In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. They are making a difference in healthcare. This is the story of Bruce Ribner, MD.
This profile was published in the December, 2014 issue of HealthLeaders magazine.
"We learned how intensive the medical management was both from a physician and a nursing perspective."
Bruce Ribner, MD, an infectious disease specialist at Emory University Hospital in Atlanta, has more than a decade of experience treating or preparing for contagious diseases such as SARS, Marburg virus, and Ebola.
For the most part, he says, the clinical team at the hospital was well prepared for the arrival from West Africa last summer of the first two Ebola patients to be treated on U.S. soil. But even with three days' notice to prepare, and help from advisors at the Centers for Disease Control and Prevention just down the street, there were surprises.
"It sounds funny, but one of the biggest eye-openers we had was waste disposal," Ribner recalls. "We had always planned that anything coming out of a room of a patient infected with the Ebola virus or any viral hemorrhagic fevers was going to be autoclaved before we gave it to our contractor who disposed of our regulated medical waste. We rapidly discovered that the autoclave we had in the unit was grossly inadequate. It was an old laboratory autoclave that looked fine to us, but over the first 24 to 48 hours we started getting more and more garbage cans of infectious waste lining up in the hallway."
Hospital officials wheeled in a larger autoclave, but with that problem solved, another quickly emerged.
"There are a few disconnects between official CDC guidance and realities of life," Ribner says. "For example, CDC says that regulated medical waste is everything that comes out of an area where there are infectious pathogens. Our contractor said, 'We will not take any infectious waste unless you can guarantee there is no Ebola virus in it.' So, again, we couldn't just take the waste and give it to them. We had to make sure it all got autoclaved. We had to track every box of infectious waste because that was required by our contractor."
Once the first two Ebola patients, Kent Brantly, MD, and Nancy Whitebol, were brought into the specially designed Serious Communicable Disease Unit, Ribner and his team quickly learned that the two missionaries would require a tremendous amount of oversight in the several days before their conditions improved.
"We had a nurse in each patient's room continuously for at least the first week and a half. They required an enormous amount of nursing care," Ribner says. "They have diarrhea like patients with cholera have diarrhea. They are putting out four to six liters of stool a day, almost continuously—that plus all of the other blood pressure support and interventions and so on."
Within the first day, the normal 12-hour ICU shifts were reduced to eight hours. "Even with the eight-hour shifts, the nurses needed a one-hour break in the middle of the shift to survive for eight hours. We had to have one of our physicians in the unit because there were always questions coming up about management. We have now decided that whichever physician is on that day, that is absolutely the only thing they are going to be able to do that day. We learned how intensive the medical management was both from a physician and a nursing perspective."
Accessing the isolation unit also proved difficult. "The official guideline from CDC is contact precautions, which means no blood or body fluids from the patient comes into contact with the healthcare provider," Ribner says. "Now, officially, you are supposed to wear a fluid-impervious gown, gloves, shoes, and leg coverings. When you get finished saying all of that, we just found it was much more efficient to use the body suits. The media accused us of overdramatizing everything. It was a practical way for us to meet the requirements, especially when you have patients putting out four to six liters of stool per day and you are trying to prevent stuff on your shoes and legs."
The clinicians weren't prepared for what Ribner called "the tsunami of media." "We thought, 'Meh! We might get a little bit of PR when we bring these two patients back, but it would be like when we brought the guy back with Marburg virus infection about seven years ago.' We couldn't have been more wrong," he says. "There must have had 50 media tents on our campus for the first week that these patients were in the hospital. We called it Ebola village."
While the public interest was warranted, Ribner says the undertone of fear that crept into some of the coverage was not.
"I read a survey that said that 40% of Americans felt there was a good chance we would have an Ebola outbreak in the United States, and the authors of this survey attributed this to the way the media has handled the event," he notes. "I saw that in my emails. I can't tell you how many hundreds of hate emails I got. Things like 'You're going to feel so guilty when people are dropping in the streets of Atlanta from Ebola virus.' 'You've brought the next plague to the United States.' We actually had all of our packages and mail screened in an outside security facility. My understanding is that there were several bomb threats made on campus during that first week. There was a lot of angry citizenry responding to this event." By the time a third Ebola patient was brought to Emory in early September, though, much of the media hoopla had subsided.
Ribner says he has grave concerns about the spread of Ebola across Africa, but virtually no worries about the virus gaining a toehold here. "The potential for spread in the U.S. is close to zero, if not zero," he says. "All you have to do is look at those two MERS patients who came at the beginning of the summer. How many secondary cases do we have? Zero. We are more attuned to hygiene."
With Emory's ready access to some of the most advanced medical resources on the planet, Ribner says he also has a profound respect for the physicians, nurses, and other caregivers in Africa, who are often exposed to great risk of acquiring the virus while "flying blind" with few medical resources available.
