Four years into an ACO pilot program, physicians at Catholic Health Initiatives are easing into a new era of healthcare that requires more care coordination.
When one of the largest integrated healthcare systems in the country issues a stamp of success on a pilot project, it's a good idea to pay attention, especially if that success is rooted in one of the health models that leaders are counting on to transition from volume to value.
The accountable care organization as a model of care has its supporters and detractors. It's supposed accomplish the triple aim of healthcare, but the results from Medicare's 2012 Pioneer ACO program are mixed.
On one hand, nine out of the original 32 ACOs shared in savings; 19 reported no savings or losses. On the other hand, nine ACOS left the program. Two departed completely while seven transitioned to the similar, but less-stringent Medicare Shared Savings Program ACO arrangement.
CHI was not part of the Medicare Pioneer ACO group, but rolled out its own ACO pilot in three markets in 2010 anyway to test how well it was prepared for population health. The health system has since enrolled five of its six of its organizations into the MSSP ACO program, but early lessons from its own pilot are helping population health efforts for other patients now.
During its pilot project, CHI focused its efforts on coordinating care and payment for Medicare patients with one of four chronic diseases: coronary artery disease, chronic obstructive pulmonary disease, congestive heart failure, and pneumonia.
The ACO Pilot
Barry Hoover, MD, CHIS's executive sponsor of one of the pilot ACO sites in Nebraska reported reduced readmissions and improved outcomes. Hoover is also vice president and chief medical officer of The Physician Network, a subsidiary of CHI. The Physician Network includes more than 50 locations with PCPs, specialists, as well as urgent care providers.
Hoover maintains that the early ACO pilot helped inform the organization's next step of treating its 20,000 employees in Nebraska as a defined population.
"Employees came after the success of pilot, definitely," says Hoover. "There was a change in philosophy from an illness model to a wellness model."
Health coaches emerged as a success key from the ACO pilots and Hoover incorporated the coaches into the employee model. The health coaches are RNs and available to employees for help on typical wellness initiatives such as encouraging smoking cessation, weight management, and stress reduction.
But the coaches are not passive wellness caretakers, they are an active part of the care team, which Hoover says physicians learned to appreciate after initial skepticism about including another provider in a patient's treatment.
"There were concerns from doctors about sharing responsibility, and it took a while to earn trust, build relationships, and define roles and build team based care," he says. "Doctors learned quickly that health coaching skills are around patient engagement. It's time consuming to visit with patient to find out what they're motivated to work on. Once docs saw patients were benefitting, it was an easy sell."
At the outset of the pilot in Nebraska, Hoover says there were only two health coaches, but requests from physicians increased that to well over two dozen across Nebraska and parts of Iowa. Hoover reasons that investing in health coaches is the right thing to do because patient engagement is going to be a primary driver of successfully transitioning into a healthcare system that values wellness over illness.
The Value of Coaches
"Physicians manage about 20% of a patient's health, the rest is really determined by a patient's lifestyle," he says, adding coaches are trained to get patients to claim more ownership over their health. He points out that as a doctor, he can tell a patient to "lose 30 pounds," but knows that advice may be taken to heart only for the duration of the visit. A health coach has a different approach, an admittedly better one.
"A true skill set of health coaches is motivational interviewing," he says. "Let's say you have a patient who is 30 pounds overweight, smokes, and leads a sedentary lifestyle. What health coaches are skilled at doing is saying, 'Which of these areas would you like to approach now? It's identifying where the patient is motivated to do something now. They feel like it's a collaborative relationship."
Weight management is one of two focus areas Hoover says is most important among employees and patients. The other disease Hoovers says is important to get under control is diabetes.
As far as evidence pointing to the benefit of health coaching, Hoover uses an internal study done by senior year nursing students from the University of Nebraska Medical Center. They specifically wanted to find out the effects of having health coaches for patients who either had hypertension, diabetes, or needed to lose weight.
The study analyzed 80 patients, 40 who had a health coach and 40 who did not. Patients with hypertension had more progression and less regression than those without a health coach. Ninety percent of patients with a health coach improved managing their hypertension and only 10% regressed. The percentage of patients who regressed jumped to 30% without a health coach.
The findings were similar for patients with diabetes: patients who had a health coach reported progress 61% of the time; while only 30% improved when patients had no health coach. Weight management results were the same, too. Health coaches helped patients reduce their BMI and according to Hoover, maintain it, too.
Hoover also says they identify and connect with employees who are at high risk of developing chronic conditions.
"We are reaching out in a very proactive way to assist patients with diabetes, asthma, COPD, weight management, smoking cessation," says Hoover. We're learning to identify risk factors around heart failure, because heart failure patients are likely to be readmission."
Cost is Only One Factor
A side benefit of testing population health with employees is the residual effect on morale. That's not been studied yet, however Hoover says the job satisfaction rate among the health coaches is very high.
As for bending the cost curve for caring for these patients, Hoover says the expenses are not as much as originally thought and patient satisfaction is steady.
"Across our clinics, our patient satisfaction scores have been continued to be high; they haven't decreased," he says, cautiously pointing out that cost is not the only factor to consider when measuring success.
"My compass point is around the triple aim – improving the help of populations, in this case, our covered employees and their family members, decreasing per capita costs, and improving patient satisfaction. The goal is to branch out for other populations, whether it's in an ACO model, or state Medicaid model, or large employers."
New models of collaboration (even among competitors) are producing shorter boarding times and fewer instances of aggressive behavior in the emergency department.
This article appears in the May 2014 issue of HealthLeaders magazine.
Three prominent scars on the forehead and cheeks of Virginia State Sen. Creigh Deeds are a recent and visible reminder that hospitals and health systems are straining to meet the mental health needs of patients across the country on a daily basis. Last November, Deeds' 24-year-old son, Austin "Gus" Deeds, attacked his father with a knife, slashing his head and torso, then killed himself—all within 24 hours of being released from a local emergency room because there wasn't a psychiatric bed available.
Deeds had taken his son, who was diagnosed as bipolar in 2011, to a hospital in November 2013, because of concerns about erratic behavior. With an emergency custody order in hand, Deeds as able to have his son in emergency care for six hours while hospital officials searched for a psychiatric inpatient bed. An appropriate bed couldn't be found within the time frame, so they returned home to what would be Gus Deeds' last night alive and the beginning of his father's fight for more mental health resources in Virginia's emergency rooms.
Not every psychiatric patient who is released too early from an ED commits violence or suicide, but nearly every ED in the country is struggling with the same issues: more psychiatric patients and not enough resources to properly treat them. In the face of this challenge, hospitals and health systems have had to form partnerships across departments and, in some cases, across town with competitors.
Success key No. 1: Collaboration among competitors
More and more patients with behavioral and mental health issues are showing up in EDs across the country because of the reductions in the number of psychiatric beds, mental health funding, and psychiatrists.
The National Alliance on Mental Illness, one of the largest nonprofit advocacy groups for people living with mental illness, estimates more than half of the states cut mental health budgets by $1.6 billion between 2009 and 2012. The Treatment Advocacy Center, another nonprofit aimed at helping mentally ill patients, released a 2012 study showing a 14% decrease in state-funded psychiatric beds from 2005 to 2010.
But as most states found out quickly, fewer beds doesn't mean fewer patients. Instead it means crowded EDs, says Jeff Klingler, CEO of the Central Ohio Hospital Council, which spearheaded an effort six years ago in central Ohio to coordinate psychiatric bed availability among competing hospitals.
"The situation had gotten so dire in 2008 that this was not an issue that a single institution was going to be able to manage by themselves," Klingler says. At the time, psychiatric patients were being boarded in hospital EDs for up to six days before a bed became available. "That's not good for the patients; that's not good for the hospital."
In May 2008, three large hospital systems serving the Columbus area joined together to form the Franklin County Mental Health Collaborative: Mount Carmel Health, a four-hospital system that is part of CHE-Trinity; OhioHealth, a nine-hospital nonprofit health system; and The Ohio State University Wexner Medical System, an academic medical center.
The purpose of the collaborative was to find psychiatric inpatient beds for the patients who were showing up in the hospitals' EDs no matter where the patient went for care initially.
"The hospitals agreed early on that the discussion was about the patients," says Klingler. "It was about getting the patient in the right bed at the right time, and we were able to kind of put aside all of the competitive stuff and really focus on getting a patient into a bed as quickly as we could."
After nearly a year of talks, the three health systems developed a simple protocol: The patient who has been waiting the longest for a psychiatric inpatient bed gets the first one available, no matter where it is located. If a patient is in a Mount Carmel ED, and an inpatient bed opens up at an OhioHealth hospital, the patient goes to OhioHealth.
"Right now the bed board is all about getting a patient into the bed quickly," says Klinger, who is in charge of managing the online bed board hospitals log in to daily to input and monitor the county's psychiatric patient load in the EDs.
The database has provided relief. In May 2009, there were 400 psychiatric patients in Franklin County EDs, when wait times for a bed could number up to six days. A year later in May 2010, the wait time had fallen to 30 hours, and by October 2013, the average length of stay for a psychiatric patient needing an inpatient bed was down to 19 hours despite an increase the number of psychiatric patients seeking care in Franklin County EDs.
Participation among providers in the Franklin County Mental Health Collaborative has grown, too. When it began, only three hospital systems participated; now, Klingler says, every organization with psychiatric inpatient beds is a using the bed board.
