A Pennsylvania health system has scheduled 145,000 same-day appointments in this year’s debut of the offering, and they now make up 15% of its primary care visits.
Patients want same-day appointments. Providers resist because they replace filled appointments with open blocks. But to drive patient volume, same-day appointments work. Allegheny Health Network drove primary care volume at least 5% in a single year behind a strategy of same day appointments.
Following months of preparation, Allegheny Health Network started offering same-day appointments in January for more than 150 primary care physicians and 20 specialties including surgical practices. Since the initiative was launched, AHN has scheduled 145,000 of them.
Patients can request a same-day appointment if they call before 11 a.m.
The program gives AHN a competitive advantage and supports quality clinical care, says Kenyokee Crowell, AHN's senior vice president of clinical access.
"If you call for a same-day appointment and are a primary care patient of AHN, even if you do not see your [usual] provider, you will see a colleague of the provider who will have access to your medical records, your medical history, and your medication."
She says patient satisfaction has been high among patients booking same-day appointments, with primary care patients posting 96% satisfaction and specialty patients posting 92% satisfaction.
AHN, with eight hospitals in western Pennsylvania, is a subsidiary of Pittsburgh-based Highmark Health, with $18.2 billion in 2016 operating revenue.
Currently, Crowell says about 15% of AHN's primary care appointments are same-day and 2% to 3% of specialty appointments are same-day. She says same-day appointments are largely responsible for an increase in AHN's patient volume this year, with new patient volume up 7% and existing patient volume up 5%.
"The increase started exactly when the same-day appointments rolled out for the organization, so we feel the same-day appointments have contributed to that increase., she says.
Planning, Executing and Tweaking
Pre-launch planning was a primary key to success for the initiative, Crowell says. "We started a process of analyzing historical data in July of last year in advance of our go-live in January."
During the planning phase, she says health system officials focused data analysis on primary care because those practices had historically received the highest volume of requests for same-day appointments.
"We looked at that primary care data, we looked at Epic, and we met with each of our physicians and administrators for the different service lines to try to put together an algorithm. … It was not a cookie-cutter approach. The algorithm tended to be a little bit different depending on the specialty and, in some cases, by market."
AHN assured physicians that their appointment inventories would be handled with care, with the needs of individual physicians taken into consideration, Crowell says.
"For newer physicians in our organization, they may have plenty of availability; but for our busy providers, we had to think carefully about what the need for same-day appointments was, because we wanted to make sure we had adequate access to provide the service."
Including practices in the planning process was critically important, she says.
"That's where the magic came into play. This was not a spreadsheet exercise—the analytics are great and the numbers are great, but they only tell a portion of the story. You need to talk with the people who know their business best, which are our physicians."
She cites the example of a physician with a special clinic one day a week. If six same-day slots were needed per day at the practice, most days it made sense to deploy those slots equally among the practice's providers. However, on the clinic day when the doctor was seeing certain types of patients, fitting in his share of same-day slots did not make sense.
Tailored to Patient Behavior
Implementing same-day appointments involved technical elements and setting appointment inventory to fit patient behavior, she says.
"Once we had an idea of what we thought the need would be, we needed to take an inventory of appointment slots off-line, so they would be available for same-day appointments in the future. We worked with our IT department to create an appointment type in our Epic medical record system."
AHN's centralized scheduling center was tasked with setting most same-day appointments. For patients who call requesting a same-day appointment but have a potentially pressing clinical need, the appointment is often scheduled at a local practice.
Understanding patient behavior at the practice level was essential, Crowell says. "The inventory did vary by specialty, by geographic locations, and, sometimes, by day of the week. Anywhere from 25% to 40% of our same-day appointments for an entire week are booked on Mondays, which are by far the highest volume days for same-day appointment requests."
Spreading the Word
When AHN launched same-day appointments, the health system promoted the initiative with a "multi-channel marketing campaign," Crowell says. The effort included television, radio, print and online advertising, public transportation ads such as bus-wraps and notepads and stickers in physician offices.
After the initiative was launched, the appointment inventory at many practices required adjustment throughout the year, she says.
"The biggest lesson that we learned is that this is not a program that you can research, develop, launch and put it on the shelf. It is a very active process to continue to tweak it."
