A new set of guidelines and recommendations helps healthcare organizations establish policies and programs that promote physician well-being.
A charter published in the Journal of the American Medical Association promotes best practices and interventions designed to reduce physician burnout.
The charter was crafted to provide direction to health systems, hospitals, and physician practices seeking to increase the well-being of physicians, says Jonathan Ripp, MD, MPH, senior associate dean for well-being and resilience at Mount Sinai's Icahn School of Medicine in New York.
"We're trying to provide a framework for policymakers, so they can put practices in place that align with physician well-being. We are seeing large systems adopting these types of practices and policies," he says.
Physician burnout should be a top priority for leaders and staff on moral and practical grounds, Ripp says.
"As a result of the work that physicians and other providers do, they have higher levels of depression and suicide. For this reason alone, physician well-being is important."
"But it's not just that. We now know that physician well-being has several ramifications for health systems: there's lower patient satisfaction, higher medical errors, increased physician turnover, decreased productivity, and increased malpractice," he says.
Physician turnover is financially draining, Ripp says. "If you take any intervention that decreases physician burnout, you are more likely to retain physicians at their practices. Probably one of the highest costs in healthcare is physician turnover. … Oftentimes when a physician leaves a practice, there is a several-month period when no one is in place and there is a shortfall of revenue."
To be effective, efforts to improve physician well-being must include the well-being of coworkers, he says. "We recognize that addressing physician well-being is not just about the physicians, it's about medical students, trainees, and all the members of the healthcare system."
Best practices and recommendations
The effort to draft the charter started in 2016. A medical and research group, the Collaborative for Healing and Renewal in Medicine, spearheaded the initiative. Ripp serves as co-chair of the group.
The charter was published March 29, in an article titled "Charter on Physician Well-being." The document has the support of several national associations, including the American Medical Association and the Association of American Medical Colleges.
The charter's best practices and recommendations are organized in three sections: societal commitments, organizational commitments, and interpersonal and individual commitments. Some examples of the recommendations are as follows:
Healthcare organizations need to make a societal commitment to advocate for policies and rules that foster well-being. Influencing national policies can improve the well-being of physicians such as easing administrative burdens and improving mental health care for clinicians.
Organizational commitment includes an engaged leadership team. Methods that leaders can try to boost physician well-being include having well-being initiatives in strategic planning, using organizational awareness efforts to identify well-being challenges, and adopting well-being metrics into assessments of organizational performance.
Part of interpersonal and individual commitment is rooted in the emotionally demanding role of physicians such as enduring adverse events and patient deaths. Actions organizations can take to ease emotional pressure include adding coping skills to training and continuing education, as well as offering confidential debriefings during the workday.
Researchers call on hospitals to embrace 'culture of health' as well as reforms and care redesign to help address income-related healthcare disparity.
Poverty is associated with higher rates of inpatient stays for pediatric patients, and hospital reforms can help address the problem, according to an article published this week in Health Affairs.
The study focuses on Hamilton County, Ohio, which includes Cincinnati and has a population of about 190,000 children. For the period 2011 to 2016, the researchers collected data from all pediatric hospitalizations at Cincinnati Children’s Hospital Medical Center, then paired each pediatric patient with a Census tract.
"Poorer communities disproportionately bore the burden of pediatric hospital days," the researchers wrote. "If children from all of the county’s census tracts spent the same amount of time in the hospital each year as those from the most affluent tracts, approximately 22 child-years of hospitalization time would be prevented [annually]."
Bed-day is a key metric in the study and is calculated by dividing the number of days that children from a community are hospitalized by the total number of children living in the community.
Bed-day data shows that pediatric patients from Hamilton County's low-income areas are disproportionately more likely to be hospitalized:
Low poverty: 87.7 per 1,000 children per year
Low medium poverty: 113.3 per 1,000
Medium poverty: 130.7 per 1,000
High medium poverty: 144.1 per 1,000
High poverty: 171.4 per 1,000
Addressing Income-Related Disparity
The researchers identified several poverty "hot spots" near the medical center, and the 628-bed facility has launched several initiatives to better serve the disadvantaged neighborhoods.
In Avondale, which borders the medical center on three sides, bed-day rates are more than double the county average. The medical center has targeted Avondale for population health improvement efforts as well as tighter community partnerships with schools, primary care practices, and pharmacies.
The researchers call for a "culture of health" at hospitals as foundational to addressing income-related disparity.
"This may require an expanded focus on inpatient-to-outpatient transitions and community-connected work that gets to shared root causes affecting disparities across conditions and subspecialties. Such an approach may be more fruitful than attempting to tackle disparities condition by condition."
The researchers say that reforms and redesign of care models is needed to serve low-income neighborhoods:
Enhanced discharge services such as filling prescriptions and arranging follow-up appointments with transportation
Addressing social determinants with partners such as social workers and community health workers
Strengthening communication between inpatient and outpatient settings
"In Cincinnati, we have invested in relationships between providers of inpatient and outpatient care; nonprofit organizations; public schools; the local health department; social service agencies; faith-based entities; businesses; and, importantly, parents and families," the researchers wrote.
