News & Updates

Modern Healthcare Source Article | Comments Courtesy of Matt Zavadsky

This is an issue that all healthcare providers and payers should try to work collaboratively to address. 

The National Governor’s Association did a great job bringing payers and providers together in October 2018 for a roundtable on the subject to perhaps draft some guidance for states.  EMS was represented by MedStar Mobile Healthcare, the National Association of EMTs and the American Ambulance Association.

Additional recent articles on the subject below:

Health insurer, employer groups call on Congress to end surprise billing

Analyzing Senator Hassan’s Binding Arbitration Approach To Preventing Surprise Medical Bills

Analyzing New Bipartisan Federal Legislation Limiting Surprise Medical Bills

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Surprise medical billing gets increased industry lobbying

By Susannah Luthi  | January 28, 2019

The debate over federal curbs on surprise medical bills has it all: inter-industry finger-pointing, slippery-slope warnings about rate-setting and dueling narratives about what the problem is.

Last week President Donald Trump invited people who have been hit with surprise bills to the White House, where he vowed to end the practice that puts patients on the hook for the often exorbitant price tag of out-of-network treatment. The issue is a political winner.

Senate offices are wrangling over the legislative mechanics of tackling surprise bills, and insurers and providers are clashing over who needs to concede more. Insurers frame the problem as one of surprise medical billing; providers as surprise gaps in coverage.

"I think there's intense fighting on the mechanics of the surprise billing legislation," said one analyst close to discussions who spoke on condition of anonymity. "Everyone agrees consumers should be held harmless, but the huge fight is over payment situation between insurer and provider."

Sen. Bill Cassidy (R-La.) who launched the surprise billing discussion last September with a bipartisan draft bill, and Sen. Maggie Hassan (D-N.H.) have been talking with one another and working on their separate proposals, but don't yet have an estimated date to release new versions.

Both proposals require industry to leave the out-of-network patients alone. Patients would only have to pay the co-pays set by their insurance plans.

Cassidy's draft would cap the charges for an out-of-network treatment at 125% of the median regional rate for the same service.

Hassan's proposal would leverage independent arbitration to resolve final payment disputes between the provider and insurer. The arbiter would look at Medicare and current network rates as the benchmark rather than the provider charges. 

But some policy analysts think the two proposals are two sides of the same coin, as the government and arbitrators' ultimate pricing would likely be similar.

"It's not like they have more information, although maybe they have more flexibility to deal with outlier," said Loren Adler of the Brookings Institution in Washington. "But there's nothing magical to arbitration other than maybe it's more politically palatable."

That's not how the healthcare industry sees it.

Insurers are fighting the arbitration proposal, arguing the process could be costly and long.

"For the vast majority of payments, it would be better to use some other type of benchmark, one that is set at where hospitals would be paid if they're in network facilities rather than have everything resort to arbitration," said Kris Haltmeyer of the Blue Cross and Blue Shield Association.

Specialty physicians, like emergency doctors and anesthesiologists who play leading roles in the debate because they sometimes offer patients out-of-network care at in-network facilities, see arbitration as their best option.

"When certain services are offered, insurers don't always play fair," said Dr. Michael Simon, an anesthesiologist who spoke on behalf of the American Society of Anesthesiologists. "There should be some sort of arbitration mechanism when one or both sides don't play fair."

Providers are quick to argue that capped charges in this context could lead to a much broader rate-setting system insurers could game by further shrinking their provider networks.

Molly Smith, vice president for coverage and state issues at the American Hospital Association, said the trend in health plans that use a reference-based pricing model instead of contracted networks supports this potential outcome.

"I'm generally not prone to slippery-slope arguments, but the fact we're seeing real growth in no network plans is evidence there is growing interest from insurers and out of network insurers that they are interested in this model," she said. 

Cassidy acknowledged the squeeze from both sides.

"I think everybody recognizes that rate setting has a two-edged sword — that if done poorly one group might use it as a ceiling and the other as a floor," he told Modern Healthcare earlier this month. "Everybody is trying to avoid that, and come to something that works."

New York's balance billing law was an industry compromise and since it has been in place since 2014 some stakeholders view it as a potential federal model.

The state uses an arbitration system that defaults to a regional payment standard as a guide.

But the system may not work for patients in the long run, according to Adler. He said physician payments track with a high percentile of the Fair Health Rate, which is based on median regional in-network costs. Adler estimated this payment rate translates into about 400% of Medicare for emergency physicians, and higher than that for anesthesiologists. It's not too different from the rate proposed by Cassidy, he noted.

"The risk is that you tie it to provider charges, a rate that providers pull out of a hat with no counterveiling force," Adler said. 

This could incentivize hospitals to raise rates over time, he added.

"Then you are solving one problem while creating a new one and forcing inflationary pressure into premiums," he said.

So far, New York's system hasn't increased charges or premiums, according to Simon, who represents the anesthesiologists. He framed the use of the Fair Health Rate as "normalizing" charges and eliminating high and low outliers.

"It's important to understand that we are always looking for a solution that is a fair balanced rate of reimbursement that is fair to providers and insurers, not taking advantage of other side — especially with federal legislation," Simon said.

Adler acknowledged the political battle ahead with independently-contracting specialists.

"They have a lucrative out of network billing option unavailable to any other specialty," he said. "You have to compensate them to forego that."

While Cassidy and Hassan have not put a timeline on the next draft, one analyst close to talks hopes to see a fresh take as soon as next month.

"They're at the table," Cassidy said of industry groups. "They recognize that something has to be done, that the American people are kind of pounding the table, and that their representatives are listening."

There's a third option hospitals are floating, according to Smith, who has worked on the issue at the state level for the American Hospital Association. They are considering a policy where federal law would hold the patient harmless but leave it to the providers and insurers to hammer out the details for the rest.

