Disclosing physician-level outcomes data can lead to better patient care, but it's not always welcome news, says former NY exec.
During the time Nirav R. Shah, MD, was New York State Health Commissioner, the state analyzed surgical outcomes data and found that 23% of the coronary angioplasty procedures in the state were being done inappropriately.
"When we said we were going to release the data, the cardiologists, of course, complained—'My patients are sicker … the data is wrong … this will cause fear and confusion for patient … you are doing a great disservice by releasing this data,' "he said.
Nevertheless, the state collected the data, analyzed it, and sent it to the physicians. Within 18 months, the rate of inappropriate procedures dropped from 23% to 8%, said Shah, now senior vice president of Kaiser Permanente's Southern California region.
"All we did was release the data. It changed the culture," he said.
He recounted his experience during a recent seminar titled "Can Transparency Improve Healthcare?" Shah and co-presenter Marshall Allen, a reporter for ProPublica, made the case that using—and reporting—outcomes data to measure physician quality does lead to better care.
"One of the hardest things to do in healthcare and is change physician culture," said Shah. "The power of transparency— even incremental transparency among peers—made a big difference."
ProPublica created the Surgeon Scorecard last year, which uses Medicare data to calculate death and complication rates for surgeons performing one of eight elective procedures, adjusted for differences in patient health, age, and hospital quality.
"The problem is kept secret and the self-policing in the medical industry, generally speaking, just does not work,"Allen said.
Allen and his colleagues expected to find variation in complications rates, but were surprised to find large variations within the same hospital.
Some major players in the medical and patient safety community criticized the investigation, calling it "vigilante"research, but others embraced it, Allen said.
The searchable database went live in the summer of 2015. Since then, it has been used by more than 2 million people, he said.
Shah said smaller hospitals can benefit from transparency, and they might be surprised at the data troves residing on their own servers.
"Look at the readmission rates in your hospital by surgeon. It's probably sitting there with the surgeon's name next to it," he added. "All you have to do is go to a surgical chief meeting and say 'Did you see this Excel spreadsheet?' "
Patients who were co-managed by hospitalists had higher return rate when discharged to home care and assisted living settings.
Differences in demographics, cancer types, and hospital interventions had no impact on readmission rates for cancer patients who were co-managed by specialists and hospitalists, according to a new study.
However, the researchers did find a correlation between post-acute care setting and readmissions for these patients.
Co-managed patients who were discharged to hospice or a skilled nursing facility were less likely to be readmitted than those who were discharged to home or assisted living and those who had undergone surgery, according to the study, which was published in The American Journal of Medical Quality.
For the study, researchers from Mayo Clinic and Duke University reviewed 322 patient charts. They found that 74 patients, or 23%, were readmitted within 30 days.
In past studies, different methodologies looking at readmission for cancer patient have had varying results, the researchers noted. Two recent studies found rates of 22.6% and 11%.
Although not a direct comparison, the new study corroborates previous research that showed unplanned readmissions for cancer patients are significantly higher in those who were living alone or had difficulty finding caregivers.
The authors called for more research into readmission risk factors for cancer patients to guide targeted interventions to decrease readmissions and improve cancer patient care.
Hospitals continue to use chargemaster updates to maximize revenue from commercial and self-pay patients, researchers find.
Hospitals charged more than 20 times their actual costs for some services, including CT scans and anesthesiology services, according to research from two Johns Hopkins researchers which was published recently in Health Affairs.
The study authors refuted the belief, held by many hospital senior leaders, that chargemaster prices are irrelevant to revenue and profit margins because Medicare switched from a system that used list prices to determine reimbursement to the so-called prospective payment system in 1985.
The prospective payment system has not eliminated the relevance of the chargemaster, contended study authors Ge Bai of the Johns Hopkins Carey Business School and Gerard F. Anderson of the Johns Hopkins Bloomberg School of Public Health.
Rather, the chargemaster—a comprehensive list of every billable product or service a hospital can provide and their prices—is actually an important tool for maximizing revenue. Medicare, after all, represents only about 35% of hospital revenues.
Through 2013, at least, hospitals were using chargemaster updates to maximize revenue from commercial and self-pay patients, and that the practice likely continues, the study found.
Anderson, who is a professor in the business school's department of health policy and management, said the impact of these markups is vast.
"They affect uninsured and out-of-network patients, auto insurers and casualty and workers' compensation insurers," he claimed in a press release. "The high charges have led to personal bankruptcy, avoidance of needed medical services, and much higher insurance premiums."
