News & Updates

  • 31 Mar 2017 3:00 PM | AIMHI Admin (Administrator)

    CHICAGO — Massive disruptions are ahead in health care, including blowing up the fee-for-service model and making care more affordable, Bernard Tyson, chairman and CEO of Oakland, Calif.-based Kaiser Permanente, told attendees at the American College of Healthcare Executives’ 2017 Congress on Healthcare Leadership on Tuesday.

    Tyson challenged ACHE members to use their “firepower” to take health care to the next level and to invest in a system that provides something better than “episodic care after something has gone wrong.” This includes early diagnosis and treatment and helping patients with the behavior modification needed to manage chronic conditions.

    “This is on our collective watch,” Tyson said. “We need to turn up the volume [about moving] from a sick-based system to a health-based system.”

    Tyson noted that he was a supporter of the Affordable Care Act and was applauded when he said that it does not meet his definition of “disaster,” even though some politicians describe it as such.

    Tyson told of how he met with President Donald Trump and said the president listened intently and asked “great” questions. Tyson didn’t dwell on the American Health Care Act, the GOP’s repeal-and-replace legislation, but told ACHE members that it was up to them to “pick up the pieces and move forward.”

    “It looks like the Affordable Care Act will have another day,” Tyson said. “My hope is that, with whatever we come up with in Round 2, we don’t lose ground.”

    He described the ACA as a “great step forward” in providing care to the working poor, and Tyson pledged to work toward further reducing health care disparities.

    This means everyone having access to the health care system’s “front door,” Tyson said.

    The future of health care also involves addressing the social determinants of health and recognizing that a person’s family history, personal behavior and where they live can have more influence on their well-being than anything that can be provided in a hospital or physician’s office, he added.

    Tyson closed by recalling his own short hospitalization and how fortunate he was that he didn’t have to ask, “Am I going to be broke after this?”

    Gina Calder, vice president of ambulatory services for Yale New Haven’s Bridgeport (Conn.) Hospital, said she was glad to hear Tyson speak to audience members about their collective responsibility to the country and their communities to provide care that is accessible to everyone.

    “It doesn’t stop at our front door,” Calder said.

    She also noted that value-based care “is here to stay.” In reference to Tyson’s comment about blowing up fee for service, Calder said, “I’m not sure that’s something we can avoid.”

    Being reimbursed for outcomes allows organizations to invest in things like information-technology systems that provide data on what strategies produce the best outcomes, Calder said.

  • 31 Mar 2017 1:00 PM | AIMHI Admin (Administrator)

    One recurring problem payers and providers grapple with is 30-day readmissions, and the financial penalties associated with them. To help address this issue, and improve patient outcomes, more organizations are turning to community paramedic (CP) programs that enlist the services of EMS teams to answer calls and offer short-term interventions that help divert patients away from emergency departments and funnel them back into appropriate care channels.

    Kevin McGinnis, MPS, program manager of Community Paramedicine-Mobile Integrated Healthcare and Rural Emergency Care for the National Association of State EMS Officials, says community paramedicine got its roots in the late 1990s in the Northeast United States and Canada but didn’t come to prominence until the mid-2000s. There are roughly 170 documented CP programs nationwide.

    “We can start to help the health system affect savings where others in the traditional healthcare system can’t because we’re in the community 24/7 and we’re used to being in patients’ homes,” McGinnis says. Data suggests CP programs are effective in reducing repeat ED admissions and 30-day hospital readmissions, he adds. “… This is one small solution that the healthcare system can invoke.”

    Diversion tactics
    CP programs work by allowing EMS personnel to answer emergency calls and assess patients’ needs to determine whether less-costly, more beneficial interventions are appropriate. Patients may need a quick fix for low blood glucose and a referral to an endocrinologist, for example. “They can take care of the issue right then and refer the patient for primary care at a future date. Or they can refer patient to a higher level of care more immediately,” McGinnis says. “It’s very powerful. It’s that triage force. You don’t want triage being done in the ED, you want to come out in front of the ED to do that.”

    CP programs are also offering additional services. Dan Swayze, DrPH, MBA, MEMS, vice president and chief operating officer of the Center for Emergency Medicine of Western Pennsylvania, Inc., says that while community programs vary from state to state, most utilize the services of community paramedics for areas within their scope of practice where there are gaps in traditional care, such as for patients without insurance who don’t qualify for home health nurse visits. “Some home nursing agencies are actually contracting with CP services to supplement their care, to help reduce the likelihood their patients will be readmitted to the hospital,” Swayze says.

    CP programs are also helping bridge the gap between health and human services, he says. They can provide patient navigation and patient advocacy services for patients who can’t get them on their own or who need help finding the right program.

