Paper suggests that “implicit bias”—doctors and nurses subtly or subconsciously treating some patients differently than others—or patients’ perception of it could have consequences for patients’ health.

Attending To The 'Human Element' Is Key To Keeping Patients Healthy

KFF Health News, September 2, 2016

Paper suggests that "implicit bias"—doctors and nurses subtly or subconsciously treating some patients differently than others—or patients' perception of it could have consequences for patients' health.

This article first appeared September 2, 2016 on Kaiser Health News

By Shefali Luthra

Racial minorities and lower-income people typically fare far worse when it comes to health outcomes. And figuring out why has long been one of health care's black boxes. Forthcoming research may help shed light on what's driving those inequities — and how the system can fix them.

What is needed? Better bedside manner, so patients actually trust their doctors. Communication that is easily understood by everyday people. And transparency about what medical care costs, plus a willingness to discuss how price points fit into consumers' health decisions.

Those ideas were highlighted in a white paper presented last week at a health communication conference sponsored by the Centers for Disease Control and Prevention. The findings, which will be published in full later this fall, are based on interviews with 100 health professionals and 65 "disadvantaged patients," along with a nationally representative survey of 4,000 consumers. The examination is part of a larger project funded by the Robert Wood Johnson Foundation, a health-focused nonprofit. It was conducted by the Altarum Institute, a research and consulting organization.

The paper suggests that "implicit bias" — doctors and nurses subtly or subconsciously treating some patients differently than others — or patients' perception of it could have consequences for people's health. Patients who felt that they had experienced bias based on factors like race, income or insurance were less likely to follow advice about medication, for instance, and ended up sicker in the long run.

"We for a long time have neglected the human element," said Chris Duke, director of Altarum's Center for Consumer Choice in Health Care, and the white paper's author. "The number one predictor of patient satisfaction is if your nurse listened to you. We neglect this at our great peril."

Duke stressed that the research isn't enough to draw conclusions about causality — that feeling disrespected causes worse health. But the study builds on years of investigation that suggests implicit bias and how patients perceive it could contribute to differences in health outcomes.

Insurance status was the largest predictor of how patients viewed their doctor-patient interaction, Duke said. People on Medicaid, the state-federal health insurance program for low-income people, or who were uninsured, were more likely to perceive disrespect than those with private insurance or Medicare, which provides coverage for senior citizens and some disabled people. Income was the next predictor for how well people felt they were treated. After that came race.

Meanwhile, racial minorities and low-income people also were more likely to be sensitive to concerns about a doctor's bedside manner, and to seek out someone they thought would treat them well, Duke noted.

Often, these patients cue in on subtle behaviors, such as the doctor not making eye contact or not asking questions about their symptoms and health conditions, their lifestyle or their preferences on how to manage a disease. But that can be enough, Duke said, to keep people from seeking care, or following through on medical advice.

He recalled one interviewee: a lower-income black woman with high blood pressure. She said her physician never asked her meaningful questions about her health, instead just writing her a prescription. She was so dissatisfied she ignored the recommendation, meaning her condition only worsened.

"There's a huge need for provider training in communication and warmth, and the understanding that how you interact with your patients can have an implication … on their health," he said.

That interaction could have major consequences for patients with chronic diseases, like diabetes or heart problems, noted Ben Handel, an assistant professor of economics at the University of California, Berkeley, who has researched health consumer decision-making. These patients need regular follow-up, but they are less likely to seek it out, because they aren't in significant pain. But if they don't get regular treatment, they could develop severe medical complications.

"If you feel like your doctor doesn't respect you, you're not going to go the doctor unless you have to — and preventive care is something you don't get unless you have to," he said. "And that kind of stuff is in some ways the most important."

To address that, both Duke and Handel said it's worth examining how Medicaid pays doctors, so that they see more value in treating low-income patients. Currently, Medicaid reimburses physicians at a lower rate than do other insurance programs.

Encouraging more diversity in medical professions — from a racial and a socioeconomic standpoint — could also help, they said. That idea tracks with other suggestions researchers have made when brainstorming ways to tackle gaps in health care and to make the system more responsive to people who are typically overlooked.

"If you are a lower-income racial minority, and you walk into a hospital and none of the pictures of people look like you, and none of the staff looks like you, you may not feel welcome," Duke said. "People need to feel welcome for them to trust information, and trust guidance."

The paper also highlighted consumers' concerns about understanding their medical recommendations and how much their care costs. Expense in particular "is a big sticking point," Duke said, and it's something doctors have long been discouraged from discussing. But for patients, avoiding the subject means they're more likely to go without.

That's true across the board, but likely even more so for lower-income people, Handel said. "That's basic economic theory. If you're low-income and the marginal value of income is higher, you're going to be more price sensitive," he said.