Patient-Centered Approach
With same-day appointments usually driven by convenience rather than clinical need, the initiative reflects a patient-centered approach to care, Crowell says.
Same-day appointments also exemplify a business imperative for a consumer-oriented approach to medical care, she says.
"Healthcare needs to get its act together. If there was any other industry where you had to wait days or weeks for a service, you would probably go someplace else."
The investor-service company gauges impact of new 'association' health plans, expanded short-term insurance, and elimination of subsidies on the Obamacare exchanges.
President Donald Trump's health-insurance executive actions last week are credit negative for insurance carriers operating on the Obamacare exchanges, New York, NY-based Moody's Investors Service reported today.
On Oct. 12, Trump took two executive actions that will likely undermine the insurance exchanges established under the Patient Protection and Affordable Care Act (PPACA), Moody's says:
In an executive order, the president eased regulations on "association" health plans and expanded the definition of short-term health insurance. The executive order calls for the federal departments of Labor, Treasury and Health and Human Services to expand insurance coverage for individuals such as allowing insurance purchases across state lines.
Although regulations must be put into place, association health plans will likely allow small businesses to band together to offer insurance to their employees. "Associations likely would be allowed to offer plans with lower benefits and lower costs," Moody's reported.
In a decision that did not require an executive order, Trump announced that his administration would end cost-sharing reduction (CSR) payments that subsidize the purchase of health insurance on the exchanges. The subsidies help insure low-income individuals who do not qualify for Medicaid coverage but can't afford to buy commercial insurance health plans.
This year, the federal government spent about $7 billion on CSR payments.
The executive order is expected to promote creation of skimpy health plans, which would undermine the PPACA exchanges, Moody's reported. "The introduction of lower-benefit, lower-cost plans and short-term insurance would be credit negative for health insurers that are still participating in the PPACA-governed individual market. These new plans would incentivize healthy people to exit the PPACA market, which would increase risk in the remaining pool of insureds."
The decision to stop CSR payments will also have a credit negative effect on commercial carriers operating on the exchanges, Moody's reported. This negative impact will fall particularly hard on commercial insurers that did not submit rates for next year based on the assumption that the CSR payments would be eliminated.
Health insurance rates are set on a state-by-state basis.
There could be an "offset" linked to the executive order that would soften the financial blow for commercial carriers operating on the exchanges, Moody's reported. "If the executive order succeeds in bringing more healthy but currently uninsured people into the small group or individual market, that could mitigate at least some of the order’s negative effects."
Moody's highlighted the PPACA-exchange risk exposure of four commercial carriers in today's report, which lists the companies' beneficiaries on the exchanges as a percentage of their total number of health-insurance beneficiaries:
Indianapolis-based Anthem Inc.: 2.9%
Chicago-based Health Care Service Corporation: 6.8%
St. Louis-based Centene Corporation: 9.2%
Long Beach, CA-based Molina Healthcare Inc.: 20.4%
What does innovation really mean to you? We asked the members of the HealthLeaders CFO Exchange for their innovation keywords.
Innovation has become such an overused word in healthcare leadership that leaders must further define what the term means to their organization. At the 2017 HealthLeaders CFO Exchange, members were asked to define what innovation means to them and their organizations.
Disruption: "I would use the word disruption—not in the usual sense of talking about other organizations coming into a market—but in the sense that we have to do something different," said Rick Hinds, executive vice president and CFO of UC Health in Cincinnati, Ohio.
Lacking: "We are lacking innovation as an industry," said Michael Browning, CFO of ProMedica Health System in Toledo, Ohio.
"As individual organizations, some of us are being innovative, but as an industry we tend to be more status quo. Many organizations are continuing to hold on to the historical healthcare models, and they are not taking risk and being innovative."
ProMedica has made the difficult strategic decision to invest in innovation for the long term, Browning says.
"Many people think that they cannot be innovative because it does not have an initial return on investment. Innovation can have a return on investment, but the return make take longer to materialize."
"Our board understands the importance of being an innovative organization and they support this investment. So, when you ask about margin and whether the ability to generate a margin hurts innovation at ProMedica, it doesn't. … Our board will say, 'Continue to invest even if we are running a financial deficit because we believe in the strategy and what you are doing.' They know the dollars are coming down the road."