    “Our CPs often accompany patients to their providers’ visits so we can reinforce and translate the next steps in ways the patient will understand when they get back home,” Swayze says. “Once we address the underlying social determinant issues facing the patient, we find that their dependence on 911 and the local emergency department goes down drastically. It’s much more effective to have a paramedic call these patients than it is to continue to react as we have traditionally done.”

    He adds that more CP programs are coming from hospitals that operate their own ambulance service. “The medics are already FTEs in the healthcare system and hospital administrators are beginning to realize it’s more cost effective to deploy the medics to the patient based on their predictive and risk stratifications models rather than waiting for the patient to call 911,” he says.

    Financial drivers
    Matt Zavadsky is director of public affairs for MedStar Mobile Healthcare, a governmental agency that is the regional 911 EMS provider for 15 Texas cities, including Fort Worth. MedStar also operates a CP program. Zavadsky says EMS teams have traditionally only been paid for transporting patients to the hospital or ED, with no reimbursement for patients treated on the scene without transport. “So we transport them to pay our employees and that’s just silly,” Zavadsky says.

    Now, hospitals and payers are using incentives from the ACA earned through lower ED admissions and hospital readmissions to change the reimbursement structure. “Any health system migrating to a population health strategy has to recognize that all their efforts can be thwarted by the patient with a quick call to 911. As systems consider how best to transition to value-based care, they should take a serious look at their local EMS agencies as partners in the process,” Swayze says.

    MedStar is paid primarily for 911 ambulance service, Zavadsky says. It also is paid for CP services. Hospitals and other agencies, such as an IPA, pay an enrollment fee for the enrollment. It also receives per member per month payment from hospice agencies. Third party payers are negotiating with the cost savings plan, though it was not yet in effect at press time, says Zavadsky.

    Filling an unmet need
    Zavadsky says that patients who are surveyed after hospital stays say they only understand their discharge instructions 40% of the time. They may have questions that only come up after they leave the hospital, then forget by their next appointment. These things that can lead to ED visits and readmissions.

    “It’s not that they want to be noncompliant, it’s just that they don’t know any other way to be. Nobody has the time to sit with that patient in an area that’s comfortable for that patient and explain,” says Zavadsky. “We’ve put 3,000 to 5,000 patients through these [CP programs] and 80% of what we’re doing with these patients isn’t clinical. It’s educational.”

    Zavadsky says his agency has tracked 475 patients using the CP mobile healthcare services for 24 months and found that EMS calls were reduced by about 55% in patients enrolled in the CP program. That translates to an estimated $8 million cost savings to health systems thanks to the change in the patient’s utilization of services. That estimate, Zavadsky says, is based on ED facility payments and Medicare cost savings and isn’t inclusive of additional costs for lab work or specialist care.

    Original article can be accessed here.

  • 31 Mar 2017 11:00 AM | AIMHI Admin (Administrator)

    Misunderstanding about the role of the Agency for Healthcare Research and Quality within the federal government may lead to its demise.

    The agency is the lead federal agency involved with improving safety and quality of the nation’s healthcare system, and it develops the tools and data needed to help providers and consumers make informed health decisions. It has played a critical role in funding research devoted to health IT.

    But the agency’s independent status may be coming to an end if President Donald Trump’s proposed budget is approved. The administration wants to merge it with the National Institute of Health (NIH), which also faces a $5.8 billion cut in funding.

    AHRQ takes a hard look at healthcare costs and makes sure medical practice is evidence-based and not motivated by financial interests. But Republicans argue the agency’s work is duplicative and wasteful, noted STAT.

    In defense of the administration’s consolidation plan, Health and Human Services Secretary Tom Price said during a budget hearing Wednesday the changes would improve efficiency while continuing to fulfill the agency’s mission.

    But supporters of AHRQ believe that lawmakers don’t completely understand the role of the agency and that the proposal is short-sighted, according to STAT. The agency looks at the effectiveness of healthcare practices, such as identifying strategies to reduce medical errors and hospital-acquired conditions.

    Lisa Simpson, chief executive of Academy Health, a healthcare research organization, told the publication that although it is well-known and respected within the scientific community, AHRQ lacks the visibility of larger agencies like the Centers for Disease Control and Prevention and the NIH.

    “When you think about how many taxpayer dollars are spent to pay for healthcare under any scenario—Medicare, Medicaid, CHIP—to not invest a tiny amount of money to understand how to improve the quality of care seems so ill-advised and shortsighted,” Simpson told STAT.

    And though the proposal is a threat to the agency’s future, it could be beneficial if it’s reorganized under the right conditions, wrote Andrew Bindman, M.D., in a blog post for Health Affairs. Bindman is a professor of medicine, epidemiology & biostatistics, and an affiliated faculty member within the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco.

    Perhaps, he said, the AHRQ could lead efforts on how to prioritize the allocation of resources for practice-based research and implementation science available through the NIH and other federal investments.

    Original article can be accessed here.