The study found that a one-unit increase in the charge-to-cost ratio (the chargemaster price divided by the Medicare-allowable cost) was associated with $64 higher patient care revenue per adjusted discharge.
It further found that hospitals appeared to systematically adjust their charge-to-cost ratios, an activity that should produce no effect if chargemasters were, in fact, irrelevant to revenues.
Instead, the charge-to-cost ratio varied widely across patient care departments. For-profit hospitals were associated with a higher charge-to-cost ratio than government and nonprofit hospitals.
The findings suggest that hospitals, despite their protestations, still consider the chargemaster to be an important way to enhance revenue, the study authors stated.
They recommend policymakers consider developing additional tools that improve markup transparency to protect patients from unexpectedly high charges for specific services.
"We realize that any policy proposal to limit hospital markups would face a very strong challenge from the hospital lobby," Anderson said in a press release, "but we believe the markup should be held to a point that's fair to all concerned―hospitals, insurers, and patients alike."
Heart infection hospitalizations are skyrocketing among white young adults, inpatient data shows.
Another ripple effect of the country's opioid drug problem is emerging: There has been significant rise in hospitalizations for infective endocarditis, a heart valve infection often attributed to injection drug use.
That increase is especially pronounced among young, white adults.
Infective endocarditis is a sometimes lethal infection of the heart valves, and while some cases are related to things like congenital defects, the infection can also come from injection drug use, which can introduce bacteria into the blood stream.
Injection drug use-related infective endocarditis (IDU-IE) represented about 12% of all infective endocarditis hospitalizations in the United States in 2013, according to a study by Tufts Medical Center and Tufts University School of Medicine, published in Open Forum Infectious Diseases.
That's up significantly from just 7% in 2000. The increase represents an estimated growth from 3,578 cases in 2000 to 8,530 in 2013. The rise is especially dramatic among young people, whites, and females, the researchers found.
People age 15 to 34 accounted for 28% of all IDU-IE cases in 2000, but the proportion grew to 42% in 2013.
White patients represented 40% of all IDU-IE hospitalizations in 2000, and that number increased to 69% in 2013. The trend was magnified among white young adults, growing in proportion from 57% to 80%.
Females represented 41% of all IDU-IE hospitalizations in 2013, but they accounted for 53% of 15- to 34-year-olds hospitalized for IDU-IE, the study showed.
"As clinicians, we have observed a major increase in young people with opioid addiction cycling in and out of the healthcare system, and many end up with devastating complications of injection drug use like infective endocarditis," first author Alysse Wurcel, MD, said in a statement.
"Our study confirms that this trend is increasing across the U.S. and represents yet another indicator of the challenges we face with the national opioid epidemic."
The researchers analyzed data from the Health Care and Utilization Project's Nationwide Inpatient Sample data set for 2000 to 2013.
They excluded infective endocarditis cases linked to congenital defects, and included cases of reported drug use and young patients with hepatitis C, which is a strong indicator of injection drug use.
Medical doctors are largely overwhelmed by their work and disengaged from key healthcare reform measures such as value-based payments, accountable care organizations, and electronic health records, survey data shows.
Half of physicians are disengaged, burned out, and demoralized and plan to either retire, cut back on work hours, or seek non-clinical roles, according to a new nationwide survey commissioned by The Physicians Foundation.
"Many physicians are dissatisfied with the current state of the medical practice environment and they are opting out of traditional patient care roles," said Walker Ray, MD, president of The Physicians Foundation, in remarks accompanying the survey.
"The implications of evolving physician practice patterns for both patient access and the implementation of healthcare reform are profound."
The majority of the 17,236 physicians surveyed (54%) describe their morale as somewhat or very negative, 63% are pessimistic about the future of the medical profession, 49% always or often experience feelings of burn-out, and 49% would not recommend medicine as a career to their children, according to the survey.
Physicians identified regulatory/paperwork burdens and loss of clinical autonomy as their primary sources of dissatisfaction. They spend 21% of their time on non-clinical paper work duties, according to the survey, while only 14% said they have the time they need to provide the highest standards of care. About two-thirds (72%) said third-party intrusions detract from the quality of care.
In response to regulatory burdens and other concerns, physicians are seeking alternatives to traditional, full-time private practice.
The survey indicates that only 33% of physicians now identify as private practice owners, down from 49% in 2012, while 58% identify as employees, up from 44% in 2012.
A growing number of physicians (13.5%) said they will seek non-clinical, administrative jobs, 21% will cut back on hours worked, 11.5% will take temporary (locum tenens) positions, 10% will switch to part-time practice, 14% will retire, and 9% said they will switch to concierge medicine.
