals of Internal Medicine about 10 years ago as a way to explore the ethical dilemmas presented by difficult patients.
"I cracked and gave her the brand name drugs," says Lee. "Ultimately, I realized it was about me. Being a good doctor is not just checking off items on a checklist. It is being the kind of physician each individual is hoping for."
Lee is also chief medical officer at Press Ganey and works with physicians and healthcare executives to help them understand that the relationship with a patient is usually worth saving.
Cutting Patients Loose
Not all physicians are invested in keeping patients who may be considered difficult. But there various and differing state laws that regulate the practice of dismissing a patient.
The American Medical Association's guidance is to wait until a patient is stable, then notify the patient in writing with physician recommendations.
That did not happen with one patient in Tennessee, who told me that his physician's office dismissed him the same day he returned a survey from the practice. [Because I have not reached his physician to verify the claim, both names are being withheld.]
"I got an email survey and I gave the practice all positive marks except for my experience with the receptionist," he says. "I didn't say it was terrible, I just marked neutral. She was snippy, and talked to me in a hateful tone. I'm just left hanging."
This man says he's been seeing the same physician for more than 15 years, and his entire family uses him, or used him. This patient may be the one who was dismissed, but his family members are looking for other doctors, too.
"What's strange is the last time I was in his office… he made a point to say, 'You know, it's patients like you and your family that make me work harder.' This is why I'm totally shocked."
According to Lee, this type of dismissal is rare. And, he says, unfortunate.
"Physicians dropping patients because they haven't made the relationship work is not a good strategy," says Lee. "Speaking as a doctor, to actually cut your relationship with a patient and do it responsibly is a lot of work. It's a lot less work to take care of that relationship."
Lee also doesn't believe that physicians dismissing patients is on an upward trajectory. First, because doctors need market share, and second because leaving a patient "hanging" opens up the possibility of a malpractice suit (and a bad online review).
"These are relationships," says Lee. "Different people have different needs. It's the job of physicians to look across the table and see a human being."
With the rise of consumerism and the arrival of CG-CAHPS, physician practices will have to pay more attention to the emotional, empathetic aspect of patient care. Doctors can be choosy, but so can patients.
At the annual HealthLeaders Media CEO Exchange, leaders of hospital and healthcare systems speak candidly about both the difficulty and necessity of managing the health of populations.
Achieving the triple aim of healthcare is a messy road that will likely be paved with programs that haven't come close to improving cost, quality, or health outcomes. Population health, however, is one initiative that healthcare leaders believe is here to stay.
At the annual HealthLeaders Media CEO Exchange in Colorado Springs last week, leaders of hospital and healthcare systems spoke candidly about both the difficulty and necessity of managing the health of populations as a way to reign in healthcare costs while improving patients' health.
"Population health management is a fact," says Mark Herzog, FACHE, President and CEO of Holy Family Memorial, a health system that includes a medical center as well as a network of clinics and physicians in Manitowoc, WI.
Herzog, who has led HFM since 2001, is on a mission to improve the health of the 80,000 residents who live in the organization's service area. He calls it "right care," as in the right care at the right time and in the right place, but the most important thing, to Herzog, is that HFM does what is right for the community.
The singular focus aided in reworking HFM's mission statement to a single sentence that provides a clearer path to what it hopes to achieve: "Holy Family Memorial is a network of health professionals who, rooted in the healing ministry of Jesus Christ, provide services to help individuals and our communities achieve healthier lives."
Through Lean Six Sigma leadership principles, HFM is now a flatter organization, administratively, which Herzog believes helps its ability to adapt to changing healthcare industry pressures while staying true to its mission. For example, in 2001, there were 10 senior leadership positions, now there are five.
HFM's strategy to improve the health of its community members has primarily been focused on reducing utilization of inpatient services and instead providing access to the appropriate care in its outpatient clinics.
Emphasizing outpatient care is a popular strategy. While inpatient hospital charges command higher reimbursement rates, organizations also run a higher risk of negative incidents, such as hospital-acquired infections, for which they hospitals can be penalized if patients have to readmitted within 30 days.