Over the past two years, IU Health has slashed the cost of hip and knee replacement implants by fostering competition among nearly a dozen vendors.
This article first appeared in the March/April 2018 issue of HealthLeaders magazine.
Through a market-based approach that promotes price transparency and competition, Indianapolis-based IU Health, an organization that includes hospitals, physicians, and allied services, has cut the cost of hip and knee implants by 25% in the past two years.
The following tactics are how IU Health achieved these results.
"We have an open market that encourages competition between vendors," says Anthony Sorkin, MD, medical director of the statewide orthopedic strategic service line.
IU Health's Orthopedic-implant Procurement Enhancement (OPEN) program takes an unconventional approach to lowering implant costs, by declining to select only one or two winning bidders.
"The role the hospitals have played in the past is that they have received proposals or contracts from the vendors, then they have kept them silent and confidential, and a very small group at the health system decides who the winners and losers are going to be," Sorkin says.
"The current mantra across the country has been to isolate down to one or two vendors, and they sign a three-year deal. Then some surgeons are happy and other surgeons are unhappy," he says.
However, cutting three-year deals is often financially disadvantageous, he says. "In a three-year deal, like with any other commodity, the value of that commodity can and will decrease, while the health system is held to the contracted price."
IU Health features 15 acute-care hospitals, and orthopedic surgeons at nine of the facilities have been participating in the OPEN program. For the fiscal year that ended December 2016, the health system posted an operating revenue of $6.2 billion.
Use color-coded transparency
The primary ingredient of the OPEN program is a red-yellow-green implant pricing board that is posted in orthopedic units at each hospital, with red representing the most expensive implants and green representing the least expensive implants.
"You create transparency for both the surgeons and the vendors, then you allow the vendors to do their job, which is to promote sales in a constructive environment. For a standard procedure, whether it is a hip or a knee, about 80% of the costs are in the operating room," Sorkin says. "A significant part of that 80% cost in the operating room is the implants."
As the country's Medicare-eligible population mushrooms, hip and knee replacement procedures are growing steadily, which is generating a growth opportunity at hospitals and health systems nationwide, he says. "If you can create an environment where you can decrease the cost of the implants, then you can improve the financial position in what is a dramatically growing market."
Engage stakeholders
There were two key steps to launching the OPEN program in 2016: physician engagement and vendor engagement.
For more than a year after OPEN's launch, one-on-one meetings were held with surgeons about their performance metrics, surgical supplies, and implants, says Megan Brown, an analyst in the IU Health clinical value analytics group.
"We provided specific metrics to physicians based on their surgeries and their patients, which focused on overall cost, length of stay, and other metrics for quality and performance improvement. In addition to that, we would provide the surgeons with their implants from the surgical logs as well as all of the items that were used in the surgical procedure," she says.
"They were very surprised by the cost of a lot of the items they were using," Brown says.
Quarterly meetings were also held with each surgeon and key members of the surgeon's operating room team to discuss product utilization and cost, she says.
Boost incentives
Sorkin says surgeons were given a financial incentive to embrace the OPEN program's drive for cost efficiency.
"IU Health decided to allow gain-sharing with the surgeons. It's not much money, but it created a general attitude among the staff that they are involved in the process of value-based care, and that helped pull everybody along," he says.
Gain-sharing is based on costs from admission to discharge, with an average cost figure established for IU Health's nine participating hospitals. Surgeons ranking in the top quartile for low cost receive a 20% gain-sharing payment of the savings their procedures achieved.
Sorkin says IU Health's approach to vendor engagement is consciously capitalistic. "What we wanted to do was to open the market to all vendors, then let them freely compete."
IU Health's vendor-engagement strategy for hip and knee implants has been nationwide, and vendors can re-bid at six-month intervals.
"We had all of the vendors come together, and we talked with them all at the same time in a large room," Sorkin says.
"We had 11 vendors in the room from across the country. If we had picked a winner, we would have had one happy company and 10 very unhappy companies. This way, all of the vendors were engaged," he says.
The OPEN program has improved surgeon engagement, helped the health system meet its metrics, and kept vendors happy with opportunities to sell their products, Sorkin says.
"We took a situation where all three parties were in some way disappointed; and now that we are more than a year into our program, all three appear to be doing well," he says.
Give physicians options
Having multiple vendors and implants available to surgeons gives physicians flexibility to pick the best implants for individual patients, Sorkin says.
"This allows our physicians to not be forced to either use a product from a company they are not familiar with or to limit the products that are available to them based on patient needs. A hip replacement in a very active 55-year-old is very different from a hip replacement in a very inactive 75-year-old. All patients are different, so it seemed to make sense to us at IU Health that we should create and foster an environment where the surgeons can do what they are trained to do, which is demand-match products and technology to the various patients."
Having price transparency has led to cost-cutting among vendors and surgeons alike. "No vendor wants to be red. … No surgeon wants to be known as the high-cost provider," he says.