"Before we started this process, the hospitals were calling each other saying, 'Hey I've got so many patients in my ED; do you have any beds open?' And the other hospital would say, 'No, I don't have any beds open,' when maybe they did have a couple of beds open but they kept them for themselves," he says. "Now, it's very transparent, and they're more trusting."
Success key No. 2: Regional psychiatric emergency service
Coordinating the emergency care of psychiatric patients among hospitals has also caught on in California's Alameda County, an 800-square-mile expanse that includes Berkeley, Oakland, and Fremont.
Scott Zeller, MD, chief of psychiatric emergency services for Alameda Health System, an integrated public health system based in the city of Alameda, says that routing psychiatric patients to a dedicated regional facility reduces the length of stay in the ED, and helps stabilize patients who are in a mental health crisis.
"The key idea is that there is a lot that can be done for a psychiatric patient in an emergency situation in the first 24 hours, and in too many places around the country, they're just sitting, waiting, when hospitals could probably have most of them much improved and on their way back home or somewhere less restrictive than an ER," says Zeller, who is also past president of the American Association for Emergency Psychiatry.
At AHS, Zeller developed what he calls the Alameda Model. In this approach, psychiatric patients are transferred from general hospital EDs to a regional psychiatric emergency service facility, which can receive direct transfers from other hospital EDs and assess and treat patients who are presenting with mental health emergencies. In this case, the PES is the John George Psychiatric Hospital, an 80-bed AHS facility in San Leandro.
Fewer than 10 of California's 58 counties use the PES model, something both Zeller and the California Hospital Association are hoping will change with the release of Zeller's 2013 study of the Alameda Model, published in the Western Journal of Emergency Medicine.
"This is a model that's evolved over several years," says Zeller, who wanted to prove that what AHS was doing as a PES would work for even the more difficult psychiatric patient emergencies, such as when police have an adult under an involuntary mental health hold. "We decided to set up a study and see if our assumptions were correct."
Zeller says 90% of psychiatric patients come into the John George Psychiatric Hospital because of an involuntary hold by law enforcement. In California, this type of psychiatric hold is called a 5150, which is short for the state code governing the treatment of psychiatric patients. Hold times also vary from state to state; in California, the limit is 72 hours. Ambulance crew members are the first point of triage for these patients (police who initiate this order call an ambulance for transport; they do not bring in patients) and will determine a patient's medical stability. If the patient needs medical care first, the ambulance will take the patient to one of the county's 11 EDs. If patients are considered to be medically stable, then they are taken to John George Psychiatric Hospital.
In the study, Zeller tracked the boarding times for psychiatric patients who were under an involuntary mental health hold. The study took place over 30 days and tracked patients from five area hospitals. He wanted to measure the difference in how long a patient was boarded. The comparison data he used was from a 2012 CHA study he also worked on that showed the average boarding time of these psychiatric patients as 10 hours.
After tracking boarding times for 30 days, Zeller found that the average boarding time in the Alameda Model was less than two hours (107.6 minutes). Zeller also says he found out something else equally important from the study's results: Only 24.8% of patients actually needed an inpatient bed. "The one thing that has been missing over the concern of a dwindling number of inpatient beds is any alternative to inpatient beds," says Zeller. "All too often the default solution for every mental health problem is to admit a patient to the hospital first and start treatment later. It doesn't make any sense to me. Not nearly enough places are considering trying to do urgent treatment on arrival, seeing what they can do in those first 24 hours when so many patients can have their urgent symptoms relieved."
Success key No. 3: Telepsychiatry on demand
Seton Healthcare Family in Austin, Texas, an 11-hospital system that is part of Ascension Health, is trying to make a dent in helping psychiatric patients within the first 24 hours of their presenting in an emergency room.
It just opened a new stand-alone psychiatric ED at its downtown Austin location, University Medical Center Brackenridge.
"This is the Seton hospital which bears the brunt of psychiatric patients in the ED," says Kari Wolf, MD, vice president of medical affairs for psychiatry, who is overseeing the psychiatric ED. "It's located close to the local mental health center, and there's a large homeless population in the geographic area."
Wolf says Seton decided to include a 24/7 telemedicine suite in the new psych ED. She expects it to reduce the boarding time of psychiatric patients, inpatient admissions, and ED costs.
"We spend $30,000 a month at University Medical Center Brackenridge on sitters in the ED," says Wolf. "We anticipate that will be pretty much gone with new psychiatric ED because we're not going to need them. It's a safer environment."
Wolf says Seton began using telemedicine in its Brackenridge ED and then spread it to its more outlying hospitals in 2012.
"If someone gets brought in, we were able to get a psychiatric assessment right away and some were able to go home," says Wolf. "Before, if they came in Friday night, they would have had to wait until Monday morning for an assessment. Other times, we were able to treat people, so instead of waiting until Monday morning to start treatment, they could start Friday night."
The on-demand telepsychiatry even helped patients who were going to be admitted and were waiting for a bed, she says, because beginning treatment reduced their anxiety, which can be compounded by the chaos of an ED.
Success key No. 4: Behavioral emergency response team
Another aspect of treating psychiatric patients in regular EDs is the danger they can pose to staff. Furniture, IV poles, and trashcans that are typical in an ED room can become weapons if a patient is in an elevated state of agitation.
At SSM Health Care–St. Louis, a seven-hospital system, a new emergency response process is in place because of the results of a pilot program called BERT, for behavioral emergency response team.
BERT is a three-person team that is paged when a psychiatric patient begins to show verbal signs of anxiety.
"It has to do with vocal tones, pacing, shifting about, being more demanding," says Lawrence Kuhn, MD, medical director for behavioral health at SSM. "These are early signs of anxiety and frustration. If you address patients at these early stages, you can usually find out what's going on and they will respond and let you know, and that's the key to this."
The BERT protocol began at SSM St. Mary's Health Center in Richmond Heights, Mo., a 525-bed hospital, in August 2012.
"Before BERT, everything had been done at the leadership level," says Sarah Lohse, RN, BSN, director of behavioral health services for SSM St. Mary's. "What's great about BERT is that it is owned by the employees and the staff. The people who respond are not leadership. They are the frontline experts."
Each BERT team includes a charge nurse, house supervisor, and security officer. Each person has a role, says Lohse. The charge nurse takes the lead, the house supervisor determines what resources are needed, and the security officer tries to build rapport.
"Security is stationed in our EDs so a lot of patients know security," says Lohse. "They're not necessarily there as a use of force; they're there as a use of support. If things do escalate and it becomes a security issue, then we have a security officer there."
Since implementing BERT, there has been a decrease in Code Strongs, the code that indicates a psychiatric patient's behavior has escalated and physical intervention is needed, often the use of restraints. Lohse calls the decrease one of the "biggest successes" of BERT.
"BERT is for when someone is verbal; we have a different code for when someone is physical," says Lohse. "The Code Strong was originally the only method we had for when someone was escalated. BERT has been added as an additional layer to encourage people to call earlier. We want to continue to see Code Strong declining and BERT increasing."
From August 2012 to September 2013, just a little over a year, 209 calls for help with a psychiatric patient in the ED have gone out at SSM St. Mary's; of those 172 were BERT and 37 were Code Strong.
Kuhn says there's been another benefit, too.
"Overall, I think it's made a difference in the way many of the people in the ED—as well as on the medical floors—see psychiatry," he says. "It's improved the way in which our staffs are talking with one another. I've been asked to go to a medical floor, if they have a problem patient, and do some consultative work with the staff as to how to manage them. I think it's improved the overall profile of psychiatry within the hospitals."
Reprint HLR0514-6
This article appears in the May 2014 issue of HealthLeaders magazine.
Physician leadership expertise doesn't have to come from a consulting firm. A large nonprofit health system in the Pacific Northwest has developed its own leadership academy, which is saving money and providing physicians with problem-solving tools and skills.
Like many other health systems and hospitals, Legacy Health, one of the largest health systems in metropolitan Portland, OR, looked to outside help provide leadership development opportunities for its employed physicians. With six hospitals, a medical group, hospice, and other health clinics, the large system needed a robust program that could handle volume with ease.
After weighing the benefits and costs, Legacy Health decided instead to launch its own leadership initiative in 2009, called the Physician Leadership Academy.
After five years, Lisa Goren, co-director of the academy and program director for physician alignment & engagement, says Legacy Health has saved money and provided physicians with crucial training they don't get in medical school by building its leadership program internally.
"We estimate savings of at least $500,000 by offering it in-house," says Goren. "When I look at doctors, most don't have a first job until 26, then they get so much medical training in residency that by the time they're in their early 30s, patients ask, 'Why are they like that?' We have to take it into our own hands to mold the rest of their professional development. It was an obligation, but now it's a necessity."
Legacy's Physician Leadership Academy offers physicians free continuing medical education credits to its physicians as a way to encourage participation in leadership classes.
Goren says physicians, by nature, are eager students, and by offering free, traditional CME classes, she and Physician Leadership Academy co-director, Melinda Muller, MD, clinical vice president for primary care, tap into what the doctors want to learn through the formal evaluations that physicians must fill out to earn CME credit.
That philosophy reminds me of the childrearing advice known as Grandma's Rule: Do what you need to do first, then you get to do what you want.
Muller says that initially, the leadership classes were based on the programs she attended through various societies, organizations, and conferences. At first, the classes were basic. For example, early healthcare finance classes were along the lines of "how-to-read-a-spreadsheet."
But those classes have since evolved, because physicians are telling Muller and Goren that they want to learn more. "Now we talk about capitalization, and it is one of the highest-rated classes," says Muller.