"On the other hand, it is not that labor intensive for them because there isn't much they can do," he says. "That is not being derogatory. It's kind of like 80 years ago doctors did house calls because there wasn't much they did for you anyway. I wonder how we would do if we took all of our ICU patients and treated them at home. I don't think we would do a whole lot better than our colleagues in Africa."
Comprised of a wide array of stakeholders from across the care continuum, "mega boards," with members trained in thinking about the health of the community as opposed to the financial performance of a hospital, could change rural healthcare delivery.
Rural healthcare delivery doesn't need to be tweaked. It needs an overhaul.
Even after years of talk and studies and calls for reform, most healthcare delivery in rural American remains overly reliant upon small hospitals with limited resources that provide fee-for-service inpatient sick care.
Care coordination, community outreach, and wellness and prevention programs often don't get the money or the emphasis they deserve because hospital leaders with immediate budgetary concerns aren't reimbursed for them.
This happens even though almost every rural provider and hospital leader I've spoken with understands that cost-effective care delivery must extend beyond the walls of the hospital.
We have well-intentioned rural hospital leaders and other providers who are ready and willing to act, but who are constrained by lack of money and other resources and must continue operating under an antiquated care delivery system.
A. Clinton MacKinney, MD, MS, a clinical assistant professor at the University of Iowa, and a family physician in rural Minnesota, says rural providers "are hamstrung on a payment system that is focused on hospital and illness and we are hamstrung by a small scale that tends to leave us out."
"The Centers for Medicare & Medicaid Innovation has a $10 billion budget. They tend to look to places to implement projects that have large scale to begin with. That automatically excludes rural," he says.
Blueprint for Change
"We can put together some scale and we can develop opportunities for learning that can be expanded. But if CMMI says off the bat that a particular demonstration project must have 50,000 or 100,000 lives to be considered, then we are already behind the eight ball. Therefore 25% of the population and provider workforce gets left out."
MacKinney is a coauthor of a new report from the University of Iowa's Rural Policy Research Institute that offers a blueprint for changing rural healthcare delivery.
"We are really trying to move past this antiquated concept of a hospital providing inpatient care," MacKinney says. "In reality, the locus of human and other resources in rural communities is often focused at the hospital. Whether that is good or bad, it just is. Thoughtful rural hospital leaders are saying we cannot be insulated inpatient-four-wall institutions any longer. They're thinking about how we can make our community a healthier place to live and raise children and retire rather than treating sick people in inpatient beds. But when the payment system doesn't reward you for doing that work, we have a challenge on our hands."
Seeking a 'Glide Path'
MacKinney says rural providers need a "glide path" to value-based care.
"We are now stuck in a fee-for-service environment, especially in rural, that is counter-productive to delivering value," he says.
"Making the switch, like flipping a light switch to a population-based healthcare payment system would be so disruptive it would be impossible. So our suggestions are glide paths from the current broken system to one that makes more sense but also along the way doesn't destroy rural infrastructure."
MacKinney says rural providers who buy into the concept need to convince other stakeholders to tear down the institutional silos that block care coordination.
"How do we start helping people understand that this isn't a traditional hospital way of thinking?" he says. "I've been working with one community where the hospital leadership is trying to do that, but the people they are reaching out to—public health, the agency for aging, human social services—don't get it."
"They are in the same kind of silos that the hospital has been in," he says. "It was frustrating for the hospital leadership because usually they are the ones who get blasted for simply thinking about making money and treating patient who are sick."
'Mega Boards'
Among its many recommendations, the study suggests that rural providers and community leaders create "mega boards" comprised of a wide array of stakeholders from across the care continuum who would identify patient service areas and their needs, and build a coordinated care network in that space.
"This isn't a hospital board in the old sense of the word," MacKinney says. "It is going to require education. We just can't have the board members who show up for the free dinners but never read the material who [are] participating in something that is as important as the health and welfare of the community."
Mega board members will need to understand how care delivery works outside of the hospital.
"Individuals who have all of their experience and focus around the old definition of hospital need to be trained in thinking about the health of the community as opposed to simply the financial performance of a hospital which is dependent upon beds being filled and patients through the door," MacKinney says. "That is a very different mindset."
The existing mindset, he says, is failing the people it is supposed to serve.
"We are sitting here with about 1,330 critical access hospitals, some of which aren't serving their communities as well as they can," MacKinney says. "They don't have a system yet to get to what thoughtful rural healthcare leaders know they need to be—which is more responsive to preventive health issues, playing a role in the social determinants of health, expanding beyond inpatient units, thinking of how we connect in real time clinically with care partners in the local community, and also connect regionally."
The physician staffing sector has grown by more than 10% annually over the past four years, and that pace is expected to continue, says a Moody's Investors Service analyst.
The Patient Protection and Affordable Care Act and the healthcare sector's move toward value-based reimbursements have created a favorable environment for hospital-based physician staffing companies to consolidate and grow even larger, Moody's Investors Service, Inc. says.
