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."
Georgia's new 23-hospital collaborative, with its focus on operational initiatives and improving population health, "represents a formidable force with substantial bargaining power" and may be the first stage of something bigger, says one healthcare analyst.
Ninfa Saunders, CEO/president of Central Georgia Health System
Twenty-three hospitals and health systems and about 1,500 physicians in central and south Georgia on Tuesday announced the formation of a clinically integrated non-equity partnership called Stratus Healthcare.
Ninfa Saunders, CEO/president of Macon-based Central Georgia Health System, which along with Tift Regional Health System in Tifton were among the original advocates for Stratus Healthcare, says the initial focus of the collaborative will be to improve population health using best practices, networking, shared services, and coordinating primary and specialty care needs for the region.
"The one thing that is different about this part of Georgia is that every hospital wanted to remain independent," Saunders said in an interview. "So mergers and acquisitions, unlike a lot of areas, were not in the recipe for this area. What was desired was more independence and a focus on local healthcare by local physicians and to develop a collaborative or a strategic partnership that allows us to do as many things as possible in an aligned way to meet the health needs of the population."
Healthcare economist Adam Powell believes Stratus Healthcare has been created as the precursor to something else.
"Although it has been formed as an alliance, the press release announcing its creation mentions that it intends to eventually transform into an LLC. I see this as a merger in the making that may have been announced early for strategic reasons. Given the number of organizations involved, it may have been easiest to accomplish this in stages," Powell wrote in an email exchange with HealthLeaders Media.
"Furthermore, Tift Regional Health System is currently actively seeking a new COO through the executive search firm Witt/Kieffer. Given the operational changes associated with this alliance, the announcement may have been made rapidly so that progress would be underway before the installation of a new COO. Tift is operating from a position of strength, as it held $336 million in net assets at the end of 2012, $42 million of which had been accumulated during the year. Participating offers it the opportunity to continue its success," Powell wrote.
Saunders says she expects that Stratus will evolve to include more operational initiatives, and grow to include more hospitals in the coming years.
"What I see in terms of strengthening the partnership is a slight movement from non-equity partnership to some shared equity, but not quite mergers and acquisitions," she says. "We may find some projects we want to invest in together. Now we are pooling resources specific to hospitals to meet the particular needs of that particular area or population. That is where I begin to see this sharing, which is joint projects, joint investments, joint collaboratives, with equity associated with it. As we are able to formulate systems of care that not only connect hospitals but also the post-acute and retail side, the outpatient ambulatory side, then it begins to define itself differently and it will be open to many other arrangements."
While plans are underway to form a group purchasing agreement, Saunders says there are no immediate plans to use the clout of the partnership to barter for better rates with health insurance providers.
"The focus right now is on four objectives: How do we get physicians and hospitals together so that our patients will have the right access to the right care at the right time at the right cost?" she says. "We said to ourselves 'let's go back to basics. How do we improve the quality of care with this population first? How do we put the processes in place so that we are evidence-based and we can measure processes in the same way and focus on outcomes, raise the bar in terms of our outcomes and then anything can come after that."
Saunders says another target is the development of a primary and specialty care networks for the region.
"We are spread out so we are concerned about recruiting to the region, given the shortage. We are looking at specialty care networks and what specialties are needed," she says. "The medical center that I run is a teaching hospital, the second-largest in Georgia. So one of the things was what specialists might we make available for our partner hospitals. Or if there is a need to hire in a particular hospital how could we join like-minded people that have the same needs so that not everybody is investing and capitalizing 100% of that expense," she says.
The partnership also plans to examine shared services. "How can we begin to look at the redesign of care together? How do we reduce the cost through group purchasing, maybe looking at running programs under one umbrella as opposed to everyone having one," Saunders says.
The partnership will also consider forming a regional emergency medicine consortium.
