An operator of 14 Chicago-area MRI centers will settle allegations they paid illegal kickbacks to doctors to win patient referrals, Illinois Attorney General Lisa Madigan's office confirmed. Under the settlement, Virginia-based MIDI LLC will pay $1.2 million, much of it to fund state grants for low income patient care, and is prohibited from paying referring doctors under what the centers called "lease agreements" or "technical service agreements." Madigan's office alleged the agreements were shams merely used to pay doctors to refer patients to the centers.
Physician-owned hospitals in Texas will infuse $2.3 billion into the state's economy this year, the largest projected economic impact by such hospitals in the nation, according to a study. Texas physician hospitals also will pay close to $86 million in property, payroll and income taxes this year, according to Health Economics Consulting Group, the Morristown, NJ-based health policy research firm behind the study. Many of the state's largest nonprofit hospital systems have partnered with physicians to create joint venture models in which the nonprofit and physicians share ownership.
At a time when many hospital expansion and improvement projects are on hold, the New England Rehabilitation Hospital in Woburn, MA, debuted a renovation to keep business up and patients confident in its services. While the $1.1-million project didn't expand the facility, increase services, or replace medical equipment, the upgrade to the cardiopulmonary wing has created a more comfortable place for patients to stay and a more efficient workspace for hospital staff. Hallmark Health System, which has hospitals in two Boston-area communities, has no planned improvements for 2009 or 2010, rather it will invest in its quality of care such as through recruiting and retraining healthcare professionals.
The Center for Fibromyalgia, Fatigue and Chronic Pain said it would close its three Chicago area locations, citing the economic downturn and a dip in payments from insurance companies. The closure of the center means 500 patients will have to find alternatives for care, said Michael McNett, MD, a family physician who ran the clinics.
The second interim report of the Medicare Health Support (MHS) project, released to Congress just before the new year, brings into better focus why CMS ended the disease management project last year.
Looking back at the first 18 months of the three-year MHS pilot, the report found that DM programs did not save money, improve beneficiary self-management, and physical and mental health functioning, or cut acute care utilization or mortality. None of the companies involved in the pilot reached the targets that would warrant program expansion as the programs did not improve clinical quality of care and beneficiary satisfaction, or achieve budget neutral spending targets, according to CMS.
Ouch.
MHS was created as the first test of DM in the Medicare fee-for-service (FFS) population, and as these interim results show, it was not a success. In fact, when I asked a CMS official what was learned from MHS, she said CMS did not find much that actually worked. Double ouch.
DM struggled in its first foray into the Medicare FFS population after growing into a more than $2 billion business in the commercial and Medicare Advantage populations, but DM leaders hope the industry can learn from the pilot.
The eight Medicare Health Support Organizations (MHSOs) used the call-center foundation of DM as the primary model in MHS, and supplemented different approaches, such as physician outreach and face-to-face interactions with beneficiaries. So far, through its two interim reports, CMS has not broken down the projects to highlight the MHSOs' different approaches and their affect on quality, self-management, and outcomes.
Gordon K. Norman, MD, MBA, executive vice president, science and innovation, at Alere, a DM company in Reno, NV, and chairman of DMAA: The Care Continuum Alliance, which represents the DM/population health industry, says the industry needs to know: What worked? What didn't work? When it did work, why? When it didn't work, why not and for whom?
"We can ill afford to reject looking at any promising solution just as we can ill afford to throw out any favorable baby with the undesirable bathwater from MHS. There has to be some valuable learnings hidden by this sort of blanket up or down evaluation bias that I think has been portrayed in the first two reports," says Norman.
Though the DM industry as a whole remains in the dark about the answers to Norman's questions, the MHSOs did learn from the project and tweaked programs to better serve both the FFS population and their larger patient population.
I talked to two Health Dialog officials about the project and they provided three takeaways the Boston-based DM company learned from participating in MHS:
Target the right people for interventions and support those patients with the appropriate services. Those involved in the project say the FFS beneficiaries selected to take part were from a much broader health status than initially expected. Instead of including only those who would benefit most from a DM program, MHS included individuals from the either health extreme: those who were healthy but suffered a brief health setback when CMS created MHS and those who were at the end of life and institutionalized. Neither of these groups are the typical people who gain from DM programs. Healthier individuals do not need intensive programs, while the sickest are not able to reverse their conditions. To take this to the larger DM population, companies must remember to target the right people with the proper individualized program. Otherwise, the intervention will be too costly and wasteful.
Get timely information so you can reach at-risk and recently discharged patients as soon as possible. Reaching patients shortly after discharge or diagnosis (or even better during hospitalization or when they are at-risk of disease) plays an important role in whether you can change a person's behavior. The MHS project was hampered by a claims lag with MHSOs not receiving timely hospitalization and medical claims data. Not connecting with beneficiaries promptly meant some beneficiaries' health slipped further, making effective change difficult. Waiting until after that window of opportunity is closed means the person most likely won't be at their highest level of activation and you have lost your best chance.