Ron Neysmith, a senior analyst at Moody's Corporate Finance Group, says the physician staffing sector has grown by more than 10% annually over the past four years. That pace is expected to continue, he says, as hospitals embrace outsourcing to streamline operations and create efficiencies.
In addition, Neysmith says, the Medicaid expansion under the PPACA means that more people will have health insurance and that bad debt levels will fall at physician staffing companies doing business in Medicaid expansion states.
Unfortunately, providers in states that have rejected the Medicaid expansion will likely continue to see high bad debt levels in the near term.
Neysmith singled out TeamHealth Inc., Envision Healthcare Corp., and AmSurg Corp., as particularly well positioned to take advantage of the shifting care delivery and reimbursement landscape.
"Physician staffing companies will continue to grow through a combination of acquisitions, new contracts and organic growth," Neysmith says. "The industry is very fragmented, so acquisitions will be a focus for TeamHealth, Envision and AmSurg. These likely will be small-to-medium tuck-in acquisitions that they can fund from cash flow, maintaining their credit quality."
Up-Selling Services
Neysmith says the big three staffing companies will also focus on "up-selling" complimentary provider services to clients.
Mike D. Snow
President and CEO of TeamHealth
"Once they get into a hospital and show that they've got a high level of proficiency of managing a medical department, certain departments sort of lead themselves to being outsourced," he says. "Once they are already there, they try to provide additional services."
Neysmith says he expects that larger staffing firms will use their size and scale to wrest new business away from smaller, regional operators.
Hiring staffing companies also relieves hospitals of the burden of recruiting and retaining hospital-based physicians.
"A lot of hospitals are having trouble recruiting and managing some of those physicians and physician staffing companies help them fill that role, Neysmith says.
Working for staffing companies is also an attractive alternative for physicians, Neysmith says, because the often have greater job flexibility, and upward mobility.
"I wouldn't say it's necessarily about compensation," he says. "A lot of physicians are not looking to be self-employed. These physician staffing companies have those systems in place and one of the benefits is clearly the mobility."
Mike D. Snow, president/CEO of Knoxville, TN-based TeamHealth, agrees that "a convergence of issues" has created a favorable climate for physician staffing companies.
"First it's the pressure that hospitals feel to produce results," Snow says. "They have come under pressure in their reimbursement. Whether it is readmission penalties or quality initiatives the metrics under which they are being paid are changing and they have real skin in the game. They in turn have put pressure on their hospital-based physicians to deliver."
"No. 2, that pressure has led to those physician groups looking for partners who can bring the resources and the processes and capabilities to help deliver on the promise to client hospitals. When you wrap around that Medicare payment reform and the whole Affordable Care Act and the move towards a new paradigm those three things have combined to make the physician staffing space a fairly interesting space to be in right now."
70% Emergency Medicine
TeamHealth employs or contracts with nearly 10,000 physicians and serves clients in 47 states. Snows says about 70% of TeamHealth business is emergency medicine, 10% is anesthesiology, 10% is hospitalist, and 10% is various specialty services.
While recruiting is a challenge, Snow says TeamHealth has a strong recruiting and retention program and physician turnover is limited to no more than 8% annually.
"Most of our recruitment is to fill new opportunities," he says. "We have a pretty stable group of physicians. The vast majority of the time, once they join us they stick with us. That helps a lot. Once you develop a reputation as a physician-friendly culture, it makes recruiting much easier."
A pioneering population health initiative launched by NewYork Presbyterian Hospital years ago—an experiment in care delivery at the time—has reduced 30-day readmissions by 36%. And that's not all.
Healthcare delivery is evolving so quickly that looking back a mere five or 10 years ago is like gazing at old sepia photos, quaint reminders of a long-gone era.
Emilio Carrillo, MD, MPH
VP of Community Health,
NewYork-Presbyterian Hospital
J. Emilio Carrillo, MD, MPH, vice president of community health at NewYork-Presbyterian Hospital and an associate professor of clinical medicine at Weill Cornell Medical College, was in on the ground floor of the collaborative that now provides care to about 205,000 people in the Washington Heights-Inwood section of Manhattan.
"For a long time our emergency room was the primary source of care for so many people and we saw that it didn't make any sense. We needed a better infrastructure for providing care," Carrillo says. "We developed a model that could provide better care using the right settings for the care and improve health and even reduce costs. We felt that providing care in the emergency room was just not right."
Beyond responding to acute care needs, the collaborative was looking for a way to identify, monitor, and treat chronic health conditions in the community before the problems required hospitalization.
"We're an academic medical center. We practice evidence-based medicine," Carrillo says. "We felt we needed to study the needs of the community scientifically and analyze what the needs were and determine what we had to do to meet those needs and scientifically measure the quality of the results and make that an ongoing process."
