The lessons learned about population health management and the value of medical homes and coordinated care come straight from the nation's community health centers, which celebrate nearly 50 years of providing healthcare access.
Lindsay C. Farrell, President/CEO
Open Door Family Medical Center
If imitation is the sincerest form of flattery, then next week we should forgive the healthcare professionals serving the working poor and vulnerable populations at the 1,128 or so community health centers across the nation who might suffer a well-deserved swell of pride for the job they do.
August 11 marks the start of National Health Center Week 2013. After nearly 50 years of providing access to care for a generally sicker demographic of lower-income people in often medically underserved areas, the lessons learned at community health centers about population health management, and the value of medical homes and their coordinated and follow-up care are being replicated across the nation as other provider venues serving more-affluent patients cope with the move towards value-based reimbursements and a post-fee-for-service world.
"I have to say that we really have some capabilities that the marketplace really needs now and will need into the future. We were doing population health 10 years ago," says Lindsay C. Farrell, president/CEO of Open Door Family Medical Center. The nonprofit center has a $34 million annual budget and operates five clinics and five school-based programs that serve about 40,000 people in the Ossining, NY area.
"Population health is a relatively new term out there and it's been a term of art as a result of Accountable Care Organizations. But the feds were making us do it a long time ago because they wanted to make sure we were delivering value for the dollars they were investing. Those skills are important in our entire approach to patients and that is what the marketplace wants today so I have to believe that is going to serve us well in the future."
Farrell says community health centers are key institutions in the communities they serve because they not only provide proactive and preventative care, they teach wellness. "We are focused on prevention," she says. "We realize that a prescription might not necessarily be the be all and end all, that very often it is lifestyles and behaviors that have the most significant impact on health."
"That is not to say we don't write a lot of prescriptions over the course of the day, but we try to do more than that. We realize that life isn't about quick fixes. Rather, being healthy takes effort over time, and so we like to partner with our staff and our patients and their families that rely on us so that we can all be a little healthier.
The National Association of Community Health Centers estimates that the nation's health centers serve about 22 million people each year, and save about $24 billion by providing proactive and preventative primary care for low-income and uninsured people that keeps them out of the emergency room. In addition to primary care, community health centers often provide behavioral health services, dental health services, pharmacy, wellness and nutrition programs, and health counselors for their patients.
"We are cost effective because we are primary care providers and our job is to keep people healthy and out of the hospital. That is our primary focus," Farrell says.
"Also, our patients don't have a lot of money and we have a lot of uninsured patients, so that impacts the way we practice. If you have a patient who doesn't have insurance coverage, you are not going to be ordering a gazillion lab tests or diagnostic studies because the patients just can't afford it. You are going to be a bit more cautious because our patients can't have it all when they want it. That is actually not such a bad thing because there is a lot of literature that suggests that an overuse of the healthcare system doesn't necessarily make you healthier or happier."
Follow-up care coordinated by health counselors plays a big part in the success at Open Door. "There are lots of follow-up calls or face-to-face meetings to make sure that they got their medication and that they're taking the medication and that they can afford their medication. Do they know how to test their blood sugar? Can they afford the types of foods that they should be eating?" Farrell says. "We have classes and facilities outside of the exam room so that is how we are a little different than more traditional physician practices."
Unlike community health centers in rural areas, which serve a wider socio-economic demographic because they're often the only care provider in town, Farrell says Open Door's patients are largely working poor people, mostly Latinos, who have no other affordable venues in a part of the nation that is otherwise teeming with providers.
"We are in suburban New York and if anything, we are over-doctored and over-hospital bedded here," she says. "Isn't it fascinating that despite that federally qualified health centers still need to exist because our patients couldn't get served in the traditional setting? You wish that physician practices and hospitals could be accommodating, but the fact is that they aren't and that is why we needed to be here."
NACHC's Amy Simmons Farber says more than 1,000 events are planned next week under the theme of Transforming Health Care in Our Local CommunitiesCommunity health centers across the nation will host dignitaries and the public and members of Congress enjoying their well-earned five-week recess will be invited to learn about the unique services the centers provide and the impressive track record compiled while delivering nearly 50 years of value-based and coordinated care.
"Health centers go beyond the reach of traditional primary care and offer a number of other services that don't just focus on preventing illness but also looking at the factors that cause illness, such as nutrition, housing and unemployment," Simmons Farber says.
Community health centers are actually one of the few venues that command bipartisan support in the otherwise dysfunctional Congress. With about 39% of the programs funded through Medicaid and federal grants, community health centers avoided the impact of the 2% Medicare cuts mandated by sequestration.
"In fact we got more money," Farrell says. "That shows you how great our folks are and it also shows you how much Congress likes the work we are doing. We get results. We are very judicious about our resources. We are lucky that the feds have been as generous as they have been of late but that hasn't been the way it's always been over the last 30 years. We operate on the premise that dollars are scarce and precious and we have to utilize them for the greatest impact."
No clear reason or firm date was given for Farzad Mostashari's plan to exit the Office of the National Coordinator. His unexpected move comes at a critical time as HHS grapples with complex issues over the implementation of Meaningful Use Stage 2.