Lean: "My one innovative word for our organization is lean," said Mary Ann Freas, senior vice president and CFO of Southwest General Health Center, Middleburg Heights, Ohio.
"It's the way we approach our delivery of services, and it applies to promoting ease of access to our services, the patient experience when it comes to access, coordination of care, and patient safety and quality."
"As we think through any improvements, we think through the process and how we can take waste out."
"Whether we are looking at how to increase access to our services or how to reduce sepsis, it really is a general concept of taking a look at the process, then finding duplication and unnecessary steps."
Passion: "We align passion behind what we are doing. We have a very disciplined, high-performance healthcare model that we follow every year on the calendar," said Randy Van Straten, vice president of business health at Bellin Health in Green Bay, Wisconsin.
"We study the voice of our customers, our patients, our physicians, our employees, and our insurers. Every year, we go through and we evaluate our mission, our vision, and our strategic objectives. Then we narrow down to focus on three breakthroughs, so we can align our resources. Otherwise there is too much competition for resources."
Risky: "There is so much innovation, especially when you look to technology. Everyone has a new technology tool coming out. But some of these technologies do not work, or some of them do not have anywhere near the effectiveness they claim that they have," said Garrick Stoldt, CFO of Saint Peter's Healthcare System in New Brunswick, New Jersey.
"For me, there are so many things that are being developed right now, and you only have limited resources; so, if you pick the wrong bets, you waste a lot of resources unnecessarily and end up with no resources for the right bet."
Risk-Tolerance: "If you pursue the idea du jour and if you are struggling with a 2% to 3% margin, if you make one mistake, you can end up upside down. It is not easy to get out once you are in—putting your toe in the water is just not doable in most situations," said Richard Rothberger, executive vice president and CFO of Scripps Health in San Diego, California.
"I am most concerned about too many initiatives, the lack of bandwidth to handle them, and picking the right one for the organization that will make a difference."
Transformational: "You have to look at everything you have done in the past and make adaptations. We have created an innovation department, and that includes investing in start-ups. We have started investing in start-ups for future growth," saidMike Simms, vice president of revenue cycle at Cone Health in Greensboro, North Carolina.
"To be transformational in revenue cycle, you must look at your technology and how you interact with patients, because they want the same experience that they have with the airlines and other industries. They want to have self-service on a web portal. They want to create payment plans on their own, and not have to call into a customer service department. You have to be transformational and willing to change."
Research released today shows that hospitals acquired in an M&A deal often struggle to generate financial gains from economies of scale in the first two years after the transaction.
A study on hospital mergers and acquisitions published today provides insights about why many acquired hospitals fail to meet their post-transaction financial goals.
The research features quantitative analysis of more than 750 hospital M&A deals from 2008 to 2014, along with survey data collected from 90 hospital-finance leaders. The study was conducted by the Westchester, IL-based Healthcare Finance Management Association (HFMA) and the Deloitte Center for Health Solutions, a division of New York, NY-based consultancy Deloitte.
"This study makes it clear that mergers are unlikely to succeed unless leaders tackle the tough decisions early on," HFMA President and CEO Joseph Fifer, CPA, said in a prepared statement. "Prospective merger partners should sit down together and figure out what the organizational structure and management team will look like after the merger. They should also recognize that it takes sustained effort to blend organizational cultures."
In the first two years after a hospital M&A deal, the research shows many acquired hospitals struggle to achieve their financial objectives.
"Acquired hospitals collectively saw a decrease in operating expenses after a transaction; however, operating revenue tended to decline at a greater rate, resulting in a decline in acquired hospitals' operating margins. These trends leveled-off two years post-transaction," the researchers wrote.
There were two primary causes of weaker-than-expected financial performance. "Survey respondents acknowledged that immediate investments and additional staffing were sometimes required to improve quality at an acquired hospital, which can impact financial performance."
About 80% of executives surveyed said there were significant capital investments after an M&A transaction was completed. "Nearly 40 percent of all survey respondents used the capital to upgrade or implement clinical information systems, the top-reported use of capital," the researchers wrote.
The motivations to seek and complete an M&A deal varied between acquiring organizations and acquired hospitals.
About 40% of survey respondents at acquiring organizations said boosting market share was the top reason to pursue an M&A transaction. "Increased market share can help a health system broaden its physician network and expand its access to patients, both critical factors for bearing increased financial risk in an evolving, value-focused healthcare market," the researchers wrote.