"We think a legitimate question is whether policymakers need to weigh in on how to resolve a dispute," Smith said.

Matt Zavadsky, MS-HSA, NREMT

Chief Strategic Integration Officer

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ACEP Source Article (PDF) | Comments Courtesy of Matt Zavadsky

Just released: ACEP proposal to end balance billing… 

Very interesting proposal – especially the provision for the creation of the Commission on Access to Quality and Affordable Emergency Care.

Framework for Protecting Patients When Emergency Care is Out-of-Network

Background

By oath and by law, emergency physicians will treat any patient, regardless of their ability to pay. Federal law under the Emergency Medicine Treatment and Labor Act (EMTALA) forbids emergency care providers from discussing with the patient any potential costs of care or details of their particular insurance coverage until they are screened and stabilized. Patients can’t choose where and when they will need emergency care – so they should not be punished financially for having emergencies.

Expanded Patient Protections that Truly Take the Patient Out of the Middle

• When a patient receives out-of-network emergency care, the emergency services provider cannot make any demand for payment from the patient -- balance billing is prohibited;
• The patient won’t pay any more out-of-pocket (i.e. coinsurance, copay, and deductible) than they would have paid if their emergency care were in-network (currently such protection only applies to coinsurance and co-pays);
• Insurers will directly pay any coinsurance, copay, and deductible for emergency care to the provider.
• • Insurers can then collect back these amounts from the patient. This ensures patients only have a single point of contact for emergency medical billing and payment, and will no longer receive and have to reconcile multiple, confusing bills and EOBs that result from the many providers that are often involved in a single emergency episode.
• To ensure policyholders better understand the limits of their insurance coverage and all potential out-of-pocket costs when seeking care, insurers will be required to display the patient’s deductible amount on policyholders’ insurance cards.
• Insurers must provide their policyholders with clear, concise and meaningful explanations of their plans’ emergency services benefits, an up-to-date list of in- and out-of-network providers, and beneficiary rights under EMTALA.

Take the Patient Out of Insurer-Provider Billing Disputes

• The insurer will pay directly to the emergency care provider within 30 days the amount of the deductible and cost-sharing (plus an additional amount as determined below). When provider-insurer disputes arise over reimbursement for out-of-network emergency services, the following will be used to resolve them:
• • The payment amount will be determined under any state law that takes a comparable approach to this proposal.;
  • For claims under $750 (amount to be adjusted for inflation), the balance will be paid in full. For inflation-adjusted amounts over $750, the insurer will pay an interim payment directly to the provider.
• Required payments will be made within 30 days of claim submission. Failure to do so will trigger civil monetary penalties (CMPs) of $500 per day.
• Either party may trigger the alternative dispute resolution (ADR) process described below within 30 days of the provider receiving the interim payment.

Alternative Dispute Resolution (ADR)

• HHS will maintain a database of ADR entities that meet certain qualifications (e.g. freedom from conflicts of interest, reasonable fees) to resolve disputes. Costs related to this will be offset by any collected CMPs, as referenced above. HHS may delegate responsibility of the database to a third party such as the American Arbitration Association or to any state that already undertakes a similar function.
• The emergency care provider and insurer will submit to the arbitrator the amount that was charged or billed for the emergency medical services, and the interim amount paid, respectively. Either party may consolidate multiple disputed claims between them into a single adjudication.
• The arbitrator will select one of these two amounts as the payment amount, and in doing so consider the following:
• • The provider’s level of skill, education and training,
  • The nature of the services provided,
  • The circumstances and complexity of the case,
  • 80th percentile of charges for comparable services in the same geographical area, as determined by a transparent and wholly independent Medical Claims Database (such as FAIR Health),
  • 150% of the average in-network rate for comparable services in the same geographical area as determined by a transparent and wholly independent Medical Claims Database (such as FAIR Health)

• Arbitration will be completed within 30 calendar days of either party commencing the ADR process. Any payment owed by one party to the other must be made within 15 calendar days of a determination. The costs of the ADR shall be borne by the non-prevailing party.

Commission on Access to Quality and Affordable Emergency Care.

HHS will establish a Commission on Access to Quality and Affordable Emergency Care with diverse, cross-sector representation to study and provide recommendations to Congress within three years of bill enactment on specified matters including:

• Adequacy of patient protections, including network adequacy standards and clarity of enrollee notification language from insurers
• If the bill’s new processes surrounding out-of-network emergency care are providing sufficient provider protections to ensure continued access to high-quality emergency care for patients;
• The merits of establishing supplemental funding for uncompensated care by incurred by emergency physicians pursuant to their practice of medicine under the requirements of EMTALA.

Milwaukee Journal Sentinel Source Article | Comments Courtesy of Matt Zavadsky

Ok, this is a very long article, but the reporter does an AMAZING job covering all the aspects and outcomes resulting from the practice of ambulance diversion.

I strongly encourage you to grab another cup of coffee, sit back and READ this news story – it’s one of those stories that just might actually create the public outcry to help resolve this practice…  It’s already been re-circulated by several national media outlets.

She collapsed next to the best stroke center. 
Her ambulance was turned away. 
It was policy. 
She died.

By John Diedrich of the Milwaukee Journal Sentinel

Jan. 17, 2019 

As she got ready to work the breakfast shift at the Medical College of Wisconsin cafeteria, Tiffany Tate didn’t feel well.

Tate, 37, was a fixture on the cafeteria’s “hot line,” where she worked behind a steaming grill. She knew the names of many workers and their kids, always sharing smiles and small talk.

With a teenager and 8-month-old at home, recent months had been an exhausting blitz for Tate. That morning, she told some of the other kitchen workers she had a headache and felt weak. She figured it was due to a new medication for her back pain.

