This article appears in the March 2013 issue of HealthLeaders magazine.
Six years ago, the 1,239-bed Cleveland Clinic began to systematically take on one of the biggest challenges looming in healthcare: an increasing aging patient population that needs neurological care.
In 2007, the Cleveland Clinic in Ohio had only "a handful of neurologists in our regional hospitals" who treated perhaps 1,000 elderly patients with neurological conditions a year, recalls Stephen Samples, MD, vice chairman of the Cleveland Clinic's Neurological Institute. By 2012, he says that number grew to 38 physicians overseeing the care of 52,000 patients, reflecting the urgently expanding needs in neurological care, especially in geriatric medicine.
At the Cleveland Clinic and other facilities around the country, the burgeoning 65-and-older population is expected to drive up the number of neurological geriatric patients, increasing volumes in hospitals that focus on complex conditions, with subspecialties targeting dementia and other cognitive disorders. Programs aimed at older people with such disorders, or those afflicted with Alzheimer's or Parkinson's disease, are expected to grow dramatically as the country ages.
Some hospitals are ramping up their care planning with specialized clinics in neurological institutes and changing their specialties to meet the demographic needs of their aging communities. In other cases, hospitals are using holistic approaches to care, emphasizing multidisciplinary programs to improve education and rehabilitation programs for patients to address their debilitating conditions.
"We already know that neuroscience has a predominant geriatric flavor," says Samples. "We firmly believe that neurology is not one specialty, but different specialties, like Parkinson's disease, dementia, spinal disease, dizziness, and balance problems. In the next 10 to 15 years, neurological care would be for each disease process, like how there are now different specialties for cardiology care, which was all considered internal medicine years ago."
The need for geriatric care in neurology is blossoming. About 5.4 million people have Alzheimer's disease, and most of that, 5.2 million, represents those 65 and older. The dire consequences of these illnesses give medical centers financial headaches of their own. "We're not making money; we're trying to reduce the cost of care for that patient population," says Deborah Spielman, assistant vice president of Florida Hospital and administrator of the Florida Hospital Neuroscience Institute in Orlando, part of the 2,247-bed Florida Hospital system that has acute care facilities in Orlando, Tampa, and Daytona Beach.
While hospitals must brace for a growing number of patients, reduced reimbursements and shortages of neurologists and geriatric physicians are forcing them to be innovative in their care. That, in turn, is prompting hospitals to initiate changes in their care models to avoid needless or more expensive programs, says Spielman. Focusing on geriatric neurological ailments, the hospital established a Maturing Minds Clinic adjacent to its 120-bed neurological facility in Orlando. There, physicians can evaluate conditions and work toward avoiding hospitalizations of neurological geriatric patients, who can be cared for through alternative programs. "More and more, the adult children are at their wits' end, and we feel it's our obligation to offer comprehensive programs," Spielman says.
Hospitals are refocusing on geriatric neurological conditions to ease the strain on other parts of their operations, such as the emergency department, says Laurie Delgado, president of Cleveland-based 101-bed total UH Regional Hospitals, Bedford and Richmond Medical Center campuses. In that way, the Ohio health system organized a specialized "senior" ED within its main ED to accommodate patients who have dementia or Alzheimer's disease, she says.
Success key No. 1: Coordinated care
To improve its neurological programs, especially for those in the geriatric community, the Cleveland Clinic—with a main campus in Cleveland, eight community hospitals, and other facilities—coordinated care among its hospitals, pinpointing demographic needs and expertise in specific areas as it braced for continued demand. In one hospital, Cleveland Clinic added more Parkinson's disease experts and in another boosted the number of available Alzheimer's specialists. The clinic designated its main hospital as a hub for neurological specialties.
"We populate the region with complementary skill sets in each geographic area," says Samples. That expertise is focused on categories such as peripheral nerve and movement disorders as well as stroke. The communities served by the 46-bed Euclid and 35-bed Lakewood rehabilitation hospitals are areas on which to put geriatric and neurological focus, Samples says. For instance, there are two Parkinson's experts at Euclid, and another who specializes in movement disorders at Lakewood. They work at the suburban hospitals and also coordinate care with the main campus. "We are developing a matrix so we get coverage with specific disease disorders," Samples says.
The hospital's internal neurological scorecard shows that it has made dramatic improvements in areas of cognitive behavior, Alzheimer's disease, as well as other afflictions impacting geriatric patients who have neurological ailments. In a review of 3,000 Alzheimer's patients between October 2010 and December 2012, the coordinated care resulted in improvements in mood, sleep, and appetite; additional data shows reduced fatigue among 49% of patients in a one-year-period, which hospital officials characterized as significant. In addition, PHQ-9 scores, a measurement for assessing mental health, improved in 60% of patients with Parkinson's disease. The PHQ-9 is a nine-item scale of the Patient Health Questionnaire, a tool for assisting primary care clinicians to monitor depression and select treatments.
Coordinating care among its hospitals and the main campus has been particularly important while the Cleveland Clinic system faces a paradox, Samples adds, citing increasing demand in the wake of funding cutbacks and anticipated physician shortages in neurological care.
Fewer medical students are choosing neurology, leading to potential workforce shortages, according to the American Academy of Neurology. The organization estimates there are 18,000 Americans for every neurologist, but by 2020, there will be only one neurologist for every 21,000 in the United States. Beyond that, a "shortage of well-trained neurologists to train an increasing number of neurological physicians" is projected in an AAN report, The Critical Role of Neurologists in Our Health Care System.
To address those potential shortfalls, the Cleveland Clinic is focusing on increased use of midlevel providers and nurse practitioners specializing in neurological care; psychologists, social workers, and counselors are also used in the geriatric neurology program.
Success key No. 2: The geriatric ED
At UH Regional Hospitals, Bedford and Richmond Medical Center campuses, the special geriatric ED—dubbed the Senior ER—includes senior-friendly amenities and specially trained clinical staff. The unit's personnel receive extensive training to better recognize and treat acute and chronic medical conditions specific to the geriatric population. Before the hospital initiated the senior ER, it found that at least 54% of ED visits involved people over the age of 65, according to Delgado. The changes have led to a 30% reduction in the number of people in that age range who have returned to the ED within 72 hours of their previous visit.
Patients receive clinical assessment within 30 minutes and have 24-hour access to physicians and nurses trained in senior care. One of the most important elements in the care for geriatric patients is having a pharmacist working with the ED staff, which enables staff to coordinate with patients and their families to "provide education as needed and get them into physical therapy if need be," says Howard Dickey-White, MD, the president of University Emergency Specialists and a UH Regional Hospitals ED physician. He says it was important that the hospital not only deal with the presenting emergency issue, but also with the chronic medical conditions and social needs.
The patients are screened for depression, dementia, delirium, or functional decline, and the hospital refers social services, if needed, for psychological concerns. The evaluation includes medication reviews, especially for those who have experienced falls or a sudden acute mental status change. There are also evaluations for potential abuse or neglect. The hospital works with a caregiver to ensure safe transition to home or other healthcare facilities.
"We really felt we had an opportunity and responsibility for due diligence to see what we could do to elevate care. It was not that much of a stretch to see that the Senior ER can be a life-changing event. Often, it was confusing the patients to navigate the system," Delgado says.
"When we have the assessment, the additional risks can be identified, such as dementia and depression and those sorts of things," she adds.
As part of the evaluation and screening for geriatric syndromes such as depression, dementia, or functional decline, the hospitals hire nurses who have designation as Nurses Improving Care for Healthsystem Elders. These professionals are trained to address the challenges of elderly patients in acute care hospitals. The NICHE program is based at the NYU College of Nursing and involves almost 450 hospitals and healthcare facilities.
Success key No. 3: Maturing Minds Clinic
A growing elderly population is virtually a constant in Florida, and at Florida Hospital, leaders are working to unravel some of the mysteries of dementia to reduce readmissions and emergency department use.
Through its Maturing Minds Clinic, the hospital evaluates elderly patients who may have had a misdiagnosis of dementia. The hospital has enrolled at least 100 elderly patients in the program, which uses a multidisciplinary team to assess patient needs. Specifically, patients are evaluated for normal pressure hydrocephalus, which has symptoms similar to dementia but can be reversed with appropriate treatment.
An estimated 375,000 Americans are misdiagnosed with dementia or Parkinson's disease, yet have symptoms caused by NPH. Florida Hospital officials estimate as many as 10% of patients who are diagnosed with dementia may have NPH.
"Some of those symptoms actually mimic dementia symptoms," says Spielman. "If you don't evaluate for it, which can include an MRI or other testing, you may not know what it is. It was important to have a fully integrated team, including neurology specialists in rehab, surgery, neuroradiology, neuropsychology, and nursing." Each member "does a full assessment from his or her specialty standpoint on these patients."
The NPH condition occurs when cerebrospinal fluid accumulates in the brain without a significant increase in pressure. The accumulation may lead to the slow onset and progression of symptoms. Because of the difficulty in diagnosis, it is often untreated for extended periods.
Florida Hospital officials say they want to identify NPH patients who may benefit from the placement of a stent to reduce inpatient admissions and avoid potential ED visits. The hospital also wants to increase knowledge and treatment of NPH through evaluations.
A University of Florida analysis shows that patients with Parkinson's disease are 50% more likely to visit an ED than those who do not have the disease. Often, they are treated because of ancillary issues such as urinary tract infection, pneumonia, and heart failure, according to the National Parkinson Foundation.
Florida Hospital officials say that patients with Alzheimer's are readmitted to hospitals more often than other patients. "We have looked at our data, and patients with a primary or secondary diagnosis of Alzheimer's have almost a 10% higher chance of being readmitted to the hospital multiple times," Spielman says. "The change in mental status, many times caused by other medical conditions such as UTI or pneumonia, continues to bring them in over and over.