"That allows all of the emergency room physicians to identify how we can [provide] care without having to repeat things over and over again," Saunders says. "When a patient is transferred to another hospital we tend to repeat the diagnostics. Why do that if our processes of care and our algorithms of care have been agreed upon by all of the players. The same thing with hospitalist medicine, which is one thing we are interested in growing in a regional way so that not every hospital is attempting to manage this on their own."
Powell, president of Boston-based consultants Payer+Provider Syndicate, says this week's announcement builds upon several other recent partnerships in Georgia. "In April 2012, Central Georgia Health System developed a partnership with Tift Regional Medical Center to coordinate information systems, clinical services, and business services. Central Georgia Health System also recently partnered with Peach Regional Medical Center to build The Medical Center of Peach County, a new facility that will expand access to care in the community," he points out.
Powell says that by sharing information Stratus Healthcare hospitals will be able to manage risk and expenditures as they migrate to value-based payment.
"Under (accountable care organization) contracts, health systems are liable for the cost of care a patient incurs, even if the patient goes outside of the ACO to receive care. Poor information sharing can lead to duplicative testing," Powell says. "By pooling information, the health systems can avoid performing duplicative testing and can better coordinate care for patients seeking care at multiple institutions within the region."
"Stratus goes a step further," Powell explains, "by enabling its members to engage in collective purchasing and the sharing of business resources. Given the substantial proportion of Georgia hospitals in the alliance, it represents a formidable force with substantial bargaining power."
"Across the country, we have seen a wave of provider consolidation and integration. While Stratus is notable for the relatively large number of organizations it contains and its relatively loose nature, it is part of a greater trend of cooperation," Powell says. "While state governments have been forming regional health information networks, this alliance goes a step further, as it moves the organizations towards operational integration.
Stratus Healthcare member hospitals and their medical staffs include:
Bleckley Memorial Hospital (Cochran)
Central Georgia Health System, which includes: Medical Center of Central Georgia (Macon); Central Georgia Rehabilitation Hospital (Macon); and Medical Center of Peach County (Byron)
Coffee Regional Medical Center (Douglas)
Columbus Regional Health System, which includes: Columbus Regional Medical Center (Columbus); Doctors Hospital (Columbus); and Hughston Hospital (Columbus)
Crisp Regional Hospital (Cordele)
Dodge County Hospital (Eastman)
Houston Healthcare, which includes: Houston Medical Center (Warner Robins); and Perry Hospital (Perry)
Jasper Memorial Hospital (Monticello)
Oconee Regional Medical Center (Milledgeville)
Putnam General Hospital (Eatonton)
South Georgia Medical Center Health System, which includes: South Georgia Medical Center (Valdosta); Smith Northview Hospital (Valdosta); and Louis Smith Memorial Hospital (Lakeland); Clinch Memorial Hospital (Homerville); SGMC Berrien Campus (Nashville)
Taylor Regional Hospital (Hawkinsville)
Tift Regional Health System, which includes: Tift Regional Medical Center (Tifton); and Cook Medical Center (Adel).
Researchers report that the existing distribution model of organs for liver transplants is unbalanced and depends upon longstanding relationships among medical centers. Organ donor advocates are calling for a change in the allocation process.
David C. Mulligan, MD
Organ donor advocates want to copy the mathematical formulas that draw boundaries for political maps and zoning districts and use them to create a more equitable allocation of transplanted livers from deceased donors.
"Currently the geographic disparity for access to livers in this country is great," says David C. Mulligan, MD, director of Surgical Transplantation at Mayo Clinic Hospital in Phoenix, AZ. "We need to find better ways to improve our system of allocation to reduce this disparity so that in the end, access to liver transplants will be the same or as close to the same as possible no matter where you live in this country."
Geography can mean the difference between a 10% – 90% chance of dying while on a waiting list for a donor liver, researchers say. "The existing system is based on the geography of where a handful of centers that were performing liver transplantation were located," says Mulligan, who is also chair of the liver committee for the Organ Procurement and Transplantation Network/United Network for Organ Sharing.
Researchers at Johns Hopkins University School of Medicine reported this month that the existing "unbalanced" distribution model depends upon the longstanding relationships among medical centers.
