Many third-party organizations rate hospital quality, but healthcare leaders are finding limited value in the plethora of grades, stars, and rankings.
This article first appeared in the July/August 2014 issue of HealthLeaders magazine.
Clarification: This story has been updated to address an editing error in which comments by Mark Chassin, MD, president and CEO of The Joint Commission, were misstated.
The crowded field of hospital rankings, ratings, lists, and grades elicits strong opinions from both the organizations attempting to measure and rate quality, and the organizations that are on the receiving end of letter grades, star designations, and appearances on top-10 lists.
Critics of these proliferating hospital evaluations have a laundry list of complaints: The methods aren't transparent enough, consumers don't pay attention, and the grade, rating, or ranking given out doesn't match up with other public reports. But for every critic, there is also a proponent, and pointing out statistical shortcomings is a losing battle, says Mark Chassin, MD, FACP, MPP, MPH, president of CEO of The Joint Commission, an Oakbrook, Illinois–based organization that accredits and certifies more than 20,000 healthcare organizations and programs in the United States.
"The constituencies that love this stuff love this stuff," says Chassin, who is a strong supporter of public reporting and an equally strong critic of the methods used by some of the well-known consumer-oriented evaluations, such as U.S. News & World Report's Best Hospitals list, The Leapfrog Group's Hospital Safety Score, and Healthgrades, a website that measures the performance of physicians, hospitals, and dentists, and issues annual reports identifying the nation's best hospitals in various specialties, and by state.
"The central problem is that the data in all of these reports have fatal flaws that render them invalid as measures of quality," says Chassin. "The research-supported fact that patients don't use these data to choose doctors or hospitals is, in many ways, a good thing, because those patients aren't being misled by faulty data."
But, according to Chassin, the reports are also problematic in another way. "Hospitals, doctors, nurses, and other caregivers devote a lot of time, energy, and resources to improve their numbers to be part of these reports," says Chassin. "The biggest harm is that trying to make invalid metrics look better diverts attention from far more productive improvement efforts."
A PricewaterhouseCoopers Health Research Institute study in 2013 showed that out of the 1,000 individuals surveyed in November 2012, only 21% reported using the publicly available evaluations to choose a doctor; 16% used them to choose a hospital. Consumers still relied heavily on personal recommendations from family, friends, and physicians. The study also concluded that part of the problem was that too much information confused consumers.
Measurement chaos
The methodologies organizations use to determine the order, grade, or star ratings come under fire from academics, specialty societies, and hospitals.
Concerned about the confusing results of one hospital getting named as a best hospital but receiving an F on another list, the Association of American Medical Colleges this year developed 25 guidelines meant for hospital leaders to gauge the value of public scorecards and the like. The guidelines are based on three overarching themes: purpose, transparency, and validity. The AAMC said that no single publicly available hospital performance evaluation met all of its guidelines.
The Healthcare Association of New York State issued a similar study in 2013. It released a report card on well-known public raters, doling out between 1–3 stars, with three stars being the highest score. Two organizations earned three stars—The Joint Commission, for its Quality Check website, and the Centers for Medicare & Medicaid Services' Hospital Compare website—while several well-known ratings organizations received a single star.
But even the HANYS approach shows how tricky it can be to measure quality because neither Hospital Compare nor Quality Check are lists; rather, they are online measurement tools populated with publicly available data for consumers to use to compare hospitals.
The difference between hospital comparison tools and performance-based lists may be a fine point of distinction, but it's one that Evan Marks, chief strategy officer at Healthgrades, says is important for consumers and hospitals to understand. Denver-based Healthgrades has been evaluating hospital performance since 1998, and does issue various reports on top hospitals by state, specialty, and other indicators, such as patient experience, patient safety, and clinical quality, but Marks says publicly reported measures and ratings should not be lumped together. They should be considered separately for their meaning.
"Healthgrades doesn't give hospitals report cards," says Marks. "We provide consumers information on our website. These kinds of 'best hospital' lists are accolades. I don't think anyone should solely base their decision on where to get care on a 'best hospital' list."
At issue is the lack of standard measurement across these public performance assessments. A quick glance at the most well-known raters shows that the methods for attaining an honor vary widely. How can the Cleveland Clinic, for example, be a top-ranked hospital by U.S. News & World Report but not get named to The Joint Commission's Top Performers list? It happened this year. And, Consumer Reports, which began issuing safety scores based on a 100-point scale in 2008, gives the renowned hospital a score of just 46. Leapfrog issues 11 different grades for the hospital, broken out by location with the grades ranging from A–C. Meanwhile Healthgrades has named the Cleveland Clinic among the best 100 hospitals for cardiac care, cardiac surgery, and patient experience.
Michael Henderson, MD, chief quality officer for Cleveland Clinic Health System, which has more than 1,440 beds at its main campus and more than 4,450 total beds throughout the system, does not outright dismiss these external evaluations of hospital quality, but he says getting an A from Leapfrog or a perfect score from Consumer Reports is not going to change how the hospital operates.
"That data is not useful for driving performance-improvement change," says Henderson. "That depends on much more timely internal data, which inevitably looks different. It's having communication and understanding about the two types of quality-data sources: one to identify gaps and one to drive performance improvement. But what you're driving to improve isn't going to look the same as what's publicly out there."
The main campus of Cleveland Clinic fills out Leapfrog's hospital survey and the one from U.S. News & World Report, but like other large hospital systems, it also produces its own quality report on each of its 11 hospitals, as well as what are called outcomes books on 14 specialties. Both types of internal reports contain detailed outcomes and measures on the same types of information that Hospital Compare, Leapfrog, Healthgrades, Consumer Reports, and U.S. News & World Report use, such as heart attack, heart failure, and surgical care. But there is more information in Cleveland Clinic's reports. And the hospital shows both good and bad outcomes.
For example, at Cleveland Clinic's main campus, the hospital quality report shows the rate of central line–associated bloodstream infections in the ICU by quarter from mid-2011 to December 2013. Its goal is zero CLABSI events, which it has not been able to accomplish over the time period, though the rate of CLABSIs has continued to fall over time after a spike in 2012. It came close to the goal of zero in fall 2013 when the rate fell between 0.5 and 1.0. That's still better than the national average, which is all Hospital Compare and Healthgrades reports. Leapfrog represents Cleveland Clinic's ICU CLABSI events with two green bars out of four, meaning "some progress."
The hospital also lists information that is not easily found in the public domain, such as falls with injuries. Cleveland Clinic reports 28 patient falls with injuries during the 2013 calendar year. Its goal is zero patient injuries due to falls, and as of March 2014, a new protocol requires making frequent check-ins at the bedside, providing nonskid socks, offering bathroom assistance, and making sure the call light is within reach of patients.
The commitment to being transparent, says Henderson, comes directly from Cleveland Clinic President and CEO Delos "Toby" Cosgrove.
"Toby took the lead of saying, 'I want you guys to put our outcomes out there: good, bad or indifferent,' " says Henderson.
Most organizations that evaluate hospital quality for the public rely on Hospital Compare, which is maintained by CMS. It's a primary source of data collection because it is one of the largest repositories of information on the nation's Medicare-certified hospitals. CMS, The Joint Commission, the National Quality Forum, and the Agency for Healthcare Research and Quality all had a hand in picking the more than 100 measures on quality, safety, and patient experience available for the public to view on Hospital Compare. Medicare Provider Analysis and Review (MedPAR) data, information from specialty societies, state departments of health, state hospital associations, and the Centers for Disease Control and Prevention also are popular sources of data for organizations evaluating hospital care.
The variations in the results are due to different combinations of data used by each organization, different weights each organization places on individual measures to come up with a composite score that is understandable to the public,or because some raters use self-reported or proprietary surveys, such as Leapfrog and U.S. News & World Report.
Transparency in methodology has become increasingly important, and most rating organizations detail step-by-step how they determine their rankings; but for patients and hospitals, the scores and methodology can add up to confusion.
"Consumers want to know one thing," says Marks, noting that while clinicians and academics may be interested in the details, the patient's attitude is "Don't bore me with how you risk-adjust the data; just tell me where to go."
Emphasizing internal scorecards
Similar to Cleveland Clinic's focus on being transparent about its quality performance, Arlington-based Texas Health Resources unveiled its own quality report for 14 of its wholly owned hospitals. THR operates 11 other hospitals in the Dallas-Fort Worth metroplex, either through affiliation or joint venture, but that data isn't available for scrutiny because THR doesn't own it.
THR's new quality report includes 300 measures on 16 indicators, many of which are the same ones found on the CMS Hospital Compare website and are part of the Joint Commission's core measures, which hospitals have to report on to receive Joint Commission accreditation. Using external organizations' standards was intentional, says Dan Varga, MD, chief clinical officer and senior executive vice president of THR. He says self-reported data can be viewed as suspect, and it's better to use measures and indicators that are already vetted through independent entities trusted by the healthcare industry.
"As opposed to THR creating a definition for what we think a healthcare-acquired condition is, Medicare has a definition, for example; it is publicly available, and that indicator has gone through the National Quality Forum for approval," says Varga. "What we're saying is THR won't invent its own indicator, with its own rules and own methodologies. We're going to look at a national consensus definition, and we'll be very transparent with it so people can understand where the opportunities to improve are or why a score is at a particular level."