Shortly after 8 a.m., as Tate and a group of workers came off a break, she felt worse. Tate asked for a piece of bread with honey. A co-worker hustled to get it. She returned to find Tate leaning against a counter, supporting herself with one hand. The left side of Tate’s face drooped; she was slurring her words.

A customer walked up. Both could see what was happening and said the same thing, almost in unison: 

“She’s having a stroke.”

At its most basic level, a stroke is an attack on the brain. Typically, it’s the result of a clot becoming lodged in an artery, choking off vital blood flow. Every minute blood flow is interrupted, it can cause irreversible damage to millions of brain cells.

A stroke can rob a victim’s ability to speak or to see and cause brain damage and paralysis. More than 140,000 people die each year in the United States from strokes, making it the fifth leading cause of death. It is a leading cause of serious, long-term disability.

The latest research says sending patients directly to top-level stroke centers — hospitals that can administer clot-busting drugs or go in through arteries to physically remove clots — offers the best chance at survival. The ideal window for care is within the first three hours.

On that morning four years ago, Tate was having a stroke on the grounds of the Milwaukee Regional Medical Center, and 350 yards from Froedtert Hospital, the area’s most advanced, experienced stroke care center. 

It would be a quick ambulance ride.

If only the ambulance had taken her there.

It didn’t.

Little-known practice of diversion

Every day as thousands of ambulances zig-zag through city streets, along congested highways and rural roads across the nation, it’s easy to imagine they’re headed to the nearest hospital or to the emergency room best suited to care for the sick or injured person on board.

KEEP READING>

Fierce Healthcare Source Article | Comments Courtesy of Matt Zavadsky

Another excellent example of innovative healthcare systems investing in foundational needs of at-risk populations as a way to reduce preventable healthcare utilization…

Other recent news items on this issue:

https://www.npr.org/2018/01/30/581778796/er-use-goes-down-as-hospital-program-pays-homeless-peoples-rent

https://www.hhnmag.com/articles/7818-why-hospitals-are-housing-the-homeless

Kaiser Permanente just bought a housing complex. Here's what it's doing with it

by Paige Minemyer

Jan 16, 2019

https://www.fiercehealthcare.com/hospitals-health-systems/kaiser-permanente-aims-to-address-homelessness-by-investing-affordable

Kaiser Permanente has gotten into the business of housing.

The health system announced in May that it would put $200 million toward initiatives targeting housing insecurity and homelessness in the communities it serves. On Tuesday night, it announced the first investment is the $5.2 million purchase of an affordable housing complex in Oakland, California, in partnership with Enterprise Community Partners and the East Bay Asian Local Development Corporation. 

The 41-unit building is in an Oakland neighborhood “on the brink of gentrification” which puts the existing residents at risk for displacement. By purchasing the building, it will be blocked from redevelopment that prices out the existing residents, preventing displacement, Kaiser Permanente CEO Bernard Tyson said at a press event on Tuesday.

Preserving buildings like this is a “key component to addressing the national homelessness crisis,” he said. “We know that preserving affordable housing is more effective than building new units.”

It's part of a comprehensive strategy, officials said, to invest in addressing the economic, social and environmental conditions that ultimately affect the health of their patients.  

Kaiser also announced it is “adopting” 500 homeless individuals in the city, Tyson said. He said that several of the system’s employees took a 12-week course aimed at devising ways to part with community groups to house older homeless patients with chronic conditions. 

All 500 people identified by the system have at least one chronic condition. The system is working with local groups to secure housing and other needed services for this group. 

The plans unveiled by the system on Tuesday also expand beyond Oakland and the Bay Area, where Kaiser is headquartered. On top of the two initiatives focused in that region, Kaiser and Enterprise are teaming up to launch a $100 million loan fund to create or maintain affordable housing units in all of the communities Kaiser Permanente serves. 

Tyson said the health system will make future announcements about specific plans under that fund. Tackling this issue, he said, “ties into who we are and what we’re about as Kaiser Permanente.” 

“This is the beginning of us being in traffic and backing our talk that we want to help to make a difference in Oakland, in the Bay Area, in this great country,” Tyson said.

Put the power of PR and strong partner relationships to work for your ambulance service. Don't miss these insights from AIMHI Communications Chair Alexia Bratiotis Jobson of REMSA. Read now on JEMS.com> 

Becker's Source Article | Comments Courtesy of Matt Zavadsky

A little lengthy, but a nice consolidation of takeaways from one of the premier healthcare conferences in the country…

The No. 1 takeaway from the 2019 JP Morgan Healthcare Conference: It's the platform, stupid

Written by Dan Michelson, CEO, Strata Decision Technology | January 11, 2019 

If you want to understand the shifting sands of healthcare, you'll find no better place than the nonprofit provider track during the infamous JP Morgan Healthcare Conference that took place this week in San Francisco.

Over 40,000 players were in town from every corner of the healthcare ecosystem. However, if you want to hear the heartbeat of what's happening at ground level, you needed to literally squeeze into the standing room only nonprofit provider track where the CEOs and CFOs of 25 of the most prominent hospitals and healthcare delivery systems in the country shared their perspectives in rapid-fire 25 minute presentations.

This year those presenters represented over $300 billion, or close to 10 percent of the annual healthcare spend in U.S. healthcare. These organizations play a truly unique role in this country as they are integrated into the very fabric of the communities that they serve and are often the single largest employer in their respective regions. In other words, if you work in or care about healthcare, understanding their perspective is a must.

Every year I take a shot at condensing all of these presentations into a set of takeaways so healthcare providers who aren't in the room can share something with their teams to help inform their strategy. So what do you need to know? Glad you asked, here you go.