The findings underscore a need for inclusivity, Duke said. "We heard many patients say, 'The system is for them and not for us,'" he said. "The fact that we have large disparities along the lines of income and race — it shows there's a lot of ground to be covered."

'Simple Choice Plans' To Debut In 2017 Marketplace Enrollment

KFF Health News, September 2, 2016

Aiming to make picking a health plan easier, the federal government, which runs the marketplaces in roughly two-thirds of states, is encouraging insurers to offer "simple choice plans" as an option this fall.

This article first appeared September 2, 2016 on Kaiser Health News

By Michelle Andrews

Despite much hand-wringing about health insurers exiting the marketplaces where people buy individual coverage, in many areas consumers will likely still have a choice of plans when the 2017 open enrollment starts in November. Aiming to make picking a plan easier, the federal government, which runs the marketplaces in roughly two-thirds of states, is encouraging insurers to offer "simple choice plans" as an option this fall.

The six new standardized plan designs will eliminate many of the moving parts that have bedeviled consumers trying to make apples-to-apples comparisons between plans. The government is providing guidelines for a simple choice plan at each of the bronze, silver and gold levels, and three more silver options for people who qualify for cost-sharing reductions based on their income.

In these plans, the deductibles and annual limits on out-of-pocket spending will be standardized, as will many of the consumer payments for medical services.

In the simple choice silver plan, for example, the deductible will be $3,500 and the maximum amount that someone will owe out-of-pocket for the year will be $7,100. For many specific services, consumers will have flat dollar copayments for services up front rather than having to meet their deductible before the plan picks up any of the tab. Some of these include primary care visits ($30), specialist visits ($65), urgent care ($75) and generic drugs ($15).

Insurers won't be required to offer standardized plans on the federal marketplace, just as they aren't required to do so in most of the state-based marketplaces that offer such plans.

Offering both standardized and non-standardized plans can present a challenge for consumers, say experts. Both need to be clearly differentiated online or consumers will have no easier time comparison shopping than before, said Sabrina Corlette, research professor at Georgetown University's Center on Health Insurance Reforms who coauthored a recent report examining state efforts to offer standardized plans.

"It's really important to get the consumer shopping experience right, otherwise you might as well not bother" with standardized plans, she said.

When the administration announced the simple choice plans in April, Kevin Counihan, CEO of the healthcare.gov marketplace said the plans would "display prominently" on the website and have "clear visual cues" that would distinguish the simple choice plans from others.

A CMS official said there was no further information available at this time about how the plans will be displayed this fall.

In addition to potentially helping consumers wade through a bewildering array of options, standardized plans make it harder for insurers to design plans to be less attractive to people with expensive health care conditions, said Corlette. Insurers may be limited in their ability to make certain types of specialist care or drugs more expensive, for example.

Behavioral economics research tells us that simplifying consumer choices helps people make better ones. It makes sense that it will work with marketplace plans, too, but at this time that's an unknown.

"We don't yet know that standardized benefit design will help people make better choices and get into the plan that's right for them," Corlette said.

Tentative targets of the population health plan are to reduce disparities in obesity, smoking and heart-disease deaths by 15% by 2020.

Baltimore Draws 10-Year Blueprint To Cut Racial Health Disparities

KFF Health News, August 31, 2016

Tentative targets of the population health plan are to reduce disparities in obesity, smoking and heart-disease deaths by 15% by 2020.

This article first appeared August 31, 2016 on Kaiser Health News

By Jay Hancock

Baltimore officials presented a 10-year plan Tuesday that sharply highlights the poor health status of African-Americans and aims to bring black rates of lead poisoning, heart disease, obesity, smoking and overdoses more in line with those of whites.

"We wanted to specifically call out disparities" in racial health, said Dr. Leana Wen, who became the city's health commissioner early last year. "And we have a moonshot. Our moonshot is we want to cut health disparities by half in the next 10 years."

Black Baltimore leaders praised Wen for putting disparities squarely in the conversation even as they acknowledged the difficulty of achieving the plan's goals.

"It's a big challenge. There's no debating that," said Diane Bell-McKoy, CEO of Associated Black Charities, a Maryland nonprofit. "She takes a step forward more so than anybody else I've seen because she calls it out. Most of the time we find code words for it. We don't call it out."

Violence last year following the death of Freddie Gray, a black man who died after being injured in police custody, exposed Baltimore's health divide as well as its criminal justice differences, officials said. Gray's family had won a settlement for alleged lead-paint poisoning, which is blamed for low test scores and cognitive challenges among thousands of Baltimore children.

"What happened last year with Freddie Gray put Baltimore in the national media spotlight," said Helen Holton, a Baltimore councilwoman who represents a portion of the city's west side. "That made people stop and take notice of what had been going on and stop treating it as business as usual."