THR's quality report is modeled after the one used by Louisville, Kentucky–based Norton Healthcare, where Varga was chief medical officer in 2005. That's the first year Norton published its quality report, and Varga had a front-row seat to its development. Initially, Norton—which includes five hospitals, 12 immediate care centers, and more than 90physician practice locations—included approximately 200 indicators; now that number is approximately 800, says Kathleen Exline, system vice president of performance excellence and care continuum for Norton.
"This provides an internal benchmark that we use to either sustain or enhance excellent results or improve our process and outcomes where needed," she says. "We believe transparency is the right thing to do, even when the numbers aren't what we would like for them to be."
Exline also says the information in the quality report for the public is the same information that clinical and administrative staff begin with before it is broken down at the service line and unit level.
"It is the same data," says Exline. "For example, we will slice the data to show nursing unit performance, whereas on the website, we'll show hospital performance. The nurses look at unit-level and patient-level data for root-cause analysis. It's more specific because of our desire to find out the failure point in the process."
That is what Varga plans to do with frontline clinical staff at THR, and its usefulness to doctors is one of the reasons THR decided to publish its own quality report.
"It is an important thing to tell the community how we perform, but the other big, big audience is us," says Varga. "When we're able to show physicians data that's endorsed and standardized, they'll embrace that more than they will a five-star or three-star rating."
THR's push to issue its own quality report comes despite generally positive public rankings. The hospital system and its individual hospitals tend to score well across the external rating organizations. THR doesn't always pay the licensing fees that some organizations, such as Leapfrog, U.S. News & World Report, and Healthgrades, require to highlight the honor online or on advertising. But Varga explains those calculations and conclusions aren't transparent enough for THR.
"Healthgrades responds to the public's desire to simplify down to a score or grade, and when we ask them, 'How did you come up with that score or grade?' it basically exists in a black box; they consider it proprietary," says Varga. "So we can't really understand in many cases how they calculate the outcome they publish. If you're going to improve, which is one of the things we like about being transparent with this information, you have to understand how things are measured."
While Henderson from Cleveland Clinic agrees that the methodology isn't good for driving quality improvement, he points out that external reports serve a purpose. "We love U.S. News," says Henderson. "It's good in the sense that it profiles where to go if you've got the sickest of the sick patients. That is their stated goal."
Varga says he focuses on the internal operations and initiatives at THR.
"For us, we don't pay a whole lot of attention [to external scorecards], to be quite honest," says Varga. "We don't, at THR, teach to the test, or teach to multiple, different, specific tests. We try to set an incredibly high bar, which is the THR way, and then we go out and pursue it. If that gets us a five-star [rating], then we're excited about it, that's great, but it's not an intentional pursuit of ours."
THR's public quality report also isn't really new, at least among its employees and hospital leadership. Varga says the public report is an expanded version of the measures THR has been collecting for years. The report aggregates internal data, Hospital Compare data, and puts it into a format the public can easily understand. Like the example set by Cleveland Clinic and Norton, THR says it will report the good and the bad, as well as compare THR hospitals side by side, and to state and national averages when applicable.
The value of public perception
Despite the lack of consensus on their usefulness, external decrees of hospital quality and performance continue to flourish. Consumers might not be using them to make healthcare decisions, but they are reading the results of these reviews.
Ben Harder, managing editor and director of U.S. News & World Report's healthcare analysis team, says the publisher's online hospital rankings garner millions of user views each month.
"They don't come in, look at a ranking, then leave," says Harder. "They're much more engaged—several pages per visit."
Harder also says that viewership of the hospital rankings and related health advice content has grown by 70% from last year, which is a greater increase in viewership than that of U.S. News & World Report's college rankings, its oldest and still most-read list.
But the list of best hospitals that U.S. News & World Report puts out is an annual punching bag for critics because of its methodology.
One such critic is The Joint Commission's Chassin. "I have problems with all the other measurement systems whether it's Healthgrades, Leapfrog, or U.S. News," he says.
In 2011, The Joint Commission began issuing its own scorecard of sorts, an annual Top Performer on Key Quality Measures list that recognizes hospitals that achieve 95% on its accountability measures taken together and 95% on each measure individually. They are the same measures for which hospitals must achieve an 85% performance score just to be accredited. Chassin says the Joint Commission's science behind the list is strong because it is evidenced-based and drawn from clinical data that show the severity of each case.
While U.S. News does derive its rankings in part from publicly available data that is risk-adjusted and used in other evaluations, the rankings also rely on the reputation a hospital has among physicians who are surveyed. The list ranks hospitals in 16 specialties, and four of the specialties—ophthalmology, psychiatry, rehabilitation, and rheumatology—rely solely on the reputation score from surveyed physicians. The reputation score is a component of the other 12 specialties.
Chad Smolinski, senior vice president for U.S. News & World Report, says he thinks critics sometimes lose sight that its hospital rankings evaluate care for the sickest patients.
While U.S. News & World Report's Best Hospitals list receives poor marks from some rankings critics, many hospitals nonetheless consider it a badge of honor.
DeAnn Marshall, senior vice president and chief development and marketing officer for Children's Hospital Los Angeles, used CHLA's recognition by U.S. News & World Report as one of the top 10 children's hospitals in the country to launch its major rebranding campaign in 2011.
"Within Los Angeles, everyone wants the best of everything. Every city has a culture, and that happens to be our culture," Marshall says. "We are keying into the mind-set, and what we did with our brand platform is we equated the best of L.A. with the best children's hospital."
CHLA, which has 347 active beds overall and treats more than 104,000 children annually, has a long-running history with U.S. News & World Report. The children's hospital has been ranked on the publisher's top children's hospitals list since 1990, and has been on its exclusive honor roll for six consecutive years, 2009–2014. For Marshall, that was enough to put the familiar blue badge on nearly every piece of advertising during the relaunch of the CHLA brand in 2011.
"From our perspective, it's a brand moniker that is important to our hospital, especially given the fact that we are on the honor roll, and we are the only children's hospital in the west to have that designation," says Marshall. "It's important to us."
CHLA has also received honors from other groups that evaluate hospitals. The Leapfrog Group in 2013 named CHLA as a Top Hospital. CHLA also received a pediatric safety award from Healthgrades in 2010. But the only designation other than the U.S. News & World Report ranking that Marshall promotes widely is its Magnet Recognition from the American Nurses Credentialing Center.
"I could literally put every single one of those designations on everything we send out," says Marshall, who explains that while it is an honor to be a Leapfrog Top Hospital, the recognition is like "insider baseball."
"Those of us who work in healthcare understand what those designations are; I don't think consumers generally do."
Even though CHLA has been ranked highly by U.S. News & World Report for nearly 25 years, it didn't promote the ranking prior to the brand's relaunch. For Marshall, the pre- and post-rebrand metrics show clearly that using the publication's ranking on hospital advertising is effective for its patient population.
"We look at hits to our website," she says. "For example in 2010, we had 542,000 visitors. In 2013, we had 1.4 million."
Marshall also says the hospital has seen a marked increase in online donations since the rebranding campaign.
"In 2010, we were at $1.1 million, and as of 2013, we were at $1.7 million," she says.
The U.S. News & World Report ranking is so important to CHLA that Marshall says a 30-member executive team that includes administrative and physician leaders reviews the survey.
"It's a very detailed process that our hospital goes through on an annual basis, and as an executive leadership team, we focus on that questionnaire and take it very seriously."
Fighting for transparency and more measures
The Leapfrog Group, an employer-based coalition and advocacy group based in Washington, D.C., is another hospital quality reporting organization that is no darling of critics but has found growing support among hospitals.
Since 2001, it has been publishing the results of surveys it developed to gauge safety at hospitals. In 2012, it began publishing a Hospital Safety Score, which is represented by a letter grade of A–F. The scores are based on a composite of 28 publicly reported measures, such as hospital-acquired conditions, ICU physician staffing, and patient safety indicators. The primary sources are CMS Hospital Compare and data from Leapfrog's own hospital survey it administers annually.
Leapfrog's purpose is to "shine a light on hospital safety and alert consumers and give them tools to protect themselves," says President and CEO Leah Binder. She believes that hospitals and other healthcare providers should supply more data beyond what the government or an accreditation organization requires so that consumers can see a full picture of a hospital's safety and quality track record.
Hospital participation in Leapfrog's surveys is voluntary—but Leapfrog attempts to measure hospital quality even for nonparticipating hospitals.
Rexburg, Idaho-based Madison Memorial Hospital, a 69-staffed-bed hospital, was rated by Leapfrog as one of the 25 worst hospitals in the country in 2012. Madison Memorial officials publicly voiced their disagreement with the score, saying it was penalized for not participating in the survey.
When Memorial officials finally did fill out the survey, its hospital safety score rose three letter grades to a B.
Nolan Bybee, director of risk management and compliance at Madison Memorial, says the only thing that changed between 2012 and 2013 was filling out the survey.
"When we were labeled one of the worst hospitals in the U.S., they were using [data from] two years prior," says Bybee. "When we took the [Leapfrog] survey, we were 100% compliant. If you can go from one of the 25 worst to a B in less than a year, then there's something wrong with
the survey."
The bad press that resulted from being named as one of the worst hospitals is the primary reason Bybee says Madison Memorial continues to fill out Leapfrog's survey, though he's not sure how much longer he'll continue to do it.
