Too many specialists overwhelm a primary care provider's ability to coordinate care and can lead to more intense, and costly treatment.
Regions of the country with greater primary care physician involvement in the last six months of life appear to have lower-intensity, lower-cost end-of-life care, according to research by published in the January/February 2017 issue of Annals of Family Medicine.
For purposes of the study, "primary care involvement" was defined as the ratio of PCP to specialist visits. The following interview with researcher Claire K. Ankuda, MD, MPH, with the Robert Wood Johnson Clinical Scholars Program at the University of Michigan Health System in Ann Arbor, and colleagues about the significance of these findings has been lightly edited.
HealthLeaders Media:Your study found that there was lower Medicare spending in the last two years of life in regions with more primary care physician involvement ($65,160 vs. $69,030). Can you put those numbers into context for healthcare leaders?
Claire Ankuda, MD: While the absolute dollar amount of around $4,000 over two years may not seem like a tremendous amount, even to some people within the healthcare industry, it's very significant if you think about the sheer number of Medicare beneficiaries we're talking about.
It's also important to understand that this is not a randomized controlled trial. We are really comparing regions of the country, so we did adjust for other factors that are different from place to place and which might also impact cost. With that in mind, our estimates are likely quite conservative.
HLM: In instances where there is more PCP involvement, where do the savings come from?
Ankuda: We know that a lot of what drives cost at the end of life are things like intensive care use and acute care hospital stays.
In our study, we found that the regions where PCPs were more involved at the end of life had less intensity of care, meaning fewer ICU days and such, which is likely what's really driving the cost savings.
Others have done good work to probe what drives this decision-making. A study published in the Annals of Family Medicine, for example, demonstrated the considerable role that PCPs have in coordinating care. It's possible that coordination really does keep people home in this critical time.
Previous research has also found that PCPs' role in coordinating care can become somewhat overwhelmed when there are too many specialists involved, which makes sense. It's one thing if you're a PCP and your patient is seeing two other physicians, but it's another thing if all of a sudden they are seeing five, seven, or 10 other physicians, who are all prescribing different medications and maybe have slightly different perspectives on that patient's illnesses and prognosis. It can be very difficult to coordinate that.
HLM: Your study uses claims data from 2010, before the advent of codes for chronic care management and advance care planning. Are you hopeful that these reimbursement changes will help optimize primary care and cost savings even further?
Ankuda: I'm very hopeful, certainly about some of the additional codes that doctors can bill for. Now you can have a conversation with a patient about his or her advanced directive or goals of care and bill for that, which is great. You can also get paid for the after-hours work that you and people in your clinic are doing to help coordinate care. That's really critical.
Potentially, the bigger shift is in some of the alternative payment models that we're now thinking about more, which can be more flexibly used by clinic teams to help meet the needs of patients and improve care at all stages of life.
Texas Health Resources has developed a strategy to both recruit and retain top physicians by remaining competitive in an ever-changing marketplace. Learn THR's top tips for physician recruitment and engagement by watching this on-demand HealthLeaders Media webcast.
Summit Medical Group and the MD Anderson Cancer Center collaboration will provide NJ patients with ambulatory cancer care close to home at a lower cost than most local hospitals, says CEO.
Summit Medical Group, the largest privately held multispecialty medical practice in New Jersey, last spring partnered with University of Texas MD Anderson Cancer Center to deliver comprehensive multidisciplinary, ambulatory cancer care at a lower patient cost.
HealthLeaders Media: How and when did your partnership with MD Anderson Cancer Center come about?
Jeffrey Le Benger, MD: Previously, we had good cancer care at [Summit Medical Group], but we didn't have the full spectrum of care. We did some clinical trials, but care was fractured for the community.
So about three years ago, we decided to look for a partner in cancer care that would give us the attributes we were looking for—especially the ability to provide seamless care for patients—and decided to partner with MD Anderson because they were very inclusive.
HLM: Without naming the institutions you didn't pick, what were the qualities you wanted to go after or avoid?
Le Benger: In discussions with other practices in the New York City area, it seemed almost as if they looked at us as a resource for them to get cancer patients to move into the mothership in NYC and then send them back to us for post-care of cancer.
MD Anderson, on the other hand, would expose us to all of its clinical history and expertise in taking care of cancer patients by credentialing our physicians to treat patients at our site. Now we not only have all of the clinical pathways that MD Anderson has, but we also have access to their research, clinical trials, and tumor boards.
And because we're an ambulatory setting, the infusion therapy and radiation oncology we provide is cheaper than the same services provided in a hospital setting. We're very cognizant of patients needing to be able to afford their treatment.
