Medicare's bundled payment programs are profoundly impacting the way acute-care providers are working with their post-acute care partners.
Hospitals and health systems participating in federal hip and knee replacement bundles are adopting two post-acute care strategies: limiting referrals to skilled nursing facilities and integrating with SNFs.
For hospitals, establishing strong relationships with SNFs can drive positive clinical outcomes and financial gains, researchers say.
The research features 22 hospitals and health systems that participated in Medicare's Comprehensive Care for Joint Replacement (CJR) model or its Bundled Payments for Care Improvement (BPCI) program from August 2017 to November 2017.
Under CJR and BPCI, hospitals face increased responsibility for post-acute care.
"These programs shift the financial responsibility for post-discharge care to hospitals and set incentives for stronger coordination between hospitals and post-acute care providers, including SNFs," the researchers wrote.
The hospitals and health systems in the Health Affairs research project took two approaches to the increased financial risk associated with bundled payments—reduced SNF referrals and closer SNF integration.
1. Limiting SNF referrals
Shifting patients away from SNFs was a primary response to bundled payments, the researchers wrote.
"A common response to bundled payment participation was to reduce SNF referrals for joint replacement patients and to shift discharges to home, with or without home health."
The researchers say there were four primary methods of limiting SNF referrals:
Risk stratification of patients before surgery, including targeting patients for pre-operative medical optimization such as weight loss
Education of patients who expected discharge to a SNF based on prior experience or the experience of friends and family. Hospitals adopted discharge planning that included presurgical education for patients.
Home care supports were provided to patients such as meal preparation and medication reminders.
Hospitals enhanced relationships or integrated with home health agencies to boost transitions of care. One chief medical officer told the researchers that his hospital acquired a home health company and they expected to merge their electronic medical records (EMRs).
2. SNF partners
Fifteen hospitals and health systems in the Health Affairs research project established networks of preferred SNFs to impact quality and cost, the researchers wrote.
All 22 organizations tried at some level to work closer with SNFs, they wrote. "While some hospitals reported efforts to reduce SNF use, all twenty-two hospitals employed new strategies to include SNFs in care management."
The researchers found several methods for hospitals and health systems to integrate with SNFs:
Sharing clinicians across hospital and SNF settings
Rounding in SNFs by hospital-based internists, geriatricians, and specialists
Placing hospital-based physicians in SNF medical directorships
More than two thirds of the hospitals and health systems in the Health Affairs research project reported that they formed preferred SNF networks in response to bundled payment incentives, the researchers wrote.
"Hospitals reported having formed preferred networks as one way to exert influence on the quality and cost of care, focusing on SNFs that historically received larger shares of their discharged patients."
Market geography was another key driver for preferred SNF networks, they found.
In selecting potential SNF partners, hospitals and health systems had limited access to SNFs that ranked well in Nursing Home Compare's star ratings, the researchers wrote.
"In any given market the number of available SNFs with high ratings was often limited. Many hospitals thus developed their own metrics, which included hours of therapy offered, SNF leadership churn, and quality of medical directorships."
The premier university and its health system have adopted an approach to wellness that focuses on promoting efficiency, supporting resilience, and creating a culture of wellness.
Personal resilience is only part of Stanford University's burnout strategy for physicians and other employees.
"Wellness is much more than that. It's about the culture. It's about giving people the tools they need to succeed. It's also about getting in the flow and being engaged in our work," Patricia Purpur de Vries, director of the Stanford Health Promotion Network, said this week at the Virtual Health Care Summit in Boston.
Stanford has been focusing intently on physician burnout since 2013. Internal survey data from 2013 to 2016 showed burnout was a potentially devastating financial liability.
For every physician Stanford loses, the replacement cost ranges from $250,000 to $1 million. Burnout-related physician departures can hit the health system's bottom line hard, de Vries said.
"From 2013 to 2016 our burnout rates went up and our professional satisfaction rates went down. We estimated from the number of physicians who left from 2013 to 2016 that we would lose 88 physicians over the next year, which could amount from anywhere between $11 million and $88 million."
