Risk factors that can adversely affect a patient's recovery or trigger a hospital readmission include behavioral issues. The chair of the Cedars-Sinai Department of Psychiatry discusses how screening for depression will become more widespread as hospitals adopt value-based reimbursement models.
Bysome estimates, about 18 million people in the United States, roughly 7% of the adult population, experience an episode of major depression each year. Undiagnosed and untreated, depression can have a profound effect on hospital patients who are also dealing with seemingly unrelated health issues.
>Itai Danovitch, MD, MBA
Chair of the Cedars-Sinai Department of Psychiatry
With that in mind, Cedars-Sinai Medical Center in Los Angeles, CA announced this month that it has begun screening all adult inpatients for depression along other risk factors that could adversely affect their recovery.
Itai Danovitch, MD, MBA, chair of the Cedars-Sinai Department of Psychiatry, spoke with methis week about the need for screening, and how it will become more widespread as hospitals enter value-based reimbursement models. The following is an edited transcript.
HLM: Why did you start screening all inpatient adults for depression?
ID: At Cedars Sinai Medical Hospital the psychiatry department does a lot of consultations. That means that doctors call on us when there is a problem with a patient that they think is related to mental health and is affecting their medical care.
Depression is incredibly common and one of the things we know is that often, by the time we get called for helping a patient with depression, they have already had that depression for a period of time. If we could get calls earlier, or if the depression could get recognized sooner, there [would be] opportunities to intervene and help that patient earlier on.
That was our personal experience, and in reading the quite extensive literature on the prevalence of depression in patients with medical illness and also its impact on outcomes.
The rate of depression prevalence in patients who have medical disorders ranges from about 10% to 30% and in some diseases, such as cardiac disease, it is 30%. The presence of depression impacts basically every feature of a patient's medical care. It impacts their experience with care, their satisfaction with care, it impacts their adherence to care regimens. It impacts the disease outcomes from the medical diseases they are suffering from.
For cardiac patients the risk of myocardial infarction goes up substantially when someone also has a history of depression for reasons we don't fully understand. It also impacts their utilization of healthcare services. Having depression is associated with a two-fold increased risk of being readmitted to the hospital.
Essentially virtually every feature of healthcare is impacted in a negative way by depression. You can only address it and help somebody with depression if you first recognize it. The purpose of this initiative is to screen patients so that we can identify them more readily and give the patients information they need to empower them to be able to get help if they choose to.
HLM: What does the screening process involve?
ID: It is quite straightforward. There are a number of screening tools for depression. The ones we are using are called the Patient Health Questionnaire. There are two forms of it: the PHQ-2 and the PHQ-9 that screen for depression. They ask about the symptoms of depression and the purpose of the PHQ 2 is a broad screener. Are they depressed? Have they lost interest in things? That's used by the nurse to then ask the rest of the questions if the patient is positive.
If not, they move on with the rest of their assessment. It is easy to do and it is a measure that has been tested and validated in many different healthcare environments. It can be appropriately administered by many different health professionals.
The challenge of detecting depression in the medical setting is that there are many medical conditions that can cause symptoms or syndromes that can look like depression. So it is important to have a physician or an allied health professional evaluating the patient to disentangle various forms of depression and give the patient guidance on how to find treatment for it.
HLM: Are the screenings expensive or do they require significant time or resources?
ID: The screening cost in and of itself requires a little bit of extra labor on the part of nurses, but our experience here and in other locations is that nurses are readily able to integrate this.
It doesn't impact their work flows too much. Of course, more and more quality demands are placed upon nurses and we are very sensitive to that. But the nurses here really feel that this is a sufficiently important aspect of healthcare to make it a priority and to involve themselves in the screening.
The costly thing is actually referring patients and having them get treatment for their depression. That is a cost that ultimately patients and their insurers bear. What the literature shows is that it is even costlier not to address depression.
HLM: Many providers across the nation have problems accessing behavioral health services. Why bother screening patients if you can't get them the help they need?
ID: It should be the healthcare professionals' role first and foremost to determine what is wrong with a patient, to be able to diagnose them and refer them to the services that the patient needs in order to get better.
As a society we have a different problem, which is how do we finance the things that we know to be helpful to patients? What we are recognizing now is… that in the long-term some of the interventions that are simple and benign can be helpful in producing long-term gains for patients in reducing costs whereas in the short term it can be hard to recognize those values.
So, the closure of a lot of mental health services is a function of the fact that those services don't reimburse very well because our field and our society haven't done a very good job of recognizing the value of those services.
HLM: What happens if you determine a patient has depression?
ID: We notify the patient's medical doctor and the social worker that the patient has screened positive. Every patient has a social worker assigned to them and the social worker does additional assessments to determine if the patient is already in care.
Do they have a treating psychiatrist, psychologist, or therapist who is able to educate the patient? The physician for the patient is also asked to assess the patient, to advise them about the findings of the screening and their relevance to their medical care and to assist them with a referral if the patient wants that referral.
HLM: Do you see these screenings become more common as hospitals shift to population health and value-based reimbursements?
ID: Absolutely! When we talk about bending the cost curve, which really means trying to get better outcomes without spending more for them, some of the greatest opportunities to do that are in improving the behavioral and mental health of patients.
HLM: How will you know if these screenings are successful and a good return on investment?
ID: The worthiness of the screening has been established by a number of other groups besides us. The U.S. Preventive Services Task Force has adopted depression screenings as a best practice. That is a function of extensive data supporting the idea that identifying and screening depression is cost effective and valuable.
At Cedars-Sinai our measures are how well we identifying patients. Are we screening every admitted patient? Are we educating our allied health providers and nursing staff? Eventually we are going to look at other things such as how do positive scores on depression relate to other important features of care, such as patient satisfaction with care, readmissions, length of stay in the hospital, are we able to increase the referral rate for treatment services for patients who screen positive, etc.
