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The Truven Health Blog


The latest healthcare topics from a trusted, proven, and unbiased source.


Sharing Quality Insights With Providers


By Michael L. Taylor/Tuesday, August 18, 2015

BlueCross/Blue Shield of Illinois (BCBSIL) recently announced a new data sharing arrangement with the DuPage Medical Group, a large independently owned physician medical group in the Chicago area.  This arrangement calls for BCBSIL to share its medical claims and (unnamed) quality data with physicians of the DuPage Medical Group. These data will help the physicians better understand the healthcare services their patients are receiving outside the DuPage clinic walls, including the quantity and quality of care their patients are receiving from non-DuPage physicians.

This information is becoming more important to physicians as their reimbursement for services provided is increasingly tied to patient outcomes. The Blues organization also announced their goal of having 75% of their Illinois market to be paid on the basis of improved quality and lower costs within the next 5 years. This trend has been driven by the Center for Medicare and Medicaid Services (CMS), with HHS Secretary Burwell announcing the 2018 CMS target of 50% of payments based on value, and 95% of fee for service payments having a quality component as part of the payment.

We are likely to see many other arrangements similar to the BCBSI deal in the commercial market over the coming months and years. The country is gradually realizing that fee for service payment arrangements become an incentive to provide more care, while value based payment models incent higher quality care.

Rewarding higher quality care and penalizing poorer quality care is a step in the right direction, and for certain elements of care, quality can be readily measured. For example, for most common surgical procedures, standards have been developed to measure complications, length of stay, hospital-induced infections, mortality and other discrete endpoints. It may not be as straightforward to measure quality of care in the primary care settings, but quality can be measured.

An interesting article published in 2012 in The New England Journal of Medicine offered a framework for measuring system-related quality of care. The authors suggested 6 domains of quality that could be measured:

  1. Patient safety
  2. Patient and caregiver-centered experiences and outcomes
  3. Care coordination
  4. Clinical care
  5. Population and community health
  6. Efficiency and cost reduction

This framework may be well suited to measure the effectiveness and quality of care being delivered in the primary care setting, and these efforts need to be supported. Hopefully this BCBSIL and DuPage Medical Group partnership will spur other large carriers to try similar arrangements with hospitals and physicians. Combining cost metrics with quality metrics can deliver the type of transparency that is lacking in today’s fee for service world. The payer community has been asking for this type of transparency, and consumers are now asking for the same information.

I’m hopeful the metrics agreed upon will be shared publicly.  It will be interesting to follow this new arrangement over time to see if the quality metrics are robust, and if patient care actually improves.

Michael L. Taylor, MD, FACP
Chief Medical Officer

 


Inpatient Medical Care Transitions


By Michael L. Taylor/Monday, April 20, 2015

One of the architects of the Affordable Care Act, Ezekiel Emanuel, has famously said, “We don’t need 5000 hospitals.” For several years, the number of inpatient admissions has been declining, and that trend is not likely to change. According to the American Hospital Association, 27 hospitals permanently closed their doors in 2014. Inpatient days have declined by 5% over a recent 4 year period, and the US hospital occupancy rate is down to 60%. There are myriad reasons for this decline, including the shift to outpatient centers for many procedures, fewer elective surgeries, declining length of stay, and more patient awareness of other options.

Other factors include the readmission penalties instituted by CMS, the increase in “observation” stays, and the growth of high deductible health plans with the resulting shift of costs to employees.  A newer driver of the fall in hospital days and services utilization is the move from Fee for Service (FFS) to more shared risk/reward strategies. As Accountable Care Organizations (ACOs) and similar arrangements become larger and more prevalent, hospitals will see payment reform impacting all lines of services. Under the FFS form of payment, high tech services were revenue generators, and hospitals were incented to build more MRIs and cardiac catheterization labs. Due to payment reforms, these services now are cost centers, and hospitals are urgently seeking new ways to manage their costs. 

Many communities across the country have an excess number of beds given the falling demand, so hospitals will find other uses for these extra beds – or close them.  Shedding unneeded capacity should help hospitals run more efficiently and decrease redundancies in many markets. Hospitals can use data to decide how many services are needed, and can build facilities based on need, rather than as a revenue driver. Hospitals need more data to understand the market they serve, to analyze the efficiency of the services they provide and the quality of the service lines they do keep.