At acquired hospitals, nearly a third of executives surveyed cited access to capital as their prime motivating factor for seeking an M&A deal.
"Many acquired organizations were in financial distress, or required investments in staff, health information technology, physician recruitment, facilities, medical equipment, or pension funding to improve operations and quality of care," the researcher wrote.
Significant numbers of the executives surveyed said the quality of patient services improved after an M&A transaction:
27% reported increased Hospital Consumer Assessment of Healthcare Providers and Systems scores
23% reported decreased hospital readmissions
17% reported decreased physician appointment wait times
17% reported reductions in patient mortality rate
The executive survey identified eight keys to success in an M&A deal:
Developing a strategic vision for the transaction
Identifying clear financial and non-financial goals
Holding leadership accountable for integration efforts
Identifying cultural differences between acquired and acquiring organizations
Establishing transparency in decision-making
Aligning clinical and functional leadership as early as possible
Following best practices for integrating the organizations
Following best practices for project management such as tracking targets and milestones
Critics call the three-day inpatient stay requirement for patients to qualify for Medicare coverage at a skilled nursing facility archaic, irrelevant, and a threat to patient safety.
Skilled nursing facilities and their partners are pushing hard to reform a half-century-old law that requires a hospital-inpatient stay spanning three midnights to qualify patients for Medicare coverage at nursing homes.
Led by the American Health Care Association, which represents 13,500 long-term and post-acute care facilities, a coalition of nearly three dozen national organizations is seeking to change the law,, contending the three-day stay requirement is outdated and denies Medicare beneficiaries access to medically necessary services.
"On average, hospital stays are much shorter than they were in the 1960s, but the three-day stay requirement still applies to all Medicare patients. … As the hospital stays become shorter, the effect of the three-day rule is to block more and more Medicare beneficiaries from being able to access the skilled nursing facility benefit," says James Michel, senior director of Medicare reimbursement and policy at AHCA.
Under Medicare law, a patient must be categorized as an inpatient at an acute-care hospital for at least a span of three midnights to qualify for Medicare Part A coverage of SNF stays. Patients categorized as under observation at a hospital are considered outpatients under the law, and days under observation do not count toward the three-day stay requirement.
The Improving Access to Medicare Coverage Act of 2017 would allow Medicare beneficiaries to count observation days toward the three-day stay requirement. The 34-member Observation Stays Coalition includes several physician and patient-advocacy organizations, but hospital groups such as the American Hospital Association have not joined the coalition.
The legislation has 21 bipartisan co-sponsors in the Senate and 71 bipartisan cosponsors in the House.
Richard Salter, co-owner of Salter Healthcare, a Massachusetts-based post-acute care organization that operates three SNFs, says the three-day stay requirement is detrimental to Medicare beneficiaries.
"It's dramatically reducing the number of admissions to SNFs. In some cases, people are being sent home from hospitals unsafely," he told HealthLeaders recently.
In March, a new law went into effect that requires hospitals to give notice to Medicare beneficiaries on observation status that their outpatient categorization could affect Medicare coverage. The Medicare Outpatient Observation Notice is an inadequate protection for most elderly hospital patients, Salter says.
"Basically, what they get is a notice that says, 'We are going to observe you, rather than treat you, and that will affect your ability to get post-acute care in certain settings.'
One of the House sponsors of the Improving Access to Medicare Coverage Act, U.S. Rep. Joe Courtney, D-CT, recently co-authored an editorial in the Journal of Hospital Medicine calling for reform of the inpatient-stay requirement.
In it, Courtneyand his co-author, Ann Sheehy, MD, MS, claim the Office of Inspector General reported a $10,503 beneficiary out-of-pocket cost per uncovered SNF stay following an observation hospitalization in 2012.
They also say several key changes in hospital stays since Medicare was launched in 1965 make a change necessary. Among them:
Average hospital length of stay for patients 65 and older in 1965: 14.2 days
Average hospital length of stay for patients 65 and older today: 5.2 days
From 2006 to 2014, Medicare beneficiary outpatient visits at hospitals, including all observation stays, increased 44.2% nationally
The editorial also cites a research article in the Journal of Hospital Medicine that examines the potential safety threat posed by the three-day requirement. The researchers reviewed actual discharge rates from two hospitals to SNFs when hospitalists recommended that a patient receive care at a nursing home.