Stanford has adopted a three-part strategy to address burnout among its 32,000 employees: creating a culture of wellness, establishing efficiency of practice in the workplace, and promoting personal resilience.
1. Culture of Wellness
Leadership is an essential ingredient to create a culture of wellness, de Vries said. "Under a culture of wellness, we have found out that leader support of employees is absolutely key."
Supervisors and workers are encouraged to develop positive relationships that foster meaningful conversations, she says.
"There are a lot of simple ways we can talk through things and help our leaders see the value of getting the best out of employees. We get the best out of people when they feel motivated and cared for."
2. Efficiency of Practice
There are several components to efficiency of practice, de Vries said. "These are workplace processes and practices that promote safety, quality, effectiveness, and positive patient and collegiate interactions."
At Stanford, employee engagement is a crucial factor in achieving efficiency, she said. "Inefficiency is an enormous problem for us. The inefficiencies in our entire workforce are difficult to address. It stems from people not being engaged in their work."
Employee engagement has become a top priority at the university and its health system, de Vries said.
"If we can tie every employee's worth, value, and mission back to the organization, we are all more likely to be happy in the job we were hired for and hopefully do our jobs with more enthusiasm."
Electronic medical record optimization has also been a priority, she said. "We found the EMR was a huge problem at the hospitals. It was so big, nobody was talking about anything else."
3. Personal resilience
Stanford views personal resilience programs as an old-school but crucial element of combatting burnout and nurturing wellness, de Vries said.
"For personal resilience, we feel that it is our traditional wellness program—how we eat, move, and think. It's important to us. At Stanford, we have amazing fitness facilities, two enormous pools, and tracks. We have world-class facilities that our employees can use for no charge."
Stanford has built up its personal resilience infrastructure beyond fitness facilities, with 1,000 fitness classes and healthy living programs offered annually.
The university also provides wellness incentives, she said. "We have biometric screenings that we offer and 57% of our employees have completed their biometric screenings."
To address social determinants of health, Houston Methodist makes direct interventions with grants and builds community partnerships.
Necessity spurred Houston Methodist to address social determinants of health in the communities that it serves.
Participation in Track 3 of the Medicare Shared Savings Program (MSSP) highlighted the need to address social determinants, says Julia Andrieni, MD, vice president of population health and primary care at the Houston-based health system.
"We realized that if we were not addressing nonclinical factors, we could not impact chronic condition management. Illnesses were just the tip of the iceberg—there were a lot more factors that contributed to health status when you took a holistic view of a patient," Andrieni says.
Houston Methodist joined MSSP Track 3, which features upside and downside risk, in January 2017. The Medicare program and population health efforts have prompted development of several social determinants of health initiatives at the health system, Andrieni says.
"Before MSSP Track 3, we were not addressing factors like transportation, food insecurity, social isolation, and economics such as affordability of medications. If we could not address those factors, we could not impact care," she says.
Here are two ways that the health system addresses social determinants of health in the communities it serves:
"We give out millions in grants every year," Andrieni says.
Patients who do not have a medical home have access to Houston Methodist–supported federally qualified health clinics throughout the Houston area, which gives patients access to care in their neighborhoods.
The health clinics coordinate care with Houston Methodist, says Janice Finder, MSN, BSN, director of population health and performance improvement at the health system. "Appointments can be made prior to discharge and reminder calls are provided by the clinic in case patients have to cancel or change appointments."
In disadvantaged communities, grant funding for the health clinics helps support essential services such as behavioral health, Finder says.
Harris County, which is the largest county in Houston, has a 21% uninsured rate and low access to mental health services, with 1 provider to 1,020 patients. The federally qualified health clinics help address a pressing need, she says.
"Behavioral risks such as anxiety, depression, stress, and substance abuse go untreated. The FQHCs as well as our community-based social workers help to alleviate a small portion of this burden," Finder says.
Another grant-supported program—Homeplate—provides food and daily checks for inpatients after discharge.
"Food is one of the primary social determinants affecting health. We have found that many patients who come out of the hospital do not normally require Meals on Wheels or similar programs, but they may need help with meals and a daily check for the first 14–30 days postop," Finder says.
