GPIN Members in the News

April 23, 2013

A Health Provider Finds Success in Keeping Hospital Beds Empty

By ANNIE LOWREY

CHICAGO - On a stormy evening this spring, nurses at Dr. Gary Stuck's family practice were on the phone with patients with heart ailments, asking them not to shovel snow. The idea was to keep them out of the hospital, and that effort - combined with dozens more like it - is starting to make a difference: across the city, doctors are providing less, but not worse, health care.

For most health care providers, that would be cause for alarm. But not for Advocate Health Care, based in Oak Brook, Ill., a pioneer in an approach known as "accountable care" that offers financial incentives for doctors and hospitals to cut costs rather than funnel patients through an ever-greater volume of costly medical services. Under the agreement, hospital admissions are down 6 percent. Days spent in the hospital are down nearly 9 percent. The average length of a stay has declined, and many other measures show doctors providing less care, too.

This approach is one small part of a growing effort by providers to hold down costs without restricting needed care. Nationwide, health care spending has grown over the last three years at the slowest rate since the federal government started keeping data more than 50 years ago. While the bulk of that is related to the poor economy, changes among insurers and health care providers have contributed as well. If the trend continues, even at a reduced pace, it could help alleviate Washington's long-term deficit problems and ease the strain on family budgets.

"The part that's not driven by the economy, that's the part we can theoretically control," said Drew Altman, president of the Henry J. Kaiser Family Foundation. "If we can shave even a small percentage off of it, it has a huge impact on public programs, a huge impact on premiums, a huge impact on employers."

But even as more health systems seek to replicate Advocate's early success, its experience shows just how hard it may be to expand the approach and keep medical costs from resuming their relentless rise.

"It's hard to imagine that you could start from scratch and do this and be successful in three years, said Dr. Lee Sacks, Advocate's chief medical officer, noting that other systems may find it far harder to flip the traditional fee-for-services system on its head. "We had a running head-start going back to 1995."

Nonetheless, the Affordable Care Act, President Obama's health care law, has helped encourage a shift to Advocate's payment model. Such agreements were merely a theory four years ago. But an estimated 428 accountable-care organizations now cover four million Medicare enrollees and millions more people with private insurance.

Under Advocate's deal with Blue Cross Blue Shield, certain patients are assigned to the accountable care framework - about 380,000 - and their health costs are projected. If Advocate achieves savings below that amount while meeting explicit quality targets, it splits the money with the insurer. If not, its revenue is at risk.

In some ways, accountable care resembles earlier efforts to control medical spending, including the health maintenance organizations that proliferated in the 1980s but fell out of favor, in part because they severely limited patients' choices. But accountable care differs by giving doctors and hospitals a direct financial stake in saving money and a reason to invest in various programs of preventive care rather than relying exclusively on the fees they would normally earn from providing services.

"There's an enormous amount at stake in getting these reforms to work," said Alan Krueger, the chairman of President Obama's Council of Economic Advisers.

To help control costs, Advocate has hired scores of workers to coordinate care and keep an eye on the highest-cost patients, like those who are obese or have diabetes. It started providing doctors' offices with report cards on their performance. Dozens of quality-control measures cover items as varied as blood pressure, rehospitalizations for asthma attacks or the use of expensive imaging machines.

On a blustery spring morning, those changes were visible in Advocate care centers across the metropolitan area. Sumera Khan, a clinical pharmacy specialist, popped into the hospital room of Noraine Scarpelli, an elderly woman with congestive heart failure, to check her prescription drug levels, an additional level of scrutiny that can help prevent complications. In another building, Dr. Karen O'Mara flicked between eight computer screens, peering at intensive care patients miles away, ready to alert a doctor if they looked in distress.

Advocate, a faith-based nonprofit, has an advantage over other health systems just jumping into what is more broadly known as "value-based care." In the late 1990s, well before it forged its contract with Blue Cross Blue Shield, Advocate began taking steps to control costs and improve quality. A decade ago it adopted a "clinical integration" program, requiring doctors to work together on patients in common. It was also a pioneer in the use of electronic health records.

