The slow pace of hospital quality improvement frustrates patient safety advocates.
ORLANDO – Hospital leaders must adopt safety and quality as primary business strategies, rather than regarding them as tertiary metrics that rank below finances and other stressors on the C suite's list of top priorities.
That's according to Derek Feeley, president and CEO of the Institute for Healthcare Improvement.
Speaking to reporters here this month at IHI's 31st National Forum, Feeley says there are moral and financial imperatives for making safety a priority.
"The thing that should be uppermost in every healthcare leaders' minds is safety," he says. "If we create high-quality, safe healthcare systems, they are much more likely to be thriving and financially viable than healthcare systems that are unsafe and delivering a quality of care that patients need or want."
Given the stressors of hospital operations, Feeley says it's not surprising that hospital leaders get sidetracked.
"It's the way the system works. The current environment is one of growing consolidation and (people) are trying to figure out how to make sense of these often-conflicting payment models," he says. "Some of it's also what the board of governance and senior executives value, and part of that is the financial vitality of the institution."
"I keep trying to bring them back to there's another way to think about this. Is it at least possible to conceive that we can make quick progress on safety as our business strategy?" he says.
In August, the World Health Organization issued a report that one-in-10 hospital patients in "high-income countries" suffer harm, and that half of those adverse events are preventable.
IHI President Emeritus and Senior Fellow Donald M. Berwick, MD, was asked by reporters to assess what progress the healthcare sector has made over the past 20 years since the Institute of Medicine's landmark 1999 To Err is Human report.
"I'd say it's a B+ on the project-level improvements," Berwick replied, citing notable reductions in infections, pressure ulcers, ventilator pneumonia and surgical complications.
"Place-by-place you can see pretty serious improvements once people decide to work on it," he says.
The problem, he says, is that safety improvements are missing on a system level and can vary greatly among healthcare providers, and within geographic areas.
"We're at the really the point now where it's time to get serious," Berwick says. "We now know we really don't need to have pressure ulcers. We really don't need to have surgical site infections. We know how to virtually eliminate them."
"The bad news is we're seeing surveys, and when you ask healthcare executives and senior teams to rank what's on their mind, whereas safety was pretty high up there, number one or two a few years ago, it's now five or six, and we're finding places backing away," he says.
Rick Pollack, president and CEO of the American Hospital Association, disagreed "categorically" with the IHI leaders, adding that the "focus on quality in the DNA of our own organizations."
He noted that, between 2014 and 2018, hospitals in the AHA's Hospital Improvement Innovation Network program saved $1.2 billion in health care costs, prevented 141,000 patient safety events and saved 14,000 lives.
"To coin a phrase, quality is job one. If you're not providing the highest quality possible, then you're not serving your mission," Pollack told HealthLeaders. "The reality is that what you often see is people will rather shut down the service completely in order to provide the highest quality and services that they do provide.
That commitment to quality and safety metrics plays out in executive compensation.
"We see more performance-based compensation linked to quality Improvement than we ever have the past," he said.
Feeley said quality and safety are being address, but not quickly enough.
"It's not that we haven't made progress, but 20 years on, this ought to be the norm," he says. "We should have already moved on from patient safety being something we do and our project being a way (to do it), but it's not yet embedded. It still requires constant attention and maybe it always will."
"That's why I'm feel so passionately about this, as I see the risk of that diversion of attention and energy. It's right that we remind people that what started 20 years ago in earnest has made some progress but there's still so much to do," he says.
Abortion rights advocates say the new rule continues the Trump administration's 'attack on patients and their ability to obtain health are coverage for abortion care.'
The Centers for Medicare & Medicaid Services issued a final rule Friday that mandates separate billing and collection for abortion services coverage provided by state exchange plans under the Affordable Care Act.
"The rule better aligns with Congress' intent that qualified health plans collect two distinct payments, one for the coverage of abortion services, and one for coverage of all other services covered under a Qualified Health Plan," CMS said in a media release.
Health and Human Services Secretary Alex Azar called the separate billing requirement "an essential step in implementing the Affordable Care Act's bar on tax credits going toward coverage of abortions for which public funding is prohibited."