Homeplate also provides meals to newly diagnosed diabetic patients so they can get used to weighed and measured portions.
Homeplate gives food to a patient's family, too.
"We have found when one is hungry many are hungry, and the patient will give their meal to other family members and even their pet. Homeplate provides meals for the entire family and the pets," Finder says.
Drivers who deliver food for Homeplate check on patients and ask basic health-related questions, such as whether appointments have been attended and medications picked up. "If there is a "no" answer, the driver calls our nursing staff, and we handle the alert," she says.
Homeplate has increased patient satisfaction and lowered readmissions, Finder says.
2. Partnerships
Community partnerships are the health system's primary focus to address social determinants, she says. "As a health system, we probably can't be providing transportation and food and actually be the resource for social determinants, but we have partnerships."
Selecting appropriate partners is essential to the success of social determinant initiatives, Andrieni says. "You need to have partners who are aligned with your goals, and you should outline those goals and the outcomes you are working for. The right partner will help you track shared goals and help manage outcomes."
Partnerships with community organizations should be formal business relationships, Finder says.
"You need to set up a legal structure and contract with the organizations you are partnering with, and make sure that you are keeping the confidentiality of your patients," she says.
Three of Houston Methodist's social determinant partnerships help close key care gaps, such as home health, care coordination, and elder resource services:
Grand-Aides
Houston Methodist has a home health partnership with Houston-based Grand-Aides, which provides health workers who support nurses in the home setting.
From August 2016 to December 2017, the partnership with Grand-Aides generated $101,000 in ROI for Houston Methodist. Grand-Aides helped avoid 18 readmissions, which garnered a cost savings of $216,000.
Golden Care Program
As part of Houston Methodist's Chaplaincy Office, the Golden Care Program connects uninsured and Medicaid patients with a primary care physician at one of the federally qualified health centers in the Houston area. Appointments are made for patients before they leave the hospital and are scheduled for seven to 10 days after discharge.
Additional patient services include coordinating community and congregational resources for at-home services, such as patient transportation and food delivery.
Baker Ripley Sheltering Arms
The Baker Ripley Sheltering Arms program helps elders who need assistance accessing general resources such as transportation, health benefits, and care needs. The service targets people with dementia or cognitive impairment who may need case management services or care consultant services for patients and caregivers.
Addressing social determinants of health has had a significant impact on Houston Methodist, Andrieni says. "It has helped us meet our goals to decrease readmissions, to decrease ED utilization, and to be proactive in managing nonclinical as well as clinical issues with our medical and clinical pharmacy staff."
Houston Methodist has more opportunities to close social determinant gaps, Andrieni says. "We have started on this journey, but there is a lot more to do. As we understand our population more and more, we are going to pick up on other gaps that we need to address."
Recommendations fall into three categories: communication, tracking, and acknowledgement of an information review and associated actions.
Healthcare IT has a key role to play in limiting diagnostic errors and botched medication changes, an ECRI Institute report says.
"Results can be—and often are—missed when the loop of receipt, acknowledgment, and action remains open. The resulting consequences stem from these now delayed, missed, and incorrect diagnoses. A closed loop provides timely and effective therapies and mitigates diagnostic error," the report says.
Healthcare IT can help ensure that patient data requiring action is delivered to the right people at the right time in the right format, but the challenge can be daunting.
"Information throughout the healthcare delivery process is transmitted between entities such as laboratory, radiology, and pathology testing facilities, pharmacies, and other providers, all with a potential for interruptions of communication," the report says.
Diagnostic errors have negative impacts on patients and provider bottom lines.
A 2015 Institute of Medicine report, "Improving Diagnosis in Health Care," asserted that every American will experience a meaningful diagnostic error at some point in their lifetime.
On the financial front, diagnostic errors are responsible for about $34 billion in annual U.S. malpractice payments.
The ECRI Institute report's recommendations feature three categories: communication, tracking, and acknowledgement of an information review and associated actions.