The health plan, called Healthy Baltimore 2020, was first reported by the Baltimore Sun. Officials plan to track blood-lead levels, overdose deaths, child fatalities, healthy-food availability and other indicators year by year. It's called Healthy Baltimore 2020 because officials have set ambitious goals to achieve before 10 years is up, Wen said.

Tentative targets include cutting youth homicides by 10 percent and disparities in obesity, smoking and heart-disease deaths by 15 percent — all by 2020.

Tactics include more programs to reduce street violence, expanded anti-smoking campaigns, more home visits for pregnant women and increased access to naloxone, which blocks the effects of heroin.

The blueprint is "an ongoing document" that will be amended with community participation and results closely scored, Wen said.

"Our community is sick of us overpromising and underdelivering," she said.

Baltimore officials have made substantial progress in reducing lead poisoning, lowering teen pregnancy and cutting infant mortality.

But as in many other areas, Baltimore is still divided by health. Residents of Gray's west-side neighborhood of Sandtown-Winchester live 10 years less on average than Marylanders in general. Poor neighborhoods have far higher rates of heart disease, diabetes, addiction, HIV infection and other illness than more prosperous parts of the city.

Black leaders emphasized that Baltimore's health won't improve unless policymakers address deeper causes of illness such as poverty, unemployment and poor housing.

"It is affirming to see someone in Dr. Wen's role address the uncomfortable truths behind health inequities," said Debbie Rock, CEO of LIGHT Health and Wellness, which offers health and other community services on Baltimore's west side. "This is a great platform to also address upstream factors" such as low incomes, she said.

Holton compared the health blueprint to a Justice Department report this month alleging a pattern of excessive force and violation of constitutional rights by the Baltimore Police Department.

Both documents address racial differences and offer challenges for improvement, she said.

"You can travel 5 miles from one neighborhood to another and it's like you are in two different communities" in health levels, Holton said. "Freddie Gray was like the tipping point. Let's take this and make it a teachable moment of how to be better moving forward."

Copious Prescriptions For Hospitalized Elderly

'America's Other Drug Problem': Copious Prescriptions For Hospitalized Elderly

KFF Health News, August 30, 2016

The polypharmacy problem "is huge," says the director of the inpatient geriatric unit at UCLA Medical Center in Santa Monica.

This article first appeared August 30, 2016 on Kaiser Health News

By Anna Gorman | Photos by Heidi de Marco

SANTA MONICA, Calif. — Dominick Bailey sat at his computer, scrutinizing the medication lists of patients in the geriatric unit.

A doctor had prescribed blood pressure medication for a 99-year-old woman at a dose that could cause her to faint or fall. An 84-year-old woman hospitalized for knee surgery was taking several drugs that were not meant for older patients because of their severe potential side effects.

And then there was 74-year-old Lola Cal. She had a long history of health problems, including high blood pressure and respiratory disease. She was in the hospital with pneumonia and had difficulty breathing. Her medical records showed she was on 36 medications.

"This is actually a little bit alarming," Bailey said.

He was concerned about the sheer number of drugs, but even more worried that several of them — including ones to treat insomnia and pain — could suppress Cal's breathing.

An increasing number of elderly patients nationwide are on multiple medications to treat chronic diseases, raising their chances of dangerous drug interactions and serious side effects. Often the drugs are prescribed by different specialists who don't communicate with each other. If those patients are hospitalized, doctors making the rounds add to the list — and some of the drugs they prescribe may be unnecessary or unsuitable.

"This is America's other drug problem — polypharmacy," said Dr. Maristela Garcia, director of the inpatient geriatric unit at UCLA Medical Center in Santa Monica. "And the problem is huge."

The medical center, where Bailey also works, is intended specifically for treating older people. One of its goals is to ensure that elderly patients are not harmed by drugs meant to heal them.

That work falls largely to Bailey, a clinical pharmacist specializing in geriatric care.

Some drugs can cause confusion, falling, excessive bleeding, low blood pressure and respiratory complications in older patients, according to research and experts.

Older adults account for about 35 percent of all hospital stays but more than half of the visits that are marred by drug-related complications, according to a 2014 action plan by the U.S. Department of Health and Human Services. Such complications add about three days to the average stay, the agency said.

Data on financial losses linked to medication problems among elderly hospital patients is limited. But the Institute of Medicine determined in 2006 that at least 400,000 preventable "adverse drug events" occur each year in American hospitals. Such events, which can result from the wrong prescription or the wrong dosage, push health care costs up annually by about $3.5 billion (in 2006 dollars).

And even if a drug doesn't cause an adverse reaction, that doesn't mean the patient necessarily needs it. A study of Veterans Affairs hospitals showed that 44 percent of frail elderly patients were given at least one unnecessary drug at discharge.