HLM: Can these screenings be done at hospitals where resources are already stretched?
ID: An increasing number of hospitals, including community hospitals, are engaging in various alliances and partnerships with other parts of the health continuum to manage the lives of populations.
Whether it is with insurers or outpatient clinics, the first questions are 'who are the stakeholders in the patients' healthcare and what is the best point of service to screen the patient for depression? So, there is very little question that, from the patients' experience, they need to be screened for depression and they need to be offered services. Exactly who does that and where in the system that happens and how it is managed depends upon the arrangements of those particular health systems. It is hard to answer that question totally generically. A lot of health systems do this in the primary care setting.
HLM: Do you anticipate that this could be mandated at some point by the federal government?
ID: It is a good question and I don't know the answer. Some regulatory bodies like The Joint Commission and others have considered and evaluated some quality metrics that get to behavioral health outcomes and possibly depression. The Joint Commission has established suicide screening as a national patient safety goal and detecting patients at a high risk of suicide is accomplished in part through this measure.
Globally, if we look at trying to enhance value and improve outcomes for patients, this effort to improve value and outcomes is going to drive more health systems to be screening and identifying underlying behavioral health issues. That is an area where overall we haven't done a really great job of meeting patient needs and where the failure to meet patient needs costs us a lot in terms of financial costs, but also more importantly in terms of patients health outcomes.
It's an important opportunity because we can both potentially reduce utilization and improve their health outcomes.
On the first day of an AHIMA-organized summit, the Coalition for ICD-10 picked up a strong ally, America's Health Insurance Plans, but got no new information from federal officials about an implementation date.
ICD-10 advocates attending a two-day summit in Washington, D.C., got stonewalled by federal officials who declined Tuesday to provide a new start-up date for the medical coding set.
Godwin Odia, who is leading the Medicaid ICD-10 implementation for the Centers for Medicare & Medicaid Services updated stakeholders on the status of Medicaid readiness at the federal and state level, but didn't go much beyond that.
"He basically read a script and said 'don't ask me any other questions. I can't answer anything,'" said Lynne Thomas Gordon, CEO of the American Health Information Management Association, which organized the summit. "I kept asking 'When? When?' and he kept saying 'stay tuned.' It was very scripted."
"The intent of his talk sounded like we are moving ahead. Medicaid sometimes gets a bad rap because people say they aren't ready. Odia said 'we are ready.' He was trying to reassure everybody."
The stakeholders also heard from Donna Pickett, a medical classification administrator with the Centers for Disease Control's National Center for Health Statistics. "She also had the same line: 'I can't tell you anything,'" Thomas Gordon said.
The Protecting Access to Medicare Act of 2014, signed into law this month by President Obama, delayed implementation of the ICD-10 code set until at least Oct. 1, 2015. Stakeholders want some sense of a new implementation date when they hear from Denise Buenning with CMS'sOffice of e-Health Standards and Services.
Also Tuesday, the Coalition for ICD-10 gained a strong partner with the announcement that America's Health Insurance Plans has joined the industry's lead advocacy group.
"The implementation of ICD-10 is a critical step on the path to a more sustainable health system for consumers," AHIP President/CEO Karen Ignagni said in a media release. "We look forward to working with all members of the Coalition to help advance this important transition."
In addition to AHIP, Coalition for ICD-10 members include: American Health Information Management Association; American Hospital Association; BlueCross BlueShield Association; College of Healthcare Information Management Executives; WellPoint; Siemens Health Services; and 3M Health Information Systems.
"AHIP has always been for no delay and we are glad to have them on the coalition," Thomas Gordon said. "Everyone talks about end-to-end testing and 'are we ready?' so it's nice to make sure the payers are with you."
AHIMA and other ICD-10 stakeholders say they want to know when federal officials intend to set a new implementation date for the delayed code set.
Stakeholders and other supporters of ICD-10 are scheduled to meet in Washington, DC Tuesday with a senior official at the Centers for Medicare & Medicaid Services with the hope of learning when the federal government is going to act on the oft-delayed medical coding set.
The Protecting Access to Medicare Act of 2014, signed into law earlier this month by President Obama, delayed implementation of the ICD-10 code set until at least Oct. 1, 2015. Stakeholders want some sense of a new implementation date when they hear from Denise Buenning with CMS'sOffice of e-Health Standards and Services. The two-day summit is being organized by the American Health Information Management Association.
AHIMA CEO Lynne Thomas Gordon says ICD-10 stakeholders have been left in the dark ever since the delay was slipped in as part of a bill that delayed implementation of the sustainable growth rate funding formula for Medicare reimbursements.
"We have been trying to keep our eyes and ears attuned to what the news is and we have not gotten anything official," Thomas Gordon said Monday in a telephone interview.
"Perhaps we might hear something (Tuesday). We would like to try to pin them down because we feel it should be no later and we are just assuming it will be Oct. 1 2015. We will definitely be asking those questions."
Thomas Gordon says the delay is somewhat "understandable" because CMS has been preoccupied with the Obamacare rollout over the past several weeks, with departure of Health and Human Services Secretary Kathleen Sebelius announced last week, and with the nomination of Sylvia Burwell, the director of the Office of Management and Budget, as her replacement.
"They've had some turnover there so I can understand with a new secretary coming in she probably wants to get her feet on the ground before things are announced, but maybe we will hear something (Tuesday)," Thomas Gordon said.
The silence from HHS has fostered a growing sense of frustration and urgency among ICD-10 stakeholders. Last week, the Coalition for ICD-10 asked HHS to establish Oct. 1, 2015 as the new ICD-10 implementation date. In a letter to CMS administrator Marilyn Tavenner, the coalition said the delay has caused great uncertainty across the healthcare industry about the future of ICD-10.