The requirements are part of a broader package of regulations in the Exchange Program Integrity Final Rule, which federal policymakers say will strengthen oversight of state-based exchanges and ensure beneficiaries' eligibility for premium subsidies.
"Pursuant to the law, this rule will ensure that taxpayers do not contribute funds to pay for coverage of abortion services for which funding isn't allowed by law, and will alert consumers that their health plan covers abortion services, allowing them to make fully informed decisions about their coverage," CMS said.
'A Non-solution'
Margaret A. Murray, CEO of the Association of Community Affiliated Plans, called sending beneficiaries two separate bills every month "a non-solution in search of a problem."
"This misguided rule will only succeed in introducing confusion to the Marketplace on a massive scale, and put millions of consumers at risk of losing their coverage," she said.
Murray noted that failure to pay both bills each month could jeopardize coverage for beneficiaries.
"It’s hard to think of another industry where the government mandates, as the Trump administration would here, that consumers cut two checks a month for the same service," she said. "This rule is a departure from standard accounting practices and imposes operational and financial challenges for plans as they work to comply with the separate billing requirements. But the most significant burdens of this rule fall on the consumer."
The added and needless complexity and administrative burden of the new rule imposed upon insurers and consumers could also lead health plans to drop abortion coverage, she said.
"This provision of the Program Integrity rule will wrap Marketplace coverage in red tape," Murray said. "The administration should withdraw these requirements immediately."
April Lockley, MD, a family medicine physician in New York and Fellow with Physicians for Reproductive Health, said the new rule continues the Trump administration's "attack on patients and their ability to obtain health are coverage for abortion care."
"Navigating the confusing medical insurance industry is already difficult enough and this new rule further burdens patients," she said.
Margarida Jorge, executive director of Healthcare for America Now, called the final rule "just another example of the Trump administration's concerted efforts to strip abortion access from millions of people."
"This extra bureaucracy is aimed at causing confusion among consumers, stigmatizing abortion and limiting access to insurance coverage for abortion by discouraging insurers from offering this coverage," she said.
Jorge urged insurers to "take a stand against this burdensome rule and continue offering coverage for reproductive health services, including abortion care."
Under the new final rule, state-based exchanges will be required to conduct ongoing eligibility verifications with outside data sources at least twice a year, CMS said.
In addition, the rule aligns federal regulations with the statutory requirements of the ACA to help ensure consumers understand the coverage they are buying.
With the new requirements in place, CMS said it will be able to better identify and correct eligibility and enrollment issues sooner, which can minimize the time consumers inadvertently receive tax credits that they will have to pay back later, and mitigate risks that they are paying premiums for a plan they no longer need.
The separate billing requirements in the final rule become effective June 27, 2020. The rest of the final rule takes effect nationwide in February 2020.
CMS said the final rule was crafted after the HHS Office of Inspector General and the Government Accountability Office identified weaknesses in the process for determining eligibility for advance payments of the premium tax credit (APTC) and cost-sharing reductions (CSR) in both state and federal exchanges.
The rule enhances oversight of state-based exchange program reporting to confirm states are correctly identifying eligible enrollees, including those who are qualified for APTC and CSRs, CMS said.
In addition:
CMS is finalizing changes that clarify the scope of such annual SBE audits, including procedures to test eligibility and enrollment transactions to ensure SBEs that operate their own eligibility and enrollment platforms are properly determining consumer eligibility for QHPs, APTC and CSRs.
The rule also implements safeguards regarding the eligibility and enrollment process across all Exchanges, including SBEs, State-based Exchanges on the Federal Platform, and Federally facilitated Exchanges. This includes enhanced periodic data matching that will allow CMS to more frequently identify and resolve issues related to consumers who are dually enrolled in both Medicare and a QHP through the Exchange.
"This will ensure that people are enrolled in the most appropriate type of coverage for them," CMS said. "Beginning with plan year 2020, CMS will require SBEs to conduct Medicare, Medicaid/CHIP, and as applicable, Basic Health Plan periodic data matching at least twice a year for QHP enrollees who receive subsidies."
