The program has been shown to reduce length of stay, complications, and costs for colorectal surgery patients.
The patient safety team at the Johns Hopkins Armstrong Institute for Patient Safety and Quality will be introducing "enhanced recovery after surgery" (ERAS) protocols to 750 US hospitals.
The Hopkins team will help hospitals adopt the approach through its Comprehensive Unit-Based Safety Program (CUSP).
CUSP as "a five-step culture change intervention that engages front-line healthcare staff members in preventing harm." It is designed to "overcome the lack of local buy-in that often dooms improvement efforts."
Peter Pronovost, MD, PhD, director of the Armstrong Institute, said in statement that the program will combine the ERAS and the CUSP approaches "together into one coordinated, unified program where everyone—clinicians, patients, and their loved ones—understand what they must do for the best possible outcome."
After the program was put into place at Hopkins, length of stay, complications, and costs dropped for colon surgery patients. For these patients, Hopkins reported a 1.5-day reduction in LOS, a 50% decrease in surgical-site infections, and $1,500 savings in hospital costs.
The American College of Surgeons (ACS), which will work with Hopkins on the effort, notes in a statement that trainees will get a toolkit and "support from a senior executive to help overcome any barriers they may face."
The ACS will recruit hospitals for the project, which will initially focus on abdominal operations in colorectal surgery. ERAS, however, is expected to eventually be applied to bariatric surgery, orthopedic surgery, gynecology, and emergency general surgery among other procedures.
Introduced in Europe, ERAS is described by the ACS as a combination of "preoperative, intraoperative, and postoperative practices that have been shown to decrease surgical patients' complications and speed their recovery."
It uses patient and family engagement, limits pre-operative fasting periods, and applies methods of pain control that reduce the need for opioids. The ERAS effort involves surgeons, anesthesia providers, and nurses.
Johns Hopkins has received $4 million in support from the Agency for Healthcare Research and Quality to roll out the program, and will be eligible for additional funds over the next three years.
A paper from the Institute for Healthcare Improvement offers strategies aimed at advancing patient safety via leadership, teamwork, negotiation, and transparency.
The Institute for Healthcare Improvement released a 30-page policy paper Monday aimed at steering the nation's many patient safety efforts in the right direction.
The document, A Framework for Safe, Reliable, and Effective Care promises "in one place all the strategic, clinical, and operational concepts that are critical to achieving safe, reliable, and effective care."
IHI envisions a system of safety, "not just a collection of stand-alone safety improvement projects." The authors write: "The reality of today's healthcare environment is that the systems that support patient care are complex and error prone, and most organizations lack a comprehensive method for making them less so."
Listen:Derek Feeley, CEO of IHI, and President Emeritus Don Berwick, MD, MPP, FRCP, discuss the study, including the errors made in the name of patient safety, the glut of metrics, and the need for more science.
The paper offers strategies aimed at advancing patient safety issues in a range of areas, including leadership, teamwork, negotiation, transparency, reliability, improvement and measurement. It suggests a shift in approach in a number of areas and urges:
Proactive rather than reactive safety management.
Clinicians to investigate errors "to understand how things usually go right as a basis for explaining how things occasionally go wrong."
A shift in attitude "From fear, blame and liability to humility, trust, transparency."
Patient safety to be thought of as "more than the absence of physical harm, it is also the pursuit of dignity and equity."
The authors also characterize patient engagement and the engagement of patients' families as "the core of the framework… In safe and reliable organizations, patients and families are as much members of the care team as clinicians and other health care staff."
Additionally, the authors call for "leveraging improvement science to develop, test, implement, and spread changes that result in better outcomes."
Palliative Illness Management uses predictive analytics to shift the center of care to the home or community.
The healthcare industry is scrambling to adapt to senior policyholders' needs, particularly the serious illnesses that are more likely to strike older patients.
Turn-Key Health, of Philadelphia, is an advanced illness management company that uses predictive analytics to deploy community-based palliative care teams and identify individuals earlier in the disease trajectory.
Turn-Key Health recently launched Palliative Illness Management (PIM), which integrates specialized advanced illness assessments and services in conjunction with supporting medical resources.