The organization has made significant strides in its effort to increase outpatient services. Since 2001, hospitalizations are down by 40% while clinic visits have increased by 38%.
HFM also began looking at its population from a different point of view. Instead of asking how to help the sick get better— which it does, of course— Herzog emphasizes keeping the community out of the hospital by getting them and keeping them healthy.
An independent analysis of the health of Manitowoc's residents shows it has improved. In 2010, the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute released the state's county health rankings.
Based on behavioral, social, economic, and environmental factors, Manitowoc County ranked 50th out of 72 counties on the study's summary of health factors. In 2014, Manitowoc County had climbed 21 spots and now ranks 29th.
Physician Engagement
Another key component to making population health work for an organization is putting physicians in more leadership roles and holding them accountable for the delivery of care to patients.
Two organizations, Baylor Scott & White Healthcare, a nonprofit, 46-hospital integrated healthcare system based in Dallas that is one of the largest systems in the country, and Methodist Le Bonheur Healthcare, a seven-hospital, nonprofit health system based in Memphis, Tennessee, are bringing physicians to the forefront of their population health efforts, but in different capacities.
Baylor Scott & White has developed a network of employed and independent physicians to populate what it calls its Baylor Scott & White Quality Alliance (BSWQA). The effort was started at Baylor prior to its merger with Scott & White, but the idea was embraced and it continues to grow in size and scope.
The idea, says Joel Allison, FACHE, CEO of Baylor Scott & White Healthcare, was to truly have a clinically integrated network that engages physicians to help improve quality, cost, and outcomes. The structure of the BSWQA includes 3,700 physicians at 31 hospitals in north central Texas. To be part of the alliance, physicians must pay $1,500 to join and agree to use the BSWQA electronic medical record system and meet its quality standards.
"This is that bridge from volume to value." says Allison.
Allison says quality has always been part of Baylor's and Scott & White's identities. The population health proposition relies on quality to capture revenue. The future of reimbursement is in value-based care, and Allison says the BSWQA is helping build its foundation.
The quality alliance was tested on Baylor's employees first, but the model of care has since been picked up by a teacher's union in Texas because of its success at reducing cost and readmission rates.
There have been physicians who haven't met the quality criteria, and have been let go from the organization. But in its first 23 months, covering 34,000 lives, there was a 4.3% reduction in hospital admissions; an 18% drop in 30-day readmissions, resulting in a 7% savings totaling $13.9 million.
Baylor Scott & White's effort to hold physicians to a higher level of care for its patients is being echoed in other systems throughout the country, including at Methodist LeBonheur in Memphis, though that narrow, or preferred network approach is in its infancy compared to the organization's physician leadership initiative.
Physician Leadership Academy
This month, Methodist LeBonheur will graduate its first cohort of about two dozen doctors from its Physician Leadership Academy, a year-long program that emphasizes creating a consistent culture across its system.
To get into Methodist Le Bonheur's Physician Leadership Academy, doctors must be nominated by on one of the seven hospital CEOs and go through an interview process.
Once accepted, the classes are rigorous, and for the most part, are at a physical location, once a month for four hours. Some of the classes are online in the summer months to allow flexibility for physicians, but teaching in traditional classroom setting was intentional.
Since the system has seven hospitals, it's not uncommon for physicians who share common leadership goals to never set eyes on one another. It builds bonds and reinforces common goals physicians can take back to the hospitals or clinics where they practice.
"Traditionally, physicians focus on their specialty," says Michael Ugwueke, FACHE, President and COO of Methodist LeBonheur. "We wanted to change that culture and have physicians bring solutions that apply to all our hospitals."
Finding growth opportunities through partnerships while managing the disruptive nature of healthcare transformation is difficult but necessary, say hospital and health system chiefs attending HealthLeaders Media's annual CEO Exchange.
Despite the regional differences that exist in hospital markets across the country, CEOs of hospitals and health systems are responding to the pressure to improve clinical quality, patient experience, and healthcare costs in similar ways.
More than 40 healthcare executives gathered this week at the annual HealthLeaders Media CEO Exchange in Colorado to share ideas and challenge conventional strategies that hospitals have leaned on in the past.