"Fewer than 20% of previously community-dwelling hospitalist patients followed recommendation for post-acute facility stay after observation hospitalization, and more than 40% cited financial concerns as the reason for declining. Patients recommended for SNF also were more likely to be rehospitalized in the subsequent 30 days after discharge, confirming this as a vulnerable patient population," the researchers wrote.
"The three-day rule is becoming increasingly irrelevant as a utilization management tool," Michel says. "It is archaic. It is a vestige of a Medicare program that looked very different when it was established compared to today."
Two-Pronged Effort
The Access to Medicare Coverage Act faces a daunting hurdle in Congress, Michel says. "The reality is, the three-day rule acts as a barrier to Medicare covering services for beneficiaries who might otherwise need to get care in a skilled nursing center. So, any easing of that rule is going to result in increased spending, which creates a barrier in Congress."
The Congressional Budget Office has yet to score the legislation.
AHCA is also pursuing a regulatory strategy at the Centers for Medicare & Medicaid Services (CMS), Michel says.
"The inpatient and outpatient designations were established in regulations. They were not established in statute. So, in our interpretation, CMS can define inpatient status and outpatient status however the agency likes. We are suggesting that CMS consider observation stays as inpatient stays, only for satisfying the SNF three-day stay rule, not for billing or payment."
An analysis of Virginia insurance claims indicates there are practical opportunities to slash billions of dollars in wasteful healthcare spending nationwide, researchers say.
The best way to make deep cuts in healthcare spending is to start with reductions in low-cost, high-volume services, according to research published today in Health Affairs.
"An analysis of data for 2014 about forty-four low-value health services in the Virginia All Payer Claims Database revealed more than $586 million in unnecessary costs," wrote the authors of the research paper, "Low-Cost, High-Volume Health Services Contribute the Most to Unnecessary Health Spending."
The researchers examined fee-for-service claims from 5.5 million Medicare, Medicare Advantage, Medicaid, and private commercial insurance beneficiaries. The benchmark for a low-cost, low-value service was set at $538.
Several methodologies were used to assess service value, including the ABIM Foundation's Choosing Wisely campaign, the U.S. Preventive Services Task Force, and Medicare's Healthcare Effectiveness Data and Information Set. The researchers pegged the percentage of low-value healthcare services at 2.1% of total healthcare spending in Virginia.
"A substantial proportion of healthcare costs in the United States is allocated to low-value care, defined as patient care that provides no net health benefit in specific clinical scenarios—such as early diagnostic imaging for uncomplicated low-back pain. Despite decades of attention to this issue, U.S. expenditures on low-value care persist," the researchers wrote.
A key finding of the research was drawn from contrasting low-value services based on cost—showing that the total cost of spending on low-cost, low-value services was nearly double the spending on high-cost, low value services. "The total cost for the low- and very-low-cost low-value services (65 percent of costs, or $381 million) was nearly twice as much as the total cost of high- and very high-cost low-value services (35 percent of costs, or $205 million)," the researchers wrote.
This finding contradicts conventional wisdom.
"Although higher-cost low-value services are frequently showcased in policy deliberations and the media, lower-cost low-value services (those in the bottom two quartiles of our study) accounted for almost twice as much unnecessary cost as did services in the top two quartiles."
The researchers say their study has a pair practical implications in the nation's quest to cut healthcare spending:
Given that the researchers identified $586 million in wasteful spending in one state, "even a modest decrease in the use of low- and very-low cost low-value services could lead to savings and serve as a feasible strategy for catalyzing a broader movement to tackle low-value care."
Focusing on low-cost services "would not present a financial threat to any particular clinical specialty or advocacy group."
Low-cost, low-value services could be the best starting point in meaningful efforts to cut healthcare spending, the researchers wrote: "Instead of pursuing a politically charged strategy to reduce the use of high-profile and higher-cost low-value services, an alternative approach that initially targets the reduction of high-volume and less costly items might be a more strategic way to catalyze the movement to tackle the problem of low-value care."
With Medicare and other payers shifting to value-based-care business models, rural doctors face a fundamentally changing marketplace, a pair of rural healthcare leaders says.