The data-driven and evidence-based program will help payers avoid costly, inappropriate interventions and care that is fragmented, uncoordinated, or inadequate, according to the company.
PIM will be especially beneficial for individuals whose illness might otherwise go undetected until late in the progression of disease, company President Greer Myers wrote in a blog on the company website.
"For payer-driven population health programs, this approach has a significant impact on the overall economic healthcare burden, mitigating patient and caregiver financial consequences and improving member/patient satisfaction," he wrote.
The program uses affiliations and partnerships with community-based palliative care teams and organizations across the country, tapping into the expertise and synergies of existing resource, Greer explained.
This specialized approach, which includes conducting progressive and difficult conversations around quality of life in the remaining months of life, helps payers save money and provide the best quality of care that meets the patient's wishes.
"Individuals often suffer through unnecessary, costly and even harmful treatments, despite overriding expert opinion that when patients have a terminal illness and the outlook for recovery dims, more treatment does not equal better care," Greer wrote.
"The financial and social consequences extend to family caregivers who spend nearly 66 hours a week providing care to a loved one during the person's last year of life. This erodes earning potential and imposes a profound economic toll."
The PIM model shifts the center of care to the home or community, placing the focus on care coordination and patient-centric services, Greer stated.
PIM generates outcomes and results that are measured and valued at a population level, and by optimizing pre-and post-acute care it can reduce hospitalizations, re-admissions and number of ICU days, resulting in a drop in the average claims cost per member per month.
Proposed changes to the composition of the U.S. Preventative Service Task Force include a requirement that specialists and subspecialists be involved in its reviews.
Representatives of the American Academy of Family Physicians and the American Urological Association squared off last week over proposed changes to the make-up of the U.S. Preventative Service Task Force.
The two groups testified before the health subcommittee of the U.S. House Energy and Commerce Committee. The subcommittee is considering changes to the organizations' rules, including adding a requirement that specialists and subspecialists be involved in task force reviews.
USPSTF panelists review and make recommendations on the efficacy of preventative health services. The group is convened by the federal Agency of Healthcare Research and Quality and its reports often guide coverage decisions made by both private and pubic payers.
The scientific debate over the efficacy of some forms of cancer screening has played out in panel decisions. While some physicians and patient groups have supported USPSTF decisions questioning the efficacy of mammography and prostate cancer screening, others have challenged the panels decisions.
Physicians with Opposing Views Testify
That was the focus of testimony from John Lynch, MD, a urologist at Georgetown University Hospital in Washington, DC. He said many urologists question the group's 2012 decision against the routine use of PSA testing as a screening test for prostate cancer.
Instead, he said, "it would be better to 'screen smarter' by testing most men at individualized intervals… These decisions are best made between a physician and a patient." Lynch advocated for the inclusion of more specialists on the task force panels.
John Meigs, Jr., MD, president of the American Academy of Family Physicians, advocated against making changes to the panel.
'While we have the highest level of respect for our specialty and subspecialty colleagues, their role in treating specific conditions and organ systems is not the same as developing guidelines to prevent such conditions," he said.
Meigs also noted that the legislation would require input on panel decisions from health care industry representatives. That would impact the objectivity of the task force, he argued, "changing it from an evidence based body to a group influenced by concerns about financial and political influences."
A video of the hearing, as well as complete testimony, is available on the subcommittee website.
Spending on healthcare grew last year at the fastest pace since the start of The Great Recession, a federal report says.
Expanded health coverage, increased service utilization and rising prescription drug costs drove the country's healthcare spending growth to 5.8% last year.
It was the highest hike in healthcare expenditures since 2007, according to a report Friday by the Centers for Medicare & Medicaid Services' Office of the Actuary.
Spending on prescription drugs and healthcare coverage expansion under the Patient Protection and Affordable Care Act were key drivers of last year's spending spike, a co-author of the actuary report in the journal Health Affairs said during a media conference call Friday.
"If we look at recent history, we had health spending grow at historically low rates between 2009 and 2013, during and just after The Great Recession. Between 2010 and 2013 healthcare spending grew at about the same rate as the overall economy as measured by GDP. That was a relatively stable growth rate," said Aaron Catlin, deputy director of the National Health Statistics Group, CMS Office of the Actuary.