"There are a lot of souvenirs from being in the hospital: medicines they may not need," said David Reuben, chief of the geriatrics division at UCLA School of Medicine.

Some drugs prescribed in the hospital are intended to treat the acute illnesses for which the patients were admitted; others are to prevent problems such as nausea or blood clots. Still others are meant to control side effects of the original medications.

University of California, San Francisco researcher and physician Ken Covinsky said many doctors who prescribe drugs in hospitals don't consider how long those medications might be needed. "There's a tendency in medicine every time we start a medicine to never stop it," Covinsky said.

When doctors in the hospital change or add to the list of medications, patients often return home uncertain about what to take. If patients have dementia or are unclear about their medications, and they don't have a family member or a caregiver to help, the consequences can be disastrous.

One 2013 study found that nearly a fifth of patients discharged had prescription-related medical complications during their first 45 days at home. About 35 percent of those complications were preventable, and 5 percent were life-threatening.

UCLA hired Bailey about three years ago, after he completed a residency at University of California, Davis. The idea was to bring a pharmacist into the hospital's geriatric unit to improve care and reduce readmissions among older patients.

Speaking from his hospital bed at UCLA's Santa Monica hospital, 79-year-old Will Carter said that before he was admitted with intense leg pain, he had been taking about a dozen different drugs for diabetes, high blood pressure and arthritis.

Doctors in the hospital lowered the doses of his blood pressure and diabetes medications and added a drug to help him urinate. Bailey carefully explained the changes to him. Still, Carter said he was worried he might take the drugs incorrectly at home and end up back in the hospital.

"I'm very confused about it, to tell you the truth," he said after talking to Bailey. "It's complicated. And if the pills are not right, you are in trouble."

Having a pharmacist like Bailey on the team caring for older patients can reduce drug complications and hospitalizations, according to a 2013 analysis of several studies published in the Journal of the American Geriatrics Society.

Over a six-month stretch after Bailey started working in UCLA's Santa Monica geriatric unit, readmissions related to drug problems declined from 22 to three. At the time, patients on the unit were taking an average of about 14 different medications each.

Bailey is energetic and constantly on the go. He started one morning recently with a short lecture to medical residents in which he reminded them that many drugs act differently in older patients than in younger ones.

"As you know, our elderly are already at risk for an accumulation of drugs in their body," he told the group. "If you put a drug that has a really long half-life, it is going to last even longer in our elderly."

The geriatric unit has limited beds, so older patients are spread throughout the hospital. Bailey's services are in demand. He gets paged throughout the day by doctors with questions about which medications are best for older patients or how different drugs interact. And he quickly moves from room to room, reviewing drug lists with patients.

Bailey said he tries to answer several questions in order to determine what's best for a patient. Is the drug needed? Is the dose right? Is it going to cause a problem?

One of his go-to references is known as the Beers list — a compilation of medications that are potentially harmful for older patients. The list, named for the doctor who created it and produced by the American Geriatrics Society, includes dozens of medications, including some antidepressants and antipsychotics.

When he's not talking to other doctors at the hospital, Bailey is often on the line with other pharmacists, physicians and relatives to make sure his patients' medication lists are accurate and up to date. He also monitors patients' new drugs, counsels patients about their prescriptions before they are discharged and calls them afterward to make sure they are taking the medications properly.

"Medications only work if you take them," Bailey said dryly. "If they sit on the shelf, they don't work."

That was one of his main worries about Cal, the 74-year old with chronic obstructive pulmonary disease. Standing at her bedside, Bailey pored over the list of 36 drugs. Cal told him she only took the medications that she thought seemed important.

Bailey explained to Cal that he and the doctors were going to make some changes. They would eliminate unnecessary and duplicate drugs, including some that could inhibit her breathing. Then she should take as prescribed all of the medications that remained on the list.

Bailey said he's constantly weighing the risks versus the benefits of medications for elderly patients like Cal.

"It is figuring out what they need," he said, "versus what they can survive without."

The new Case Western Reserve University Health Education campus will eventually include Case Western’s medical, dental, and nursing schools, as well as Cleveland Clinic’s in-house medical school.

Teaching Medical Teamwork Right From The Start

KFF Health News, August 29, 2016

The new Case Western Reserve University Health Education campus will eventually include Case Western's medical, dental, and nursing schools, as well as Cleveland Clinic's in-house medical school. "The idea is to create a 'mini campus' that gives each school its own identity but fosters collaboration," says one of the architects.

This article first appeared August 29, 2016 on Kaiser Health News

By Julie Rovner

CLEVELAND — There's a new building going up on the campus of the Cleveland Clinic. A very big building.

The structure will house the new Case Western Reserve University Health Education campus, eventually including Case Western's medical, dental and nursing schools, as well as Cleveland Clinic's in-house medical school.