Farzad Mostashari, MD, ScM
National Coordinator for Health Information Technology
The physician leading the federal government's sweeping and aggressive efforts to implement healthcare information technology has announced that he will leave the job this fall.
After four years at the Office of the National Coordinator for Health Information Technology and leading the office since 2011, Farzad Mostashari, MD, ScM, made the unexpected announcement Tuesday in a letter to colleagues.
"It is difficult for me to announce that I am leaving. I don't know what I will be doing after I leave public service, but be assured that I will be by your side as we continue to battle for healthcare transformation, cheering you on," Mostashari wrote.
He declined to say why he was leaving and did not say what he planned to do after leaving the office. Officials at HHS declined to comment on the reasons for his departure.
Health and Human Services Secretary Kathleen Sebelius issued a statement praising Mostashari's tenure as a "time of great accomplishment."
"Farzad has been an important advisor to me and many of us across the Department. His expertise, enthusiasm and commitment to innovation and health IT will surely be missed. In the short term, he will continue to serve in this role while a search is underway for a replacement," Sebelius said.
While no firm date for Mostashari's last day at ONC was given beyond "the fall," his departure comes at a critical time as HHS grapples with complex issues and grumbling from providers over the implementation of Meaningful Use Stage 2, which goes into effect for hospitals on Oct. 1, and on Jan. 1, 2014 for physicians. The American Hospital Association and the American Medical Association have asked Sebelius to roll back the implementation dates.
Mostashari confirmed via Twitter on Tuesday his intention to leave ONC
Mostashari has resisted calls to roll back the implementation date. He is the lead author in a study published this week in Health Affairs which shows that health information exchanges between hospitals and other providers jumped 41% from 2008 to 2012. The study examined national surveys and found that six in 10 hospitals routinely swapped electronic health information with providers and hospitals beyond their walls in 2012.
"We know that the exchange of health information is integral to the ongoing efforts to transform the nation's health care system and we will continue to see that grow as more hospitals and other providers adopt and use health IT to improve patient health and care," Mostashari said in remarks accompanying the study. "Our new research is crystal clear: health information exchange is happening and it is growing. But we still have a long road ahead toward universal interoperability."
With Mostashari leaving, it's not clear if HHS will reconsider rolling back the implementation dates.
In his letter Tuesday to colleagues, Mostashari conceded that "there are formidable challenges still ahead for our community, and for ONC. But none more difficult than what we have already accomplished. In these difficult and challenging times, your work gives us hope that we can still do big things as a country. That government and the private sector working together can do what neither can do alone. We have been pioneers in a new landscape, but that landscape is one changed forever, and for better."
As news of Mostashari's departure spread Tuesday, the paeans rolled in.
"Through Dr. Farzad Mostashari's leadership, we saw the Office of the National Coordinator lead our nation's providers through the first gates of measured, meaningful use of electronic health records, and address in reality those initial standards that make our health information portable across the U.S. healthcare system," College of Healthcare Information Management Executives President/CEO Russell P. Branzell and Chairman George T. Hickman said in a joint statement.
American Hospital Association senior vice president of policy Linda Fishman issued a statement saying: "We appreciate the hard work of Dr. Mostashari in supporting the adoption of electronic health records and working toward our shared vision. America's hospitals are on a pathway toward a reformed health system that is supported by the use of EHRs. We wish him the best of luck in his next endeavor and we will continue to work collaboratively with HHS to realize our shared vision."
Six in 10 hospitals routinely swapped electronic health information with healthcare providers and health systems beyond their walls in 2012, says a study from the Office of the National Coordinator for Health Information Technology.
Health information exchanges between hospitals and other providers jumped 41% from 2008 to 2012, according to federal government research published this week in Health Affairs.
The study, led by National Coordinator for Health Information Technology, Farzad Mostashari, MD, examined national surveys and found that six in 10 hospitals routinely swapped electronic health information with providers and hospitals beyond their walls in 2012.
"EHR adoption and HIE participation were associated with significantly greater hospital exchange activity, but exchanges with providers outside the organization and exchanges of clinical care summaries and medication lists remained limited," the study said.
"New and ongoing policy initiatives and payment reforms may accelerate the electronic exchange of health information by creating new data exchange options, defining standards for interoperability, and creating payment incentives for information sharing across organizational boundaries."
Mostashari said research suggests that EHRs and HIEs are complementary tools used to enable health information exchange. Stage 2 Meaningful Use, which requires hospitals to exchange data with outside organizations using different EHRs, and to share summary of care records during transitions of care, can accelerate hospital use of HIE to enhance care quality and safety.
"We know that the exchange of health information is integral to the ongoing efforts to transform the nation's health care system and we will continue to see that grow as more hospitals and other providers adopt and use health IT to improve patient health and care," Mostashari said in prepared remarks. "Our new research is crystal clear: health information exchange is happening and it is growing. But we still have a long road ahead toward universal interoperability."