Physician engagement is crucial to shifting to value-based healthcare in rural communities, says Kevin Halter, CEO of Ashland, KY-based Bon Secours Kentucky Health System, which features 215-bed Our Lady of Bellefonte Hospital.
"My biggest challenge is getting my physicians educated on the front end because they all see the wave coming. And that's true for any of the new initiatives—bundled payment and financial changes like& MACRA are in the journals, but it's not right in front of them as it is in places like Richmond, Virginia."
Bon Secours Kentucky Health System is part of the Marriottsville, MD-based Bon Secours Health System, which operates 19 acute-care hospitals in six states and has more than 25,000 employees.
Halfway across The Bluegrass State in Elizabethtown, Hardin Memorial Health features a 300-bed acute-care hospital. Hardin Memorial is affiliated with Louisville, KY-based Baptist Health, operator of eight acute-care hospitals with a total of 2,700 licensed beds.
Primary-care physicians are crucial players in the shift to value-based care, says Hardin Memorial President and CEO Dennis Johnson.
"You don't have to employ every physician on the planet, but you do need to drive the primary care referrals... And if you have good primary care, you are going to be able to manage a population's health."
Halter and Johnson say there are several approaches that rural physicians and their practices can take to adopt value-based care models:
Engaging with Local Hospitals and Health Systems
The relationship between hospitals and physicians is critical to success in value-based care, Halter says.
"Hospitals have been in value-based purchasing for five-plus years, now it's going to go to physicians, and my physicians are just now starting to see it. The reason they are seeing it is I am putting it in front of them. We had a board retreat with about 40 physicians to start educating them."
Building Integrated Clinical Networks
Hospitals and health systems can build the infrastructure needed to support value-based care models, and they need to convey this advantage to potential physician partners, Halter says.
"This is coming, you need to get prepared, we are going to help you get prepared by putting in a clinically integrated network.' Now, we are helping them work through the change so they don't find relief in the channels outside the hospital."
Hospital-employed Physicians
Our Lady of Bellefonte has about 250 physicians on staff, with 30% of the staff hospital-employed. Employment status has had a significant impact on adoption of value-based care models among physicians at the hospital, Halter says.
"Employed docs get force-fed. They are in these programs. Bundled payments for instance, and MSSP ACO. We sign them up."
The Primacy of Primary Care
In 2011, Hardin Memorial and Baptist Health engaged the Healthcare Strategy Group, a provider of physician integration services, to help craft their strategic plan, Johnson says.
Identifying new primary-care partners was an essential element of the planning process. "HSG assisted both Baptist and Hardin on a primary-care strategy… to help identify those markets where we had an opportunity."
Primary-care practices can function successfully in both fee-for-service and value-based business models, he says. "Primary care is really a low-risk, high-return investment."
This week's anticipated Senate vote on a repeal-and-replace plan for the Affordable Care Act is likely the GOP's last chance to enact healthcare reform this year.
This week marks a major milestone in congressional efforts to repeal the Patient Protection and Affordable Care Act (PPACA), a pair of beltway watchers says.
Majority Leader Mitch McConnell, (R-KY), is maneuvering for a vote on repeal-and-replace legislation sponsored by Sen. Bill Cassidy, (R-LA), and Sen. Lindsey Graham, (R-SC). The Senate Finance Committee is scheduled to hear testimony at 2PM Monday.
Earl Pomeroy, ex-president of the National Association of Insurance Commissioners is a Democrat and a former US representative from North Dakota. He says the Cassidy-Graham legislation is the Republican Party's "last gasp" to repeal and replace the PPACA before the 2018 elections.
"There are many Republican senators who have committed to voting for the bill who have not had time to fully consider it. The bill is being driven by calendar, not content."
"At the end of the month," says Pomeroy, "the ability to pass health reform with 51 votes using the budget reconciliation vehicle of 2017 expires, because we move into the 2018 fiscal year."
The time pressure linked to the Senate calendar gives the Cassidy-Graham proposal a political push, he says. "It's now-or-never."
Cost Forecasting
The Cassidy-Graham Plan has not been scored by the nonpartisan Congressional Budget Office. It aims to release a preliminary assessment this week. Others, such as Avalere, CMS, and the Kaiser Family Foundation have been weighing in.