Shift Happens — Moving from Being a Healthcare Provider to Creating a Platform for Health and Healthcare in Your Community

Trying to synthesize 25 presentations into a single punch line is pretty stressful. I listened to every presentation, debriefed with other healthcare providers in the audience afterwards and then spent the next 48 hours trying to process what I heard. I was stumped.

But then, finally, it hit me. To take a new spin on an old phrase, "It's the platform, stupid." To be clear, even though I've been in healthcare for close to 30 years, "stupid" in that sentence is absolutely referring to me.

So the No. 1 takeaway from the 2019 JP Healthcare Conference is this — for healthcare providers, there is a major shift taking place. They are moving from a traditional strategy of buying and building hospitals and simply providing care into a new and more dynamic strategy that focuses on leveraging the platform they have in place to create more value and growth via new and often more profitable streams of revenue. Simply stated, the healthcare delivery systems of today will increasingly leverage the platform and resources that they have in place to become a hub for both health and healthcare in the future. There is a level of urgency to move quickly. Many feel that if they don't expand the role that they play in both health and healthcare in their community, someone else will step in.

Folks in tech would think of this as the difference between a "product" strategy (old school) and a "platform" strategy (new school). Think of this as the difference from cell phones (Blackberry) to smartphones (iPhone and Android devices). One was a product, the other was a platform. Common platforms that we're all familiar with such as Facebook, Amazon, Google, Apple and even Starbucks have always 1) started with a very small niche, 2) built an audience, 3) built trust and 4) then added other offerings on top of that platform. By now there is no need for a "spoiler alert." We all know that this strategy works and these companies have created a breathtaking amount of value. The comforting news for hospitals and healthcare delivery systems is that many have already completed the first three steps and have many of the building blocks they need to leverage a "platform" as a business strategy. The presentations at the JP Morgan Healthcare Conference made it clear that most are now actually taking that fourth step to separate themselves from the pack.

There is enormous upside to those who understand this pivot and take advantage of this change in the market. Dennis Dahlen, CFO of Mayo Clinic, shared his perspective on this: "Thinking differently in the future is essential. In many ways, at Mayo, we are already operating as a platform today, but we have to continue to leverage this approach to uncover additional ways that we can be a hub for both health and healthcare in our community." Mayo's platform includes leveraging research, big data, expert clinic insights and artificial intelligence to create new value for Mayo's clinical practice as well as new opportunities for Mayo's partners.

To be clear, the mental shift here is massive. It's the difference of being on defense (where most healthcare providers are) to be being on offense (which is where they know they need to be). Executive teams have focused their time, energy and resources on driving and supporting inpatient admissions via a traditional bricks and mortar presence coupled with the acquisition of physician practices. The difficulty of thinking through what it means to truly be "asset light" and taking a different approach shouldn’t be underestimated. The good news is that the recent financial results of many health systems have improved, providing a little breathing room for investments to enable this shift in strategy. Those who don't may fall way behind. 

A New Way of Thinking — What it Means to be a Hub

Being a hub is essentially bringing together people with common interests to spark innovation and facilitate work getting done more efficiently. Examples include Silicon Valley as a "tech hub," Los Angeles as an "entertainment hub," New York as a "financial hub," Washington, D.C. as a "hub for politics" and how essentially every college town is or can become a "research hub."

Given that hospitals and health systems are the largest employers in their community, they are already set up to become a hub. In the past, they leveraged that position to simply care for the sick. Increasingly in the future, these organizations will be health and healthcare hubs for innovation and building new companies, for bringing the community together to tackle issues like hunger and homelessness, for education and training, for research and development partnerships, for coordinated, compassionate and longitudinal care delivery for treatment, for support groups for specific chronic conditions, for digital and virtual care, and for thoughtful and effective support for mental and behavioral health. Changes in the care delivery market over the last 10 years have put the right building blocks in place to make this happen.

Hiding in Plain Sight — The Single Biggest Change in Healthcare We May Ever See Has Already Happened

Taking advantage of becoming a hub and leveraging the strategic concept of being a platform requires new thinking, new structures and new skill sets. The great news for healthcare providers is they have already made the toughest move of all in order to set this in motion.

Over the last decade, there has been a massive level of consolidation with hundreds of hospitals and thousands of physician practices being acquired every year. While more mergers and acquisitions will still happen, this stunning and fundamental restructuring of healthcare delivery has taken place and there is no turning back. This is likely the single biggest shift relative to how healthcare is structured in this country that will take place during our lifetime, and it barely gets mentioned. The strategy many were chasing was primarily being driven by a "heads in beds" pay-off that was both based on offense ("an easier way to grow") and defense ("we better buy them before someone else does"). That said, as this consolidation happened most healthcare delivery systems were really just an amalgamation of stand-alone hospitals set up as a holding company that provided no real leverage other than more top-line revenue.

During the JP Morgan Healthcare Conference, it was clear that most have made the shift from a holding company into a single operating entity. Chicago-based Northwestern Medicine shared a very refined playbook for quickly bringing acquisitions onto their "platform," and the results are pretty stunning as they have transformed from a $1 billion academic medical center into a $5 billion regional healthcare hub in a handful of years.

And over the last few years, these organizations have gotten super serious about making the toughest decisions right away. The mega-merger of Advocate Health and Aurora Health, the largest healthcare delivery systems in Illinois and Wisconsin respectively, was accompanied by a gutsy decision to fast-track the implementation of Epic at Advocate to get the leverage of a single EHR platform across the system. While many focus on the cost of the transition and the shortcomings of some of the applications, what gets missed is the enormous long-term leverage this provides regarding communication, integration, continuity of care and, of course, access to data and the potential to improve clinical and financial performance. This creates a "platform-like" experience for both employees and customers. 