3 Levels of Leadership Courses The first level of Legacy's Physician Leadership Academy is sort of like a starter course for leaders, and helps identify potential leaders for the future.
There are also two other levels within Legacy's Physician Leadership Academy. There is what Muller and Goren call an "emerging leadership" class, a one-day event offered only to employed physicians at Legacy. It's a big picture overview of how to lead at Legacy. It's offered twice a year, and is geared toward a smaller group class, with room for about 10 physicians.
Muller says within primary care, she's seen physicians go through the emerging leadership class go on to become medical directors.
"I can see the growth in how they lead, as their supervisor," says Muller. "The number of people I'm getting notified about getting nominated to [this class] is also increasing. In our system all of our physician leaders are paired with an administrator and interactions are much more fruitful and constructive. I can see culture changing."
The third level of classes is the deepest dive, called Leadership Foundations. It's a two-and-a-half day program, and the participants have to be in a formal leadership position at Legacy Health. This is the class where physicians leadership skills are put to the test, says Muller.
"One of our leaders who just went through the Foundations course is responsible for surgical site infections, and was struggling to push things to the next level," says Muller. "He felt that the skills he learned helped him look at the problem differently. He looked at the process of patient flow and staff… made changes in both, which increased throughput. We've seen an improvement in quality. Is it all physician leadership? No, but it is part of it."
Muller and Goren both use anecdotes from physicians who attend the leadership academy to show improvement. It's difficult to empirically tie outputs to the soft, but important skill of physician leadership. A 2011 study attempted to show the relationship, but the quality indicators the study relied on were U.S. News & World Report rankings, which are not widely accepted as healthcare industry standard for quality.
Expansion
However, Muller believes that Legacy's readiness to become certified as an NCQA patient-centered medical home would not have happened without Legacy's Physician Leadership Academy. Legacy has applied for, and believes it will attain this year, PCMH status for all 23 of its primary care clinics. It piloted the medical home model at five sites from 2007–2010. That number quickly grew to 18 by 2011.
"Once we got the model down, figured out what it was, we were able to roll it out to other sites," she says. "As we've opened new clinics, we've opened them in the model. Part of the reason we've been able to push it quickly is because of the training and coaching.
A key ingredient to Legacy Health's Physician Leadership Academy is that the classes are taught by leaders of the organization. The CEO teaches, but more than that, he leads by example, which underscores the value an organization places on leadership attributes. Developing physician leaders, or any leader, is more than throwing a few buzzwords around in a memo or meeting. Real leadership skills are learned over time, and by example.
Much attention has been paid to the disproportionate balance of the supply and demand of PCPs. Fewer PCPs also means fewer geriatricians, for which there is already acute demand.
The shortage of primary care physicians around the country affects more than run-of-the-mill patients who endure longer wait times and shorter doctor visits. It also affects a patients who are sick, frail, and may be at the end of their lives—the elderly. That's because the number of geriatricians, PCPs with one to two years of additional training in elder care, is also diminishing.
Caring for an aging patient presents unique challenges for physicians even when the patient is relatively healthy. And when an elderly patient has dementia, their individual needs are more acute, and they need specialized a care beyond what a PCP can give.
"Dementia is not treated in a holistic manner," says Kyle Allen, DO, vice president for clinical integration and medical director for geriatric medicine and the lifelong health division for Newport News, VA–based Riverside Health System made up of seven hospitals, a medical group, and a full continuum of care for aging patients. "Geriatricians who've had the training understand that this is a family illness. This is not just an individual."
The American Geriatrics Society estimates that there will need to be 30,000 geriatricians by 2030, that's when one in five Americans will be eligible for Medicare. There are currently 7,500 geriatricians in the U.S. The gap is so wide, that it casts a pall on the quality of care that could be available in the future.
Dementia is Misunderstood There are several types of dementia, but Alzheimer's is the most common and arguably the most well-known type of dementia. And though dementia isn't a sign of aging, the elderly are most at-risk for developing it.
Alzheimer's received a lot of attention earlier this year when a 2014 study published in the New England Journal of Medicine named it as possibly the third leading cause of death behind cancer. But it's not enough attention, says Evelyn Granieri, MD, MPH, chief of the division of geriatric medicine and aging at New York-Presbyterian/The Allen Hospital.
"AIDS, cancer, breast cancer, colon cancer, they all have their celebrity spokespeople," she says. "There's no one really willing to stand up in popular culture and say, 'Look, this is a reality of life. If you're lucky enough to turn 85, you have at least a 65% chance of having dementia.' "
Granieri cares for the frailest of the frail at a 23-bed inpatient site that's part of The Allen Hospital in New York City. She only has about 300 patients, and they are all over 70 years of age with significant markers of frailty. She says the most consistent marker is a cognitive disorder, such as dementia.
Granieri cares for this population with an interdisciplinary team that is made up social workers, nurse practitioners, and five fellowship-trained, board-certified geriatricians. She laments the current and projected shortage of geriatricians because she believes that interferes with delivering quality care.
"Truthfully, there are so few geriatricians and even fewer geriatric psychiatrists in this country that it becomes problematic to deliver the kind of wholesale care that this coming epidemic of dementia requires," says Granieri.
Granieri identifies four barriers to caring for patients with dementia:
Low reimbursement
Societal dislike
Diminished respect for aging
Training
Medicare does reimburse for caring for the elderly, but the rates don't accurately capture the time it takes to see a patient with dementia. Depending on the stage of Alzheimer's or level of dementia, a routine office visit can take twice as long because the patient may need help getting onto an exam table, undressing, or just an extra dose of patience from the physician.
Training physicians
Allen says that at Riverside, he began integrating dementia care into the systems' medical group practices in 2011 because that's where people go. An accurate diagnosis of dementia needs a geriatrician's expertise, but often, the initial touch point is with the PCP. Allen is a trained geriatrician and created a task force to help physicians better understand dementia and the patients who have it.
"Physicians don't recognize it, or they treat dementia in a very nihilistic way," says Allen. What I mean by that is an attitude of, 'There's nothing I can do about it,' or 'I feel inept to do it,' or 'I don't have the time, I don't have the resources. This really isn't medical care, this is more social care.' " says Allen.
A first step for physicians is to use a standardized memory loss screening tool for patients. Granieri agrees with this approach, as well, and says it can be a very simple, five-minute test. It won't diagnose dementia, but it will set a baseline of memory loss for patients that physicians can measure and track.
Treating Dementia with Dignity
The amount of care a patient with dementia requires is significant and increases exponentially as the cognitive decline increases.
Kelly Blair, a 50-year old nurse in Arlington, Texas, cares for her 81-year old father, William, who has Lewy Body dementia, a common form of dementia, recently notable because it is the same disease that long-time radio personality Casey Kasem has.
Blair's father was diagnosed at age 73 and is now in the late stages of dementia. The first doctor he saw was a neurologist who suggested returning a year later. Blair's medical education and background pointed her to keep looking for another provider, and she ended up taking her dad to UT Southwestern Medical Center in Dallas, which has a memory clinic.
Blair says physicians at UTSW help coordinate care for her father when he's had to go to the hospital, which can be full of landmines for patients with dementia. Unfamiliar environments increase anxiety which can lead to difficulty care for minor issues let alone the main problem that landed the patient in the hospital in the first place, which in Blair's father case, it was cracked hip from falling out of bed.
"It would change his whole mental status if one of us was not with him," she says. "In the hospital, they can't do one-on-one. You can put him close to the nurse's desk, but that's about the best they can do."
Subsequent trips to the hospital for UTIs got easier when they found a hospital whose nurses were willing to care not only for her father, but her mother.
"They were great," says Blair, "They made arrangements for my mom to sleep in the room with my dad. They gave her a roll-away bed, they made sure she had meals. She was helping them out—when he tried to get out of bed, she could talk him back into bed. Not all facilities are willing to do that."
Geriatricians who are on the front-lines of caring for the elderly see what's coming, and the challenges associated with developing a care path for aging patients. Declining numbers of geriatricians likely portend a decline in quality of care, especially without a team-based approach at the practice level.
"It's not about specialist consults," says Allen. "It's about getting the physicians, nursing, social workers, the families… and working together as a team around these illnesses, and honoring the patients' wishes. It's burdening our society, and more importantly people are not getting the care they deserve."
From its virtual care center now under construction, the Missouri-based healthcare system says it will be able to extend telehealth services to patients across the entirety of its 42-hospital system 24/7 through audio, video, and data connections.
If there was any doubt that telemedicine could be the next big thing in healthcare, St. Louis-based Mercy erased it this week with an announcement that it will build a $50 million virtual care center in the nearby town of Chesterfield, MO.
The 42-hospital system, which bills itself as the nation's sixth largest Catholic healthcare system, broke ground this week on a four-story, 120,000 square foot telemedicine mega-building that, when finished, will be the command center of the health system's already large telehealth program.
"The center will bring together the nation's best telehealth professionals to reach more patients, develop more telemedicine services, and improve how we deliver virtual care through education and innovation," said Lynn Britton, Mercy's president and CEO, in a statement.
Mercy's journey into providing telemedicine began nine years ago, says Tom Hale, MD, executive medical director for the organization's telehealth services. The provider has acute and specialty hospitals in four states: Missouri, Kansas, Oklahoma, and Arkansas. It offers 75 different telemedicine services to more than 3 million patients, and as Hale told me, Mercy's telemedicine component of care is only expected to grow.