Mulligan agrees.
"When liver transplantation was first developed in this country, the transplants were done at a handful of centers, five or six centers started the whole process," he says. "They were distributed across the country from Pittsburgh and Dallas and Los Angeles and Omaha NE so each of these programs as they were beginning to develop needed to try to determine where organs could potentially come from."
"They knew that the cold storage time had an impact on the outcome of the transplant so they didn't want to be pulling organs from one part of the country in those days and putting them in on the other coast into their patients. They tried to develop systems or regions so that organs when they were recovered by the organ procurement organizations as they were being developed could get placed into the patients on the transplant lists that were closest in proximity to get the best possible outcome," Mulligan explains.
"As the success of organ transplant continued, we could see that the ability for preserving these organs improved, the ability to do the transplants improved, the outcomes improved, and more and more centers started to perform liver transplants and there became a need for a more developed and complex way of trying to approve the allocation for these organs to get to their patients."
Dorry L. Segev, MD, an associate professor of surgery and epidemiology at the Johns Hopkins University School of Medicine is the author of a report that examines the use of mathematical formulas to create a more equitable distribution, which he calls "gerrymandering for the public good."
"We have applied to transplantation the same math used for political redistricting, school assignments, wildlife preservation and zoning issues," Segev said in a media release. His report was published this month online in the American Journal of Transplantation.
Mulligan says he supports the recommendations from the Johns Hopkins study and that the OPTN/UNOSliver committee is reviewing redistribution models. Now, however, he says the biggest roadblock towards a coordinated national system may be turf wars among transplants centers.
"I would love to say that everyone is on the page. We all agree that all of the transplant physicians and surgeons and organ procurement organizations want what is best for their patients. The biggest roadblock is getting buy-in for thinking in a different parameter, taking a step back and saying what is best for all patients in the United States," Mulligan says.
"The big piece is to get everyone to look at the big picture, to look at all patients in the country and not just their own. Because in areas where there is a huge disparity and long waiting times in liver transplants those centers are going to be excited to see a new opportunity for their patients to get organs more effectively and efficiently."
"On the flip side," Mulligan says, "centers and regions in the country that have very productive organ procurement organizations and a lot of organ donation and populations of donors who are very motivated, those centers look at this type of a proposal as a hurt to their patients, that their patients are now going to have to wait longer because they are sharing with other centers."
If it were up to him, Mulligan says he'd like to see a nationally coordinated allocation plan for donated livers in place within the next few months. "But realistically, I would like to see the first step of Phase 1 of a redistricting plan in place and out for public comment and going forward with board approval for implementation within the next two years," he says. "That is going to be a bold undertaking, but that is what we are trying to achieve. It may take longer, but I am going to do everything possible to make it as short a time as possible as I can."
If the coordinated effort works for donated livers, Mulligan says it could serve as a distribution model for other donated organs, which often have their own unique distribution networks.
"If this is successful in liver [allocations] we will need to study to see if there is something we can do to improve the way hearts are distributed, because they do a whole different system," he says. "They are distributed based on circle distribution from each donor hospital, how many hundreds of miles they go out and how sick they are. We would look to applying these types of mathematical models to all organs and maybe adjust the models to factors that are necessary for each of these organs to make the process better."
Observers believe such a change would result in potentially far-reaching consequences for companies that fall under the purview of the SEC, including private, for-profit hospitals, their directors, officers, and employees.
G. Derek Andreson
At The Wall Street Journal CFO Network's Annual Meeting in June, Securities and Exchange Commission Chair Mary Jo White said she would push to modify the commission's "no-admit no-deny" policy and require more admissions of guilt from defendants when settling enforcement cases.
White's proposal represents a pronounced departure from the SEC's longstanding no-admit no-deny policy under which defendants settle cases without admitting or denying wrongdoing. Currently, the SEC requires such admissions in a narrow array of cases where defendants admit certain facts as part of a guilty plea or other criminal or regulatory agreement.