"The idea is to create a 'mini campus' that gives each school its own identity but fosters collaboration," said Chris Connell, one of the architects.

The building, which will cost almost half a billion dollars, will provide an estimated 8.5 football-fields' worth of space and enough concrete to build a 75-mile-long sidewalk. It is expected to be open to the first classes of students in 2019.

But this part of the project is less the beginning and more the culmination of a long-running effort at Case to train different types of health professionals how to work together. Health care in the 21st century is increasingly being provided by teams, say the projects' advocates, yet most health care professionals don't encounter their "teammates" until they are well along in their training.

"Health care is no longer a gladiatorial sport, where you had the one health care provider; you know mano a mano, one on one, battling a disease," said James Young, a cardiologist who heads the Cleveland Clinic Lerner College of Medicine. "I'm involved with heart transplantation and mechanical devices for the heart," he said. "Boy, you can't do it by yourself."

On this particular day, about a mile away from the construction site, a small group of students from the medical, dental, nursing, and social work schools were gathered on Case's main campus around a conference table. Every student in every health professions school is required to attend a seminar like this twice a year — one of the ways in which the training programs are already encouraging collaboration.

At this particular session, the students are tasked with figuring out how to best treat a (hypothetical) patient — a 35-year-old woman with hypertension, obesity and diabetes. She has come to the (fictitious) clinic with a series of injuries she said she got falling down a flight of stairs. Meanwhile, her boyfriend is in the lobby acting disruptively.

The students discuss and argue about which of the patient's problems to address first, and what to do about the boyfriend. They don't end up reaching a consensus, but faculty overseeing the group say that's OK.

"I think that's fabulous," said Kristin Victoroff, an associate dean at the dental school. "It is actually an indicator of a functioning group, where's there enough trust in the group where you can say what you really are thinking."

But that's not the only way the university is trying to foster "interprofessional" education. For example, at a free oral health clinic elsewhere in Cleveland, dental students and nurses collaborate to treat real patients. Other activities bring students together to discuss problems that cross professional lines, like obesity or pain.

"We all have to deal with pain whether it's dentists or social workers or nurses," said Carol Savrin, an administrator at the Case nursing school.

Efforts such as these to train doctors, nurses and other health professionals together have been tried for years. And they haven't always been successful.

"I think they come in with some preconceived or stereotyped notions of what a doctor [or] a social worker is," said Scott Wilkes, an assistant dean at the Case social work school.

Yet getting everyone on the same page is critical to preventing medical mistakes, said Patricia Thomas, a vice dean at the Case medical school.

In studying the problem, she added, "the root of many of our errors had to do with the fact that our professions were not working effectively together for patient care."

Administrators say that is why the new building is so important.

It's not just the formal training together, said Victoroff of the dental school, "I'm excited about the informal interactions that are going to happen."

Doctors Raise Concerns For Small Practices In Medicare's New Payment System

KFF Health News, August 25, 2016

"The ways it's structured now, the large practices will do well and the small practices will do badly," says Paul Ginsburg, director of the Center for Health Policy at the Brookings Institution.

This article first appeared August 25, 2016 on Kaiser Health News

By Steven Findlay

Dr. Lee Gross is worried. He has practiced family medicine in North Port, Florida, near Sarasota, for 14 years. But he and two partners are the last small, independent practice in the town of 62,000. Everyone else has moved away, joined larger groups, or become salaried employees of hospitals or health companies.

"We're struggling to survive," Gross, 47, said. "Our kind of practice is dying in this country, and medicine itself is changing so rapidly that doctors everywhere seem to be burning out."

Indeed, in their professional journals, at conferences, on social media and health care blogs, and in comments to federal regulators, the nation's doctors are expressing growing anger and frustration.

The focal point of their angst is a 2015 federal law that changes the way Medicare pays doctors.

The Medicare Access & CHIP Reauthorization Act — is Congress' boldest step since the 2010 Affordable Care Act to push the health care system to reward quality over quantity. It replaces a reimbursement system that was widely criticized by doctors and regularly ran into budget problems on Capitol Hill.

"This is a big change, we know," said Tim Gronniger, deputy chief of staff at the Centers for Medicare & Medicaid Services. But, he added, "the current way we pay doctors incentivizes them in bad ways — to waste resources, for example."

The law has bipartisan support and does not come with the political tension of the ACA. Still, the Obamacare battles have shown that broadly reshaping health care is no easy task.

Poor and wasteful care accounts for a quarter to a third of all health care spending, according to the National Academy of Sciences' Institute of Medicine.

That would total between $875 billion to $1.1 trillion of the $3.5 trillion expected to be spent on health care in the U.S. in 2016.

The law sets up two payment tracks. All doctors must choose one, except for those who see too few Medicare patients or whose income from Medicare is too low.