Stakeholders will have the next 75 days to comment on the proposed rule, which largely follows an outline HHS provided in July.
Health and Human Services Secretary Alex Azar unveiled a two-pronged proposed rule Wednesday that lays the groundwork to allow states and drug companies to import prescription drugs from Canada.
"New pathways for importation can move us toward a more open and competitive marketplace that supplies American patients with safe, effective, affordable prescription drugs," Azar said Tuesday afternoon during a call with reporters.
Azar said the proposed rule would allow for the importation of the kinds of drugs consumers would obtain from a retail pharmacy, but it would exclude controlled substances and IV drugs, including insulin.
Under the "first pathway" of the proposed rule, the Food and Drug Administration sets the rules that would authorize states, potentially working with wholesalers, to develop programs that allow for drug importation of FDA-approved drugs.
"We appreciate the strong interest and leadership we've seen regarding this possibility from governors in both parties," Azar said, noting that Florida, Maine, New Hampshire, Colorado and Vermont have expressed an interest in the plan.
HHS's proposed "second pathway" provides draft guidance for drug makers to import FDA-approved drugs when the drug is made abroad, authorized for sale in any foreign country, and originally intended for sale in that foreign country.
Azar said the second pathway would allow drug makers to sidestep middlemen pharmacy benefits managers and the "bizarre way in which we pay for drugs in the United States" that passes rebates to insurance companies and sticks consumers with list prices.
"What drug companies have told us, and we'll have to see if they live up to this, is that if they could only get a new national drug code for that exact same drug, that they could issue that drug at a lower list price, bringing savings to patients at the pharmacy counter," Azar said.
"And so the second pathway says, if you're a drug company and you're selling the exact same product in Europe or Canada or Japan and you would like to bring that same product in the United States to basically compete against your own product but at a lower list price, that we will give you a new national drug code to be able to do that," he said.
Stakeholders will have the next 75 days to comment on the proposed rule, which he called "largely consistent" with an outline HHS provided in July.
"This is the fleshing out of all the legal and implementation parameters of it," he said
Azar provided no firm date on when the rule would take effect, but he said HHS is moving "as quickly as humanly possible."
"As for pathway two, that guidance may perhaps be able to move even faster, given the fact that that that's a guidance procedure on issuing new drug codes," he said.
PhRMA Pans the Proposal
Pharmaceutical Research and Manufactures of America President and CEO Stephen J. Ubl dismissed the proposed rule as "a political maneuver."
"At a time when there are pragmatic policy solutions being considered to lower costs for seniors at the pharmacy counter and increase competition in the market, it is disappointing the Administration once again put politics over patients," Ubl said in prepared remarks.
"The Administration chose to proceed with an importation scheme that could endanger American lives, could worsen the opioid crisis and has been called unworkable by Canadian officials," Uble said. "Instead, they could have worked with stakeholders to develop and advance meaningful solutions that would directly benefit patients."
Nonetheless, Ubl said PhRMA would review the proposal and provide feedback "with the hope that no patients are endangered by this political maneuver."
Only FDA-approved Drugs are Eligible
Assistant HHS Secretary Admiral Brett P. Giroir, MD, said that drugs eligible for importation would need to be approved by Health Canada and would need to meet the conditions in an FDA-approved new drug application.
"Essentially, eligible prescription drugs are those that could be sold legally in either the Canadian market or the American market with appropriate labeling," he said. "Eligible prescription drugs would have to be relabeled with the required U.S. labeling and undergo testing to ensure that they are authentic, not degraded, and in compliance with established specifications and standards."
"Importantly, the products imported under the pathway described in the draft guide could be available to patients in a variety of settings, including hospitals, healthcare providers' offices and licensed U.S. pharmacies and would include the FDA-approved labeling," Giroir said.
Giroir said the draft guidance does not address generic drugs, "because we are not aware of similar private market challenges for reducing the cost of generic drugs."
"However, the agency is soliciting comments from manufacturers of generic drugs, and other interested stakeholders on whether it would be appropriate to provide guidance on a similar import approach for generic drugs," he said.