It's not clear if the government-sponsored research will assuage the misgivings of leading provider organizations that have asked the federal government to dial back the implementation dates for hospital Stage 2 Meaningful Use, which go into effect on Oct. 1 for hospitals and on Jan. 1, 2014 for physicians. Last month the American Hospital Association and the American Medical Association sent a joint letter to Health and Human Services Secretary Kathleen Sebelius telling her the requirements for Stage 2 MU were "overlyburdensome."
"Our members, and the vendors they work with, report growing concerns that the rapidly approaching start date for Stage 2 is on a trajectory that will not provide enough time or adequate flexibility for a safe and orderly transition unless certain changes are made," AHA President/CEO Rich Umbdenstock and AMA CEO James. L Madara, MD, said in the letter.
"As of July 17, the official federal list of certified vendor products shows only nine complete 2014 Edition certified EHRs for the inpatient setting, produced by only six vendors. By comparison, the list shows 313 complete 2011 Edition certified inpatient EHRs. On the ambulatory side, only 11 complete 2014 Edition certified EHRs are listed, while about 1,300 were certified for 2011."
The Office of the National Coordinator for Health Information Technology study found that:
58% of hospitals exchanged data with providers outside their organization in 2012 and hospitals' exchanges with other hospitals outside their organization more than doubled during the study period.
Hospitals with basic EHR systems and participating in HIEs had the highest rates of hospital exchange activity in 2012, regardless of the organizational affiliation of the provider exchanging data or the type of clinical information exchanged.
The proportion of hospitals that adopted at least a basic EHR and participated in an HIE grew more than fivefold from 2008 to 2012.
Between 2008 and 2012, there were significant increases in the percent of hospitals exchanging radiology reports, laboratory results, clinical care summaries, and medication lists with hospitals and providers outside of their organization.
84% of hospitals that adopted an EHR and participated in a regional HIE exchanged information with providers outside their organization.
Mostashari said more research is needed for care summaries and medication lists because only about one-third of hospitals exchanged clinical care summaries or medication lists with outside providers.
Preliminary data from the Bureau of Labor Statistics marks July as the third month this year in which the hospital sector lost jobs. But one analyst is not ready to call it a trend.
With 2013 more than halfway completed, new federal data shows that hospital job growth has slowed considerably.
Caroline Steinberg, vice president, Health Trends Analysis at the American Hospital Association says the 2% cuts to Medicare mandated under the federal budget cuts known as sequestration are to blame.
"Medicare represents more than 40% of the care provided by hospitals and when you just lop off 2% of that, it's a big impact on hospitals," she says. "They have to provide the same amount of care they were providing before, but now instead of getting paid 92 cents on the dollar it's closer to 89 cents on the dollar. They were already losing money on Medicare and this makes it worse."
Bureau of Labor Statistics preliminary data marks July as the third month this year in which the hospital sector lost jobs, with 4,400 fewer jobs in July than in June. Since January, hospitals have created 1,700 new jobs. In the first seven months of 2012, hospitals created 38,600 jobs.
The larger healthcare sector, which includes hospitals, nursing homes, ambulatory surgery centers, clinics, and physicians offices, created a mere 2,500 jobs in July, well below the monthly average of 15,700 new jobs in the first seven months of 2013. The 2013 monthly average is well below the 24,300 new jobs that healthcare averaged in the first seven months of 2012. BLS figures for June and July are preliminary and can be subject to considerable revision.
Steinberg says most hospitals are trying to soften the blow of sequestration by first shedding administrative jobs to protect caregivers and patient services. "But when the rubber hits the road they start to cut programs and those programs that lose the most money are the first to go, things like psychiatric care, post-acute care, home health programs," she says. "You really do begin to see access suffering."
The across-the-board cleaver cuts mandated by the sequestration will lop $1.2 trillion off the federal budget over the next nine years, averaging more than $109 billion each year. This includes $11 billion in Medicare funding in 2013 in the form of the 2% reimbursement cuts.
Nicole Smith, a senior economist at the Georgetown University Center on Education and the Workforce, agreed that sequestration is playing a role in the slower job growth for healthcare, but she says it's too early to call it a trend.
"Because healthcare job growth as a whole has been strong for so long I am just really reluctant to look at two to three months in a year and call this a pattern of decline," she says. "Healthcare is one of the few sectors that even in the height of the recession continued to add jobs. Maybe we are observing a little correcting of the market. I don't think three or four months is enough of a trend to discredit the other six or seven years of growth."
The loss of hospital jobs in July was offset by the 6,600 jobs created in the ambulatory care sector. But even that job growth is down somewhat when compared with 2012. Ambulatory services created 100,700 jobs so far in 2013, an average of 14,300 per month. In 2013 ambulatory services created 108,300 jobs, an average of 15,400 per month.
Steinberg says the AHA will continue to press Congress and the Obama administration to find an alternative to the sequestration cuts. Until then, she says, hospitals will likely continue to cut services and staff, and cities and towns across the nation will feel the adverse effect for both access to care and local economies.
"Healthcare has always been an economic engine. The jobs tend to be high-quality jobs with good benefits. They tend to be, relative to the service sector, a little higher-paying. It's bad for the economy when hospitals cannot continue their contributions," she says.