"No matter how good you are, [and] how much waste you've reduced, there is still waste in the system. But you can't there through cutting, it's through redesigning," says Mark Laney, MD, President and CEO of Heartland Health/Mosaic Life Care, an integrated healthcare delivery system based in St. Joseph, MO.
Heartland Health achieved the highly coveted Malcolm Baldrige National Quality Award in 2009. Laney says operating costs have been reduced by $8–10 million using Malcolm Baldrige strategies, but with a population that isn't growing, the system had to think creatively for growth opportunities.
The system built eight clinics in north Kansas City, and the gamble has paid off.
"The model is focused on optimal health versus disease management, and in about 18 months, have an 11.2% market share," he says. "You have to grow, but the sweet spot for the futures is reinventing yourself."
Most leaders say they are starting to feel the pressure of consumerism in their communities. With high deductible plans gaining ground, patients want more pricing transparency, and they are looking more closely at where they are spending their healthcare dollars.
Some systems, like Crouse Hospital, a 506-bed nonprofit hospital in Syracuse, New York, are responding by posting prices online. The average cost of procedures does not include physician fees, and the price a patient will pay varies depending on his insurance plan.
But the step to include healthcare cost information online is a direct reaction to the rising tide of consumerism.
Looking for Growth Opportunities
The value equation for hospitals also hinges on reducing variability in quality and utilization while at the same time trying to grow sometimes razor-thin margins.
One area of promise remains outpatient services, which hospital executives say will be key to maintaining or increasing the bottom line. Results from HealthLeaders Media Industry Survey 2014echoes that sentiment. Expanding outpatient services was the number one way healthcare executives said they will fuel their financial growth over the next five years (60%).
An informal survey of the healthcare executives attending the CEO Exchange bear that out in even stronger numbers.
Amy Perry, president of Sinai Health and executive vice president for LifeBridge Health, a regional healthcare system in Baltimore, MD with a wide spectrum of patient care services, including hospitals, physicians, skilled nursing, and rehabilitation centers, says increasing the outpatient focus means increasing access for patients and expanding LifeBridge Health's portfolio of partnerships.
"We've invested in retail pharmacy, home health, ambulance, Medicaid managed care, all the various pieces of the continuum," says Perry. "We're either owning them completely or partnering with people who know how to run those businesses in the most effective way."
Partnerships can stitch together the often fragmented nature of healthcare. When patients are discharged, the locus of control shifts from the hospital to the next care provider, which can significantly impact the patient's health outcome.
When partnerships are formed, either formally or informally, the goal of better patient care is easier said than done because agreeing on similar quality metrics can be tricky, says Joe Harrington, President and CEO of Lodi Health, a private, nonprofit health system in Lodi, CA.
Establishing common quality goals
Lodi Health is participating in a bundled payment care improvement program (BPCI) with CMS for total joint replacements. Bundled payment initiatives have caught on with some payers and providers for procedures that are episodic by nature. Harrington says partnering with skilled nursing facilities (SNFs) has emerged as an important point in order to control costs.
Over 70% of Lodi Health patients who had a total joint replacement were being discharged to SNFs, which is a cost disruptor. Harrington says it was family members of patients that were driving the decision to go to SNFs, not the orthopedic surgeons.
After developing a plan with the surgeons to release the patients home with the help of home health, nurses, physical therapists, and appropriate family support, the percentage of discharges to SNFs has fallen significantly.
"The model is get them in on Monday morning, do the surgery, and back home on Tuesday or Wednesday, and cut out that SNF," says Harrington. "In the first year, we went from about 74% going to SNF to 30% going to SNF."
For patients who are going to SNFs, Lodi Health looks for quality. He says SNFs have to meet Lodi Health's quality benchmark in order for them to be considered a good partner.
Looking for growth opportunities with partnerships while managing the disruptive nature of healthcare transformation is a difficult charge, say leaders, but it's key to their role as CEO, especially now, post-Obamacare, post-health insurance exchange, post-health information exchange.