This 11th-hour attempt to repeal and replace Obamacare is expected to result in health insurance and Medicaid coverage cutbacks equal to GOP legislation proposed earlier this year that would have cut more than 20 million people from healthcare coverage.
Republican candidates for Congress would pay a political price from a rollback of healthcare coverage, Pomeroy says.
"If the Republican Party votes to destroy the Affordable Care Act, that will be a political problem for Republicans for years to come. Millions [of Americans] will lose their coverage, and they will be extremely unhappy for many elections."
Passage would also create a political opportunity for the Democratic Party, he says. "The Democrats will be flat-out on the attack, and the Republican position on healthcare will be extremely defensive."
The course of healthcare reform through the 2018 election will turn on this week's Senate vote, Nicholas Manetto, prinicipal at Washington-DC-based law firm Faegre Baker Daniels.
"If Cassidy-Graham fails, it would embolden those in the Republican caucus who want to move away from healthcare and toward taxes or other issues, and it could potentially revive the bipartisan efforts that were terminated [last] week," Manetto says.
Predicting the Senate Vote
A razor-close vote is likely in the Senate this week, he says.
"The four most prominent names are [Republican] Senators Paul, Collins, Murkowski and McCain. Paul is opposed because in his view Cassidy-Graham does not do enough to scrap the ACA, while the other three were the pivotal 'no' votes during the summer. Sen. Collins certainly appears to be a likely 'no' given the concerns she has expressed on Medicaid."
McCain is a perennial "wild card," Manetto says. "Sen. McCain may be gettable—he is close with Sen. Graham."
"Murkowski remains a big question. Others to keep an eye on are senators like Rob Portman and Shelly Moore Capito, both of whom had significant concerns earlier in the year, particularly on the Medicaid side."
In a bid to solicit Murkowski's vote, special accommodations would have to be made in the bill for Alaska, Sen. Graham reportedly told conservative activists.
After seven years and more than 40 attempts to repeal and replace Obamacare, many Republican lawmakers in Congress are eager to drop healthcare as a priority issue, Manetto says.
"Much of the GOP caucus wants to move far away from healthcare toward taxes and other issues they see as being more favorable to them. You also have the reality of an election year that, before too long, will focus much attention on the polls."
Dozens of hospital patients who were evacuated from the U.S. Virgin Islands have received care in Puerto Rico that is reimbursable under a federal program.
In response to evacuations linked to Hurricane Irma, federal officials are drawing on the National Disaster Medical System (NDMS) to help pay for patients' bills.
This is the first time the NDMS Definitive Care Reimbursement Program has been activated since the 2010 international response to an earthquake disaster in Haiti. The program reimburses hospitals and other medical facilities for care provided to patients who are evacuated from their communities after a disaster and cannot access care at their local facilities.
The program is overseen by the Department of Health and Human Services (DHHS) Assistant Secretary for Preparedness and Response (ASPR). The federal departments of Defense and Veterans Affairs also participate in the program.
At least 85 patients have received care in Puerto Rico through the reimbursement program, DHHS reported Sunday in a prepared statement. The patients were evacuated from the U.S. Virgin Islands after Hurricane Irma dealt a devastating blow to many Caribbean islands and the Florida Keys last week.
"Hurricane Irma significantly affected access to medical care in the areas hardest hit by the storm, and patients who need care in these impacted areas must rely on facilities in areas spared by the storm," said ASPR Robert Kadlec, MD.
Under the NDMS reimbursement program, patients such as those impacted by Hurricane Irma are transported to NDMS-approved medical facilities. The U.S. Virgin Island patients were taken to Puerto Rico with "resources" drawn from the Department of Defense and the Federal Emergency Management Agency's national ambulance contract, the DHHS prepared statement says.
Services covered through the reimbursement program include:
hospital care, which can extend beyond a 30-day stay
home care
rehabilitation and physical therapy
primary care
The reimbursement rate for services provided through the NDMS program are as high as 110% of the Medicare rate, or a similar rate if there is no comparable Medicare benchmark. To participate in the program, medical facilities must have at least 25 licensed beds available for evacuation patients. This year, more than 1,900 hospitals are eligible to participate in the reimbursement program.