"A lot of these early adopters were systems that were already putting things in place," said Ani Turner of the Center for Sustainable Health Spending at the Altarum Institute, a national health care research group based in Ann Arbor, Mich. "In a way, the contracts are rewarding behaviors they were already pursuing."

So far, Advocate has achieved a small but significant savings of about 2 percent below projected costs, Blue Cross Blue Shield said, but it is not clear whether it can continue to make progress. Already, some Advocate hospital chiefs have expressed fears over losing revenue and warned about the threat to their financial performance. Doctors fret that their incomes may suffer. "We're doing it because it's the right thing to do for patients," said Dr. Stuck, the Advocate family physician. "We're not making more money."

At the same time, Advocate and Blue Cross Blue Shield have no way to prevent patients that fall under the accountable-care agreement from seeing doctors outside Advocate's network. That means patients might see doctors without an incentive to cut costs as well as deliver excellent care, eroding or even erasing the cost savings the agreement achieves.

"You're trying to overlay a payment design onto a benefit model that allows a patient to go anywhere he wants," said Steve Hamman of Blue Cross Blue Shield, noting that patients can undermine the advantages of the new approach if they ignore the advice or insist on unnecessary tests and procedures. "We can talk all we want about provider accountability and how important that is. But there is a measure of patient accountability that is critical as well."

For all the obstacles, most health economists agree that accountable care organizations are one of the most promising recent developments in the giant industry. Kaufman Hall, a consulting firm that studied Advocate's results, said its research showed that the older and the bigger a value-based care system, the more capable it proved at controlling costs - and the more it was able to influence the larger community of health care providers.

"Doctors who practice with Advocate often also practice at other hospitals," said Mark Grube, Kaufman Hall's managing director. "What is occurring is that even when they are practicing at hospitals that are not under value-based contracts, they've changed how they practice. We're seeing declines in utilization there, too."

That ultimately might be what helps the accountable care model catch on and hold down spending in the longer term.

"You can see a synergy with all these initiatives," said Ms. Turner of the Altarum Institute. "There are a lot of forces out there trying to move things in the same direction."

NCQA Announces First Healthcare Provider To Receive ACO Accreditation.

Modern Healthcare (12/13, Robeznieks, Subscription Publication) reports, "Kelsey-Seybold Clinic, a Houston physician group, is the first healthcare provider to be accredited as an accountable care organization by the National Committee for Quality Assurance." The 350-doctor, 20-location clinic "was one of six organizations that first applied for ACO accreditation after the NCQA began taking submissions in March of this year." Margaret O'Kane, NCQA president said in a press release, "By being the first organization to earn NCQA ACO accreditation, Kelsey-Seybold has demonstrated to payers and other purchasers that it has met challenging requirements designed to show the efficiency, integration and high quality expected of an accountable care organization."

 The Houston Chronicle (12/14, Lee) notes that O'Kane announced during the 13th annual Health Services & Outcomes Research Conference, "Kelsey-Seybold has demonstrated a real commitment to quality and value, and I believe that purchasers are looking for reassurance that they can get quality health care without paying unaffordable prices. So Kelsey-Seybold is stepping up to the plate." Spencer Berthelsen, chairman and managing director of Kelsey-Seybold, said, "With a focus on high-value care, we can reduce cost by 20 percent...this accreditation indicates we do that."

Congratulations Kelsey-Seybold on this achievement!

Better Patient Flow Boosts Physicians Group Revenue by $3.5M

Managed Contracting & Reimbursement Advisor Staff, November 13, 2012

If you want to get serious about improving revenue in your practice, you may have to consider an entire culture change. That was the experience of Atrius Health in Auburndale, Mass., the largest primary care physician group in the state, which is enjoying increased revenue of $1.75 million per year, after a gain in the first year of $3.5 million.

The improvements were the result of an ongoing cultural transformation, says Chief Medical Officer ­Michael Pinnolis, MD. Taking a page from Toyota Motor Group, FedEx, and the manufacturing world, Atrius is applying the tenets of Lean management to healthcare to identify and seek out waste. The results have been steady and are accelerating as more of the organization is trained. Best of all, Atrius' first-year return was achieved while simultaneously improving patient care.