By 2010 NYP and collaborative partner Columbia University Medical Center and its medical school had identified key drivers of healthcare utilization and cost within the predominantly poor and underserved Latino neighborhoods they serve. The leading maladies included diabetes, asthma, heart failure, depression, and childhood obesity. The collaborative created seven patient-centered "medical villages" at clinics across WHI, and plugged patients and providers into a common electronic health record that tracked medical histories and care delivery for each patient.
Better Tools
"We maximized our use of information systems and information technology. We implemented culturally competent strategies. Those are the two keystones," Carrillo says. "We worked with Microsoft and they had developed a data aggregator that can look for diabetes. Everyone who has touched our clinics that has a diabetes diagnosis gets pulled into this registry."
"Once you pull in the individual's record number that pulls in lab results and records of utilization of ED and inpatient services and all elements of electronic medical record we designate. We are able to pull in all the data on all the diabetics we have access to."
It wasn't enough to simply identify, for example, the diabetics in their patient base. Carrillo says the collaborative designed extensive community outreach to ensure those diabetics got the care they needed.
"We instituted interdisciplinary teams that are at the heart of these medical homes," he says. "Using the IT and embedding nurse care managers into these teams we were able to identify diabetics who have not come to clinic for six months, who've been to the ED at least once, and who have hemoglobin A1c greater than 9. Hit the button and you get 50 names. We go after them."
The care teams rely on "culturally competent" health workers who live in the community and who can visit patients in their home and engage them in their own care.
"We have diabetes educators, social workers, psychologists, nutritionists, besides the traditional doctor and nurse and of course the nurse care manager," Carrillo says. "We have team meetings once a week and prepare for the people coming for the following week who have any one of these risks."
"We identify the people who have the risk of diabetes, stratify them by risk depending upon lab results and if they are using our system effectively, and we employ a team to bring them in line to control their disease, doing it all at once, using best practices, and putting them to work in concert and making the most of IT and culturally competent human resources."
Lower Readmissions, Higher Satisfaction Scores
The results have been impressive. The collaborative has reduced emergency department visits by 29%, and hospital admissions by 28% for patients with diabetes, asthma, or heart failure. In addition, 30-day readmissions and average length-of-stay declined by 36% and 5%, respectively, and patient satisfaction scores improved across all measures.
Beyond the hospital and clinic walls, the WHI collaborative outreach program includes a network of school-based health clinics connected to the medical village by information technology that provide mental health and primary care services to more than 7,000 students. The collaborative's childhood obesity prevention program, Choosing Healthy & Active Lifestyles for Kids (CHALK) program is now in 225 schools in 42 states after becoming a model for first lady Michelle Obama's Let's Move! Active Schools program.
The success of these programs has not gone unnoticed. Earlier this month the Association of American Medical Colleges awarded NewYork-Presbyterian Hospital with its Spencer Foreman Award for Outstanding Community Service.
There is nothing that Carrillo said when I spoke with him that I haven't heard dozens of times before about population health. It's important to remember, however, that what now is common sense and commonplace was less than a decade ago an outlier—an experiment in care delivery.
It's understandable why providers get depressed and frustrated amid the everyday issues that plague healthcare delivery, the various snafus and political haggling over Obamacare, the challenges of HIT interoperability, etc. The list of challenges is long, the problems seem endless and insurmountable and beyond the control of most providers.
When you take the long view, however, programs such as the WHI collaborative demonstrate that care delivery is improving, and at a fairly good pace too.
Efforts to repeal the formula by which Medicare reimburses physicians are being bolstered by a report from the Congressional Budget Office indicating lowered costs associated with rescinding the reimbursement cuts.
The American Medical Association wants the lame duck 113th Congress to permanently repeal the reviled Sustainable Growth Rate funding formula for Medicare before the session adjourns next month.
"It's important that we take advantage of the momentum that was created by all the worked that was done earlier this year to create HR4015 and Senate bill 2000," AMA President Robert M. Wah, MD, told HealthLeaders Media Tuesday, referring to the ill-fated legislation that failed to repeal the SGR last spring.
"The prevailing opinion is that everybody wants to get rid of this. They have the legislation in the form of these two bills to get it done," Wah said.
At the AMA's annual House of Delegates meeting in Dallas this month, Wah told attendees: "Congress must eliminate the SGR in the lame duck session. Why? Because it's essential to sustainable practice and preserving access… It might not happen during this lame duck session, but the end of SGR is not a matter of if, but when."
Robert Wah, MD
"All three committees of jurisdiction worked hard on creating a bipartisan bicameral bill that will work to end the SGR finally. That was done in such a regular and transparent way and each bill was reported out by the committees unanimously. We are hoping to capitalize on that work and that momentum and get this finally dealt with in the lame duck session we are currently in."
20% Cuts Loom
A 17th attempt at repealing the SGR—the top legislative priority of the AMA for the past decade—seemed on the cusp of reality in late March with broad support in both chambers. However, momentum faltered and lawmakers instead opted for another temporary fix that will expire on April 1, 2015. If that happens, physicians will see a more than 20% reduction in Medicare reimbursements.