So, the twist in the story is that the pay-off for consolidation will likely be very different and perhaps much better than many had originally intended. They have the building blocks in place to be a health and healthcare platform for their community. But now they need to figure out how to truly take advantage of it.

Your Action Plan — 6 Ideas from 25 Healthcare Delivery Systems on How to Leverage Your "Platform"

During their presentations the 25 non-profit provider organizations opened up their playbooks on how others can leverage their platforms and the idea of becoming the hub for health and healthcare in their respective communities. Here is what they shared.

1. Create the Digital Front Door — or Someone Else Will

The big shift in play right now is the moving away from traditional reliance on transactional face-to-face interactions with individual providers. Building relationships and trust is something that has been a core competency and core strategic asset for hospitals in the past. In the future, this simply won't be possible without leveraging digital platforms as we do in every other aspect of our lives today. As Stephen Klasko, MD, CEO of Philadelphia-based Jefferson Health, shared, the real strategy will be to deliver "health and healthcare with no address."

Many provider organizations are moving aggressively to create digital front doors. Kaiser Permanente delivered 77 million virtual visits last year. Intermountain introduced a virtual hospital that provides over 40 services and has delivered over 500,000 interactions. Nearly every health system leverages MyChart or a similar personal health record platform. There is an enormous amount of risk for hospitals and health systems that don't take action here, as traditional healthcare providers will be competing with more mainstream and polished consumer brands for the relationships and trust of the folks in their community.

As the team from Spectrum Health shared, "87 percent of Americans measure all brands against a select few — think Amazon, Netflix and Starbucks." Google, Apple and Facebook as well as Walgreens or CVS are all going after this "digital handshake," and are big threats to healthcare providers. There is no question that some of these organizations will be "frenemies," where they are both competing and collaborating. Healthcare organizations will need to approach any partnerships mindful of that risk.

2. Drive Affordability and Reduce Cost — or Risk Being the Problem

As the burden of the cost of care increasingly shifts to the patient's wallet, healthcare providers will need to play in driving affordability. Coupled with the recent federal requirement to post prices online, there is a great deal of visibility around the price of care, even if the numbers are way off the mark. Understanding and reducing the total cost of care is now viewed as a requirement. As legacy cost accounting applications relied on charges as a proxy for cost and were limited to the acute care setting, most provider organizations have or are now in the process of deploying advanced cost accounting applications with time-driven and activity-based costing capabilities including a number that presented during the conference, such as Advocate Aurora Health, Bon Secours Mercy, Boston Children's Hospital, Hospital for Special Surgery, Intermountain Healthcare, Northwestern Medicine, Novant Health, Spectrum Health and Wellforce.

This was one of the hottest topics during the conference, and there was significant buzz regarding having a single source of truth for the cost of care across the continuum. Vinny Tammaro, CFO of Yale New Haven Health, commented, "We need to align with the evolution of consumerism and help drive affordability in healthcare. How we leverage data is mission critical to making this concept a reality. Bringing clinical and financial data together provides us with a source of truth to help both reduce the cost of care as well as reallocate our finite resources to high impact initiatives in our community." Organizations like Intermountain Healthcare, which implemented a 2.7 percent price reduction in exchange pricing, are taking the next step in translating cost reduction into lower prices for consumers. And now healthcare systems are starting to work together to create additional leverage via Civica Rx, which now includes 750 hospitals joining forces to help lower the cost of generic drugs.

3. Tackle Social Determinants of Health — or You Won't Be the Hub for Health in Your Community

It is always less expensive to prevent a problem than it is to fix it. The good news is that the economic incentives for hospitals and healthcare delivery systems to both think and act that way are beginning to line up. They are certainly there already for providers that are also health plans such Intermountain, Kaiser Permanente, Providence St. Joseph Health, Spectrum Health and UPMC. They are also in place for providers that have aggressively taken on population-based risk contracts such as Advocate Aurora Health. With that said, it feels like every health system is starting to lean in here — and they should.

Being the central community hub for these issues makes a ton of sense. The way that Kaiser framed it is that while they have 12 million members, there are 68 million people in the communities they serve. Taking that broader lens both allows them to make a bigger impact but also broaden their market. Many organizations, such as Henry Ford Health System, are taking on hunger via fresh food pharmacies. Geisinger shared how a 2.0 reduction in Hemoglobin A1c reduction leads to a $24,000 cost reduction per participant in their fresh food "farmacy." So while hospitals are perfectly positioned, have the resources and know it's the right thing to do, they are now also beginning to understand the business model tied to targeting the social determinants of health. There is also strong strategic rationale associated with taking on a broader role of driving health versus only providing healthcare.

4. Create Partnerships for Healthcare Innovation — or Lose the Upside

Spectrum Health has a $100 million venture fund. Providence St. Joseph's Health announced a second $150 million venture capital and growth equity fund. Mayo Clinic Ventures has returned over $700 million to their organization. Jefferson Health has a 120-person innovation team focused on digital innovation and the consumer experience, partnering with companies to build solutions. These are all variations on a theme as virtually every organization that presented is leveraging their resources to make a bigger impact and drive additional upside from their platform. "We have close to 900 agreements with over 500 partners," stated Sanda Fenwick, CEO of Boston Children's Hospital. "Our strategy is to be a hub for research, innovation and education in order to help evolve how care is delivered. This can only be done by collaborating with others."

5. Become the Hub for Targeted Services and Chronic Conditions — or They Will Go Elsewhere

Perhaps the best example here is the work of Hospital for Special Surgery, the largest orthopedics shop in the world. It has become a destination for good reason — fewer complications, fewer infections, a higher discharge rate to home and fewer readmissions. The most compelling data point is that when patients come to HSS for a second opinion, one-third of the time they receive a non-surgical recommendation. The same type of shopping is increasingly going to happen for chronic conditions.