Even with the slower job growth, Smith remains bullish on the job growth prospects healthcare sector. "Despite all of these short-term adjustments we have to make to the industry our forecasts still show healthcare as being a robust and buoyant sector over the next couple of years," she says. "Not only will it continue to grow. It continues to upscale. The newer entrants will certainly look different in terms of the credentials they hold compared to the existing workers who are there now."
More than 14.5 million people worked in the healthcare sector in July, with more than 4.8 million of those jobs at hospitals and more than 6.5 million jobs in ambulatory services.
In the larger economy, nonfarm payroll employment rose by 162,000 in July, with most of the new jobs coming in retail sales, food service, financial activities, and wholesale trade. The unemployment rate fell slightly to 7.4%, BLS reports.
Even with the modest gains, BLS said 11.5 million people were unemployed in July, a slight improvement from June. The number of long-term unemployed, defined as those who have been jobless for 27 weeks or longer, fell slightly to 4.2 million people in July who represented 37% of the unemployed.
CareConnect, the first provider-owned commercial health plan in New York, will offer lower prices and gives the healthcare provider "serious control" over quality and care coordination, says an NS-LIJHS executive.
North Shore-LIJ Health System has been granted a license by New York to launch the first provider-owned commercial health insurance plan on the state's health insurance exchange.
When enrollment begins on Oct. 1, members of the new North Shore-LIJ CareConnect, will have several plans to choose from. When the plan takes effect on Jan. 1, 2014, members will have access to one of the state's largest integrated healthcare systems, which includes 15 hospitals and ambulatory services at more than 400 physician and ambulatory practices in Long Island, Queens, Staten Island and Manhattan.
"As the first provider-owned health plan in New York, North Shore-LIJ CareConnect will be able to deliver a simple, total solution for individuals, families and businesses looking to access both high-quality medical care as well as more-affordable insurance coverage," North Shore-LIJ President/CEO Michael J. Dowling said in a media release.
"During an era when healthcare is becoming increasingly confusing, we're simplifying the process and transforming the way we connect with and serve our customers. In addition, taking risk for a population in this manner will significantly add to our capabilities to work productively and creatively with other third party insurance company partners."
Howard B. Gold, North Shore-LIJ's executive vice president of managed care and business development, told HealthLeaders Media that ConnectCare hopes to enroll between 10,000 and 15,000 lives in its first year of operation and offer a line of plans that are significantly less expensive than those of their competitors.
"The difference with us is that we are limiting the network to our providers where we have some serious control over quality and coordination. We can make it a much simpler process to get into care and get coordinated care among the various providers," Gold says.
"We are also setting the price lower than almost any other plan out there in the commercial marketplace now or even projected to be on the exchange. We are going to be about 10% or more lower than the Oxford Liberty plan which is the lowest in the market. The numbers we have seen right now [show] we are about $420 for an individual on the exchange this October on the silver plan. That is what has been approved so it is public. We have also seen that Aetna is about $600 for the silver plan on Long Island. United's plan that is out there is going to be about 30% higher than us."
Gold says CareConnect gives North Shore-LIJ the opportunity "to improve our ability to coordinate the care not just for this product but for anyone who comes into our health system. We are using this as a way to transform the model of care from fee-for-service to one where there are alternative arrangements for reimbursements. It has a major effect on the way you deliver care for everyone."
Healthcare economist Adam Powell says CareConnect is part of a growing trend towards payer-provider integration.
"We have recently witnessed the acquisition of West Penn Allegheny Health System by Highmark and the acquisition of Neighborhood Health Plan by Partners HealthCare," he says.
"As has long been demonstrated by Kaiser Permanente, when the delivery and financing of healthcare are integrated it is possible to offer high-value, innovative services that are otherwise less feasible. Integrated delivery systems are able to invest in services that improve quality and lower costs, but may not be billable using conventional fee-for-service means. As the insurer arm of an integrated delivery system can capture the savings from unbillable provider services the services can be financially justified."
Powell, president of Boston-based consultants Payer+Provider Inc., says that North Shore-LIJ can use CareConnect to increase the size of its patient population.
"Patients covered by the health plan are steered towards North Shore-LIJ providers," he says. "As the health system works toward treating more patients under value-based payment arrangements it has invested in developing the capabilities necessary to manage risk and keep patients out of the hospital. By running a health plan, North Shore-LIJ increases its ability to financially benefit from the risk management capabilities that it already must develop."
Alan Murray, vice president of managed care at North Shore-LIJ says CareConnect "signals a different way for health insurers and providers to work together."
"I also think it signals a different way to design products and for doctors, hospitals and insurers to design their plans so that services are coordinated better and that the highest quality providers rise to the top," he says.
"Those providers who are not involved in these kinds of activities or those insurers who are not involved with providers who are willing to be in these kinds of activities will fall by the wayside. Plans that do this, whether it is a provider that owns the plan or a plan that wants to work with providers like us, are the ones that are going to succeed and be very successful under the Affordable Care Act."
Gold says he does not anticipate that CareConnect will create friction with established health plans that now do business with North Shore-LIJ.