Docs Drop Out
Physicians also signaled that they're disengaged from key initiatives of healthcare reform. Only 43% said their compensation is tied to value. Of these, the majority (77%) have 20% or less of their compensation tied to value. Only 20% are familiar with the Medicare Access and CHIP Reauthorization Act (MACRA) which will greatly accelerate value-based payments to physicians.
While 36% of physicians participate in accountable care organizations (ACOs), only 11% believe ACOs are likely to enhance quality while decreasing costs. Physicians also are dubious about hospital employment of doctors, another mechanism for achieving healthcare reform.
Two-thirds (66%) do not believe hospital employment will enhance quality of care or decrease costs. Even 50% of physicians who are themselves employed by hospitals, do not see hospital employment as a positive trend.
Though the great majority of physicians have adopted electronic health records, only 25% said EHR has improved efficiency in their practices while 54% said EHR has detracted from efficiency.
"Clearly, more physician participation in and acceptance of the key levers of healthcare reform will be needed for a true transformation of the healthcare system from volume to value," Ray said.
Additional Findings
Additional survey findings include:
80% of physicians are overextended or are at capacity, with no time to see additional patients
48% of physicians said their time with patients is always or often limited
Employed physicians see 19% fewer patients than practice owners
46.8% of physicians plan to accelerate their retirement plans
20% of physicians practice in groups of 101 doctors or more, up from 12% in 2012
Only 17% of physicians are in solo practice, down from 25% in 2012
27% of physicians do not see Medicare patients, or limit the number they see
36% of physicians do not see Medicaid patients, or limit the number they see
Only 6% of physicians said ICD-10 has increased efficiency in their practices
The survey was conducted by the physician recruiting firm Merritt Hawkins.
Lower spending on episodes of care and high quality outcome do not allay fears about the overall impact of the bundled-payment model, research indicates.
Bundled-payments contracts for hip and knee replacement surgeries can reduce costs without sacrificing quality, but policymakers must beware unintended consequences, according to a research paper published in the Journal of the American Medical Association this week.
The paper examined hip and knee surgery data from the first 21 months of Medicare's Bundled Payments for Care Improvement (BPCI) initiative using data from 176 hospitals that participated in the BPCI initiative and a comparative sample of 841 nonparticipating hospitals.
"In the first 21 months of the BPCI initiative, Medicare payments declined more for lower extremity joint replacement episodes provided in BPCI-participating hospitals than for those provided in comparison hospitals, without a significant change in quality outcomes," the research paper's 14 coauthors wrote.
At the beginning of the study period, the baseline mean Medicare payment for hip and knee replacement episodes of care at BPCI-participating hospitals was $30,551. Reduced utilization of post-acute care services drove the lower spending level achieved at BPCI-participating hospitals during the first 21 months of the program, the researchers found. "The mean Medicare episode payments declined by an estimated $1,166 more… for BPCI episodes than for comparison episodes, primarily due to reduced use of institutional post-acute care. There were no statistical differences in the claims-based quality measures, which included 30-day unplanned readmissions," they wrote.
Unintended Consequences of Bundled Payments
Although spending levels on episodes of care at BPCI-participating hospitals were lower than the comparison group of hospitals, the researchers found no evidence to allay concerns over two of the most vexing potential unintended consequences linked to bundled payments.
One concern "is that they may provide incentives to increase the number of episodes, particularly with less intensive patients, because of the opportunity for greater financial rewards. If more beneficiaries undergo a procedure, then total payments may increase even if per-episode payments decrease," the researchers wrote.
Another concern "is that participants may select patients who would be less costly to treat. Although several indicators of patient complexity, such as mean number of hierarchical condition category indicators, did not differ between the BPCI and comparison populations, hospitalizations, SNF stays, and home-health care use prior to the episode decreased for the BPCI population relative to the change for the comparison population. This could indicate that BPCI participants treated or sought a less costly mix of patients under the initiative."
Published Response
The BPCI research paper published in JAMA is one of the most extensive and thought-provoking studies about bundled payments to date, according to an editorial JAMA published in conjunction with the study.
"This report is important for several reasons: it is by far the largest study of bundled payments to date; it focuses on bundled payments for lower extremity joint replacement (approximately 400 000 procedures per year); and the payment model evaluated is similar to the recently launched Comprehensive Care for Joint Replacement initiative," wrote Elliott Fisher, MD, MPH, director of The Dartmouth Institute for Health Policy and Clinical Practice.
More studies should be conducted to confirm the JAMA research paper's findings, Fisher wrote.