White told the CFOs that the no-admit, no-deny policy will still be used in the "majority" of cases and that "having 'no-admit, no-deny' settlement protocols in your arsenal as a civil enforcement agency [is] critically important to maintain," according to a Reuters report.
The change comes after recent criticism of the policy from two federal judges and U.S. Sen. Elizabeth Warren (D-MA). Observers believe such a change would result in potentially far-reaching consequences for companies that fall under the purview of the SEC, including private, for-profit hospitals, their directors, officers, and employees.
G. Derek Andreson, a partner at the law firm of Pillsbury Winthrop Shaw Pittman LLP, and an expert on SEC enforcement matters, spoke with HealthLeaders Media about the potential effects of such an SEC policy shift.
HLM: Why is the SEC doing this?
Andreson: The SEC has been on the receiving end of some criticism both from the bench and others concerning the fact that this policy of 'no-admit no-deny' leads to perhaps a policy that is too lenient and that it really behooves both the government and the public to have a policy with a little bit more teeth. They tried to strike the balance here by including this option now, which gives the SEC more teeth certainly on the negotiating table. It remains to be seen what the effects are but it gives them the teeth they're looking for.
HLM: How will the SEC decide when to apply this new policy?
Andreson: You are going to see this policy evolve over time. They are going to be relatively conservative with how they roll it out. They will identify cases where the evidence is particularly egregious or particularly strong and they will certainly choose those initial cases to roll this out and you will see some flexibility built in down the road as it evolves and people become more aware of it.
More importantly, its significance will be at the negotiating table and perhaps give them results that they otherwise wouldn't be able to obtain for fear of simply the SEC pressing this issue.
HLM: Is there a set-in-stone implementation date? Do they require any legislation to do this?
Andreson: This is something that they have the ability to do on their own. It falls within their purview. I am not sure exactly when they are going to begin this process. This is something that I believe was spearheaded by Mary Jo White, a former federal prosecutor and U.S. attorney for the Southern District of New York.
It is consistent with her prosecutorial approach, a little bit more aggressive. It gives them more leverage. They really wanted to give some teeth to an agency that sometimes finds itself needing more leverage.
HLM: SEC commissioners are political appointees. Will we see uneven applications of this policy?
Andreson: Well, sure. Things change. Commissioners come and go and as leadership changes at the SEC the policy may be modified. It may be used more or less depending upon who is there.
But once they lay the groundwork for it and roll it out, presumably in the near future they are going to set certain bench marks. Consistency, particularly in enforcement matters, is one of the most important principles. So you are going to see them try to see some consistency applied through the years. But again it is certainly subject to who is running the show.
HLM: Would forcing some defendants to admit their guilt compel them to fight when they otherwise would have settled?
Andreson: Absolutely. That is one of the anticipated effects that remain to be seen. But you are already seeing some of the commentary out there referencing that fact particularly in parallel investigations where you might have private litigants waiting in the wings watching to see what happens.
Certainly in the case of parallel Department of Justice and SEC matters where admission of wrongdoing in an SEC enforcement matter may well embolden DOJ prosecutors. Perhaps they had shelved the case or perhaps they had hit a wall in the case as far as evidence.
This may embolden them to pursue further that target in particular. It may embolden private litigants to move forward particularly given the heightened procedural processes that they must go through. Having an admission like that certainly gives strength to the case for private litigants or at least their motivation and their conviction going forward.
HLM: Why is it so important for so many of these entities to have no admission of guilt?
Andreson: Without admitting guilt it doesn't give a leg up to private plaintiffs or DOJ. It is simply a neutral factor. That is what was so helpful to them, particularly in these parallel investigations. Now I think it is going to forestall those investigations or cause them to go to trial because if their hand is forced by the SEC to admit it then they are going to have other problems.
HLM: Could other federal regulatory entities, such as the Department of Health and Human Services, look at the SEC policy shift and do the same thing?