Healthcare delivery systems that take a more holistic yet targeted approach have significant potential. They will need to think more deeply about the end-to-end experience and become immersed within the community outside of the four walls of the hospital. Other players in the community, such as CVS Health and Walgreens, would say they have a platform — and they would be right. The platform that healthcare providers have built and are building will absolutely be competing against other care delivery platforms.  

6. Leverage Applied Analytics — or You'll Lose Your Way

In order to enable everything listed above, the lifeline for every health and healthcare hub will be actionable data. Applied analytics is a boring term that is actually gaining traction and starting to dislodge buzzwords like big data, machine learning and artificial intelligence relative to its importance to healthcare providers.

Similar to how analytics are being used in a practical way in baseball to determine where to throw a pitch to a batter or position players in the field, healthcare providers are pushing for practical data sets presented in a simple, actionable framework. That may seem obvious, but it is simply not present in many healthcare organizations that have been focused on building data warehouse empires without doors to let anyone in. Many organizations, such as Advocate Aurora Health, Bon Secours Mercy and Spectrum Health, have deployed more dynamic business decision support solutions to access better insight into performance and care variation. This allows them to assess opportunities to reallocate resources to invest in more productive ways to leverage their platform.   

While leveraging a platform as a business strategy is new to healthcare providers, the good news is that building blocks are already in place. It's time to leverage that platform to drive better outcomes and more affordable care in the community. And now is the time to get started.

Dan Michelson is the CEO of Chicago-based Strata Decision Technology. Mr. Michelson has authored recaps of JP Morgan Healthcare conferences for the past several years for Becker's. Read his account of the 2018 event here and the 2017 event here.

Presenting non-profit provider organizations during the 2019 JP Morgan Healthcare Conference included the following: AdventHealth, Advocate Aurora Health, Ascension, Baylor Scott & White Health, Bon Secours Mercy Health, Boston Children's Hospital, CommonSpirit Health, Geisinger, Hartford HealthCare, Henry Ford Health System, Hospital for Special Surgery, Intermountain Healthcare, Jefferson Health, Kaiser Permanente, Mayo Clinic, Memorial Sloan Kettering, Northwell Health, Northwestern Medicine, Novant Health, Oregon Health & Science University, Providence St. Joseph Health, Spectrum Health System, SSM Health, University of California Health, UPMC and Wellforce.

Source Article from Blue Zones | Comments Courtesy of Matt Zavadsky

Interesting article from an organization committed to helping people live healthier lifestyles. 

The findings in the referenced studies is not very dissimilar to those found in the EMS Fatigue study by Daniel Patterson, et. al.; the evidence-based guidelines to reduce fatigue in EMS workers, and the NHTSA guidance on fighting fatigue in EMS.

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Is Not Sleeping the New Smoking?

By Joel Frohlich, science writer and postdoctoral researcher studying consciousness in the laboratory of Martin Monti at the University of California, Los Angeles. He is also editor in chief at Knowing Neurons. 

Down with the larks: on the virtues of sleeping like a sloth

In the sixth century, Pope Gregory I compiled an infamous list of seven deadly sins. Of these seven, sloth is the only sin that shares its name in English with an animal. But are these curious animals truly guilty of vice?

Sloths personify laziness in Western culture through a reputation for sleeping a lot (though they actually sleep for less than 10 hours a night in the wild). Indeed, seen through the value system of medieval Catholicism, this cute, tree-loving mammal must really be a demonic Snorlax hellbent on dragging humanity into a sleepy damnation.

But is slothfulness actually wrong? If slothfulness means avoiding responsibility and failing to accomplish important, meaningful goals, then most likely yes. However, if slothfulness means getting more than seven hours’ sleep a night to improve health and increase productivity, then surely there’s nothing wrong with that.

A Gallup poll in 2013 found that Americans sleep, on average, 6.8 hours a night, with 40 per cent getting less than the recommended minimum of seven hours.

According to Nationwide Children’s Hospital in Ohio, teenagers get a little more than seven hours of sleep a night, while actually needing at least nine. Yet society continues to function … if only like a frail, untuned clock.

According to the sleep neuroscientist Matthew Walker at the University of California at Berkeley: ‘The number of people who can survive on six hours of sleep or less without measurable impairment, rounded to a whole number and expressed as a per cent, is zero.’ In fact, most adults need between seven and nine hours of sleep per night to be healthy.

Sleep Deprivation and its Effect on Cardiovascular Health, Mental Health, Alzheimer’s Disease, Immunity, Cancer

Not convinced? To really appreciate human sensitivity to sleep, consider daylight savings time (DST). Each year, millions of people lose an hour of sleep when clocks ‘spring forward’ on the first Sunday of DST. Like a cruel experiment, we watch the health consequences of this spring forward: heart attacks and even suicides spike the following week as bodies are put under stress by the sudden change.

Though it might feel like we aren’t doing anything when we sleep, nothing could be further from the truth. During sleep, the fluid-filled ventricles of the brain open so that deadly toxins – including the amyloid plaques that cause Alzheimer’s disease – can drain.

Volunteers who were kept awake for 31 hours straight showed huge spikes in the Alzheimer’s causing molecule compared with well-rested participants. The implications are clear – pulling an all-nighter is hardly harmless.

Beyond staving off Alzheimer’s, sleep generally strengthens the immune system and protects us against cancer. Because our daily sleep cycle, or circadian rhythm, appears to regulate many biological functions, a night of light sleep throws a wrench into the gears of health and rejuvenation.