But some hospitals that received failing grades from Leapfrog and have since turned their scores around are grateful.
Chicago-based Norwegian American Hospital also landed on Leapfrog's worst 25 hospitals list in 2012. Back then, the 200-licensed-bed critical access hospital on the poor northwest side of Chicago was not at the top of any organization's list. Its Joint Commission accreditation was in jeopardy, CMS was monitoring the hospital for patient safety issues prior to 2010, and its finances and relationships with physicians were dismal.
President and CEO José R. Sánchez, LMSW, LCSW, has helped turn around the hospital to be a safer place for patients, and credits Leapfrog for helping the hospital focus on patient safety.
"Leapfrog assists us to reevaluate ourselves on an ongoing basis," says Sanchez. "It is important for this community to see we were ranked by an outside, objective entity."
Norwegian American went from an F in 2011 to a B in 2013 and this year. Sanchez says filling out Leapfrog's hospital survey takes time—a lot of time. Binder estimates hospitals spend anywhere from 40 to 80 hours completing its 65-page survey. Sanchez says it takes more than 80 hours.
"I do expect at some time we'll get an A, as we continue to progress on quality care and patient safety," says Sanchez. "It is important."
Whether hospital leaders are filling out Leapfrog's hospital survey because they're afraid of the bad press that could accompany a low score or, like Sanchez, they view it as an opportunity to identify areas to improve, the bottom line is more hospitals are participating voluntarily.
"We have had increases steadily over time, but we had a record year in 2013," says Binder. "The Leapfrog Hospital Survey has 1,439 hospitals participating, which is an all-time record. In 2012, we had around 1,200 hospitals."
That's still a far cry from the 5,723 hospitals in the United States, and the more than 4,500 that report to CMS. The survey's lack of complete participation, while a shortfall, does not stop Binder from public advocacy on the need to improve patient safety.
She says the real shortcoming is CMS data. Leapfrog, Joint Commission, Healthgrades, Consumer Reports, and other reports rely on CMS data on Hospital Compare, but Binder is exasperated with the data's limits.
"On Hospital Compare, 90% of hospitals are rated 'average' on every single one of the things they measure," she says. "That's not going to give consumers what they need to know."
So Binder attempts to go further, using standards Leapfrog developed to measure patient safety and quality at hospitals. ICU physician staffing, evidenced-based hospital referral, and computerized prescriber order entry are all Leapfrog metrics.
Binder says ICU physician staffing is intended to improve errors in the ICU; EBHR use is aimed at lowering adverse outcomes for high-risk surgery patients; and CPOE use at a hospital is intended to reduce medication errors, one of the most common mistakes made at a hospital.
But not all hospitals have these metrics in place, and if they don't fill out Leapfrog's hospital survey, Leapfrog has limited ability to verify these activities. Binder admits the method isn't perfect, but stands by it as a "pretty good" indicator of hospital safety, particularly its measurement for medication errors, CPOE.
"Leapfrog's standard on CPOE is quite rigorous," Binder says, explaining that for hospitals to meet Leapfrog's threshold for CPOE, they must take a two-hour Web-based test.
"We give the hospital a set of dummy orders for a set of dummy patients, then we ask them to enter those orders into their CPOE system, and then report back to us what the system does. We're testing the decision-support system underneath the CPOE system. It's a proxy measure. We don't have the actual number of errors made in a hospital."
Neither does anyone else. The Joint Commission does not include medication errors as part of its core measure sets available to hospitals. Chassin says that's because errors are all self-reported, and there is no current process by which they can be validated and therefore "would pass our accountability measure test."
Cleveland Clinic's Henderson, who serves on the leadership advisory council for The Joint Commission's Center for Transforming Healthcare, says that setting up a national system for reporting medication errors is a huge undertaking. "Medication errors have not risen into that space yet because of the difficulty of having a standardized, agreed-upon measure of approach," says Henderson. "We all struggle."
This is a sticking point for Binder and other healthcare leaders who point out not only varying methodologies of report cards, lists, and rankings, but also key measures
missing from these reports.
"There are lots of limitations," says Binder. "I'll be the first to tell you that. I spend 90% of my life trying to get better data and better measures. But we have some pretty good measures and some pretty good data. It's not perfect, but we have some pretty good understanding now about how hospitals are doing. And 'pretty good' is a lot when you're entrusting your life in a hospital."
Ultimately, however, the usefulness of consumer-oriented scorecards is questionable, and not just because the methodologies for calculating scores vary. It's because going to an acute care hospital is often not a planned event, explains Barclay Berdan, FACHE, chief operating officer and senior executive vice president at Texas Health Resources.
"More than half of the patients that are in the beds of our hospitals right now came through the emergency room," says Berdan. "I think people who are going to be using hospitals or doctors electively will find a quality and safety report like the one we're putting up can be very useful. But do I think that a patient who is worried they're experiencing signs of a stroke is going to take the time to pull out their laptop or smartphone and advise the ambulance driver they ought to go here instead of there because there is a better score? I don't think so. What I think it will do over time is that EMS providers will pay attention to better outcomes."
Clinical leadership at hospitals doesn't view public scorecards the way that ratings organizations would like, Berdan says. But their participation, either by filling out Leapfrog's surveys or using the U.S. News & World Report badge as a marketing element, shows these popular scorecards aren't completely ignored by hospital leadership, particularly because hospital boards notice them, says Berdan.
"They certainly pay attention to the various reports that come out in the media and ask us a lot of questions," says Berdan. "It's given us the opportunity to help educate the board about the various natures of these various ranking systems, and really I think is, in part, the impetus for management to propose—as well as the quality committee of the board to embrace—creating our own report that we'll look to first."
A constant barrage of ads from hospitals, health systems, and payers urges patients to get screened for some of the deadliest diseases. But casting a wide net is totally at odds with controlling healthcare costs through evidence-based data.
Heart disease is the leading cause of death for both men and women and reducing those numbers is a prime target for hospitals and health systems, public interest health groups, and medical specialty societies.
Years of research and data have given clinical leaders tools to help patients reduce their risk for heart disease: stop smoking, lose weight, exercise, and lower blood pressure. The treadmill stress test and other, non-invasive imaging screening tests aren't on that list because they don't improve patients' outcomes.
But those clinical best practices either aren't well-known enough or haven't trickled down to hospital marketing departments. Or both.
The logo-wrapped mobile screening buses and newspaper ads offering patients peace of mind through a screening test for any number of diseases make Patrick Alguire, senior vice president for medical education at the American College of Physicians, cringe most of the time.
Expensive, Invasive, Dangerous
"It's a sore point with me," says Alguire. "We have to be really careful about the harms that screening can do. For example, you may have a screening test with false positives that can lead to more tests, and generally, the additional tests can be more expensive, invasive, and dangerous. If nothing more, it may create worry and anxiety."
The American College of Cardiology estimates that low-risk, asymptomatic patients make up 45% of unnecessary screenings. The ACC and ACP are two of 58 healthcare provider organizations that have created a list of five common tests or procedures that physicians and patients should talk about rather than automatically ordering as part of the American Board of Internal Medicine's Choosing Wisely campaign.
Aimed at reducing wasteful healthcare spending while ratcheting up the reliance on evidenced-based outcomes, Choosing Wisely has made healthcare organizations sit up and take notice of their own clinical attitudes toward testing and diagnoses practices.
At Reliant Medical Group, a Worcester, Massachusetts–based independent multi-specialty physician group with more than 250 doctors at 20 sites, leaders asked specialists to pick at least two of 58 Choosing Wisely Top 5 lists to assess its own reliance on tests or procedures that may be unnecessary.
"It's about shared decision making," says Betsy Hampton, vice president of population health for Reliant.
The ACP is also launching its own initiative to help physicians and other healthcare providers know when more testing or additional procedures are warranted. It's partnering with the Cleveland Clinical Journal of Medicine in a new periodic series called Smart Testing. The series' articles are presented as clinical vignettes that present common test-ordering scenarios.
For example, the first installment of Smart Testing series presents a healthy 48-year old man who wants to know if he should get a cardiac stress test. The conclusion, based on clinical, evidence-based guidelines that are consistent among the ACP, the American Heart Association, and the American College of Cardiology, is no.
Not All Diseases 'Amenable to Screening'
Alguire writes in the conclusion, that "several studies that included symptomatic and asymptomatic patients who had undergone angiography reported between 39% and 85% of patients had no coronary artery disease." The risk is low, if the patient undergoes stress testing, but Alguire says it's more cost without more benefit.
"Not all diseases are necessarily amenable to screening," he says.
The American Heart Association agrees. AHA President Elliott Antman, MD, a practicing senior cardiologist at Brigham and Women's Hospital in Boston, says doctors have to talk to their patients about when further testing is warranted and not have patients rely on the mass screenings.
"We prefer them coming through their primary care provider or cardiologist so we can make reasoned judgment about who needs additional testing."
Unfortunately for physicians trying to shift the perception from more tests are better to less is more, the ACP's vignette is a common reality across the country.
At Loyola University Health System, based in Maywood, Illinois, a large bus sweeps through Chicago's western suburban streets offering the community six "comprehensive heart screening" tests for $179. One of the six tests is an electrocardiogram, the same test that physicians are told to avoid in asymptomatic or low-risk patients.