An article in the Archives of Internal Medicine looked at non-emergency cardiac stent placement. In this report two cardiologists reviewed the records of 7000 patients who had stents placed as part of 8 different clinical trials. That analysis suggested nearly 2/3 of the stents placed were not needed – which is both a cost and a quality issue. A Truven Health analysis found nearly 30% of the medical spend in the US was unnecessary. Payment reform under the Affordable Care Act is designed to lessen the burden of unneeded care, and as the healthcare delivery system becomes more efficient, the need for hospitals will continue to decline. As hospitals become more efficient, driving out waste and improving quality, we may see the cost curve stabilize and even “bend” in the right direction. 

Michael L. Taylor, MD, FACP
Chief Medical Officer



The CMS Readmission Program — Plus or Minus for Seniors and Hospitals?


By Michael L. Taylor/Thursday, February 19, 2015

Michael Taylor photoAs CMS expands its 30-day readmission penalty program, more financial pressure is placed on hospitals and seniors. This program has driven hospitals to increase the use of outpatient observation services. Inpatient stays are paid by Medicare Part A, but outpatient observation is paid by Medicare Part B which covers only 80 percent of the bill. Here is what is happening in some markets. Let’s say a person is admitted to a hospital for heart failure. The length of stay might be 3-4 days and then the patient is discharged. If that same person has a recurrence of heart failure within 30 days of the initial discharge, the hospital will not be paid for that episode. However, if the 2nd episode is handled under outpatient observation status, the hospital is paid, but the patient (who probably didn’t realize he/she was not admitted to the hospital) receives a bill for 20 percent of the charges. 

This is an issue, but the larger issue is how the law assigns all the risk to the hospital. Perhaps the thought was that poor inpatient care is the cause for readmissions, but the reality is that many other factors not under the hospital's control can drive readmissions. The patient has some responsibility — the patient needs to be compliant with medications, follow up with his/her primary care physician, and follow all discharge instructions. In some cases, a primary care physician might not be available, or the patient might not be able to travel to pharmacies and doctors offices, thus not getting needed follow-up care.

Another issue is that heart failure is a complex clinical condition, and despite the best level of care, sometimes symptoms recur and patients need to be re-admitted. The 30-day provision doesn’t seem fair to hospitals in the case of heart failure; if the patient is readmitted on day 29, the hospital is not paid, but if the 2nd episode occurs on day 31, the hospital is fully paid. The 30-day rule makes more sense for certain surgeries such as hip and knee replacements. With those surgeries, a readmission within 30 days could be avoided.

Given these issues, I believe the 30-day rule should be modified. Certain medical diagnoses could use a “sliding scale” based on number of days since discharge. I don’t think the rule should be dropped, however. This rule is forcing hospitals to consider continuity of care issues, ensuring that appropriate post-discharge planning and care does occur. It also further encourages ACO and patient centered medical home approaches, which are designed to provide continuity.  It discourages fee-for-service approaches, which are typically not structured to provide these services very well. For these reasons, I think the 30-day rule is (and should be) here to stay.

Michael L. Taylor, MD
Chief Medical Officer

Walmart’s Move into Primary Care


By Michael L. Taylor/Friday, September 5, 2014
Mike Taylor imageLast year, Walmart announced a plan to provide full primary care services to consumers nationwide within five to seven years. With its latest announcement, as reported by The New York Times, it now intends to start fulfilling its promise. Starting with six clinics in South Carolina and Texas, Walmart announced its intention to open six more clinics by the end of 2014. Walmart stores are often in rural areas that are medically under served, and they may be leveraging their locations to provide medical services in these under served areas. A big winner in this new development may be QuadMed, the service provider who won the contract to partner with Walmart in this effort.

How Walmart intends to use these primary care clinics isn’t completely clear. The traditional QuadMed model has been to provide comprehensive primary care services and to be the patient’s sole primary care provider. Their clinics typically use primary care doctors, with nurse practitioners supplementing the care. Specialty care is typically referred to the specialists in the community, but QuadMed doctors provide all the primary care, even in the care of complex cases.

But in the Walmart deal, there’s a subtle difference. Nurse practitioners will be providing the care with oversight of physicians, but the physicians won’t actually see patients – just providing oversight. This is a different model that may have implications for Walmart. As reported in The New York Times, the QuadMed Medical Director, Dr. David Severance said, “In that circumstance (complex care patients), it’s our desire to get those individuals established with a primary care provider, preferably a physician within the community.”