"So much crossover occurs in this particular population, and so many things can be going on: What's causing the illness?" Spielman asks. "They may have multiple readmissions. They are not coming back necessarily because of dementia, but because of congestive heart failure. It's not the ideal situation if they have dementia or Alzheimer's. They end up staying twice as long, in some cases, as somebody else. Their condition requires a special communication style, a special approach. It's case management on steroids for this subset of Medicare patients, and we are trying to keep them out of the hospital for avoidable medical conditions."
For dementia patients, it's a case of issues on top of issues—from medication complexities to pulmonary complications and urinary tract issues—which compounds the readmission quandary.
In the latest Hospital Compare reports from 2012, Florida Hospital had a 27.3% readmission rate for 3,666 heart failure patients, compared to the national average of 24.7%. The hospital also had a 20.7% readmission rate for 2,223 pneumonia patients, compared to 18.5% for the national average. Readmission for elderly patients is more complicated because of their array of conditions.
Success key No. 4: Outpatient programs
Parkinson's disease, a progressive disorder of the nervous system, affects a patient's movement, balance, speech, fine motor skills, thinking, and behavior. In the United States, up to 60,000 cases of Parkinson's are diagnosed each year, and 1 million people currently have it. While the disease can't be cured, a combination of medications, therapy, and other programs reduce the symptoms—as does surgery.
The 60-bed Spaulding Rehabilitation Hospital Cape Cod in East Sandwich, Mass., utilizes a holistic approach that includes medication management. Spaulding's solution consists of timely rehabilitation and coordinated care using neuro-rehab specialists, says David Lowell, MD, CMO at Spaulding's Centers for Geriatric Neurology. Through a combination of outpatient and inpatient treatment approaches, elderly Parkinson's patients have been able to extend the time they are able to live at home on average 1.5 more years, instead of needing to live in an assisted living or skilled nursing facility, Lowell says.
The Centers for Geriatric Neurology are part of the Spaulding Rehabilitation Network, which is part of Partners HealthCare System based in Boston. When they opened in 2010, the centers served 62 patients. In 2012, they admitted 124 new patients, Lowell says.
What began as the Parkinson's Center for Comprehensive Care expanded to also include care for stroke, gait disorders, and cognitive disorders. Lowell says the centers' rehab model offers functional and holistic therapies along with medical management.
Such programs may seem simple, but they are important for patients. During patient visits, hospital staff may adjust devices, carry out gait training, make suggestions for improved mobility, adjust medications, and even advise on changing pajamas—such as from fleece PJs to those with silk liners—to improve movement. These are "little tips we can provide," says Dawn Lucier, neuro-rehab physical therapist.
"It's different from the standard medical model," Lowell adds. "Typically, the person says, 'I've fallen twice,' and the doc would write a prescription for a physical therapy evaluation and send the patient to the therapist, who would then do an evaluation and develop a treatment program. We're actually watching the people and seeing what's wrong with their gait and then developing an individualized plan of action. Sometimes it doesn't require a physical therapy evaluation; it's something simple, like a reminder for them about how to walk with the walker and adjusting the walker."
The hospital continually works to reduce fall rates and bedsores among patients, Lowell says. Over the past year, the hospital fall rate was reported at 4.12 falls per 1,000 patients, compared to peer groups statewide that had 4.64, according to PatientCareLink, a quality and transparency collaborative established by the Massachusetts Hospital Association and the Organization of Nurse Leaders, MA-RI. The rate was calculated from April 2011 to March 2012. Patients having falls with injuries were calculated slightly higher at Spaulding, at 0.84 per 1,000 patients, compared to 0.78 among other rehab facilities. Those injuries are described "very broadly" to include a bruise or scrape, say Spaulding officials.
Pressure ulcers were reported at zero per 1,000 patients at Spaulding Cape Cod, compared to 0.65 per 1,000 patients for the reporting periods of June, September, and December 2011 and March 2012. Lowell attributes Spaulding's rounding program as a key reason for both reductions in falls and reduced bedsores. Spaulding started a nurse rounding program that "quickly evolved into a multidisciplinary" rounding program, Lowell says. The rounding occurs hourly during the day and every two hours at night. At that time, a member of either the nursing or therapy staff checks the patient and reviews key indicators that have a high correlation to quality, including the need for toileting, changing of position, and medications.
"We know that improvements in strength, balance, and endurance help people regain their footing if they should be caught off balance. The education we do around safety and mobility also helps people avoid potentially challenging circumstances at home and in the community," Lucier says.
Officials see the wellness program as an integral part of improving patient care, especially those with Parkinson's disease. Spaulding Rehabilitation Hospital's Cape Cod outpatient centers in Sandwich and Framingham, in partnership with Boston University's Sargent College of Health & Rehabilitation Services, runs the Parkinson's Disease Wellness and Exercise Program.
Participants learn exercises and also a problem-solving approach to manage daily mobility, self-care, and communication issues. The program addresses issues such as balance, strategies to facilitate self-care, improving volume of speech, and conserving energy.
The results of testing 17 patients in the most recent group in 2012 showed significant milestones of success for the geriatric patients, she adds. Fourteen of the 17 patients who completed the six-minute walk test showed improvement in distance. All of the 16 patients who completed the functional gait assessment, which assesses balancing during turning and stepping over obstacles, showed improvement.
Expanding care for the growing population with neurological needs will require innovation and creativity, as programs must be tailored to a wide array of symptoms, causes, and impacts. Watching some of the "best in class" medical centers adapt to the demographic demands of the neurological service line landscape will pave the way for other hospitals looking to do the same.
Joe Cantlupe is senior editor for physicians and service lines. He may be contacted at jcantlupe@healthleadersmedia.com.
Reprint HLR0313-7
This article appears in the March 2013 issue of HealthLeaders magazine.
For some primary care doctors, hearing that a patient has consulted with a chiropractor can be a real pain in the neck.
MDs have been clashing with DCs (chiropractors) for years over their abilities and qualifications for certain procedures, and there's no sign of the debate letting up any time soon. In fact, as the national demand for spine care accelerates as quickly as an aging population's aches and pains, the chiropractor and physician debate over care is bound to intensify.
There's already a skirmish brewing over the Patient Protection and Affordable Care Act, which chiropractors cite as a path toward improved reimbursements. Physicians, predictably, are putting up resistance.
A Fight as Big as Texas But there's been no longer or bigger clash between the two maladjusted professions than in Texas, where litigation between the Texas Medical Association and the Texas Board of Chiropractic Examiners is underway. At the heart of arguments by physicians is whether chiropractic work should be allowed to cross the line into the practice of medicine, in general and specific procedures.
One case centers on whether chiropractors may perform electromyography needle biopsies or manipulation under anesthesia, or whether such practices should be conducted only by licensed medical doctors. The case has been bouncing around various levels of courts in Texas, with appeals and reversals along the way.
The Texas Supreme Court, however, may soon consider part of that case, after a state appeals court ruled favorably for the Texas chiropractic board, saying that chiropractors can make limited diagnoses with these procedures. The court said that the chiropractors could diagnose conditions related to the spine and muscle system, and be within the scope of their practice.
TMA: 'A public safety issue'
In another case, the Texas Medical Association won. In December, an Austin state judge granted the association's motion to prevent chiropractors from performing vestibular testing. The vestibular system, a component of the inner ear, is linked to the central nervous system. The judge declared that chiropractors who performed vestibular tests went beyond their profession's lawful scope of practice.
"We think there's a legitimate public health issue, a public safety issue," David Bragg, an attorney for the TMA, says of the physicians' legal battles with the chiropractors.
"From a patient's point of view, many times they don't understand the difference between a doctor of chiropractic and a doctor of medicine," Bragg says. "Potentially, there could be someone exhibiting symptoms of a profound (physical) problem, and chiropractors argue that they should be allowed to diagnose that condition. But these patients maybe should immediately go to the appropriate medical provider. Is this person having a stroke? A heart attack? There should be no delay built into the process."
The chiropractors' claims for diagnostic qualification "dilutes the medical license; it weakens the medical license," Bragg says.
Although some of the debate is still being played out in court, chiropractors are winning in the legislative arena in Lone Star State. Legislation has been introduced in the Texas statehouse that would allow chiropractors to make limited diagnosis on patients. The legislation essentially expands the definition of chiropractic medicine in the state to include diagnosing the spine and muscle system.
JC Smith, MA, DC, a Georgia chiropractor who has been in practice for 33 years, supports the Texas legislation. He has been an outspoken critic of the medical establishment, which he says has unfairly labeled chiropractors as second rate, with patients being the losers. Smith is author of The Medical War Against Chiropractors, a book that traces historic obstacles faced by chiropractors in a medical doctor-dominated healthcare world.
He acknowledges that chiropractors won a big victory with the passage of the PPACA. Smith and others point to Section 2706 of the act, the so-called non-discrimination clause. It could be a potential opening for chiropractors to get equal consideration in reimbursement as physicians, he says.
Specifically, Section 2706 of the PPACA prevents health insurance plans from excluding a range of integrative health practitioners from coverage, based on licensure. That could include chiropractors and others such as massage therapists or midwives.
"It's a real blessing for us, the non-discrimination clause, that finally gives the freedom of choice" to insurers, Smith says, referring to the possible "choice" of greater reimbursement.
AMA opposes expansion of coverage
Smith noted, however, that the American Medical Association wasn't exactly pleased with the Section 2706 provision within the PPACA. "What does the AMA do?" Smith asked. "Its House of Delegates passed a resolution to repeal it."
Indeed, the AMA House of Delegates at its meeting last year reaffirmed its opposition to the non-discrimination clause, or Section 2706 of the PPACA. The House of Delegates meeting minutes showed that the AMA intended to work to repeal Section 2706, "as enacted in the PPACA through active direct and grassroots lobbying."
AMA officials declined to comment when contacted this week, but its website notes that "non-physician healthcare providers should only provide patient care in accordance with their education and in accordance with applicable state laws."
'Drugs and shots and surgery' have not worked
Generally, chiropractors are maligned, Smith says. As far as he is concerned, the AMA isn't the only problem; it's the general coverage of chiropractors by the news media. "Chiropractors remain a mystery science profession in the media," Smith says.