Investing in Telemedicine
Hale says that in addition to the many telemedicine services Mercy provides, even more are being piloted.
"Our biggest effort is with pediatric psychiatry," says Hale. He illustrates his point: "We have a pediatric psychiatrist out of Springfield. There is a family who takes care of seven foster children, and all seven kids had to be treated. It was a two-day event to care for all seven foster kids. Can you imagine?"
Those kids, says Hale, can now be treated over the course of hours, not days. That access to care, at the right place, and the right time, is why telemedicine holds so much promise.
Mercy's virtual care center is scheduled to be complete in 2015 and to be able to house 300 physicians, nurses, specialists, and IT staff. From the virtual care center, which hale calls the "brain" of Mercy's telemedicine operations, clinical staff will be able to extend care to patients 24/7 through audio, video, and data connections across all of the organization's locations.
Telemedicine is one of the fastest growing segments of patient care. It is especially good for connecting physicians to care for patients in rural areas, where there are shortages of nearly every specialty, including primary care physicians. It also helps to alleviate shortages of specialists, no matter where patients live.
Telepsychiatry, for example, is one way that hospitals are dealing with not only the need for mental health providers for children, but also the rise in psych patients in emergency departments. With the click of a button, a remote psychiatrist can be available in an Austin, Texas, emergency room.
Hale hopes Mercy will eventually get to that point, too. "Telepsychiatry would be helpful," he says. "With 50% of our business being in rural areas, we have a significant problem getting behavioral health providers."
Telemedicine's Reimbursement Challenge
Despite Mercy's sunny outlook on the future of telemedicine as a growing component of how it cares for patients, Hale is realistic about the payment barriers that exist.
"We've been able to demonstrate effective care, but we haven't moved the needle with payers, nationally," says Hale. "We have a lot of contracts with local insurers and directly with employers. We have 300,000 patients who are in a gain-share or shared savings model, so locally we've made an impact, but not nationally."
Reimbursement for telemedicine services varies from payer to payer and from state to state. Some states have tried to push through laws mandating that payers treat a telemedicine visit just like an office visit, but so far, the payment issue is at best a patchwork.
Hale says the reimbursement challenges are likely to remain until healthcare has made a full transition from volume to value. "If payment methodologies were different, telemedicine would be exploding,"
"Fee-for-service is a 'feed-the-beast model'; population health management is a 'grow the village' model. What we will see over time is the breaking of that barrier," he says.
Virtual Doc Visits Under Fire
Yet another challenge to telemedicine is the concern that a virtual visit lacks the same quality as an in-person visit. Really? Have you been to the doctor lately? A quick 10–15 minute visit isn't what I, or most physicians, for that matter consider high quality care.
For organizations leery of taking the plunge into telemedicine for fear that patients won't like it, Hale says relax.
"In my experience, patients are very accepting," says Hale. But he cautions that there is a need to train physicians on making sure that the patient's experience is good.
"We teach doctors how to best use the technology and manipulate it," Hale says. "The whole key is training. Physicians need to understand that this is a relationship, and once they're reminded this is not a video visit, but a patient visit, it becomes better after about four to five visits."
Hale is hopeful that telemedicine is a ticket out the fee-for-service model, but he doesn't think that it will lead to "Stepford doctors practicing medicine over television."
"I think that telemedicine as a whole is augmentation not replacement," he says. "It will change it in a fashion that will allow for much greater access to care. This is a possible solution to our quality and cost issues, but only if it's used to maintain the relationship between caregivers and patients by providing access to care that they didn't have before."
An ambitious project by the Robert Wood Johnson Foundation has been able to make the connection between public reporting and healthcare quality improvement in specific communities.
Organizations that rate doctors and hospitals want to believe that the public ratings, rankings, grades, and stars they issue help improve quality and safety as well as inform patients, but for the most part, those reports are mere snapshots in time and do not play a part in driving quality improvements inside the walls of a hospital.
"We love being recognized in the Top 100 hospitals," says Dan Varga, chief clinical officer and COO for Texas Health Resources, which has begun publishing its own quality and safety report for consumers and clinical staff.
"We love being recognized by The Joint Commission. We love having our Leapfrog scores rank up near the top in the [Dallas/Fort Worth] metroplex, etc., but it's not something we're sitting with our clinical leaders and saying, 'Okay, this is what we think the Leapfrog methodology is, or the Healthgrade's methodology is, let's try to get that fifth star this year.' "
Ouch.
An argument can be made that quality at hospitals is in fact rising because scorecards like Leapfrog's and The Joint Commission's Top Performer on Key Quality Measuresboth show gains in their individual indicators. But whether large-scale quality improvements can be directly linked to these national scorecards has yet to be demonstrated.
An ambitious project by the Robert Wood Johnson Foundation, however, has been able to make the connection between public reporting and quality in specific communities. Called Aligning Forces for Quality, the 10-year, $300 million project is focused on improving quality for patients, reducing racial disparities, and developing models of care.
Initially, the focus was on ratcheting up outcomes at physician offices, and included four pilot sites. There are now 16 sites in 14 states (two are in Ohio and Michigan), and hospitals are also included. One of the requirements of sites participating is that they begin measuring outcomes. Most sites use a mix of nationally recognized measures and those developed at the community level.
Additionally, the findings have to be publicly reported. Instead of comparing physicians to those that are in another state or halfway across the country, it makes more sense to look across the street, says Anne Weiss, team director and senior program officer at RWJF.
"Healthcare is local," says Weiss. "I think one of the things about doing something community-wide and joining forces is it sets a table for everyone else who is delivering care in the community."
Working Together in Wisconsin
The Wisconsin Collaborative for Healthcare Quality (WCHQ) is one of the 16 sites participating in the AF4Q. WCHQ was not developed specifically for the project, but its goals are the same: to improve healthcare quality in local communities by measuring outcomes and sharing them with payers, hospitals, health plans, and medical groups.
"The presence of the word 'collaborative' is not accidental," says Chris Queram, president and CEO of WCHQ. "It's a philosophy that collaboration around evidenced-based metrics that are validated, audited, and accepted, are an apples to apples comparison and drives improvement."
WCHQ began participating as an AF4Q site in 2007. It began developing metrics its members four years earlier in 2003. The first indicators were for diabetes care and management, and Queram says a workgroup met weekly putting in hours and hours of "sweat equity."
The goal was to use evidenced-based indicators accepted by clinicians that captured data for all patients, not just those enrolled in a commercial health plan or Medicare, which Queram says is a shortcoming of using CMS data to benchmark outcomes.
Inclusive Metrics, 'Irrespective of Payment Source' "To take nothing away from the good intentions of CMS, they only represent a subset of a practice," says Queram. "Medicare can be a stubborn set of the population where performance is hard to move. The strength of our measures is we take a lot of pride in building metrics inclusive of all patients irrespective of the payment source. It's represented in data we report, so interventions are holistic, directed at a single standard of care to improve care for all patients."
WCHQ's initial quality indicators for diabetes has grown to more than 30 for physician groups and five for hospitals.
Most of the physician indicators were developed by WCHQ, and includes screenings for breast and cervical cancers, tobacco use, osteoporosis, and others. Three of the five hospital indicators WCHQ uses were developed by the Society of Thoracic Surgeons (STS) and two were developed by the American College of Cardiology (ACC).
When physicians first began keeping track of their outcomes, Queram says they were surprised.
"We began to hear anecdotally that the conversation among the groups was beginning to change because there was data to show if performance matched perception," he says, adding that doctors were discovering they weren't as good as they thought. "They were then motivated to seek performance improvement."
Measureable Improvements
The gains made are traceable to beginning of the WCHQ's 2007 participation in the RWJF project. They're also publicly available in their report. Not only are patients (and other physician groups) able to see the performance of physicians, they can also compare it historically, without having to click to another screen. The data is side by side, year over year. That's missing from most other quality scorecards aimed at the consumer.
One of the biggest quality achievements WCQH points to is that 50% of primary care providers have improved in four diabetes-related quality measures within two years, as well as colorectal screen rates.
"We are confident in the gains made because we have rigorous data audit to ensure it is reliable," says Queram. "Participation is also completely voluntary, so we have to work very, very hard to have a value proposition that is useful to our organizations, and that hinges on the metrics we feed back to them for improvement."
Queram says 38 physician groups participate in the WCHQ representing about 60% of physicians licensed to practice in Wisconsin. The main metro areas are represented, and it's hoping to grow representation in the northern part of the state that is very rural. Queram also hopes more small to medium-sized primary care practices begin participating.
The collaboration happens informally, through information sharing among providers, but also formally. Six times a year, WCHQ hosts a one-day collaborative assembly that brings together consumer, administrative, clinical, and payer perspectives.
Tying Public Reporting to Quality
The big payoff for WCHQ was when the Medical College of Wisconsin studied diabetic patients who were seen in practices participating in WCHQ and found that public reporting on outcomes increased the likelihood a physician practice would implement interventions shown to be improving diabetes outcomes.
Three things to know this week: How much a physician earns is largely dependent on practice size and geographic location, quality reporting is expanding, and a new Tennessee law is tough on drug addicted mothers.
This week I've rounded up some news items that caught my eye because they illustrate some of the the quality reporting, financial, and legislative forces affecting physicians and their practices.
Hospital System Issues Texas-sized Quality Report—On Itself
In addition the new safety scores announced by the Leapfrog Group this week, Texas Health Resources, the nonprofit, faith-based hospital system in north Texas has unveiled a quality and safety report that it says will show both the good and the bad at each of its wholly-owned hospitals.