"Then in 2014 and 2015, we had the one-time effect of the ACA-expansion of coverage, and that occurred at the same time that we had the emergence of high-cost specialty drugs," said Catlin.
Last year, total national healthcare expenditures reached $3.2 trillion, with per capita spending pegged at $9,990. In 2014, healthcare spending increased 5.3%.
PPACA-fueled growth of healthcare coverage through Medicaid expansion and the individual insurance market exchanges also drove national healthcare expenditures higher in 2015, the report says. "Increased use and intensity, associated in part with expanded insurance coverage, drove the growth in spending for hospital care and physician and clinical services, which together accounted for 52% of total national health spending in 2015."
20 Million Insured via PPACA
"In 2013, the insured share of the population was 86.0%, which is approximately where it had been in 2008. However, from 2013 to 2015 the number of uninsured individuals fell by 15.0 million, and the insured share of the population reached 90.9%," says the report.
"Between 2014 and 2015, nearly 10 million (9.7 million) people gained private health insurance coverage (average growth of 2.5%), while an estimated 10.3 million more people enrolled in the Medicaid program (average growth of 8.4%)."
In a prepared statement, CMS acting Administrator Andy Slavitt said last year's spike in total healthcare spending should be viewed in a positive light because it reflects improved access to affordable care.
"Our significant progress in reducing the nation's uninsured rate, while providing strong protections for Americans if they get sick, would not be possible without the Affordable Care Act," he said. "As millions more Americans have obtained health insurance, per-person cost growth remains at historically modest levels."
From the payer perspective, the actuary report shows 2015 per capita healthcare spending growth rates ranged in the low single digits:
Commercial insurance at 5.2%,
Medicaid at 3.8%
Medicare at 1.7%
Higher Spending on Clinical Services
According to the CMS report, "Total expenditures for physician and clinical services grew 6.3% in 2015, reaching $634.9 billion. This was an increase from the growth of 4.8% in 2014 and the first growth rate above 6% in ten years. The faster growth in spending on physician and clinical services was driven by growth in non-price factors, such as residual use and intensity of services. Increased insurance coverage through private health insurance and Medicaid contributed to this growth in non-price factors."
In terms of gross domestic product (GDP), healthcare expenditures accounted for 17.8% of the national economy last year, up slightly from 17.4% in 2014.
Even though upward spending pressure from health coverage expansion is expected to have a short-term impact, healthcare expenditures are likely to continue to account for an ever-larger share of the national economy, the report says.
It describes the 2014 to 2015 period as "unique, given the significant changes in health insurance coverage that took place," and projects spending on healthcare to continue grow as a share of the overall economy over the next decade, influenced by "the aging of the population, changing economic conditions, and faster medical price growth."
HR 34 promises investments in cancer research, mental-health parity, opioid addiction, and more.
The U.S. House of Representatives this week passed the complex and controversial 21st Century Cures Act by a vote of 392 to 26, opening the door to sweeping changes in healthcare policy ranging from funding for biomedical research to the speed with which the Food and Drug Administration approves new drugs and devices.
"Like all comprehensive legislation, the bill is not perfect, and there are provisions the Administration would prefer were improved, but the legislation offers advances in health that far outweigh these concerns," the White House said Tuesday.
HR 34 is expected to pass through the Senate to receive the President's signature promptly, according to the Office of the Press Secretary. A previous version of the legislation stalled in the Senate before Congress's election-year summer session.
The latest iteration spans 996 pages and designates $6.3 billion in spending over the next decade. Funding for the bill comes from reallocation of funds previously allocated for the Strategic Petroleum Reserve, the Affordable Care Act's Prevention and Public Health Fund, and territory funding. Other offsets include Medicare and Medicaid payment changes.
Those funds, however, must be re-appropriated annually, a stipulation being criticized by Democrats.