"The delay is going to be disruptive and costly for healthcare delivery innovation, payment reform, public health, and health care spending, and uncertainty on the implementation date only adds to the disruption and cost," the letter stated.
The coalition, comprised of hospitals, health plans, professional associations, hospital and physician office coding experts, vendors and the health information technology community, says it would "work with CMS to identify measurable milestones on the path toward implementation to demonstrate that preparatory work is proceeding smoothly toward successful implementation."
Thomas Gordon says she also hopes to hear from ICD-10 industry leaders at the summit about what they're doing to cope with the delay. "What we are hearing anecdotally is that people are moving ahead, trying to beef up their clinical documentation improvement programs, working with their vendors, educating their physicians and training their staff on ICD-10," she says.
"We want to know if that is really true. We will take some polls. We are trying to take a pulse of the industry, what is going on and how can we help."
A Community Hospital Corporation deal illustrates the great financial strain on Georgia 's small and rural hospitals as a result of a decade-long decline in state Medicaid reimbursements, the economic recession, and the challenging demographic of older, poorer, and sicker patients.
Monroe County Hospital, a 25-bed critical-access hospital serving the Forsyth, GA area, has hired Community Hospital Corporation to provide advisory and management support services.
Kay Floyd, CEO of Monroe County Hospital, said the county 's hospital authority elected to hire CHC after considering everything else on the spectrum from loose affiliations to an outright sale of assets.
"We have a very proactive hospital board that has had their mind on strategic planning and mapping the future of the hospital for the last couple of years. It took us into a pretty extensive [request for proposal] process looking at affiliation, " Floyd said in a telephone interview.
"We were prompted by the concerns around shrinking reimbursements, some concerns that are directly related to the healthcare reform law and the shortage of physicians. We are in a community of 26,000 in the county and trying to get primary care physicians in rural communities is a significant challenge. "
In the end, Floyd says, it came down to maintaining local control.
"My hospital authority feels strongly about keeping control of the healthcare delivery local, strongly about governance, and strongly about having the delivery site be accessible in the community itself and preserving the hospital, " she says.
"Healthcare delivery should be local. We want to preserve our services. We are pretty heavy on the geriatric demographic with people who have limitations and an inability to travel very far to get their services. Transportation is a big hurdle for some of the people in our community. We serve a lot of people in our hospital who walk to our emergency room. "
The deal comes as Georgia 's small and rural hospitals are under tremendous financial strain owing factors including to a decade-long decline in state Medicaid reimbursements, the Great Recession and its continuing after-effects, and the challenging demographic of older, poorer, and sicker patients.
Established in 1957, Monroe County Hospital is located about 60 miles south of Atlanta Under its critical-access designation, Monroe County Hospital has a transfer designation agreement with the Medical Center of Central Georgia, about 24 miles to the southeast in Macon. HCA also has two hospitals in Macon.
Craig Sims, CHC 's senior vice president of operations, says many of the smaller rural hospitals that CHC contracts with want to remain independent.
"They are looking for affiliation strategies or a way where they can continue to serve that community, " he says. "What has worked best in our model is the relationship that brings in a larger or tertiary partner in that market for clinical affiliations. So, it really varies by the opportunity and what the board and the hospital and the local market have that cause us to make those decisions. "
Floyd says she will be able to tell relatively soon if the contract with CHC is a success.
"I don 't mean to be coy, but the bottom line is the answer, " she says. "We 're going to be looking for some financial improvements right away. I will also be looking for some clinical improvements where the service line that we have available would be concerned. "
The MCH deal was one of two new contracts that CHC announced this month. The Plano, TX-based not-for-profit company also signed a contract to manage 49-bed Bowie (TX) Memorial Hospital, located about 90 miles northwest of Dallas.
CHC owns or leases 10 hospitals. Bowie Memorial and Monroe County are among the 12 hospitals that CHC 's consulting arm, CHC Consulting, manages or supports.
"Our primary objective is to ensure that community-based hospitals achieve long-term success, especially as federal and state governmental mandates drive down reimbursements for both hospitals and physicians, " CHC President and CEO Michael D. Williams said in a media release.
Bowie Memorial Board Chairman Tim Winn said the relationship with CHC "will help to strengthen our hospital for future success and prepare for the myriad of changes occurring within the healthcare environment. "
VCU Health to Acquire Community Memorial Healthcenter
Virginia Commonwealth University Health System in Richmond will acquire Community Memorial Healthcenter in South Hill, VA, in a deal that is expected to be completed this summer, the two health systems have announced jointly.
The hospital, located about 70 miles south-southwest of Richmond and near the North Carolina state line, will be renamed VCU Community Memorial Hospital. VCU Health System will commit at least $75 million in new investments in CMH, including a new hospital, healthcare technologies, clinical initiatives and physician recruitment.
CMH is licensed for 99 acute care and 161 long-term care beds and provides inpatient and outpatient services. It is one of the area 's largest employers with approximately 800 employees, 200 volunteers and 85 physicians who represent more than 30 medical specialties. VCU has an existing relationship with CMH through the Massey Cancer Center.
CMH employees join about 9,000 VCU Health System employees. The CMH board of directors will continue with local and VCU Health System appointments. Under the new structure, local leaders and CMH will continue to represent local interests on governance and strategic planning, and the CMH Foundation will continue to be a philanthropic arm of CMH.
CMH Chairman John Lee said in prepared remarks that the acquisition was the culmination of an extensive affiliation study conducted by a committee of stakeholders.
"Our committee 's charge was driven by a desire to ensure CMH 's long term sustainability, and allow it to not only continue its legacy of high quality healthcare offerings, but to expand and enhance its services, and do so from a new state of the art hospital worthy of those CMH is here to serve, " Lee said.