Azar said HHS has not done any estimates on the potential cost savings under the proposed rule "because we do not know which states will come forward with plans once a rule is finalized."
"We don't know what those plans will be. We won't know which particular drugs would be in their plans and we don't know the volumes. It's undefinable for purposes of cost projection, at this point," he said.
'This is Not a Silver Bullet'
Speaking to reporters Wednesday in Tallahassee, Florida Republican Gov. Ron DeSantis called the proposal "just one step in the grand scheme of things."
"This is not a silver bullet. This is one step in a long process that we've got to go through and obviously we in Florida don't control all of it," he said. "I'd much rather be here, moving forward, than just being on the sidelines chirping and saying 'Oh why doesn’t somebody do something about it."
DeSantis noted that a quarter of the Florida's Department of Corrections' healthcare budget goes for prescription drugs. "So, even if you get some modest savings out of this for them, that could be tens of millions of dollars in savings for the state of Florida," he said.
Azar, who attended the Wednesday press conference in Tallahassee with DeSantis, said he hopes the Canadian government "will work with us" to facilitate the importation plan.
"Obviously, the Canadians are going to be looking at for Canadians just as the president and myself and Governor Santos we're here to put American patients first," he said.
"But as long as they're getting lower prices, as long as they are free-riding off of American investment in innovation, the president is committed to ending foreign free-riding and we're committed to bringing the lower price discount products to the United States."
"If the drug companies are willing to give discounts to other countries that are similarly positioned economically to the United States, then the United States, where we are the largest pharmaceutical market in the world, we ought to be getting deals like that," he said.
In a separate announcement on Wednesday, the Associated Press reported that New York Democratic Gov. Andrew Cuomo plans to create a commission to investigate the potential benefits of importing prescription drugs from Canada.
The lawsuit alleges that Omnicare billed Medicare and other government-sponsored health plans for hundreds of thousands of invalid prescriptions.
The federal government on Tuesday joined a whistleblower civil lawsuit alleging that Omnicare, Inc. and parent CVS Health Corp. fraudulently billed invalid prescriptions to federal healthcare programs for hundreds of thousands of drugs dispensed to elderly and disabled customers.
"Omnicare put at risk the health of tens of thousands of elderly and disabled individuals living in assisted living and other residential long-term care facilities by dispensing drugs for months, and sometimes years, without obtaining current, valid prescriptions from doctors," Manhattan U.S. Attorney Geoffrey S. Berman said in a media release.
"A pharmacy’s fundamental obligation is to ensure that drugs are dispensed only under the supervision of treating doctors who monitor patients’ drug therapies," Berman said. "Omnicare blatantly ignored this obligation in favor of pushing drugs out the door as quickly as possible to make more money."
CVS issued a statement saying: "We do not believe there is merit to these claims and we intend to vigorously defend the matter in court. We are confident that Omnicare’s dispensing practices will be found to be consistent with state requirements and industry-accepted practices."
The lawsuit, which intervenes in two private False Claims Act whistleblower suits, alleges that, from 2010 through 2018, Omnicare, the nation's largest provider of pharmacy services to long-term care facilities, failed to get new prescriptions from patients' doctors after the old ones had expired or run out of refills.
Instead, Omnicare allegedly assigned a new number to the old prescription and kept on dispensing drugs for months, and sometimes years, after the prescriptions had expired. The company billed Medicare, Medicaid, and TRICARE for these "rollover" prescriptions, DOJ said.
CVS acquired Omnicare in 2015, and DOJ said the retail pharmacy giant "thereafter assumed an active role in overseeing OMNICARE's operations" that allowed the allegedly fraudulent practices to continue.
"Omnicare repeatedly disregarded prescription refill limitations and expiration dates that would have triggered doctor visits to evaluate whether the drug should be renewed, choosing instead to push drugs out the door as fast as possible based on stale, invalid prescriptions," DOJ said.