Still, he insists that chiropractors are making headway in healthcare, not least by the mere fact that people are recognizing the outrageous costs involved, specifically over failed back surgeries. "After a century assailing chiropractors as practicing quackery, the table has finally turned with the medical profession on the defensive," Smith insists, referring especially to changes afoot in the Affordable Care Act.
"The paradigm of drugs and shots and surgery hasn't worked," he says.
He isn't confident, however, that physicians will embrace the chiropractic profession anytime soon. "Nobody seems to be listening," he says.
For some physicians and the hospitals where they work, an audit by a Recovery Audit Contractor may be a wreck waiting to happen—through no fault of their own.
The 391-bed Munson Medical Center, in Traverse City, MI, might feel that way. It failed to receive millions of dollars from Medicare following RAC audits for services provided to patients even though the care was deemed in advance to be reasonable and medically necessary.
RACs, which are paid a percentage of the money they recover from hospitals and other providers, have been determining, as in the Munson case, that many procedures billed as inpatient hospital care under Medicare Part A should instead have been delivered as outpatient procedures under Medicare Part B.
There were literally "hundreds of times" between 2007 and 2012 that Medicare demanded repayment from Munson for patient care the government agency believed should have been performed and billed as outpatient, according to court papers in a lawsuit the American Hospital Association (AHA) filed against Centers for Medicare & Medicaid Services (CMS).
All told, the RAC denials required Munson to repay Medicare $6.4 million.
Munson appealed. In court papers, the medical center noted that it had paid plenty to deal with the RAC audits. It hired a coordinator to oversee the appeals process, two billing employees—one full-time and one part-time—two registered nurses, and spent more than $165,000 on technology upgrades to track the status of RAC records, requests, and audits and appeals.
CMS Changes Course, Slightly The medical center's costly investment in people and technology was due to CMS nonsense, Lawrence Hughes, JD, assistant general counsel for the AHA, told me. Ultimately, CMS agreed that it had not only violated policy—but the law, Hughes said.
As a result, the government has announced that it will change its policy of denying reimbursements to hospitals that provide medically necessary care, even when it is later determined by auditors to have been delivered inappropriately in an outpatient setting.
CMS's changed position is due, in part, to the AHA's lawsuit, which referred to Munson's situation and similar experiences at three other hospital systems.
The CMS interim rule (PDF) reflects the agency's revised position and is seen as a major victory for hospitals, which had claimed that the existing rule prevented them from collecting hundreds of millions of dollars in reimbursements. The suit is continuing, however. "We are in the process of filing an amended complaint," noted Hughes, who declined to detail what the complaint will claim.
Audits are Lucrative So the government is making a tiny effort on RAC audits, but apparently it's too lucrative for the government to make wholesale changes, for now. Obviously, the RAC audits mean hefty returns for the government, despite the unevenness of enforcement.
The U.S. Government Accountability Office has estimated that $32.7 billion a year in improper Medicaid payments are made, with the federal share accounting for $18.6 billion and states' improper payments set at $14.1 billion. The government probably will continue to be aggressive in its use of RACs, says Jon Elion, MD, a cardiologist at The Miriam Hospital in Providence, RI. The Medicare program may amount to $2 billion per year, he says.
"The Medicaid RACs do include contingency fees, and for that reason, folks predict that the Medicaid RAC auditors will be more aggressive," says Elion, who also is founder and CEO of ChartWise Medical Systems, which offers a comprehensive system to support clinical documentation improvement, and is an expert in RAC audits.
Battle to Cap RAC Requirements Ensues
Now the American Hospital Association and some members of Congress are trying to derail the RACs, or at least make them more manageable.
"Our current litigation is part of a larger strategy around RACs and the concerns hospitals have about [them]," Hughes, the AHA lawyer, says. That includes support of legislation, the so-called Medicare Audit Improvement Act , which would include a "cap" on documents that could be sought by Medicare audit contractors.
"Smaller hospitals in particular have expressed deep concern over the administrative burdens being placed on them by Medicare audit contractors, including large increases in the number of documents being required," one of the co-sponsors, Rep. Sam Graves, (R-MO) said in a statement.
The voluminous records sought by RACs are only one problem, Hughes says. "RACs [also] have a poor record in terms of accuracy of their decisions" related to denying hospital claims. And overall "transparency," is another issue the AHA is concerned about, Hughes adds. "The RAC bill is also focusing on improving the performance by a number of contractors."
Appeals Costly A CMS study reveals that about 40% of RAC findings are appealed, but providers win those appeals about 75% of the time. Despite the good odds of winning an appeal, providers complain that the process is cumbersome and too costly.
In the past, RAC audits solely focused on Medicare. Soon, they will expand to include Medicaid. And RAC audits are only some of the financial reviews hospitals face. Others include Medicaid integrity contractors, zone program integrity contractors and state Medicaid program integrity audits.
It's important to "get your documentation as good as it can possibly be—what was documented and what was billed. That's the position you want to be in," says Elion.
Physicians and their hospital leadership should look at some elements to avoid problems with government audits, especially RACs. Among the recommended checkpoints:
Examine potential physician self-referral Hospital leadership should "look carefully at categories of payments that may be considered as Medicaid overpayments" related to providing incentives to physicians, or self-referrals, Elion says. Those areas could be violations of the Stark Law, "for services induced by kickback, (or related) to drug and medical device company payments to physicians," he adds.
Also, Elion advises that hospitals check the Office of Inspector General's list of excluded individuals and entities before making new hires. Every six months that list should be reviewed, to avoid the risk of receiving payment for services ordered or provided by an excluded provider, he says.
Establish a tracking system on RAC requests for reviews
Elion says hospital leaders should familiarize themselves with various state limits on how many records and how often they would be reviewed by RAC. He says that authorities should especially review Medicare claims that already have been audited, or ones that are more than three years old, to assure accuracy of the data.
Establish a Comprehensive Clinical Documentation Program Such a program would ensure "complete and accurate clinical documentation," Elion says. Hospitals "are scared and got too conservative with their billing and only hurt themselves," he adds. "That's what I think is happening. They are so afraid of the headlines, so afraid of the newspaper, so afraid of treble damages," he says.
"I maintain hospitals should be paid fairly for the work they did," Elion adds. "Hospitals are finding themselves in a dilemma."
That may be putting it mildly. Some would say they are finding themselves in a vise.
Amid economic turbulence and regulatory changes, service lines are becoming more integrated into hospital strategic plans, where these areas of specialization can thrive—although many healthcare leaders are checking the vitals of their service lines to see what treatment may be needed.
While general surgery, cardiovascular care, and orthopedics still head the list of service lines with strong positive margins, more areas of specialization are popping up or expanding, such as geriatrics or plastic surgery, depending on the demographics and needs of a region. Hospitals large and small are reviewing their service lines, with some leaders feeling the need to revisit these programs to take advantage of multidisciplinary approaches, subspecialties, or technological advances.
Various models are being implemented to improve coordination and data collection that allow hospital and health system leaders to scrutinize the direction of their service lines for greater ROI. Throughout the country, leaders have been retooling their service lines by changing strategic plans and evaluating demographic and coordination needs while using technology to eliminate waste and improve patient engagement.
Officials of Allina Health—a Minneapolis-based nonprofit that serves Minnesota and western Wisconsin and includes 11 hospitals, 42 clinics, and 1,677 beds—began revamping clinical service lines several years ago to overcome what they called "fragmented care delivery" in the programs, says Penny Wheeler, MD, chief clinical officer for Allina Health.
Using a medical process to align physicians and facilities, Allina Health has imposed changes leading to cost savings—millions of dollars over the past three years—while reducing length of stay and readmissions. In its revamped structures, Allina worked to coordinate programs from wellness to palliative care, Wheeler says.
Leaders at Indianapolis-based Indiana University Health, a nonprofit organization with 3,326 licensed beds, also thought they had a disjointed system. They consolidated oversight of 19 hospitals—each with its own institutional board. The prior lack of full systemwide integration shortchanged delivery and income, says Doug Schwartzentruber, MD, system medical director for cancer services and associate director of clinical affairs for IU Health's Melvin and Bren Simon Cancer Center.
The demographics of a market also are a driving force for strategy, physician alignment, and growth, says Mark Loos, system vice president for clinical services at the 1,138-licensed-bed nonprofit Palmetto Health in Columbia, S.C. To accommodate the needs of an older population, for instance, the importance of working with employed and independent physician groups to provide appropriate access to care has never been greater, Loos says.
Organizations are finding that technology can play a critical role in improving service line care. Hackensack (N.J.) University Medical Center relies on technology to improve patient engagement with its cardiology service line, which helped prevent hospital readmissions and improved patient satisfaction, says Louis E. Teichholz, MD, chief of cardiology at the 775-licensed-bed hospital.
Despite the complexities, the potential for service lines is enormous, especially with the need to eliminate wasteful spending, says Peggy L. Naas, MD, MBA, vice president of physician strategies for VHA Inc. based in Irving, Texas. VHA includes more than 1,400 not-for-profit hospitals and 25,500 nonacute healthcare organizations.
Service lines can overcome work flow waste and unexplained variations in clinical processes and operations, Naas says. Even service lines that may have originated from a marketing and sales inspiration can tell a community, "Look! Our hospital specializes in this area," according to Naas. Now, she sees more hospitals being concerned about service line care delivery and tightening their organizational structures and management.
"Much of healthcare happens outside the hospital; a real unmet opportunity point is in the transition and in the continuum of care," says Naas.
Revised strategic vision
Allina Health, Indiana University Health, and The Christ Hospital, a 555-bed not-for-profit acute hospital in Cincinnati, are among the healthcare organizations that found it necessary to revamp their clinical service lines to overcome inconsistency of care by changing their strategic vision.
Over the years, Allina Health tried repeatedly to make changes to its service lines, and each time, it was unsuccessful. "Four times it was tried in our organization and it failed," recalls Wheeler. The clinical service lines were based primarily on operational and business practices but failed to improve coordination of clinical programs, she adds.