"We recognized that meeting those objectives would likely require the ongoing support and clout of a world class organization, and this mutually beneficial relationship with the VCU Health System very successfully accomplishes all those goals. "
In our December Intelligence Report, more than one-third of healthcare leaders (36%) said it is likely they would drop clinical services as a way to cut costs or enhance margin. What do those results suggest generally, and how is your organization handling its clinical services?
Alison Page
CEO
Baldwin Area Medical Center
Baldwin, WI
Healthcare needs to change, and it will change. The biggest challenge for healthcare organizations is going to be riding the transition to a future reimbursement model based on value, and how do you reduce costs and increase quality while designing the delivery system of the future?
How do you move from our current world in which all the revenue is based on face-to-face visits and admissions to a world where revenue is based on effective management of total cost of care? Right now if we do a group visit or health coaching, we don't get paid for that. These things are a great way to reduce costs, so the challenge is going to be moving to the new care delivery model incrementally in a way that allows you to keep your margins steady.
There are a lot of services that we offer that we don't make money on, and we are going to have to evaluate which of those we can continue to offer or other ways that we can reduce costs. We are a critical access hospital, so closing services means people have to travel further. You want to offer services that meet the needs of the people who live in your region, but you also have to have a black bottom line.
Mark Bogen
Senior Vice President and CFO
South Nassau Communities Hospital
Oceanside, NY
On balancing revenues: The hope and expectation is that there are enough profits being earned on the service lines such as orthopedics and oncology and cardiology to allow the continuation of access to things such as behavioral health or pediatrics or outpatient clinics.
We have seen that on Long Island with both the private and even the state-run hospitals for behavioral health. That has dumped a lot of patient issues on the doorstep of those of us who still have programs.
On feeling the squeeze: As hospitals feel squeezed and feel like their overall financial viability is threatened, they are going to take a look at those programs that have the least contribution margins and they may feel that it's better to close to keep everything else going. That reduces access for people who have grown dependent on those institutions to provide for those services. You see that as a microcosm when you look at those hospitals or systems that start to show the cracks financially. You cut services that aren't performing and somehow that is not enough and you continue to cut and pretty soon you don't have anything left.
On long-term implications: That may take a year or 10 years, but I have seen it all too often where it is like water going down the drain. I understand the finance guy. The survival of the organization is always at the most critical level in making these decisions. But you start to lose the identity and the mission the organization was originally founded upon.
Dennis Wolford
CEO
Macon County General Hospital
Lafayette, TN
We are a 25-bed critical access hospital. We are not-for-profit. We have to look at these services we provide and how much is in Medicare or Medicaid. We look at that closely. We can't provide services like obstetrics. That is not reimbursable and we haven't had any docs or OB-GYN services since 1984.
One thing we are concerned about is our rehab services: physical therapy and occupational therapy. The provision there is, do you need direct supervision or can you use general supervision? We got it clarified and it looks like we are exempt from that, but there are a lot of other critical access hospitals that are providing a lot of services that require direct supervision and it is going to kill them. It almost feels like CMS has got it out for critical access hospitals.
We do at least a three to five-year strategic planning but with so much up in the air—the impact of Obamacare and these other pending changes, and Tennessee has not approved Medicaid expansion—we are almost living from month to month and day to day. It's hard to project. We have been treading water for some time. Financially we are holding our own, but with what is coming down the pike I don't know how much longer we can hold on and I know all the other critical access hospitals in this state are facing the same thing.
Tammy P. Mims
COO
Effingham Health System
Springfield, GA
It is very likely that Effingham will drop clinical services as a way to cut cost. Our organization is examining each service line to determine profitability.
Any service line that is a drain on the bottom line will be thoroughly examined and may be eliminated. Or we may restructure to eliminate waste and reduce operating costs to keep the service line at a minimum. It is unknown today if any service lines will be dropped.
They generate $1.6 trillion in economic activity, but as a class, physicians are slow to upgrade and adopt technologies that would make them—and the nation's healthcare system—more efficient and less costly.
The general public is getting some mixed signals these days from physicians.
The American Medical Association came out with a report this week that says that physicians generate about $1.6 trillion in economic activity, support 10 million jobs, and are "vital economic drivers at state and national levels."
I won't quibble with that figure. Physicians are among the most highly educated, highly trained, highly respected, and highly compensated professionals in our country. It would only make sense that we trust them to have a key role in supervising the nearly 20% of the economy that the healthcare sector occupies.
On the other hand, we have another report this week about efforts to wean doctors away from fax machines. That's correct: Fax machines. I had to double check the article to make sure it wasn't a satirical piece from The Onion.
Why are some of these "vital economic drivers" still using 1980s technology? Did they get a special closeout deal on thermal paper down at the office supply store during the Y2K scare? Perhaps it was part of a package deal that came with a beeper, a mimeograph, and a rotary phone.
At many physicians' offices patients still have to fill out paper forms and medical histories every time they go for an office visit. Take-out pizza joints and auto lube shops use more sophisticated, consumer-centric IT than many physicians, because most retailers are light-years ahead when it comes to customer satisfaction and delivering value.
So far, consumers have put up with a healthcare system that treats them as an afterthought. At some point they won't. And that change will occur quickly and probably sooner than anyone expects, now that consumers are responsible for more of the cost of their care through high-deductible insurance plans.
Therefore, while physicians boast about controlling $1.6 trillion of economic activity even as some of them continue to use cumbersome, antiquated technologies to collect and share patient information, they shouldn't be surprised when the government steps in and mandates health information technology upgrades.
Yes, there are still a lot of snags and snafus associated with electronic health records systems, but this industry-wide movement toward EHR was not done in a vacuum and it didn't sneak up on us. I was sitting in the audience at Vanderbilt University in May 2004 when President George W. Bush said that EHR would be a national priority.
I don't know of any other industry or sector of the economy that has had to be forced by the government to enter the digital age, nor been given such a long lag time and financial incentives to get up to speed.