The free-market approach has been a crucial element of the OPEN program's vendor strategy, Sorkin says.
"We told all of the vendors that we wanted all of them to participate, that this was not about winning or losing, and that we were not setting a price. We did not tell them that they had to hit a price in order to participate. We just asked for their best price, and we showed them how the red-yellow-green [pricing system] would look," he says.
"Everybody else wants to pick a winner—that is the take-home message. Whenever you pick one or two winners, you are going to create ill will no matter how you do that," Sorkin says.
A medical group's organizational efforts have improved its electronic medical record's user friendliness.
At Gould Medical Group, a multipronged effort to ease the use of its electronic medical record has contributed to physician satisfaction and low burnout rates.
The physician group contracts exclusively with Sacramento, California–based Sutter Health, which features 20 acute care hospitals.
"Internally within Sutter, which has eight medical groups, we consistently have the highest or second-highest physician satisfaction score, and we have the lowest physician burnout score," says Martin Pricco, MD, MBA, president of Gould Medical Group.
In recent American Medical Group Association survey data, Gould has ranked at about the 75th percentile for physician satisfaction. A decade ago, the ranking was about the 55th percentile.
In addition to enhancing the EMR for ease of use, Gould has taken several actions in recent years to boost physician satisfaction. "We did individualized rounding with physicians and board members, changed the organizational structure within the group, and added leadership talent at the department level," Pricco said.
Enhancing the electronic health record at Gould, which employs 360 clinicians, has boosted physician satisfaction and quality of care, he says. "We're pleased that we have an efficient and satisfied medical group when it comes to the EHR. It contributes to having more satisfied patients and better quality of care, and that is hard to put a price on."
Learning the ropes
Robust training is essential for physicians using an EHR, Pricco says. "Research shows that onboard training is the most important predictive factor in provider success and satisfaction when using the EHR."
Gould provides both classroom instruction and on-the-job training for the EHR. "We realize the value of initial training in our own organization. We typically provide about four hours of classroom training, then about one week of at-the-elbow support," he says.
A key point in the training is data retrieval.
"One of the biggest frustrations that we have heard over the years from physicians is that they can't find what they are looking for in the EMR, and that often happens when they are working directly with patients," Pricco says.
Individual attention
Personalization settings increase a physician's speed and efficiency using an EMR.
"Generally speaking, the less time a physician has to spend on the EHR and gets other work done, the higher the satisfaction and the lower the risk of burnout," Pricco says.
Gould, which uses Epic as its EMR, has launched several personalization setting efforts, such as:
Documentation templates
Text macros for shortcuts
Chart review filters
Customization of EMR pages such as removing unused tabs and features to reduce clutter
Specialty configuration
Specialty-specific customization in the EMR drives significant ease of use for physicians, Pricco says.
"They have the data they need to take care of their patients in their specialty. The other data throughout the EHR is still available but it isn't in the way. This really streamlines the view of a patient from a specialty perspective."
Gould rolled out specialty-specific customizations from 2015 to 2017. It used a team approach to roll out the customizations that included physicians from the specialties, EHR build specialists that included Epic representatives brought on-site, and Sutter and Gould EHR analysts, Pricco says.
The customization efforts had a structured development plan.
"Each team used an iterative process of designing, building, and testing over a three-week period before going live. After the builds went live, there was a six-week follow-up on each build to make sure everything was working properly," Pricco says.
In cardiology, Gould's customized version of the EMR includes snapshot windows such as a lab testing display with test panels, specialty-specific notes, and recent progress notes. The EMR's problem list has cardiology-related problems at the top of the list, with other specialty problems dropping lower.
In-basket management
Gould's EMR in-basket includes several tasks and messages, such as lab results, prescription refills, patient phone calls, and emails.
A cluttered in-basket can overwhelm a physician, Pricco says. "In our internal survey data, physicians who get more than 100 in-basket messages per week are at double the risk of burnout."
One method to taming a physician's in-basket is help from nurses and medical assistants, he says. "They can review the messages and oftentimes take care of them without burdening the physician. For example, on medication refills, we have an RN refill system."
Another key to in-basket efficiency is folder removal or consolidation, he says. "We look at the different folders that compose a physician's in-basket and see which ones can be eliminated altogether or combined to reduce clutter."
Gauging impact
Finance is not foremost in Gould's accounting for its EMR enhancement work, Pricco says.
"We've always viewed the benefits from the perspective of physician satisfaction, physician efficiency, and reduction in burnout. From that perspective, the initiative has been very successful—we've had good physician satisfaction scores and relatively low physician burnout," he says.
Other benefits include higher physician productivity and lower physician turnover, Pricco says. Costs are mainly in the labor category, including training and personalization staff time. In addition, redesigning in-baskets requires analyst and physician time.
Quality improvement teams at physician practices generate gains from including patient partners in the efforts.
Including patient representatives in quality improvement efforts at physician practices benefits both the patient partners and the practices, according to research being published next month.