No doubt the mobile screening unit raises awareness for the health system and catches and stops heart disease from progressing further in some patients. But casting a wide net is totally at odds with controlling healthcare costs through evidence-based data.
"The health screening is kind of like the cheering section for the old guard," says Howard Brody, MD, PhD, director of the Institute for the Medical Humanities at the University of Texas Medical Branch at Galveston, who is credited with spurring the Choosing Wisely campaign to come up with a "Top Five" list. He proposed the idea in his 2010 New England Journal of Medicine editorial that called out physicians' overuse of tests and procedures without any real benefit to the patient.
Contrary to Evidence-based Guidelines As for the juxtaposition of patients being told one thing while physicians are told another, Brody says it's too early to expect the long-held view of more testing to be uprooted.
"It's early days for Choosing Wisely," says Brody. "Right now, the dialogue hasn't gone on long enough for any consensus point of view to emerge."
Meanwhile, Loyola and the contractor that provides the mobile screening unit, Health Fair, have come under fire for promoting screenings that are contrary to evidence-based guidelines. Loyola officials did not return phone calls or emails asking to clarify its screening practices or use of Choosing Wisely guidelines.
The AHA, a group that is received (and believed) by consumer and medical professionals is more diplomatic than Brody and Alguire about the delicate balance of promoting awareness and excessive screening.
But Antman ultimately comes down on the side of caution.
"The key is for healthcare practitioners to exercise their responsibility appropriately by taking the time to talk to their patients and use the available tools and guidelines to screen for heart disease and stroke rather than resorting to a policy of broad and unchecked use of imaging."
Faced with a growing elderly population, healthcare leaders are investigating strategies to treat dementia patients with dignity while trying to keep them out of the hospital.
This article appears in the June 2014 issue of HealthLeaders magazine.
An aging population is already expected to strain U.S. healthcare resources, and recent studies suggest that dementia represents both a major health risk and a considerable cost driver. In addition, this long-term decline in cognition takes a significant toll on patients, their families, and the providers who care for them.
Some healthcare systems and hospitals are now coordinating care for these patients so they can stay at home and also avoid unnecessary hospitalizations. Patients with dementia are at risk for falls, pneumonia, medication noncompliance, anxiety, and other comorbid conditions that could lead to long hospital stays. Not addressing the needs of what's been called a silver tsunami now could be a prescription for readmission rates that are difficult to drive down in the future.
A 2013 RAND study of dementia published in the April 2013 New England Journal of Medicine estimated the cost of caring for patients with dementia will more than double by 2040, from $109 billion to at least $259 billion, and that figure does not include the costs shouldered by family members and caregivers who pay out-of-pocket for sitters and other services, or forgo careers in order to stay home to care for a family member.
Success key No. 1: Thoughtful avoidance of medical intervention
Among the special considerations for caring for patients with dementia is defining the goals of care, including possibly paring down the number of medications a patient is prescribed.
"We're talking about supportive care, rational, [and] reasonable care that's going to provide them with increased quality of life because we can't increase their life span with the dementia but we can increase the number of days that they have that are more functional," says Evelyn Granieri, MD, MPH, chief of the division of geriatric medicine and aging at New York-Presbyterian/Columbia University Medical Center, which is part of the six-hospital New York City–based New York-Presbyterian. "And oftentimes, some of the medications that are prescribed by other clinicians actually decrease the quality of their life."
For example, Granieri says diuretics that are often prescribed for blood pressure require frequent trips to the bathroom. For a patient with dementia, not only is medication adherence complicated by memory issues, but mobility also becomes a problem. Other maintenance medications, such as statins, may not be optimal for dementia patients because the drugs are not increasing or maintaining their quality of life.
"When you're looking at a limited life expectancy, you don't need medications that are meant for 40-, 50-, or 60-year-olds that are meant to help them live a little bit longer," she says, calculating the number of medications the average patient comes to her with at 10–12, which she usually reduces to 4–5.
Granieri also advises physicians to be more thoughtful about other medical interventions, such as mammograms and colonoscopies.
"They don't need these to keep them alive any longer," she says. "We try to work with other physicians they may see and say, 'Look, this is not necessary at this point. It's not going to provide them with any benefit. Yes, you would expect to do this for a younger person or someone who doesn't have a cognitive disorder, but they're not going to get a benefit from it.' "
The Allen Hospital, where Granieri practices, is a community hospital serving northern Manhattan, the Bronx, and parts of New Jersey. For patients over the age of 70, the hospital offers geriatric consultations for nursing units at the hospital, an outpatient practice, and a house call program for patients who are too frail to come into the hospital or physician's office. Granieri says more than 300 patients, on average, receive services from an interdisciplinary team that includes social workers, nurse practitioners, and five fellowship-trained, board-certified geriatricians.
"Our practice is small," she says, and describes the patient population in the primary care practice as very frail. "We don't take care of healthy old people. We take care of people who … have to be over 70, they have to have some other markers of frailty, and the most consistent of them is that they have cognitive disorders."
One of the barriers to coordinating care for patients with dementia is the dwindling number of geriatricians, and the general unfamiliarity with dementia on the part of nonspecialists. But New York-Presbyterian, with its affiliation with Weill Cornell Medical College and Columbia University College of Physicians and Surgeons, is helping change that, says Granieri. She gives oversight to the medical residency rotation in geriatric medicine. There are about 50 internal medicine residents who get a chance to see the team-based approach to geriatrics and dementia care.
"We've now taught almost eight years' worth of residents, and they get it," she says. "The environment is not always helpful for them because they get pressured by other clinicians to do extra things that may not be necessary, but they understand which medications older adults should not have. There are physicians now who have been exposed to and participated in what we like to think of as optimal care of older adults with cognitive impairment."
Success key No. 2: Treat the family, not just the patient
Lee Memorial Health System, a Fort Myers, Florida–based public health system with a medical group and 1,423 beds among four acute care and two specialty hospitals, expanded its services for patients with memory issues, including dementia, three years ago with the addition of a house-call program and a 112-bed skilled nursing facility, HealthPark Care & Rehabilitation Center. Lee Memorial's memory care program is aimed at taking care of patients with dementia in a more coordinated way, starting with screenings in the community. For 10 years, a volunteer nurse has been screening seniors in southwest Florida for free every Monday morning.
"Catching people as early as possible so we can monitor them for a significant drop in memory is very important," says Sunny Kozak, practice manager for the Lee Physician Group Memory Care, House Calls, and Geriatrics Service program. "We are seeing an increase in people coming in at a younger age. Instead of waiting until the late 60s, early 70s, they're coming in at their mid-60s."
As a designated memory disorder clinic for the state of Florida, Lee Memorial must reach a state-imposed benchmark of 100 screenings annually, which they exceed every year. From July 2012 to June 2013, Lee Memorial Health System completed 145 free screenings. Only 8% were 65 years or younger. From July 2013 through December 2013, there were 35 free screenings, a low number that staff attributes to the holidays; however, the younger age group already accounts for 8% of screenings with six more months to go.
If the screening indicates further testing is warranted, the providers tell the person who was screened "gently."
"It's a screening examination, not a diagnostic test," says Avra Bowers, MD, MBA, system medical director of primary care and community health services at Lee Memorial Health System, who is overseeing memory care at the system level. "We handle it very gently and advise them to get a full evaluation with a referral coming from the PCP because we do think it's extremely critical that the primary care doctor who is going to handle their other issues and medical conditions is involved in the full understanding of the potential dementia diagnosis and what we need to do next."
The memory care screenings are staffed by Lee Physician Group providers, but aren't limited to LPG patients. That's because the hospital system views dementia as a communitywide issue.
"We try to keep a healthy pulse on the patient's dementia progression and their needs from a safety perspective," says Kozak, noting that it's important to continuously monitor patients, sometimes for years, to determine what kind of care is appropriate. If the patient's memory problems are progressing, Lee Memorial can suggest adult daycare, home care services, or long-term care placement to try to prevent a hospital visit. "Hospitalization for patients with memory impairment, unfortunately, often turns into a worse situation than it needed to be," Kozak adds.
Similar to New York-Presbyterian, Lee Memorial assembles a team to help care for patients with dementia. It includes three geriatricians, two neuropsychologists, an advanced registered nurse practitioner, a social worker, and case managers who are embedded at 17 of LPG's primary care offices. The case managers are part of Lee Memorial's goal to attain patient-centered medical home status, which Bowers says helps coordinate care for dementia patients once they're diagnosed. But one of the most important members of the care team is the caregiver.
"We're essentially caring for two patients," says Kozak. "The most important thing we try to do is not allow that patient and caregiver to silo themselves from everything, which is the natural tendency. Alzheimer's is a family disease. We actually invite the caregiver and family members to come in for every appointment."
If an LPG patient with dementia is admitted to a Lee Memorial hospital, one of six ARNP liaisons follow patients into the hospital and communicate back to memory care staff and LPG doctors. These ARNP liaisons are assigned to one facility each, which is important for patients with memory and cognition problems. The liaison becomes a familiar face to the patient and the patient's family, making sure the patient's needs are met, questions are answered, and information is shared between hospitalists at the facility and the primary care physician.
Bowers says Lee Memorial has not started tracking readmission rates on this population, but attests to the seamless care.
"It's all about the patient; it's about the family members and helping them through it because it is critical for the quality of care for the patients."