Key provisions of the bill in its current forms are:
New funding of $4.8 billion (down from $9.3 billion) for the National Institutes of Health
Investment of $1 billion in grants to states to fight the nation's heroin and prescription opioid addiction epidemic
Investment of $1.8 billion in new resources to support the Vice President's cancer moonshot
Investment of nearly $3 billion during the next 10 years to continue the President's BRAIN and Precision Medicine Initiatives to research and seek cures for diseases such as Alzheimer's
Expansion of the President's Mental Health and Substance Use Disorder Parity Task Force
Funding of $500 million for the FDA (reduced from $550 million) to hire more staff and speed up processes
A change of particular interest to physicians would have made exceptions for certain educationally related gifts, such as textbooks, from pharmaceutical companies to doctors. It has been removed.
The public / private partnership is tasked with finding digital solutions to the Commonwealth's population health challenges such as the opioid addiction epidemic.
Massachusetts has launched one of the first statewide initiatives to coordinate digital health in the service of population health.
The council brings together providers and solution providers in an economic development alliance around the challenges and opportunities presented by digital health advances.
Tasked with looking for innovative digital solutions to the Commonwealth's population health challenges, members are leaders in the life sciences, EHR systems, consumer wearable devices, care systems, payment management systems, data analytics, and telemedicine.
"This council will collaborate to move past barriers in the healthcare industry and solve significant challenges to make advances in patient care, lower health care costs, and address public health crises, like the opioid epidemic," said Governor Charlie Baker, (R),in a media statement released by his office.
The council will be co-chaired by Katie Stebbins, assistant secretary for innovation, technology and entrepreneurship at the Massachusetts executive office of housing and economic development; and Jeffrey Leiden MD, chairman, president, and CEO of Vertex Pharmaceuticals.
"The digital health industry presents an enormous economic development opportunity for the entire Commonwealth," said Massachusetts Lieutenant Governor Karyn Polito in the media statement.
"The industry is poised to create jobs across the Massachusetts through its impact on patient care in community hospitals, potential for advanced manufacturing applications, and for our innovation hubs that span from Springfield to Lowell, to Worcester and New Bedford."
Among the council's members:
David Torchiana, MD, president and CEO of Partners HealthCare
John Halamka, MD, chief information officer of the Beth Israel Deaconess System
Atul Gawande, MD, executive director of Ariadne Labs at Brigham and Women's Hospital, and also the Harvard T.H. Chan School of Public Health
Andrew Dreyfus, president and CEO of Blue Cross Blue Shield of Massachusetts
Sandra L. Fenwick, president and CEO of Boston Children's Hospital
Elizabeth G. Nabel, MD, president of Brigham and Women's Health Care
Kate Walsh, president and CEO of Boston Medical Center
Rick Weisblatt, chief of innovation and strategy at Harvard Pilgrim HealthCare
Joel Vengco, vice president and chief information officer of Baystate Health; and
Keith A. Hovan, president and CEO of Southcoast Health
The body, which is to meet four times per year, will also steer the Massachusetts Digital Health Initiative, a public-private partnership that launched in January.
Service and solution provider participants include Optum, athenahealth, GE Healthcare Digital, Atrius Health, PatientKeeper. Flybridge Capital Partners and Bessemer Venture Partners are also participants.
Researchers offer practical steps to ensure clinicians follow patients' advance care plans.
Although patients often have advance planning documents that specify their end-of-life healthcare preferences, it's not always clear whether those plans are being followed.
The five recommendations for improving consistency with patient preferences are:
Document specific treatment preferences in the medical record, such as "do not place feeding tube," instead of simply saying "comfort care."
Record treatment preferences in a consistent format and location in the patient medical record.
Review and update patient preferences regularly to reflect current preferences as his or her clinical condition changes over time.
Implement prospective data collection strategies to capture decisions to withhold interventions.
Adopt a consistent measurement approach to share process and outcomes data with other healthcare providers.
"Advance care planning is a process, not just a form," co-author Alexia Torke, MD, said in a statement. "It is important that when a person faces serious illness and can no longer make decisions, the care they receive is consistent with the wishes they have previously expressed."
The authors also discussed the challenges of implementing and measuring the "Care Consistency With Documented Care Preferences" quality indicator. This metric is widely used in hospice and palliative care.