The communication recommendations are designed to facilitate the efficient flow of information, with all diagnostic results and medications communicated to providers, pharmacists and patients on a timely basis:
Improve the flow of information using standards to format normal, critical, abnormal-noncritical, and abnormal results
Adopt standards for reporting of actionable findings to include results priority and timing of responses to diagnostic testing
Use universally recognizable display icons in the electronic health record for alerts and notifications
Enhance the usability of diagnostic results communications
Automate notification processes with existing EHR capabilities
Optimize alerts to improve notification and reduce alert fatigue
Avoid interruptions of diagnostic results communications
Provide diagnostic findings directly to patient
The report makes four tracking recommendations:
Seek opportunities where health IT can be used to correct deficiencies and improve monitoring
Create accountability for oversight of tracking
Adopt laboratory standards that improve tracking
Establish bi-directional communication between hospital computer systems and third-party systems such as laboratory partners. Bi-directional capability eases the ordering and reporting of laboratory, radiology, pathology, and diagnostic results.
The report makes two recommendations use health IT to acknowledge the review of information and document the action taken:
Use health IT to link and store an acknowledgment and to record the action taken
Develop the capability to communicate actions taken along with acknowledgments or instead of them. For example, diagnostic-results notification messages should be modifiable by the recipient to add the action taken to "close the loop" such as read, acknowledged or patient notified.
In the emergency room setting, agitated patients with delirium experience higher rates of hospital admissions and adverse events, researchers say.
Agitated patients represent a small but challenging portion of emergency department visits, researchers at an urban Level 1 trauma center found.
The researchers, who published their study this month in Annals of Emergency Medicine, screened 43,838 ER patients and found 1,146 (2.6%) were in an agitated state.
Agitated patients can require significant levels of care in the emergency department setting, the researchers wrote.
"We found that severe agitation occurs frequently in the ED, and often requires both chemical sedation and physical restraint to control the patient to allow a comprehensive medical evaluation and to protect medical providers and the patient from injury."
Acute states of agitation can be deadly, the researchers wrote. "Injuries and sudden deaths have been reported among agitated persons during attempts to restrain and care for them in both custodial arrests and medical stabilization."
None of the agitated patients in the Annals of Emergency Medicine research project died.
Data collected in the research project shows characteristics of agitated patients and their care:
84.6% of agitated patients required physical restraint
72.3% required sedation with an intramuscular injection
1.8% required physical restraint and sedation
16% had clinical events that required intervention such as mild hypoxia treated with supplemental oxygen
7% experienced an adverse event—either intubation or hypotension
23% had delirium symptoms
Delirium danger
Delirium is a serious condition for agitated patients, the researchers wrote.
"The rate of clinical and adverse events was much higher in patients with delirium symptoms, with a two-times-higher rate of intubation, two-times-higher rate of hypotension, and two-times-higher rate of hospital admissions."
Excited delirium syndrome, an acute form of delirium associated with extreme physical violence, is particularly problematic.
The American College of Emergency Physicians recognized excited delirium syndrome in 2009. For a diagnosis of excited delirium syndrome under the ACEP guidelines, a patient must exhibit at least six of 10 potential symptoms, including pain tolerance, sweating, agitation, lack of tiring, and unusual strength.
The Annals of Emergency Medicine researchers found that the histories and vital signs of delirium patients were similar, which indicated that different rates of complications for the patients could be caused by the nature of agitation associated with delirium. "This supports the theory that excited delirium syndrome may represent a condition that is higher risk than typical agitation," they wrote.
The stakes are high for excited delirium syndrome patients, the researchers wrote.
"Because the estimated mortality rate of patients with excited delirium syndrome may be as high as 16.5%, it is critical to identify treatments or interventions that may curb the metabolic derangements of patients with suspected excited delirium syndrome."
Recommendations
While more research is necessary to develop comprehensive best practices for the treatment of agitated patients, the researchers highlight several care guidelines.
In a minority of agitated patients, the condition is linked to a medical illness and performing a timely assessment is crucial, the researchers wrote. "Rapid assessment is imperative because previous research has demonstrated that up to 1% of similar patients ultimately require critical care resources while in the ED."