This is a different approach for QuadMed. The Walmart clinics won’t be a primary care center, but will employ a nurse practitioner model that uses physician in the community for primary care, in some cases. This model has similarities to the Walgreens and CVS approach of “retail clinics” that provide a limited scope of services and don’t deliver primary care. QuadMed has provided more comprehensive services, that of a patient-centered medical home led by a strong primary care physician. Their clinics have an excellent track record of providing cost-efficient, high-quality care in a timely manner. This new model of care will need to be delivered with a mid-level approach and a partnership with a physician in the community. That may be tricky.

The Walmart approach to delivering outpatient care could fill an important void, especially in under served areas. I was surprised to learn the Walmart clinics will only be open 8:00 a.m. – 5:00 p.m. Monday through Saturday, and 10:00 a.m. – 6:00 p.m. on Sunday. I imagine the hours will expand over time to offer more evening hours to better compete with urgent care centers—especially in Texas, which doesn’t restrict free-standing emergency and urgent care centers. To be successful over time, the clinics will also need to accept their patient’s private insurance; this will be another change in the QuadMed model.

Medical care can be fragmented, with multiple physicians treating the same patients, but not communicating well. This fragmentation can lead to medical errors, inefficiencies and increased cost. The physicians overseeing the Walmart clinics should have a clear method of communicating with other physicians caring for these patients, ensuring all involved are aware of any diagnoses and treatments resulting from the clinic visit. There should also be a method to avoid duplicate lab tests and x-rays – a common problem in today’s medical care community. Well-run centers generally do a better job of using generic prescriptions, managing referrals to specialists, and avoiding unnecessary tests, especially CT and MRI exams. Since the actual care will be delivered by nurse practitioners, not by physicians, close oversight will be important to avoid these pitfalls.

This is a big step for Walmart, and I’m hopeful these clinics perform well. Will Walmart one day be the largest provider of primary care in the U.S.? Don’t be surprised to see that happen.

Michael L. Taylor, MD, FACP
Chief Medical Officer

Care Coordination Under Medicare


By Michael L. Taylor/Wednesday, September 3, 2014
Mike Taylor imageThe recent announcement by the Centers for Medicare and Medicaid (CMS) concerning payment for care coordination is a step in the right direction.

Dr. Matthew Press, an internist in academic medicine, aptly described how demanding excellent care coordination can be. In the August 13, 2014 edition of the New England Journal of Medicine, Dr. Press wrote of his work with a patient (Mr. K.) who had recently been diagnosed with a mass in his liver:

“Over the 80 days between when I informed Mr. K. about the MRI result and when his tumor was resected, 11 other clinicians became involved in his care, and he had 5 procedures and 11 office visits (none of them with me). As the complexity of his care increased, the tasks involved in coordinating it multiplied. I kept a running list and, at the end, created an “instant replay” of Mr. K.'s care (see diagram; also see animation, available with the full text of this article at NEJM.org). In total, I communicated with the other clinicians 40 times (32 e-mails and 8 phone calls) and with Mr. K. or his wife 12 times. At least 1 communication occurred on 26 of the 80 days, and on the busiest day (day 32), 6 communications occurred.”

Dr. Press went on to comment he doesn’t have a full-time practice, but splits his time between teaching and caring for patients, and acknowledged how difficult care coordination can be for a physician practicing medicine full-time.

Many primary care physicians have provided care coordination without compensation, but it’s hoped this policy change by CMS will drive improved outcomes. I should point out that care coordination is an integral part of the patient-centered medical home concept. It’s generally a process used by most organizations that provide care using a team-based concept that is value-based, not based on traditional fee-for–service reimbursement.

There will be challenges.  Most physicians are highly ethical, but there’s a potential for abuse and perhaps even fraud. I can imagine a physician hiring a nurse practitioner to do nothing but make telephone calls to elderly patients with several chronic diseases. The CMS requirement for the patient to agree, in writing, beforehand and the patient footing 20% of the bill should drive accountability, but this new program will require oversight. Is the $42 per month proposed by CMS enough compensation to make this worthwhile? I would expect that smaller practices won’t find this feasible at that rate of pay. The requirement that someone from the medical practice be accessible 24/7 may also give physicians some pause.

Even with the inevitable uncertainties of any new program, I think larger, well-organized practices will find this new policy helpful in caring for some of their most complex patients, and I’m hopeful many practices will integrate care coordination into their management of the care of these patients.

Michael L. Taylor, MD, FACP
Chief Medical Officer

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