HLM: How does the partnership benefit MD Anderson?
Le Benger: MD Anderson's mission is to eliminate cancer. So they need exposure to as many new cases as they can to get into their clinical trials to figure out what is right in the world of genomics, amino therapy treatments, and other promising ideas that aren't yet where they need to be.
To do so, they want to affiliate and partner with as many good practitioners as they can on the outside to bring cancer therapy to the next level.
HLM: What have been some of your challenges or lessons learned thus far?
Le Benger: Do your due diligence in picking the right partner, and be careful with your local and state regulations. When you start to develop a 130,000-square-foot site, as we have, you have to really watch your cost structure as you're developing it because it's going to be a huge capital outlay.
HLM: How have Summit physicians responded to the partnership?
Le Benger: The surgeons and people at the cancer center are ecstatic. The primary care physicians and others who wrap around this partnership now feel comfortable knowing that we are affiliated with the number one cancer institute in the world.
Understanding practice differences between men and women and applying them in clinical settings can have very real consequences. But don't take the data too personally, says one researcher.
Female physicians are better than males.
That's the essence of the findings of Harvard researchers, distilled by headline writers and social media users. The study was published in JAMA Internal Medicine in December.
Senior study author Ashish Jha, MD, MPH, is more nuanced in his assessment of the findings.
"Modest but clinically important" is how he, a professor of health policy at the Harvard School of Public Health, describes the roughly half-percent difference in mortality and readmission rates of Medicare patients treated by male versus female physicians shown in a study of 1.5 million hospital visits throughout the United States.
Jha spoke with HealthLeaders Media recently about what healthcare leaders can learn from these findings, which suggest that male physicians could save 32,000 lives per year if they practiced more like their female counterparts. The following transcript has been lightly edited.
HealthLeaders Media: What made you want to research this topic?
Ashish Jha, MD: There are a dozen or so studies out there that suggest that women physicians are more likely to practice evidence-based medicine (EBM), more likely to stick to clinical guidelines, and that they communicate more effectively with patients than male physicians do.
We wondered simply whether all of this translates into better outcomes.
Jha: There's been a range, from people who are not surprised to those who are very skeptical. It's been mostly male physicians who are skeptical, but there are many male physicians who have been very supportive.
The key here is not to take the findings too personally.
Obviously I'm a male physician and I think it's quite possible for male physicians to be quite terrific. I think people have to look at this more in terms of what it teaches us about how to provide high-quality care as opposed to turning it into a battle of the sexes.
HLM: What have been the skeptics' specific criticisms?
Jha: People have brought up that short of a randomized controlled trial, you can never be 100% sure of a finding.
But we're not going to do a randomized controlled trial, and we see lots of policy decisions made without them. There hasn't been a randomized controlled trial that shows that smoking causes lung cancer, but we know it does.
So while the evidence here is not perfect, it's pretty compelling if you look at the size of the data sets we examined and all of the ways in which we tried to make sure we were finding something real and not just a statistical fluke.
HLM: What can healthcare leaders, including physicians, take from these findings to improve outcomes overall?
Jha: In our study, we couldn't figure out the exact mechanism by which women had better outcomes. But if you look at the broader set of data that is out there, and if we really can draw some conclusions around women's tendency to practice more EBM or communicate more effectively, those are very translatable skills.
Those are things that everybody can do better. The key lesson here is to try to really identify why it is that women seem to achieve better outcomes and then figure out how to translate that more broadly so that all patients have good outcomes irrespective of the gender of physicians.
HLM: With physician reimbursement becoming more closely tied to outcomes, do you expect we'll see the pay gap between male and female physicians close?
Jha: While the pay gap is very problematic, it's not clear to me that the measures that we're using for changing the way we pay physicians are going to necessarily help close the pay gap.
I do think we need a renewed focus to ensure that the gender pay gap, which has been very clearly documented, is addressed effectively. And the fact that women are actually achieving better outcomes should certainly give us yet one more impetus to make that happen.
Atrius Health's Care in Place program brings urgent medical assistance to patients who can't get to the doctor's office, boosting patient satisfaction and cutting costs.
Medical groups have come a long way toward providing same-day access for patients in need of prompt care.
However, for elderly patients who can't arrange transportation or don't feel well enough to the visit the office, the options—delaying care or calling an ambulance—don't bode well for patients or healthcare organizations.
To solve the problem, Atrius Health deploys care to patients who can't come to the office, says Steven Strongwater, MD, president and CEO of the Newton, MA-based nonprofit health system. Atrius spans 29 clinical locations, 50 specialties, and 750 physicians.