Andreson: Any regulatory body out there that relies on the same policy of no-admit no-deny is really going to take note of what the SEC has done and they are going to really pay attention to what effect that policy has in the short term to see how it is playing out.
HLM: What are the implications for investor-owned hospitals?
Andreson: I am not sure I could share observations about the specific effects this may have on that sector. It remains to be seen. They have crafted this new policy. They are getting ready to roll it out. They are going to choose their initial cases carefully and use them as benchmarks.
But I am not sure it is going to have sector specific implications at this point. It's going to depend upon the evidence in the case and how it reaches the conduct is at issue. Those are going to be the driving factors here, not so much the sectors.
HLM: How should businesses prepare as this policy is ramped up?
Andreson: Having an awareness that this new policy is about to be implemented is important. But if they find themselves on the receiving end of an SEC inquiry it certainly behooves them to take a look at what private litigation may ensue from that, whether there is any prospect of DOJ involvement or a parallel investigation by DOJ, and if so how that might be affected by this new policy.
Evaluating for themselves what potentially the evidence is and whether that new policy might be applied to them. The SEC has made clear that in the majority of cases going forward they are not going to be seeking this but that they are going to use this sparingly. We will see if that actually happens.
Secondly, recognize that the SEC has intimated that they are only going to be using this is a small subset of cases, at least initially. Assuming that is the case it is important for hospitals that might be subject to SEC jurisdiction to first and foremost be aware of the policy and second if they find themselves on the receiving end of an SEC inquiry, to do two things.
The first is to ask themselves if there are other agencies or parallel investigations that potentially may ensue, whether it is private litigants or DOJ, and be aware of the effect it may have on the parallel litigation. The second thing is to evaluate what the evidence may be in that case.
How strong is the case? A bit of introspection might be helpful at that point because if they are dealing with facts or evidence that potentially egregious from the perspective of the SEC it may be one of those cases where the SEC throws this new policy out on the table as leverage.
In our April Intelligence Report, the top challenge cited by leaders in pursuing a collaborative care model is "concerns about the ultimate cost savings." Members cited coding discrepancies, budget cuts, and convincing physicians to share the risks as barriers to incorporating a collaborative care model.
What do you see as the path to ensure cost savings in a collaborative care model, and what can leaders do to facilitate that?
Robert Ross, MD
Medical Director of Community Health Strategy St. Charles Health System, St. Charles Medical Group
Bend, Ore.
On behavioral health: We have four clinics that are Tier 3 medical homes and in three of them we have fulltime behavioral health folks. For example, if a physician or actually any member of the team identifies a patient as being depressed they can get help not just in terms of medication but also using both psychotherapy or some type behavioral therapy and medications, which results in better outcomes for patients.
On coordinating payments: One of the problems we encounter is that you have to divide up the billing and costs for the separate services. Ultimately to have the many services, not just behavioral health but other things like pharmacy services, you could name a billion things, especially with people who have difficulty with access, so combining those and paying for them with some sort of global fee, probably capitation, would make it easier for everyone concerned and not just physicians. It eliminates costs for insurers as well in terms of verifying that services were delivered. Ultimately that is where we are heading, but that is a guess.
On coding shortcomings: There is a huge unexplored area of what is not coded and what things that patients have or experience that potentially are in the notes but not discerned by payers. The data we mine is determined by the provider codes and that is not a particularly accurate way of getting at people's problems because you code for what you are paid for and not necessarily for all the problems that are contained in a patient visit. It's a very complex problem.
Andre Boyd
COO TriStar Greenview Regional Hospital
Bowling Green, Ky.
We are starting the whole process of clinical integration through our lead CMO for our division. We are garnering support from each of the physician practices in each of our cities that we provide services for.
With that, will have a true infrastructure to help manage the data collection as well as help manage the partnerships and the follow-up care that we need to do with our physicians.
In my organization typically collaborative care means partnering with our providers and other ancillary organizations to provide the best care possible for our patients. The biggest issue is getting doctors to understand that it makes a difference. When we talk about partnering to share risk it means we are taking an opportunity to move the quality agenda forward for our organization and for their patient population but doing it where if you are able to achieve this outcome, then you get incentivized.