ICD-10 Delays
Technophobia was in bloom last month when specialty physician associations allegedly convinced Congress to delay by at least one year more–again–the implementation of ICD-10. History tells us that ICD-10 was ready in 1992 and that every advanced country in the world has already adopted the code set, including China, Thailand, and South Africa.
And just as with the EHR mandate, ICD-10 didn't sneak up on anybody. If you didn't have plenty of warning that this was coming, you were asleep.
The American Health Information Management Association was so certain that ICD-10 was a done deal that they nearly destroyed what they reasonably assumed were obsolete ICD-9 instruction manuals. Now, twice-burned AHIMA won't certify for ICD-10 until it is up and running. Community colleges across the country are pulling those old ICD-9 texts out of the dumpster and scrambling to retrain many of the 40,000 students who naively thought they'd have a job coding ICD-10 on Oct. 1.
Instead, they'll be learning a medical coding technology that was adopted in 1979, a year perhaps best remember for the Iran hostage crisis, and the debut of The Dukes of Hazzard. I am struggling to make an analogy here with any other huge, data-reliant industry that would advocate for a shift away from say, Windows 8.1 to MS-DOS.
Pay Data Transparency
Also this month, physicians' associations were bracing for the worst when the Centers for Medicare & Medicaid Services released Medicare payment data on individual physicians, a data dump detailing the use of taxpayers' money that the American Medical Association and other physician groups had fought for years.
Why the trepidation? So far, the data is showing that the vast majority of physicians provide competent care at a reasonable cost to a challenging patient demographic. Predictably, many of the outlier physicians who've received millions in Medicare dollars grabbed the headlines for a day or two. But even many of them have legitimate and commonsense explanations that the public will accept. The few docs who are ripping off the system should be exposed.
While a growing number of providers understand that healthcare can no longer operate under business models from the 20th century, a significant minority still do not. Payment schemes are shifting from volume to value and that shift will require a tremendous amount of data to support and verify outcomes for large groups of people.
Turf Battles
There are problems on at least two other fronts.
Physicians' associations in many states are fighting rearguard actions to limit scope of practice for nurse practitioners and higher highly skilled clinicians. This is a fight physicians are going to lose. Their best option now is to negotiate surrender on favorable terms.
And deep-pocketed drug store chains and other retailers with a long history of meeting consumer demand see the value of walk-in clinics and they will lobby hard to expand their purview. It's common knowledge that there aren't enough physicians to provide adequate access to care, and that's a problem that will only get worse in the coming decade as more physicians retire.
More importantly, this is what consumers want and it's not clear if some physicians' associations understand this. The American Academy of Pediatrics, for example, recently stated that "retail-based clinics are an inappropriate source of primary care for children because they fragment children's healthcare and do not support the medical home."
This may be true in some cases, but the AAP's nuanced arguments about the continuum of care might be lost on a wage-earning single parent who's got a bawling two-year-old child with an earache at 9 pm on a Friday and no place else to go, other than the nearest hospital's emergency department.
Instead of criticizing the proliferation of walk-in clinics, physicians' associations should ask themselves why this is happening. Clearly someone in the marketplace is attempting to meet a consumer demand. Perhaps physicians' associations should urge their member physicians to do more to expand their office hours and make themselves more available to the public after hours and on weekends.
Jump or Be Pushed
We have heard many of the arguments for why some, but most certainly not all, physicians are so reluctant to embrace change. Many docs and their professional associations may have perfectly legitimate reasons for resisting a particular policy or technological mandate.
Here's the problem: If your response to EHR, ICD-10, and other innovations or data releases or consumer trends is "no" or "not now" or "there's no value in it for me," then people are going to stop asking you. They're going to make you do it, or they're going to find someone else to do it for them.
One reason why physicians are the object of government mandates is because a significant percentage of these "vital economic drivers" often appear unwilling to take on the task by themselves.
The American Hospital Association wants CMS to adjust measures in pay-for-performance programs to reflect factors such as race and income, even though doing so "would be a complex undertaking" for everyone involved.
Rick Pollack
AHA Executive Vice President
Two hospital associations are providing a ringing endorsement of a National Quality Forum draft report that recommends risk adjusting quality measures for hospitals' patient mixes to reflect socioeconomic factors such as insurance coverage, race, and income.
The American Hospital Association on Monday sent a letter to NQF and the Centers for Medicare & Medicaid Services urging them to act quickly on the report's recommendations.
"A large body of evidence demonstrates that sociodemographic factors such as income and insurance status affect many patient outcomes, including readmissions and costs," AHA Executive Vice President Rick Pollack writes in the letter.
"Sociodemographic adjustment allows for all providers to be fairly and accurately assessed on the quality of care they provide and their contribution to patient outcomes while mitigating negative unintended consequences of measurement. Identifying appropriate sociodemographic adjustments also may help to highlight the impact of those factors on patient outcomes, allowing them to be addressed."
AHA wants CMS to use the NQF guidelines to adjust measures in quality reporting and pay-for-performance programs on markers such as readmissions, even as Pollack concedes that adopting the recommendations "would be a complex undertaking" for everyone involved.
'Really Important Things to Consider'
"The negative unintended consequences of failing to adjust measures for sociodemographic factors are substantial," Pollack said in the letter, which was sent at the close of the 30-day comment period. "Moreover, we urge NQF to place a high priority on working with CMS to rapidly address its measures."
"Lastly," the letter says, "we concur with the panel's recommendation that NQF expand its role by developing more detailed implementation guidance for measures, and clarifying for what uses a measure is endorsed."
Nancy Foster, AHA's vice president of quality and safety policy, says clinical factors are already baked into hospital outcome measures to reflect hospitals that serve sicker or older populations. The NQF recommendations take the process one step further.