In those attempts, Allina initiated changes to service lines to cut costs and make them "more efficient in terms of resource use." That was a mistake because "there was very limited engagement of those who made care decisions—the patients, the doctors, and other caregivers," Wheeler says. "While well-intended, it did not get directly to the real mission of the organization—providing exceptional care—and so didn't speak to the true interests and motivation of the clinical community."
So the healthcare system conducted a strategic review of clinical service lines. A 2010 Allina blueprint dubbed "clinical service lines" addressed the way the organization planned to improve. It said that employed and independent physician partners would be involved in a leadership structure, along with "active involvement" of patients in advisory committees. In the meantime, it adopted "deliberate implementation of processes that first and foremost facilitate improvements in clinical care." From the C-suite to the emergency department, Allina officials reviewed many systems throughout the country to study ways to improve its service lines.
"Like most U.S. healthcare organizations, Allina's current delivery model is based largely on location of services," the blueprint states. "Care processes, quality outcomes and operational efficiency vary across providers and sites of care. This variation may not serve patient or community need. Clinical service lines offer a foundation for a more fully integrated care delivery model that serves patient and community needs across the continuum of care by improving clinical quality, patient experience, and operational efficiency, and reducing total cost of care."
Allina took significant steps to change the focus of its service lines via the strategic plan, Wheeler says. "Fortunately, if you have the clinical folks define with the patients the best care, efficiencies follow through by reducing unhelpful treatments and costs are reduced. We focused on building the clinical service lines around care conditions of the patients."
Allina Health began to concentrate on high-volume service lines, such as cancer, neuroscience, spine care, women's health, and mental health, and in the past year added gastrointestinal care because of a growing need. The oncology programs focused on breast and lung care. The provider also developed programs focusing on underserved populations, through its Allina Mental Health system and Sister Kenny Rehabilitation Institute.
The health system revised its organizational leadership team over service lines with a physician governance committee that reports to the Allina board of directors. It also improved alignment of physicians through a physician network. "We continue to build these service lines and balance them as rapidly as possible to benefit more patients, while focusing on building them incrementally to focus and do the programs well," Wheeler says.
With this transformation, Allina sees service lines as core areas of hospital care that could flourish. Service lines have the potential to "increase the value of care, provide better outcomes and experiences for patients," Wheeler says. "I think you will not only see service lines surviving nationally, but they are representative of a structure that everyone is going to need."
The Christ Hospital initiated Vision 2020, a strategic plan that includes revamping its overall service line structure with designs on greater efficiency for inpatient as well as outpatient needs. Part of the plan includes clinical service portfolio and medical staff development, says Herb Caillouet, MS, PT, executive director of the musculoskeletal services for the hospital.
Under Vision 2020, hospital officials evaluated various practice models, in part by looking at how service line physician groups and organizational staff "relate to one another and the hospital." In addition, the hospital leadership stated in the plan that the "acute care hospital should no longer be the center of the health system, but rather part of a coordinated continuum of care delivery to serve people through the illness, healing, and wellness phases of life."
Indiana University Health made a strategic decision about how to deliver services as a large system, according to Schwartzentruber, noting that the system's oncology service line, for instance, "had been functioning as a bunch of independent components" at its various hospitals. The components were not coordinated. As they developed the strategic plan, leaders examined other facilities within the Indiana University Health system to determine how best to proceed.
About 18 months ago, the IUH officials examined their hospitals' experiences to review the quality of service lines and get tips whenever and wherever they could. "We were charged with putting together the service line and basically we traveled the state. We created a vision for what the service line would be like," Schwartzentruber recalls.
Dealing with demographics
Depending on regional needs, one service line may be important for a hospital or healthcare facility, while it is a losing proposition for another. One factor that could have an impact on individual service lines is the healthcare needs of those who may be among the 32 million people to be insured within the next two years under the Patient Protection and Affordable Care Act.
The Christ Hospital initiated a new musculoskeletal program geared toward the elderly population and younger baby boomers who are now reaching age 50. The hospital chose musculoskeletal services to form a "market-leading program," Caillouet says.
"It was important to develop a strategic network of care—similar to what we had in successful heart and vascular programs—for musculoskeletal," he says. The Christ Hospital musculoskeletal service line includes surgical and nonsurgical spine, total joint replacement, sports medicine, and general orthopedic services. The program was added to the hospital's other service lines: heart and vascular, oncology, women's health, and geriatrics. Other hospital departments fall into either "specialized surgical care" or "integrated medical management" categories, Caillouet says.
"The ortho community here was quite fragmented and so we believed there were great opportunities," Caillouet says. Recruiting and realigning physicians was essential, with "surgeons and nonsurgeons working together to streamline the service," as well as improving relationships with primary care, rehab, and neurology physicians, he adds.
With a better-aligned and -positioned service line, The Christ Hospital had 7,100 orthopedic surgical cases in 2012—a 9% increase over 2011, which had 6,500 cases. In addition, the hospital led the tristate area with 24% share in spine surgery. Surgical complications rates decreased to 24% last year. In the meantime, inpatient direct variable cost per case in the 2012 fiscal year decreased by 8% compared to the same period the previous year, Caillouet says.
The hospital is coordinating the new musculoskeletal program with The Christ Hospital Spine Surgery Center, a freestanding facility for outpatient spine surgeries and pain management procedures. The surgery center is included in a partnership among The Christ Hospital, spine specialists from the Mayfield Clinic in Cincinnati, and United Surgical Partners International, a Dallas-based for-profit that owns and operates surgery centers and private surgical hospitals in the United States and the United Kingdom.
Keeping an eye on competition is critical, says Loos of Palmetto Health. "You don't want to be a patient and wait six months to see a specialist." If they faced that kind of wait, "patients may choose to go to Charleston or Greenville to competing hospitals," he says. So Palmetto is examining potential shortages in key medical and surgical positions or subspecialties that it may need to buttress to maintain or expand patient access. Service lines are being designed not only for improved clinical care and outcomes, but also with an eye to the manner in which the organization can attract them into the system, he adds.
Patients' expectations for care are changing how orthopedic, cardiac, and oncology services are delivered, as a more educated patient population is increasingly active and engaged in the care process. "They are ready to participate in their care. They are doing research online and asking questions and using social media," Loos adds.
Coordination of cancer care
Oncology service lines are among the most popular and the most important for hospital revenues. As a disease with a single name but thousands of variations, cancer requires many treatments, as well as types of care. That is just one of the facts that can make running a high-functioning oncology service line complex.
At Indiana University Health System's cancer centers, leaders identified inconsistent levels of cancer care through the system and determined that they needed a more coordinated service line, says Schwartzentruber. Before IUH moved ahead, hospital officials identified several key goals: Achieve buy-in from internal stakeholders, create benchmarks to measure progress in the system, and compare its plan with other systems, he says.
The numbers alone were telling the story of the need to improve an oncology service line, says Holly Goe, RN, MSN, vice president of cancer services at IUH.
"Obviously we have a lot more cancer survivors than we did 10 or 20 years ago. We're making sure that we continue to provide what care survivors need, treating [cancer] more as a chronic disease than we have in the past," says Goe. "One of the first things we had to do was integrate all the sites and create buy-in. We brought all the leaders together [to decide] how we should move the service line forward."
As leaders developed the program, they did so with the recognition that cancer patients need a comprehensive model of care, Schwartzentruber says. All employed and independent oncology practice sites were to include patient navigation, use of clinical pathways to drive treatment decisions, plans of care and treatment summaries for each patient, and the multidisciplinary approach to care, including access to a broad array of cancer clinical trials, he says.
"When the vision was created, we realized we needed to be comprehensive throughout the cancer journey, from diagnosis through survivorship," Goe adds. In addition, the hospital created outpatient programs for palliative care and survivorship programs for cancer care.
As part of the change, hospital officials created a service line administrative and clinical management team to ensure all operations carried out at network sites are consistent with tactical goals. That leadership at the IUH system includes the medical director, the leadership council, and Goe as vice president of cancer services. Each facility within IUH has an operational leader and medical director. The oncology leadership council includes physician leadership and administrative leaders responsible for all representatives of the practices and sites.
Importance of data
Data improvements have been necessary to keep track of potential problem areas in service lines. Allina Health's enterprise data warehouse has the ability to track, report, and analyze care over time to allow the health system to understand clinical outcomes, utilization, and costs, according to Wheeler. A financial officer and a physician leader have been assigned to each clinical service line as part of the data warehouse oversight. They report to an executive committee, which includes presidents from each of the hospitals.
"The data infrastructure is one of the keys to all we do, with the other being the engagement of caregivers and patients," she says. "The EDW continues to expand and gives those in a position to improve care information on the greatest opportunities to do so.
"It does so from an aggregate population level all the way down to an individual level," she adds. "We would not be able to understand our outcomes improvement without the integrated data warehouse. It is vital to our future of demonstrating quality and value to all we serve."
Technology also can play a role in improving patient engagement. Leaders at Hackensack University Medical Center discovered a need to better the cardiovascular service line to help prevent hospital readmissions and enhance patient satisfaction.
The University Health Network is the nonprofit New Jersey–based parent company of HackensackUMC and corporate joint venture partners with LHP Hospital Group, a Plano, Texas–based for-profit organization in ownership of two hospitals: HackensackUMC at Pascack Valley and HackensackUMC Mountainside.
As hospitals move from volume- to value-based healthcare programs, "interacting with our patient more often and more effectively" is a key to better outcomes and reduced readmissions, says Teichholz, the medical director for cardiac services at HackensackUMC.
"When you look at the statistics for congestive heart failure and heart attacks, we give excellent care. Our mortality rate is very low, but our readmission rate has not been at the top and is something we wanted to improve on," Teichholz says. "We were very concerned about moving that forward and, of course, the government will be penalizing hospitals for readmission rates."
Indeed, in 2012 HackensackUMC reported a 26.7% all-cause heart failure readmission rate for 1,889 patients, compared to 24.7% for the national average, according to the Centers for Medicare & Medicaid Services' Hospital Compare website. Within the past year, however, HackensackUMC decreased the all-cause heart failure readmission rate to about 21%–23%, Teichholz says.