For patient partners, three quarters of those surveyed reported that they were better advocates for their own healthcare, two thirds reported being more in tune with their health, and more than half reported that being a patient partner improved their caregiving for family members.
For physician practices, 8 out of 10 quality improvement team leaders surveyed reported that patient partners made improvement efforts more patient-centered, 43% of respondents reported that patient partners impacted the implementation of new policies and initiatives, and 35% of respondents reported that patient partners had made suggestions to improve practice communication with patients.
The research, which is being published in The Joint Commission Journal on Quality and Patient Safety, is based on data collected from 2011 to 2016, mainly from patient partners and quality improvement team leaders. The data includes focus groups, in-depth interviews, and online surveys.
The primary focus of the research, titled "How Patient Partners Influence Quality Improvement Efforts," is the patient partner program at Aligning Forces for Quality-South Central Pennsylvania. AF4Q SCPA is a healthcare improvement organization originally funded by the Robert Wood Johnson Foundation and supported now by WellSpan Provider Network, an ACO where most of the AF4Q SCPA patient partners volunteer.
In 2011, AF4Q SCPA started its patient partner program with 14 volunteers in seven physician practices. Last year, there were 77 patient partners working with 45 practices.
AF4Q SCPA is based in York, Pennsylvania, and has patient partners at physician practices spread across four counties: Adams, Lancaster, Lebanon, and York.
Having Impact
The researchers found there are three primary methods for patient partners to impact quality improvement efforts:
Providing feedback
Making suggestions
Symbolism associated with being part of the team
About 91% of patient partners reported being asked for feedback on written materials for patients, which often involved review of draft informational or educational documents. The same percentage of patient partners reported being asked for feedback on new policies or initiatives at a practice.
The researchers found patient partners most often made suggestions in four areas: practice communication with patients, educational materials, physical space, and clinical care processes.
The most common area of suggestion was improving communication with patients, such as the welcoming of patients. "Several patient partners encouraged staff to acknowledge patients when they entered, even if they were on the phone; to be friendlier; and to be clear with patients when they have an extended wait," the researchers wrote.
There is powerful symbolism in having patients represented at office meetings or during conference calls, quality improvement team leaders reported.
"The discussion changes when you have a patient in the room because then it really re-centers you on what you should be doing," an improvement team leader told researchers.
Lessons Learned
The researchers drew three lessons from the study:
Quality improvement team leaders reported that patient participation in improvement efforts was essential to incorporate the patient perspective. Patient partners also advocate for broad patient interests and serve a symbolic role in patient-centered care.
Development of patient partner programs requires time and support. For patient partners, it can take time to learn medical vocabulary. For improvement team leaders, integrating patient partners into decision making is new and unfamiliar, including transparency with patients about troubled areas.
Effort is required to recruit patient partners who are demographically representative of a physician practice's patient population.
The health system adopts an onboarding system for new primary care physicians and specialists designed to populate patient panels with data analytics, market analysis, and targeted marketing.
Winchester, Virginia–based Valley Health is working with a healthcare consulting firm to revamp how the health system develops the practice of newly hired physicians.
"The average new physician takes about three years to build up a patient panel and reach the point where they are effective and efficient," says Carol Koenecke-Grant, vice president of strategic services at Valley Health. "What Doctivity does is they try to take that ramp up time and make it much shorter."
Doctivity is a physician onboarding program developed at Moorestown, New Jersey–based SystemCare Health that features data analytics, market analysis, targeted marketing, and helps with establishing referral relationships.
Valley Health, which onboards about 150 physicians annually, started implementing Doctivity in 2016, with positive results. Eight of nine specialists who started the Doctivity program in October 2016 achieved their productivity targets within the first year. The specialists generated more than $225,000 of unplanned revenue.
Data analytics
A lean approach to data analytics plays a foundational role in the Doctivity program, Koenecke-Grant says.
"One of the things that makes Doctivity so successful and effective is they look at what you have. For Valley Health, they saw we had Epic as our electronic medical record, a market leakage report, and operational practice reporting."
Once the trove of data is pulled together, a customized operational and market report is generated. "What Doctivity did for us is to take all of the different reference points that we have throughout our data systems, which often don't feed information into each other cleanly, and package everything for us," she says.
Data analytics have also been used to develop direct-mail campaigns targeted at potential patients for new physicians, including patient base analysis, locations of competitors, and patient demographics by zip code. "We're not doing a shotgun approach when we do direct mailing. We are being very targeted, where we know we can help onboard a physician fast."
Doctivity has also helped Valley Health, which features six acute-care hospitals, harness data to monitor the progress of new physicians as they build their practices.
"We track new physicians on a monthly basis. We look at new referrals—where they are coming from, patient demographics, and downstream revenue. Then this information gets bundled into a situational report. At a glance, you can see whether a doctor is trending the way we thought he should," Koenecke-Grant says.