Within three months of launch, the Care in Place program's estimated $97,000 up-front development and implementation costs have generated savings of $509,000 in avoided ambulance fees, and emergency department and hospitalization costs, says Eliza Shulman, DO, MPH, a senior chief innovation engineer at Atrius Health.
Atrius based the program's estimated savings on patient and provider feedback. "Half of these patients have said, 'I would have gone to the ER if you hadn't been able to come here today,' " Shulman says.
Decreases in patients' total medical expenses are very good news for Atrius, which receives 75% to 80% of its revenue from global capitated risk and does not own any hospitals.
"Essentially, we behave as though we're at full risk," Strongwater says.
More than Money
Both patients and physicians have lauded the service, showing that cost savings isn't the program's only benefit.
A sample patient testimonial from Strongwater's presentation:
"Everybody did a great job; they are all very good. The X-ray tech… made it as easy as possible to get an X-ray, it worked out very well. I'm glad I didn't have to go anywhere."
Physicians' feedback has also been highly favorable, says Shulman.
"Whatever we develop out of the Innovation Center has to increase joy in practice and not be added work on the clinician. So we've said, 'These patients you're worried about—we're going to see them, create a plan of care, and not interrupt your day to make you coordinate a lot of services.' "
After the home visit, the provider (usually a registered nurse) generates a care plan and gives it to the patient's primary care physician, Shulman explains.
Eventually, the system hopes to expand the program to high-risk populations, such as those with congestive heart failure.
How it Works
Deploying care to patients can be challenging to implement. One major task is educating patients to call the office when they are very ill or injured, Strongwater notes.
Under Massachusetts law, if a patient calls 911, he or she must be taken to a hospital ER, he adds, noting that the elderly have a 51% chance of being admitted under such circumstances.
When Atrius Health patients call their physician office instead of 911, triage nurses determine whether the problem is serious enough to send them to the ER, or if a same-day office visit is sufficient.
If a patient over age 65 is eligible for a same-day visit but can't make the trip, an Atrius nurse places a referral for a nurse from the Visiting Nurse Association to visit the home within two hours, with no copay to the patient.
Because of Atrius's close relationship with the VNA, the visiting nurses have access to patients' medical records, Shulman says. The nurses also have phone access to a medical control officer at Atrius to help with decision-making, which cuts down on the cost of personnel deployed to the home.
That access to information is key to Atrius's program, according to Shulman. "Being on the same medical record is so important because you're able to provide a much higher level of care when you know a lot about the patient."
A Senate Finance Committee report calls for "additional measures" to address two major concerns related to the practice of overlapping surgeries: patient safety and improper payments.
Hospitals that haven't yet settled on strict definitions and policies governing the practice of simultaneous surgeries are on notice.
A Senate Finance Committee report released Tuesday acknowledges that "evidence on the practice—safe or otherwise—of concurrent or overlapping surgeries is lacking," but calls for "additional measures" to address two major concerns, patient safety and improper payments by the Centers for Medicare & Medicaid Services.
"Absence of data," the report notes, "does not mean that there is no risk."
The American College of Surgeons (ACS) updated its guidance on concurrent surgeries last spring in the wake of an investigation into the practice at Massachusetts General Hospital by the Boston Globe.
The Senate Finance Committee's investigation was in turn sparked by the Globe's report, which rendered the Committee "alarmed by the allegations of patient harm, surgeon misconduct, and inappropriate billing."
In response, its chairman, Senator Orrin Hatch (R-UT), ordered an investigation of 20 hospital systems to ascertain the nature of their policies for simultaneous surgeries.
Defining and Disclosing
While 17 of the 20 hospitals in the Senate inquiry modified or created policies to measure up to ACS standards, the policies of three systems were not complete in time for inclusion in the report.
The Committee reviewed conformance with ACS guidance along six dimensions:
Defining "concurrent" and "overlapping" surgeries
Defining the "critical portions" of an overlapping surgery
Disclosing information to patients
Defining what it meant for a surgeon to be "immediately available"
Arranging for a backup surgeon
Ensuring compliance with new policies
"The Committee staff commends the efforts that some hospitals and surgeons have taken in a relatively short timeframe to address many of the concerns surrounding concurrent and overlapping surgeries," the report stated.
But given the small sample size and ongoing concerns about patient safety and improper payments from CMS, the Committee report recommends that CMS should raise its policy standards for simultaneous surgeries to the level of the ACS' current guidelines and encourages accrediting bodies to do the same.
Mayo Clinic Offers New Data
Meanwhile, new data on the practice has surfaced.