"This is a report that says beyond the clinical factors there are really important things to consider when you are looking at outcomes, particularly outcomes that you are measuring, and a considerable amount of times measuring post hospitalization," Foster says.
"Things like a patient's ability to follow the instructions that were given to him or her upon discharge, whether they can get to a rehab facility or they can get to physical therapy or they can get out and exercise in a safe environment or they can find appropriate food in their local grocery store. All of those things play into whether or not a patient actually recovers as quickly and as well as we'd all want, and certainly the patient would want," she says.
AHA and other hospital groups have been calling for a socio-demographic metric for years and Foster says the federal government may now be responding to research.
"Enough questions and enough research has been published that Health and Human Services thought it was important for NQF to look at this question and determine whether there was something really there," Foster says. "We have reason to believe that the sociodemographic factors are significant and outside the control of providers, and perhaps should be adjusted for."
"There have been any number of stories," says Foster, "usually published about readmission measures, and because they have significant penalties attached to them and because the data are out there now one can actually do the analyses."
Safety Net Hospitals Also Supportive
Beth Feldpush, senior vice president for policy and advocacy at America's Essential Hospitals, said the safety net hospital lobby "strongly supports the NQF panel's recommendations."
"We think that there is a large body of emerging evidence showing the sociodemographic factors can influence health outcomes," Feldpush says. "That includes these factors in risk-adjustment models where there is evidence to do so will really improve the science of performance measurements."
Practically speaking, Feldpush says bringing sociodemographic data such as income, race, and access to insurance will create "a more accurate picture of performance, which means that some institutions that are doing very well now may not do as well, and some institutions that are not doing as well now may do better. We think the overall effect is that it will improve accuracy and really shed light on the true performance for various hospitals."
Currently none of that is taken into account now. "For individual patients for example with readmissions measures, their medical history is taken into account and I guess some very common socio-economic demographics such as age and gender are used," Feldpush says. "But you don't get any sense as to the individual's income level or education level or anything related to the community in which they live."
Feldpush says she can't predict how safety net hospitals or any entire class of providers will be affected if CMS takes up the NQF recommendations. "We think it will really improve the clarity of the picture and you're certainly going to see a difference in performance across the field," she says.
Data Collection 'Will Take a Little Time'
"But we believe that because of the patients that we serve, having this information in the risk adjustment models will be very helpful to our providers because they do tend to serve a disproportionate number of low-income individual. But there is no way you could say at this point that all safety net hospitals do better or all or some other type of hospitals will do worse."
"It's not easy to collect the data on these sociodemographic factors and that is one reason that some have argued that you shouldn't do this—that it is too challenging," Feldpush says.
"We would push back and say that just because something is hard work doesn't mean we should back away from it. But it will take a little time to make sure we are collecting the socio-demographic information in an accurate way. Although I would also say that providers and hospitals are engaged in collecting race and ethnicity and language preference data now, and this recommendation—particularly if it was going to be put into use for quality measures—would certainly put momentum behind those efforts already underway to collect the data."
Multispecialty medical practices with non-physician providers typically perform better financially than those without physician assistants and nurse practitioners, an MGMA report finds.
Susan L. Turney, MD, President and Chief Executive Officer, MGMA-ACMPE
The use of physician assistants, nurse practitioners and other "non-physician providers" continues to accelerate with the advent of value-based, coordinated care delivery, a Medical Group Management Association analysis shows.
The report examined growth in the use of non-physician providers at multispecialty practices and found that the number of full-time-equivalent NPPs per FTE physician has increased by 11% since 2008. Correspondingly, the analysis determined that medical practices with NPPs typically perform better financially, perhaps because the NPPs boost patient capacity and improve access to providers.
"While it's encouraging to see that practices who invest in employing non-physician providers benefit financially from such arrangements, medical groups are driven by the desire to serve patients and improve their satisfaction with their experience," MGMA President/CEO Susan L. Turney, MD, said in remarks accompanying the report.
"Being successful in a value-based environment will require practices to innovate and staff their organizations thoughtfully to ensure patients have access to their providers and are satisfied with their experience," she continued.
The MGMA analysis is consistent with the rise in demand for NPs and PAs seen at healthcare recruiters Merritt Hawkins & Associates. Travis Singleton, senior vice president at the Irving, TX-based firm, says search requests for these non-physician providers "grew by 300% year-over-year from 2012 to 2013, which is insane."
Singleton says the appeal of non-physician providers is obvious, starting with the fact that compensation for NPs and APs is about one-third that of physicians, "and maybe even a little bit less."
Tallying the Cost Advantages
But that's just for starters. "Where you are starting to see the real cost advantage is in the fully functioning co-management type of world," Singleton says.
"There is this spectrum of duplication where the physician and the nurse practitioners are doing too many of the same things. On the other end of the spectrum you are maybe allowing the nurse practitioner to do too many things and you have a problem with continuity of care. If you find that middle range ratio in your medical group – most people will tell you it's about two NPs to one primary care physician—then the cost efficiencies are incredible."
In a well-coordinated practice, Singleton says, the non-physician providers are seeing "the coughs and sniffles and things an MD probably shouldn't be handling on the front line anyway. So, you are able to see two and three times the production you would see out of one MD and you are getting better care because this allows the NPs to spend more time with the patients who fall under their scope of care while allowing the MD more time with more chronic or complex patient."
One of the biggest, but often overlooked drivers in the use of non-physician providers, Singleton says, is that payers are now recognizing and reimbursing for the services they provide. "That is the difference. It is going to follow the money," he says. "If the third-party payers continue the trend of recognizing more and more expanded duties by NPs and PAs you are going to see people use more of them."
Tight Demand, 'Spotty Supply'
With demand for non-physician providers expected to remain strong, Singleton says the supply will remain tight and "spotty" in different parts of the country and within urban and rural settings. "Unlike the MD population, we are able to affect NPs and PAs much more quickly," he says. "Even though you are only seeing an increase in schools of 2% to 5%, we have seen a really healthy increase over the last decade."