  • 31 Mar 2017 9:00 AM | AIMHI Admin (Administrator)

    The current healthcare landscape is ever-changing, complex, fragmented and a thousand other adjectives. From cybersecurity to quality, policy changes to rising drug costs, there are myriad issues in the industry that are worth addressing.

    For physicians, the complicated healthcare environment is only exacerbated by the country’s current insurance system.

    A recent LinkedIn survey found 48 percent of physicians support a single-payer healthcare system, according to a post by LinkedIn’s healthcare news editor Beth Kutscher.

    “It was a surprising number,” Kutscher told MedCity in a phone interview.

    Another 32 percent of respondents were opposed to the idea of a single-payer system and 21 percent said they didn’t know.

    The survey, which was part of a larger LinkedIn survey, was conducted between February 7 and February 19. A total of 511 United States physicians responded, 449 of whom are currently practicing. The participants, who come from various specialties, were selected at random. All the respondents noted in their profile that they have an MD degree, Kutscher said.

    Why do almost half of the surveyed physicians favor a single-payer system? Some pointed to patients who move from provider to provider through the years.

    “There was also a strong human rights theme that came out of the survey,” Kutscher said.

    Other respondents noted the inconvenience of negotiating with numerous insurance companies. This frustration was fairly common. Fifty-four percent of physicians claimed they spent time negotiating with insurers. “It’s notable that more than half are actually doing it themselves,” Kutscher said. On average, they spent about four hours per week doing so. “That’s time out of their day. If all patients were in a single platform, [physicians] wouldn’t have to worry about these things,” Kutscher added.

    Additionally, 64 percent of respondents said they’ve put new measures into place to ensure payment from patients with high-deductible health plans. Thirty-three percent said they offer payment plans, while 26 percent demand upfront payment. Another 19 percent said they bring on additional team members such as financial counselors to ensure timely payment from HDHP patients.

    What about the 32 percent of respondents who said they oppose a single-payer system? Many said they think it could cut down competition or suppress innovation initiatives. Other opposers said they “fear it would give the government too much power over reimbursement rates or that they mistrust the government’s ability to create a viable single-payer system,” according to Kutcher’s post.

    The statistics from LinkedIn’s survey show physicians are varied in their opinions about what should happen next in the U.S. healthcare system. But given last week’s AHCA failure, it looks like we’re staying where we are for right now.

    Original article can be accessed here.

  • 22 Mar 2017 8:00 AM | AIMHI Admin (Administrator)

    While Congress continues to hash out the details of a GOP bill to repeal and replace the Affordable Care Act, leading public health experts say the debate fails to address the actual challenges to American health and healthcare and will have a limited impact on the health of the population.

    The National Academy of Medicine (NAM) has released a new discussion paper (PDF) that goes beyond the debates over insurance coverage and creates eight policy directions that are essential to advance American health, healthcare and scientific progress.

    The publication is part of NAM’s Vital Directions for Health and Health Care Initiative, which called together more than 150 leading experts 18 months ago to examine ongoing healthcare problems, including high costs, disparities in health and the burden of chronic illness and disability.

    The report was written by a bipartisan steering committee, which included Mike Leavitt, former governor of Utah and former secretary of the Department of Health & Human Services; Mark McClellan, former commissioner of the Food and Drug Administration; and Tom Daschle, former Senate majority leader.

    “In the midst of all this debate, we cannot afford to lose focus on the ultimate goal of achieving better health for all, for an effective healthcare system that not only helps people prevent and treat their ailments but also helps every American to reach their best health and well-being,” Victor J. Dzau, M.D., co-chair of the committee and the president of NAM, said Tuesday during a conference to unveil the findings.

    To achieve this goal, McClellan said the report identifies four priority actions to advance a more efficient and patient-focused health system, as well as four infrastructure needs to support the system.

    Priority actions
    Pay for value: One of the recurring themes in the 19 papers released as part of the report is the problem with the nation’s fragmented payment system. The report describes the need to align payments with outcomes and results and focus on activities that deliver the best outcome for patients at the lowest costs. To advance value-based care, policy reforms must drive healthcare payment and innovation providing incentives for outcomes and value, help clinicians develop the core competencies required for new payment models and remove barriers to integration of social services with medical services.

    Empower people: Healthcare needs to be more democratic, McClellan said. The report calls on policy reforms to encourage clinicians to work with patients and families to ensure the care they provide matches the individual’s goals, work to improve health literacy and communicate in a way that is more understandable to patients, promote effective telehealth tools, and ensure patients have access and ownership of their personal information.

    Activate and support communities: In most cases, health is determined by where patients live, what they are exposed to and who they spend time with, according to McClellan. Therefore, the report recommends strategies to support stronger, healthier communities, such as investing in local leadership and infrastructure for public health initiatives, expanding community-based strategies that target high-need individuals, such as patient-centered medical homes, and utilizing resources at the local level to customize and scale community health innovations.

