The Truven Health Blog

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

 

Care Coordination Under Medicare

By Truven Staff
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

Reducing Readmissions Must be Addressed Across the Care Continuum

By Truven Staff
Byron Scott imageA lot of attention has been given to hospital readmissions in recent years, and the establishment of a readmission outcome measure by the Centers for Medicare & Medicaid Services (CMS) in value based purchasing has incentivized hospitals to work diligently on the problem. The recent article in Kaiser Health News about Beth Israel Deaconess highlights the challenges and obstacles we must overcame to reduce readmissions. The reasons to address this issue go beyond the cost of it. One reason alone should be to improve the overall quality by preventing the re-exposure of a patient to the hospital environment where they can be subject to hospital-acquired infections and other safety concerns, such as falls.

For some of the top readmission diagnosis like Heart Failure and Pneumonia, the biggest obstacles to reducing readmissions have been not what goes on in the hospital, but what occurs when the patient is discharged. It really involves more about the psychosocial aspect of healthcare than the science of the disease and treating it. When the patient is discharged after a heart failure exacerbation, the medical component is typically stabilized. The failures often occur in the process, communication, and overall care coordination. 
  • Was the follow-up outpatient procedure scheduled before discharge?
  • Is a family member or caregiver aware of the follow-up appointment?
  • Can the family member or caregiver drive the patient to the follow-up appointment? 
  • Did the patient receive the proper diet instructions before discharge?
  • Do they have the resources at home to help comply with the dietary guidelines?
  • Can the patient afford the prescribed medications, and does the patient understand the instructions for taking their medications?
  • If the patient needs outpatient intravenous antibiotics, were home health services arranged? 
These are some of the questions that must be asked in order to reduce the risk of readmission.

Hospital systems and hospitals that have been successful in reducing readmissions have ensured a coordinated team of visiting nurses, social workers, pharmacist, and case workers all work together to coordinate the process, education, follow-up visits, and overall answers to questions that may come up to family and patients. The future of our healthcare system  will be tied to coordinating care using an overall population health analytics system that not only tracts information across inpatient and outpatient settings, but also enables all care providers to communicate more effectively, tying in real time surveillance, monitoring, and alerts. Therefore no matter where the patient is along the continuum (inpatient, outpatient, emergency department, or home) and whoever is interacting with the patient, information is constantly brought together and communicated to improve the health of the patient and reduce risk of readmission for high risk patients and chronic disease.

Byron C. Scott, MD, MBA, FACPE
Medical Director, National Clinical Medical Leader

Maternity Care the Ideal Setting for Evidence-Based Practice and PCP/Specialty Collaboration

By Truven Staff
Michael R. Udwin imageThe recent Crain’s New York Business article “Birthing biz booms for hospitals,” captures the complex dynamic of balancing hospital service lines to support revenue, manage costs, and ensure the well-being of a community – in this case mothers and babies. Successfully managing these three objectives requires strong leadership and evolving business intelligence resources. As negotiated reimbursement rates shift from volume to value, it won’t be enough to merely focus on high-margin procedures. 

The best hospitals and health systems recognize the importance of integrating clinical pathways that invite evidence-based practice from both primary care and specialty providers. Maternity care is an ideal setting for such collaboration, since the stakes are so high. Rapid identification of high-risk mothers can not only ensure the health of the mother, but also the well-being of the newborn, with a reduced likelihood of needing to use neonatal intensive care resources.

Effective care coordination for any service line depends on timely, accurate and actionable data across the care continuum. Accomplished leaders leverage such intelligence to identify gaps in care, quality below expectations and costs attributable to inefficiencies. As negotiated reimbursement rates shrink, penalties for avoidable events expand and transparency to consumers evolves, healthcare data will be the medium by which we not just measure our achievements, but ensure the health and well-being of our collective mothers, babies, and families.

Michael R. Udwin, MD, FACOG
National Medical Director

Shifting the Data-Sharing Mindset for the At-Risk Healthcare Environment

By Truven Staff
Larry Yuhasz imageThe shift from fee-for-service (FFS) to at-risk reimbursement also represents a shift from siloed data sources and facilities to physician-driven networks that need to be connected with patient-centric decision support and work flow applications. In the FFS world, health systems and health plans often thought of patient data as a strategic asset to help recruit and retain both physicians and patients to their networks and services. Yet, in the at-risk world, the more data available about the patient, the better the ability to manage risk and coordinate care. The change in mindset from controlling patient data to allowing it to flow freely (albeit, securely) across networks is a radical transformation in the U.S. healthcare system. The three key barriers to overcome are business model, proprietary data formats and governance.

At the business model level, as health systems, providers, and payers form new at-risk arrangements, they need to under gird those arrangements with the relevant flow of administrative and clinical data to manage performance and risk. Health plans that have been reticent to share claims data need to shift gears both culturally and operationally to help the new provider-driven networks understand costs.

In terms of format, the Federal government has been trying to stimulate interoperability standards through the ARRA HITECH roll out, but many vendors (particularly EMR vendors) have been fighting back to defend their proprietary data formats. As the volume of at-risk contracts grows, new at-risk entities will not be able to function without some form of interoperable gateway to share and receive patient data. So that means that EMR customers will be the ones to request and implement interoperable gateways from their vendors. And if they continue to resist, there is a new generation of interoperability platform vendors that will fill the need.

Finally, from a legal perspective, no one entity actually “owns” the patient data. The patient owns his/her own data. Yet this creates a quagmire of governance models that is bogged down in consent management policy and privacy mechanisms. If patients do not allow an at-risk network to see their data, the network cannot optimize performance. So we may see a new market dynamic whereby network participation requires upfront patient consent to data sharing (an opt-out consent model).

Larry Yuhasz
Director for Strategy and Business Development

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