The public report includes clinical outcomes on more than two dozen indicators, including cancer, pneumonia, patient satisfaction, and heart failure, among others. Under the heading of each condition, Texas Health Resources lists quality indicators from third-party organizations such as the CDC, CMS, the Joint Commission, and others.
"We never have really had a comprehensive stewardship report for the community around how we perform our work," Dan Varga, MD, chief clinical officers and senior executive vice president told me.
"The report will be somewhere between 300 and 400 indicators, all of them are national consensus indicators that are owned by some other indicator developer. All of them have transparent, non-proprietary rules for the gathering and collection reporting of the indicators. We'll aggregate those into a single report and put them out on the web for the public to have access to."
Now public, the report is modeled after a similar one used by Louisville, KY-based Norton Healthcare, one of the state's largest healthcare systems with five hospitals and 90 physician practice locations. It's also where Varga was CMO in 2005 when the system developed its quality report.
With nearly a decade of data and practice at developing quality reports, Norton's includes information on 23 indicators, and is interactive. Texas Health Resources says it anticipates having the same interactive functionality for its report by October.
Even though the aim of the public quality report is to be transparent to the public, Varga says Texas Health Resources is also a big beneficiary of the information. "We are as big an audience for this report as the community is," he says.
Leapfrog's CEO and President Leah Binder told me reports like the ones produced by Norton and now Texas Health Resources are a good step toward being more transparent, but she still considers them "ads."
On-call Doc Pay Depends on Size A new survey of 2,513 providers shows that compensation for physicians who are on-call varies depending on the location and the size of the practice. Medical Group Management Association (MGMA) issued its findings this week. Primary care physicians and nonsurgical specialists earn the highest daily rate in the western region of the U.S. PCPs earn $1,103/day in that region; nonsurgical specialists earn $750. Surgical specialists report earning the highest daily rate of $838 in south. All three earn the least in the Midwest.
The size of the practice also affects the on-call rate paid to physicians and specialists. MGMA's survey shows surgical specialists get paid more if they're providing coverage in a practice with 75 or more full-time physicians while the opposite is true of nonsurgical specialists.
Another key finding of the survey, which looked at data from 2013, is that 37% of those who responded reported not getting paid for their on-call coverage, and of those who aren't paid, a little over one-third are given additional time off instead of pay (33%).
New TN Law Puts Addicted Moms in Legal Peril Let's start in Tennessee, where Republican Governor Bill Haslam has signed into law a controversial bill that gives prosecutors the option of pursuing jail time for mothers who give birth to babies while withdrawing from drugs ingested during pregnancy.
The bill has drawn strong criticism from several groups including Planned Parenthood, the ACLU, and a U.S. drug official, Michael Botticelli, acting director of the White House Office of National Drug Control Policy. A petition with more than 10,000 signatures did not sway Haslam, who waited until the last day available to sign the bill into law.
At issue is the desire to drive down the number of babies born in Tennessee with neonatal abstinence syndrome (NAS), essentially drug withdrawal as a result of the mother using drugs during pregnancy. In 2013, the first year the state's health departments began requiring hospitals to report of cases of NAS, there were 921 cases of NAS. So far in 2014, there have been 253.
Opponents fear the law will prevent drug-addicted mothers from seeking treatment while advocates cite the need for a tougher alternative. Previously, mothers could be charged with a misdemeanor, which triggered treatment through the state's drug courts.
The new law, which goes into effect July 1, allows mothers who give birth to babies with NAS to be prosecuted for homicide if the baby dies because of the drugs taken during pregnancy, or for assault if a baby is born addicted or is harmed. Mothers who get into treatment can avoid criminal charges.
In a statement, Governor Haslam emphasized the bill was aimed at ultimately getting mothers into treatment programs. The state's health commissioner, John Dreyzehner, MD, MPH wants physicians to be more cautious of the medications prescribed to pregnant women. According to 2013 state health data, in 63% of NAS cases, at least one of the medications was prescribed by a healthcare provider.
Early results of a new program focusing on anesthesiologists' interactions with patients show promise toward improving patient satisfaction. "As hospitals prioritize patient satisfaction, anesthesiologists play a more visible role," says a Florida physician key to the program.
It's not by drugs alone that anesthesiologists can reduce patient anxiety and make them feel good about their experience in the hospital. Patient education provided by these specialists is helping one Florida hospital improve on a key indicator of patient satisfaction.
Boosting patient satisfaction can be a hard concept for leadership to grasp for many reasons:
Each patient brings a different set of expectations for what "good" means;
Measuring a patient's satisfaction with his or her care isn't an exact science despite the HCAHPS tool;
Sometimes difficult to pinpoint who exactly is responsible for patient satisfaction when teams of caregivers share the load
At Memorial Regional Hospital in Hollywood, FL, however, a new program focusing on the anesthesiologists' interaction with the patient holds some promise toward improving patient satisfaction.
Anesthesiologists are part of a specialty committed to improving patient satisfaction and experience. In April 2013, the American Society of Anesthesiologists and its Committee on Performance and Outcomes Measurement issued a white paper detailing the importance of the anesthesiologist's role in patient experience, and issued four recommendations for collecting data to measure satisfaction.
"As hospitals prioritize patient satisfaction, anesthesiologists play a more visible role," says Adam Blomberg, MD, vice chief of anesthesiology at Memorial Regional Hospital and education director for the anesthesiology division at Sheridan Healthcare. "We realize that patients are becoming consumers and we thought, 'Who better to educate patients but anesthesiologists?' "
Blomberg says patients who are scheduled for surgery receive a welcome letter and are directed to an online portal that provides education about anesthesia services, such as what to expect before and after surgery. It's led to patients coming in and asking more pointed questions.
As a result, he says patients are also less anxious, which in turn can affect their perception of the quality of care they received pre- and post-surgery. "We started it [the patient education process] in mid-2013 with all surgeries," says Blomberg. "The goal is for patients to have one place to go for their questions, rather than going to Google."
Coordinating Care in the OR
Another key component to trying to improve patient satisfaction through Memorial's anesthesiology program is coordinating care among the clinical team. Blomberg says that by using a patient-centered approach during the perioperative experience, Memorial has reduced unnecessary testing.
Decreasing the number of tests a patient needed before surgery did not happen as quickly as the patient education element. Instead, Blomberg explains that process started slowly, and only began at the end of 2013. He had to educate providers, hospitals, and surgeons on latest guidelines to explain why he wasn't recommending as many tests.
Essentially, Blomberg found that more tests led to more information, but not necessarily meaningful information that changed a patient's surgery path. That line of thinking, or rather questioning, has caught on with specialty organizations and is an initiative of the American Board of Internal Medicine ABIM.
Cancellations Rack Up Costs, Dissatisfaction
Through its "Choosing Wisely" campaign, the ABIM, in partnership with the ASA, released five pre-operative and intraoperative tests or procedures that patients and physicians should question.
Blomberg says that more tests can lead to same-day surgery cancellations, which was both a red flag and an opportunity to improve at Memorial. "One of the biggest patient dissatisfiers is same-day cancellation," says Blomberg.
Same-day surgery cancellations also rack up hospital costs. A 2012 study from Tulane University Medical Center found that 6.7% of scheduled surgeries were cancelled on the same day in 2009, at a cost of $1 million. The cancellations were not exclusively due an excessive number of tests, but subsequent studies came to a similar, broad conclusion that most cancellations were preventable.
"The new coordinator of care is the anesthesiologist," says Blomberg. "We are the air traffic controllers of the OR."
The new processes in place at Memorial Regional have not yet been put to the patient satisfaction test; however, Blomberg says the hospital has been able to reduce same-day cancellations from 8% to 4% in just one year.
Memorial Regional performs 10,500 surgeries annually, which means, in real numbers, 420 fewer patients were inconvenienced by having to return home after fasting, mentally preparing for surgery, and taking time off of work for a surgery that got cancelled. That's a lot of HCAHPS surveys.
By integrating a behavioral health team and a telemedicine component into all 250 of its primary care practices, Carolinas HealthCare System is trying to head off a potential behavioral health crisis in doctors' offices and emergency departments.
Mental health deserves, but fails, to garner the same amount of attention that guns get whenever there is a mass killing involving a firearm. The mental health question is asked, but never really explored in mass media the same way that guns and the laws that govern them are.
Maybe the television talking heads can't find two experts to talk about this complex issue because there is a nationwide shortage of mental health providers. Or maybe it's too complicated to fit into a 30-second sound bite.
Whatever the reason, emergency departments around the country are seeing patients whose behavioral needs are not being metat increasing rates. The growing shortage of mental health providers, services, and facilities is national, but one health system is trying to head off impending crises in primary care offices.
Carolinas HealthCare System has begun integrating a behavioral health team into all 250 of its primary care practices. The initiative comes on the heels of CHS opening an inpatient psychiatric facility, Behavioral Health-Davidson, serving the Charlotte area, where the nonprofit integrated health system is based. The 66-bed psychiatric hospital also includes an adjoining outpatient clinic.
Services for behavioral health in North Carolina mirror shortages that are found in the rest of the country. According to the federal government's last count in 2013, thirty-six of the state's 100 counties are designated as Mental Health Professional Shortage Areas (HPSA), and another report estimates 28 counties are without a psychiatrist.
Martha Whitecotton, senior vice president for Behavioral Health at CHS says the organization is providing a behavioral health team to its primary care practices for a couple of reasons. One is that patients are less likely to feel the societal stigma of mental illness in their primary care doctor's office.