"Omnicare managers exerted pressure on overwhelmed pharmacy staff to fill prescriptions quickly so that Omnicare could submit claims and collect payments. Many pharmacies had to process and dispense thousands of orders each day," the complaint said.
The suit also alleges that in some cases Omnicare would assigned a fake number of authorized refills to a prescription – usually 99 allowable refills for Medicare patients – to allow for continuous refilling.
Senior management at Omnicare and CVS were aware of the scheme, the suit alleges, but they failed to begin to address the problem until after they learned of a DOJ investigation.
The suit quotes an Omnicare compliance officer's internal email, which stated: "An issue that I am running into more and more in multiple states concerns the ability of our systems to allow prescriptions to continue to roll after a year to a new prescription number without any documentation or pharmacist intervention."
In addition to the alleged fraud, the suit claims that Omnicare's alleged illegally dispensing of drugs to the elderly and disabled people living in residential facilities exposed them to a significant risk of harm, in part because assisted living facilities often do not have physicians on staff to monitor drug therapies.
"Many of the prescription drugs dispensed by Omnicare without valid prescriptions treat serious, chronic conditions, such as dementia, depression, and heart disease," DOJ said. "They include antipsychotics, anticonvulsants, cardiovascular medications, anti-depressants, and other drugs that can have dangerous side effects and need to be closely monitored by doctors, particularly when taken in combination with other drugs by elderly patients."
The 150-bed facility in Dearborn, Michigan is expected to open by mid-2021.
A joint venture between Beaumont Health and Universal Health Services has broken ground on a $40 million mental health hospital in Dearborn, Michigan, the two companies announced.
The 150-bed hospital will be located across the street from Beaumont Hospital, Dearborn, and is expected to open by mid-2021.
UHS, which operates more than 200 behavioral health hospitals across the country, will be the majority owner of the joint venture and will oversee operations and management of the hospital.
Under the JV, Fox said Beaumont Health and UHS will provide specialized care for patients, along with medical residencies, clinical training and the telehealth services.
The 100,00-square-feet hospital will double Beaumont's capacity for inpatient mental health care. Beaumont Health plans to transition its existing inpatient mental health services to the new hospital, with expanded programs that serve adult, pediatric and geriatric patients.
Beaumont Health CEO John Fox said in a media release that the hospital will house psychiatric clinical training and outpatient programs that will improve access to mental health services across southern Michigan.
"Our mental health plans extend beyond the walls of the new facility," he said. "The new hospital will help us coordinate the entire continuum of services for comprehensive inpatient and outpatient mental health care, clinical training and innovative new approaches to accessing care."
Beaumont Health and UHS also plan to implement a comprehensive telemedicine program to support its nine emergency rooms and other patient care settings across the system.
Michigan has seen a 33% increase in suicides since 1999 and it is one of the leading causes of death in the state, according to the National Institute of Mental Health and the Centers for Disease Control and Prevention.
SEC filing shows the for-profit health system sold the hospitals for $350 million.
Investor-owned Tenet Healthcare Corp. is selling its two remaining acute care hospitals in Tennessee to Memphis-based non-profit Methodist Le Bonheur Healthcare, the two health systems announced.
The deal includes the 519-bed Saint Francis Hospital – Memphis, the 196-bed Saint Francis Hospital – Bartlett, six MedPost urgent care centers, and physician practices affiliated with the two hospitals, the health systems said.
Tenet’s Conifer Health Solutions subsidiary will continue to provide revenue cycle management services to the hospitals after the sale is finalized.
The deal is expected to be completed in 2020 after clearing regulatory review.
Financial terms were not disclosed. However, the Memphis Commercial Appeal, citing an Securities & Exchange Commission filing by Tenet, said the sale price was $350 million.
"Consistent with our mission, the addition of Saint Francis hospitals will increase access to high quality healthcare, expand services and enhance the delivery of care to improve the overall health of the communities we serve," said Michael Ugwueke, President and CEO of Methodist Le Bonheur, which currently operates six hospitals in West Tennessee.
Ugwueke says the acquisitions mesh with Methodist Le Bonheur's broader plans by providing improved access to primary, specialty, and charity care, increased investment in medical technology, and by developing improved strategies population health outcomes.