    Connect care: McClellan said the final action involves creating principles and standards for end-to-end interoperability, which involves making necessary regulatory and infrastructure changes for clinical data accessibility and use, and identifying information technology and data strategies to support continuous learning.
    Essential infrastructure needs
    To drive these actions, the report calls for different infrastructure needs, such as:

    Measure what matters most: This means a consistent set of core measures must be developed. The report calls on HHS to identify a lead organization for each of the 15 core measures, and ongoing investment in improving performance measurement.

    Modernize skills: The country must invest in and train the healthcare workforce to manage increasingly complex patients and populations. This will require reforms in healthcare training and education.

    Accelerate real-world evidence: There is much promise in the potential to analyze large amounts of health-related data from actual patient care. But the report says progress has been hampered by technical, regulatory and cultural barriers. Policy reform must draw on real-word evidence to advance continuously learning clinical research, create incentives and standards that foster a culture of data sharing, and partner with patients and family to support evidence generation and sharing of information.

    Advance science: To advance the pace of innovation, policies must invest in scientific innovation, support collaboration among government, academia and industry scientists, and streamline regulatory processes.

    Article can be accessed here.

  • 20 Mar 2017 1:00 PM | AIMHI Admin (Administrator)

    Health systems and insurers are actively seeking out technologies and innovations that drive change in the healthcare system, many focusing on solutions that make healthcare a more seamless experience for people to access and navigate. Given that healthcare represents 17.8 percent of the U.S. economy, health plan investment in innovative startups that create efficiencies and enable better patient outcomes should continue for the foreseeable future.

    However, while investments are being made, many health plans are challenged to launch and scale commercial partnerships with these innovators after the closing dinner. Some are stuck in a health plan’s procurement spin cycle, or unable to grow beyond an initial pilot, all of which can be a life-or-death challenge for a startup company, only adding to the underlying investment risks.

    For health plans’ strategic investment programs to mature, they must resolve the challenge of bringing innovations to scale for the benefit of broader membership.
    Ultimately, the burden falls to entrepreneurs to decide where to invest their time and limited resources. I have observed decades worth of partnerships, many of which have not lived up to expectations.

    Entrepreneurs should consider the following when evaluating potential strategic partners and investors to increase their chances of success:

    Do they have a long-term vision?
    Every company has their mission on their website, but is their business structured to support their vision? Not all health plans are aligned with their often transformative-sounding mission statements, and their annual business objectives are not always driving toward marketplace disruption. Entrepreneurs should really examine whether the plan and its leaders are incentivized to implement innovations – or just keep doing what they do.

    Right room, wrong people
    Time and time again entrepreneurs make agreements with health plans to fund a pilot, the teams get to work, and as the pilot wraps up, no long-term agreements are made. At times technology and time spent are wasted, and entrepreneurs are left scratching their heads.

    To ensure a long-term partnership, entrepreneurs must ensure they’ve established direct relationships with a cross-functional team inside the health plan — including an executive sponsor (with real budget and decision-making authority) and leaders from other business units touched by the startup’s technology. Ensuring these key players are making decisions, and offering input from the start will lead to successful partnerships.

    Adapt. And then adapt again.
    Every health plan has their own processes and systems. Some require procurement approvals in advance, others after some work has been accomplished. Some parties may require roundtables and constant check-ins, while there are organizations that want progress reports at the end of each quarter. In every aspect of health care, no size fits all.

    Entrepreneurs must be nimble and adapt to each plans’ internal processes and requirements.

    Are they tire kickers?
    Not every health plan has deep experience in partnering with startups – and it is clear that few of us get it right the first few times. There are many lessons for organizations to learn about aligning incentives, driving project budgets, making systems integrate and data sharing easier. Entrepreneurs must examine the plan’s track records: Do they stick it out for the long term, or are they tire kickers? Can they execute on the partnership once they make the investment? If entrepreneurs find stage-agnostic portfolios with a track record of long-term investment commitments, chances are the plan is in it for the long term, and not looking to kick the small guys to the curb.

    Healthcare is a mess, and the industry has many problems and needs. Smart entrepreneurs have no shortage of opportunities to create billion dollar companies. However, if companies choose to use partnerships to speed their growth and development, entrepreneurs must always keep in mind that the wrong partner can smother them with attention, bury them in the process, and ultimately freeze them in pilot mode. Many strategic investors are looking for ways to facilitate these partnerships to run more efficiently and allow for better functioning. Startups and entrepreneurs, let us know what you are experiencing, what’s working well, and what’s not, in the market.

    Original article can be accessed here.

  • 20 Mar 2017 7:00 AM | AIMHI Admin (Administrator)

    The newly merged Envision Healthcare is looking into divesting its once indispensable ambulance and medical transportation business to focus on growth of its bigger physician staffing division and reduce debt.