"We will work and need to work with every payer and every carrier," he says. "I am anticipating that this will improve it because it gives us the capability to work with them in a way we haven't had before. If I can manage the care of my own employees and the members who join our plan, we can help manage their care better too. And if we can manage their care better too, they have the opportunity to share risk and premium and coordination and to sell products with us. We have done that in a number of cases already with the full knowledge of the plans that we are going to go out into this market. We didn't hide from anyone that we're trying to do this."
A Montana health clinic about to mark its one-year anniversary has already saved the state $1.5 million by making available primary care services to about 11,000 employees, their dependents, and pre-Medicare retired state employees. Members pay no out-of-pocket costs.
National Public Radio had an interesting piece this week about Montana's innovative and effective efforts to curb healthcare costs by opening "the nation's first clinic for free primary healthcare services to its state government employees."
In an otherwise commendable story, however, NPR makes the mistake of repeatedly calling the services provided at the clinic "free." These services are not "free." Nothing in healthcare is "free."
In fact, the price of the primary care services is baked into the health insurance premiums paid by state employees and their employer, the state of Montana. It is part of a conscious decision by the state to launch affordable alternatives to fee-for-service medicine. It is much more accurate to say that these clinics are proving to be cost effective. This is not pettifogging. This is an important distinction.
Russ Hill, the administrator overseeing the Helena clinic for Montana's Health Care and Benefits Division, was interviewed for the NPR piece. In a subsequent interview with me, however, he made it clear that he's never said the services were free.
"There is nothing free. You won't hear me use that word," Hill says. "What we say is that we have no out-of-pocket costs for our members. They can get their office visit with their primary care physician. Normally that is $15. Under our plan there is no copayment if you come into the health center. With our normal program we have co-insurance and deductible that applies to lab and X-rays, but we don't have any co-deductible for lab or X-ray [work] that is done at the health center, or ordered by a health center provider."
"We have a self-funded medical plan and that pays for claims and can also pay for the services at the health center," Hill says. As with most company-sponsored health plans, the cost of premiums for Montana state employees "depends upon what plan they are on and if they are an employee, with family or with spouse only. There are a variety of things."
With that distinction made clear, we can better appreciate the success of the Helena clinic. It's not a money-losing giveaway. It's a willful strategy that adds credence to the idea that providing easy access to affordable and proactive care is a proven way to actually curtail the rising costs of healthcare.
The Helena clinic will mark its one-year anniversary on Aug. 31, but it has already saved the state an estimated $1.5 million by making available primary care services such as health screenings, flu shots, and wellness counseling that are done by a contracted provider staff to about 11,000 employees, their dependents, and pre-Medicare retired state employees. Screenings and flu shots are also made available to Medicare-eligible retired state employees.
Hill says the $1.5 million figure was attained in a cost-effectiveness analysis that compared the per-patient per-visit cost in the clinic with the same number of services delivered in the private, fee-for-service environment.
The savings come, he says, "because we are able to deliver services without the mark up that has to happen in the private fee-for-service model."
This $1.5 million savings does not factor in the enhanced productivity from state employees who are less likely to call in sick or have other health-related issues, thanks to their improved health status. With that in mind, the savings could be much higher. "It is part of our plan to measure all of that," Hill says.
The initial success in Helena has prompted expansion plans. "We opened our first health center on Aug. 31, 2012. That was in Helena. We opened our second one on June 3, 2013, in Billings. We will probably have nine or 10 of them around the state where we have concentrations of state employees," he says. "It has met and actually exceeded all of our expectations."
NPR notes that the clinic is a first for state employees, but businesses have been using this model successfully for several years now. And Hill is quick to call the state's decision to set up the clinics "an employer solution, not a government solution."
"It's an important distinction because we are not opening this to all citizens. This is just for Montana employees who are members of our health plan," he says.
In addition to providing primary care services, the clinics also offer wellness coaches. "On staff we have a registered dietician, an exercise physiologist, a behavioral health coach, and a wellness nurse. Those people work with the clinical team to work with our patients who have chronic diseases or even potentially acute diseases," Hill says. And because employees aren't tagged with out-of-pocket co-pays every time they go to the clinic, Hill says they are more likely to follow the advice of the physicians and the wellness staff.
"One of the patients was found to have extreme diabetes. He was a walking sugar cube," Hill says. "He came in and said 'I am ready to change everything with my life. I am a smoker. I know I need to lose weight. I know I need to exercise more.' Our wellness coaches were able to work with him and develop a program. Rather than 'we are going to start this and you are going to get really sore in the first week trying to do all of this' they developed a year-long process for him to make lifestyle changes. That is a big difference for people to make a real lifestyle change."
It would be interesting to compare the cost effectiveness of Montana's clinics and their ilk with those of high-deductible plans – which are the exact opposite. Rather than encouraging enrollees to seek preventive and proactive medical care, high-deductible plans make access to care virtually unaffordable.
Low income wage-earners on high-deductible plans who have medical needs are forced to decide between a $100 urgent care visit (if they're lucky) and ignoring the problem with a hope for the best. It's a roll-the-dice strategy, but nothing good comes when people delay medical care because they can't afford it.