"Although the findings reported by Dummit and colleagues are promising, the study has important limitations. First, the study reported on the first few months of what will be at least a 3-year program in which participation was voluntary. Early positive results could be an anomaly, or the volunteering organizations could differ from the comparison group in unmeasured ways."
Patrick Conway, MD, acting principal deputy administrator of the Centers for Medicare & Medicaid Services, was a contributing author of the research paper.
The nonprofit provider is forming two divisions, Ascension Healthcare and Ascension Solutions, and renaming a number of health systems.
Ascension Health, the nation's largest nonprofit healthcare company by number of hospitals, plans to split into two divisions and rename several health systems in Michigan and Wisconsin.
The moves are the first steps in aligning the faith-based organization's national structure with its local identities and increasing care coordination for its patients.
The realignment will enhance internal collaboration, better support physicians and other caregivers, and ultimately provide more affordable, high-quality care for its patients, the company stated in a press release.
The two divisions will be named Ascension Healthcare and Ascension Solutions.
In addition to hospitals and clinics, Ascension Healthcare will include:
Ascension Senior Living (nursing homes)
Ascension At Home (homecare and hospice)
Ascension Clinical Holdings (community clinics)
Ascension Medical Group (physician practices)
Ascension Solutions will include mainly the organization's holdings that don't offer direct patient care. These include subsidiaries that provide clinical care management, information services, contracts through Ascension's provider-sponsored group purchasing and business transformation organization, biomedical engineering, venture capital investing, and an SEC-approved investment management company.
Many of these holdings also offer services to other healthcare providers.
"For the past several years, Ascension has been on a journey to create what we call 'One Ascension,' " said Robert J. Henkel, president and CEO of Ascension's Healthcare division and executive vice president of the parent company, in a press release.
"As we work together to sharpen our focus on clinical quality and safety, we also are expanding beyond traditional hospital-based approaches, collaborating with community partners to build clinically integrated systems of care to eliminate health disparities and improve the health of communities."
Facilities in Michigan and Wisconsin will be first to adopt the Ascension name. Ascension Michigan sites include Borgess in the Kalamazoo region; Crittenton in suburban Detroit; Genesys in the Flint/Grand Blanc area; St. John Providence in metro Detroit; St. Joseph in Tawas City; and St. Mary's, with services in Saginaw and Standish.
Ascension Wisconsin systems—Ministry Health Care, Columbia St. Mary's, and Wheaton Franciscan Healthcare—will now use the Ascension name.
In August, employees of Wheaton Franciscan Healthcare and Columbia St. Mary's reported layoffs at those facilities, but Ascension did not confirm those reports. Unionized workers circulated a petition articulating their concerns.
Three of four physicians expect to purchase, buy into, merge or sell their practice within the next four years, a survey of small practices shows.
Financial uncertainty in the healthcare sector is changing the way independent physicians and other medical professionals run their practices, according to a survey commissioned by TD Bank.
The survey of more than 340 small practices found that 50% of doctors either have or would consider purchasing, buying into, merging or selling their practice, and 73% expected to do so within the next four years.
Nearly half of the respondents (46%) said they're being pushed to make the change because it's becoming too expensive to run a practice.
"We are seeing a growing trend of more healthcare providers buying into practices with a partnership or purchasing an existing practice because they are seeking added financial security and well-established businesses," said Dan Croft, head of Healthcare Practice Solutions at TD Bank, in a media release.
"The survey findings reflect a shift in the industry because of the rising cost of doing business—from technology to insurance."
Key findings include:
Practices are growing: 43% of respondents are expecting to increase revenue over the next two years. Women (56%) and Millennials (75%) are most optimistic about expected revenue growth.
More women are becoming practice owners: While respondents on average have been in practice for 16 years, 36% of women report they have owned their practice for less than five years, while 47% of men have been in practice for more than 20 years.
Practitioners face a range of challenges: Respondents cited timely reimbursements from insurance providers (52%); managing overhead costs such as supplies, rent and taxes (51%); and keeping up with technology (35%) as current issues.
In addition, 56% of medical professionals expect partners or colleagues to take over the business when they retire, and 30% will have to postpone their retirement to later than originally planned.
"It is understandable why many near-retirement age physicians plan to cut back on time in the office, but this is not the best strategy," Croft said. "Decreasing hours or patient load can negatively impact practice or partnership value, thereby affecting retirement plans.
"While most physicians said they are confident they will have enough money to retire, that's not always the reality, and often it is due to the fact that they made changes in their schedule or practice that derailed their plans."
The survey was conducted by MARU VCR&C on Aug. 7-12.