HackensackUMC, as part of its effort to reduce readmissions, was among four
hospitals to participate in a pilot program designed to follow up with congestive heart failure patients after discharge. The hospital uses EmmiTransition—an automated, interactive system of outreach tools—to call patients for 45 straight days after discharge, reminding them when to schedule an appointment with their primary care doctor, take their medication, or complete other actions.
The voice response system asks patients questions, such as their weight, and reports the information to the hospital. The pilot program saved an estimated 600 hours and found more than 313 red flags—recognition of a possible risk factor, such as weight gain—that otherwise may not have been captured, according to Teichholz.
"Through at least one initial telephone call to every patient from our nursing staff, improvement in postdischarge instructions for all patients, and the use of Emmi, we have met our goal of decreasing all-cause CHF readmissions," Teichholz says.
"It did make a substantial difference compared to usual care. For congestive heart failure patients, the communication program has shown to be more effective than not using it, based on a comparative review." The program enabled the hospital to decrease readmissions of more than 60 patients by 20%–25%, he says. Total CHF readmissions are now 7% with a readmission diagnosis of CHF, Teichholz says.
"The key to preventing readmission is the engagement of patients," Teichholz says. "What we've learned is that trying to educate patients before they leave the hospital doesn't always work. They just want to go home. In this way, we're getting patients involved as a partner in their care and making sure that they make an appointment to see their primary care physician, making sure they get their medication and continue with the medication."
Joe Cantlupe is senior editor for physicians and service lines for HealthLeaders Media. He may be contacted at jcantlupe@healthleadersmedia.com.
Reprint HLR0313-2
This article appears in the March 2013 issue of HealthLeaders magazine.
The upholders of the Hippocratic oath are acting a lot like self-styled brokers lately, actively looking for buyers of their practices. Indeed, physicians are taking the initiative in hospital-based acquisitions of their practices, in a big way.
The latest evidence comes from a recent survey by Jackson Healthcare, the Atlanta-based healthcare staffing recruiter. When asked about physician practice acquisitions, 70% of healthcare leaders said doctors are approaching their hospitals, seeking to sell their practices. It's definitely not the hospitals taking the first steps in the courtship with physicians, as much as it is docs knocking on the door.
Physicians seeking hospital employment are setting the stage for this evolution in how healthcare is delivered, says Sheri Sorrell, market research manager for Jackson Healthcare.
"Physicians are approaching the hospitals and are seeking to sell," Sorrell said in an interview. "That's the number 1 reason why hospitals are acquiring physician practices."
The trend is expected to continue "at a rapid rate," Sorrell says. When asked about the disposition of acquisitions in 2012, 44% of hospitals closed the deal, while 56% said they didn't. Those hospitals hesitant about acquiring are more likely to be rural hospitals, Sorrell says. About 70% of hospitals that say they are not planning to acquire physician practices have 150 beds or less.
This year, 8% more hospitals – for a total of 52% - plan to acquire physical practices, and 48% said they will not. Jackson Health did not do a comparable survey in 2011, so year-over-year comparisons are not possible. A total of 118 participants completed the surveys, from November 1 through December 15, 2012.
"A lot of solo practices and solo physicians are looking to sell," Sorrell says. "They can't afford to put in the resources necessary to comply with the ACA, (Affordable Care Act) and they're just looking to get out. Employment seems to be a better option for them at this time," Sorrell says.
While physicians appear to be the primary initiators, hospitals aren't merely passive bystanders. The survey showed that 58% of hospitals are bringing physicians on board to build "competitive" advantage, 55% to maintain a competitive advantage, and 57% say it's part of a "physician recruitment strategy."
Another 28% said improving patient safety was a key motivator in their physician acquisition strategy. (Editor's note: A HealthLeaders Media Webcast, Recruiting and Retaining the Right Physicians for the Post-Reform Era is slated for Friday, March 22, with Jim Stone, president of The Medicus Firm, and Floyd Wilson, Jr., executive VP of marketing, physician relations, and community outreach at Metro Health System in Wyoming, MI.)
Over the last several years, recruiting and retaining doctors have been challenging, against the backdrop of uncertain economic conditions, physician shortages, and regulatory challenges. Hospitals and physician groups are working to overcome the obstacles.
Sorrell says the hospital plans for physician acquisitions seem "more opportunistic than strategic." The physicians are taking the first step, and hospitals are jumping at it, she adds.
And what of those "competitive advantages" in buying physician practices? Sorrell sees it this way: "Building a competitive advantage would be acquiring physician practices in specialties in which you do not currently have an advantage—trying to go up against a competitor that already has an advantage over local competition—strengthening that advantage."
Of the hospitals surveyed, family practice and internal medicine are the primary targets in the acquisition of physician practices, Sorrell says, which is not surprising. While 54% of leaders reported interest in family practice for 2012, only 31% planned an acquisition of family practice in 2013.
In other specialties, only 2% to 6% of leaders reported acquisitions in areas such as radiology, cardiothoracic surgery, and gastroenterology in 2012. The leaders report even lower interest anticipated in 2013 for podiatry, sleep medicine, and sports medicine, at 1%.
It will be interesting to see the focus shift of specialties, Sorrell says. "Right now, it's what we all expected. They are acquiring family practices, primary care, internal medicine. It will be very interesting if they shift more toward specialties, focusing on their catchment areas," she said.
Of those hospitals acquiring physician practices, at least 30% say they plan on being involved in the formation of accountable care organizations, a figure that is "a little higher than I thought," Sorrell says.
She noted that 250 ACOs have been created, to date, with reports showing that there may be as many as 500 more organizations applying to be ACOs. That would account for 14% of the nation's 5,500 hospitals, Sorrell says. The 30% figure mentioned in the survey shows "a trend toward ACO development or laying the groundwork for it," she explained.
As 2013 continues, Sorrell doesn't anticipate a drop off in doctors' interest in obtaining hospital employment. "Physicians are approaching the hospitals asking, 'Do you want to buy the practice? Hospitals are saying, 'Here's a primary care doc or practice looking to sell. Let's take advantage and buy it.'"
The president of Partners Healthcare and a Harvard University economist contend that primary care in the U.S. needs to be restructured to improve physician business practices and provide more value for patients.Under this "subgroup management," primary care physicians would oversee improved coordination of care for greater efficiencies and clinical outcomes.
So say Thomas H. Lee, MD, network president of Partners Healthcare, and Michael E. Porter, PhD, the Bishop William Lawrence University Professor at the Harvard Business School, and director of The Institute for Strategy and Competitiveness, both in Boston, in a Health Affairs article this month. I spoke to both of them about their primary care challenge. (Erika Pabo, MD, MBA, a resident at Brigham and Women's Hospital in Boston, was a co-author.)
"If we're going to make primary care as effective as we want to, we have to start with a clear overreaching goal and try to restructure primary care," Porter says. "It starts with value and that's the true north compass. Primary care isn't really one thing. It's a lot of different things for a lot of different patients with very different needs."
"If we can segment the needs and take patients and group them into fairly straightforward categories, such as healthy adults, or someone with one or two chronic conditions or very disabled people, we can understand the needs of a defined group of patients, and change the nature of primary care," Porter adds.
The primary care framework isn't working now, they say. As Lee sees it, too many physicians are "stumbling down a road, not sure where they are trying to go, as opposed to a bunch of people effectively moving down a road." For doctors, it's a vital question: their livelihoods are at stake.
"Market share is going to places that can meet patients' needs and do it more effectively," Lee says. He warns that physicians who "won't be able to get their act together to adopt a strategic framework will be less successful and lose market share to organizations that can."
Under their plan, a physician practice would divide patients into small groups reflective of differences of "core needs and circumstance," Porter and Lee write. A practice may refer some patients to other providers better equipped to meet particular needs.
As it is now, an absence of a "robust overall strategy" is one of the causes of primary care's problems, according to Porter and Lee.
"Thinking about primary care as a single service not only undermines value but also creates a trap that makes value improvement difficult, if not impossible. We will never solve the problem by trying to do primary care better," they write. "Instead, primary care must be redefined, deconstructing the work that goes on within those practices and rethinking how it is performed."
Examples of the team focus: integrated cancer teams that increasingly include both palliative care specialists and a psychiatrist to measure patient outcomes. Or, patients with end-stage renal disease may be referred to a dialysis team that provides primary as well as nephrology care.
As Porter and Lee envision a new primary care structure, they say care teams and delivery processes can be designed for each patient subgroup, with measurable outcomes. Such data measurement is woefully lacking under current primary care, they say.
The possible changes would touch not only on clinical care, but also go into the day-to-day function of existing primary care practices, which includes scheduling or patient visits. Patients with common chronic diseases can be "preferentially" scheduled to facilitate more efficient visits that may include group educational programs, they write.
Diabetes sessions could include an expansive team of specialists such as endocrinologists, podiatrists, and nephrologists. Especially complex case sessions with patients could involve mental health specialists, palliative care consultants, and social workers.
It's no surprise, they say, that some of the best work in primary care is now focused on specialty care, especially the complex needs of elderly and disabled patients. "Various organizations have built a whole care model for those people," Porter says.
To finance all of these primary care changes, Porter and Lee endorse the bundled payment model for a "total package of services for a defined primary care subgroup during a specific period of time, the approach most aligned with patients."
While some healthcare organizations are moving in the right direction to improve primary care, much is lacking. Lee was even tough on his own health system. "We've got 65,000 employees, and the number of people whose job it is to improve the value of our care for healthy people, which is most people out there? The number is zero," Lee says of Partners. "It's not anyone's job right now. Therefore, no one does it in a systematic way."
Indeed, there is much discussion about population health, medical homes and Accountable Care Organizations with primary care physicians playing important roles. That's nice, Porter and Lee say, but those models still fall short of the multidisciplinary, collaborative teams needed to augment primary care.
"We're saying 'let's take it one step further,'" Porter says. "What are the primary care needs of different individuals?"