And it's a strategy that isn't gaining traction with Montana state employees. "We don't offer a high-deductible plan to our employees," Hill says. "We evaluate high-deductible plans every year and whether we want to go that route and at this point it has not been the route we need to go to manage our costs. We have found other ways to keep our costs under control."
The processing of federally mandated quality measures by electronic health records systems "raises costs and effort for providers without leading to accurate data and is not sustainable," the American Hospital Association asserts.
Diane Jones
The American Hospital Association is continuing its call to delay the Oct. 1 deadline for Meaningful Use Stage 2 because of widespread complaints that electronic health records cannot accurately process federally mandated quality measures.
"(The) successful implementation of current policy requirements for eCQMs (electronic clinical quality measures) must be redirected so that the EHRs are working for the clinicians rather than the clinicians spending extensive amounts of time working for the EHRs," AHA recommended in a report.
AHA said that EHRs were initially expected to collect data through the routine care process and that the eCQM reporting tool would accurately extract and report measurements from the existing data and reduce provider burden. So far that hasn't happened because much of the needed data was not captured in the required format.
Instead, the report said "the current process raises costs and effort for providers without leading to accurate data and is not sustainable. More time is needed to develop and test a smaller set of eCQMs and demonstrate their feasibility."
Diane Jones, senior associate director of policy at AHA, declined to offer a definite timeframe for the rollback her association is seeking.
"We don't really have that," Jones says. "Our challenge is that we really need to see some evaluation about the real experience. We did this study based on our members and I would imagine that (Centers for Medicare & Medicaid Services) and others would have even more resources available to understand the larger scope of the problem. But we are very concerned about these requirements and the current pace of the program."
Jones says there are a number of reasons for the problems that have dogged EHR quality measures.
"The cumulative effect of all of these problems was system failure," she says. "It started out with the whole design of the policy itself, that we have this requirement that we report using specifications that are published after the final rule for the meaningful use program are published and there is a mad dash to actually implement them."
"Slow down the timeline to bring forward these specifications so that the vendors know what it is they are supposed to support and the providers have a clear understanding of what it is they are expected to do with this technology."
The AHA report examines the efforts of four hospitals of varying sizes and locations across the country as they try to make operational quality measures within their EHRs. The hospitals were not identified in the report.
"We decided to not focus on the 'who' and focus the uniform experience across the hospitals," Jones says. "We made a point of reaching out to hospitals that are not just champions of EHR but had experience using EHR even prior to the Meaningful Use program, and yet these folks were experiencing challenges. This is a diverse group. It is not one region of the country. They didn't use the same EHR technology and yet their experience was the same."
The report recommends:
Slowing the pace of the transition to electronic quality reporting with fewer, but better-tested measures, starting with Stage 2. The additional time would allow: policymakers to create a reliable policy process for eCQM implementation, a mechanism to provide eCQM updates, and a robust EHR testing/certification program; vendors to develop tools that support logical workflows, produce accurate measures and leverage all data already in the EHR; and hospitals to implement the tools in a way that supports their quality goals without excessive burden or risk to patients.
Making EHRs and eCQM reporting tools more flexible so that data capture can be aligned with workflow and interoperable so that data can be shared across hospital department systems.
Improving health IT standards for EHRs and eCQM reporting tools to address usability and data management to achieve Meaningful Use program expectations. Additional EHR fields to capture structured clinical information disrupts the usual clinical workflow, increases time on narrative and structured data documentation and decreases time for patient care.
Testing eCQMs for reliability and validity before adopting them in national programs. Implement eCQMs within hospitals as part of testing to ensure information flow is accurate and there is no adverse impact on quality and patient safety.
Providing clear guidance and tested tools to support successful hospital transition to increased electronic quality reporting requirements.
The report marks the latest public push by the AHA to roll back the MU Stage 2 Deadlines. Last week AHA President and CEO Rich Umbdenstock and AMA CEO James. L Madara, MD, sent a joint letter to Health and Human Services Secretary Kathleen Sebelius urging more "flexibility" in meeting the program's "all or nothing requirements."
"Our members, and the vendors they work with, report growing concerns that the rapidly approaching start date for Stage 2 is on a trajectory that will not provide enough time or adequate flexibility for a safe and orderly transition unless certain changes are made," the letter states.
"Geographies don't make decisions. Providers and provider organizations do," says a member of the Institute of Medicine. The focus should instead be on incentives designed to hold providers accountable for quality outcomes, an IOM committee urges.
The Institute of Medicine spoke out strongly this week against the federal government's use of geographically based value indexes as a way to address the significant variations in Medicare payments across regions of the nation.
"Also, the data showed there is as much variation within any geographical area we looked at including increasingly smaller ones, as there is between them suggesting that the criteria would be unfair because it would reward low-value providers in high-value regions and punish high-value providers in low-value regions," Hastings said at an IOM teleconference.
Committee Chair Joseph Newhouse, a professor of management at Harvard University, said the focus should instead be upon incentives designed to hold providers accountable for quality outcomes.