"We look forward to creating a more dynamic team of physicians, nurses and staff dedicated to delivering compassionate high-quality care to anyone who walks through our doors, regardless of their ability to pay," Ugwueke said.
With the sale, Dallas-based Tenet's footprint in Tennessee will shrink to include one surgical specialty hospital in Nashville, and more than two dozen surgical centers, urgent care centers, and other outpatient care venues across the state.
In the third quarter of 2019, Tenet reported that it doubled its adjusted net income to $61 million, but saw its net loss reach $233 million.
The company reported an adjusted EBITDA of $631 million, up 9.4% year-over-year, while its net operating revenues from the hospital operations segment increased 2.3%.
Tenet also completed a $4.2 billion debt refinancing, increasing its borrowing capacity by $1.5 billion.
The IHI president emeritus wants healthcare providers to reach beyond the hospital walls and embrace the 'moral determinants of health.'
ORLANDO – Patient safety guru Donald Berwick, MD, is urging healthcare providers to take quality, access, and equity of care a step further and embrace a sweeping, global movement that grounds care delivery on moral convictions.
"At last, I think we're starting to recognize the inescapable importance of the social determinants of health," Berwick said here Wednesday at the keynote address of the 31st Institute for Healthcare Improvement National Forum.
"But now we need to go one very hard step further. We need to call out, not just the social determinants of health, but also the moral determinants of health, because without that we are not going to find the will to act," he said.
To the rousing applause of thousands of forum attendees, the IHI president emeritus and senior fellow used the dais to propose "a new campaign for our quality movement, founded on a shared commitment to act on what really matters to the people of our nation, to all the people of the world, boundaries, notwithstanding."
Berwick urged healthcare providers to embrace his unabashedly progressive agenda that looks beyond their own immediate needs and margin pressures, and actively confronts the root causes of the vast social and moral issues that ultimately affect the health of humanity, such as a lack of access to food, shelter, healthcare, and hope.
"The campaign that I would envision would consist of those actions, those goals, those investments that that moral compass points to," he said. "They are what we must work on or must choose to work on if we're going to be true to that moral core. Our project then becomes to improve the social determinants of health that our moral determinants illuminate."
Berwick outlined seven steps to make it happen.
Commit to human rights: "First, declare a commitment to achieve U.S. ratification of key human rights treaties," he said. "The U.S. technically has ratified the Universal Declaration of Human Rights, but we have not ratified subsequent covenants or treaties, especially pertaining to the right to health and healthcare. We need to join the global human rights community formally and now."
Push for universal coverage: "Second, make healthcare unequivocally a human right in this nation," he said. "At this moment this country still has 30 million people without health insurance. It is time to end that cruel embarrassment. This quality movement should stand foursquare, vocally for universal health coverage in the United States of America now."
Combat climate change: "Third, we need to restore American leadership to the fight to reverse climate change," he said. "The evidence is overwhelming. Our nation is not doing its job to reverse that imminent tragedy. It may be too late I fear, but we have to try. Neither healthcare nor the quality movement can responsibly be a bystander."
Back criminal justice reform: "Fourth, please let's achieve radical reform in our nation's criminal justice system," he said. "We have more people in prison per capita in this nation than any other nation on Earth, except Russia. ... The people who are incarcerated are overwhelmingly people of color by a factor of six or eight. This is the cruelest form of racism in our nation in our time. It is as erosive of health and well-being for entire generations as the most toxic bacteria or the most sinister cancer. We have to fix it."
Encourage inclusive immigration policies: "Fifth, we've got to end policies of exclusion and achieve meaningful immigration reform in this nation," he said. "I have had it up to here with cruelty at our borders."
Take poverty head-on: "Sixth, we need to end hunger and homelessness in America," he said. "That ought to offend every sensibility of a civilized and compassionate people; the claim that our rich nation cannot assure food and clothing and shelter to absolutely everyone. ... that claim is insane. And let me be clear, this absolutely requires a big dose of redistribution of wealth in America. It means once and for all ending the practice of blaming people who are less fortunate."