Unfortunately for proponents of primary care, a growing number of non-physician providers are following physicians into more urban areas and into subspecialties because that's where the money is. "It's a much easier quality of life and it pays a lot better," Singleton says. "Where we need them most is in general primary care."
"For NPs specifically, 88% are focusing on primary care. But only 18% of those are in rural areas, and rural areas are where we need them the most."
New players in healthcare are gaining a toehold with frustrated consumers who are "ready to abandon traditional care models for ones that echo experiences in banking, retail and entertainment," research from PwC's Health Research Institute indicates.
Chris Wasden
Managing Director and Global Healthcare Innovation Leader at PwC
Healthcare consumers appear willing to dump the doctor's office for cheaper and more convenient retail and remote alternatives that could amount to tens of billions of dollars in lost revenues for traditional providers if they fail to adapt, according to a report from PwC's Health Research Institute.
Despite controlling nearly 20% of the economy, traditional healthcare is years if not decades behind other industries when it comes to adopting a business model and technologies that assess and meet consumer needs.
With traditional players dragging their feet, consumers are taking the lead with increasing demands for pricing transparency, extended office hours, telemedicine and other and other innovative and consumer-friendly uses of technology that other sectors of the economy have used for years.
New players in healthcare are gaining a toehold with frustrated consumers who are "ready to abandon traditional care models for ones that echo experiences in banking, retail and entertainment," PwC says.
Chris Wasden, a managing director and global healthcare innovation leader at PwC, spoke with HealthLeaders Media about his company's report and what its findings mean for traditional providers. The following is an edited transcript.
HLM: How is the role of the consumer changing the way care is delivered?
CW: Increasingly, consumers are really forcing providers to try new things because providers are not going try new things on their own. [This is] because providers think the old way is just fine and they don't know how to do it a new way and they don't want to figure out how to do it a new way.
So it's the consumers who are saying 'I am going to be an early adopter and try something new.' That is putting pressure on the physicians to try something new. So this is going to be consumer-driven and led, not physician-driven and led.
HLM: How does traditional healthcare stack up to other sectors in the use of technology?
CW: Other industries became digital decades before healthcare became digital. Banking, for example, became digital in the 1970s with digital data sharing around money transfers. You've got the digitization of media and retail that occurred around the turn of the century.
Healthcare didn't become digital until just a couple of years ago. We are four decades behind finance and one to two decades behind most other industries that have been transformed through digital technology. You can't create these new business models that we see in banking and retail as well as media if you don't have digital information.
HLM: Why is traditional healthcare a laggard on technology?
CW: It's been a mom-and-pop industry that has been very local in nature and hasn't ever been scaled on a mass basis where leveraging technology for economies of scale made a difference. When you look at traditional healthcare providers, physicians for example, their view was that adding this digital overlay was unnecessary.
It was an overlay in addition to what they would do on a paper basis. They said, 'Look, if you ask me to put digital information into an electronic health record, I will see fewer patients, it will be more cumbersome, and it provides no value to me or the patients. It just provides value to some other higher healthcare systems of organization and so unless you are willing to pay me to digitize this information, I am not going to do it.'
So, what happened with Obamacare is that they created carrots and sticks to create additional information.
Healthcare providers are also very traditional in the way they provide care. They follow what they learned in medical school and medical schools and haven't even been teaching about digital healthcare until the last couple of years.
You have an entire industry that is trained on analog protocols that have never required digital information so nobody knows how to do it.
Unlike a big industrial company that has policies and procedures that they apply en masse across the entire organization, every doctor has the freedom to practice medicine any way he or she wants to. So there has not been the imposition of 'cookbook medicine' on doctors.
HLM: Customer satisfaction has been a mantra in retail forever. Why is it such a challenge in healthcare?
CW: Whether it's the pharmaceutical companies, device makers, payers, or providers, nobody considers the patient as their customer so they've never tried to come up with solutions that were consumer-friendly or consumer-centric.
The only time that was considered valuable was the physicians' time. So the economics is around how much you pay the physicians and the clinicians and how much of their time is used. Whereas, if you look at other industries, they view consumers' time as valuable.
They are trying to come up with solutions to save the consumers' time. How many new healthcare solutions do you see that say 'we can decrease the time it takes to get an appointment or the amount of time it takes to visit the doctor or the time in the waiting room?'
Nobody cares about that in healthcare, whereas in every other industry they do.
HLM: Your survey showed that people ages 35–54 were most receptive to new care delivery models. Why?
CW: Younger people don't go to doctors and aren't ever sick. It's difficult to get them engaged in healthcare service models when they don't use them. In the 35–54 age group you have people who are young parents going to the doctors all the time with ear infections and bumps and bruises.
If you have new care delivery that cuts the time in half, they are interested.
They are also getting into their 50s where they start to have some of their own problems and in many cases they are managing the cases of other people such as their parents. They're very interested in technologies that help them better manage someone else's healthcare more efficiently because they have a full-time job. They're busy. If they can do things over the phone, using apps and other remote services they're all in for that.
Most healthcare providers and systems are not providing these types of options. They will say the reason they don't provide them is because patients don't want them. It's a chicken-and-egg thing. How do you know if a patient doesn't want them if they have never tried them before and they don't know what they are?
HLM: We've been hearing about the transformation of healthcare for years. What is different this time?
CW: The risk is being shifted to the consumer. I am on a high-deductible health plan at work, which means I bear the first $5,600 of risk. So, when my wife called and said 'the doctor says I need an MRI,' I said 'I don't think so. Let's ask the doctor four questions and see what happens.' She asks the doctor:
'Do you know how much the MRI costs?'