Some of the challenges they encountered were inaccurate or incomplete documentation and patients' preferences changing over time.
"What we choose to measure and how we measure drives how we set up our systems to deliver that care," first author Kathleen Unroe, MD, MHA, said in a statement.
"We need to focus on patient outcomes, not just processes."
The American Hospital Association urges the President-elect to avoid 'abrupt changes' to the ACA, to cancel Stage 3 of Meaningful Use, to standardize the M&A merger review process, and to reform the RAC program.
The American Hospital Association this week urged President-elect Donald Trump to avoid "abrupt changes" to the Affordable Care Act that could destabilize the healthcare sector.
The plea from AHA President and CEO Rick Pollack came near the end of a four-page wish list the hospital lobby sent this week to the president-elect, who has vowed to repeal Obamacare on his first day in office.
"Given that healthcare represents a significant portion of the economy and essential public services, we urge you not to make any abrupt changes that could lead to significant instability for patients, providers, insurers and others," Pollack told the president-elect.
"Currently, there is much uncertainty about the future, given discussions of repealing and replacing the ACA," he said. "We urge you to ensure that any repeal of portions of the ACA simultaneously include a replacement plan that continues to provide a mechanism for individuals to obtain affordable insurance coverage. In addition, providers' payments were reduced significantly to fund coverage expansion, and also should be reexamined as we debate the future of the ACA."
Pollack's letter highlighted five areas of concern for hospitals; reducing the regulatory burden; enhancing affordability and value; continuing to promote quality and patient safety; ensuring access to care and coverage; and continuing to advance healthcare system transformation and innovation.
"The regulatory burden faced by hospitals is substantial and unsustainable. We urge your Administration to modify or eliminate duplicative, excessive, antiquated and contradictory provider regulations," Pollack said. "Reducing the administrative complexity of healthcare would save billions of dollars annually and would allow providers to spend more time on patients, not paperwork."
The AHA wants the Trump administration to:
Cancel Stage 3 of the meaningful use program so that hospitals will not be forced to spend large sums of money upgrading their electronic health records solely for the purpose of meeting regulatory requirements;
Revise the Recovery Auditor Contractor contracts to incorporate a financial penalty for high rates of incorrect denials that lead to unnecessary appeals;
Create safe harbors and waivers under the Anti-kickback statute to protect clinical integration arrangements and revise the "Stark law" to protect arrangements that meet the Anti-kickback safe harbor so that physicians and hospitals can work together to improve care;
Standardize the federal merger review process between the Federal Trade Commission and the Department of Justice to better support hospital transformation;
Eliminate outdated regulations that threaten access to post-acute care, such as the long-term care hospital "25% Rule" and the onerous home health agency pre-claim review demonstration project.
To enhance affordability and value, Pollack urged the new administration to:
Adopt comprehensive solutions to address escalating drug prices, including providing support for the introduction of generic alternatives, discouraging anti-competitive tactics such as "pay-for-delay" and "evergreening," improving access through drug re-importation, providing mandatory rebates and placing requirements around direct-to-consumer advertising;
Protect the 340B Drug Pricing Program;
Continue to challenge the major health insurance company mergers and other anticompetitive conduct to prevent harmful repercussions for consumers and providers;
Explore policies to help rein in medical liability, such as instituting a cap on non-economic damages and allowing courts to limit lawyers' contingency fees;
Explore Medicare structural reforms to make the program more sustainable while maintaining access to care, ensuring adequate payment for care, and protecting individuals from excessive financial burden, such as combining Medicare Parts A and B, limiting Medigap coverage, further means-testing Medicare premiums and raising the Medicare eligibility age.
To promote quality and patient safety, the Trump administration was asked to:
Streamline, prioritize and simplify quality reporting to identify and focus on meaningful and valid "measures that matter;"
Modify the current readmissions policy to include a sociodemographic adjustment so that providers are not penalized for factors outside of their control;
Suspend the flawed hospital star ratings on the Hospital Compare website, as they are inaccurate and provide misleading information to consumers;
Develop a performance reporting option that allows hospital-aligned physicians to fulfill the Medicare Access and CHIP Reauthorization Act (MACRA) quality reporting requirements based on hospital measures;
Stop federal agency intrusion in private sector accrediting body standards and survey processes;
Advance health IT by supporting the adoption of interoperable EHRs, promoting a more consistent use of IT standards and providing improved testing, certification and transparency about vendor products;
Reject reductions in Medicare funding for graduate medical education to ensure we have the workforce necessary to provide high quality, safe care to patients.