Defend civil institutions: "Finally, seventh, we need to restore order and dignity and equity toward democratic institutions," he said. "Most of all, assure the right of every single person's vote to count equally. ... When the institutions no longer serve mercy and compassion and health and shared well-being the rules must change. I believe deeply that America's project and democracy, however fragile however sometimes wandering or maddening it can become, it's still the best route to the communities that we want."
An age-friendly health system uses an evidence-based framework called the 4Ms to improve outcomes, shorten hospital stays, and meet the expectations of older patients.
ORLANDO — The Institute for Healthcare Improvement (IHI) has joined with the nation's major hospital associations to expand a program that promotes and recognizes providers of "age friendly" care.
The initiative, Age-Friendly Health Systems, uses evidence-based framework called the 4Ms: what matters to older adults; medication that is age friendly; attending to mentation, including delirium, depression, and dementia; and mobility, so seniors can maintain function.
Funded by a $6 million grant from The John A. Hartford Foundation, the initiative is in partnership with the American Hospital Association and the Catholic Health Association of the United States.
"We have a big problem in this country with an aging population," Mate says. "In some communities that we're working with now the growth of the over-65 population is upwards of 80% while every other demographic is shrinking."
"We started with five systems. We didn't give them a cheat sheet on how to do it. They invented it themselves, how to implement the specific care guidelines," Mate says. "From those five systems, two years later, we've now reached 450 healthcare systems, both hospitals and ambulatory practices all over the country."
As of November, 284 hospitals and other care venues have earned the level-one designation as Age-Friendly Health System participants, and Mate says IHI aims to expand age-friendly care to 1,000 hospitals and other healthcare venues by the end of 2020.
Mate says 117 providers have earned level-two designation for exceptional program outreach to older adults over at least three months.
"It's created quite a buzz," he says. "There are some really interesting systems that are taking this under their wing and making it their strategy."
In building the 4Ms framework, Mate says, researchers were surprised to find that solid, evidence-based care models for older adults were already being used in many places.
"Of the 17 highly evidenced models, 13 or 14 of them were in place in systems in total discoordination," he says. "The left hand was not talking to the right hand, that kind of stuff."
The researchers studied the evidence-based models, extracted key ingredients, and spoke with those who initiated the models, Mate says.
"We found that there were 90 different things that these models encompassed," he says. "We distilled them down to 13 different concepts. There were a lot of redundancies, but then we said we can't build a national campaign around 13 things."
"We asked the creators to give us a handful, and that's how we got to these 4Ms," he says, adding that the 4Ms have been "extremely resonant" among providers.
"If you put in the clinical interventions around them, it saves money, improves care for older adults," he says.
"So, if you reduce exposure to the opioids and benzodiazepines in the medication column, it reduces mobility problems for older adults and it reduces delirium incidents among older adults," he says, "and those things translate into real money and hospital length-of-stays declines."
The bill would fix a regional calculation that forces accountable care organizations to measure their performance against themselves and disproportionately impacts rural providers.
Rural healthcare stakeholders are rallying around bipartisan legislation newly introduced in Congress that would eliminate an inadvertent methodological flaw known as the Affordable Care Act's "rural glitch."
The Accountable Care In Rural America Act, H.R. 5212, introduced by Republican Rep. Jodey Arrington of Texas and Democrat Rep. Suzan DelBene of Washington, would amend Title XVIII of the Social Security Act to improve the benchmarking process for the Medicare Shared Savings Program.
The bill's Senate sponsors are Republican Sen. Pat Roberts of Kansas and Democratic Sen. Catherine Cortez Masto of Nevada.
Since 2017, a glitch in the ACO reimbursement formula has inadvertently punished rural health care providers, even as they reduce costs, according to the bill's sponsors. That's because, under the current formula, reimbursement rates are based on a comparison of the per-patient costs of a region's ACO with the operating costs of non-ACO regional peers.
In many rural areas, an ACO may be the major provider with no peers for comparison. As a result, rural ACOs that have a lower spending benchmark often get a smaller savings bonus than do their urban counterparts that compete against more providers.