Research published Dec. 1 in theAnnals of Surgery compared thousands of overlapping and non-overlapping operations performed at the Mayo Clinic's Rochester, MN, campus, and found no difference in the rates of postoperative complications or deaths within a month after surgery between the two groups.
"Our data shows that overlapping surgery as practiced here is safe," said co-author Robert Cima, MD, acolorectal surgeon and chair of surgical quality at Mayo Clinic's Rochester campus. "We think it provides value to our patients because it allows more patients timely access to surgery and care by expert teams."
In addition, Mayo researchers noted that patient safety may even be enhanced by planning surgeries to overlap during the day, as complications are more likely for night surgeries.
Experts hope for continued expansion of coverage for substance-abuse treatment and broader acceptance of addiction as a brain disease requiring medical care.
The harrowing brutality of the opioid crisis is old news to addiction professionals.
"We could have told you that opioids were at epidemic levels years ago," says Clay Ciha, CEO of AMITA Health Behavioral Medicine, which includes Alexian Brothers Behavioral Health Hospital in Hoffman Estates, IL.
What's somewhat novel is that the brain disease of addiction has become a top priority for many people outside the medical field.
Just last week, U.S. Surgeon General Vivek Murthy, MD, issued his office's first report about alcohol, drugs, and health. Now treatment advocates are watchfully waiting to see whether the incoming Trump administration takes actions that make the problem better or worse.
For an insider's perspective on these developments, Ciha and his colleague, Gregory Teas, MD, chief medical officer of the behavioral medicine service line at AMITA Health, agreed to answer a few questions. The following transcript has been lightly edited.
HealthLeaders Media:How might Trump's election affect addiction treatment policies nationally, and AMITA in particular?
Ciha: I can't speak to that directly, but I do think Congress, the legislative branch is making some great strides in understanding the importance of addressing both behavioral health and substance use disorders, so I would hope that wouldn't backslide in any way.
I think there's some really good bipartisan support for almost all of these bills. I don't know that the role of the president is going to affect the cooperation that currently exists in Congress.
Teas: I agree. We've seen important legislative acts in the last five years to increase parity in coverage between general medical conditions and both mental illness and addictions that have allowed access for many more people to treatment, and I think that would be a hard policy to reverse, and hopefully is going to continue to expand coverage for those who are willing to seek treatment.
HLM: Also on election day, California, Massachusetts, and Nevada joined the ranks of states with some measure of legalized recreational marijuana. Does this trend make your jobs harder?
Ciha: I'll let the doctor answer that one.
Teas: It's a concern. According to insurance statistics, the number one drug that teenagers seek treatment for is marijuana. Now we're putting marijuana in a legalized form into households where it can lead to exposure to minors as so-called acceptable adult behavior.
One of the real problems we may see down the line through this exposure to youth is rising rates of cannabis use, a trend that's already noteworthy in high-school-age kids. That makes me nervous, particularly with the latest data about cannabis on the developing brain in that age group.
HLM: We've seen that language matters in reducing the stigma surrounding addiction. What terms should healthcare providers use or avoid when discussing addiction and recovery?
Teas: The federal government agencies, including the office of the Surgeon General, now refer to addiction as a brain disease, and that gives it the status of a medical problem rather than a moral problem.
Ciha: Simply put, it's wrong to say that these are people who need to pull themselves up by their bootstraps. This is a disease like any other disease, and if we treat it as such, I think you're going to see a lot more acceptance of people wanting to get treatment, as well as better social support from families.
We can also remove a lot of negativity from the conversation. People get better. Their lives get better. Their relationships grow and mature and exceed their wildest expectations. The good news here is that people do recover and people do get better—and we have the tools to make that happen.
From the president to your next door neighbor, people are increasingly aware of and excited about genetic medicine. But how should hospitals get involved?
This article first appeared in the December 2016 issue of HealthLeaders magazine.
Whether you call it precision medicine, personalized medicine, genetic medicine, or by a term yet to be coined, decoding DNA has begun to revolutionize the practice of medicine. In many instances, the science exists to quantify an individual's predisposition for a specific disease or target a precise mutation within a tumor's own genes.
The promise of such advances is so powerful that President Barak Obama earmarked $215 million of the country's 2016 budget to the Precision Medicine Initiative, intended to accelerate the development of new genetically based tests, tools, and treatments.
And the majority of U.S. adults are interested in being part of these discoveries, according to a study funded by the Foundation for National Institutes of Health. The study, published by PLOS ONE, revealed 79% of those surveyed support the idea of a national cohort study, while 54% would definitely or probably participate if asked.