Overwhelmingly, leaders say they are falling back on the mission of their organizations and reinvigorating the culture that has been at the core of their business model.
"You celebrate. You recognize," says David Brooks, FACHE, President of St. John Hospital & Medical Center, a 772-bed faith-based hospital in Detroit that is part of Ascension Health. "When we're presenting a safety award, I'm there. It's what we spend our time on that reinforces what's important."
Providers are realizing that case managers are an important piece of the readmissions puzzle. That often means placing a greater emphasis on coordinating care and focusing on the patient discharge process.
As hospitals and health systems work toward a future where payments are based on the longitudinal care of patients, they have to continue to maintain their financial viability in the current and polar opposite fee-for-service reimbursement model.
Many physician leaders of hospitals, health systems, and even health plans, have admitted that it is difficult to navigate to a different payment structure, especially while trying to react to current initiatives that require timely action.
One initiative that aims to prepare healthcare leaders for a fee-for-value payment structure emphasizes reducing hospital readmissions. Readmissions penalties levied by the Centers for Medicare & Medicaid Services have forced health systems to review clinical processes to remedy a tough situation.
Different Strategies, Similar Results
Some hospitals have restarted the bygone practice of making house calls for their most frail and sickest patients. A study published in The Journal of American Geriatrics Society found that MedStar Washington Hospital had a lower rate of readmissions for the 722 patients who took part in the hospital's house call program, and also saved on average $4,200 per person per year in Medicare costs.
Others, like Albany Medical Center, the 734-bed academic medical center in Albany, NY, have tackled readmissions by focusing on the patient discharge process.
In a pilot project with CDPHP, a community-based nonprofit health plan in 24 of New York's counties, Albany Medical Center saw a 40% reduction in readmissions among CDPHP Medicare beneficiaries.
Bruce Nash, MD
CMO and Senior VP of Medical Affairs at CDPHP
"We focused on what was happening prior to discharge," says Bruce Nash, MD, chief medical officer and senior vice president of medical affairs at CDPHP. "And, you always try to focus on the highest need population, and this is an across the board look at Medicare patients-all cause readmissions."
Another reason that CDPHP focused on its Medicare population arose from the medically and socially complex reasons that land those beneficiaries back into the hospital within 30 days of discharge.
"Hospitalization can change how they [Medicare patients] do at home," says Charlene Schlude, director of care management at CDPHP.
Case managers are an important piece of the readmissions puzzle, say Schlude and Nash. CDPHP has 13 case managers, and one visits each patient at bedside before discharge. The aim is threefold: patient education, medication reconciliation, and other bedside support, and coordinating the care transition.
"It's a relay race," says Schlude. "The key is the face to face evaluation of each patient at the bedside. Then the nurse at our health plan follows up by phone within two days. The case manager gets buy-in from the bedside nurse at Albany Medical Center."
There is an additional step taken, too. Medicare patients are given a business card with the name of a nurse who will follow up with them. It's an important extra step that helps patients know what is coming next. That could serve to calm their anxiety, which also can be a driving factor in readmissions from emergency departments.
Charlene Schlude,
Director of Care Management at CDPHP
"Medicare beneficiaries are skeptical about cold calls," says Schlude, who adds that the personal interaction with patients at the bedside before they are discharged gives nurses and case managers an opportunity to find out what is going on at home that could impact their care.
"It's a high leverage point," says Nash. "We first tried to reduce readmissions with a physician-centric program—providing incentives to get patients into their office, but the effect wore off after 6–9 months. It showed us we needed to get at it with active management instead of leaving it to the marketplace."
Nash estimates that by focusing on bedside factors prior to discharge, CDPHP has saved roughly $1 million on the 706 Medicare members who were part of the pilot program that began in 2013. So far this year, there have been 915 Medicare and Medicaid patients who are participating in the expanded case management pilot.
Nash also credits CDPHP's patient-centered medical home concept, called Enhanced Primary Care (EPC), with helping to reduce readmissions. "We have over 200 practices participating in EPC, and part of that program is how to work constructively with case managers," he says.
