A first-of-its-kind intensive training program gives non-specialist pharmacists confidence to deal with complex and critical medication issues for ICU patients.

RWJBarnabas Health System has developed a new, team-based model for intensive care unit pharmacists that improves medication response times for critically ill patients.

Writing in the Journal of Clinical Outcomes Management, researchers at the New Jersey-based health system said that general practice pharmacists working in the ICU are not comfortable responding to complex issues such as determining if a delirious patients needs to switch medications.

That lack of training can mean that medication adjustments can be delayed if a hospital pharmacist who specializes in critical care is off duty.  

To remedy this, the RWJBarnabas pharmacists at the Robert Wood Johnson University Hospital Hamilton developed a first-of-its-kind, six-month intensive classroom and clinical training program for non-specialist pharmacists, that dealt with complications for patients on mechanical ventilators, infectious disease risk, and blood flow management.  

Eventually, all pharmacists on the newly formed Critical Care Pharmacist Team could provide the range of interventions that previously only critical care specialist could do.

"Before we tried this model, the non-specialty pharmacists in the ICU were often uncomfortable with clinical issues, which sometimes meant going to the bedside to assess the situation. As a result, relatively minor issues were frequently escalated with a call to the specialist, who was not always readily available," said lead researcher Liza Barbarello Andrews, a clinical associate professor at Rutgers University’s Ernest Mario School of Pharmacy.

"Our new model effectively empowers all of our pharmacists to act as specialists," she said.

In addition to improved patient outcomes, the pharmacists who took the training said they felt confident providing specialized levels of care, and that it gave them a greater sense of professional satisfaction.

Physicians and nurses in the ICU said pharmacy care improved with the team model, and that they saw a consistent, high level of care even when the specialist was not on duty, Andrews said, adding that the new model was adopted without significant cost and could benefit other community-based hospitals with limited resources.   

Researchers at Robert Wood Johnson University Hospital Hamilton and Rutgers University also participated in the study.

AI was taught to identify subtle differences in a normal EKG that would indicate changes in heart structure caused by afib.

Artificial intelligence has proved to be adept at detecting recent or impending atrial fibrillation, even if symptoms aren't noticeably apparent, new research shows.

In a study published in The Lancet, Mayo Clinic researchers found that AI can detect the signs of an irregular heart rhythm in an EKG, even if the heart is in normal rhythm at the time of a test.

Study senior author Paul Friedman, MD, chair of the Department of Cardiovascular Medicine at Mayo Clinic, says the findings could prove critically important when treating stroke victims.  

"When people come in with a stroke, we really want to know if they had AF in the days before the stroke, because it guides the treatment," Friedman said in comments accompanying the study.

"Blood thinners are very effective for preventing another stroke in people with AF. But for those without AF, using blood thinners increases the risk of bleeding without substantial benefit," he said. "That's important knowledge. We want to know if a patient has AF."

Using 450,000 EKGs of the over 7 million EKGs in the Mayo Clinic digital data vault, the researchers taught AI to identify subtle differences in a normal EKG that would indicate changes in heart structure caused by afib. The changes were not detectable without AI.

The researchers then tested the AI on normal-rhythm EKGs of 36,280 patients, of whom 3,051 were known to have afib and found that the AI-enabled EKG correctly identified afib with 90% accuracy, the study said.

In addition to improving diagnoses for afib, Friedman said AI-guided EKGs can be processed using a smartphone or watch, making it readily available on a large scale.

"An EKG will always show the heart's electrical activity at the time of the test, but this is like looking at the ocean now and being able to tell that there were big waves yesterday," Friedman said.

"AI can provide powerful information about the invisible electrical signals that our bodies give off with each heartbeat — signals that have been hidden in plain sight," he said.  

Under the proposed rule hospitals would have to make their 'real, negotiated prices known to patients.'

The Centers for Medicare & Medicaid Services on Monday unveiled proposed rules that mandate "consumer-friendly" price transparency for hospitals, a proposal that the Trump administration says will increase competition among hospitals and lower healthcare costs for consumers.

In a conference call with reporters on Monday, CMS Administrator Seema Verma said the enhanced rules on price disclosure apply "not just for Medicare patients, (but) for the entire healthcare system at large."

"What we are proposing is that the hospitals would be required to post this on the Internet in a searchable format, and they would be required to post their negotiated rates by payer and by plan," she said.

The Trump administration last year mandated that hospitals publish their charge masters, but Verma noted that the information provided in charge masters is often confusing for consumers.

"With the proposals announced today, starting January 1 of 2020, hospitals will have to publish price information organized in a standardized way so patients will be able to do an apples-to-apples comparison on the price of a procedure across hospitals," she said.