What individuals crave even more, it seems, is insight into their own genetic profile, which can be bought for as little as $199 and some spit. The cost of full genome sequencing is now around $2,000, a modest expense compared to the $100 million it cost in the not-too-distant past.
Expanse of the unknown
But for all of the enticing questions genetic research can currently answer, it raises exponentially more.
When it comes to any genetic test, the healthcare community has before it two key questions, according to Lawrence Brody, PhD, director of the division of genomics and society at the National Human Genome Research Institute (NHGRI): "Do they enhance outcomes and do they make healthcare essentially more effective?"
"I think that's the bar most of us in our institute would like to be able to test," he says. "We're at a very intense phase of research where we're trying to figure out what we can learn in regard to treating patients and potentially in regard to preventing them from being patients in the first place."
Among genetic experts, there are two schools of thought surrounding the extent a person's DNA should be explored, says Brody. In the minority are proponents of sequencing a person's entire genome at a certain time, such as birth or age 18, and having that information available in a person's electronic medical record to be consulted as necessary throughout his or her life.
"We're not jumping on it yet because the technology for sequencing the genome keeps changing and there is definitely some worry that you would want to just sequence it again and again," he says. Another quandary raised by such broad testing is the multitude of genetic "variants of unknown significance."
In other words, while scientists have the ability to sequence the entire genome, they don't yet have the knowledge to evaluate it.
For those reasons, a more traditional point of view is that specific genes should be tested to answer specific questions. But even with that approach, it's possible to end up with answers to questions you didn't ask, also referred to as accidental or incidental findings.
"Often I'm pleasantly surprised that patients are smarter than their doctors and they recognize that they could be at genetic risk for disease A or disease B and they refer themselves."
For example, a person undergoes exome sequencing to understand an abnormal lipid profile, and incidentally learns about increased risk for an unrelated disease. "Now you've got a different kind of problem," Brody says.
The Cleveland Clinic approach
Nonetheless, the opportunities are vast for healthcare providers who are able to harness existing genetic expertise.
At Cleveland Clinic's Genomic Medicine Institute, for example, patients can receive personalized genetic healthcare for diseases ranging from cancers to cardiovascular diseases.
Charis Eng, MD, PhD, chair and founding director of the institute and a cancer geneticist, estimates that one-third of the patients in her subspecialty self-refer, while the rest are referred by other physicians. "We firmly don't discriminate," she says. "Often I'm pleasantly surprised that patients are smarter than their doctors and they recognize that they could be at genetic risk for disease A or disease B and they refer themselves."
Approximately 40,000 patients have benefited from personalized genetics visits during Eng's 11 years at the Cleveland Clinic, she says.
That said, there is a screening process patients undergo before genetic testing. The web-based screening tool, which Eng invented, she says, collects the patient-reported family health history, uses algorithms to assess risk, and pushes clinical decision support through the EMR to primary care physicians.
Patients deemed to be at genetic risks comparable to that of the general population can at that point receive reassurance with no further testing, while those at higher risk can be referred to the genetics department.
"We built the clinical practice so that we can see patients on the same day if necessary," Eng notes. "And that is rare in genetics in the country."
That access is possible because the team, made up of 2.5 full-time equivalent physician geneticists and nine FTE genetic counselors, is spread over several clinics throughout Cleveland Clinic's main campus and beyond. The team also practices some telehealth, which it plans to expand, and conducts shared medical appointments to address certain issues, such as predictive testing for a known mutation in a family member.
Addressing the DTC market
In some cases, patients visit the Cleveland Clinic with direct-to-consumer (DTC) genetic test results in hand. Eng and her team developed their strategy for managing the DTC factor when awareness of companies such as 23andMe began.
The first step focused on physician education. "The primary care doctors were afraid that patients would walk in and have this genetics test results document and they would have no idea what to do with it," Eng says. Eng and colleagues over seven months arranged seven continuing medical education presentations at various Cleveland Clinic locations with healthcare providers from primary care and OB-GYN clinics to discuss counseling, conflicts of interest, and other matters related to what she calls "nonclinically actionable recreation genetics."
Next, Eng and her team provided the physicians back-end support by providing two types of genomic counseling to which patients could be referred. One type is an in-depth genetics session that goes into family health history and includes a thorough evaluation and counseling, Eng explains. "The second is what we call a genomic counseling executive summary."
With the latter, the genetics team evaluates a patient's DTC test results and—unless it spots something actionable—provides a high-level overview. "At the time, most of the things we saw were completely nonactionable."
There are numerous reasons hospitals may want to get into genetics services, but that doesn't mean that organizations should start offering full exome sequencing just because the technology exists, Eng says.