Mastering the competitive landscape
Market analysis is a key component of the Doctivity program. The primary focal points are competition in the market and finding opportunities to gain patients. The market analyses include factors such as the service line being targeted and potential referral sources for a new physician.
These analyses form the basis of a marketing and referral plan. "The plan will say we need to target specific physicians for referrals, a particular market, and highlight particular qualities of the physician that may be attractive to referring specialists," Koenecke-Grant says.
A key marketing tool in the Doctivity program is a one-page physician "fast fact" brochure. "Physicians are very busy, so the 'fast facts' have the most critical information they need to know about a particular surgeon or a particular physician. We make it clear where the individual physician practices and their specialty or expertise," she says.
The one-page marketing document has several elements:
Photo of doctor
Medical education and training, including medical school, residency, and fellowships
Brief description of medical specialties
Listing of conditions the physician treats
Contact and referral information
In the Doctivity program, establishing referral relationships is a precise and targeted process, Koenecke-Grant says.
"For example, we will consider the dynamics of a cardiology group that we could refer to one of our cardiovascular surgeons. Then we consider the characteristics of the cardiology group that tell us what they would need most from our surgeon. It's more than just driving a physician by a practice and saying, 'Hey, here is our new cardiovascular surgeon—keep him in mind.' "
With its new onboarding processes and infrastructure in place, Valley Health expects to no longer require SystemCare Health's services later this year.
Rush University Medical Center is applying data technology in several areas, including documentation improvement, value-based care, dashboard development and implementation, readmissions reduction, and cost of care.
At Rush University Medical Center, an effort to investigate low quality scores has blossomed into a highly ambitious data analytics and machine learning initiative.
In early 2015, the Chicago-based medical center had three stars in Medicare's Hospital Compare rating system, and the organization's new CMO, Omar Lateef, DO, wanted to know why, says Bala Hota, MD, MPH, vice president and chief analytics officer.
"We are both practicing physicians. We saw patients at Rush, and we knew the quality of care for a lot of the service lines was excellent, but we weren't seeing that reflected in the ranking systems," says Hota.
While systematically reviewing documentation data, Hota and his colleagues found clinicians were underreporting the severity of patient illness. "We were consistently seeing that our severity of illness ranked among the lowest—in the bottom decile," he says.
The need for documentation improvement became even clearer after a review of patient transfers from other facilities, Hota says. "Patients were getting transferred to us and they were getting a lower acuity than they had at the hospital they were transferred from, which made no sense."
Documentation improvement that has improved severity of illness reporting has helped raise Rush's Hospital Compare rating to five stars.
Documentation is the key ingredient in most ranking systems at the Centers for Medicare & Medicaid Services, he says. To help find opportunities to improve documentation, Hota's team developed customized algorithms and gathered documentation data.
"We do see variation between different provider groups and different providers. There is more opportunity with some, with others there's less. Just being armed with that information helps us to educate, guide, and change behavior," Hota says.
Rolling out dashboards
After using data analytics to delve into Rush's quality ratings, Hota's team continued to seek opportunities for data to drive change.
A primary effort has been harnessing key performance indicator [KPI] data and displaying the data on dashboards, often in real time. "We have a level of detail needed to drive behavior change," Hota says.
The dashboards track several KPIs:
Documentation
Care variation
Cost of care
Length of stay
Mortality
Patient safety indicators
Quality domains
"We have about 200 key performance indicators in executive dashboards that we have rolled out over the past four months. These dashboards are shown on large monitors in the offices of our president, chief operating officer, and chief financial officer," he says.
Predictive modeling
Rush is conducting predictive modeling with its Epic electronic medical record and with a cloud-based Big Data capability.
With Epic, Hota's team has developed five predictive models for illnesses, including congestive heart failure.
With the cloud-based technology, data can be drawn from any IT system in the cloud's "environment" such as sensor data and clinical engineering. "The advantage of this approach is we are using machine learning. Deep learning models allow us to customize models to our unique situation," Hota says.
Predictive modeling is being used primarily in three areas at Rush:
Cost of care to identify high-risk patients and help ensure they are on the best care pathways or protocols
Emergency department throughput to drive reductions in the length of time patients are spending in the ED
Readmission reduction to identify negative factors after discharge
Data drives value-based care
Data analytics are playing a crucial role in value-based care at Rush, which features four acute-care hospitals.
In the Medicare Shared Savings Program (MSSP), Rush is using data analytics to track access to care, patient residence, in-network versus out-of-network utilization, and total cost of care.
Documentation is a key to MSSP success, Hota says. "We are looking at how documentation relates to our severity of illness and our care. We are looking for opportunities to improve what we document."
Data analytics is helping Rush manage the impact of the Hospital Readmissions Reduction Program and the Hospital-Acquired Condition Reduction Program.
For readmissions, Rush uses predictive modeling and risk adjustment to anticipate and affect readmission rates, which have improved. "We have seen readmission declines over the past four years, which has switched Rush from a Medicare penalty to a bonus for our academic medical center," he says.