Wah says the threats of massive reimbursement cuts and the annual sideshow surrounding an 11th hour temporary fix have left physicians anxious and frustrated.
"For the last several years it has been a close to 20% cut hanging over physicians' heads and it wasn't dealt with until the last minute," he says. "Not knowing what your revenue stream is going to be makes it very hard to plan or even think about any sorts of innovations."
CBO: Costs Have Dropped
Efforts to repeal the SGR may have been bolstered this month by a new scoring from the Congressional Budget Office, which lowered by $5 billion the estimated cost of rescinding the reimbursement cuts and freezing the reimbursements at $118.9 billion through 2024.
If an additional 0.5% in annual reimbursement increases is factored in, the cost of the SGR repeal would be $140.2 billion through 2024.
Nonetheless, paying for the SGR remains the biggest stumbling block. Wah says he's not going to make suggestions. "It is up to them to choose from the menu of options they have," he says. "Just like I wouldn't want them to tell me how to do surgery, I don't feel it's my job to tell them where to find financing for this legislation. It is the work of Congress to make those choices from the menu of options."
Wah says another failure by the 113th Congress to repeal the SGR likely means that the incoming 114th Congress will not have much time to address a permanent fix before the Medicare reimbursement cuts kick in on April 1, 2015.
"When Congress comes back in January and has to go through the reorganization and all of that business and reintroduce bills it will slow things down in our estimation," he says.
"We want to see something done in the lame duck session to capitalize the work that has been done and the momentum that has been created. This bipartisan bicameral bill was supported not only by Democrats and Republicans, but also by 600 physician organizations who contacted their representatives and senators to encourage them to pass this."
This article first appeared in the December 2014 issue of HealthLeaders magazine.
HealthLeaders Media Council members discuss some of the most effective cost-reduction efforts that their organizations have implemented.
Nate Blackford
Chief Operating Officer
Northwest Medical Center
Albany, MS
The first and probably the most impactful cost reduction program has been to right-size and renegotiate many of our contracts with various vendors. That improves our purchasing power. We've negotiated contracts with our pharmaceutical distribution companies and we have also initiated a 340B drug pricing program that has had a positive impact from an expense and a revenue perspective.
About 65% to 70% of our total operating expenses are on the personnel side. We've taken a comprehensive view of our people plan and tried to make adjustments where appropriate, and it's definitely my job to get staff to buy into it. We've been transparent and open and honest. We've let them see our financials and our patient statistics, and asked them to be part of the solution. That's how we've chosen to engage them, and it's gotten them to buy into the process because they have contributed to the solution.
We are not unlike other small independent critical access hospitals. We are looking for ways to strategically partner with other organizations to improve efficiencies, effectiveness, and ultimately reduce costs and improve quality.
Kris Zimmer
Senior Vice President of Finance
SSM Health Care
St. Louis, MS
On staffing: For us, No. 1 continues to be improving operational management given that our staffing costs are the largest components of our costs. With today's tools and technologies you can do a better job of predictive modeling: when the patient load is going to be heaviest and making sure your staffing patterns match with that.
On supply costs: Instead of having an inventory at every location, including all the physician clinics and all the ambulatory items, by having a warehouse we've been able to be much more efficient in total inventory and yet develop a distribution model that ensures supplies are available whenever they are needed. It's both reduced cost and improved the quality of the service delivery.
On integrated health: As we evolve into more of an integrated delivery network that is positioned to meet our customers' needs in a population health environment, including leveraging the assets that we acquired last year from Dean Health System, there are a couple of categories that we found very valuable. The first is our pharmacy benefits management company, Navitus, which we have implemented across our entire system. We are seeing notable savings from the way they help us manage our benefits and their transparent model so there is understanding of what the spend trends are and why, and what can be done to influence them. We haven't converted all of our employee benefits to the Dean Health Plan, yet we have immediately implemented Dean as a care manager and gave them responsibilities for influencing some of our care management processes across all of our health plans.
Mary Ann Freas
Chief Financial Officer
Southwest General Health Center
Middleburg Heights, OH
We have a labor productivity system that helps us on an ongoing basis, and benchmarking helps us with annual budget setting. Last year we used a vendor that helped to focus on nurse staffing levels. We hired about 75 new nurses, and we saved money in premium pay and overtime pay.
We have been successful in outsourcing certain services. We continue to save $500,000 a year and received better service by outsourcing transcriptions.
We also have had significant success in a couple of areas where we insource services previously outsourced in management areas. We had external management of certain clinical areas such as acute rehab, and we brought that back in-house. In our home health agency, we had used agency physical therapy because that function wasn't fully integrated with what was going on at the health center itself. We brought that physical therapy back in-house and saved quite a bit of money within that service. The rule of thumb that I use and many of my colleagues use is that if it doesn't touch the patient, then it may be a good candidate for outsourcing.