Bowers says Lee Memorial is on the road to viewing dementia as a population health initiative. Part of working toward PCMH status means having a robust electronic medical record, which Bowers says is in place and helps coordinate all the moving parts a dementia patient often requires. She says the system already has patient registries for asthma, diabetes, and obesity; dementia is in the future.
"We should be able to build registries of our patients with dementia and then as to where they are in their dementia issue," says Bowers. "Then we'll be able to reach out and be more proactive. We're in that phase of population health in developing registries elsewhere, but we can and will be bringing that into the memory care program, hopefully within the next year."
Success key No. 3: Establish clinical practice guidelines
Team-based, interdisciplinary care for dementia patients is not a common practice nationwide. Large health systems and academic medical centers often are better able to bear the burden of low reimbursements from Medicare and to employ fellowship-trained and board-certified geriatricians who may serve in multiple roles, such as provider, researcher, or educator.
Kyle Allen, DO—vice president for clinical integration and medical director for geriatric medicine and the lifelong health division for Riverside Health System, a nonprofit system based in Newport News, Virginia, that includes seven hospitals, a medical group, and a full continuum of care for aging patients—says a patchwork of grants and philanthropy help pay for care of patients with dementia, but it's not enough.
"Geriatric assessment and team management of this illness is evidenced-based and effective," he says. "Medicare does not pay for it. So we can only do so many of these assessments because we can only afford so much of it."
Allen is also part of the administrative team for Riverside Health's Center for Excellence in Aging and Lifelong Health, which looks for and implements programs to help the aging population. He says that approval of a grant request to the Patient-Centered Outcomes Research Institute (an independent nonprofit organization authorized by Congress in 2010) holds what he believes is the most promise for patients with dementia. The grant would fund an initiative to standardize clinical practice guidelines in primary care offices.
Allen says established protocols for evaluation, screening, treatment, and care planning would fill the existing gaps in care and lessen the overwhelming nature that a dementia diagnosis presents to the family members of the patient.
"We have mapped out the workflow of how to do this," says Allen, who also describes the care coordination of dementia patients as a reengineering of the doctor's office. "We started putting together a task force in 2011, and the missing piece was the integration of physicians. And that's where people go."
Allen says PCPs may feel they don't have the resources to address dementia, and in some cases, early warning signs may even go unnoticed. Using guidelines will help the practice staff and physicians understand how to recognize patients who may need to be screened for dementia and what to do with patients who have it.
"For example, if you're a front office manager and Mrs. Jones comes to see the doctor on the wrong day, and she's 70 years old, and she forgets her prescriptions, that should be a warning sign," says Allen. "If we don't train the office staff to do it, they'll just say, 'She's just a confused little old lady.' "
If approved, the grant would fund advanced practice providers, such as a nurse practitioner or physician assistant in Riverside's primary care practices, who would be what Allen describes as a dementia care manager. They've already been piloting practice guidelines and tools in one of its practice locations since November 2013.
"What we've seen is that it takes a lot of time," says Allen. "The challenge is the time, the energy, the training, and how do we scale this across 30 practices?"
We have prepared a grant application that we will send to funding agencies to aid in Riverside Health System's approach to memory care issues. The system's Lifelong Health division is dedicated to the medical conditions that arise from caring for an aging population.
With more than 2,500 employees, the division cares for more than 6,000 older adults daily in their service area, which covers more than a dozen counties in eastern Virginia. There are five fellowship-trained geriatricians on staff, and they plan to hire two more. Allen says 40% of its dual-eligible population has dementia as a diagnosis, and in general, 5% of patients over 65 have some form of cognitive impairment that increases each decade over the age of 65.
Its dedicated program for patients with dementia is called ClearPath, an integrated service model that aims to help patients and families understand what it means to have and live with dementia.
The ClearPath model began developing in 2009 with its memory care households, which are assisted living and long-term care facilities designed to feel like home instead of an institution.
There are five such households. They are small, with only 20 residents, and are meant to be that way so that the space is not overwhelming. The residents have private bedrooms and bathrooms, but there is a common dining hall and kitchen. The smaller, home-like setting of these residences reduces anxiety in patients and families.
"The goal is to enhance dignity and provide the best quality of life possible while offering peace of mind for families," says Bob Bryant, senior vice president of Riverside Health System's Lifelong Health division.
In addition to residences, Riverside's ClearPath program also includes adult daycare, home care, and community-based care.
Bryant says they view a patient with dementia holistically and believe that community organizations, such as the Alzheimer's Association and Area Agencies on Aging, play a key role with the health system and families.
Families of dementia patients often will lean on advocacy organizations for help in securing resources, such as respite care options, education about the disease, or support groups, but Riverside Health also benefits from such partnerships.
Eastern Virginia Care Transitions Partnership—a coalition of five health systems, including Riverside Health, 11 hospitals, and five Area Agencies on Aging—helps patients transition from hospital to home with a health transitions coach. The coaches are funded by federal dollars that are awarded to community-based organizations, which means there is no financial outlay for Riverside Health.
"This is very different from case management," says Allen. "With the Eastern Virginia Care Transitions Partnership, they have a whole way of motivational interviewing that kind of teaches the patient how to manage their own conditions.
"The coach sees them once in the hospital, once at home, and then there are two phone calls. It's a 30-day intervention, and has been very effective at reducing 30-day readmissions by 9%–10%."
Riverside Health is attempting to build a longitudinal continuum of care for patients with dementia that improves the quality of life for the patient by bringing together clinicians and communities.
"It's a team-based approach; it's about getting the physicians, nursing, social workers, and the families together as a team around these illnesses and doing it in a way that we improve quality, service, and reduce costs," says Bryant. "We need to continue the innovation of new services, programs, and models of care that can deliver on the triple aim of improved outcomes, better experiences, and reduced costs."
Reprint HLR0614-8
This article appears in the June 2014 issue of HealthLeaders magazine.
Froedtert & the Medical College of Wisconsin, a network of three hospitals and 30 clinics, has intentionally avoided lumping women's health services together under one department and puts its focus on population health.
With all the attention primary care physicians get—their declining numbers amid an increased demand to cope with more insured patients and their leadership needed to accommodate the rise of patient-center medical homes—it is easy to overlook that obstetrician-gynecologists are facing similar pressures while providing similar care.
Like primary care providers, ob-gyn physician numbers are also falling. The American Congress of Obstetricians and Gynecology estimates a shortage of 9,000 ob-gyns by 2030. The declining numbers, says ACOG, are due, in part, to physicians retiring and to the cap on federally funded residency slots.
And just as primary care providers who are leading care teams, ob-gyns are stepping up as leaders to coordinate care for women. In some cases, the approach is trumping the care model that places women's health under one roof.
For example, Milwaukee-based Froedtert & the Medical College of Wisconsin, a network of three hospitals, including an academic medical center and 30 clinics, has intentionally avoided lumping women's health services together under one department.
"We're focused on population health," says JoAnne Hill, MD, JoAnne Hill, MD, medical director of care management and patient experience for Froedtert & the Medical College of Wisconsin's Community Physicians. "We're not doing something specifically for women. Our focus is to risk-stratify populations to deliver the most appropriate care."
Hill says the development of patient registries through its electronic health record allows physicians to catch gaps in care. If a woman misses a breast cancer screening, the physician knows, and can follow up quickly.
Holistic Care
"We continue to advance those registries so it's capturing more holistic care," says Hill. "We also know a lot more about them. We know if they're diabetic."
Diabetes is a particular area of research for Timothy Klatt, MD, head of the division of general obstetrics and gynecology and chief patient safety and quality officer. Klatt, who also sees patients, is at the center of health care for women.
He retains his focus on providing traditional ob-gyn care, but explains that because of focusing on women's health before conception, he is able utilize resources outside of that traditional sphere to care for his patients' health holistically.
"We get to meet the cardiologist, the endocrinologist, the neurologist, all the people in the different specialties," says Klatt. "We have not only professional relationships, but personal relationships that make the referrals and information flow work in the best interest of our patients."
Focus on Prevention
Klatt's focus on a woman's health before she becomes pregnant, specifically her blood sugars, is due to his interest in reducing preventable birth defects, such as cardiac and neural tube defects. The American Diabetes Association recommends a glycohemoglobin level of <6.0% before conception. If that level exceeds 7.0% the risk of birth defects increases.
Klatt says providers already have a good relationship with endocrinologists and other specialists who can help a woman who is already pregnant with high blood sugars. But he aims to coordinate care further with the system's primary care physicians because the birth defects can be deadly.
"From the referrals we get in, it's really disheartening to be on call in the middle of the night covering a transfer of a baby with a major cardiac problem and see that the mom's sugars were elevated at the time of conception, and think, 'That was possibly preventable.' That's where urgency for change is coming from," says Klatt.
The Clinical & Translational Institute of Southeast Wisconsin recently awarded Klatt a $25,000 grant that is aimed at reducing birth defects by identifying women with elevated blood sugar levels before getting pregnant, and by coordinating care with primary care providers, where appropriate. But in some cases, Klatt acknowledges, that an ob-gyn may be the de-facto PCP for women.
"The hard part for the primary care docs is they have to focus on so much," says Klatt. "A diabetic specialist may be so focused on her kidneys or other aspect of the diabetes that they just miss she's not effectively preventing pregnancy."