Focusing on outcomes data is important to limiting hospital-acquired conditions, Hota says. "We are measuring every case of a condition. We are looking for where we have outcomes that we need to fix."
Scaling paced to growth
Rush has contained the costs for its data analytics initiative by leveraging internal resources and scaling growth strategically.
"We have tried to use existing staff and existing resources. We started out by dipping our toes in the water, [to] see whether there was value, and scaling it as we moved along," Hota says. "There has not been a lot of upfront expense."
Utilizing cloud technology is financially advantageous, he says. "From the start, we planned an in-the-cloud implementation because that allows our costs to scale as the data scales. So, we do not have a large capital investment for infrastructure on-site."
The cost of the initiative has increased over time, Hota says. "We were able to keep the costs relatively low—almost at a pilot-project level of funding—for the first six months. Since we have seen some successes, we are scaling the budget as time goes by."
Over the next few years, he expects Rush's investments in data analytics capabilities to reach "millions of dollars, not tens of millions of dollars."
"We want to grow this program and make it the source of truth for data and analytics at the medical center and the Rush system," says Hota.
In first blow to a CMS 2017 Final Rule, a court ruling in Missouri has invalidated the agency's attempt to deduct Medicare and private insurance payments as offsets when calculating outlays to hospitals under the DSH program.
A federal District Court ruling has invalidated an attempt to change the payment formula for the Disproportionate Share Hospital program in a way that would reduce payments for hospitals across the country.
If the ruling withstands an anticipated appeal, it could spare hospitals nationwide DSH payment recoupment ranging into hundreds of millions of dollars.
The case was filed by the Missouri Hospital Association against the secretary of the federal Department of Health & Human Services and the Centers for Medicare & Medicaid Services. The primary issue is CMS rule-making, including 2010 FAQ guidance and a 2017 Final Rule requiring hospitals to deduct private insurance and Medicare payments as offsets when calculating outlays to hospitals under the DSH program.
The CMS 2017 Final Rule, "Disproportionate Share Hospital Payments—Treatment of Third Party Payers in Calculating Uncompensated Care Costs," became effective June 2, 2017. The is the first time the Final Rule has been invalidated in federal court, and it is also facing federal District Court challenges in Washington, D.C., and New Hampshire.
Under federal Medicaid law, hospitals in states participating in the Medicaid program receive federal DSH payments to cover some of the Medicaid-payment shortfall associated with care of Medicaid-eligible patients.
In his Feb. 9 ruling, District Court Judge Brian Wimes highlighted the competing DSH formulas favored by MHA and CMS:
MHA formula based on laws and regulations prior to 2010: Total cost of treatment for Medicaid-eligible patients – total payments from Medicaid not under the DSH program = Medicaid shortfall
CMS formula based on 2010 FAQ guidance and 2017 Final Rule: Total cost of treatment for Medicaid-eligible patients – (total payments from non-DSH Medicaid + total payments received for Medicaid eligible treatments from Medicare and private insurance) = Medicaid shortfall
In a declaration submitted to the court, an executive from St. Louis-based Barnes Jewish Hospital said deducting payments received for Medicaid-eligible care from Medicare and private insurance would cost the hospital millions of dollars annually. Larry Kayser, vice president of finance at Barnes Jewish Hospital, wrote the new CMS formula would result in recoupment of $5.9 million for fiscal year 2011 alone.
Under the FAQ guidance, CMS conducted DSH hospital payment audits under the new formula from 2011 to 2014. For the 2011 and 2012 fiscal years, Missouri hospitals face recoupment of $95.7 million if the new DSH payment calculation formula withstands legal challenges, according to the MHA.
National impact uncertain
While last week's ruling blocks recoupment of DSH payments in Missouri, it is unclear whether the decision will have a national effect, says Jane Drummond, general counsel of the MHA.
"We asked for a nationwide injunction in our lawsuit, but the opinion that was rendered just says our motion for summary judgment was granted. It is not specific on whether the court intended the ruling to apply nationwide."
Unless Judge Wimes issues a national injunction, CMS' reaction to the ruling will determine whether it has a national impact, she says. "There was an injunction issued on the FAQs in the federal District Court in Washington, D.C., but CMS took the position that the injunction only applied to the parties in that case, so it did not have nationwide effect."
Drummond expects the Missouri ruling will be appealed. "We are one of three cases that have challenged the Final Rule and this is the first decision invalidating it, so they will most certainly appeal to preserve their position in those other two cases."
If MHA prevails in an appeal, the hospital association expects the DSH payment audits conducted from 2011 to 2014 under the new calculation formula would be repeated under the old formula, sparing hospitals nationwide hundreds of millions in recoupment. If it loses an appeal, CMS would have to seek legislation from Congress to include Medicare and private insurance payments in the DSH outlay formula, Drummond says.
MHA pevails in federal court
Wimes sided with the MHA's claims against the 2017 Final Rule as well as FAQ 33 and FAQ 34 of reporting and auditing guidance promulgated in 2010. Both the Final Rule and the FAQs seek to establish the new CMS DSH formula.