By improving patient flow, the MRI suite at Atrius Health has decreased turnaround time, yielding a net gain of more than $750,000 per year and decreasing patient wait time. The endoscopy suite has improved capacity and access for patients without increasing overhead or staffing costs, which resulted in a gain of almost $1 million per year to the practice.

The effort started four years ago at Atrius's 15 practice sites in the Boston area.

"We take a lot of managed care contracts and we're at just over 50% capitated," Pinnolis says. "Something over 80% of our revenue comes from risk-based contracts, and when we looked down the road at where Massachusetts and the rest of the country were headed, we wanted to do something that would help us improve our practice efficiency and lower our medical expenses."

The solution had to include creating a system of care, Pinnolis says. The Lean methodology first promoted by Toyota seemed like the most promising avenue, and Atrius began adopting the methodology in March 2009. Lean management is a production practice that considers the expenditure of resources for any goal other than the creation of value for the end customer to be wasteful, and thus a target for elimination. Essentially, Lean management is centered on preserving value while decreasing the amount of work.

"We wanted to change the way we managed the practice and create a system based on that," Pinnolis explains. "In the beginning our physicians were almost all skeptics and wondered if it was another thing ­management was doing to drive the physicians crazy."

However, physicians are almost unilaterally on board now, ­Pinnolis says. In applying Lean management to the physician practice, ­Pinnolis and the other leaders had to get the frontline caregivers and other employers involved in problem solving and process improvement. Previously, upper management would address any problems that came up and pass the solution on down the line.

"That had not worked very effectively. With the new approach, we wanted to enlist the staff and their knowledge, expertise, and enthusiasm in this process of change," Pinnolis says. "Continuous improvement is a big part of Lean management, with people trying to ­improve processes and solve problems all the time."

Geisinger, Merck team up to make sure patients follow doctors' orders

Philadelphia Inquirer , June 20, 2012

The interests of Merck & Co. Inc. and Geisinger Health System intersect enough that the pair announced on Monday a multiyear collaboration to improve the coordination of care and get patients to take prescribed medicine more regularly than they do now.

Geisinger is a physician-led, nonprofit enterprise, based in Danville, Pa., that treats patients and provides insurance for the costs. It is often cited as one of the most innovative health-care operations in the country.

Merck, a drugmaker based in Whitehouse Station, N.J., has operations in Philadelphia's suburbs and 140 countries.

"We believe that health care is most effective when patients are active partners in their care," Glenn Steele Jr., president and chief executive officer of Geisinger Health System, said in a statement. "Our collaboration with Merck will allow both organizations to leverage our individual expertise and joint resources to improve patient engagement, including finding new interventions to increase the likelihood that patients will adhere to their treatment plans."

Neither side offered financial specifics about up-front contributions or hoped-for revenue or savings.

Mark Timney, Merck's president of global human health for the U.S. market, said in an interview that Merck would contribute millions of dollars in employee time and energy, but not product, meaning Geisinger doctors won't be obligated to write prescriptions for Merck drugs ahead of competitors.

"There is nothing specific in this contract about that," Timney said. "A big focus is adherence and this collaboration is agnostic regarding brand or company in what that solution might look like."

Getting patients to actually take medication and refill maintenance drugs - "adhere" to the doctor's prescribed plan - especially medicine for chronic diseases, can help pharmaceutical companies because it means more pills would be purchased. But plenty of health-care professionals with no particular allegiance to drug companies also say that improved adherence dramatically decreases catastrophic health events that result in emergency room visits, hospital stays, and huge costs.

Geisinger has 37 community practice sites and five hospitals (a sixth joins in July), with doctors serving patients in 31 counties in central and northeastern Pennsylvania. It is unusual in that it provides medical services and insurance.

While employing doctors, nurses, and staff to treat patients in clinics and with follow-up calls when they are at home, Geisinger also employs the accountants and actuaries of an insurer. The goal is to improve overall care for less cost than the disjointed fee-for-service system.

Theoretically, that negates, at least some of the time, expense and frustration inherent in the fee-for-service system, marked by constant reimbursement disputes between doctors and insurers with patients stuck in the middle.