Coordinating Care Transitions
One of the biggest determinants of how a patient will fare at home is the environment they are returning to after discharge. Schlude says case managers and nurses have found that many of the patients are caregivers to someone at home, which impacted how well patients could take care of themselves.
"There's more than meets the eye at home," she says. "You find out a lot, but that's just one step of the process. Once you get their information, you then know how to develop a plan of care."
If patients don't know a lot, or enough, about their diagnosis, case managers will reach out to the primary care providers. "A provider may see someone for 15–20 minutes. We try to be a link to the provider, and to community-based services that can pick up where their Medicare coverage leaves off."
Coordinating care is more than making sure a patient has the clinical information they need, it increasingly means to cover all the bases for discharged patients, from medication reconciliation to transportation issues, says Nash.
"Where it works most smoothly is where we have embedded case managers in the practice."
The main reason patients return to the emergency department is fear and uncertainty about their conditions. The remedy? Teaching future physicians how to talk to patients, says one medical educator.
This article first appeared in the October 2014 issue of HealthLeaders magazine.
Better physician communication and more coordinated patient care in the emergency department could have an impact on hospital readmission rates, a new study suggests.
The results of a five-month study at two Philadelphia area hospitals was published this week in the Annals of Emergency Medicine. It offers insight into why patients return to the emergency department based on information learned directly from patients and gleaned from medical records.
ED use frequently focuses on the socioeconomic, demographic, and clinical data to determine who the frequent fliers are. While these studies are useful, little has been done to assess the patient's perspective, an important component in designing processes that improve care, cost, and satisfaction.
To find out why patients were returning to the ED, the authors interviewed 60 adults who were at least 18 years old and had returned to the ED within nine days of their initial discharge. The study was done over a period of five months, and excluded patients who were supposed to return to the ED for a wound check, or who left against medical advice.
Though the study was open to anyone over the age of 18, the average age of patients who returned was 43 years old, and 65% were women. Slightly more than half the patients (31) had been to the ED once or twice in the previous year, while slightly more than one-third (21) were considered frequent ED users, having been to the ED more than four times the previous year.
Most of the patients who returned to the ED did so within six days of being initially discharged. The discharge process has been closely studied and monitored to streamline issues that can come up and contribute to a readmission.
But most patients (41) said they didn't have a problems with their discharge instructions or process. Instead, patients reported they returned because they were afraid the medical condition that prompted them to visit the ED in the first place was getting worse.
"Well, I came because symptoms have gotten worse, and it was kind of a decision I had to make on my own," one patient told researchers. In addition to the anxiety, the patient's belief that no one else was available to help determine whether returning to the ED was the right decision underscores the problem of fragmented care that exists throughout healthcare.
Increasing Emotional Intelligence
Hospitals and health systems are increasingly focusing on smoothing out the continuum of care for patients, but it's difficult. Christopher Zipp, DO, FACOFP, FAAFP, osteopathic director of medical education for Atlantic Health System, a nonprofit, five-hospital system based in New Jersey told me that patients and physicians stereotype who takes care of what.
"You go to your family physician for hugs, and you go to a surgeon for steady hands," says Zipp, who runs a residency program that attempts to incorporate treating the patient as a whole and treat them as more than their medical condition.
Zipp's work of teaching future physicians how to talk to patients is the core recommendation of the study. Kristin Rising, MD, director of acute care transitions and attending physician at Philadelphia-based Thomas Jefferson University Hospital, writes, "emergency providers should be more proactive in ensuring that patient concerns have been addressed before discharge…."
How do you tell a doctor that they need to do a better job communicating?
"With proper coaching," says Zipp.
Many times, data is used as the catalyst to force physicians to change. But when you're trying to change interpersonal behavior, data doesn't always work, says Zipp. Instead, what he tries to do is relate to the physician's sense of wanting to provide good, even better care.
"It depends on how the learner needs to receive information," he says. "If I said, 'Your emotional intelligence needs to be higher,' the doctor is not going to receive that well. What he or she needs to hear is, "I'm going to give you feedback now."