Equipping Physicians Another important, and potentially overlooked reason, is that while primary care doctors often prescribe medications addressing common behavioral health conditions, such as anxiety and depression, physicians are not adequately supported to initiate a conversation about mental healthcare and/or follow up with those patients.
"When a patient does speak up to their primary care doctor, if intervention doesn't happen, no one knows it doesn't happen," Whitecotton told me.
And if there is no intervention, the likelihood of a crisis with that patient increases. Those crises can be scary for the patient, their families, and the public.
Setting aside the divisive issue of whether physicians have a public health role to play in educating patients about guns, there is no question a doctor's guidance at the right time can help a patient in need.
Embedding Mental Healthcare in Primary Care Offices
Whitecotton says CHS is taking a tactical approach to the behavioral health team that will be available to its primary care practices.
"We deconstructed the behavioral health provider," she explains. "If you think of the roles, there is [a gamut from] diagnosis… to scheduling. We took all those roles and put them in a team the practice could access virtually via telephone or video."
The team also includes a health coach, psychiatrist, and psychopharmacist.
CHS has a long history of providing telemedicine, which Whitecotton says was a big help in moving this type of service forward. The system can't afford to embed mental healthcare physically at each practice, but the team will spend about a month at each primary care office educating the physicians about drugs, dosing, screening, accessing the team, and getting comfortable with the types of conversations they will have with patients about mental and behavioral health.
"The [behavioral health] team becomes part of the primary care team," says Whitecotton. "As each week goes by, they spend less and less time physically there, but more virtually."
CHS has rolled out its new behavioral health model in one practice, a five-physician family practice in Mint Hill, NC, a suburb of Charlotte. At this location, physicians will hone their skills at screening patients.
"We're not screening everyone, we don't have the resources to handle that onslaught of volume," says Whitecotton. "We're relying on patients who self-identify or a provider, upon evaluation, identifies a problem."
Patients who are prescribed anti-depressants will also be screened. If their screening indicates further diagnosis is needed, the patient will be moved out of an exam room and into another room where the behavioral health team can be accessed for a diagnostic interview.
Drugs and dosage are decided there, and the patient is given a health coach who will call "at prescribed intervals" to make sure the medication is being taken. "The health coach is a safety net," says Whitecotton, who estimates that CHS will eventually have 40 health coaches when the initiative is fully up and running at all of the primary care practices.
Patients also have access to online cognitive behavioral therapy (CBT). Whitecotton says CHS can offer eight online CBT treatments for the price of one face-to-face appointment.
"We're striving to do things that are economically viable," she says.
Some Challenges
Fitting mental health into a primary care practice does bring challenges, mainly time. Primary care physicians are already squeezing patients in, sometimes for only 12–15 minutes at a time.
"We need much more capacity in our healthcare system for mental health to work," says Molly Cooke, MD, FACP, president of the American College of Physicians, who last week renewed its advocacy for treating gun-related violence and deaths as a threat to public health.
Cooke, who is a general internist, says she is used to screening for depression, but with more people coming into the healthcare system through the exchanges and the expansion of Medicaid, the ability to provide some mental healthcare to patients will get even more "challenging."
Removing the shame that comes with a diagnosis of depression, anxiety, bipolar disorder, and other mental health conditions could help patients adhere to medication and other treatments. It's an unexpected benefit that in addition to treating the disease, doctors can also help ease its stigma.
To say doctors are under tremendous pressure may be the understatement of the year. One key indicator to how well they are navigating the healthcare system is reimbursement.
This article appears in the April 2014 issue of HealthLeaders magazine.
When the enrollment period opened for the new health insurance exchanges in 2013, it was a signal to physicians that a key element of the Patient Protection and Affordable Care Act had, indeed, arrived and would start to play out in their waiting rooms this year. Other changes providers are now contending with include the implementation of ICD-10, public disclosure of any financial gain doctors receive from drug and device manufacturers because of the Physician Payments Sunshine Act, and attesting to meaningful use requirements. All of this is happening against the backdrop of an evolving industry in which physicians are facing an influx of more patients with insurance coverage but without annual limits or preexisting condition clauses.
To say physicians are under tremendous pressure may be the understatement of 2014. A key metric to assess how well physicians are navigating the healthcare system is reimbursement.
"The pressure everybody is experiencing, to a large degree, is revenue related," says Armin Ernst, MD, president and CEO of Worcester, Mass.–based Reliant Medical Group, an independent multispecialty physician group with more than 250 doctors at 20 sites in central Massachusetts. The practice has 106 primary care physicians and 150 specialists.
A cornerstone of PPACA is to get healthcare costs under control, which means moving away from a fee-for-service reimbursement system and replacing it with one that rewards quality and outcomes. It's a transition welcomed by most physicians, but alternative payment models are still relatively new and many organizations are treading carefully. For example, in Massachusetts, a state often lauded as a healthcare pioneer, FFS remains the dominant payment method used by commercial insurers. According to a 2013 report from the state's Center for Health Information and Analysis, while state-based payers have implemented some alternative payment methods, only one national payer was participating in an APM model in Massachusetts. The rest relied on FFS.
This means in Massachusetts, and elsewhere, providers are stuck navigating two payment arrangements, if they venture out to be part of an alternative payment model at all.
"It is very difficult to have your feet in two different worlds and to maintain the divide," explains Ernst, who believes the physician of the future needs to prepare for more scrutiny now in order to survive financially.
"There's less money around," says Ernst. "We all have to do more with less, and we've all recognized that quality has to be a significant driver in how we're getting paid."
Reliant has chosen to pursue contracts that put its providers on the hook for more risk, and it has made strong headway. In 2012, $157 million—52% of Reliant's total revenue—was associated with risk contracts. It's a trend that began five years ago, says Marc-David Munk, MD, chief medical officer for Reliant Medical Group.
"Every year, it seems to increase," says Munk. "We're looking forward to a point in our future where we have next to no FFS patients."
Reliant leaders hope to be at that point in five years. For 2014, Reliant's goal is to have more payers handing over risk to the multispecialty practice—up to 80% of its patient panel by year's end. The more risk, the better, according to Munk. Right now, 71,000 of its patients are fully capitated, about 40%.
"Being in a risk environment allowed us to do many of the things that physicians wished they could do," Munk says.
For example, Reliant offers shared medical appointments for certain chronic conditions, such as diabetes. Patients with high blood pressure or cholesterol and weight management issues can also participate in a shared appointment. The 90-minute, once-a-month appointments also give patients a way to be more engaged with their care and understand they are not alone. In addition to a physician, a nurse is present at the appointments to address other issues, such as depression and anxiety. Munk says the appointments are very popular with patients and easier with global-risk contracts because it's difficult to bill for a shared appointment under a FFS structure.
Another program that Reliant is piloting, HomeRun, involves providers seeing frail elderly patients in their own homes. The home visit is done by geriatricians and nurse managers. Munk says he also is looking to begin a separate hospital-at-home program that would allow patients to stay home with support instead of being admitted to the hospital.
"It comes at a lower cost for us," Munk says. "And it's something that we would find difficult to bill for in a FFS environment. The bottom line for us is these kinds of things improve the care that we can deliver to patients and also deliver it to the bottom line. It's frankly a much less expensive way of providing care than waiting for patients to get sick at home and then having them bounce back to the emergency department two or three times and get readmitted. Don't forget we bear the cost of all of those visits. Everybody benefits when we get a little more intelligent about how to spend those dollars."
Reliant's aggressive strategy is due, in part, to its affiliation with Atrius Health, a Newton, Mass.–based nonprofit organization that has assembled more than 1,000 physicians among its seven community-based medical groups in Massachusetts. Atrius is a Medicare Pioneer Accountable Care Organization and has an alternative quality contract with Blue Cross Blue Shield of Massachusetts.
On its own, some Reliant locations have also achieved level 3 patient-centered medical home recognition—the highest level awarded by the National Committee for Quality Assurance. While PCMHs are not necessarily engaged in APM models, payers often offer incentives to practices and physicians that attain the recognition.
Reliant's confidence in succeeding with global risk comes from its history. Before 2011, Reliant was known as the Fallon Clinic, established in 1929 as a medical group in central Massachusetts. Its members embraced the idea of capitated payment and, in the 1970s, created their own HMO known as the Fallon Community Health Plan. Ernst credits the early adoption of capitated care as one reason Reliant has been able to move forward more quickly with modern alternative payment models.
"I think we were lucky here somewhat because of the culture that existed at the Fallon Clinic," Ernst says. "It has a long history of managed care, so it was not a new concept that had to be sold to leadership, administration, and physicians, which certainly helped. But, I don't want to underestimate how difficult this can be if you start out from scratch. I think it's extremely difficult."
In addition to Reliant's cultural comfort with APM models, the medical group has a robust electronic health record system that supports a patient portal to schedule appointments, view lab results, email physicians, and even can support e-visits for patients 18 years old and up. The portal is a "big patient satisfier," according to Munk, especially for the younger patients who communicate digitally.
Reliant's $24 million investment in its Epic EHR system, which is maintained by two dozen full-time employees, took years to customize, but has paid off. The medical group received a Stage 7 Ambulatory Award from HIMSS Analytics, its highest designation, which recognizes an organization for having achieved all the steps necessary for a paperless environment.
Munk says such investments benefit all of Reliant's patients, regardless of the reimbursement method.