Oral sedatives are probably not appropriate for many agitated patients because they may not be rapid-acting enough or feasible for distraught patients who struggle with compliance.
If parenteral sedation is required, intramuscular injections can accomplish faster sedation than establishing an intravenous line for an agitated patient.
For physicians, nourishing core professional values such as curiosity and love of knowledge could ward off burnout.
The practice of medicine has changed in ways that are damaging the professional identity of physicians and fueling burnout, a cardiologist and medical school professor says.
Knowledge is at the heart of the physician identity, says John E. Brush Jr., MD, FACC, a cardiologist at Sentara Healthcare in Norfolk, Virginia, and professor of medicine at Eastern Virginia Medical School in Norfolk.
"Physicians study hard to become who they are. They became board certified specialists by taking exams that certify that they have the requisite amount of knowledge to call themselves specialists. But the current practice environment has blown physicians off course," Brush told HealthLeaders Media this week.
Among physicians, automation and business-like relationships in clinical settings have eroded the veneration of scientific knowledge and the desire to apply knowledge that benefits patients, he says.
"Medicine has become so automated and transactional that physicians have forgotten about that central mission and have lost their sense of professional identity."
Dehumanizing effects
Several factors practice environment have become dehumanizing for physicians, Brush wrote in a recent JAMA Cardiologyarticle.
"Physicians are now spending more time with computers
and less time with patients. They are pushed to provide greater productivity but are burdened with increasing administrative tasks, leaving little time for reflection and study. They have become homogenized into providers, a term that signifies how transactional medical care has become."
Digital innovation is threatening to overtake the reliance on physician knowledge and reasoning for medical judgment, Brush wrote.
"This is the digital age of dizzyingly rapid innovation involving digital health, big data, precision health, and artificial intelligence. Disruptive innovations could revolutionize how clinical problems are solved."
Brush told HealthLeaders that two developments have had particularly profound impacts on the practice environment: electronic medical records and the drive toward more productivity measured by relative value units.
"These factors have had a dehumanizing effect on medical practice. These factors have also distracted physicians from their central mission—to use specialized knowledge to improve the health of their patients."
Battling burnout
Reconnecting with devotion to knowledge can help physicians regain their sense of professional identity and curb burnout, Brush told HealthLeaders.
"Having a firm idea of identity can re-humanize physicians and give them a renewed sense of mission. Remembering the love of knowledge and renewing the sense of curiosity and wonder of science can provide a beacon—a true north—that can re-orient physicians and help them avoid burnout."
Knowledge and professional identity are essential to warding off physician burnout, he says.
"A firm appreciation of knowledge and a clear sense of professional identity can give them resilience. Physicians need to have the courage to stand firm against the distractions of modern medicine and nurture their love of knowledge. A renewed love of knowledge can be the cure for physician burnout."
Diagnoses have tripled over the past 25 years, mainly as the result of increased detection of small papillary thyroid cancers. Is it time for a less-aggressive approach?
A pair of physician researchers are urging the adoption of less intensive detection and treatment of thyroid cancer.
Total thyroidectomy is the most common surgical procedure for thyroid cancer, accounting for 80% of operations. It is also the highest-risk surgical treatment, with potential complications including hypoparathyroidism and risk of injury to the recurrent laryngeal nerves.
In the New England Journal of Medicinethis week, H. Gilbert Welch, MD, MPH, of Dartmouth College and Gerard M. Doherty, MD, of Dana Farber Cancer Institute say the prevalence of total thyroidectomy procedures and the potential for harm are unjustifiable.
"The basic problem is the belief that more is always better—particularly in the treatment of cancer," Welch told HealthLeaders Media this week.
The primary surgical alternative to total thyroidectomy is thyroid lobectomy, which removes about half the thyroid gland.
Thyroid lobectomy has several advantages over total thyroidectomy, the researchers wrote.
"This surgery carries a lower risk of nerve damage, avoids the risk of hypoparathyroidism altogether, and preserves thyroid tissue—for many patients, obviating the need for permanent thyroid hormone-replacement therapy."