"The key is to employ competent, well-trained genetics professionals," she says. "We went to training to take that family history, to talk to the patient, to examine the patient to see if there are any clinical red flags that suggest one disease or another or whether it's time to order a panel of genes."
One solution is for organizations to partner with existing genetic medicine centers, Eng says. There are still licensing and reimbursement problems to be resolved in increasing use of telehealth, she adds, but she expects they will be resolved in time.
And as the field of genetic medicine expands, part of the NHGRI's mission is to ensure its promise isn't limited to individuals with the willingness or means to pay, Brody says.
"One of the things we worry a fair bit about is having this information easily accessible, and not just for people who can afford $2,000 out of pocket," he says. "We really want to have this be equal access and not make any kind of health disparities."
To thrive in today's marketplace, healthcare organizations must offer female-specific medical expertise that meets women's expectations as consumers.
This article first appeared in the December 2016 issue of HealthLeaders magazine.
Less than a generation ago, medicine generally approached female patients as though they were simply smaller men, with the differences in reproductive organs and sex hormones representing somewhat of a "black box," says Dixie Horning, executive director, COE and associate chair, finance and administration, in the department of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco (UCSF) National Center of Excellence in Women's Health.
UCSF was designated with the National Centers of Excellence in Women's Health in 1996, sponsored by the Office on Women's Health in the U.S. Department of Health and Human Services. The center was tasked with promoting sex and gender research as essential for understanding women's (and men's) health and disease, encouraging the development of multidisciplinary clinical care organized around the needs and preferences of women and based upon the emerging evidence, and more.
While the science of women's health is better understood than it was 20 years ago, female-focused service lines must continue to evolve to meet women's unique lifelong health needs in an ever-shifting healthcare landscape.
Success key No. 1: Appreciate the power of female consumers
The top reason to make women's health a priority, experts agree, is because of the tremendous buying power women have as healthcare consumers and influencers. According to the U.S. Department of Labor, women make about 80% of healthcare decisions for their families.
"They're also the toughest critics," says Adrienne Kirby, PhD, FACHE, president and CEO of Cooper University Health Care, which includes Cooper University Hospital, an academic tertiary-care medical center, and more than 100 outpatient locations throughout New Jersey.
"We know that when you look at the distribution of patient experience scores, women between the ages of 40 and 60 tend to be the hardest raters," she says. "When you have a decision-maker who is also a discerning consumer, it makes sense to us that you would consolidate services into a wonderful environment where women can delight in what they experience so they will feel loyalty to your organization and select your organization when making decisions about other family members."
In 2007, Cooper University Health Care sought after that goal with the creation of The Ripa Center for Women's Health & Wellness, named for TV personality Kelly Ripa and her family, which has supported the Cooper system. The facility features internal medicine, obstetrics, gynecology, imaging, cardiology, pulmonology, neurology, endocrinology, gastroenterology, plastic and breast reconstruction surgery, behavioral health services, as well as various exercise and cooking classes.
Not only does the center offer "one-stop shopping" for women's health needs, but patients get assistance from a navigator to help coordinate their care. The organization's Half-day for Health program even offers women the opportunity to handle many of their health needs within one three-hour block.
While not all women's health service lines are centralized in one facility, executives agree that convenience matters.
"We found that having OB-GYN and primary care services less than a block from pediatric services is an important key because women are often taking their children or parents to appointments," says Horning. "So colocation or close proximity to other services a woman would want to access will improve her adherence to coming to her own appointment."
At the same time, women have high standards for clinical quality, says Scott Hayworth, MD, FACOG, president and CEO of CareMount Medical, an independent multispecialty medical group in New York State, with more than 400 physicians representing 42 specialties throughout eight major campuses.
"Women are sophisticated consumers," says Hayworth, an OB-GYN by training and former chair of the New York district and former treasurer of the American College of Obstetrics and Gynecology. "They will check out the credentials of doctors to make sure they are board-certified and that advance practice providers are well trained. They want to know the expertise of the individuals they're seeing before they make their first appointment."
Success key No. 2: Build a primary care foundation
And contrary to perceptions even within the healthcare industry, the medical expertise women need extends far beyond OB-GYN. "Women's health is not OB-GYN renamed," says Horning. "The concept that it's much more is a philosophical and cultural change."
After all, reproduction represents a relatively short period within women's life spans, but they have unique needs from birth to puberty and beyond child-bearing years as well. "OB-GYN is only a small portion of women's health proportionate to our longevity," she adds.
According to Horning, holistic women's health should begin with primary care, which lines up with today's reimbursement climate more than in the past. "The Affordable Care Act is pushing the very thing that women and our population need, which is preventive primary care," she says.