The bill would fix the glitch by excluding the ACO's beneficiaries when calculating the per-patient costs of a region.
"Fixing the rural glitch is a practical and meaningful change that will make the program fairer, especially for rural providers who can be disproportionately impacted by the current benchmark methodology," DelBene said.
"This change will also make it fairer for providers who are already delivering efficient care like those in Washington state," she said. "I believe fixing the rural glitch will encourage more providers to participate in the ACO program which will be a benefit to seniors and taxpayers alike."
Brock Slabach, senior vice president for member services at the National Rural Health Association, says the bill stands a good chance of passing because it has bipartisan support, is budget neutral, faces no organized opposition, and "it's an easy correction."
"This is commonsense legislation, so opposition would be negligible. I don't know how anyone could oppose this because all it does is make the process fair," he said.
The bill has the support of 13 stakeholder groups, including the American Hospital Association and the American Medical Association, who complained that the glitch makes it harder for rural providers to achieve savings even when they improve quality and reduce costs on par with their urban colleagues.
"No ACO should be placed in a less favorable financial position due to their geography alone, and design flaws that discourage ACOs from operating in rural areas should be eliminated," the stakeholders said in a letter to the Congressional sponsors.
"Today, the regional adjustment includes an ACO's own beneficiaries in the regional calculation," the letter said. "While this has minimal impact for ACOs in urban areas with a lot of provider competition, the impact is significant in rural areas where an ACO covers a large number of the region's fee-for-service beneficiaries."
The co-founders of the start-up allegedly enriched themselves by fraudulently inflating revenues and the extent and effect of their advertising.
Four former executives at Outcome Health have been charged with fraud in an alleged $1 billion scheme that cooked the books on revenues and lied to investors and clients about the reach of its advertising inventory, the Department of Justice said.
An indictment alleging wire fraud, bank fraud, mail fraud, and related charges was unsealed this week in a federal court in Chicago against:
Rishi Shah, 33, of Chicago, the co-founder and CEO of Outcome Health, known as ContextMedia before January 2017;
Shradha Agarwal, 34, of Chicago, co-founder and president of Outcome Health;
Brad Purdy, 30, of San Francisco, COO/CFO; and
Ashik Desai, 26, of Philadelphia, executive vice president of business operations and chief growth officer.
Also indicted were Kathryn Choi, 29, of New York, and Oliver Han, 29, of Chicago, both former analysists at the company.
The indictment alleges that, from 2011 to 2017, the alleged schemers at privately held Outcome – which provides physician waiting rooms with video screens featuring health tips and drug ads – sold tens of millions of dollars of advertising inventory that did not exist, mostly to drug companies. Despite these under-deliveries, Outcome allegedly still billed clients as if it had delivered in full.
Using the claims of the bogus inventory, the scheme allegedly inflated financial statements that the former executives used to raise nearly $1 billion in debt and equity financing in 2016 and 2017.
To conceal the alleged fraud, the indictment claims that the former executives and employees allegedly falsified affidavits and proofs of performance to make it appear the company was delivering advertising content to the number of screens in its clients' contracts.
The scheme also allegedly inflated patient engagement metrics regarding how frequently patients engaged with Outcome’s tablets, and altered studies presented to clients to make it appear that the campaigns were more effective than they were.
The company's outside auditor signed off on the 2015 and 2016 revenue numbers because Purdy, Desai, Choi and Han allegedly fabricated data to conceal the under-deliveries, the indictment says.
The former executives allegedly used the inflated revenue figures to raise $110 million in debt financing in April 2016, $375 million in debt financing in December 2016 and $487.5 million in equity financing in early 2017.
The $110 million debt financing allegedly resulted in a $30.2 million dividend to Shah and a $7.5 million dividend to Agarwal. The $487.5 million equity financing allegedly resulted in a $225 million dividend to Shah and Agarwal.
Shah and Shradha resigned in 2018 after Outcome reached a fraud settlement with investors. In October, thecompany agreed to pay $70 million to the federal government to resolve fraud allegations.