Data for the 25-year risk of death from thyroid cancer also indicate the preferability of thyroid lobectomy, Welch and Doherty found. "First, the risk of death from thyroid cancer is extremely low (roughly 2% over 25 years), and second, that risk is unaffected by the choice of procedure."
Removing less of the thyroid gland makes more sense than total thyroidectomy procedures, Welch says. "More is just that—more—and carries more harm. In the whole vs. half thyroid question, half is as good and produces less problems."
Overzealous detection
This year, more than 50,000 Americans are expected to receive a thyroid cancer diagnosis. Over the past 25 years, diagnoses of thyroid cancer have tripled—mainly as the result of increased detection of small papillary thyroid cancers.
Welch and Doherty say there is overdiagnosis of thyroid cancer.
"Despite [the] dramatic rise in incidence, mortality due to thyroid cancer has remained stable, which suggests that there is widespread overdiagnosis—detection of disease that is not destined to cause clinical illness or death."
The researchers call for less aggressive detection activity. "Efforts to reduce thyroid-cancer detection are clearly warranted—for example, refraining from screening for cancers and from biopsying small thyroid nodules."
Treatment should take an equally conservative approach, the researchers wrote.
"We support the option of active surveillance for selected patients with small papillary thyroid cancers, but we recognize that some patients will prefer to have their cancer removed. In such cases, the question becomes how much thyroid to resect."
Changing standard of care
Welch and Doherty say the preference for total thyroidectomy is at least partly due to insufficient knowledge.
"Surgeons may underestimate their own complication rates, particularly if they rarely perform the operation. Furthermore, low-volume surgeons may be unaware of new practice guidelines, since thyroid surgery represents a small part of their practice."
Surgeons also appear to be clinging to an outdated view of thyroid cancer risk, the researchers wrote.
"Conventional practice pathways and surveillance strategies were designed for patients with higher-risk disease. It is hard for providers to de-intensify care. To do less for today's patients than for the patients of the past may make clinicians feel exposed."
A less intensive approach to thyroid cancer also could increase patient anxiety, and primary care can play a key role in alleviating concerns, Welch and Doherty say.
"Primary care practitioners can help by educating patients about the heterogeneity of the conditions we call 'cancer,' as well as by shepherding patients through a system that was designed for more advanced disease."
Several research studies over the past four years have drawn similar conclusions. The field is moving toward widespread acceptance of the overdiagnosis problem, Welch told HealthLeaders.
"Both the American Thyroid Association and the American College of Radiology now recommend that small thyroid nodules not be biopsied. And thyroid cancer doctors are now beginning to offer active surveillance—just like urologists do for low-risk prostate cancer."
IU Health has a five-pronged strategy for hip and knee implant procurement, featuring pricing, contracting, physician engagement, vendor relations, and value.
Transparency and competition have become driving forces in the procurement of hip and knee implants at IU Health.
The approach has cut the cost of hip and knee implants at the Indianapolis-based health system by 25%.
"We have an open market that encourages competition between vendors," says Anthony Sorkin, MD, medical director of statewide orthopedic strategic service line.
IU Health's Orthopedic-implant Procurement Enhancement (OPEN) program has a five-pronged approach to lowering implant costs.
1. Pricing
The primary ingredient of the OPEN program is a red/yellow/green implant pricing board that is posted in IU Health orthopedic units, with red representing the most expensive implants and green representing the least expensive implants.
IU Health has 15 acute-care hospitals. Orthopedic surgeons at nine of the facilities have been participating in the OPEN program.
The pricing board is a powerful transparency tool, Sorkin says. "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."
Reducing implant pricing can achieve significant cost savings, he says. "For a standard procedure, whether it is a hip or a knee, about 80% of the costs are in the operating room. A significant part of that 80% cost in the operating room is the implants."
2. Contracting
Three-year contracts without re-bidding provisions are often financially disadvantageous, Sorkin 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."
The OPEN program has flexible three-year contracts for vendors, with rebidding allowed in six-month intervals. The rebidding process has stirred competition and put downward pressure on prices, Sorkin says.