Moreover, we often fail to take sleep deprivation as seriously as alcohol intoxication, even though both immediately impair our behavior and cognition. According to Walker: ‘After 20 hours of being awake, you are as impaired cognitively as you would be if you were legally drunk.’ Driving after being awake for 24 hours straight gives similar levels of impairment as driving with a blood alcohol concentration of 0.1, higher than what is considered over the legal limit in many jurisdictions.

Walker, the author of the book Why We Sleep: Unlocking the Power of Sleep and Dreams (2017), also points to what is perhaps the most appalling irony of all: that doctors – the very people who are supposed to be caring for our health – are often complicit in creating today’s sleep-deprived culture. New medical residents serve 30-hour shifts, and this sleep deprivation affects not only them but also their patients. Indeed, Walker states that: ‘Residents working a 30-hour shift are 460 per cent more likely to make diagnostic errors in the intensive care unit relative to when they’re working 16 hours.’ Doctors’ lack of sleep might literally be killing patients.

We have a cultural problem in the West. From bosses to self-help gurus to school administrators, responsible and otherwise intelligent people who should know better advocate that we sleep less and accomplish more.

Even when we’re not explicitly told to sleep less, advice that often passes for wisdom leaves little space for eight hours of sleep a night. Consider the retired US Navy SEAL, author and podcaster Jocko Willink, who relentlessly encourages his followers to wake up before the crack of dawn. Sure, waking up at 4:30am and hitting the gym can be a healthy habit – if you’re in bed by 9:30pm. Willink himself goes to sleep around 11pm or midnight, but admits that more sleep is healthier.

‘We are with sleep where we were with smoking 50 years ago,’ Walker said on a recent podcast. ‘We had all of the evidence about the … disease issues, but the public had not been aware, no one had adequately communicated the science of, you know, smoking to the public. The same I think is true for sleep right now.’

As we plough recklessly through the night, coffee cup in one hand and smartphone in the other, we curse sleep while slumbering in a deeper, mental sense. True slothfulness isn’t sleeping eight hours a night – it’s ignoring our health and taking on important responsibilities in an underslept state. As we update our values based on empirical evidence, it might be only a matter of time before society appreciates the true wisdom of the sloth.

This is an adaptation of an article originally published by Knowing Neurons and Aeon.

Business Insider / Reuters Source Article | Comments Courtesy of Matt Zavadsky

Interesting study – perhaps a good time to review decontamination processes...

Tip of the hat to healthcare and EMS icon Don Jones for sharing this story!

Ambulance equipment contaminated with drug-resistant superbug

Jan. 4, 2019

By Manas Mishra

(Reuters Health) - Ambulance oxygen tanks are likely to carry the "superbug" MRSA, a small U.S. study suggests, pointing to the need for regular disinfection of medical equipment.

Researchers tested nine oxygen tanks carried by three ambulances based at an emergency medical services (EMS) station in Alabama. They found MRSA, or methicillin-resistant Staphylococcus aureus, on all nine tanks.

They also swabbed oxygen tanks in a storage area, finding MRSA on 96 percent of the stored cylinders.

MRSA infections are difficult to treat because the bacteria are resistant to common antibiotics. Although usually mild, MRSA infections still cause thousands of deaths each year.

Other equipment on the ambulances, such as heart monitors and blood pressure cuffs, tested negative for MRSA contamination. But the floor of all three ambulances and a door handle in one ambulance tested positive.

"Oxygen cylinders are exchanged pretty rapidly between facilities, they (need) to be refilled, they're not like normal pieces of medical equipment or supplies, which are disposable," study author Cody Gibson, who was with Calhoun Community College when the study was conducted, told Reuters Health over the phone.

Because oxygen tanks are exchanged between facilities, the bacteria could spread across large areas, Gibson notes in the Emergency Medicine Journal.

The presence of MRSA on the tanks could be due to a lack of universal disinfection protocols for oxygen equipment, said Gibson, who is now at the University of Alabama at Birmingham.

Most ambulance equipment is disinfected after each patient because of company protocol or as directed by regulatory authorities, but oxygen cylinders could oftentimes be overlooked.

Gibson interviewed EMS personnel and found the staff was not aware of when the oxygen cylinders were last disinfected, while other surfaces that patients contacted were regularly decontaminated with disinfectants.

Dr. David Tan of Washington University in St. Louis, Missouri, who is President-Elect of the National Association of EMS Physicians, told Reuters Health, "While it would be safe to say there is no 'universal' protocol for disinfection of an ambulance, there are a number of guidelines available for agencies to develop their own policy and procedure for ambulance disinfection."

"MRSA exists in firehouses and EMS stations as well," Tan said, "and the challenge is finding universally effective disinfection procedures and techniques that are both effective and efficient, especially in busier EMS services where there is constant system pressure to get back in service to answer the next call for help."

Dr. Michael David, assistant professor of Medicine and Epidemiology at the University of Pennsylvania's Perelman School of Medicine in Philadelphia, said contamination of ambulance oxygen cylinders is not widely discussed.

"This paper raises the problem of these specific objects being contaminated by MRSA and resulting in a previously unaddressed reservoir of MRSA in ambulances," he told Reuters Health. "This observation importantly may result in new standard procedures to clean these objects with an antiseptic between uses."

The study didn't look at actual transmission rates, so it's unclear whether anyone actually became infected from bacteria on these tanks. Also, Gibson points out, the samples only came from a single EMS station, and at only one point in time.

Still, he concludes, "Oxygen cylinders appear (likely to carry) MRSA. The development of universal disinfection protocols for oxygen equipment could help reduce the risk of patient infection due to cross-contamination."

SOURCE: http://bit.ly/2QgqJX5

Emergency Medicine Journal, online December 1, 2018.

FierceHealthcare Source Article | Comments Courtesy of Matt Zavadsky

Interesting summary in Fierce Healthcare about the study published in JAMA.