Porter and Lee acknowledge that their model certainly poses difficulties for small practices, but they insist small physician groups should not be excluded.
"There are a whole bunch of forces challenging the one and two doctor practice going forward," Lee admits. "I don't think anyone will look back and say this paper by Mike Porter and Tom Lee put them over the edge. There are ways to get physicians spread out, even in rural settings, to work together. They have to be ready to want to work together and collaborate with colleagues to improve the value of care for patients over time."
Change must be in the offing for primary care, Lee insists. "I don't think anyone feels like things are stable and that all (physicians) need to do is just show up for work and work as they currently are working and be OK," Lee says. "We want to provide this strategic framework to make something happen, as opposed to fretting about it."
This article first appeared in the January/February 2013 issue of HealthLeaders magazine.
When UnitedHealthcare first met two years ago with five oncology medical groups that volunteered to participate in a bundled payment program designed to reduce costs for cancer care, there was definitely uncertainty, but "nobody came into this kicking and screaming," says Lee Newcomer, MD, an oncologist and vice president of oncology for UnitedHealthcare, a Minnetonka, Minn.-based health benefits company with 2012 revenues (through September 30) of nearly $77 billion and earnings from operations exceeding $6 billion.
"Everyone knew the world of healthcare had to change," Newcomer says. "Everyone was eager to try something new."
Their target: to evaluate 19 clinical scenarios for breast, colon, and lung cancer and identify the best practices for the care of those patients. Each group selected the chemotherapy it believed was the best and agreed to participate in measurement of those results.
As the five physician groups evaluated their chemotherapy selections for early-stage breast cancer, the cost of treatment proposed varied greatly, Newcomer says. There was also a wide variation in the number of imaging tests physicians believed they needed to evaluate relapsed patients with breast, colon, or lung cancer.
"Clearly some groups are doing far more radiology studies than others and getting the same results," Newcomer says. UnitedHealthcare and the physicians worked on "standardizing the tests to decrease utilization."
As time went on, the physicians and insurer worked to minimize variations of care, reaching agreements for breast, colon, and lung cancers. Physicians receive an up-front payment for the episode that is equal to the drug margins they used to receive from their previous fee schedule. Fee-for-service vanished, but the drugs are always reimbursed at cost, even if changes are made. It was only November 2010, and UnitedHealthcare was testing the bundled episode payment approach with five medical oncology groups for more than 430 patients.
Bundling is one of the new payment models being scrutinized across the country as a way to get a handle on skyrocketing service line costs, including those for oncology programs. These models, which include accountable care organizations, have a twist: Providers and insurers are teaming up instead of facing off. Under the bundling initiatives, payments are made for multiple services under what is termed an episode of care for a patient. Instead of a surgical procedure generating multiple claims from many providers, the entire team is compensated with a bundled payment with the thought that such a move would provide incentives for more efficient care. Medicare now makes separate payments to providers for services, leading to what CMS has called "fragmented care" with minimal coordination.
Under a bundled savings program, there is an incentive for providers to share in any savings, and it can increase physicians' payments with improved patient outcomes. Physicians "have the opportunity to be paid more for the work they do taking care of patients," Newcomer says. In addition, he says physicians have a "chance to mold and influence a new payment model."
Establishing the bundling program is a complicated structure, and UnitedHealthcare learned a lesson the hard way. While the insurance leaders believed they could quickly tally outcome measures, it didn't turn out that way. "It takes a large number of patients to identify a statistical difference," Newcomer says, referring to oncology patients whose treatment costs were included in the bundling. "Cancer costs can vary by 100% routinely, and detecting a difference among those wide swings means that we needed nearly 700 patients before we could begin the analysis," he adds.
The Northwest Georgia Oncology Centers physicians are among the groups working with UnitedHealthcare on the episode of care payment plan, says Bruce J. Gould, MD, medical director of the organization, which has 10 treatment centers and more than 20 physicians; he also is a staff physician at WellStar Kennestone Hospital in Marietta, Ga. Gould acknowledges that there are risks involved for physicians in the bundling package.
"If a patient ends up in the hospital, we don't get charges for our services for that hospital care," Gould says. He remains adamant, however, that physicians in the practice will make profits in the shared savings, though results may be long term. "We're in the transition from fee-for-service to one in which we get paid for global care, which is taking ownership of the cost of caring for those patients."
"Ultimately," he adds, "this plays to our strength. We have always tried to be thoughtful to patients who would likely benefit from it and no more. Some doctors will give chemotherapy to the bitter end. However, most stakeholders agree substantial cost savings can be realized by more appropriate use of chemotherapy at end-of-life care. They are in the minority, but it's there. With this we are trying to solve the problem of out-of-control cancer care costs and not be part of the problem."
Indeed, the cost of cancer care continues to skyrocket, in part because of more costly advanced treatments being used, according to the National Institutes of Health. Medical costs for cancer are anticipated to reach $158 billion in 2020, an increase of 27% over 2010, the NIH states.
The Congressional Budget Office projects that bundling hospital and postacute care for Medicare patients alone would reduce federal spending by $19 billion, from 2010 to 2019, according to the Commonwealth Fund. Bundling appeared several years ago in cardiology care and then moved to hip replacement, obesity, and other medical services. UnitedHealthcare says it was the first insurer to become involved in bundled payments for oncology care. The Centers for Medicare & Medicaid Services has begun partnering with providers through a bundled payments initiative.
In another team effort involving an insurer and providers, Florida Blue (formerly Blue Cross Blue Shield of Florida) is coordinating an accountable care organization shared savings plan with Baptist Health South Florida in Coral Gables, and Advanced Medical Specialties, a Miami-based oncology group, which consists of 17 physician practices. Florida Blue, based in Jacksonville, serves 15.5 million people in 16 states through affiliated companies. While the project is directed toward shared savings, the plan includes shared risk for a defined oncology population.
The importance lies in "establishing and solidifying relationships with medical staff and payers," says Ralph Lawson, executive vice president and CFO for Baptist Health South Florida, a 1,738-licensed-bed system that includes seven hospitals. Lawson is also national chairman for the Healthcare Financial Management Association.
Lawson describes it as a shared-savings arrangement because participating providers "are coordinating care for this defined oncology population with the goals of increasing quality and efficiency while reducing costs and unnecessary services."
"We started with oncology because we are fortunate to work with a premier oncology group in the South Florida area that has worked with Baptist Health for many years," Lawson says.
In another partnership, Blue Cross Blue Shield of Michigan and the University of Michigan are examining various funding sources, including bundling, as physicians evaluate cost efficiency in other oncology programs, such as prostate cancer, says David C. Miller, MD, MPH, assistant professor in the department of urology at the University of Michigan's Center for Healthcare Outcomes and Policy.
The project has initiated dozens of urology practices to evaluate prostaterelated cancer services to improve evaluation of data and assess outcomes, Miller says.
That's why a partnership between providers and insurers is crucial, he says.
Success key No. 1: Evaluating drug costs
When a new breast cancer drug, pertuzumab, was approved by the FDA, physicians in UnitedHealthcare's bundling program added the medicine to their regimens based on promising results from clinical trails; the cost for the new regimen was approximately $180,000 for a course of therapy covering an 18-month period for each patient. The medication was, indeed, costly, but the physicians agreed it would set the stage for better outcomes. In addition, UnitedHealthcare pays for the cost of the drug, so physicians are not at risk for the expense. However, physicians do not make more money for using the more expensive medication, as they would in a fee-for-service payment model.
UnitedHealthcare calculated the drug margin for each selected regimen by subtracting the average sales price—the price determined by Medicare—from the group's usual reimbursement for the drug using the existing fee schedule. To determine the episode payment, UnitedHealthcare asked physician groups to identify the chemotherapy program that it thought would be best practice for the oncology programs, Newcomer says. The discussions were not always smooth. Not every member of the group used the same regimen, and they had to come to a consensus for the program."
When new evidence requires changing an episode's chemotherapy to a more expensive drug, the drug cost is reimbursed by UnitedHealthcare to the physician and the episode payment is not increased. "They don't get paid any more money now that they are using the drug," Newcomer says. "In the old system, the physicians would have made a lot more money, but that doesn't happen in this program. Everyone knows the drug profit model is going away and this model offers a unique way to increase physician payments."
The five medical groups involved in the UnitedHealthcare program used docetaxel and cyclophosphamide chemotherapy for early-stage breast cancer, yet costs of treatment varied by 100% among the groups, Newcomer says. The cost for drugs in the regimen would range from $9,000 to $22,000, he adds.
When new evidence requires changing an episode's chemotherapy regimen to a more expensive drug, the physician's episode payment is not increased.
Coordination and quality of care are just as important to evaluate as the drug costs, Newcomer says. Over the past several years, physicians and UnitedHealthcare's oncology group discussed how to assess the value for each scenario using more than 60 measures, such as survival, complication rates, and total cost.
The current bundling system differs drastically from what Newcomer described as the "buy-and-bill" scenario, in which oncologists earned the difference between what they paid for chemotherapy drugs and the amount they billed insurers.
Before the bundling program was implemented, there was discouragement "of lower-cost generic medications, even if the clinical results are similar," Newcomer says. "All of us are struggling to change behaviors to get better outcomes."
Success key No. 2: Physician involvement
A key for success in the episode of care model relies on physician involvement and providing quality care. Everyone agrees this one will be tricky.
Medical groups may change their regimens at any time, but the episode payment will not be adjusted for new drug selections. Each physician identifies eligible patients during the initial consultation, and his or her office registers the patient with UnitedHealthcare under its program.
"We're taking on some of the ownership of the cost of care for those patients," says Gould of the Northwest Georgia Oncology Centers. "We're transitioning from fee-for-service to one in which we are paid for global care of the patient," Gould adds. The Northwest Georgia Oncology Center is part of the UnitedHealthcare episode of care pilot project.
Gould is excited about the prospects for the bundled payment program that impacts the 21 medical oncologists at Northwest Georgia Oncology Centers because, he insists, the payments are wrapped around value.