"Hospitals would also be required to post all of their payers specific negotiated rates, which are the prices actually paid by insurers, in that standard format to give patients more useful pricing information," Verma said, repeating the statement for emphasis.

The proposal was one of several initiatives unveiled Monday by CMS that include an extension of Medicare site-neutral payments, and the continuation of cuts to the 340B Drug Pricing Program.

The proposed pricing transparency rules, which would take effect on January 1, 2020, would require hospitals to:

• Make public their "standard charges" (gross charges and payer-specific negotiated charges) for all items and services.
   
• Make public standard charges on the Internet in a machine-readable file that includes information such as common billing or accounting codes used by the hospital, and a description of the item or service. This provides a common framework for comparing standard charges from hospital to hospital.
   
• Make public and "consumer friendly" payer-specific negotiated charges for common shoppable services, such as imaging, outpatient visits, and lab tests, and bundled services such as cesarean delivery. 

"Consumer-friendly means the hospital charge information must be made public in a prominent location online (or in written form upon request) that it is easily accessible, without barriers, and searchable," CMS said in a media release.

"It also means the service descriptions are in 'plain language' and the shoppable service charges are displayed and grouped with charges for any ancillary services the hospital customarily provides with the primary shoppable service," CMS said.  

Hospital stakeholders greeted the proposed rule with a chorus of boos.

American Hospital Association President and CEO Rick Pollack said the proposed rule "misses the mark, exceeds the administration's legal authority and should be abandoned."

"Mandating the disclosure of negotiated rates between insurers and hospitals is the wrong approach," Pollack said. "Instead, it could seriously limit the choices available to patients in the private market and fuel anticompetitive behavior among commercial health insurers in an already highly concentrated insurance industry."

Bruce Siegel, MD, president and CEO of America's Essential Hospitals, said the proposed rule would "create a heavy administrative burden for hospitals and undermine their ability to negotiate equitable payment, while giving consumers little actionable information with which to make informed care decisions."

Payers panned the proposal as well.

Matt Eyles, president and CEO of America’s Health Insurance Plans says that most health plans already allow consumers to comparison shop for physicians, and 90% of plans can show consumers their out-of-pocket costs, such as co-pays, coinsurance and deductibles for specific procedures and services.

"We share the Administration's commitment to empowering patients with better information about the costs of their care and lowering costs," Eyles said. "However, multiple experts, including the  Federal Trade Commission, agree that disclosing privately negotiated rates will make it harder to bargain for lower rates, creating a floor – not a ceiling – for the prices that hospitals would be willing to accept."

"Publicly disclosing competitively negotiated, proprietary rates will push prices and premiums higher–not lower–for consumers, patients, and taxpayers," Eyles said.

Site-neutral payments
 

Hospitals also voiced their disapproval of the administrations plans to continue Medicare site-neutral payments that stakeholders say will cut by 60% the payments for outpatient clinic visits.

"By continuing payment cuts for hospital outpatient clinic visits, CMS has not only undermined clear congressional intent, but has threatened to impede access to care, especially in rural and other vulnerable communities," Pollack said.

"These cuts clearly exceed the administration’s legal authority, which is why the AHA has been working to overturn this rule through legal action and by working with the Congress," he said.

Siegel said CMS "puts care at risk for vulnerable people by maintaining its flawed policy of extending outpatient payment cuts to previously excepted clinics."

"These cuts fall hardest on hospitals that care for low-income patients and create barriers to expanding access to care in underserved communities," he said.

Continued Cuts to 340B Program
 

Siegel said CMS' plan  to continue cuts to the 340B Drug Pricing Program ignores a federal court's unequivocal and explicit finding that the agency acted unlawfully when it imposed deeply damaging cuts to hospitals that rely on the program.

"This is unacceptable," Seigel said. "This proposed rule needlessly prolongs the uncertainty, confusion, and harm CMS created with these Part B cuts, which went beyond its statutory authority and continue to threaten access to care in communities nationwide."

Pollack said continuing the 340B cuts "only exacerbates the strain placed on hospitals serving vulnerable communities."

"Now that the court has ruled that those cuts are illegal and exceeded the administration’s authority, we urge CMS to refrain from doing more damage to impacted hospitals with another year of illegal cuts," he said. "Instead, as a remedy, CMS should be offering a plan to promptly restore funds to those affected by the illegal cuts.

CMS also proposed changes to the Hospital Outpatient Quality Reporting and Ambulatory Surgical Center Quality Reporting Programs that CMS said would "further meaningful measurement and reporting for quality of care in the outpatient surgical setting while limiting burden."