    Presenting at the Raymond James Institutional Investors Conference Monday, Envision CEO Chris Holden said physician service revenue and earnings before interest, taxes, depreciation and amortization are growing faster in physician services than medical transportation.

    Greenwood Village, Colo.-based Envision also has a plump pipeline of potential acquisitions of physician practices, an industry still fragmented and dominated by small “mom and pop” groups, Holden said.

    Meantime, Envision’s medical transportation business remains the largest in the U.S. with almost 5 million patient transports last year and more than 270 contracts for 911 services.

    But the lion’s share, or $750 million, of Envision’s $900 million capital budget in 2017 is earmarked for physician practice acquisitions vs. $75 million for medical transportation.

    The opportunities that Envision sees in physician services is what is giving rise to a strategic review of whether to sell the medical transportation business, known as American Medical Response, and a much-smaller population health management division called Evolution Health.

    Envision’s all-stock merger with Nashville-based Amsurg in December created the nation’s largest physician-staffing company, with more than 19,000 physicians and clinicians and annual revenue of more than $10 billion. “It is the engine of the company,” Holden told the Raymond James analysts.

    Physician staffing vendors such as Envision, TeamHealth and Mednax provide contract doctors to various hospital departments, including the emergency departments, hospitalists, radiology, anesthesiology and neonatology.

    Before the merger, medical transportation was viewed by Envision management as critical to the company’s growth strategy.

    Then-CEO Bill Sanger, who is now executive chairman of the merged Envision, noted during earnings calls that medical transportation provided cross-selling opportunities to hospitals for physician services and would play a role in Envision’s ability to bundle services from transport to departments across a hospital.

    “But that was the old Envision,” said Richard Close, securities analyst in the Nashville office of Canaccord Genuity.

    In the merger, Envision and Amsurg brought their own customer bases to the tie-up, providing abundant cross-selling opportunities, Holden said.

    And Envision wants to bring down its leverage a bit, Close said.

    At Raymond James, Holden said Envision’s debt is about 4.3 times EBITDA, which is above the 3 to 4 times EBITDA that the company feels comfortable at.

    If AMR were to be sold, it would bring Envision down into that range, he said.

    Original article can be accessed here.

  • 14 Mar 2017 1:45 PM | AIMHI Admin (Administrator)

    Jennifer L. Wiler, MD, MBA; Harold D. Miller; and Nir Harish, MD, MBA
    March 08, 2017

    The American Journal of Accountable Care. 2017;5(1):51-53

    The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 encourages the development of physician-focused alternative payment models (APMs). This creates the most significant opportunity in 2 decades to meaningfully redefine how physicians are paid for their services. Whether this results in better care and lower spending, and whether it helps or harms physician practices, will depend heavily on how HHS implements APMs. In this article, we draw on the experience of past and present payment reforms to suggest principles for successfully designing APMs.

    Five Principles for Successful APMs

    1. Provide the Resources Needed to Deliver Higher-Value Care
    An overarching goal of APMs is to slow the growth in healthcare expenditures. However, APMs, which blindly incent decreased utilization of services, can worsen access to care and health outcomes for patients.1 Adding penalties based on quality can protect some patients, but harm others whose care needs fall between the many cracks in current quality measures.

    A major weakness in the current fee-for-service (FFS) systems is lack of payment for many high-value services that could address patient needs at lower costs. For example, patient education and self-management support can help patients with chronic disease to avoid hospitalizations, but they are not adequately supported by payers. Similarly, supervised exercise therapy can achieve equal or better outcomes than surgery for many patients with diseases such as peripheral artery disease and joint osteoarthritis, but it is not adequately supported by the current payment systems. A successful APM will give physicians the flexibility and resources they need to deliver higher-value approaches to patient care.
    2. Hold Physicians Accountable Only for the Aspects of Cost and Quality They Can Control
    A second weakness of traditional FFS payment is that it neither rewards nor penalizes physicians based on the overall cost of treating a patient’s problem or the outcomes achieved. In contrast, capitation payment systems reward physicians for avoiding high-need patients and penalize them for costs they cannot control. The reasons capitation systems were abandoned in the past was not a lack of adequate information technology or quality measures, but rather the inappropriate transfer of full insurance risk to physicians. Many current payment reforms that hold physicians accountable for all spending on their patients create the same problems under a different name.

    There is a middle ground between FFS and full-risk global payments.2 In many pilot programs, physicians have demonstrated the willingness and ability to reduce costs and improve quality for the services they both deliver and order if they have the resources needed to do so. A successful APM will hold physicians accountable for aspects of costs and quality they can control (eg, how many tests they order, which procedures they perform, how well they prevent avoidable complications), but not for the things they cannot (eg, the services ordered by other physicians for different health problems, increases in the prices of drugs they prescribe).
    3. Improve Payment for Specialty Care, Primary Care, and Inpatient Procedures
    Most payment reforms to date have taken 3 forms: primary care medical homes, bundled/episode payments for inpatient procedures, and accountable care organizations (ACOs). Although high-quality primary care, inpatient surgeries, and care coordination are essential to higher-value healthcare, the majority of services are delivered outside of inpatient settings and by specialists, not primary care physicians. Not every acute condition is something that good primary care can prevent, and the mere fact that services are more “coordinated” does not mean they are achieving the highest value.