Physicians can increase their episode payments by improving their results, through either improving patients' survival or decreasing the total cost of care, Gould says.
Physician involvement is essential to get the project going, says Leonard Kalman, MD, chairman of the board of managers for Advanced Medical Specialties of Miami, an oncology practice involved in an accountable care program with a Florida hospital and insurer.
"What's in it for the oncologist?" Kalman asks. "You have to buy the proposition that's where the payers want to move, including Medicare and Medicaid, so you better get on the bus, otherwise you will be left behind. That's the motivation."
"Risk does scare some people, but it also represents a potential opportunity. So we need to get comfortable managing a population," Kalman says. "If you can manage costs while maintaining quality, it's very possible that you will attract more patients."
Success key No. 3: Coordination
Prostate cancer care is expensive and highly variable in terms of quality and cost-efficiency, both in the hospital and at physician practices.
Urology practices provide most prostate cancer-related services, but they often lack data regarding quality of care in their practices. And even when the data is available, few physicians understand how to make changes to make improvements, according to the University of Michigan's Miller.
Recognizing these concerns, urologists from throughout the state of Michigan and Blue Cross Blue Shield of Michigan have partnered to create the Michigan Urological Surgery Improvement Collaborative.
The group includes a consortium of urology practices—representing about 60%-70% of all urologists in Michigan—to initiate coordinated care, says Miller. "In prostate cancer, there has been a fair amount of variation in care that has been well documented," he says. "It's a very expensive condition."
Miller says it's important that systems build guidelines to potentially reduce unnecessary testing of men with low risk of cancer. In a study, Miller said that in 2010 surgeons collected uniform data for men with newly diagnosed prostate cancer. Of 215 men having prostate cancer, 43% underwent testing, but only 9% of those were positive for the disease.
The MUSIC program has initiated guidelines to reduce unnecessary testing, Miller says. "We may be able to improve practice patterns and avoid many radiographic tests in low-risk patients," he says. At the same time, the work may "optimize the use of appropriate radiographic staging evaluations among men with a higher risk of cancers."
Success key No. 4: Accountable care organizations
At least 16% of total Florida Blue's medical expenses over a year's period were linked to cancer care. Those figures prompted the insurer to team up with Baptist Health South Florida and Advanced Medical Specialties, the medical group, to initiate an oncology ACO.
The collaboration focuses on six of the most common forms of cancer: leukemia, lymphoma, breast cancer, lung cancer, colorectal cancer, and male and female genitourinary cancers. All told, they represent 80% of all cancer types in Florida. An early examination of data "shows trends in a good direction" for cost savings, Lawson says.
"This is an ACO-like shared savings arrangement," Lawson says. "It is ACO-like from the standpoint that participating providers are coordinating care for this defined oncology population with the goals of increasing quality and efficiency while reducing cost and unnecessary services," he says.
Baptist Health will assume the risk for cost of care. "We found cancer care has complexities unlike some of the other service lines," he says. All parties agreed that collaboration was necessary to cut costs, says Lawson. To carry out effective coordination, it was also important that senior leadership in each of the three organizations was engaged in setting strategy, he adds. Negotiations were sensitive because the parties felt they were breaking new ground, including the need to divulge financial information.
"To attempt to make an impact on the cost of care, it is important to understand the complete picture—services rendered, patterns of care, ED frequency, etc.," he says. "The only way to build the complete picture is for all three parties to share clinical and financial information. This requires a new level of disclosure and transparency among parties that are typically on opposing or competing sides and must now learn to work together toward shared goals.
"Florida Blue is very much a partner in setting and achieving these goals. Part of the initial phase of this program was the formation of several subgroups and task forces. It is the only way to ensure that, with so many moving parts, nothing falls through the cracks," Lawson says.
"The clinical subgroup is tasked with identifying opportunities along the continuum of care," Lawson adds. "Patients are often bombarded by duplication efforts, information-related material, advanced directive documentation, and reminders. By simply coordinating some of these efforts, the patient's experience is positively impacted and resources from duplicative areas can be directed to more beneficial use."
Jonathan Gavras, MD, chief medical officer and senior vice president at Florida Blue, also says that all parties were present together throughout the process. "Cancer costs have been an issue throughout the U.S. and particularly in Florida for a long time," Gavras says. "For three months, we ground through the analysis of data. We shared information with each other that we never would have shared before."
Team meetings among the groups are held to "review data and maintain adherence to time frames and initiatives," Lawson adds. The task force includes three members from all parties in the transaction and shares all the "available data concerning the cancer patients treated at Baptist Health."
Baptist Health's and Advanced Medical Specialties' information technology teams are also working diligently on the development of appropriate and compliant processes to achieve more real-time sharing of target population information. This would be a breakthrough for emergency visits to Baptist Health facilities, so cancer patients can avoid duplication of care or unnecessary diagnostic testing, according to Lawson.
"You have to have a lot of trust developed," Gavras adds.
Indeed, trust-building counts in every aspect of payment-bundling for cancer service lines.
After seeing an emergency department physician, a patient may be sent home with instructions to contact his own primary care doctor, along with a note on what medications to take, and wishes to feel better soon.
By the time the patient returns to the ED, maybe months or a year later, he may think, "Oh yeah, remember that great doc? What was his (or her) name?"
The odds are good that once the patient leaves the ED, the attending physician may not be heard from or seen again, or even remembered. Does it matter?
Some think it does. Now there is a move afoot by physicians to make the ED a greater presence in patient "after-care." Here's the prevailing wisdom: As hospital physicians step up their interactions with patients at discharge, so should ED docs.
After-care is another way to improve patient satisfaction, and possibly to prevent some of the complications that can land patients in the ED again, says Pankaj Patel, MD, an emergency department physician and former department chairman at Kaiser Permanente Medical Center in Roseville, CA, part of the Kaiser Permanente integrated healthcare system, which serves 3.3 million members at 21 hospitals and more than 160 medical offices.
Patel is lead author of a study published in the Annals of Emergency Medicine that showed ED patients who received follow-up calls or emails from emergency physicians reported that they were more satisfied with their experience than those who were not contacted after treatment.
"Patients want the ability to communicate with their doctor," Patel says. "This is a new avenue of communication between a patient and someone who would otherwise be a 'stranger' physician in the ED. That doctor may be someone a patient sees once in a lifetime."
A brief conversation outside the "rushed and stressful" environment of the ED between patient and physician can also significantly improve the patient's impression of the ED experience, he adds.
In Patel's study, 42 emergency physicians either emailed or phoned 1,000 patients within 72 hours of being discharged from Kaiser. At least 87% expressed satisfaction about the follow-up contact. Those patients who were provided no follow-up also were satisfied, but not as many. This group had a 79% satisfaction rate.
That 8% difference can be significant in terms of patient satisfaction ratings. The findings show that patients would certainly feel better about their overall ED experience if they received follow-up, Patel says. It's no secret that many physicians are reluctant to embrace technology, even if it's as simple as sending an email. But "patient satisfaction was higher when emergency physicians contacted patients briefly after their visit, either by e-mail or by telephone," the report states. "Given that emergency care is generally more rushed than inpatient care, the ED patient might have even more to gain," he says.
The Kaiser Permanente Medical Center in Roseville, CA has begun using the e-mail and phone call system for ED physicians, says Patel. Kaiser Permanente uses a secure email system compliant with HIPAA, he says. The e-mail and call protocol "has become a standard of practice for most ED physicians in Northern California Kaiser," Patel says.
The study reveals that patients showed "more appreciation that the physician cared enough to make contact," Patel says. "There's been a reaction of, 'Wow, thank you for the call,' " he adds. "There is 'thanks' for showing caring and concern and following up."
While the study has not focused on potential impacts on outcomes, Patel says he believes the added communication would have a beneficial effect. "Any time there is communication between physician and patient, it can improve outcomes," Patel explains.
"Having the opportunity to contact the patient after the ED visit, physicians can stress the importance of care," Patel adds. For instance, if the post-ED care instructions are to "keep your arm elevated," the physician can reiterate that important pointer. "It gives a second chance to confirm information," he notes.
In the complex and expensive world of healthcare, the ED email and phone exchanges can be of "critical importance because you can't cut costs unless you involve a patient in healthcare," Patel says. "This is a simple and efficient way to have physicians and patients involved."
Those are just some of the key characteristics that hospitals and physician groups want to find in the doctors they recruit, says Jim Stone, president of The Medicus Firm, a physician search firm in Dallas, TX. Beyond that, there are practical and emotional considerations: How do the physicians manage stress? How far would they be willing to move?
In the meantime, employers might consider offering signing bonuses and/or relocation allowances. Will they truly "welcome" the potential candidate? And for physicians, are would-be employers allowing a flexible schedule and making their family fit into the overall employment plan? Is a balanced life possible?
A false move by either party can result in no deal.
Over the last several years, recruiting and retaining have been challenging, especially with uncertain economic conditions. Experts say it's unlikely to get easier soon: A national physician shortage, coupled with restrictive regulations and reimbursement cutbacks, could spell trouble if hospitals and physician groups don't embrace innovative strategies to recruit and retain physicians.
It's not like physicians are exactly in the driver's seat, either. A great clinician who has terrible bedside manner or is uncooperative with colleagues isn't likely to get the job, despite his or her sparkling resume. Behavioral issues weigh more heavily with employers these days.
Moreover, a hospital may offer great benefits and a terrific salary, but be located thousands of miles from where a physician wants to work, thus throwing a monkey wrench into a potential match.
Competing forces complicate the hiring of physicians. The demand for more primary care physicians is juxtaposed against the backdrop of the healthcare transition from "volume of care vs. quality of care," says Stone, who also is president-elect of the National Association of Physician Recruiters.
Nothing can be taken for granted, says Floyd Wilson Jr, executive VP of marketing, physician relations and community outreach at Metro Health System in Wyoming, MI. "It's a great game-changer, volume versus value," Wilson says.