The deadline for submitting comments on the proposed rule (CMS-1717-P) is September 27. 

 

The report comes amid projections that Medicare spending will exceed $1.5 trillion by 2028, which is more than double the $708 billion in spending in 2017.

A federal review of 20 top-performing Medicare Shared Savings Program accountable care organizations (ACO) identified seven broad strategies for success.

The Health and Human Services Office of Inspector General, relying on interviews and self-reporting from ACO officials, asked them to identify successful strategies they used to lower Medicare spending and improve care quality.

The report comes amid projections that Medicare spending will exceed $1.5 trillion by 2028, which is more than double the $708 billion in spending in 2017. The Shared Savings Program is one of the largest alternative payment models, accounting for $168 billion in Medicare expenditures over its first three years, 2013-2015.

This OIG study is a follow-up to a 2017 study that found ACOs saved Medicare about $1 billion from 2013 through 2015, while improving quality across most metrics.

OIG also found in the 2017 report that high-performing ACOs relied heavily on frequent primary care visits that reduced the use of emergency department visits, and lowered spending by an average of $673 per person.

The 20 ACOs examined by OIG for the new report started in the Shared Savings Program, but five of them moved to the Next Generation ACO Model at the time of the OIG review.

The 20 ACOs all demonstrated a reduction in spending and overall quality scores of 90 or higher over three years, however OIG acknowledged that their findings are somewhat limited because they rely upon unverified self-reporting.

OIG took the findings and grouped them across seven areas.

1. Work with physicians
 

ACOs report that working with physicians in the ACOs is critical to lowering costs and improving quality. However, ACOs say that physicians are often unaware of the cost of services and may order more expensive services than are necessary or refer to specialists without factoring in the cost of services. In addition, physicians are often overburdened by administrative tasks, thereby reducing the time they have to care for beneficiaries. ACOs also note that they need to work with physicians to address quality measures and to close gaps in care—particularly for screening beneficiaries for needed care.

2. Engage beneficiaries to improve their own health.
 

Encouraging beneficiaries to take a more active role in their health can lead to better health outcomes, but ACOs note that it is challenging to build relationships between physicians and beneficiaries. To address these challenges, many ACOs focus on increasing beneficiaries' utilization of annual wellness visits to build relationships with physicians and to engage beneficiaries in their health.

3. Manage beneficiaries with costly or complex care needs.
 

Almost all ACOs use care coordinators. They ensure that when beneficiaries leave the hospital, they have the correct medication and equipment, as well as a follow-up visit with their primary care provider. Care coordinators also help beneficiaries schedule appointments and ensure that beneficiaries have care plans in place. Many ACOs also periodically check with beneficiaries in between physician visits to monitor changes in their health. Over half of the ACOs have care coordinators or physicians who visit beneficiaries in their homes.

4. Reduce avoidable hospitalizations and improve hospital care
 

ACOs note that hospitals are often difficult to engage; they also find that hospitals often lack the incentive to lower their costs partly because they are reimbursed primarily based on the volume of admissions. ACOs face challenges with reducing avoidable hospitalizations and with encouraging beneficiaries to seek alternatives to emergency room care when possible. Most ACOs provide additional access to primary care services.

5. Control costs and improve quality in skilled nursing and home healthcare.
 

ACOs say their ability to coordinate care and influence cost is limited because SNFs and HHAs are not typically included in the ACOs, and that these providers may not share the same incentives to lower cost and improve quality. In addition, beneficiaries must be fully-admitted to a hospital for three nights to qualify for SNF benefits under Medicare Part A's "3-day rule." That can limit an ACO's ability to arrange the most appropriate and cost-effective care. Concerns exist that the 3-day rule can result in unnecessary hospitalizations when it is safe to transfer patients directly to a SNF without hospitalization or when fewer than 3 days of hospitalization are needed.
 

6. Address behavioral health needs and social determinants of health.
 

When left untreated, behavioral health conditions often result in costly services, such as avoidable emergency room visits and longer hospital stays. ACOs report a number of challenges with addressing beneficiaries’ behavioral needs.  These most commonly include a lack of behavioral healthcare providers, limited availability of data to identify beneficiaries who have behavioral health needs, and fragmented approaches to physical and behavioral healthcare.
 

7. Use technology to increase information sharing among providers.
 

Sharing medical information is helpful to coordinate care among different providers and across different settings. However, ACOs report that they do not always have access to beneficiaries' medical information from other providers—including ACO providers and providers outside the ACO—that are involved in their beneficiaries' care. They note challenges with the interoperability of ACO providers' systems and with using State and regional data systems to communicate with providers outside their ACOs.