Data Mining
Highly coordinated care at Froedtert & the Medical College of Wisconsin is the norm. Nearly all of the system's 27 primary care practices are recognized by the NCQA as Level 3. Primary care providers, like Hill, are routinely diving into the EHR to identify care gaps.
Klatt's grant will dive even deeper to "mine" the database to find women, aged 18-45 with high blood sugars, and make that information available real-time. A preliminary look at the data showed more than 600 women who fit that profile.
The ultimate goal is to reduce preventable birth defects. But by working across specialties, Klatt may end up being an alternate door to enter the health care system, at least for women.
"Who knows where we get to touch the patient in our healthcare system?" says Klatt. "Sometimes the first time we catch them is when they come on a helicopter through our ER."
As insurers step up efforts to cover more lives with value- and performance-based contracts, physicians are under the gun to adapt to an altered reimbursement reality.
Cigna has met its goal of covering 1 million healthcare consumers under its quality and performance-based reimbursement model called Collaborative Accountable Care (CAC) arrangements, the insurer announced this month.
The Bloomfield, Connecticut-based payer has 100 such arrangements with large physicians groups in 27 states. Cigna's National Medical Executive for Performance Measurement and Improvement, Dick Salmon, MD, says large groups were targeted because they had the resources, organization, and capabilities to manage population health.
"Since 2008, we have been focusing on large physician-led organizations, including multispecialty groups, primary care groups, IPAs and the physician leadership in integrated delivery systems and PHOs," says Salmon.
"However, our research indicates that just 20% of customers with high cost conditions or complex needs receive care from a large physician-led organization, so we know that focusing on just large physician groups isn't enough."
Salmon says Cigna has expanded its reach to include smaller physician groups with small "test-and-learn" pilot projects in select markets.
Cigna is not the only large insurer refining its reimbursement approach to accommodate a value-based healthcare system. Aetna, Humana, UnitedHealth, and others are aggressively pursuing strategies that pay providers based on quality and cost-containment.
What's in a Name? These risk-sharing agreements are called various things from accountable care organizations to bundled payment initiatives. And while the range of reimbursement models do have some important differences, the thread that unites them all is rewarding for improvement in health outcomes and costs.
The transition to value-based purchasing is far enough long now to assume that while an ACO might not be called an ACO five, 10 or 20 years from now, the reimbursement model it is trying to become will be in some incarnation in the future.
Larger physician groups, as Cigna is betting on, have the resources to be positioned for this transition, but smaller physician groups are either not ready or capable, according to a March study from the Journal of Health Services Research.
The study found that 60% of physician practices were not participating in an ACO; 25% did belong to an ACO, while 15% planned on joining one in the future.
And even though the study showed that more than half of physician practices were not part of an ACO, the study's authors indicated that figure was high not necessarily because doctors had turned up their noses to the payment and care delivery model (though there are more than several examples of physicians and physician groups avoiding ACOs and similar arrangements).
Instead, the study concluded that based on its more than two dozen indicators measuring care management, quality, and other patient-centered medical home processes, physician practices that were not in an ACO scored lowest.
With the study's sample showing that if practices with more than 100 providers, it indicates smaller practices aren't ready to participate in an ACO.
Size Matters Las Vegas-based HealthCare Partners Nevada is very familiar with providing value-based care. As a network of more than 200 primary care physicians and more than 1,300 specialists, Todd Lefkowitz, senior vice president of managed care operations and network development, says nearly half of its 250,000 unique patients are in some sort of value-based contract.
"Nationally, employers can't continue to incur double-digit increases in their second largest expense," says Lefkowitz. "By 2016, our goal is to move the majority of our contracts, particularly primary care contracts, to risk-based."
Healthcare Partners Nevada is one of Cigna's CAC partners. It was also one of the Medicare Pioneer ACOs, though now Lefkowitz says it's converted to a Medicare Shared Savings Program. The large, multi-specialty practice also has other value-based contracts with other payers. He says while the arrangements aim to reach have similar goals, the cost and quality metrics are not the same, and that can be a challenge for physicians.
"Nevada doesn't look like other CAC's (Cigna's model)," says Lefkowitz. "We have huge, self-funded clients, the casinos. The incentives are aligned for the patient, provider, and employer. For the first full year, we did slightly improve on quality, and we produced shared savings. We split a percentage of those savings with the employer group."
HealthCare Partners' achievement with Cigna mirrors the results the insurer found among its participants: 73% on average had 3% better than market average in total medical cost; 2% had better than market average in quality.
Lefkowitz says its cost savings were, in fact, much better than the 3%; he puts the savings closer to 18%.
Risk-based Arrangements Inevitable Cigna's milestone of 100 CAC contracts is likely a notch in what is likely to become old news. More insurers are moving to risk-sharing arrangements, and they're being aggressive about strategy.
Already this year, UnitedHealthcare announced that $27 billion of its annual reimbursements to physicians and hospitals are tied to accountable care and performance-based programs. By 2018, UnitedHealthcare is hoping to increase that to $65 billion.
Independence Blue Cross, which is in 24 states and Washington D.C., reports that nearly 90% of the providers in its ACO payment model lowered readmission rates by an average of 16%.
Lefkowitz attributes the high rate of adoption at his practice to HealthCare Partners Nevada's long history of managing care with an eye toward value rather than fee-for-service. In fact, in 2006, the group terminated all 12 of its FFS contracts and went to a 100% global risk arrangement. They were working exclusively with a Medicare Advantage payer.
"It was a very difficult decision to make, but at the time we realized the way the organization was structured, in terms of providing more resources in our clinics, we were not able to effectively provide the same care that we would in a value-based arrangement," he says.
The practice stayed at risk for three years before acquiring a primary care practice that was mostly FFS. It swung them back into what is more likely a truer reality for other practices across the country: practicing medicine two payment models.
"It was our goal not to displace patients," he says. "And while 50% of our patients are in FFS arrangements, over 80% of our revenue comes from value-based reimbursement. I don't know if it's realistic to think 100% of the reimbursement will be value-based."
In its recommendations, the AMA cements what providers have been hearing for years: Telemedicine needs more regulation and reimbursement.
In what is seen as its biggest step forward in acknowledging the value of telemedicine, the American Medical Association issued, in early June, a list of eight policy recommendations for providers who provide telemedicine services to follow.
The AMA's suggestions include establishing a "valid patient-physician relationship" before telemedicine services are provided; requiring physicians to be licensed in the state where the patient who is receiving telemedicine services resides; transparency in services and cost, as well as encouraging more reimbursement, research, and support for telemedicine pilot projects.
The overall message received by the telemedicine provider community was a reflection of what other organizations, including the American Telemedicine Association, have been saying for years about telemedicine: It needs regulation and reimbursement.
"The policy, as a whole, is a good one," says Ben Green, MD, a medical director at Carena, a primary and urgent care telemedicine provider based in Seattle. "The fact that the AMA has recognized telemedicine is great. It's an excellent step in the right direction. We need better evidence, and clinical practice guidelines for telemedicine."
The ATA also commends the AMA's policy recommendations. ATA CEO Jonathan Linkous says the AMA and ATA have had "positive dialogue" over the years, but calls this step major progress.
"We have a good working relationship with them for the first time in 20 years," he says.
The one sticking point the ATA has with the AMA's recommendations is requiring physicians to have a license to practice in each state where their patients live. The suggested requirement is a barrier, says Linkous, because people become attached to their doctors.
"Take snowbirds, for example," says Linkous, referring to the seasonal travelers who leave behind the snow for sand in winter. "We're saying patients should have the ability to choose their physicians."
Green, an ATA member, calls the requirement limiting, but not a barrier. Green is one of more than a dozen providers at Carena who deliver telemedicine care in six states: Washington, California, Illinois, Missouri, Kentucky, and Nebraska.
"The policy is a good one," Green says regarding the AMA's stance on state licensure. "We've been able to get our providers licensed in those states, but it takes time. It's not a new issue. We're all hoping for improvements."
There are two proposals circulating that would ease the state-by-state licensing requirement. The one that Linkous holds out hope for is reciprocity, where one state recognizes the license of provider in another state. That's the easiest approach, but likely to encounter stiff resistance from state medical boards.
Another proposal is from the Federation of State Medical Boards, which creates a simplified pathway to get an out-of-state license to practice. Under the FSMB proposal, willing states would step forward and enter into a compact.
Providers would have to fill out one set of forms for an out-of-state license. They'd still have to pay the individual state medical board fees, but the paperwork would be reduced.
Karen Rheuban, MD, director for the University of Virginia Health System's Center for Telehealth, and past ATA president, says the AMA's strict policy stance is understandable and sound because it protects patients. She says:
The AMA and the Federation of State Medical Boards have taken this position so to ensure the ability of the boards to respond to complaints and enforce actions against providers. The Federation is in the process of developing an expedited licensure process that still will require any physician who provides services in another state to obtain a license in that state, albeit more quickly. Once implemented, we look forward to working with the Federation and our Board of Medicine to determine the success of this new process. There are many patients who can benefit from consulting with providers in another state, and as compared to true licensure portability, this new process still risks being time consuming and costly to providers, albeit very much an improvement.