In his decision, Wimes first invalidated the FAQs on the basis that they were promulgated without any notice or consent process such as publishing them in the Federal Register.
While the judge did not make a formal ruling on two other claims the MHA had made against the FAQs, he did write that those additional claims were valid:
Wimes wrote that the FAQs exceeded DHHS' statutory authority because they "substantively alter the formula for the calculation of uncompensated care costs for DSH hospitals"
Wimes wrote that the FAQs are contrary to the "unambiguous language" of the Medicaid statute, which does not include private insurance and Medicare payments in the formula that determines outlays to hospitals under the DSH program
Drummond says the judge's commentary on the FAQs regarding the Medicaid statute formed the basis of his invalidation of the 2017 Final Rule.
"Even had DHHS moved forward and done this change with substantive rulemaking, the FAQs would be invalid anyway because they are contrary to the Medicaid statute," she says. "While this was not a holding of the court, the judge did discuss those points and agree with our arguments, then used that rationale to invalidate the Final Rule."
The health system is confident of success based on performance in its first Medicare ACO contract as well as recent improvements in care coordination, skilled nursing partnerships, and care access.
Cleveland Clinic is taking on downside risk in the Medicare Shared Savings Program, shifting from the upside-only Track 1 of the program to Track 1+.
"The migration toward risk is something we realize is happening across northeast Ohio and the country," says James Gutierrez, MD, president and medical director of Cleveland Clinic Medicare ACO. "We know that we need to be ready to embrace greater risk and we need to be ready to do it successfully if we are going to survive as an organization."
Cleveland Clinic Medicare ACO, which manages a population of 105,000 beneficiaries, participated in MSSP Track 1 from 2015 to 2017 and posted strong financial performance. In 2016, the ACO achieved $42.2 million in savings, which was a 24.5% increase over 2015 performance. Also in 2016, the ACO received $19.9 million back from MSSP in shared savings, a 19.8% increase over 2015.
In its three-year MSSP Track 1+ contract that starts this year, Cleveland Clinic Medicare ACO faces a 30% loss-sharing rate if the ACO fails to meet its spending benchmark and as high as a 50% gain-sharing rate.
Anticipating Success
In addition to its strong performance in MSSP Track 1, Gutierrez says the health system expects to perform successfully in Track 1+ because of recent capability improvements in care coordination, post-acute care, and patient access.
He says the 11-hospital health system took a major step toward improved care coordination last fall, with the launch of Cleveland Clinic Community Health.
"Although we talk about one Cleveland Clinic and we are a unified enterprise, there are two populations that we serve," he says. "One is the regional, national and international referral base that we serve for tertiary care, the other is a large segment of the local population in northeast Ohio."
Cleveland Clinic Community Health features a newly formed leadership team designed to unify several classes of caregivers who serve the local population:
Adult and pediatric primary care services
Urgent care
Social workers
Behavioral health
Pharmacy services
Support services including analytics and finance
"It brings together many, if not most, of the types of individuals and services that we need to do well in the ACO," Gutierrez says.
Other care coordination investments have been made at primary care practices, where Cleveland Clinic has been focusing on managing the health system's high-risk and highest-utilizing patients. Adding registered nurse care coordinators to the staff is one example, he says. In addition, Gutierrez says the health system has improved care coordination for inpatient services with bolstered transitions of care in the hospital, specialty care, and primary care settings, but while rewards from these investments may be significant, costs may be as well, and the Clinic declined to provide that information.
While Cleveland Clinic does not own skilled nursing facilities, the health system has been placing physicians and nurse practitioners at SNFs with the highest-volume of its patients, he says. Skilled nursing is one of the bigger buckets of spending for the Medicare population, he says.
Gutierrez says having the health system's clinicians work with SNF patients has generated several quality and financial benefits for the ACO and its patients, including:
Decreased length of stay
Improved quality and outcomes such as a 16.7% decrease in the 30-day all cause readmission rate from 2016 to 2017
Smoothed transitions of care, both from the hospital to the SNFs and from the SNFs to the home and primary care
Patient access is a key component of meeting MSSP spending benchmarks because managing patients effectively at low-cost settings such as primary care practices can avoid expensive emergency department and inpatient care, he says.
In addition to expanding access to primary care and specialty care practices, the health system has opened several urgent care clinics, Gutierrez says. The Express Care clinics are walk-in settings that handle a range of medical issues beyond coughs, colds, and rashes.
In 2016, Express Care visits increased by 76% to 133,333, with the increase attributed mainly to the opening of six new sites, according to Cleveland Clinic's 2016 annual report. In another measure of improved patient access, same-day visits increased 10% in 2016, to 1.3 million.
Patient Attribution
Unlike MSSP Track 1, which attributes patients to ACOs retrospectively at the end of a performance year, Track 1+ features prospective patient attribution at the beginning of a performance year.
"It is in some ways akin to getting answers to the test ahead of time and being able to take it home to work on it," Gutierrez says.