May highlight the importance of safe care transitions from hospital to home – a role an increasing number of EMS agencies are providing in mobile integrated healthcare partnerships with hospitals and health systems.

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Link between readmission rates, mortality rates back under scrutiny

by Matt Kuhrt | 

Jan 2, 2019 7:20am

A new study shows a statistically significant correlation between lower readmission rates and higher mortality rates for patients with heart failure and pneumonia, renewing questions about the efficacy of the Center for Medicare and Medicaid Services' Hospital Readmissions Reduction Program (HRRP).

The new study, published in JAMA, looked specifically at changes in mortality rates in the 30- and 45-day periods after discharge for patients suffering from heart failure, heart attack or pneumonia. The 30-day data showed accelerated mortality rates for those with heart failure or pneumonia, though the 45-day data did not.

The HRRP has come under previous scrutiny for potentially raising mortality rates by offering hospitals a perverse incentive to reduce admissions in ways that don’t necessarily meet the patient’s best interest, such as discharging them after emergency room treatment or placing them in a temporary observation unit rather than readmitting them. In other studies, however, the program’s success at reducing overall readmissions has been hailed as broadly effective.

While the study’s limitations don’t necessarily indicate a causal relationship between the HRRP and the higher mortality rates, it does raise some potential red flags, according to Rishi Wadhera, M.D., a cardiology fellow at Brigham and Women’s Hospital and the study’s lead author.

Wadhera notes that the increase in mortality rates comes amid troubling context. While post-discharge deaths for heart patients with heart failure had already begun to increase in the years prior to the HRRP, the trend actually accelerated after the program was established. At the same time, the increase in mortality rates for pneumonia patients followed a period of stability in the years prior to the HRRP. Those conditions also saw significant decreases in the number of readmissions after discharge.

Whether hospitals are acting in ways that don’t necessarily benefit patients remains an open question, but Wadhera sees important lessons in the lack of clarity around how the program actually functions.

“I think one of the issues is we really haven’t done a deep dive into how physicians and hospitals have responded to the HRRP,” he said. “All we’ve really observed are the decline in admission rates and we’ve assumed that that was due to improvements in quality of care, but we don’t actually know that.”

Given the potential for unintended harm, Wadhera believes policymakers should slow down and take a more measured approach. “Our takeaway from the findings is that the HRRP should not be expanded to all hospitalized conditions, which is what some policymakers have advocated for recently, and that we should be more cautious before widespread expansion of the program.”

The findings also offer useful lessons for developing nationwide incentive-based quality programs in the future, Wadhera said. 

At the very least, he recommends more limited pilot programs or randomized studies before rolling programs out nationwide. In cases where that’s not possible, he recommends specifying analyses to identify potential unintended consequences before implementation, and monitoring after implementation with well-defined stop-loss thresholds if that analysis uncovers a signal of harm.

“The HRRP teaches us about the importance of evaluating policies rigorously before we implement them nationwide, and I think CMS and specifically the Centers for Medicare and Medicaid Innovation, which have some leeway to test policies, could really take the lead on evaluating policies before they’re implemented nationwide,” Wadhera said.

D Magazine Source Article | Comments Courtesy of Matt Zavadsky

Interesting outcome that may have implications across the country for emergency medical care providers.  Another signal that we should be partnering with payers on payment models that bring enhanced value to the patient, the provider, and the payer.

For our EMS brethren, note the reporter’s use of the term ‘emergency medical services’ to refer to the care received in the ED. 

NHTSA and the Red Flash Group are embarking on a project seeking input on terms that most accurately reflects the services provided by out-of-hospital medical care providers working on ambulances and First Response vehicles. 

NEMSAC and some professional organizations have recommended use of the term “paramedicine” as the services we provide, whereas “EMS” in its purest sense was originally intended to represent a ‘system’ of care, including pre-hospital, inpatient and post-hospital care.

We encourage all who are invited to provide input into this project to do so.

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Judge Dismisses Blue Cross Lawsuit Over Low Reimbursement Rates

12/21/2018| by Will Maddox|

A federal judge has dismissed a lawsuit against Blue Cross Blue Shield of Texas by 49 physician groups that claim the insurer is not paying enough for emergency medical care.

The groups argue  there are 250,000 claims where Blue Cross’ reimbursement rate for out-of-network providers violates Texas insurance laws and regulations.

In an emergency, patients are brought to the nearest hospital, which might not always be in network. “As out-of-network providers, the Provider Entities are not contractually bound to accept discounted rates of payment for the emergency medical services they provide to BCBSTX Members and instead expect to receive their billed charges for these services,” the lawsuit reads.

The 49 complainants, who come from all over the state, say that there have been hundreds of thousands of out-of-network claims where Blue Cross has underpaid. “Rather than pay the true and accurate bill generated by the Provider Entities, BCBSTX has knowingly lowered the reimbursement rate allowed for ‘out-of-network’ care to levels below what member plans and applicable regulatory authority require. BCBSTX paid most of these claims at a net payment rate that is significantly less than what the Provider Entities are entitled to receive as out-of-network providers.”

The lawsuit also highlights past action taken against Blue Cross by the Texas Department of Insurance. “TDI found that Blue Cross set its allowable amounts for out-of-network providers at ‘unreasonably low rates that are less than the amounts billed by facilities and also less than the rates paid to BCBSTX contracted facilities.’ TDI also stated that Blue Cross’s “reimbursement rates are so low as to violate Texas insurance laws and regulations.”

Judge Karen Gren Scholer of the U.S. District Court for the Northern District of Texas dismissed the case without explaining the decision, and the physicians have 60 days to file a new complaint with additional support. Due to the appeals process, Blue Cross Blue Shield of Texas had no comment.