    Although a majority of healthcare spending is associated with a small proportion of patients who have multiple health problems or require very expensive services, most patients receive healthcare services for individual problems. Every patient deserves high-quality, affordable care, and for many patients, that care will be delivered by a specialist in an outpatient setting, not by a primary care physician, a hospital, or a care manager employed by an ACO.

    In order to deliver higher-value care, the barriers that specialists face under the current payment system must be removed. Primary care medical homes and surgical episode payments are not readily adaptable to most types of specialty care,3 and it is neither necessary nor desirable to force every patient to be part of a large ACO in order to receive better care. Appropriately designed APMs are needed in every specialty so that all patients can benefit from higher-value care.4
    4. Allow Flexibility to Customize Service Delivery Approaches to Local Resources
    The significant variation in care delivery within and across regions has been well documented. Much of this variation is avoidable and represents an important opportunity for physicians to improve quality and reduce costs under an APM. However, some of the variation reflects fundamental differences in the resources that communities have available to deliver care. A patient who has an acute stroke may be managed by an internist, neurologist, intensivist, or stroke specialist depending on where that patient lives; similarly, patients with back pain may be managed by internists, physiatrists, pain management specialists, or spine surgeons in different communities. Local regulations, workforce capacity, disease epidemiology, and patient expectations significantly impact how care must be delivered.

    To be successful, APMs must allow flexibility in the types of services to be delivered and the types of providers who can deliver those services. Success should be measured based on outcomes, not on adherence to 1-size-fits-all standards for structure or processes, and performance benchmarks must reflect differences in the costs and outcomes that are achievable in rural areas, inner-city communities, and so on.
    5. Minimize Administrative Burden
    The complexity of current payment models and the systems used to administer them have significantly increased the costs of healthcare in the United States without corresponding improvements in outcomes. APMs represent an opportunity not only to improve care delivery, but to eliminate unnecessary administrative burdens. Just as care delivery should be redesigned to eliminate waste, no administrative requirements should be included in APMs unless the likely benefits will significantly exceed the costs.
    By encouraging APMs, MACRA provides an unprecedented opportunity to encourage innovations in care delivery. However, just because a payment model is different does not mean it will be better. The success of APMs will depend heavily on how they are designed and implemented. We believe that these 5 principles can guide the development of APMs that enable better outcomes for patients at a more affordable cost and that physicians can enthusiastically support.
    Author Affiliations: Department of Emergency Medicine; University of Colorado School of Medicine (JLW), Aurora, CO; Center for Healthcare Quality and Payment Reform (HDM), Pittsburgh, PA; Department of Emergency Medicine, Robert Wood Johnson Clinical Scholar; Yale School of Medicine (NH), New Haven, CT.

    Source of Funding: None.
    Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

    Authorship Information: Concept and design (JLW, HM, NH); of the manuscript (JLW, HM, NH); critical revision of the manuscript for important intellectual content (JLW); administrative, technical, or logistic support (JLW); and supervision (JLW).

    Send Correspondence to: Jennifer L. Wiler, MD, MBA, Associate Professor, Department of Emergency Medicine, University of Colorado Denver SOM, 12401 E. 17th Ave B-215, Aurora, CO 80045. E-mail:
    1. Grumbach K, Osmond D, Vranizan K, Jaffe D, Bindman AB. Primary care physicians’ experience of financial incentives in managed-care systems. N Engl J Med. 1998;339(21):1516-1521.

    2. Miller HD. From volume to value: better ways to pay for health care. Health Aff (Millwood). 2009;28(5):1418-1428. doi: 10.1377/hlthaff.28.5.1418.

    3. Wiler JL, Beck D, Asplin BR, et al. Episodes of care: is emergency medicine ready? Ann Emerg Med. 2012;59(5):351-357. doi: 10.1016/j.annemergmed.2011.08.020.

    4. Miller HD. Win-win-win approaches to healthcare cost control through physician-led payment reform. Clin Gastroenterol Hepatol. 2014;12(3):355-358. doi: 10.1016/j.cgh.2013.12.002.

    Original article accessed here.

  • 13 Mar 2017 9:00 AM | AIMHI Admin (Administrator)

    Hospitals and physician groups across the country are beefing up merit pay for quality and patient satisfaction in their physician compensation plans. But Geisinger Health System is doing something radically different.

    The 12-hospital system based in Danville, Pa., did away with physician bonuses altogether this summer and put all of its 1,600 employed doctors on a straight salary.