We're also working closely with our group purchasing organization and the programs they have in place for higher levels of commitment and the price advantage that we receive from that.
Timothy Putnam
President and CEO
Margaret Mary Health
Batesville, ID
We're engaging our frontline staff to identify cost reduction efforts. When we actively empowered individual managers and staff to think, "How can we provide the same service for our patients at a lower cost?" they started scouring for the opportunities. The pharmacists implemented the 340B drug pricing program; the just-in-time inventory came out of the people in materials management.
There were a lot of small projects. Nothing major. It didn't come from changing the buying group or renegotiating contracts. We joined the Suburban Health Organization a couple of years ago and have seen significant savings in buying opportunities. We worked together with them to create a program with a biomedical firm to do maintenance and repairs on all of our medical equipment. Before it was with different firms for maintenance. Now it is all coordinated and at a significantly lower cost than what we had before.
Cost has become much more top of mind. There are more retail pressures that we face, more price pressures and transparency issues in the marketplace. The organization that can be more efficient at delivering care is going to be much better placed in the future. I don't think 10 years ago that was our mind-set. Nobody likes waste, but we didn't quite see it as the enemy that we do today.
Undeterred by the results of the midterm elections, the American Medical Association is urging states that have rejected Medicaid expansion programs "to develop expansion waivers that help increase coverage options for their low income adult residents."
David O. Barbe, MD
AMA Immediate Past Board Chair
The American Medical Association is calling for expansion of health insurance coverage for adults in states that rejected Medicaid expansion under the Patient Protection and Affordable Care Act, and renewing the call for repeal of the sustainable growth rate formula.
The policy statement emerged this week from the AMA's annual House of Delegates meeting in Dallas, TX just days after Republican victories in the Nov. 4 midterm elections. Republicans flogged Obamacare for months on end during the campaign season, and many elected officials and pundits believe the PPACA may be in for more turbulence now that Republicans control the House and Senate.
Still, the nation's largest, oldest physicians association was undeterred.
"The AMA is sensitive to state concerns about expanding Medicaid in a traditional manner, but we believe they must find ways to expand health insurance coverage to their uninsured populations, especially as coverage disparities continue to grow between expansion and non-expansion states," AMA Immediate Past Board Chair, David O. Barbe, MD, said in prepared remarks.
"We encourage states that would otherwise reject the opportunity to expand their Medicaid programs to develop expansion waivers that help increase coverage options for their low income adult residents."
In his Saturday address to the House of Delegates, AMA President Robert Wah, MD, spoke with zeal about renewing efforts to repeal the SGR:
"Last spring we made another run… and achieved what we didn't have before—a framework to end the SGR, with bipartisan and bicameral support, backed by more than 600 physician groups. We're now delivering this message: Congress must eliminate the SGR in the lame duck session. Why? Because it's essential to sustainable practice and preserving access… It might not happen during this lame duck session, but the end of SGR is not a matter of if, but when."
The AMA also called on the Centers for Medicare & Medicaid Services to "approve waivers that are consistent with the goals and spirit of expanding insurance coverage. The policy also urges that states use a transparent process for evaluating the success of their efforts to expand access to care and to report the results annually on their Medicaid websites."
In other action this week, the AMA House of Delegates:
Urged that health insurance companies strengthen privacy policies to prevent the potential disclosure of sensitive medical information outside of the confidential patient-physician relationship.
Called for CMS to discontinue assessing penalties in the Meaningful Use program. While supporting interoperability, the AMA says attestation numbers show only 2% of physicians have demonstrated Stage 2 Meaningful Use.
Called on calls for insurers to make any provider terminationswithout cause prior to the enrollment period so patients can select health plans that will cover care provided by their existing physicians. Currently, AMA says, inaccurate or late revised provider directories are leaving patients stuck with plans that dropped their physicians after they enrolled.
Wah also spoke of the need for "coverage and reimbursement of telemedicine services and fewer restrictions in Medicare." CMS's final physician fee schedule which is effective January 1, 2015, includes provisions that will pay physicians for remote chronic care management.
Withholding as much as 3% of Medicare reimbursements for hospitals with higher 30-day readmissions will penalize many hospitals that are serving a disproportionate share of poor patients.
We would be hard pressed to find anyone in medicine or academia or walking down a street chewing gum who believes that socio-demographic data such as income, education, age, and Zip code don't factor into health outcomes.
Money matters in everything else we do. Why should healthcare be exempted?
The fact is, data shows that it's tough to be poor and stay healthy in the United States. It's tough to follow a physician's guidelines if you can't afford the medication, or if English is not your first language.
It's tough to take that recommended daily walkabout in a neighborhood with no streetlights or sidewalks. It's tough to recover from a respiratory ailment in a moldy apartment. It's tough to eat right when the only store in your neighborhood sells Lotto tickets, Doritos, and dusty cans of Vienna sausages.