Providers are an important part of the healthcare team. On its surface, this seems like a no-brainer, but it's a fairly new concept in DM. The industry has learned that in order to achieve lasting behavioral change DM must work together with a patient's physician. This is a key tenet in the medical home model, which CMS will test with its own demonstration starting in 2010. Collaborating with physicians and supplementing patient care with DM programs can close gaps in care, and create a complete healthcare team rather than segments not working together and potentially relaying varied messages to patients. If DM is to remain an active part of healthcare, its future is in supplementing provider care through a sort of medical home model. It can no longer expect to improve patient outcomes and lower health costs without physicians on board.
Those three learnings are exactly what DM needs to hear, but so far CMS has not included that information in its interim reports. MHS' final report will analyze all three years of MHS. It isn't expected until February 2011, which gives CMS two years to develop a report that delves into each of the interventions and provides specifics about what each MHSO offered and how it affected care, outcomes, and costs.
That doesn't mean DM should wait for CMS though. This bump in the road should show the industry that it needs to fund research to test its offerings so the healthcare system as a whole can see what works best for particular disease states.
As I wrote in my column last week, if DM expects to play a role in healthcare reform, the industry must look critically at its programs. MHS' interim results show that questions remain about DM.
The industry can't wait for the final MHS report and hope that the results are better. It must take action now.
Les Masterson is senior editor of Health Plan Insider. He can be reached at lmasterson@healthleadersmedia.com.Note: You can sign up to receiveHealth Plan Insider, a free weekly e-newsletter designed to bring breaking news and analysis of important developments at health plans and other managed care organizations to your inbox.
Health plans have been on a journey of leveraging process and technology to improve access to high quality, affordable healthcare.
Until recently, emphasis has been on optimizing care management and claims processing. Now, there's compelling evidence that the next generation of care and cost improvements will come from innovative provider management approaches.
Provider management is the common success enabler behind health plan initiatives, such as consumer-directed health plans, patient centric medical homes, pay-for-performance, the introduction of new products, and geographic expansion. Leveraging an integrated approach to provider management is the innovation that is propelling health plans forward.
What is Integrated Provider Management (IPM)?
IPM is a three-pronged approach to deliver the next generation of care and cost improvements through:
End-to-end provider process simplification
Collaborative and coordinated patient care
Transparent provider performance and incentive management
Fundamental to this approach is the ability to bring together the provider network view, patient clinical view, and claims view. By harnessing this integrated view, health plans will take the initial critical steps that allow them to facilitate holistic member care planning, innovative network design, and cost reduction. This approach represents an opportunity for a new collaborative relationship paradigm between health plans, providers, and members.
How does IPM reduce medical costs?
A logical first step in managing medical costs is to ensure that providers are reimbursed at the right level. Current barriers include the quality of provider data within the health plan system and the complexity of provider contracts. It's estimated that 2-3% of claims must be re-processed because they are priced incorrectly. The process simplification used in the IPM approach significantly improves provider data quality through automated data integrity enforcement.
The IPM approach promotes the standardization of provider contracts. Having one consolidated view of the provider allows health plans to have more streamlined provider contract negotiations, leading to better contract terms and conditions. There is market evidence of a 1-5% reduction in medical costs driven by improved contract terms and conditions.
Effective provider incentive programs could have a measurable impact on quality and cost of care. However, transparency of quality measurement methods and data is essential to alignment between health plans and providers. The integrated provider view leveraged by the IPM approach enables health plans to both measure and report on quality.
The provider and patient collaboration envisioned by the IPM approach also facilitates better compliance with evidence-based care planning. Connectivity and health information exchange with provider offices, under the IPM approach, enables a single view of patient clinical data and suggested intervention opportunities. Early intervention has been shown to increase the health of patients while reducing their medical costs.
How does IPM reduce operational costs?
The process simplification prescribed by the IPM approach reduces operational costs by increasing staff productivity, eliminating redundant processes, minimizing manual handoffs, and decreasing re-work. This process simplification is largely enabled by workflow automation and data integration.
Once the internal processes have become systematized, it enables the health plans to take those processes and extend them to the providers through self-service portals. Self-service capabilities are heavily sought after from both health plans and providers because they reduce the amount of time both parties need to carry out simple administrative activities.
The systematic recording of the process steps and information under IPM enables analytics. These analytics allow health plans to measure provider workforce performance and proactively identify process bottlenecks. The IPM approach incorporates tools to rapidly re-configure processes and eliminate bottlenecks.
How does IPM reduce provider IT costs?
As with the introduction of most of the innovative technologies on the market today, IPM solutions are allowing health plans to do more with less infrastructure and resources. For example, IPM solutions empower users to make selective changes to workflows, create new business rules and create ad-hoc reports. All of these actions, either in the past or with the existing legacy systems, could not take place without significant internal IT or external consultant intervention. Additionally, once IPM solutions are deployed, health plans have the ability to sunset redundant provider systems.
IPM can achieve savings
IPM enables health plans to turn provider networks into strategic corporate assets. By modernizing the health plan's provider environment through IPM, health plans can achieve greater medical, operational and IT cost savings.
At the same time, the innovative provider management approach allows health plans to execute new programs that answer the demand stemming from new market trends. While the health plan's mission is to ensure members have access to affordable, high-quality care, focusing on the systems and processes that directly affect the agents of care—the providers—is an important next step.
Sam Muppalla is COO of Portico Systems, a Blue Bell, PA-based healthcare technology company that specializes in integrated provider management solutions.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.