    Geisinger also made the decision to pay each physician at or above the national average whether in primary care or a specialty. “We don’t have below-average doctors so we don’t pay anyone below average,” Geisinger CEO Dr. David Feinberg said.

    That Geisinger would abandon a compensation model that previously paid physicians 80% straight salary and a potential 20% performance bonus runs counter to what’s happening with many health systems and physician groups.

    Most systems see the emergence of value-based reimbursement, encapsulated in legislation like the Medicare Access and CHIP Reauthorization Act, as requiring the rewarding or penalizing of physicians for performance on quality and patient satisfaction scores.

    They are shifting their compensation plans to put more emphasis on attaining those types of benchmarks rather than the old ways of predominantly rewarding throughput.

    For example, Crystal Run Healthcare, a 300-physician group based in the lower Hudson Valley community of Middletown, N.Y., today pegs up to 15% of total physician compensation to quality, cost and satisfaction measures, said Dr. Scott Hines, Crystal Run’s chief quality officer and medical director.

    That percentage is set to rise to 30% over the next three years because “more and more contracts are being tied to clinical quality and lower costs,” Hines said. He’s seeing the same trend with both government and private payers.

    The compensation model at the 1,200-physician Henry Ford Medical Group in Detroit is a little different but similarly aimed at elevating quality and patient satisfaction, said group CEO Dr. William Conway.

    The group’s primary-care physicians next year will get a greater portion of their compensation based on how many consumers choose them as their doctor than today’s model, which is predominantly based on the volume of relative value units they perform. RVUs represent a Medicare formula for reimbursing physician services that blends the time it takes to perform a service with the skill level behind that care. A committee of the American Medical Association establishes the relative weights of physician RVUs.

    While RVUs determine 66% of pay at Henry Ford today, it becomes a 50/50 split next year between RVUs and patient sign-ups, Conway said. That model also provides an incentive for physicians to perform well on quality and patient satisfaction since consumers will see physicians’ work rated online and can base their selections accordingly, Conway said.

    The shift is a response to changes in government reimbursement, not the markets. “It’s about the Medicare payment rate,” Conway said.

    Medicare has been coaxing hospital systems and physician groups to organize themselves around taking on more risk for the cost and quality of the care they provide. It’s part of a long process under the Affordable Care Act and MACRA of moving away from fee-for-service to value-based reimbursement.

    That philosophy has given rise to advanced alternative payment models. These are Medicare programs that give physicians extra incentives to manage the risk of certain populations or accept bundled payments for targeted procedures rather than paying in the traditional way.

    Examples include the Comprehensive End-Stage Renal Disease Care Model and the Medicare Shared Savings Program. To participate, hospital systems and physician groups have developed provider networks, in some cases accountable care organizations, to make sure their patients have access to coordinated services across geography and specialties.

    Those organizations are all a little different and offer their physicians different compensation incentives to participate. “If you’ve seen one, you’ve seen one,” Conway said.

    Alternative payment models, or APMs, have been exploding in popularity, according to the CMS. From their inception as part of the ACA the four APMs offered by CMS in 2017 now have 359,000 participating clinicians, providing care to 12.3 million Medicare and Medicaid beneficiaries, according to the CMS.

    The Next Generation ACO, a model that provides participating doctors even more risk and reward than under the Medicare Shared Savings Program, added 28 groups in 2017 and now has 45, the CMS said.

    Looming ahead is the new change agent for physician reimbursement models: MACRA. Though its implementation was recently delayed almost two years until 2018, MACRA establishes two new payment tracks for physicians treating patients holding government-sponsored insurance.

    Clinicians in advanced alternative payment models can earn annual bonuses of 5%. But the majority of physicians will participate in the Merit-based Incentive Payment System under MACRA. On that track, physicians can earn plus or minus 4% of reimbursement in 2019, 5% in 2020, 7% in 2021 and 9% in 2022.

    While physicians at Geisinger participate in a variety of APMs, the integrated delivery network has gone to straight salary for its employed physicians—rather than an 80/20 mix of salary and merit bonuses. Its physicians don’t need incentives to do the right thing for patients, said Dr. Jaewon Ryu, Geisinger’s chief medical officer.

    If they provide quality care in the right setting, Geisinger will do well financially on the 551,000 enrollees in its health plans for whom it takes full risk, Ryu said. And it will qualify to collect the at-risk portion of value-based payment models whether government-sponsored or commercial.

    UnityPoint Clinic, with 500 physicians in clinics across Iowa and Illinois, wants 33% of physician compensation by 2020 to be based on the value metrics of patient care, said Keith Seashore, UnityPoint Clinic’s chief financial officer.