To ensure access to care and health insurance coverage, the AHA called for:
Continued funding for the Children's Health Insurance Program;
Improved access to mental health services by addressing workforce shortages, increasing funding for behavioral health services, promoting policies that better integrate mental and physical health, and creating parity in coverage;
Removing barriers to mental health treatment, such as amending the Medicaid Institution for Mental Disease exclusion, eliminating the Medicare 190-day lifetime limit on inpatient psychiatric treatment, and providing funding to implement the Comprehensive Addiction and Recovery Act to help stop the opioid crisis in America;
Rejecting "site-neutral" payment cuts, which prevent hospitals from modernizing their facilities to improve the health of patients;
Congress to remove impediments preventing veterans from using the Veterans Choice Program and advocate to make the program permanent.
To advance health system transformation and innovation, the new administration was asked to:
Preserve and improve upon new payment and delivery models to drive adoption of those that are most effective in raising quality and reducing cost;
Promote the use of telehealth, remote patient monitoring and similar technologies by removing barriers to their use and payment;
Waive the skilled nursing facility three-day stay rule, telehealth restrictions and prospective beneficiary assignment from all ACO models;
Expand the definition of advanced alternative payment models to allow more clinicians who partner with hospitals on new models to achieve payment incentives under MACRA;
Provide new options on care delivery that reward better, more efficient, coordinated care and help ensure access to essential health care services.
Operating cash-flow margins for children's hospitals are consistently higher than for adult hospital margins, but over-reliance on Medicaid could change that.
Children's hospitals continue to hold an advantage over adult hospitals in the areas of patient demand, limited competition and fund-raising opportunities, all of which create stronger margins and lower leverage.
However, those advantages are offset by an over-dependence on Medicaid, which accounts for about 52% of gross revenues nationwide, compared to about 14% of gross revenues for adult acute care hospitals, according to analysis from Moody's Investor Service.
"Potential changes to federal Medicaid funding under the new presidential administration could negatively impact children's hospitals, depending on how individual states allocate Medicaid payments to hospitals," the Moody's analysis stated.
Those potential changes include a proposal to block grant funding that would give states greater flexibility in determining how and how much Medicaid dollars are spent.
Moody's also noted that children's hospitals don't benefit as much from the Medicaid expansion as adult hospitals because most children are already insured through Medicaid or the Children's Health Insurance Program (CHIP).
Children's hospital revenue growth trailed adult hospitals for the first time in 2015, although a return to historical patterns is likely, Moody's reported. The 6.2% median revenue growth rate lagged behind the 7.5% at adult hospitals, the first time children's hospitals fell behind in at least eight years.
Children's hospitals look to regain the lead, though, as growth rooted in Medicaid expansion and the healthcare exchanges moderates at adult hospitals.
Operating cash-flow margins for children's hospitals are consistently about 4% higher than for adult hospital margins, due to demand for more profitable, high-acuity services. Annual fund-raising, typically not a strength of adult hospitals, also drive margins at hospitals for children, Moody's found.
With better margins and fund-raising capabilities, children's hospitals have stronger liquidity and lower leverage than adults. These financial strengths support robust capital spending to meet strong demands for clinical services and research programs.
In addition, children's facilities tend to be newer, with a median age of plant at 8.5 years in 2015, compared to 11 years for adult hospitals.
Volume growth for children's hospitals has topped adults due to limited competition and favorable growth strategies. Median 2015 admissions at children's hospitals grew 5.6%, compared to 2.8% at adult hospitals, according to the analysis.
Some of that growth is attributable to adult hospitals closing their pediatric practices. Children's hospitals will also continue to boost volumes through partnerships and expanding services, Moody's reported.