On one track, doctors whose performance and quality of care exceeds benchmarks get bonuses up to 4 percent of their total Medicare reimbursements. Those will start in 2019, based on evaluations of care delivered in 2017, and will rise a maximum of 9 percent by 2022. By the same token, physicians who score poorly on quality benchmarks — which include requirements for the use of electronic health records — face penalties at the same levels.

The amount the government spends on the bonuses — estimated at $833 million for 2019 — must be balanced by the penalties, keeping the program "budget neutral." However, Congress also authorized an extra $500 million a year bonus pool through 2024 for doctors judged "exceptional."

On the other path, doctors choose to join larger practices or organizations — called "alternative payment models" — that would be held accountable for the quality of care delivered by all the doctors in the organization.

Congress' intent, experts say, was to push doctors to join such larger organizations, which generally are considered better equipped to manage and coordinate care, improve quality and lower costs than are solo or small groups of doctors.

Doctors get a 5 percent annual bonus between 2019 and 2024 if they join an alternative payment organization, along with any bonuses or penalties the organization chooses to mete out. Starting in 2026, doctors in such organizations will continue to get a small annual payment adjustment from Medicare that's larger than doctors who don't choose the alternative path — 0.75 percent versus 0.25 percent.

Physicians' concern is that the new payment system — laid out in a 962-page proposed regulation in April — will put doctors in solo or small practices at high risk of incurring payment penalties and will push thousands into larger practices and alternative payment organizations.

"The ways it's structured now, the large practices will do well and the small practices will do badly," said Paul Ginsburg, director of the Center for Health Policy at the Brookings Institution.

During a public comment period, the American Medical Association and dozens of other physician trade organizations and every state medical association said the system needs to be simplified and must "accommodate the needs of physicians in rural, solo, or small practices in order to enhance their opportunities for success and avoid unintended consequences."

One of those unintended consequences, the AMA says, is that penalized doctors would limit the number of Medicare patients they see, or drop Medicare.

"I have no idea what I'm going to do yet," says Dr. Jean Antonucci, a primary care physician who has a solo practice in Farmington, Maine. Half her patients are covered by Medicare. "If I'm going to lose money, I'll have to see what my options are. I don't want to limit how many Medicare patients I see."

Antonucci and Gross say they want to preserve their small practices. "I don't want to spend the bulk of my time doing paperwork or collecting data on my patients," said Antonucci. "That's what the doctors in my community who are employed [in larger groups] seem to spend most of their time doing."

Some experts agree that the burden to report quality-of-care to the government is significant.

"We don't yet have a good system to measure the performance of individual physicians," says Robert Berenson, a physician and fellow at the Urban Institute and former director of Medicare payment policy for the federal government. "And yet we are going to peg billions of dollars in payment to such measurement. It's a little crazy."

A study published in March in the journal Health Affairs calculated the scope of that data collection now. It found physicians and their staffs spend $40,000 per doctor per year — $15.4 billion nationwide — collecting and reporting information about their care to Medicare, private insurers and others.

Gronniger says CMS has, in the proposed rule, scaled back the number of measures doctors must report. "We are eager to work through the issues doctors' groups have raised," Gronniger said.

Even so, the AMA and other physician groups are pushing CMS to delay the start for collecting quality-of-care information from next January until at least July. Medicare administrators have pledged to issue final regulations by Nov. 1.

"This is all very complex," said AMA President Andrew Gurman. "A lot of doctors are very frustrated … but we are committed to trying to make the new law work."

CMS Identifies Hospitals Paid Nearly $1.5B In 2015 Medicare Billing Settlement

KFF Health News, August 24, 2016

NewYork-Presbyterian Hospital, one of the nation’s largest academic medical centers, received nearly $16 million, more than any other hospital, according to data released by the Centers for Medicare & Medicaid Services.

This article first appeared August 23, 2016 on Kaiser Health News

By Phil Galewitz

A year after paying nearly $1.5 billion to more than a third of U.S. hospitals to resolve longstanding Medicare billing disputes, the Obama administration has disclosed who got paid.

NewYork-Presbyterian Hospital, one of the nation's largest academic medical centers, received nearly $16 million, more than any other hospital, according to data released by the Centers for Medicare & Medicaid Services.

The second largest amount went to North Shore University Hospital in Manhasset, N.Y., which received $14.5 million. CHI Memorial Hospital in Chattanooga, Tenn., ranked third — $10.9 million — but two other New York-area hospitals rounded out the top five. Long Island Jewish Medical Center received $10.8 million and NYU Langone Medical Center was paid $10.5 million, the CMS data show.

In total, 2,022 hospitals shared in the government payout, which settled 346,000 claims for reimbursement for treating Medicare patients admitted on or before Oct. 1, 2013. The largest payments resolved thousands of claims at once. Memorial Hospital's settlement covered nearly 3,000 claims.