"We've built our infrastructure to support risk, which means that our FFS patients benefit from many of the same initiatives that our capitated patients benefit from," he says. "For example, we know that giving flu shots only saves us money down the road; we have an excellent flu shot delivery rate, but our FFS patients receive them at the same rate as our capitated patients."
Still, Ernst is counting on getting more patients covered by risk-based contracts. Increasing the population of patients who are considered fully at risk is a key to Reliant's financial bet on leaving FFS behind for good.
"If you are FFS, you can get away with, say, 100 patients, and you just see them 100 times a year and get paid 100 times," he explains. "That doesn't work anymore under this model so it really has to be the number of covered lives—that is the new currency against which our success is being measured. And that, I think, is foundationally different."
Embracing independent physicians
Reliant is not alone in seeking new types of relationships with payers to support the need for a more viable post-FFS reimbursement model.
San Francisco–based Dignity Health, a 21-state network of 39 acute care centers, including hospitals, primary care and urgent care clinics, and 56,000 employees, launched a physician alignment effort in 2011 that gives independent physicians who work with Dignity hospitals an opportunity to collectively negotiate with payers to not only get better rates, but also to participate in APM models that include shared savings. It's called clinical integration, and while it's in an early phase of development, Dignity has five CI networks operating in the three states where it operates acute care hospitals: California, Arizona, and Nevada.
Robert Lerman, MD, vice president and medical director for physician integration at Dignity, shares Ernst's ideas on the stress that physicians are operating under in the current environment.
"It's a very difficult time to be a physician," says Lerman. "Doctors are facing reduced reimbursement; they have regulatory requirements, increased costs to run a practice. And these pressures really sort of mirror some of the same things the hospitals are going through with value-based purchasing, penalties for readmissions, and shrinking margins for Medicare."
Instead of trying to solve the problems inside the walls of the hospital, Lerman says Dignity saw an opportunity to collaborate with the 9,000 physicians who work with its hospitals. Dignity has a distinctive relationship with physicians: Only 10% are employed by the health system. The rest are independents, many of whom, Lerman says, are confused and scared about their future.
"A lot of our physicians really do want to stay independent, but they want and need help in order to be successful in the new healthcare environment."
The physician-led Dignity Health CI programs provide a support network to those independent physicians. If they join one of Dignity's CI networks, they get access to tools and staff they otherwise might not be able to afford. For example, in concert with developing the CI networks, Dignity also is creating a healthcare management program that includes social workers, nurse coordinators, and pharmacists working with physicians and their practices to develop team-based care protocols that are found in PCMHs. In fact, Lerman says, Dignity is beginning a major initiative this year to bring as many PCMH elements into physician practices as possible.
"We don't look at the PCMH and CI network models as being mutually exclusive at all," he says. "We are making major investments in population health management information technology that we'll offer to our physician practices to allow them to have things they don't have or couldn't afford, like software that will facilitate communication with care management teams."
There is no membership fee or cost to physicians to join the CI network, but they are expected to play a significant role in building the network to include primary care physicians and specialists. In fact, every aspect of a CI network is physician-led and physician-governed.
Each network has a board of managers that is composed of both primary care physicians and specialists. The individual networks also have a quality committee, which works with the group to develop metrics and standards. Lerman says that, on average, there are 100 quality measures for each CI network.
"The quality committee gets together and they go through every single medical specialty," he says. "They talk to their peers, they develop potential quality metrics that might be utilized, and they select between five and 10 metrics per specialty, and that's how you get to about 100 for each organization."
Lerman says Dignity also recognizes that to attract physicians to the CI network, the metrics have to be reflective of the physicians' community. Likewise, to attract health plans to the CI networks, he says, the organization strives for standardization, as well. To achieve balance between the two sets of standards, Dignity created, with the help of physicians, a menu of 160 quality- and cost-related measures.
"Out of those 160, we ask the physicians to pick 90–110 measures from that menu," says Lerman, who also says that community-specific metrics can be added; but again, the process is entirely physician driven.
"We want all the physicians to feel that they have a voice," says Lerman.
Physicians who join a Dignity CI network are also expected to hold each other accountable for the quality metrics each network adopts. It's an opportunity to collaborate with other providers in a local community to develop a common set of quality and clinical standards. Dignity's theory is that patient care will improve, costs will go down, and physicians will have more job satisfaction.
Despite a built-in relationship with 9,000 physicians across three states, Dignity decided to recruit physicians for its CI network initiative in order to create closer partnerships with many of those physicians. The health system wasn't starting at ground zero, but this did represent new ground for the organization to hit the streets and convince physicians to join and, Lerman says, recruiting physicians hasn't been difficult.
"We had hoped that by July of 2012 we would have about 800 physicians throughout Dignity Health in the various CI networks, and we had about 2,700," he says. "The physician participation has been tremendous and the progress that we have made has exceeded our expectations." The number of physicians who've joined a Dignity CI network is now nearly 3,000.
The Arizona Care Network, an ACO based in metropolitan Phoenix, has 695 physicians, and the "vast majority" already has a relationship with Dignity or with its partner Abrazo Health Care, says William Ellert, MD, who helped develop the CI network as chief medical officer of St. Joseph's Medical Group, the employed physician group of Dignity's St. Joseph's Hospital and Medical Center located in Phoenix. Ellert is also chair of the Arizona Care Network's utilization review committee and chief medical officer for Tenet Healthcare's Arizona region.
Ellert says the Arizona Care Network has been able to attract physicians because of St. Joseph's long history in the area.
"St. Joseph's, which is one of the flagship hospitals of Dignity Health, has been in this community since the 1800s, and so partnering with the physicians was not a new thing for us," says Ellert. "We have a long history of trust with the physicians and so when Dignity Health says, 'This is the direction I believe we need to go in order to prepare for the future of healthcare,' a lot of the physicians believe them."
Another reason physician participation in the ACN is so large is because of the network's partnership with Abrazo Health Care, which is now part of Dallas-based Tenet Healthcare. Ellert, now chief medical officer for Tenet's Arizona region, says the addition of Abrazo's six hospitals, outpatient facilities, and medical group in the Phoenix area expand the ACN footprint throughout all of central Arizona, where two-thirds of the state's population lives. The geographic area is known as the Valley of the Sun, and Ellert says the partnership with Abrazo allows both systems to look at delivering care in a whole new way.
"As a network, we have geographic reach throughout the entire valley, and that was important for the community because you might work in the east valley and live in the west valley, so you have to have access to healthcare throughout the entire valley," he says.
The ACN gained status as a Medicare ACO in January 2013. It plans to commit 70% of the shared savings to physicians and 10% to hospitals. The remaining 20% supports the infrastructure of the ACN, with hospitals agreeing to give back 50% of their shared savings to support existing ACN infrastructure, if necessary.
Ellert says the ACN is going beyond the Medicare ACO model and is entering into a contract with Aetna that has a shared-savings component to it, as well as working with UnitedHealthcare. Giving independent physicians a voice in negotiating with payers is a big selling point of the ACN and the rest of Dignity's CI networks.
Even without years of data showing improvements in quality because the CI networks are still new, Ellert says early results from the first eight months of 2013 are promising. From January to August, Ellert says ACN saw a drop in inpatient admissions from 403 to 278 per 1,000 patients; for that same time period, there was also a reduction in emergency department visits from 419 to 353 per 1,000 patients. ACN is also credited with reducing hospital readmission rates, year over year, from August 2012 to August 2013 by 10%, from 16.1% to 14.5%. Ellert says the data indicates the CI network shows potential, and health plans are now approaching the network.
"Almost all the health plans are coming to us and saying they want to do this," he says. "Our goals are becoming more aligned. The trick is how do you jump from point A to point B, and that's where a lot of the difficult negotiations come in because we recognize that we're still building the infrastructure to be successful and the health plans, rightly, and the patients are saying, 'We want it now.' "
Both Ellert and Lerman are banking on the entrepreneurial spirit of the independent physicians to propel the network forward quickly. Ellert says the CI networks could be of particular help to primary care physicians.
"The thing that is either going to make this or break this is if we can somehow put aside some of our individual needs and biases and look at what the needs of a community are and the needs of our patients, and address those," says Ellert. "That's what PCPs have always done, but we're now being given some of the tools we need to make this successful."
Primary care's 20-minute milestone
Primary care physicians are often cited as the group of doctors under the most pressure. The American Medical Association, Association of American Medical Colleges, and more recently the National Center for Health Workforce Analysis, all project a shortage of primary care doctors by 2020.
Among the ideas to help fill the future gap in primary care practices include increasing the number of nurse practitioners and other medical staff, as well as expanding the scope of practice for nurses, putting them in more of a leadership role in primary healthcare; however, the idea isn't without criticism from the physician community.
"What's important to realize is that because of the differences in education and training, even doing the same service is different," says Reid Blackwelder, MD, president of the American Academy of Family Physicians, which represents 110,600 family physicians, family medicine residents, and medical students.
Blackwelder is also a practicing family physician in Kingsport, Tenn., and says as a trained physician, he may pick up on an issue with a patient's health that a nurse practitioner may overlook or attribute to something else unrelated to the visit.
"If I'm doing a well-child visit, for example, I'm noticing things differently than a nonphysician provider would."
Blackwelder says there is a place for NPs and others in a practice to help alleviate the patient load, but he firmly believes that the answer to primary care pressures is team-based care, led by a PCP.