And with value-based and population-health incentives rewarding organizations to keep women well, UCSF primary care providers, which Horning oversees, are doing more to create medical homes and medical neighborhoods. These models help ensure women get all of the preventive services they need at the right times, such as mammograms, pap tests, and diabetes and blood pressure screenings.
"Primary care is the foundation on which we need to build evidence-based practices to keep people out of the hospital and needing expensive care."
Success key No. 3: Evaluate emerging opportunities
That said, women can benefit from gender-specific care in numerous specialties. "Women's health is not just focused on reproductive organs, but it's the heart, it's mental health, and more. Women have different needs than men, and we have to make sure we are gearing every part of our organization to take care of women as women," says Hayworth.
Even within a major life stage exclusive to women—menopause—current evidence no longer supports hormone replacement therapy (HRT) as a given, notes Horning. "Through newer studies we now know menopause does not need to be treated as an illness," she says, adding that UCSF research has verified other studies suggesting that HRT can increase women's risk of stroke and heart attack.
There are plenty more areas of opportunity in the women's health space, but few guarantees. "We started with the traditional group of services for women, and we grew it," says Kirby. "We added behavioral health because the doctors were referring patients for it, and it turned out to be quite successful."
Similarly, the center brought on specialists in cardiology and endocrinology based on seeing more patients with metabolic disorders. "It was based off of our experience but a little bit of a calculated risk," Kirby says. "And we continue to grow, which I think is the success of the program."
There are currently 19 physicians working at The Ripa Center, 17 of whom are women, who conducted a combined 17,000 visits in 2015.
The next venture for The Ripa Center, according to Kirby, will likely involve weight-loss management as well as an exercise and fitness program. "We're hearing a lot from our patients that they want to have a place that they feel is trustworthy, where they can go to have a comprehensive weight-loss management program," she says. "We do have a bariatric program that sees patients right on that campus, and we are developing with endocrinology and the bariatric team a metabolic service to offer medical management of weight loss."
And CareMount is looking to build on its existing OB-GYN expertise by offering in vitro fertilization services, says Hayworth, who also expects growth around genetic medicine and women's cancer screening and treatment.
The group already employs specialized women's pathologists who only do gynecologic pathology, he adds, and is able to offer patients access to clinical trials through its clinical affiliation with Massachusetts General Hospital.
"Even though we're miles away we're able to offer our patients state-of-the-art cancer care," he says. "It's very unique that we're able to offer these clinical trials in the private practice setting."
Meanwhile, Cooper University Health Care's partnership with the MD Anderson Cancer Center provides patients with oncology expertise as well. If patients seen at The Ripa Center are suspected to have or are diagnosed with a malignancy, they can receive care across the street at the MD Anderson Cooper Voorhees satellite campus, a Cooper entity. All of the center's affiliated physicians are duly credentialed as MD Anderson Cancer Center (Houston) and Cooper physicians.
But the key partnership that's vital to The Ripa Center is with the physicians, Kirby says. "They have embraced this and the physicians that work there are dedicated to making this a one-of-a-kind, top-in-class center. They come up with ideas and are constantly looking at ways to make it better."
Success key No. 4: Mind your metrics
As healthcare executives know, you can't improve what you don't measure.
For CareMount, clinical quality is priority No. 1. "Whatever we do, if we're not going to do it well, we're not going to do it," Hayworth says. "We're blessed that we have a relationship with both MGH and Mount Sinai in New York. And if it's something that we can't handle, even with our subspecialists, we have the ability to send our patients to some of the best hospitals in the country."
The organization also watches financial and outcomes measures closely, he says. And Press Ganey patient satisfaction ratings are of critical importance to make sure patients are happy with their experience.
Patient experience is paramount for The Ripa Center as well. "Our goal is giving women healthcare that they could probably get in a fragmented way in the community, but giving it to them in a very comprehensive manner in a really wonderful, women-focused environment," Kirby says.
Despite uncertainty around the GOP's promise to repeal and replace the Affordable Care Act, MACRA and risk-based payment models could remain intact, says one public policy expert.
Just weeks after physicians received a clearer roadmap for implementation of MACRA, the election of Donald J. Trump has potentially thrown in a detour.
With few details available about the President-elect's plans on healthcare reform, Chet Speed, JD, LLM, vice president of public policy for the American Medical Group Association shared some insights into early response to the election among AMGA members.
The following transcript has been lightly edited.
HealthLeaders Media: What have AMGA members been saying so far about the implications of Trump's election?