The settlements were a compromise to reduce a swollen backlog of disputes over what hospitals argued they were owed. At one time, pending cases under appeal stretched more than two years.

The resolutions followed the government's offer in 2014 to pay the hospitals 68 percent of the value of inpatient claims that had been caught in Medicare's hearings and appeals process, some for years.

The new CMS data show 35 hospitals received more than $5 million each, but most were paid far less. The median payment — meaning half the hospitals got more and half got less — was $307,642, according to a Kaiser Health News analysis. The data was released in response to a Freedom of Information Act request made last year by KHN.

Medicare pays private contractors known as recovery audit contractors, or RACs, to review hospital claims for improper payments. If hospitals disagree with RACs' decisions, they can appeal. Most RAC reviews have focused on costly inpatient-status claims, questioning whether certain patients should have been admitted to hospitals. Many audits determine that short patient stays should have been billed at less-costly outpatient rates.

Last year's settlement indicated that many hospitals preferred to settle quickly for a discounted amount rather than keep claims tied up in appeals for what could have been months or even years. Hospitals that declined to settle with Medicare still had the option to continue their appeal.

Hospitals and RACs have long battled over audits and appeals. RACs — which are paid a fee for every audit that recovers money for Medicare — argue they are protecting taxpayer dollars and ensuring that hospitals are paid for appropriate patient services. Hospitals criticize the RAC process as burdensome and liken contractors to bounty hunters focused on making money for themselves.

CMS has said 18 percent of appealed claims were overturned in favor of hospitals between Oct. 1, 2013 and Sept. 30, 2014, but the American Hospital Association reported in 2014 that self-reported data by its members showed hospitals had won 66 percent of appeals since 2010.

The $1.5 billion paid in last year's settlements contrast with more than $9.6 billion collected by RACs from 2010 through September 2015. More than 90 percent of collections by RACs were from hospitals.

Sydney Lupkin contributed to this report.

Public Health Officials Struggle To Identify Sepsis Before It Becomes Deadly

KFF Health News, August 23, 2016

A growing number of doctors, hospitals, patient advocates and state and federal policymakers are pushing to educate consumers and clinicians, and ensure procedures are followed that focus on prevention and early detection.

This article first appeared August 23, 2016 on Kaiser Health News

By Michelle Andrews

After Rory Staunton fell at the gym and cut his arm in March of 2012, the 12-year-old became feverish and vomited during the night, complaining of a sharp pain in his leg. When his parents called his pediatrician the next day, she wasn't worried. She said there was a stomach virus going around New York City, and his leg pain was likely due to his fall.

However, she advised his parents, Orlaith and Ciaran Staunton, to take the youngster to the emergency department because he might be dehydrated. There hospital workers did some blood work, gave him fluids and sent him home.

How Ohio Hospitals Are Tackling Sepsis

The next day Rory's pain and fever were worse. His skin was mottled and the tip of his nose turned blue. The Stauntons raced back to the hospital, where he was admitted to intensive care. The diagnosis: septic shock. Rory was fighting a system-wide infection that was turning his skin black and shutting down his organs. On Sunday, four days after he dove for the ball in gym class, Rory died.

"It was frightening to think that something could kill my son so fast and it would be something that I had never heard of," said Orlaith Staunton.

She's not alone. Sepsis kills more than 250,000 people every year. People at highest risk are those with weakened immune systems, the very young and elderly, patients with chronic diseases such as diabetes, cancer or kidney disease and those with illnesses such as pneumonia or who use catheters that can cause infections. But it can strike anyone, even a healthy child like Rory.

Sepsis is a body's overwhelming response to infection. It typically occurs when germs from an infection get into the bloodstream and spread throughout the body. To fight the infection, the body mounts an immune response that may trigger inflammation that damages tissues and interferes with blood flow. That can lead to a drop in blood pressure, potentially causing organ failure and death.

Yet many people don't know about sepsis. Meanwhile, health care providers struggle to identify it early. There's no simple diagnostic test and many symptoms — elevated heart and respiratory rates, fever or chills, pain — are common ones that are present in many conditions.

Now, a growing number of doctors, hospitals, patient advocates and state and federal policymakers are pushing to educate consumers and clinicians and ensure procedures are followed that focus on prevention and early detection.

The Stauntons established a foundation to raise awareness about the deadly infection, and in 2013 New York became the first state to require all hospitals to put in place procedures for its early recognition and treatment. This month, Illinois Governor Bruce Rauner signed a law requiring similar actions by hospitals in that state.

The federal Centers For Disease Control and Prevention Tuesday released a study about sepsis as part of an effort to draw attention to the importance of prevention and early detection of the disease.