"We believe [the Centers for Medicare & Medicaid Services] has started down this route with a number of demonstrations that emphasize value, including accountable care organizations and medical homes, and we would encourage them to try to sort out which of these innovations seem to work well, which do not work so well, and proceed expeditiously with those that seem to work well."
The IOM committee recommended that:
Congress encourage and provide resources for CMS to make accessing Medicare and Medicaid data easier for researchers. CMS should collaborate with private insurers to collect, integrate, and analyze standardized data on spending, clinical and behavioral health outcomes, to enable more extensive comparisons of payments and quality and evaluation of value-based payment models across payers.
Congress should not adopt a geographically based value index for Medicare. Because geographic units are not where most healthcare decisions are made, a geographic value index would be a poorly targeted mechanism for encouraging value improvement. Adjusting payments geographically, based on any aggregate or composite measure of spending or quality, would unfairly reward low-value providers in high-value regions and punish high-value providers in low-value regions.
To improve value, CMS should continue to test payment reforms that incentivize the clinical and financial integration of healthcare delivery systems and thereby encourage their (1) coordination of care among individual providers, (2) real-time sharing of data and tracking of service use and health outcomes, (3) receipt and distribution of provider payments, and (4) assumption of some or all of the risk of managing the care continuum for their populations. Further, CMS should pilot programs that allow beneficiaries to share in the savings due to higher-value care.
During the transition to new payment models, CMS should conduct ongoing evaluations of the impact on value of the reforms included in Recommendation 3 by measuring Medicare spending and beneficiaries' clinical health outcomes. CMS should use the results of these evaluations to iteratively improve these payment models. CMS should also monitor how these reforms impact Medicare beneficiaries' access to medical care.
If evaluations of specific payment reforms demonstrate increased value, Congress should give CMS the flexibility to accelerate the transition from traditional Medicare to new payment models.
The American Medical Association and the American Hospital Association say they support widespread adoption of electronic health records, but are asking for flexibility to meet the program's requirements.
With Meaningful Use Stage 2 implementation deadlines looming in the next few months, the nation's two largest provider associations this week asked the federal government for "flexibility" to meet the program's "all-or-nothing" requirements.
Rich Umbdenstock
In a joint letter to Health and Human Services Secretary Kathleen Sebelius, the American Medical Association and the American Hospital Association pledged their support for the widespread adoption of electronic health records.
"However, we believe that the best way to move the program forward and ensure that no providers, particularly small and rural ones, are left behind is to realign the Meaningful Use Program's current requirements to ensure a safe, orderly transition to Stage 2," AHA President/CEO Rich Umbdenstock and AMA CEO James. L Madara, MD, said in their letter.
Stage 2 implementation for hospitals begins on Oct. 1, the first day of the federal fiscal year. For physicians, Stage 2 begins on Jan. 1, 2014. The AHA and the AMA said in their joint letter, however, that the implementation dates have placed EHR vendors on an overly aggressive deadline to provide technical support for more than 500,000 hospitals and physicians.
"Our members, and the vendors they work with, report growing concerns that the rapidly approaching start date for Stage 2 is on a trajectory that will not provide enough time or adequate flexibility for a safe and orderly transition unless certain changes are made," the letter states.
"As of July 17, the official federal list of certified vendor products shows only nine complete 2014 Edition certified EHRs for the inpatient setting, produced by only six vendors. By comparison, the list shows 313 complete 2011 Edition certified inpatient EHRs. On the ambulatory side, only 11 complete 2014 Edition certified EHRs are listed, while about 1,300 were certified for 2011."
Umbdenstock and Madara said they've also heard from members that vendors are delaying the delivery of systems updates and that providers who have not installed EHRs will be at the end of the line and won't get delivery for as long as 18 months.
"Of course, receiving an upgrade is only the first step in making the transition to the 2014 Edition and meeting the Meaningful Use requirements. It is reasonable to expect that a provider will need up to a year after receiving a technology upgrade to make all of the necessary changes to meet the program requirements," the letter states.
Umbdenstock and Madara said the aggressive Stage 2 deadline is also complicated by the demands for transitioning to ICD-10 by Oct. 1. 2014. "Furthermore, some providers are reporting significant challenges with the usability of their current certified EHRs, a situation that will be exacerbated as vendors channel their efforts to managing a nation-wide transition to the 2014 Edition," the letter stated.
The AHA and AMA said they were also concerned that the existing deadlines would "exacerbate thedigital divide" that now exists between small and rural hospitals and physician groups and their larger urban counterparts.
"Given this complexity and level of difficulty, a program with an 'all-or-nothing approach'—in which failure to meet any individual part of an objective, or missing a threshold by a small amount, leads to overall failure in meeting Meaningful Use—is overly burdensome," the letter says. "This seems especially true given that any provider failing to successfully transition to Stage 2 will not only miss an incentive payment but also receive a future payment penalty. Providers who fail to enter the program for the first time in 2014 will also receive future payment penalties."
Umbdenstock and Madara offered four recommendations that they said could be implemented without changing the law.
Allow providers at Stage 1 to meet the requirements using either the 2011 certified Edition EHR, or the 2014 certified Edition EHR. This will allow more time for vendors to complete upgrades, allowing advanced providers to move ahead to Stage 2, while holding harmless those remaining or entering the program at Stage 1.