Chet Speed: Outside of saying, "Can you believe it's happened?" members are beginning to digest how a fairly aggressive healthcare agenda may impact their operations.
Three-fourths of our members have medical groups, hospitals, post-acute facilities, or health plans—and the impact on each is going to be different.
They're doing a lot of thinking right now, and everything is unpredictable. The concrete [fact] is that Trump campaigned on repealing the ACA. The unknown is what the ACA will look like once it's re-litigated in 2017.
HLM: How might the new administration affect the healthcare industry's transition to value—and MACRA in particular?
Speed: Some of the early thinking, especially for smaller practices and community hospitals who haven't really gotten ready for value yet, is that they're going to slow their efforts in terms of integrating with other practices and looking at how they can save money on the hospital side to work under a value budget.
With the tremendous uncertainty over the ACA repeal, the appetite for the value transition will probably slow for a great swath of the industry.
However, a lot of our members are still moving forward because they've already enrolled as a Next Generation ACO, the Medicare Shared Savings Program, or they have commercial contracts with some sort of value component.
As far as MACRA is concerned, it's still statute, which reflects that Congress and CMS want to move ahead on this thing called value.
HLM: Historically, private payers follow the government's lead. Do you think we'll see a shift in that pattern?
Speed: It's interesting. Commercial payers do follow Medicare, typically, but we have conflicting ideas to consider.
On the one hand, when I think about the risk survey we conducted last year, it was clear that our members were engaging with commercial payers on commercial ACOs more than federal ACOs because, frankly, with commercial payers the negotiations tend to be easier.
Commercial payers aren't regulating them like CMS, so they just want to create products that make sense for both sides.
On the other hand, I wouldn't say the commercial payers are offering a lot of risk products in the market right now. I think one of the issues our members have is that commercial payers aren't offering enough products to continue with this value transition.
So as far as the value proposition, all providers and payers have to get together and decide how both are going to be successful in risk, because I think that transition was slowing even before Trump was elected.
Groups representing primary care physicians welcome additional codes for chronic care management, but are concerned about administrative burden.
The Centers for Medicare & Medicaid Services 2017 Physician Fee Schedule, finalized last week, emphasizes support for primary care. However, the extent to which the new rules and codes will actually benefit primary care physicians depends on whom you ask.
For deeper insight, Brian Outland, senior associate for regulatory affairs in ACP's department of health policy and regulatory affairs; and John Meigs, Jr., MD, FAAFP, president of the AAFP spoke with HealthLeaders Media about the rule. The following transcript has been edited.
HLM: What reactions have you heard from your members so far about the rule?
Outland: The final rule contains a lot of wins for the college and our members that we pushed for, so overall the feedback from members has been favorable.
We like seeing how CMS is continuing to support primary care and the efforts they're putting behind chronic care management (CCM). The codes that they have approved for primary care physicians, such as non-face-to-face prolonged service codes, will be very helpful because, as we've seen over the years, much of the work PCPs are doing is outside of the brick-and-mortar [office].
We're also happy to see some lightening of the burden for CCM.
Meigs: The general tone has been appreciation of the things that CMS has done, but in a lot of ways it's still an example of a good idea being diminished by government bureaucracy.
HLM: Do you expect that the CCM codes will be user-friendly enough for physicians to use?
Meigs: We're pleased with the addition of these codes, as they acknowledge the care that family physicians and primary care physicians provide, and that a lot of patients have very complex problems, which requires time and effort.
The fact that we no longer need the beneficiary to sign off and acknowledge that we've discussed [CCM] ahead of time takes one bureaucratic step out of the process, so we do expect some increase in use.
However, I don't think we're going to see a tremendous increase in use because the other requirements for documenting time, along with other complexities, remain in place.
Our biggest disappointment with CMS, however, is that they did not remove the copay for these essential services. That's the biggest thing that's going to get in the way.
Outland: We do expect more physicians to use the codes because, in addition to lightening the burden of them, CMS has also finalized paying for management of the complex chronic care patient.
But there's still a 40-minute gap between the non-complex patient and the complex that is not being covered by CMS, so we would like to see them go a step further and perhaps come up with an add-on code to the non-complex patient to cover that additional 40 minutes of time.
HLM: What advice do you have for your members?
Outland: Learn and actually use the new codes. As we continue to digest the information, we'll have further guidance on how internists can best do so.
Meigs: Become familiar with the new codes for CCM, cognitive evaluation, behavioral health, and so on. CMS is now paying for things that in the past [physicians] did for free.
CMS sure hasn't made getting those funds easy. The codes are complicated to use and it's a documentation nightmare. But if you have the systems in place to utilize the new codes, there's the availability of additional payment.