Telemedicine policies on regulation and reimbursement vary state-by-state. In some states, obtaining a license is relatively easy compared to others. For that reason, Green says Carena works with states "friendly" to telemedicine. Some insurers do pay for some telemedicine services, including Wellpoint, Aetna, and Medicare, and Medicaid.
The adoption of telemedicine as a viable access point to providing care has moved more quickly than legislators and state medical boards, but the AMA's policy recommendations are a shot in the arm to telemedicine, despite the state licensing requirement, says Linkous.
"Even though there are some issues where we disagree, we both agree on appropriate regulation, reimbursement, and some of the other rules," he says. "In all honesty, we have a better relationship with AMA now."
When behavioral health providers and primary care physicians work closely to coordinate care, the integration of mental health care with primary care doesn't have to break the bank.
Physicians who are resistant to treating patients with mental illness may soon have little choice but to embrace what some organizations believe will be the new normal—the integration of behavioral health into primary care practices.
The federal government will soon announce as much as $50 million in grants to healthcare organizations willing to make the accommodation. It's one of several signs that health systems may be getting prepared for an incoming wave of patients because of mental health parity.
The Health Resources and Services Administration says it's expecting fund at least 200 organizations with the grant. The federal agency says it received 600 applications. HRSA and the Substance Abuse and Mental Health Services Administration (SAMHSA) have been working together along with the National Council for Behavioral Health through the Center for Integrated Health Solutions to improve the health of patients who have both a chronic physical disease and mental illness.
Encouraging primary care and mental health providers to work more closely together is a growing trend. Carolinas HealthCare System announced this year it would integrate mental health into its 250 primary care clinics, and Harvard Medical School's Center for Primary Care continues to push the same approach with its Academic Innovations Collaborative partners.
Another major indicator that behavioral health providers and physicians are expected to begin working more closely to coordinate care comes from the 2014 patient-centered medical home standards released earlier this year.
"We began the integration of behavioral health with changes in 2011 but did evolve further for 2014," says Apoorva Stull, spokeswoman for the National Committee for Quality Assurance, the organization that determines the level of PCMH recognition an organization receives.
In 2014, PCMH standards for behavioral health include disclosing to patients the scope of behavioral health services available at the PCP location and establishing at least one referral relationship with a behavioral health provider. Stull says on-site integration isn't required, but is rewarded in scoring.
Beyond 'See-and-Refer'
Integration is a different approach than previous attempts at coordinating care through co-location, an improvement because the patient needing mental health help was referred to someone closer, often down the hall or at least in the same building, but co-location remains a treat-medical-issue-and-refer-mental-issue model.
Behavioral health integration means a psychologist, psychiatrist, licensed clinical social worker, or the like is available, sometimes immediately, to help a primary care physician and patient sort through the emotional response a patient may be having to a medical diagnosis.
Melissa Cormier, a licensed clinical social worker and clinical program manager for Maine Behavioral Healthcare, an integrated network of mental health providers serving patients in 11 counties across Maine, cites a recent example in one MBH's primary care clinics with a diabetic patient whose AIC levels were up significantly.
"The provider asked her what was going on, what had changed, and she said, not too much," says Cormier, adding that the patient indicated she was stressed. "The provider asked her a little bit more about her stress and she said, 'When I stress, I eat, and I probably eat the things I shouldn't.' So the provider was able to say in that moment, 'I have a colleague here, and she works with different ways to manage stress. Would you like to meet her?' "
Cormier was that colleague the provider identified, and she says she is now working on helping the patient work through different stress management techniques.
"That's a patient that wouldn't necessarily have a major depressive episode, she wouldn't have [self-] identified, wouldn't have come in to her provider, and said 'I'm depressed,'" says Cormier. Yet, "she was depressed. She had a huge amount of stress that was impacting her health."
Keeping Body and Mind Together
When patients with a diagnosis of diabetes, chronic pain, or other disease also have a mental illness, even a mild depressive episode, it is harder to for those patients to take care of themselves, which worsens their other medical conditions. The cost to health systems is enormous, and so is the cost to the public because many Medicaid patients have these comorbid conditions.
MaineHealth, the nonprofit integrated health system, which includes MBH, found its champion for integrating behavioral health into primary care in Neil Korsen, MD, medical director of MaineHealth's mental health integration program.
"There is good evidence that the referral process from primary care to specialty mental health care often breaks down," says Korsen. "The integrated clinician is a bridge that can help a patient who is ultimately going to need longer term treatment than we tend to provide in primary care."
Primary care physicians are used to seeing patients present with mild depression or anxiety in their offices, and that is one audience this integration initiative can help. Patients with diabetes, chronic pain, obesity, or who are abusing drugs and/or alcohol are the other populations that Korsen and others believe can be helped with behavioral health integration.
"We have demonstrated in almost every practice… that a half-time LCSW can be sustained with a modest level of productivity," says Korsen, who estimates nearly 30 behavioral health clinicians, mainly LCSWs, are now working across 40 MaineHealth primary care practices.
Korsen says the practices are breaking even financially, despite a recent media report about high executive pay in the wake of $2 million in cuts at a MaineHealth affiliate.
Dennis King, CEO of Maine Mental Health Partners, which has merged into Maine Behavioral Healthcare, attributes the break-even status to intricate planning and knowledge of proper use of behavior codes. Reimbursement is still a major challenge, but so is caring for a patient with a fragmented system.
"We took one person's [mental health] journey for 18 months and used post-it notes to document their care," says King. A banner marked with red, yellow, and purple post-its documented:
18 registrations
9 clinical assessments
17 treatment plans
20 providers
16 discharges
"The chart was 15-feet long. We calculated that we'd be able to reduce it by 2 feet. It shows how much duplication there was in our system."
A new system debuting in 2015 will both reduce the care providers and repeat interactions. There will be one registration, clinical assessment, and treatment plan, all able to be fine-tuned and changed with the coordination of a care team.
But the duplication goes beyond being a cost issue to the system. Kind says it's also harmful to patients.
"Can you imagine what it's like to have explain 10 times how your uncle raped you? It's re-traumatizing," says King. "It sounds like a small thing, but it's a big thing to a mental health patient. The human aspect of this [initiative] is pretty powerful."
The transition to value-based healthcare requires strong physician leaders. Physician engagement is the most critical factor for ACO success. But financing and working across the care continuum are challenges for physician-led ACOs.
An accountable care organization (ACO) in Palm Springs, FL, could very well be a model for designing a successful physician-led ACO. This format accounts for a more than half of the ACOs operating now, according to survey results published this month in Health Affairs.
Palm Beach ACO, one of the first to be part of the CMS Medicare Shared Savings Program, was one of 29 ACOs that generated enough savings to merit a bonus payment. It received an $11 million bonus for generating $22 million in Medicare savings. Like most of the other MSSP ACOs that received a bonus payment, Palm Beach ACO is led by physicians. It's also owned and operated by physicians, a characteristic that the Health Affairs article points out is increasingly common.
Study shows most ACOs run by docs
The study authors, who are primarily affiliated with the Dartmouth Institute for Health Policy and Clinical Practice, surveyed 173 ACOs, including those established through CMS, Medicaid, or commercial payers, and found that 51% of respondents self-identified as being led by physicians. Thirty-three percent indicated leadership was jointly held by physicians and hospitals. Just 3% said they were hospital-led only; 13% said they were led by another entity. In addition, the survey noted that physicians held the majority of board positions across various ACO types, whether physician or hospital-led.
The study also identified common characteristics of physician-led ACOs:
Most are participating in MSSP, not the Pioneer ACO program
They are less likely to include a hospital, federally qualified health center, or rural clinic
They are less likely to provide emergency and post-acute care services
"From the Pioneer [ACOs}, where they saved money was by moving patients to a lower-acuity setting," says Muhlestein. "They have a strong primary care component … and can drive change from the outpatient side."
But hospital-led ACOs face a more difficult task because they can't sacrifice inpatient revenue, so the component of care hospitals have to change is on the outpatient side, Muhlestein points out.
In contrast, physicians already are front-and-center with outpatients, which may be one reason physician-led ACOs are growing in number and may be better at capturing savings, says Ellis "Mac" Knight, MD, senior vice president and chief medical officer for Coker Group, a healthcare consulting firm.
"Physicians are closer to the frontlines of care delivery," Knight told me. "Physician engagement is the most critical factor in any ACO, and when physicians are running the show, it cuts down on the layers of bureaucracy that can bog down ACO operations."
Knight says an ideally structured ACO is a clinically integrated partnership that includes physicians and hospitals. He notes that hospitals have the capital to fund the significant costs an ACO requires, both at startup and for maintenance. The Dartmouth Institute study mirrors Knight's outlook, noting finances as one of the challenges that physician-led ACOs face in the future, despite some early success.
Another challenge that physician-led ACOs face is managing patients across the continuum of care. ACOs being run by doctors are less likely to include all the services—acute-care, behavioral, and pharmacy—a complex patient may need. Without these potentially key healthcare components, the gaps could exist for medication compliance and/or referrals, the Dartmouth Institute study says.
With physicians and physician groups increasing their participation in ACO models, they are extending their reach into partnerships with other care providers and payers. Strong leadership skills will be essential to navigating those relationships.
Thanks to healthcare reform, there are now more eyes on how doctors treat their patients and more opinions on how they should be treating them. But one physician leader says the pressure doesn't necessarily mean that doctors have to be on the defensive.