About 30 percent of Geisinger patients are covered by its insurance, with patients or employers paying the insurance premium.

The other 70 percent of Geisinger patients are insured by other plans, including government plans such as Medicare and Medicaid. About 55 percent of those with Geisinger insurance see non-Geisinger doctors.

All three sets of patient populations will help test any ideas spinning out of the collaboration with Merck, said Dr. Thomas Graf, chairman of Geisinger's Community Practice.

Geisinger is also way ahead of most health-care systems in using electronic medical records, which is where Merck comes in. The collaboration will start with development of an interactive web-based application that will try to help doctors and nurses engage patients who might be at risk for developing type 2 diabetes and cardiovascular disease.

Merck has medicine for both diseases, but one of its four core strategies is to expand into complementary areas of health care.

"If the solution is successful," Timney said, "perhaps it is something we can commercialize and scale up."

Will the name Merck be on computer screens all the time, acting like advertising?

James Peters, one of the Geisinger leaders on the project, said that Geisinger respects Merck's research in this area, but that the "spirit" of the project was not to create a "Merck-specific" product, adding, "I can't imagine that would make sense."

University of Michigan business professor Erik Gordon said that with the declining access of sales representatives to doctors, Merck and other drug companies are looking for other ways to get their products in front of anyone involved in writing prescriptions.

"Unless you believe that Merck has become an philanthropic organization," Gordon said, "there is a marketing purpose behind this."

Who are the chronically costly? Health care's 1%

By Doug Trapp, amednews staff. Posted March 5, 2012.

They are older patients with cancer, diabetes, heart disease and other serious chronic conditions. Many have multiple health problems, and their relatives might not be helping with their care. Most have private insurance, are white and female.

They are the costliest 1% of patients in the U.S. Caring for them accounts for more than 20% of what the nation spends on all of its health care. In contrast, the least costly half of all patients are associated with only 3% of total health spending, according to an Agency for Healthcare Research and Quality analysis of spending data from 2008 and 2009 released in January.

An individual in the costliest bracket typically receives much of his or her care in hospitals -- sometimes in multiple hospitals in the same city. Lack of care coordination is a significant driver of this spending. These missed connections are "probably the primary reason why we cannot manage costs on people who have multiple morbidities," said Ira Klein, MD, chief of staff to the chief medical officer at the insurerAetna.

Given the stark cost imbalance, health systems, health insurers, federal agencies and state governments are paying an increasing amount of attention to these patients. Care coordination and quality improvement are part of the Obama administration's strategy for limiting the growth of national health spending. But experience has shown that those goals will not be attained easily.

Analyzing the costliest demographic

Hospitals provide a significant amount of care to the costliest 1% of patients. Inpatient care takes up three-fifths of health spending on these patients, according to the AHRQ report. That's twice the rate of the overall population, and the figure does not even include people in nursing homes or other institutional facilities.

The costliest patients, about eight out of 10 of whom are 45 or older, also use more end-of-life care than the general population, said Steven B. Cohen, PhD, author of the AHRQ brief and director of the agency's Center for Financing, Access and Cost Trends. Fewer than 1% of all people died in 2009, but the mortality rate that year for the costliest demographic was nearly 9%.

Private health insurance was the main source of coverage for roughly two-thirds of the costliest patients. Nearly all of the remainder had public coverage, and uninsured patients represented only a few percentage points, according to the report.

Patients' health status has a big influence on where they landed on the cost scale. "People with three or more chronic conditions are usually in that top 10%," said Linda Dunbar, RN, PhD, vice president of care management at Johns Hopkins HealthCare, speaking aboutHopkins' Medicaid plan. The plan has approximately 200,000 members.

Untreated mental illness also is a frequent problem for high-cost patients. Mentally ill patients often have difficulty managing their health conditions, said Michael Albert, MD, medical director for internal medicine at the East Baltimore Medical Center, part of the Johns Hopkins system. "Failure of self-management skills is the biggest issue we see."

Dr. Klein saidAetna's costliest groups of services are for care related to cardiac illnesses, cancer, orthopedic problems and women's health, including pregnancy, delivery and care of newborns.