He says 'no I don't but I will find out.' It was $2,400 dollars.
'Doctor, if you get the MRI image will you change your care for me?'
He said 'No it's not going to change anything at all.'
'Doctor, do you know I'm on a high-deductible health plan?'
'I had no idea at all.'
'Doctor, do I still need the MRI?'
'No you don't.'
I wouldn't ask those four questions if I didn't have a high-deductible health plan. That is an important change. You change the risk and you start changing the way the risk is managed.
The other thing is that we do now have technologies that we can use for these things. The virtual care where you can take a picture with your smartphone, send it to the doctor, he can look at it and give you an opinion. In a couple of minutes you can resolve a problem that would have with the old model taken a couple of weeks.
And you have people that want to experience things in healthcare like they experience everywhere else. When I buy something from an online retailer they know me and they provide recommendations to me and I never have to input the same information twice.
Whereas in healthcare I have to give you the same information every time I see you. Have you no memory? Have you no records? Consumers are demanding this digital experience that they have everywhere else in their lives. The organizations that can deliver that now are going to be the ones that are going to succeed in a new world.
HLM: What happens to those providers who don't adapt?
CW: Something like half of all doctors are over the age of 50. They're saying 'just give me 10 more years to do it the way I've always done it and then I'm done.' So you have a significant portion of the healthcare industry that is saying 'get me to the finish line so I don't have to learn anything new.' That is a big issue.
These younger docs want to do this stuff, but you have a changing of the guard from the old way with the old docs. And the final issue is money. We continue to pay for the old way. Until we change the flow of money we are not going to change the flow of the practice of medicine.
While the latest delay of ICD-10 has created some confusion, the CEO of AHIMA says providers, payers, and other stakeholders are doing what they can to prepare staff. Those that can afford it will try to teach both ICD-10 and ICD-9.
Health systems, payers and vendors aren't the only sectors in healthcare that are scrambling with the unexpected ICD-10 delay of at least one year imposed by Congress late last month.
Accrediting agencies and community colleges across the nation that were setting the curriculum and teaching the new medical coding set to about 40,000 students in anticipation of the Oct. 1, 2014 implementation have been forced to re-introduce the older ICD-9 code set. Many of those ICD-10 trainees now find their job prospects in limbo for at least a year.
The Commission on Certification for Health Informatics and Information Management announced shortly after the delay was mandated that it would hold off on testing for ICD-10 accreditation until the new coding set is "officially implemented."
"We were in good faith trying to prepare our students for the workforce that we knew was going to come about with ICD-10," says American Health Information Management Association CEO Lynne Thomas Gordon. "So instead of having our workforce ready ahead of time, which I think is better, we are saying 'now once you change it, we will test.'"
Gordon says AHIMA was ready to throw away its ICD-9 training manuals when word came down about the delay. The old manuals will be dusted off and redistributed to community colleges to help train students for the older coding set.
"They were ready for destruction that week, but fortunately we held off," Gordon says. "We are trying not to be prescriptive. We are trying to help. We are going to provide a free webinar on the difference between ICD-9 and ICD-10 to try to help. We are also going to provide a free self-assessment online for our students so that they can see how big the gap is and how much more studying they need to do to pass the credentialing exam."
Trying to Teach Both
"Is it perfect? No. I really feel for our educators who had to work hard just to get ICD-10 onto their curriculum. You should see some of the emails we got. It is so sad. They are saying they had to get it approved; they had to develop it; their educators had to go to training. Then they had to get it through their curriculum committees. They switched over in good faith. What they are saying now is they are going to try to teach both. That is tough because there is not enough time to teach both really well."
Stacey Ocander, president of the National Network of Health Career Programs in Two-year Colleges (NN2), says her organization was not surprised by the delay. "When it comes to any type of regulation coming down, especially when it comes to healthcare, we always anticipate it not happening just because it is such a volatile discipline," she says.
"There are so many stakeholders. There are the patients the families, the community, the politicians, the educators, the students, the payers and the providers and it goes on and on. So as educators we develop a curriculum where we always anticipate carrying over the old standards for at least 12 months and interweaving those in our curriculum with the chance that something will get stalled, just like it did with ICD-10."
"Our mission as community colleges," Ocander says," is to serve our communities. The last thing we want to do is get our students in a situation where they are not prepared to take that board or that registry because that is how our folks become licensed to enter the workforce."
Ocander says there will be some rough patches as students adjust to the new requirements.
"We will do study groups, some online training, tutorials. The nice thing about community colleges is we do react on a dime," she says. "We have been watching this for months. We put out notices to all of our membership, [saying] 'You need to be writing the politicians in your state letting them know this will impact our students. In the meantime, start prepping for anything you need to do you help your students prepare.'"
"That has already come out in online tutorials, the majority of which will be free for students so we are not putting a financial impact on them. These are things they can take from home and access what they need. A lot of those programs were online programs anyway, so it is not a methodology change for students."
'Stay the Course'
While the delay of at least one more year has created some confusion, Gordon says she is hearing anecdotally that many providers, payers, and other would-be ICD-10 adopters are "staying the course."
"We are hearing they are going to use this time to continue to work with their physicians on clinical documentation improvements, whether they're using ICD-9 or ICD-10. People are going to continue to do that. They are continuing to work with their vendors to get ready for ICD-10," she says.
"As far as the resources, what I heard at the CCHIIM meeting from our members in the room is that they're saying if we can afford it, we would love to continue to do dual coding. The question is can you continue to afford it? Maybe some of the larger academic medical centers and institutions can and we know that ICD-10 is better because it has more granularity and specificity. As we go to the accountable care models, you are really going to need this specificity to make sure you have healthier communities."
"I would say to providers, 'stay the course and don't take your foot off the pedal. Continue in good faith to get ready. It will come. It's just a shame it's not as soon as we thought.'"