    Those incentives now constitute 14% of compensation, with 86% of salary measured largely as a function of productivity, he said. UnityPoint Clinic is piloting a compensation model at five locations that will take the entire organization to its 33% goals, Seashore said. In those locations, about 20 physicians and 10 advanced practitioners have 33% of their compensation based on productivity, 33% on straight salary and 33% on the quality, cost and satisfaction variables, he said.

    The physicians driving the pilot believe that mix will align better with the additional risk UnityPoint wants under MACRA and the APMs, Seashore said.

    He added that the changes will be rolled out slowly so that the clinic’s physicians feel comfortable that the data collected for determining compensation are fair and accurate.

    CareMore, a Cerritos, Calif.-based clinic operator and health plan for frail seniors, incentivizes its physicians to keep patients out of the hospital, said CEO Dr. Sachin Jain.

    Jain, a former adviser to the Obama administration, said CareMore employs 80 “extensivists,” whose job is to track frail patients so they get the medications and care they need at home and in settings outside the hospital.

    The physicians, who earn on average about $200,000 annually, can earn an additional 5% to 65% in incentives by managing their patients so that hospitalization is a last resort, Jain said. That might mean making sure a patient has proper food, that they are not being dehydrated by lack of air-conditioning and other items that might fall outside the typical things that doctors are responsible for.

    Preventing hospitalization, Jain said, “is one of the purest metrics of clinical success.”

    Original article accessed here.

  • 8 Mar 2017 1:00 PM | AIMHI Admin (Administrator)

    After years of lobbying to repeal and replace the ACA, House Republicans put forth The American Health Care Act on Monday. Here are 10 things to know about the legislation.

    1. The AHCA would eliminate the ACA’s individual mandate, or requirement for American adults to enroll in health insurance. Further, the legislation eliminates the tax penalty adults faced if they were not covered. However, the concept of penalties still remains in some form: To encourage people to buy coverage, the AHCA lets insurers charge a 30 percent penalty for those who let their health plans lapse and try to buy a new policy, according to NPR.

    2. The AHCA calls for Medicaid expansion to remain in effect through Jan. 1, 2020. This is different from earlier drafts of legislation, which called for an immediate reversal of Medicaid expansion. Thirty-two states, plus Washington, D.C., have opted to expand Medicaid under the ACA. By 2020, the government will “freeze” the expanded programs and restrict funding only to people who were in the program as of then — no added enrollees from that date on. States would keep getting that amount of federal aid for each Medicaid enrollee as long as the enrollee doesn’t lose eligibility for more than a month. There is also a provision in the AHCA that calls for grants of extra Medicaid provider reimbursement funds to go toward states that didn’t expand Medicaid.

    3. The AHCA restructures Medicaid’s federal funding to a per-capita cap opposed to the current open-ended federal entitlement, reports Politico. States would receive capped payments based on how many people are enrolled in Medicaid. The plan also calls for more frequent eligibility testing of Medicaid enrollees.

    4. The AHCA restructures Americans’ tax credits to buy health insurance. It replaces income-based subsidies under the ACA with refundable, age-based and income-capped tax credits, according to Politico. These credits increase with age, from as low as $2,000 for those under 30 or as high as $4,000 for those over 60. There would be a limit as far as credits for a single household — $14,000 — and subsidies would be eliminated over time for individuals with annual income of $75,000 and for families with annual income of $150,000, according to the report.

    5. A few ACA staples roll over in the AHCA. The ACA provision related to pre-existing conditions would remain intact, meaning insurers would not be able to deny coverage or increase prices for people with such conditions, reports Reuters. Also, the AHCA retains provisions allowing adults up to age 26 to maintain coverage through their parents’ health plans, according to the report.

    6. The AHCA eliminates the cap on the tax exemption for employer-sponsored insurance. Although earlier drafts of legislation capped the exemption at 90 percent of current premiums, the final version eliminated the proposal, according to Politico. The bill also gets rid of the penalty for businesses that do not offer employees health coverage.

    7. The AHCA delays the effective date for the ACA’s Cadillac Tax on costly health plans from 2020 to 2025, according to The Hill. GOP lawmakers are delaying but keeping the tax to make certain their replacement plan will not increase the national deficit after a decade.

    8. The AHCA bars federal Medicaid funds or federal family planning grants for Planned Parenthood clinics, according to the report. (Separate from the AHCA, the White House earlier this week extended terms for a compromise to Planned Parenthood by proposing maintained federal funding if the group agrees to discontinue providing abortions, according to ABC News.)

    9. The cost of the AHCA is not yet known. The nonpartisan Congressional Budget Office has not yet scored the legislation, which means there is neither a cost estimate for the plan or how many Americans would gain or lose insurance under it.

    10. What’s next? The House Ways and Means and Energy and Commerce committees are expected to review the AHCA legislation Wednesday. If the committees approve the measure, the full House could potentially act on it before April 7, according to The New York Times. The measure would then be taken up by the Senate.

    Original article can be accessed here.

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