In 2010, HHS launched a pair of Federal Coordinating Centers in Atlanta and Tampa under NDMS in response to the Haitian earthquake. With medical facilities devastated in Haiti, 79 Haitians and 10 U.S. citizens were evacuated from Haiti to NDMS-approved facilities for treatment of life-threatening conditions, the Obama administration reported.
In 2012, NDMS played an active role in the response to Hurricane Sandy's impact on New Jersey and New York, according to an ASPR report on the disaster:
Oct. 29: Sandy makes landfall and DHHS deploys more 160 staff, including ASPR regional emergency coordinators in three Regional Response Coordination Centers
Oct. 31: DHHS Secretary Kathleen Sebelius declares a state of emergency throughout New York and total number of DHHS staff tops 500
Nov. 1: Sebelius declares state of emergency in New Jersey, with total number of DHHS staff topping 650
Nov. 6: Response under NDMS reaches build-out point, with 1,000 DHHS staff deployed. NDMS resources deployed feature 15 Disaster Medial Assistance Teams in New York and New Jersey, each equipped with medical supplies and staffed by U.S. Public Health Service officers.
NDMS also participates in preparedness and medical support for national events such as presidential inaugurations.
The Cleveland-based health system has set ambitious multi-year goals for making changes across its clinical, physical, and operational initiatives.
For many health systems, adapting to change is a near-term inevitability. They proceed dutifully, and with caution. You can almost hear the groans.
But for The MetroHealth System, the safety net provider for Cuyahoga County, OH, change is a welcome opportunity to adopt new strategies and abilities.
"Innovations and new environments all demand new strategies and abilities," says CFO Craig Richmond. Richmond made his remarks in August at the HealthLeaders CFO Exchange in La Jolla, California.
For the fiscal year ending Dec. 31, 2016, MetroHealth reported total revenue at $1.04 billion. In 2015, the health system posted total revenue at $941 million.
The health system's patient-population has grown from 180,000 patients in 2012 to a projected 300,000 next year. "We've had remarkable success and growth over the years," Richmond says.
Expanding its services has been a top priority. From 2012 and projected through 2018, MetroHealth will have grown in these ways:
Inpatient facilities – from one to three
Emergency departments – from one to four
Outpatient facilities – from 20 to 30
System-owned pharmacies – from three to nine
The system is investing heavily at the brick-and-mortar level, Richmond says. "We just executed on one billion dollars in financing to rebuild a majority of our main campus.
From a strategic perspective, MetroHealth is trying to harness the transformational potential of change, he says. It has adopted a three-pronged operational unit called DoIT: the Department of Integration and Transformation.
The DoIT trident features business-intelligence data, robust project-management capabilities, and a decision-acceleration model that "allows us to accomplish more at an accelerated pace," Richmond says.
1. The Department of Operations Research and Analytics (DORA):
Analyzes specific business processes or questions;
Manages business rules for inter-departmental data use;
Generates forecasts, simulations, and linkages of clinical, financial, and operational data
2. Results Management Office (RMO):
Focuses on desired outcomes;
Uses data-driven methodologies for optimizing innovation and cutting waste;
Leverages employee knowledge to boost quality of decision-making;
Features several project management capabilities, such as prioritizing initiatives, optimizing resource allocation, reducing risk, and increasing return on investment.
3. Center for Disruptive and Radical Experimentation (DARE):
Fosters employee participation in decision-making, with emphasis on enabling staff to challenge the status quo.
DARE efforts include Meeting-Free Fridays, which encourage spontaneous interactions among staff members, an Idea Lab, which serves as a dedicated space for DoIT activities, and about 40 interdepartmental "game-changers" – employees who serve as proponents of change across the organization.
"Each one of these individual divisions can have a significant impact within the organization," says Richmond. "But similar to a multifunctional tool, when all three are working together you can create better results."
For the period spanning 2012 to 2018, MetroHealth set goals for transformational change in three areas—clinical, operational, and physical:
Clinical features– expansion of its primary-care network, IT-enabled integration of care settings, care management, and assumption of financial risk
Physical features– distribution of anchor facilities evenly across the local market and the construction of a new main campus
Operational features– building analytics capabilities and restructuring based on the service-line model
Creating a culture of continuous process improvement generates significant gains, Richmond says, quoting legendary basketball coach John Wooden, "If you don't have time to do it right, when will you have time to do it over?"