However, Cohen noted, the report does not examine the value of the care provided to the costliest patients, so one shouldn't assume that resources used on high-cost patients have been wasted. Examining patient outcomes is necessary to get a sense of the real benefits of this care, he said.

Staying connected to patients

Increasing the coordination of care is not easy, but many health systems have made headway. Two examples are Geisinger Health System's medical home program and Johns Hopkins' system to predict health care needs.

Geisinger Health System of Pennsylvania uses medical homes and electronic medical records to improve care quality and limit duplication of services. It is a network of physicians, hospitals and a nonprofit health plan with about 270,000 members spanning 44 mostly ruralPennsylvaniacounties.

Geisinger Health Plan's sickest patients -- those with heart failure, pulmonary disease, diabetes and other conditions -- are enrolled in its patient-centered medical home program called Proven Health Navigator, said Thomas Graf, MD, Geisinger Health System's associate chief medical officer for population health.

Proven Health Navigator patients in active case management maintain close contact with their case managers, who are registered nurses. The RNs examine patients' medical and social support needs and maintain close phone contact. Some heart failure patients have remote monitoring in their homes. The machines allow them to send their weights, prescribed medications and dosages, and symptoms such as shortness of breath to their primary care teams electronically.

Dr. Graf said the medical home program is reducing Geisinger's costs by at least $1.20 for every dollar invested, in part through decreased hospitalizations. "You don't have to avoid a lot of hospitalizations to pay for these management techniques," he said.

Medicaid enrollees represent a minority of the costliest patients, according to the AHRQ report. But the most expensive Medicaid patients also tend to have multiple health problems and the least coordinated care, saidDunbar, of Johns Hopkins.

A decade ago, Johns Hopkins created a program to predict which of their Medicaid health plan members have the highest risks of serious illnesses,Dunbarsaid. The program places patients into one of five categories based on health status, social and family support, usage of health care and other variables.

"You start to treat the people differently then,"Dunbarsaid. For example, instead of waiting for high-risk patients to get sick, Johns Hopkins case managers remind these patients about recommended medical visits and arrange transportation to appointments, she said. Medium-risk patients receive lifestyle counseling, such as smoking cessation and weight loss support. She said the program has limited annual spending growth for Johns Hopkins' Medicaid plan members to 1% at a time when the national growth average has been closer to 7%.

Dual eligibles a particular problem

But Medicaid enrollees who also are eligible for Medicare are not in the risk management program,Dunbarsaid. Johns Hopkins andMaryland's Medicaid agency have not yet been able to develop a care management program for these so-called dual eligibles, many of whom consume very high amounts of health spending.

Integrating Medicare and Medicaid is complicated. Medicare has its own systems for risk adjustment, grievances and appeals, and open enrollment, said Charles Milligan, MPH, deputy secretary for health care financing at the Maryland Dept. of Health and Mental Hygiene, the state's Medicaid agency.

"None of those [Medicare standards] cleanly align with state Medicaid programs," Milligan said. Also, Medicare is more focused on treatment of acute health conditions, but Medicaid is more focused on long-term services and support.

State grants in the health reform law are supporting care coordination innovations for dual eligibles. A challenge that faced states applying for these grants was a lack of data on the Medicare services these beneficiaries receive. But the Centers for Medicare & Medicaid Services has helped states fill this knowledge gap, said Melanie Bella, director of the Medicare-Medicaid Coordination Office at theCMSCenterfor Medicare and Medicaid Innovation. The innovation center plans to use its demonstration authority to test payment models that could reduce or eliminate the incentives for cost-shifting between Medicare and Medicaid.

Persistent health system gaps

Even such innovators as Geisinger and Johns Hopkins can't coordinate health care for all of their costliest patients.

Geisinger Health System operates in areas that are near non-Geisinger physicians and hospitals. The system's ability to share patient care information with these out-of-network doctors and hospitals varies, said Melody Danko-Holsomback, RN, a Geisinger case manager. She and other Geisinger staff are working to improve these connections.