And yet, the Centers for Medicare & Medicaid Services is ignoring reams of data and defying common sense when it mandates that many hospitals serving low-income areas must be held to the same standards on 30-day readmissions as hospitals in more affluent areas.
On its face, there is admirable altruism in the federal government's insistence that health outcomes should not depend upon a patient's income or neighborhood. CMS has a legitimate concern that creating different expectations for health outcomes based on socio-demographics will create a tiered delivery system that holds hospitals serving the poor to a lower standard of care.
Unfortunately, withholding as much as 3% of Medicare reimbursements for hospitals with higher 30-day readmissions, which CMS did with more than 2,600 hospitals this past year, will penalize many hospitals that are serving a disproportionate share of poor patients.
The policy also is countervailing to the federal government's acknowledgement that safety-net hospitals have special dispensation for their mission and the marginalized patients they serve.
Researchers evaluated three years of readmissions data on 3,018 hospitals that cared for patients with COPD and found that teaching hospitals and safety-net hospitals will be penalized more frequently, in large part because of their patient mix.
Michael Sjoding, MD
Study author Michael Sjoding, MD, a pulmonary and critical care fellow in the University of Michigan Medical School, says he understands what CMS wants, but fears the strategy could do more harm than good. "Some people think it's a backwards approach," Sjoding says. "Depending upon your perspective, some people would say you've identified hospitals that are struggling. We need to put more resources in these hospitals to help them get better."
While the emphasis on reducing readmissions over the past three years is prompting some hospitals to improve care coordination post-discharge, Sjoding says "it's hard to say what is going to happen in three or five years to these hospitals that are getting penalized 3% of their Medicare reimbursement every year. I worry that those hospitals aren't going to have the resources to provide good care to all of their patients, not just the patients with these conditions."
Sjoding says CMS should compare 30-day readmission rates at "peer hospitals" when determining readmissions penalties, rather than attempting to risk-adjust a patient base.
"The focus should be on highlighting hospitals in certain areas of the country that are providing exceptional care compared to their peers in inner cities or among large academic medical centers," he says. "It is an unfortunate reality that, especially in the case of readmissions, so many of the factors that drive readmissions are related to these social determinants of health that patients who come from advantaged backgrounds don't have a problem with. The unfortunate reality is we have to be realistic about this."
The reality right now, is that CMS's readmissions penalties take funding from hospitals that need it the most, further harming their ability to lower readmissions, and subjecting them to additional funding penalties.
"Until we figure it out, these hospitals are really suffering the brunt of this," Sjoding says. "I don't have the answer myself, but in the short term what is happening seems a little unfair."
The office of the Massachusetts Attorney General says it will investigate the closure of a 196-bed acute care hospital owned by Steward "in the context of [its] legal obligations."
Three years after Steward Health Care System bought the bankrupt Quincy Medical Center and agreed to keep it open for 10 years, the for-profit health system has announced that it will shutter the 196-bed hospital on Dec. 31.
The announcement by Steward last Thursday prompted Massachusetts Attorney General Martha Coakley to announce that her office will investigate the closure, which would leave the city of 93,000 people just south of Boston without an acute care hospital.
"We have just been notified about this decision and are currently reviewing it in the context of Steward's legal obligations," Coakley said in a brief media statement.
Steward's purchase of QMC in September 2011 was approved by Coakley's office but came with many strings attached. At the time, her office said in a media release that: "The Attorney General's approval of the Quincy Medical Center transaction will ensure that the hospital emerges from bankruptcy in the best position to provide Quincy's 92,000 residents with access to a full service acute care hospital and maintain key jobs…"
A key stipulation was that Steward would "maintain an acute care hospital in Quincy that provides at least the same scope of services during a 10-Year No Close period." Steward also agreed to maintain 22 inpatient geriatric psychiatric beds at QMC, along with significant capital upgrades.
In addition to the AG's agreement, a separate Massachusetts state law requires hospitals that are closing to provide a 90-day notice window and to submit to a public hearing, neither of which Steward appears to be doing with QMC.
In a lengthy media release posted on its QMC website, Steward Hospitals President Mark Girard, MD, did not address the apparent discrepancies with the AG's agreement from 2011. Calls to Steward for comment Friday were not returned.
Girard blamed the closure on low volumes, declining reimbursements from Medicare, and underfunding from Medicaid. He noted that in the past 20 years QMC has needed more than $100 million in city and state bailouts before falling into bankruptcy.
He also said that Steward has dropped an additional $100 million into the hospital since its purchase in 2011, but that the hospital continues to lose about $20 million a year.
"On an average day, only one-fifth of all beds are occupied and it has become abundantly clear that local residents no longer seek inpatient services from Quincy Medical Center," Girard said.