Establish a 90-day reporting period for the first year of each new stage of Meaningful Use for all providers, similar to what was done for Stage 1. This will allow upgrades to be spread out over time, rather than being clustered on certain dates.
Offer greater flexibility to providers in meeting Stage 2 to ameliorate the "all-or-nothing" problem, and recognize that the level of change in Stage 2 will take time to accomplish.
Extend each stage of Meaningful Use to no less than three years for all providers. This change recognizes that vendors need time to develop usable and safe upgrades, and providers need time to implement systems and optimize their use before undertaking yet another upgrade.
A study finds that the risk of injury deaths is 22% higher in the most rural counties than in the most urban areas. While the data reveals some surprising findings, the lead author says she can only speculate as to the reasons why.
Sage Myers, MD
Caution: Rural life may be hazardous to your health.
A study in the Annals of Emergency Medicine finds that the risk of injury death is about 20% higher in rural areas when compared with large cities.
"All of us have this maybe more emotional reaction when you talk about safety as it relates to cities and rural areas. When we think about safety, we think about things that we are scared of, people attacking us and shooting us," says Myers, an associate professor at the Perelman School of Medicine at the University of Pennsylvania, and a pediatric emergency physician at Children's Hospital of Philadelphia.
"So we have that emotional connection that cities are not safe. But when you think of safety as your overall risk of injury to your person with all kinds of injuries included, I was surprised to see that it turns out to be the opposite, that cities are the safest."
Myers and her colleagues analyzed 1,295,919 injury deaths that occurred between 1999 and 2006 and found that the risk was 22% higher in the most rural counties than in the most urban. The most common causes of injury death were motor vehicle crashes, leading to 27.61 deaths per 100,000 people in most rural areas and 10.58 per 100,000 in most urban areas.
Firearm-related deaths statistics were not much different in rural and urban areas for the entire population. However, when age subgroups were examined, firearm-related deaths were significantly higher in rural areas for children and people 45 years and older. For people aged 20–44, the firearm-related death risk was significantly lower in rural areas.
Myers says the risk of homicide is higher in big cities, but the risk of unintentional death is 40% higher in most rural areas when compared with their urban counterparts. "And overall, the rate of unintentional injury dwarfs the risk of homicide, with the rate of unintentional injury more than 15 times that of homicide among the entire population," Myers says. "The unintentional injuries are what are driving the whole thing. The unintentional injuries are so much higher than homicides and suicides in the rural areas than in urban."
While the study uncovered surprising findings, Myers says she can only speculate as to the reasons why. We've all heard about that "golden hour" of access to medical care after a traumatic injury that can mean the difference between life and death. Was that a factor?
"There probably is some component to access to care, but when we tried to adjust it in the way that we could with the data we had and look at—'do you have a trauma center in your county or surrounding county and how many do you have?'—to give an overall sense of 'do you have access to care?' and put that back into our analysis, it didn't seem to change the overall, even though there was a mild attenuation," Myers says. "But the same overall difference between rural and urban areas was still there. So it seems like there is more to it than just that."
Injury death risk fell in rural areas with larger populations of African-Americans, and Myers says she can only guess as to why. "Suicides have been found to be higher in rural areas than in urban areas and the black populations tend to be somewhat protected from suicides. That may be part of it," she says.
The opposite was true for rural counties with large Latino populations, which had significantly higher risk of injury death than rural counties with small Latino populations. And perhaps most surprisingly, the study found that risk of injury death increased in rural areas with higher income and education levels. Explaining the causes for this and other findings, Myers says, "was not our focus, but it was more hypothesis-generating. Let's have further studies that look into this and try to see some of the underlying reasons."
Myers says she hopes the study will prompt people to reexamine assumptions about healthcare needs in rural and urban America.
"First, it is important to try to dispel the myth that cities are dangerous and this information shows that when you consider injury-related death, overall cities aren't more dangerous. In fact we found them to be safer," she says.
"Second, we saw the predominance of injury-related death risk tended to be in areas of the country where we have the least access to emergency physicians and trauma care and maybe we should use this to do more of a population planning evaluation of how do we put the resources where the needs are as opposed to what is happening now, which is a little more organic."
For example, Myers' data showed that elderly falls represented a more significant injury death risk in urban areas than in rural areas. "So it may be more cost-effective and effective in general to tailor safety and injury prevention in urban areas around falls among the elderly, rather than what we are doing now, which is a bit of a global technique of 'here is something that is important in safety. Let's do something to prevent it across the country,'" she says. "There may be parts of the country where you don't need that same message with whatever it is you are trying to change."
As a practical tool, Myers says her study underscores the implications of proper staffing of emergency departments and trauma care systems in rural areas, which she says tend to be underserved as it is.
"It can only help in the quest to make sure rural hospitals have access to the resources that are needed to care for the population they're serving," she says. "There are lots of rural emergency departments that are staffed by people who may or may not have the full training they need to care for these patients who are severely injured or severely sick. This could help support them as they are trying to move forward."