Poor health among healthcare workers is linked to how often they access wellness center resources, researchers say.
High levels of stress are leading to negative health behaviors among healthcare professionals, research shows.
Researchers measured stress and health behaviors (exercise, nutrition, sleep, etc.) by examining the results of series of five annual surveys administered to employees at Mayo Clinic who had access to a wellness center. The annual survey was completed by 676 worksite wellness members between 2009 and 2013.
The research showed a significant relationship between the stress levels of an employee and four quality of life domains:
Poor physical health
Low mental health
Poor nutritional habits
Lower perceived overall health
Employees who reported the high stress levels and perceived poor quality of life also reported the lowest usage of wellness programs.
"It's important to teach individuals to monitor their stress levels over time and practice effective, ongoing stress-reduction strategies," Matthew Clark, PhD, lead author of the study and resiliency expert at the Mayo Clinic Healthy Living Program, said in a statement.
EHR Burdens Leave Docs Burned Out, in Critical Condition
Medical industry professionals face burnout at every turn, from compassion fatigue to the responsibilities associated with administrative work. Mayo Clinic has been at the forefront of studying it.
Earlier this year, a Mayo Clinic-led national study found that physicians who use EHRs and particularly CPOEs within their practices are not just less satisfied with their clerical burden, but also at higher risk for professional burnout.
Another Mayo Clinic study analyzed physician surveys in conjunction with payroll records, and found that for every point increase in the seven-point scale of "emotional exhaustion" in the Maslach Burnout Inventory, there was a 40% greater likelihood a physician would cut back his or her work hours over the next 24 months.
The study found a similar relationship for every one-point decrease in the five-point scale measuring professional satisfaction.
And last year, Mayo Clinic research looked at the relationship between physician burnout and leadership, and found that better leadership was linked with a reduced likelihood of burnout.
Mayo's latest study linking burnout and high stress levels to poor health behaviors among healthcare workers also found that those with lower stress levels used the wellness center more often, and frequently engaged in other physical activity.
Workers reporting lower stress levels used the center about two to three times per week on average, "which is indicative that they were meeting the recommended goal of engaging in physical activity most days per week," the study said.
Those who reported levels of high stress in at least two survey years averaged about one wellness center visit per week, however. And those with three years or more of high stress averaged only 68 usage days per year," the study said.
"Increasing the awareness of wellness centers and programs in academic medical environments will increase the quality of life of employees and lead to less physician and staff burnout," Clark said.
Having taken time out for retraining and internal audits, contractors may resume initial-phase reviews of Medicare reimbursement claims for short-stay inpatient hospital care, CMS says.
The Centers for Medicare & Medicaid Services has cleared resumption of initial-phase reviews for Medicare claims under the so-called two-midnight rule.
CMS suspended the initial-phase reviews, which are conducted by Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIOs), on May 4.
In an announcement Monday lifting the suspension, CMS officials said the BFCC-QIO claims reviews were temporarily halted to retrain the contractors: "CMS took this action in an effort to promote consistent application of the medical review policies regarding patient status for short hospital stays and to allow time to improve standardization in the BFCC-QIOs' review process."
Under the two-midnight rule, which has been in place since October 2013 and significantly revised in October 2015, most hospital stays spanning a period of less than two midnights are considered inappropriate for designation as inpatient status and are ineligible for Medicare A reimbursement.
The two-midnight rule changes made in October included making BFCC-QIO's responsible for the initial-phase review of Medicare claims under the short hospital stay regulation. Before October, Recovery Audit Contractors conducted the initial-phase reviews.
Two companies are conducting the BFCC-QIO claims reviews: Annapolis Junction, MD-based Livanta and Harrisburg, PA-based KEPRO.
CMS says five goals have been met since suspension of the BFCC-QIO claims reviews in May:
The BFCC-QIO contractors were successfully retrained about administering the two-midnight rule.
The BFCC-QIOs conducted an internal audit of all the short hospital stay Medicare claims that the contractors had formally denied since October.
CMS officials "examined and validated" the BFCC-QIO internal audit.
The BFCC-QIOs attempted to contact affected healthcare providers regarding the impact of the initial-phase review suspension.
The BFCC-QIOs "initiated provider outreach and education" about the two-midnight rule. These communications efforts directed at healthcare providers included website content, newsletters and one-on-one training, according to Monday's announcement.
The denial and appeals process for disputed Medicare claims is a lingering pain point for many healthcare providers.
Despite a $1.5 billion settlement deal between CMS and hospitals last year, federal officials predict the backlog for appeals of denied claims will climb to about 1 million cases by 2020.