3. Physician Engagement
For more than a year after launching the OPEN program, one-on-one meetings were held with surgeons about their performance metrics, surgical supplies and implants, says Megan Brown, an analyst in the clinical value analytics group at IU Health.
Physicians were given metrics based on their surgeries and patients, including overall cost, length of stay, and metrics for quality and performance improvement. "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," Brown says.
"They were very surprised by the cost of a lot of the items they were using."
Meetings were also held on a quarterly basis with each surgeon and key members of the surgeon's operating room team, Brown says. "We would meet with the surgeon and operating-room leaders such as the manager, orthopedic or resource coordinator, or nurse circulator. We would talk about the utilization of products and what the items cost."
In addition to cost awareness, surgeons also have a financial incentive to embrace the OPEN program's drive for cost efficiency, Sorkin says.
"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."
Gain-sharing is based on costs from admission to discharge, with an average cost figure established for the nine IU Health hospitals that perform hip and knee replacements. Surgeons ranking in the top 25th percentile for low cost receive a 20% gain-sharing payment from cost savings achieved in their procedures.
4. Vendor Strategy
Sorkin says IU Health's approach to vendor engagement is uniquely 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. "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."
The OPEN program has been a win-win-win, with physicians, vendors and the health system all generating benefits, he says.
"The surgeons' engagement has increased significantly, and the vendors are happy to have the opportunity to sell their products, so their engagement has increased. We met our metrics, so the health system is happy. 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."
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."
There is variability in patients that requires flexibility in implant selection, he says.
"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."
Price transparency has led to cost-cutting among both vendors and surgeons, Sorkin says. "No vendor wants to be red. … No surgeon wants to be known as the high-cost provider."
5. Value
The OPEN program is allowing IU Health to capitalize on a growing market without sacrificing quality, Sorkin says.
"The OPEN program is critical for us because the Medicare population is exploding. So, we need to learn how to have the highest-value care, with value being quality over cost. One of the ways we are trying to achieve that is we are looking to decrease the denominator while having no effect on the numerator."
In terms of vendor strategy, the free-market approach has been a crucial element for generating value in the OPEN program, he 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."
Open competition fosters good partnerships, Sorkin 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."
The other six hospitals do not perform hip and knee procedures
The AMGA's proposed 14-metric measurement set and proposed changes to Medicare's quality measures draw largely favorable reviews.
Recently proposed quality measure changes are generally steps in the right direction, an Electronic Health Record Association official says.
A pair of quality measure changes were proposed this month. The Centers for Medicare & Medicaid Services (CMS) have proposed changes as part of the Medicare Physician Fee Schedule for 2019, and the American Medical Group Association (AMGA) has proposed a 14-metric measurement set.
The proposed CMS changes would alter measures in the Quality Payment Program, which features the Merit-based Incentive Payment System (MIPS) and advanced alternative payment models. The proposed changes to MIPS are modest, says Ida Mantashi, chair of the Electronic Health Record Association's Quality Measurement Workgroup.
"I was surprised that the measure changes were not huge. The measures that have been proposed for removal are not that highly used—we were expecting some of them to go away," she says.
The CMS proposals include eliminating MIPS process-based quality measures that clinicians have called low-value or low-priority, according to CMS. The proposed changes to MIPS are designed to elevate the importance of measures that have a more significant effect on health outcomes, CMS says.
Mantashi applauded CMS for maintaining quality measures for specialty practices. "Some specialties have so many little measurements that they can't go to fixed measures. … I hope CMS never gets rid of the measure functionality for the specialty practices."
Evaluating AMGA measures
The AMGA, which is based in Arlington, Virginia, has proposed quality measures that are designed to reflect value in care and to lessen administrative burden.
The AMGA measurement set features both process measures such as cancer screening and outcome measures such as hospital readmission rates:
Admissions for acute ambulatory sensitive conditions composite
HbA1C poor control
Depression screening
Diabetes eye exam
High blood pressure control
CAHPS, health status, and functional status
Breast cancer screening
Colorectal cancer screening
Cervical cancer screening
Pneumonia vaccination rate
Pediatric well-child visits through age 15 months
In general, Mantashi gives the AMGA measurement set a positive review.