All working professionals, from writers to physicians, have a preference for the way their work gets done, but a doctor's penchant for how he or she cares for a patient is increasingly coming under scrutiny.
First, there are cost and quality pressures from hospitals, health systems, and payers as a result of the value-based healthcare transition that affects how physicians practice, not to mention public pressure on how much physicians get paid with the recent release of Medicare payment data.
Then there are the efforts to standardize patient care among providers in hospitals, group practices, and health systems in an effort to improve quality.
All of it leads to more eyes (and opinions) on how doctors care for patients, which can be uncomfortable.
Kevin Wheelan, MD, chief of staff and co-medical director of cardiology for Baylor Heart and Vascular Hospital, a joint venture hospital within Dallas-based Baylor Scott & White Health, says the pressure doesn't necessarily mean that doctors have to be on the defensive, or have an adversarial relationship with leaders.
Rather, Wheelan looks at the issue through a different lens. Without uniformity of care, quality can suffer, and patients leave confused. "Ten different sets of discharge instructions sets up [the hospital] for inconsistency," he says. "If the patient doesn't leave the hospital with a well-articulated game plan, that could lead to an unscheduled visit to the ER."
That's code for readmissions and possible penalties. Reducing both requires better communication with the patient, which Wheelan says has improved at BHVH with better and easier-to-understand discharge instructions.
"The tools have improved in terms of more detailed collateral materials as a resource for patients to refer back to," says Wheelan.
In addition, Wheelan says BHVH has also enhanced medication reconciliation by having both a nurse and a physician review what medicine a patient is taking at home that could interfere with medication prescribed upon release.
The post-discharge appointment is also a more focused discussion, says Wheelan.
"Instead of telling a patient, 'See you within 30 days,' for example, the goal is to have a follow up appointment scheduled, so it's not a nebulous concept of when they're returning."
Follow-up phone calls also help reduce readmissions and anxiety from patients. The phone calls are also a data mining exercise that shows variance among physicians. It's not intended to be an exercise in checking up on physicians, but it has helped standardize care and reinforce a culture of teamwork.
"We keep track of all of these phone calls," says Wheelan. "We have a document typed up, blinded to the patients' names, and those results are provided back to the physician leader and the physician practices for an opportunity for improvement issue."
Using data to show a variance can take some of the sting out of a difficult conversation with a physician. It helps, says Wheelan, that physicians see exactly what a patient is saying.
"It gives [physicians] a different insight," he says. "The doctors get to see types of concerns the patients have."
Wheelan says BHVH's system isn't not perfect. There are still difficulties with weekend discharges, but he says setting a specific follow-up appointment time is the biggest change since BHVH opened in 2002. But it didn't happen easily because of physician preference.
"It's an issue of compromise," says Wheelan. "You have a group of physicians who say, 'I need to see a patient two days post-op,' and another group who says they need five days. So we have to come to an agreement that we will see the patient within 2–5 days."
Getting standardization among physicians is difficult, admits Wheelan, but it's also an opportunity for physician leaders to emerge because "someone has to be a champion," willing to track down the other physicians and get buy in for clinical protocols.
Using data to accompany a potentially hard conversation about performance is an approach that is also used at Southwest General Health Center, a 354-bed hospital in Middleburg Heights, OH.
"Physicians tend to be logical, numbers-driven people," says Jill Barber, director of managed care operations and revenue integrity for Southwest General. "When hospital administrators meet with doctors, we talk in great platitudes, and it's easy for physicians to say, 'Well, my patients are sicker.' Data takes out the emotion. It can be a moment of shock."
Also like BHVH, Southwest General uses verbatim comments from patients to give physicians insight into patient satisfaction. "By sharing with them the actual comments, it brings it home," says Barber.
They key to delivering information unemotionally is using a physician leader as the messenger. It's what BHVH and Southwest General rely on because it is peer-to-peer, and more "collegial" rather than punitive, says Barber.
Physicians also have to think differently in a value-based era of healthcare, explains Wheelan.
"The important mental transition that has to occur within physicians is, 'This is about a team concept and approach to care. It's not just about me and why I think is best for my patient.' That's a problem some physicians have."
It's a problem they'll likely have to grow out of, too, in order to withstand the pressure, opinions, and eyes that are watching.
The new president of the American Medical Association, Robert Wah, MD, says he is "beyond frustrated" that the sustainable growth rate formula has not yet been repealed, and says finding a way to pay for it is the job of Congress.
Robert Wah, MD
Robert Wah, MD, inaugurated this week as the 169th President of the American Medical Association at the organization's annual House of Delegates meeting in Chicago, is a busy man.
Wah teaches and is a practicing reproductive endocrinologist and obstetrician-gynecologist at the National Institutes of Health and the Walter Reed National Military Medical Center, both located in Bethesda, Maryland. He is also chief medical officer for Computer Sciences Corporation, a Falls Church, Virginia-based technology company.
Nationally recognized for his technology expertise, Wah was the first deputy national coordinator for the Office of the National Coordinator for Health Information Technology (ONC) at the Department of Health and Human Services. He also served as a captain in the U.S. Navy Medical Corps for 23 years.
The first Chinese-American president of the AMA says one of the biggest challenges ahead of him is the same one that his predecessors also had: repealing the Medicare sustainable growth rate physician payment formula. He spoke with me this week about the work ahead.
Q: What concerns have you heard from physicians at this year's AMA House of Delegates meeting?
Overall, there is some trepidation about change; change is always a challenge for people. I personally like to look at change as an opportunity as opposed to a challenge. I would also say that we're very interested, as physicians, in making sure that we craft a delivery system that leads to better care for our patients in a more cost-efficient, cost-effective way.
I'm a little frustrated sometimes when we spend so much time talking about payment reform. We don't talk enough about delivery reform.
There is a clear intersection between delivery and payment, but we need to move the needle a little bit more and talk more often about how to deliver better care for our patients earlier in the conversation because oftentimes it leads to us just tinkering with the payment system and then seeing what happens on the delivery side.
Q: There is frustration that the SGR has not been repealed and is still a temporary, so-called "doc fix" Can you comment?
First, I'm on a one-person campaign to stop the phrase, "doc fix." I believe Medicare needs fixing, not doctors. All physicians and Medicare patients should be frustrated that Congress is not taking action definitively on the problem we have with the Medicare payment system, particularly with the SGR. It's been with us for many years. They just passed the 17th patch, and yes, we are beyond frustrated.
Q: The Florida delegation lined up significant support to have the House of Delegates take over control of the lobbying efforts of the AMA. Ultimately, that resolution failed. But do you believe the move reflects frustration that nothing permanent has come out of AMA's longstanding efforts to repeal the SGR?
It's important to note that the AMA has made progress on this [SGR]. Obviously, we're still frustrated that we haven't gotten the final goal of repeal, but there has been significant progress. We were encouraged by the fact that for first time in many years, we had bicameral support.
Both the U.S. House and the U.S. Senate worked together to craft a plan that had bipartisan support. The legislative process is very challenging, and so to navigate both sides of the aisle and both houses is a significant achievement.
We believe we have momentum this year, partly because the Congressional Budget Office has given us a better score in terms of lowering the overall cost of repeal. We also galvanized the federation of medicine. We had 600 organizations sign on to letter to Congress asking for repeal this time.
Q: The AMA has maintained that its role in repealing the SGR is from a policy perspective only, and it will not intervene in how to fund an SGR repeal proposal. Will the AMA continue to remain silent on how to pay for the SGR?
We will continue to expect Congress to do its job. And its job is to make those choices.
We believe they have many choices to make to pay for this. We also believe they haven't taken that step and they need to. It's their job to fix that part of Medicare.
We understand they have many challenges, but that's what they're hired to do, and we also believe they do have choices to find the funding, to make this happen. We'll work with them in any way we can, but ultimately it is the job of Congress to make those budgetary choices.
Q: As the first deputy national coordinator for the ONC, you're more than qualified to be the messenger for increasing the use of technology among physicians. How do you plan on using your background and expertise in health information technology in your role as AMA president?
A: I do have a background that is a little bit different than many physicians. I've had the privilege and opportunity to see HIT at a large scale. But, I can also talk from the perspective of a practicing physician. That's what I hope to do. I am very aware of the issues physicians face in their offices with technology, but I also know how large scale deployment of HIT can work.
I see an opportunity to have a rich conversation across policy makers, vendors, and physicians to make sure we're getting what we all want. Sometimes we get too focused on the close-up problems, and don't keep in sight the top goal, which is using technology to take better care of patients. I'm a big believer in consensus and then moving forward.
Q: What do you hope to accomplish during your term?
I hope we make significant advances in our advocacy agenda, and the SGR is certainly at the top of that. I am still optimistic that we will be able to take that momentum that we created over the last 9-12 months and get the SGR repealed finally this year. That's a huge aspiration, but I hope it's obtainable during my term.
I also really want to make sure we continue the robust conversation in the use of technology to take better care of our patients. I have a background in HIT, have had great opportunities in the Department of Defense, Health and Human Services, and see the power of how technology can improve patient care for my physicians.
I am also excited to talk about physician satisfaction. This is a great profession. We've been frustrated, certainly. There are a lot of challenges, but I'm still very optimistic about the profession of medicine. We shouldn't see change as such a challenge. It should be seen as an opportunity.