In Track 1+, prospective patient attribution helps ACOs manage the care of their patients, he says. "Knowing the population that we are accountable for is going to help us make sure we manage that population effectively and don't let people slip through the cracks."
Since joining MSSP, Cleveland Clinic has developed new population health analytics capabilities, which the ACO will be able to use more effectively with prospective patient attribution, Gutierrez says.
"Knowing who our population is will allow us to use clinical and claims data, then risk-stratify the population to identify the high-risk patients who need special attention."
Top finance executive wants growth in complex-care cases, control of supplies and drug utilization, an ongoing shift to value-based care, and investment in technology to optimize revenue cycle.
After serving in a transitional role as deputy CFO at Mission Health, Paul McDowell, MBA, is now CFO and senior vice president of finance at the Asheville, North Carolina–based health system.
McDowell's deputy CFO role was created about two years ago in anticipation of the retirement of CFO Charles Ayscue, who stepped down in early January. The deputy CFO role was created to hand over responsibilities to McDowell over time.
Before coming to Mission Health in January 2013 as vice president of finance, McDowell was senior vice president and CFO of King's Daughters Health System in Ashland, Kentucky.
HealthLeaders Media recently spoke with McDowell, and the following is a lightly edited transcript of that conversation.
HLM: What are the primary growth opportunities at Mission Health this year?
McDowell: Complex-care cases. We want to grow at the top end of the acuity scale. Over the years, we have developed programs in advanced cardiac care, for example, to alleviate the need for patients to travel outside of western North Carolina. We have also added pediatric specialties so that children and their parents can receive excellent care closer to home and avoid having to travel to Charlotte or Raleigh.
In addition to growth at our tertiary hospital here in Asheville, we are surrounded by five much smaller hospitals that are part of our system. We are focused on making sure they take on the lower acuity cases that can be safely and effectively treated in those more rural communities and closer to the patient's home. It's more convenient for patients.
We want to make sure we have our patients in the right setting. It is not only good for the patients but also frees up capacity at our tertiary hospital for more acute patients.
HLM: What are Mission Health's primary financial challenges in the coming year?
McDowell: Mission Health has a difficult payer mix. Almost 75% of our payer mix is Medicare, Medicaid and self-pay. Medicare, Medicaid and certainly self-pay have not increased their rates very much in the past few years; and with a small commercial component in our mix, it is hard make up revenue.
When you do the math, we may have a 1.5% annual revenue increase; and meanwhile, expenses are going up 3% to 5% depending on the category. So, we have an imbalance between inflationary pressures in expenses and the low rate increases on the revenue side that create a continual need for cost savings.
HLM: Is it possible to achieve cost savings that will make up that gap?
McDowell: The next generation of cost savings relates to supply and drug utilization. We have been working the unit-cost side of supplies and drugs for a long time—trying to make sure that we have the best contracts and the lowest prices.
Now, we have transitioned to focusing on the utilization of supplies and drugs. So, we have much more standardization and make sure we are using a supply that not only has a good price but also represents the best supply item for a particular need. We are getting physicians to work together to use the same supplies in the same circumstances, which creates buying power for us.
One of the most important clinical advancements at Mission Health over the past two to three years is the development of dozens of care process models, where groups of clinicians determine the best, most evidence-based approach to a given disease or condition. These models are then imbedded in the EMR and tracked through our data warehouse. The development of these care process models has systematically standardized care, improved quality, and reduced cost.
HLM: Are there other ways to close the health system's finance gap?
McDowell: We also are focused on making improvements to revenues. This includes reducing payment denials, improving the accuracy of clinical documentation, and reducing patient outmigration so that they can have care closer to home. Over the past four to five years, revenue improvements have made up approximately 30% to 40% of our annual margin improvement initiatives.
HLM: How are you preparing for the shift to value-based care?
McDowell: We are preparing for the future and the value-based world, but most of our business is still in fee-for-service. So, living in that dual world is a challenge every year and we are systematically preparing for the future. We have an accountable care organization that has more than 60,000 members—that is a significant population and an interesting opportunity from the gain-share perspective. Despite having a low spending target compared to others nationally in the Medicare Shared Savings Program Track 1, we saved the federal government just more than $11 million last year.
Our performance level is indicative that we are successfully transitioning to the value-based world. Looking forward, we are continuing to focus on improving performance and outcomes.
HLM: Do you have any other optimization goals?
McDowell: We have goals for IT investment in the revenue cycle to make sure that we are continuing to improve our performance.
One goal is getting the entire organization on the same IT system. Our acute care hospitals all are on the same system, but some of our physician practices are not. We have acquired practices and they have come into the system in various ways, and having multiple IT systems creates an incredible amount of inefficiency. You can't leverage your scale when you are on six or seven IT systems in your ambulatory settings.
A second goal is leveraging technology to optimize the revenue cycle. That includes getting all care settings on the same payment portals, getting patient scheduling on the Internet so patients can self-schedule, and adopting other patient-facing technology that can both improve efficiency and improve patient satisfaction.