Steward said the closure shouldn't greatly affect patient access because there are 15 acute care hospitals located within 10 miles of QMC in the hospital-saturated Boston area. There are also 12 surgery centers, 21 urgent care centers, more than 150 nursing homes, 130 outpatient behavioral health sites, and more than 500 physicians within that radius, Steward says.
Instead of an acute care hospital, the shuttered QMC will be replaced "with a more sustainable healthcare system to meet the community's needs," Steward said. That network will include:
24-hour emergency room access
Separately sited, urgent care centers
A multi-specialty clinic in Quincy
Radiological services including X-Ray, mammography, CT, and ultrasound
Steward PCPs and specialist physicians in Quincy
Continued access to 15 hospitals within 10 miles of QMC, including a Steward hospital four miles away
Transportation links to other community health access points
Adam Powell, a healthcare economist and president of Boston-based Payer+Provider consultants, says Steward knew it was gambling when it purchased several financially struggling not-for-profit hospitals in eastern Massachusetts, "but as a result of that, they have a substantial network that was built quickly in this market."
"What Steward has learned over the past several years is that there has not been substantial demand for commercial inpatient services at QMC," Powell says. "QMC is roughly a half-hour drive from the more-famous hospitals in downtown Boston and as a result the patients who have the finances and the transportation have elective inpatient procedures performed downtown or at competing institutions."
"As a result, says Powell, "QMC has been left mostly with outpatient procedures and inpatient procedures performed on Medicare and Medicaid patients. It's been a tough financial slog for Steward and 2014 was looking worse than 2013."
Volumes are down because the region is over-bedded, Powell says. "That was the problem to begin with. The government poured money into it and then Steward poured money into it," he says. "First you think maybe more money or different management would solve the problem, but it appears that neither has solved the problem. The problem may be that there is no need."
In the meantime, Massachusetts Nurses Association spokesman David Schildmeier says the union is "working closely" with Steward to find jobs for the more than 200 registered nurses who will be displaced by the closure.
"Steward has frozen all open positions throughout the 10 remaining hospitals in Massachusetts," Schildmeier says. "We are hoping the 221 nurses we represent get preference on positions that are open so that they don't lose employment and they get all the benefits and pay that under the law they are owed."
The hospital employs 680 people, all of whom will be paid for the next 60 days, Steward said.
Among the new rules are provisions that will pay for remote chronic care management. "The combination of the chronic care management code and being able to use it in conjunction with monitoring of those chronic conditions is a big step forward," says the American Telemedicine Association.
Gary Capistrant
Senior Director of Public Policy at ATA
New rules from the Centers for Medicare & Medicaid Services significantly broaden coverage for chronic care telehealth services.
The rulemaking changes are inside the 1,185-page document detailing Medicare payments to physicians and other providers.
The American Telemedicine Association, which had sought the expanded coverage for five years, notes that among the rules are provisions that will pay for remote chronic care management using the new current procedural terminology (CPT) code 99490, with a monthly unadjusted, non-facility fee of $42.60.
"For us, it was more important to begin to specifically address chronic care," says Gary Capistrant, senior director of public policy at ATA. "The combination of the chronic care management code and being able to use it in conjunction with monitoring of those chronic conditions is a big step forward and a very substantial change for Medicare."
Capistrant says the new rules also represent an acknowledgement by CMS that reimbursing for chronic care could prove to be cost effective.
"It's an important policy move. Whether it is sufficient, time will tell, but it is certainly a step in the right direction and an important initiative," he says. "There has been a lot of focus on primary care, even with the Medicare population. That may be the 80% of the people but it is only 20% of the problem. There's an increasing emphasis on looking at the 80% of the problem that is 20% of the people, and that is chronic and specialty care. They understand that the government is spending a huge amount for chronic care conditions and that there is a value managing those to reduce the overall expenditures."
As a practical matter, Capistrant says, the new evaluation management code for chronic care management will be a much more commonly used because "it's a better fit between management and monitoring."
As for the reimbursements, Capistrant says "only time will tell whether those amounts are sufficient to get physicians to focus on chronic care management and monitoring. I think it will be attractive to physician community, geriatricians and others who deal with these chronic conditions."
"First, they'll have to see what is involved in being a chronic care manager and to what extent you want to add that to your practice. It may involve some internal staff changes," he says. "There are services required that a lot of physicians just don't do right now, in part because they are not paid for it. This is probably the kind of thing that physicians may not be too interested in doing for one or two patients, but if they can get 100 or 200 patients then they've got the economies of scale going to make it work right."
Hospitals might also take a greater interest in chronic care management if only to avoid readmissions penalties. "More than 2,000 hospitals have a penalty this year in their Medicare rates because of readmissions," Capistrant says. "There is an increasing demand for this kind of service and it fits together."
The new rules also include seven new covered procedure codes for telehealth, including annual wellness visits, psychotherapy services, and prolonged services at physicians' offices.