That's kind of what the patient is asking for—feedback, next steps, and what to expect. Rising says in an emergency department, communication with patients is limiting. The patients are not always discharged with a clear diagnosis, but she says physicians could better manage the consequent anxiety.
Upping the emotional intelligence of ED doctors and discharge staff is not, however, enough to prevent highly concerned patients from returning. "We suggest the medical system must adapt to be able to encourage ongoing dialogues with patients in contrast to the episodic nature of current healthcare delivery," says Rising.
"The elevation of interventional radiology to a specialty level with its own distinct residency program places IR on the same level as surgery, pediatrics, and internal medicine," says one proponent.
A radiology sub-specialty is emerging as distinct medical specialty, separate from the traditional revenue-generating imaging-based model of service.
Two years ago, the American Board of Medical Specialties elevated interventional radiology from a subspecialty of radiology to a primary medical specialty.
The Accreditation Council for Graduate Medical Education is currently developing the residency program requirements for the new dual interventional radiology/diagnostic radiology (IR/DR) certificate that will replace the vascular interventional radiology (VIR) subspecialty certificate.
Accreditation of the first IR residencies for the new IR/DR specialty is likely to begin in July 2015.
As the final details are getting worked out, the President of the Society of Interventional Radiology, James Spies, MD, FSIR, and an interventional radiologist and chair of the radiology department at MedStar Georgetown University Hospital and professor of radiology at Georgetown University Medical Center in Washington, D.C., says the move will give interventional radiologists more visibility among fellow physicians and patients.
"The elevation of interventional radiology to a specialty level with its own distinct residency program places IR on the same level as surgery, pediatrics, and internal medicine in the ABMS hierarchy and brings recognition and validation to a specialty that has had a hugely positive impact on the practice of medicine."
While interventional radiologists have been an important and significant part of clinical care teams, they are still relatively unknown to patients, and even physicians.
"Our roots are in diagnostic radiology," says Mahmood Razavi, MD, director of clinical trials and research center at Orange, California-based St. Joseph Vascular Institute & partner at Vascular & Interventional Specialists of Orange County (VISOC). "The reason the public doesn't quite understand is we deal with so many disease entities and so many body parts, it is hard to brand us."
Revenue Generators
Interventional radiologists pioneered angioplasty and stenting, mainstream procedures today. Now, their vein and vascular clinics are widespread. Therapies for those diseases are clinics' bread and butter, but Razavi says the interventional radiology procedure he sees the most growth potential for is treating primary and metastatic liver cancer tumors with yttrium-90 radioembolization (Y-90).
Y-90 radioembolization therapy uses radioactive beads that are tiny—about the width of five red blood cells. Like other interventional radiology procedures, a small incision is made for a catheter that delivers the Y-90 beads to the tumor vessel, killing the cells.
Razavi says nationwide, the use of Y-90 has grown by 20—30%, but at VISOC, growth rate is even higher. "At our practice, the growth of Y-90 is closer to 50%. Y-90 will continue to grow unless the emerging research turns out to be negative or the payers take a different approach, but that scenario is unlikely… The growth is only limited by the epidemiology of the disease."
While not a cure for primary or metastatic liver cancer, Y-90 radioembolization allows for higher doses of radiation to be delivered since it is a targeted therapy. Patients benefit by having a better quality of life.
Another key component to interventional radiology procedures is imaging, but it's the imaging procedures that have also contributed to patient and physician confusion about what an interventional radiologist does.
Razavi says interventional radiologists are experts at reading x-rays, CT scans, and MRIs, but more importantly, the treat the disease they're seeing on the images.
To distance itself from imaging, Razavi's practice does no imaging.
"We use the local diagnostic imaging centers and the diagnostic radiologists to refer our patients to," he says. "We're not part of them."
VISOC's model is unique because imaging is a revenue generator, but Razavi says omitting imaging services reinforces the interventional radiologists as a clinical partner and physician rather than an image reader.
"Those interventional radiologists who still do imaging part of the time, say 2–3 days a week or the same day, that is the model that is going to fade away," Razavi predicts. "The full-time interventional radiology practices, such as ours, are financially successful. It is a viable model."