"They did a good job putting this list together. It is not an easy task to account for all of the directions and needs in healthcare. They have done a good job of bringing everything under the same umbrella," she says.
However, the AMGA measurement set is a poor fit for many specialty practices, says Mantashi, director of product management at Boca Raton, Florida-based Modernizing Medicine.
"The problem with 14 measures is that if you are in a specialty, you are going to have a very hard time reporting all 14. For example, dermatologists don't have readmissions."
The federal program's financial incentives have encouraged the development of care models that help keep frail patients out of emergency rooms and inpatient wards.
Medicare Advantage is a hotbed of innovation in efforts to improve care for seriously ill patients, researchers say.
"The financing structure of Medicare Advantage makes it a fertile testing ground for new payment and care delivery approaches, including value-based payment models," the researchers wrote in their report published this month by the Duke Margolis Center for Health Policy.
The financing of Medicare Advantage health plans includes a pair of incentives that support innovation:
Health plans receive per-member per-month payments. If enrollees' cost of care is less than their capitated payments, the health plan keeps the savings.
Health plans receive bonus payments for high-quality care as determined by the Centers for Medicare & Medicaid Services' Star Ratings program
To demonstrate Medicare Advantage's capacity to enable innovative care for seriously ill patients, the Margolis Center researchers focused on care models developed by three health services firms that contract with Medicare Advantage health plans.
The researchers found that the companies—Aspire Health, Landmark Health, and Turn-Key Health—have care models for the seriously ill that share four primary commonalities.
1. Eligibility requirements
The firms analyze claims data from Medicare Advantage health plans to ensure that enrollees meet eligibility requirements for their services.
The analysis goes beyond identifying diagnoses and gauging utilization. Predictive analytics are used to target patients who are likely to incur increasing utilization and costs as their illnesses progress.
"Without rising risk of high-cost care encounters, there is little potential savings to be gained from the intervention," the researchers wrote.
2. Health assessments
The companies' care teams conduct and maintain health assessments of patients that help form comprehensive understandings of health status and risk factors such as safety concerns in the homes of patients.
The health assessments generate a wealth of data, the researchers wrote. "The information recorded in these assessments may then be used to inform risk stratification within patient cohorts, to prioritize resource needs for patients, and to tailor care plans."
3. Aggregated data
The assessment data is combined with claims data in computer programs that monitor patient health status and risk level.
Dashboards and reporting from the combined data are used to monitor several measures, including patient engagement, quality of care, utilization, and clinical outcomes. The information helps care teams decide whether interventions can avoid high-cost encounters such as emergency room visits.
4. Home health
Health services are delivered in a patient's home or residence facility.
Access to services from the companies is extensive, the researchers wrote. "All of them provide round-the-clock accessibility to patients, which is critical for quickly addressing patient concerns and needs in order to prevent or divert emergency visits and hospital admissions."
Expanding innovative care models beyond Medicare Advantage
The researchers say Medicare Advantage's innovative care models for the seriously ill face three expansion hurdles: rural economics, workforce training, and inflexibility in traditional Medicare.
The home health approach at Aspire Health, Landmark Health, and Turn-Key Health is costly in rural areas, where the distance between patient homes can be great. Travel costs limit the financial viability of the models.
For these care models, clinical leaders are particularly difficult to find because they must have both clinical and management training. The researchers say management training should be added to medical school curricula and post-doctoral education.
If traditional Medicare embraces these care model, innovation-stifling standardized rules would likely be adopted, the researchers wrote. "Those rules would necessarily limit the flexibility of the models to meet the needs of patients."
The researchers make three recommendations to promote care models for the seriously ill:
Incentivize the care models for traditional fee-for-service Medicare patients such as expanding the Independence at Home demonstration program to support care models with interdisciplinary teams focused on seriously ill patients
Study more serious illness care models to generate data on utilization, quality, and cost
Support workforce training that better prepares providers for practicing medicine under alternative payment models