It's also making sure that we are reducing or eliminating as much variation in clinical care as possible, and to do that we have to partner with doctors and get on the same path to make sure we understand that here at Greenview we do a process for congestive heart failure. Maybe that same process will work collaboratively at another hospital we own. So let's make sure we are standardizing our policies and programs appropriately."
Maureen Swick, RN, PhD
Senior Vice President, Chief Nurse Executive Inova Health System
Falls Church, Va.
At Inova we have utilized Lean teams looking at our care delivery model, ensuring that the right person is doing the right job with regard to roles and responsibilities. We have also implemented multidisciplinary rounds. It's really about team. From the efficiency and patient and family engagement perspective, that helps facilitate a more efficient process by engaging the patient and the family up front with the plan of care for the patient. The inpatient coordination becomes much more efficient for the patient and the family.
The amount of rework, phone calls, delays, testing, and coordination is huge when that is not done in an integrated and collaborative way right up front.
When we talk about the team with the physicians and everyone working collaboratively on the plan of care that helps with the length of stay. That is how we are monitoring whether or not we are successful.
From a cost savings perspective, when we looked at our care delivery model we were heavy with RNs and now we have implemented techs because we used our Lean experts and looked at having nurses function to their full license and training. If they had anything that did not require their license, we developed a role for the clinical technicians. That shift right there from a mostly RN model to a mixed model is a huge cost savings from a labor perspective.
Thomas G. Lundquist, MD
President and CEO, AnewCare Collaborative,
Chief Clinical Integration Officer, Integrated Solutions Health Network Johnson City, Tenn.
We are an ACO that was formed in the middle of last year, a Medicare shared-savings program. But we also have commercial lives that are starting to access our narrow network under the ACO.
A big challenge is to find the right partners and the finances that work, but we are marching down that path slowly but surely. Another challenge is devoting the resources to build effective teams within the physicians' offices that are participating in the integrated care model. There is a need to, especially on the primary care front, bolster the ranks of care coordination. That could be nurses or social workers or even public health student graduates who understand population health dynamics.
Not only do you need the people, but you need the right tools to be effective and reach out to patients in a consistent and coordinated manner that can be documented in terms of how they do their work. You have to make that investment in people and process tools or you will come up with a lack of a return on investment.
We are fighting all the pressures on healthcare in terms of budget cuts and its impacts of our organizations and how they are funded. That is the goal, to put the people and the teams together and design the processes for putting the people in place who can then reach out to the patients on behalf of the physicians and work with the physician in a team atmosphere.
Members of the U.S. Senate Finance Committee suggest that Farzad Mostashari, MD, the National Coordinator for Health Information Technology, has little or no idea of the challenges rural healthcare providers face as they grapple with Meaningful Use requirements.
With all of the fighting, delays, and splashy headlines surrounding the Patient Protection and Affordable Care Act, the evolving status of meaningful use and the adoption of electronic health records often take a back seat.
Yet, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 and the $33 billion that came with it are leading and funding the development of the complex HIT infrastructure that will make possible key components of PPACA.
There are rumblings, however, that rural providers are falling behind with HITECH implementation. For example, only one-third of rural hospitals have electronic medical records systems, compared with half of all urban hospitals.
Members of the U.S. Senate Finance Committee Wednesday sought answers on the status of meaningful use in rural America from Farzad Mostashari, MD, the National Coordinator for Health Information Technology. "I'm concerned about the digital divide may only get larger as rural hospitals are expected to take the leap into the more rigorous requirements of [Meaningful Use] Stage 2," Sen. John Thune, (R-SD), told Mostashari during the hearing.
"They have already expressed great concerns about Stage 2. I am of the view that [Office of the National Coordinator] and [Centers for Medicare & Medicaid Services] ought to develop a way for rural hospitals to achieve Stage 2 while allowing more advanced healthcare systems and providers to move on to Stage 3 if they are ready. The question would be will you commit to giving rural providers more time to achieve Stage 2?"