Geisinger health plan members sometimes fall between the cracks. One 57-year-old man with lung cancer who had a non-network primary care doctor visited emergency departments 41 times in a year without being admitted. He was admitted during an additional nine visits, only one of which was planned. He also saw a variety of specialists, but none of the physicians was aware of the scope of services the man received.

Danko-Holsomback said Geisinger is using the example as a case study to improve care for its seriously ill patients.

Patients themselves also have roles to play in preventing costly care, said American Medical Association President Peter W. Carmel, MD. "More than 75% of the nation's health care spending is for the treatment of chronic, often preventable conditions that can be avoided by making healthier lifestyle choices," he said. "Physicians can help the nation get the most for our health care dollar by addressing lifestyle behaviors to reduce the prevalence of chronic disease in patients, and by leading new health care delivery models that improve care coordination while reducing costs."

Dr. Albert said sometimes the level of family involvement in a patient's care is the difference between a frequent hospital visitor and a person who stays healthy. One of his patients, an 85-year-old widower, has congestive heart failure, hypertension and diabetes. The man ends up in hospitals regularly in part because he has difficulty adhering to his medication regimen. He has relatives nearby, but they are not closely involved in his care.

But another patient of Dr. Albert's -- a man with similar health problems -- stayed out of hospitals for three years in a row before he died at the age of 90. The extended run was possible because the man's wife doggedly tracked his medications and health care needs and monitored his diet.

"We called her his little pharmacist, his little nurse," Dr. Albert said.

April 4, 2012 AHIP Hi-Wire Industry Resource Guide

HealthPartners, Regions reduce preventable hospital visits

March 19, 2012 Wall Street Journal: 

Cutting Costs with Better Care for Advanced Illness

A better approach to advanced illness, including fewer hospitalizations, could improve quality of life and satisfaction for the sickest patients - and save $25 billion in annual health-care costs, according to Gundersen Health System.

The La Crosse, Wisc.-based system is part of the Coalition to Transform Advanced Care, which aims to get more health systems to adopt programs such as caring for terminally ill patients at home instead of in hospitals. Gundersen outlines such programs in a new book, Having Your Own Say, which advocates helping patients and families prepare for end-of-life decisions, and avoiding unwanted treatments while providing comfort and pain relief.

Gundersen's Respecting Choices program is hailed as a model by the coalition, which includes health-care providers, medical societies and patient-advocacy groups. In the book, available for $19.95, Gundersen experts outline how hospitals, insurers, and patients and their families can work together to make sure people with advanced illness get the quality of care they want and have their wishes for treatment respected. (The book is published by the Center for Health Transformation, founded by former House Speaker and White House hopeful Newt Gingrich.)

Bernard Hammes, director of the Respecting Choices program and Gundersen's Medical Humanities program, says that the health system and others such as Sacramento, Calif.-based Sutter Health have shown that helping patients better manage illness at home reduces the number of health crises requiring hospitalization. That's where the cost savings come in.

"Rather than forcing patients into an acute-care hospitalization or sending them to hospice, we can provide a higher level of service at less cost in their home setting through nurse-care coordinators and telephonic support,"  Hammes says. "But it has to start with a good planning process so we can determine how best to care for patients as their  illness advances over time."

Part of the program includes having patients and physicians fill out a form known as a POLST - for Physician Orders For Life Sustaining Treatment. This is an initiative being adopted in a growing number of states that lets people with advanced illness nearing the end of life make decisions such as whether they want life-sustaining treatments on a mechanical breathing machine.

While providing palliative care is a central part to any plan, people mistakenly equate the term with end-of-life care in a hospice, Hammes says. Hospice care, particularly  for Medicare beneficiaries, is largely restricted to patients with a prognosis of living six months or less, and who agree to forgo attempts to cure their disease to instead focus on comfort and quality of life. Palliative care provides pain and symptom management, and discussions about advance-care planning, but also has life-prolonging and curative therapies.

"The ultimate aim is to make sure patients receive treatment they want based on truly informed decisions and avoiding over- or under-treatment," Hammes says. "It's about quality of living as defined by each individual and for families, it's about making sure their loved one's wishes are known and followed."