"There are a limited number of providers and everybody is looking for them," Wilson adds. Who gets hired has changed. Bringing on board "the person who has a horrible bedside manner and great outcomes, for the most part, is done," Wilson says. "If you are recruiting a physician, we are looking at the team-focused concept, and everyone coming together in a multidisciplinary team." That would result in improved patient satisfaction scores, for instance.
As Metro Health works to recruit physicians, one of its selling points is the fact that Western Michigan is a "beautiful place," Wilson says. And who helps make the sale? Physicians who already work for the health system, he says.
"The physician group has a very important role in recruiting, especially for those physicians who are from other areas. They are important for the retention piece, too. The physicians who work here are huge, in sharing that message."
In the meantime, hospitals are also considering how adept physician prospects are at using technologies such as electronic medical records and social media, Stone says. They also question their motives in hiring. Hospitals and physician groups are asking themselves these questions: Do we want the physician who's good with a robot? And do we really want a specialist just because the nearby hospital brought one on board?
"We see a lot of competition among hospitals and physician groups to offer the best quality and best variety of services," Stone adds. "I can't tell you how many times across the country a hospital recruited a urologist after another hospital recruited a urologist, or went to buy a robot after another hospital got one, while the patient population may not support two urologists or robots."
"It's a competitive dynamic that drives the recruitment effort, resulting in lengthy and expensive searches," Stone says. "Difficult searches vary from specialty to specialty. Certain searches are always difficult because of overall shortages."
At the same time, employers hurt only themselves by limiting how they carry out hiring searches, Stone says. "I think, unfortunately, employers put up walls and road blocks based on parameters they define at the outset of the search," he adds. Those parameters could be age or training, or other factors.
Stone says that hospitals also may not prepare themselves adequately in the hiring process, whether it's failure to properly plan interviews or draw up a contract.
As physicians consider their prospective employers, they will certainly expect slightly higher salaries this year than in 2012. Budgeted salary increases have risen 2.6% this year, according to the Hay Group's 2012 Physician Compensation Survey. That compares to a 2.5% increase from 2011 to 2012. Hay Group is a global management-consulting firm that works with leaders to transform strategy into reality.
Generally, physician pay increases will continue, with shrinking labor pools, says Jim Otto, senior principal at the Hay Group, and a leader of the company's healthcare executive compensation practice. But Otto doesn't expect extravagant pay increases, not by a long shot.
"Healthcare organizations and physician groups are dealing with shrinking revenues and increasing demands," says Otto. "How you deal with that is by providing more efficiency. You are going to see continued increases but you are not going to see a spike in primary care salaries."
The major focus, to no one's surprise, is on primary care physicians, Otto says. Those employed by hospitals can expect a 2% salary increase in 2013, while group-based primary care physicians can expect a 3% salary hike. That is compared to an actual increase of 5% in 2012 for group-based primary care physicians, and a 2% salary increase for hospital-based primary care physicians, he says.
"The hospitals are saying, 'we're not going to try to pay what a private practice does' and the reality is that there are benefits to being hospital employed; you have more control over your life than in private practice," Otto adds.
As a physician recruiter, Stone also sees primary care as "the main issue for most employers." While his firm works on hundreds of recruiting opportunities at a time, at least half of those involve primary care and internal medicine, he says. "That's a lot, considering the breadth of specialties there are. I don't think the competition for (primary care) is going away," Stone says.
"Everything within the context of healthcare is going to be dependent upon enough primary care providers or physician extenders to coordinate care," Stone says. Ultimately, those physicians who are able to fall in line with organizational objectives are likely to make more. Those unable to do so are likely to make less."
(A HealthLeaders Media Webcast, Recruiting and Retaining the Right Physicians for the Post-Reform Era is slated for Friday, March 22, with Jim Stone, president of The Medicus Firm, and Floyd Wilson, Jr, executive VP of marketing, physician relations and community outreach at Metro Health System in Wyoming, MI.)
Motivated by improved efficiencies and monetary incentives, healthcare is migrating to electronic health records. While this solves the issue of physicians' sloppy handwriting on paper, and creates a host of opportunities for the digitized data, it is creating a new set of challenges.
Experts are examining what doctors are entering into the EHRs, what they meant to enter, and how the information is translated. What they are finding is that plenty of mistakes are making their way into the clinical documentation process, never mind outright abuses.
"Accuracy and the quality of clinical documentation is an issue," Michelle Dougherty, MA, RHIA, CHP, director of research and development for the Chicago-based American Health Information Management Association, told me. "There's a concern about significantly compromised information captured in the EHRs. There's a lot of redundancy in the process." AHIMA represents 67,000 health information management professionals.
"As more and more organizations have only electronic medical records, how they were created and maintained is coming into question," Dougherty says. "There has to be an infrastructure that shows how the information is handled through the lifecycle of the records, that there was proper authentication, and that it was preserved without alteration." Assurances need to be built into the process to track the authenticity of authorship for any notes entered in documentation.
I spoke with Dougherty recently in the wake of her testimony this month before the HIT Policy Committee's Meaningful Use Workgroup and Certification and Adoption Workgroup, which held a hearing on Stage 3issues in Virginia. The Health HIT Policy committee makes recommendations to the National Coordinator for Health HIT on a policy framework for the development and adoption of a nationwide health information infrastructure.
While the government is starting to think about Stage 3, it hasn't yet begun Stage 2 of Meaningful Use, which starts next year. And although Stage 3 will not go into effect until 2016, the government has already released preliminary recommendations for its requirements. The HITECH portion of the American Recovery and Reinvestment Act (ARRA) of 2009 specifically mandates that incentives should be given to Medicare and Medicaid providers not for EHR adoption, but for "meaningful use" of EHRs.
In July of 2010 and August 2012, HHS released that program's final rule defining Stage 1 and Stage 2 Meaningful Use. The government states it is "strongly signaling" that that the bar for what constitutes Meaningful Use would be raised in subsequent stages in order to improve advanced care processes and health outcomes.
While EHR use is increasing dramatically, there are many flaws that must be overcome, especially, day-to-day sloppiness in use of records. Doctors and other providers are "cutting and pasting" information haphazardly to improve EHR efficiency, but their quick actions are likely to be detrimental to overall recordkeeping and patient care in the long run.
In addition, physicians are using dictation tools that are eliminating the traditional "editing" process of their work, which results in errors, Dougherty says.
Dougherty wasn't alone in her concerns about the EHRs among those who testified before the HIT committee. "All too often a patient's medical information is inconsistently stored—many times in multiple locations, within disparate systems that are not interoperable," Rosemary Kennedy, PhD, MBA, RN, FAAN, VP for health information technology, the National Quality Forum, told the committee.
Some day-to-day miscues are troubling. But large and significant alleged abuses related to EHRs are even more so. Dougherty referred to a report by Center for Public Integrity that found "thousands of doctors and other medical professionals have steadily billed higher rates" for treating older patients on Medicare in the past decade.
Those medical billing abuses were linked to improper use of EHR, Dougherty says. At least $11 billion or more were added to physicians' fees, according to the Center for Public Integrity.
"The Obama administration is forging ahead with a multi-billion dollar plan to shift from paper to electronic medical records, despite continuing concerns the program may be prompting some doctors and hospitals to improperly bill higher fees to Medicare," the center concluded.
The HIT committee's hearings are part of the government's effort to evaluate EHR issues, Dougherty says.
Dougherty told the Committee in a statement that there is inadequate attention being paid to the integrity of clinical documentation in EHR that could compromise the usefulness of records for patient care and quality reporting as well as business, compliance and legal issues.
"EHRs offer so much potential, but standards of practice haven't been adopted across all systems," Dougherty said in her statement. "Sometimes when a full medical record is needed, EHRs produce information that is redundant, difficult to read and not comprehensive."
Often, the problems have nothing to do with the evolving technology, but simply the process used by physicians and other healthcare providers in their utilization of EHRs. For instance, documentation produced by cutting and pasting information from previous patient visits "continues to be a significant problem" that creates "unnecessary redundancy and at times inaccurate information," Dougherty says.
"This can lead to clinicians checking off services they haven't performed or material being incorrectly copied and pasted," she told the committee. "If clinical documentation was wrong when it was used for billing or legal purposes, it was wrong when it was used by another clinician, researcher, public health authority or quality reporting agency."
Dougherty calls the improperly copied information as "cloned" material. That could include social, medical and family histories; visit/clinic notes, inpatient progress notes, consults, vital signs and reviews of physical exams. "We may need records [from] two years ago, but we need to know these records actually [reflect] what happened then and haven't been modified over time because of system updates," she told me.
Ivy Baer, senior director, regulatory and policy group at the Association of American Medical Colleges also expressed concerns about how the written record is being used in EMRs in testimony before the HIT committee. The AAMC represents all 141 accredited US and 17 accredited Canadian medical schools as well as 400 major teaching hospitals and health systems.
"Unlike a note written on paper, a note written in an EHR can be generated by using information that already has been recorded elsewhere," Baer told the committee. "The result can be a note that appears to be new and contemporaneous but actually is a combination of pre-existing material. Incorporating information that is not original to the author onto a note has the potential to jeopardize patient care and expose providers and/or institutions to liability."
Software advances and dictation tools also can lead to problems, Dougherty says.
Some software enables doctors, with a single mouse click, to check a box indicating that all body systems were examined and found to be normal, even if that isn't the case, she says. And the dictation tools force physicians into the role of an editor—a self-editor.
Transcribed reports are often the most frequently used and exchanged medical record documentation, according to Dougherty. AHIMA members report that errors in all voice recognition dictated reports include incorrect diagnoses, age and other demographic information or facility name, she says.
"We're hearing that this dictation is forcing physicians into an editor role and is resulting in many errors," Dougherty says. "In the old method, they used to hire transcriptionists, dictate it and then provide the review. What is lost now is any type of editor."
The comments illustrate that as the government moves through its stages of Meaningful Use, the picture of EHRs is still blurry and must be resolved to ensure proper patient care and monetary rewards that are tied to quality.
"The importance of accurate information and documentation in EHR systems cannot be overstated," Dougherty stated.