Mostashari replied that federal officials "have been quite open to dialog with the rural community and how we can help them achieve success and not necessarily accept that they are necessarily going to be further behind."
While challenges remain, Mostashari says that rural providers have made tremendous progress in adopting electronic health records. In fact, Mostashari says he is so confident in the advances that smaller hospitals are making, that deadlines have been moved up, not back.
"We set a goal of getting 1,000 critical access hospitals to meaningful use by 2014. We are going to revise that goal to get 1,000 critical access hospitals to meaningful use by the end of this year," Mostashari says.
"We think we are making good progress with those hospitals through the technical assistance and coordination that is possible. So, we are open to dialog. But I would much rather see the rural hospitals be able to keep up rather than me acknowledge that they are going to fall behind."
An independent review appears to back up Mostashari's claims that rural America is making progress on the electronic medical records front. A report from the Robert Wood Johnson Foundation, co-authored by Mathematica Policy Research and the Harvard School of Public Health, finds that the proportion of rural hospitals with at least a basic EHR increased from 9.8% to 33.5% from 2010-12. During the same time urban hospitals saw EHR adoption rates rise from 17% to 47.7%.
"The inpatient divide between rural and smaller hospitals compared to better resourced urban hospitals, particularly teaching hospitals, remains, but it is closing," says study co-author Michael Painter, MD, senior program officer at Robert Wood Johnson Foundation.
"The other thing we are finding is that the rate of adoption seems to be accelerating among the small and rural hospitals compared with the larger better resourced urban hospitals. That makes sense because the better-resourced urbans accelerated early on and now that is leveling off. The more-challenged small and rural hospitals are accelerating. Where this all plays out is hard to see. We will keep monitoring it in the coming years."
Painter says the percentages of hospitals that have achieved meaningful use actually could be significantly higher than what his report found because it uses data from 2012.
"Those numbers are a moving target. When we looked at 2011 data, only 4% were meeting Stage 1 Meaningful Use. From that dipstick to the next year it went to 44%. So we would expect that when we looked at who is close to pushing over on the Stage 1 criteria there is a huge number there."
"You can't get that mired down in what those snapshot-in-time numbers mean. What we are seeing is a trending all in the right direction, with some ongoing small and rural gaps, although that seems to be closing. But we are not out of the woods yet," Painter said.
Back in Washington, several members of the committee, including Sen. Pat Roberts, (R-KS), made jokes about Mostashari's trademark bow tie and suggested that he and other federal bureaucrats have little or no idea of the challenges that rural providers face as they grapple with meaningful use.
"My concern is I don't think we are getting the word west of Highway 81 in Kansas…," Roberts said. "It's like Paul Harvey used to do with Page 1 and Page 2. Page one and I will be back in just a minute. Well you've got Phase 1 and Phase 2. If we could just pause and make sure that most of the rural providers know what is going on."
"I get two sides of the story. I talk with the people in Topeka and they say everything is going as best as it possibly can. But I get a lot of calls from providers saying this is the proverbial wet horse blanket. My suggestion would be [to] take this show on the road. I would recommend Hayes, KS or Dodge City, KS. That is my hometown. I'm not sure I would recommend wearing a bow tie in Dodge City. But if you could go out and sort of take this digital show on the road that would be helpful. Or maybe have these folks come in because I know you are extremely busy."
That sentiment was shared by Committee Chairman Max Baucus, (D-MT), who urged Mostashari to "get out… of your offices and out to rural America. See it. Smell it and taste it, and know what it is. It is one thing to conceptualize it. It is something else to experience it."
"I mention you, Dr. Mostashari. I don't know why. I sense you are a Philadelphia guy, an eastern guy, a big city guy. There is a huge difference. Eighty percent of life is just showing up, just getting out there, being there, seeing it. Get out from behind your desk. It is well worth it. You're going to make fewer mistakes with respect to rural providers if you get out and see it."