Many modern care models include aspects of team-based care. Reliant, for example, puts PCPs at the center of its model, and Dignity's CI networks aim to coordinate patient care beginning with a PCP. But the biggest hurdle providing this type of care is the payment system, says Blackwelder.
"One of the biggest barriers is the reality that our current system pays for volume, and that has created some significant challenges all over the country in that we're not used to recognizing the value of primary care especially in the setting that physician-led teams can bring to the table," he says. "So as we transition from paying for volume to paying for value, the system we're trying to get away from doesn't have a way for me to easily document and be paid appropriately for it."
Blackwelder's complaint about not getting paid for the work he does to help manage patient care is echoed by many physicians. But that is changing, at least for Medicare patients. In 2015, physicians will be able to use a newly created "G-code" that the Centers for Medicare & Medicaid Services outlined in late 2013. The new code reimburses doctors for 20 minutes of care per month given outside of a face-to-face visit for Medicare beneficiaries who meet certain requirements. CMS calls the new code a milestone toward care coordination, but it may be more akin to a baby step if the administrative work physicians put in to manage their patient population exceeds 20 minutes.
Primary care's trailblazer
Some PCPs are not waiting for the government or insurers to catch up to the reality of how their daily practices are run. Instead, Tom X. Lee, MD, is meeting patients' demand for a high-tech, high-touch doctor visit with One Medical Group, a primary care practice he founded in San Francisco in 2005 that has since expanded to 27 sites in San Francisco, Boston, Chicago, Washington, D.C., New York City, and most recently, Los Angeles.
One Medical Group has been described as concierge medicine without the concierge price tag. But Lee describes it as a completely reengineered doctor's office.
"We are not concierge," he says. "Concierge is really designed for the affluent; ours is designed for everybody. It's a primary care system focused on delivering higher-quality care and service at lower cost. The way we manage that is through overhead reduction … and support systems."
The "support systems" are proprietary technologies Lee helped develop. The $199 annual membership fee that patients pay helps support noncovered services that are supported by technology. That in turn reduces the administrative burden and gives patients what they want now, which is access. Patients can make same-day appointments online or through the One Medical app. They can email their physicians directly, view lab results, access their medical record, request prescription refills, and request treatment for common issues—all from a smartphone.
Efficiency is what Lee focuses on most, and One Medical Group's offices are nearly paperless.
"What people underestimate is the complexity of workflow in healthcare in general, but particularly in outpatient and primary care," he says. "Unfortunately, traditionally the way doctors evolve is they have a very simple office to start, but through growing administrative and clinical complexity, they have hired staff and layered process on top of process and have continued to use legacy systems like paper and fax that are less efficient in today's world of technology."
Lee's concentration on maximizing One Medical's efficiency has reduced administrative staff from four employees per physician to two, or fewer in some offices. Lee does not want doctors spending time on paperwork; he wants them spending time with patients—a key measure he keeps track of constantly.
"In my mind, time is the key investment that we're making right now," he says, noting that a typical 10-minute doctor visit is not enough time to listen to a patient, make a diagnosis, and manage the patient's care.
"Our general bias is that in the office visit, time is the missing ingredient, and we've added that back. We're seeing 15–16 patients a day, about 30 minutes on average."
One reason Lee has been able to expand his model of primary care so quickly comes from his deep connection to Silicon Valley. After medical school, he earned his MBA from Stanford University, and while there developed Epocrates, the drug and medical reference app that debuted on Palm technology but has successfully migrated to smartphones. It is one of the most common apps physicians use today with more than 1 million downloads.
The success of Epocrates showed investors that Lee was a smart bet when it came to healthcare; venture capitalists have given him $77 million to date to invest in One Medical.
It is easy to point to the money and the technology Lee has had access to as the reason why he's been able redesign primary care for his patients, but he insists that those resources alone would not have produced such a result.
"It's a combination of process, technology, and people; all of those elements are interacting together," says Lee. "I think there are a lot of ideas in healthcare and not many people doing them. We're actually putting the ideas into action."
Lee's vision for designing a primary care practice is rooted in the days of his residency at Boston-based Brigham and Women's Hospital. He was disappointed at what he saw—heavy administrative burdens that interfered with a physician's ability to treat and care for patients. So instead of going into private or group practice, Lee headed to business school to find out how to run a practice the way he wanted to.
Now that he is, and getting attention for it—Forbes dubbed Lee one of its 12 Most Disruptive Names in Business in 2013—he wants people to know that his solution to redesigning primary care is not turnkey.
"It's hard to do," he says. "You can't model it. This isn't, frankly, assembly line production. Assembly line production is very moldable; you can calculate changes. The workflow that comes into doctors' offices is a lot more complicated."
Room for specialists
While Lee has focused on primary care redesign, Consultants in Medical Oncology and Hematology, an eight-physician oncology group in Drexel Hill, Pa., believes it has found a model of care that can be rolled out to other oncology practices. The strides made by CMOH's leader, John Sprandio, MD, FACP, focus on both improving care for patients and building a payment infrastructure for specialty physicians that can survive the transition from volume to value.
In 2003, Sprandio started building the Oncology Patient-Centered Medical Home® after being struck by what Alice Gosfield and James Reinertsen, MD, wrote in a 48-page white paper titled Doing Well By Doing Good: Improving the Business Case for Quality, which looked critically at barriers that prevented physicians from delivering consistent care.
"In that paper there was a list that details the barriers that physicians face on their way to becoming more accountable for the quality of care delivered. These barriers also happen to be significant physician time-stealers, things like utilizing an EMR that doesn't really match workflow or processes of care, communication and documentation burdens, the lack of coordination systems, etc.," says Sprandio. "All those things were really clear after reading the article, probably a dozen times."
On a mission to reduce variability and—like Lee's vision for One Medical Group, become more efficient—Sprandio began working in earnest to identify where work could be standardized among the three CMOH sites. He focused first on getting physicians to manage symptoms in the same way so that CMOH's nurses were giving consistent advice to patients who called the telephone triage system, which was designed to allow immediate patient access to clinical information and advice.
"There was a lot of variation in terms of how we managed symptoms as a practice," says Sprandio. Dr. A handled delayed chemotherapy-induced nausea different than Drs. B, C, and D. Another important goal was to try to minimize clinically irrelevant physician activity and to give physicians consistent data and have them not just be able to respond to it, but hold them accountable for responding to it."
The solution, he says, was basic communication. The physicians discussed why they liked one approach to managing symptoms over another until they finally came to a consensus on managing specific, predictable symptoms related to chemotherapy and complications of disease.
"We embraced the Dr. Brent James/Intermountain Healthcare philosophy that it rarely matters that you get symptom management strategies perfect the first time, but you have to start a process of doing things the same across your organization and then measuring the outcome and making changes based on the success or failure of those efforts," he says.
Sprandio helped physicians maintain the clinical standards they chose with a robust EMR system that he says created efficiency by getting rid of data that was irrelevant and integrating a documentation template that prompted physicians to facilitate communication with patients and referring physicians.
Once that variation in data and diagnosis was eliminated, Sprandio worked on getting physicians to improve their documentation turnaround time, which in 2006 was "abysmal."
"It was three, three-and-a-half, four weeks," he says. "We improved it to a couple of weeks in 2009–2010. After we inserted Dragon dictation into our software overlay, we're down to a day-and-a-half. That's where we are right now."
The documentation improvement, process standardization, and EMR system (along with the custom software that supplemented it), added up to fewer variations in care and the realization that CMOH was basically a PCMH.
"We turned around in 2008 after we did all this, and it was clear to us that we met or exceeded the NCQA criteria for PCMH recognition," he explains. CMOH did earn Level 3 PCMH status in 2010. Sprandio is also pursuing a new NCQA Patient-Centered Specialty Practice recognition program that aims to identify specialty practices as meeting the same stringent requirements as those that cover primary care.
Sprandio's efforts in standardizing the way symptoms are managed with the centralized phone triage system has led to an increase in the number of cases that can be handled over the phone with a nurse. In 2006, Sprandio says, 77% of all symptom-related calls were effectively managed at home; in 2012 it rose to 85%.
ED evaluations per chemotherapy patient per year have also steadily declined from 2.6 visits in 2004 to 0.82 in 2011.
Sprandio attributes the decline in ED evaluations to the physician-led care teams that engage the patients early by asking them to call the telephone triage line as soon as they suspect a problem. He also directly credits the improvement to the quick document turnaround time by physicians.
"It provides up-to-date clinical information to our triage nurses with detailed information regarding current patient-specific symptom management recommendations," he says.
CMOH's initiative to work toward better outcomes at a better value have caught the attention of payers who are willing to test specialty-based APMs. Sprandio says CMOH now has three APM contracts, in total, with Keystone First, a Pennsylvania Medicaid managed health program; Aetna; and Independence Blue Cross. All three are pay-for-performance contracts, and among them Sprandio says 54% of his patients are now covered by APMs compared to about 15% a year ago.
But for Sprandio, the desire to pioneer a way that rewards value over volume is really rooted in figuring out a way to give his patients consistently good care.
"This was all driven by the fact that I wanted patient X, Y, or Z, who was initially referred to me to get the same level of attention, same process of care, same symptom management that I would have given them if I were seeing them. And there was a tremendous amount of variability. Anybody who says, 'There's five doctors or there's 20 doctors and we all do things pretty much the same,' they're delusional. They're completely delusional. If you want to drive quality, you have to create an environment where consistency is a default mode."
Reprint HLR0414-2
This article appears in the April 2014 issue of HealthLeaders magazine.