Ebola is snagging the big headlines, but physicians have many other things to think about, not least of which is their ability to dispute the accuracy of data on payments made to them by device manufacturers and drug makers.
Most of the news of late about physicians has centered on the ebola outbreak that has doctors from across the world both riveted and worried, and rightly so. When a big health story dominates the landscape, it easy to overlook other important notable events such as the pressure CMS is under because of technical glitches plaguing yet another federal website—Open Payments. That's just one of three items that caught my attention this week.
Open Payments Website Has Healthcare.gov-like Problems
The American Medical Association is ratcheting up the pressure it is putting on the Centers for Medicare & Medicaid Services to delay the release of financial relationships between physicians and medical device and pharmaceutical manufacturers as part of the Physician Payments Sunshine Act, also known as the Open Payments Act.
Like the rollout of the federal health insurance exchange website, the Open Payments system has been plagued with technical difficulties and complaints that the registration process is too long, cumbersome, and difficult to navigate.
Among the chief concerns of physician groups is the ability to dispute the accuracy of data on payments made by manufacturers to physicians. According to the language governing disputes, if a manufacturer or GPO determines a physician's or teaching hospital's request to change data reported isn't needed, then the dispute can be dismissed.
In early August, the AMA and more than 100 medical specialty societies asked for delay of six months in three-page letter to CMS Administrator Marilyn Tavenner.
This week the AMA began surveying physicians online to gauge their experience registering with CMS to review what manufacturers and applicable group purchasing organizations were disclosing about the financial interactions they had with physicians.
Despite much consternation and speculation among physicians, and at least one erroneous media report, there is no definitive word from CMS on whether the Aug. 27 deadline will be enforced or delayed.
Federal Appeals Court Upholds Lame Duck IPAB, Sort Of A lawsuit challenging the constitutionality of the controversial Independent Payment Advisory Board created by the Patient Protection and Affordable Care Act has been dismissed by U.S. Court of Appeals for the Ninth Circuit.
IPAB has been roundly criticized by Republicans and health industry groups as a body with the intent to ration care. The actual intent of the board, according to President Barack Obama and health policy supporters, is to be a nonpartisan entity that can control Medicare costs.
Although the IPAB's 15 members were supposed to have been appointed by now, there's not been a need to form the group because Medicare spending growth has slowed and been on target. IPAB recommendations for curbing spending are only triggered with spending is projected to outpace targets.
The court's decision to dismiss the lawsuit regarding IPAB came about in part because there is no group to file suit against. There is some speculation that IPAB will not exist in the near future. In her Senate confirmation hearing, Health and Human Services Secretary Sylvia Burwell testified that cuts to Medicare recommended by IPAB weren't likely to happen during her term.
AL Hospital System Settles Alleged Kickback Scheme
Mobile-based Infirmary Health System, one of Alabama's largest health systems, will pay millions of dollars for allegedly participating in a scheme that overbilled Medicare and rewarded physicians for referrals and unnecessary tests.
The total fraud settlement amount is $24.5 million and shared among IHS, along with two of IHS clinics, and Diagnostic Physicians Group P.C. (DPG).
The suit was brought by whistleblower, Christian Heesch, MD, a cardiologist who practiced with DPG. Heesch complained to the Alabama Department of Public Health in 2009 regarding unnecessary nuclear imaging tests ordered for patients. In court documents detailing the complaints, physicians were paid bonuses for ordering medical tests on equipment that was owned by IHS.
Physicians at DPG also received a share of Medicare revenues collected by the clinics. It's illegal for physicians to receive any kind of renumeration that induces referrals of items or services that are covered by federal healthcare programs, such as Medicare and Medicaid. The total amount of Medicare claims paid was $521.6 million; the amount of bonuses paid was more than $18 million.
The Justice Department claims that a DPG attorney warned clinic employees and DPG physicians that the financial referral system was illegal. The practice did not stop until 18 months later. In the meantime, Heesch was fired a month after asking to review DPG financial records. He is suing for punitive damages, lost wages, and other expenses.
He'll receive $4.41 million of the double-digit settlement.