"Early treatment is vital," said Dr. Anthony Fiore, chief of the epidemiology research and innovations branch at the CDC's Division of Healthcare Quality Promotion. "It's an emergency that you need to deal with, like heart attack and stroke."

When sepsis advances to septic shock, characterized by severely low blood pressure, each hour of delay in administering antibiotics decreases the odds of survival by an average of 7.6 percent, one study found.

In 2013, sepsis, or septicemia as it's sometimes called, accounted for nearly $24 billion in hospital costs, the most expensive condition treated. Up to half of people who get it die. Many cases are related to health care, such as catheter use or an infection acquired in the hospital. But contrary to the common perception, approximately 80 percent of cases develop outside the hospital or at a nursing home, according to the new CDC study.

As the front line in identifying these cases, emergency departments typically have sepsis protocols in place to screen for the disease.

"The work you do in those first three to six hours in the emergency department makes more difference in cost than the whole next several weeks in the ICU," said Dr. Todd L. Slesinger, emergency medicine residency program director at Aventura Hospital and Medical Center in Aventura, Fla., who co-chairs a task force on sepsis at the American College of Emergency Physicians, which has developed a tool to help emergency department staff screen and treat the condition.

Last fall, the federal Centers for Medicare & Medicaid Services started requiring hospitals to measure and report on efforts to screen for and treat the illness. In addition, Medicare sets penalties for a variety of hospital-acquired conditions, including high rates of post-operative sepsis.

Patient advocates and policymakers agree that patients themselves are key to improving its prevention and early detection. Good hygiene can help prevent sepsis, including cleaning wounds. If someone gets injured, look for signs of sepsis, including rapid breathing or heart rate, confusion, fever or chills and pale or discolored skin.

Don't assume health care providers have it covered, experts advise. If you or someone you're caring for has these symptoms, ask the health care provider directly: "Do you think it might be sepsis?"

Geriatric ERs Reduce Stress, Medical Risks For Elderly Patients

Geriatric ERs Reduce Stress, Medical Risks For Elderly Patients

KFF Health News, August 23, 2016

Geriatric ERs have the potential to lower health care costs because staff can more carefully discern who needs to be admitted and who can be cared for outside of hospital walls.

This article first appeared August 23, 2016 on the Kaiser Health News website

By Anna Gorman | Photos by Heidi de Marco

NEW YORK — The Mount Sinai Hospital emergency room looks and sounds like hundreds of others across the country: Doctors rush through packed hallways; machines beep incessantly; paramedics wheel stretchers in as patients moan in pain.

"It's like a war zone," said physician assistant Emmy Cassagnol. "When it gets packed, it's overwhelming. Our sickest patients are often our geriatric patients, and they get lost in the shuffle."

But just on the other side of the wall is another, smaller emergency room designed specifically for those elderly patients.

Patients like Hattie Hill, who is 105 years old and still living at home. A caregiver brought her in one rainy day in late spring because she had a leg infection that wasn't responding to antibiotics. Hill, who also has arthritis and a history of strokes, said she prefers the emergency room for seniors because she gets more attention.

"I don't have to wait so long," she said. "And it's not so loud."

Packed emergency rooms are unpleasant for everyone. But they can be dangerous for elderly patients, many of whom come in with multiple chronic diseases on top of a potentially life-threatening illness or injury.

"Who is going to suffer the most from these crowded conditions?" asked Ula Hwang, associate professor in the emergency medicine and geriatrics departments at the Mount Sinai School of Medicine. "It is going to be the older adult … the poor older patient with dementia lying in the stretcher with a brewing infection that is forgotten about because it's crazy, chaotic and crowded."

Seniors who come into traditional emergency rooms are frequently subjected to numerous and sometimes unnecessary tests and procedures, according to research and experts. They stay longer and their diagnoses are less accurate than younger patients. And they are more frequently admitted to the hospital by ER doctors overwhelmed by the constant influx of very sick patients.

"You've got this surge of more and more older adults coming to the emergency departments," said Kevin Biese, co-director of geriatric emergency medicine at the University of North Carolina School of Medicine. "Yet there hasn't necessarily been this recognition that [they need] different screening, different treatment and they are going to have different outcomes."

Geriatric emergency rooms, which are slowly spreading across the country, provide seniors with more expertise from physicians, nurses and others trained specifically to diagnose and care for the elderly, researchers said.

The staff in these specialized ERs collaborate closely not only to treat the seniors' immediate health problems but also to reduce their risk of confusion, bed sores and over-medication. Senior ERs are designed to be more quiet and tranquil.

Geriatric ERs have the potential to lower health care costs because staff can more carefully discern who needs to be admitted and who can be cared for outside of hospital walls, Hwang and others said. That tends to reduce hospitalizations among the elderly.

Mount Sinai, which opened its geriatric emergency room in 2012, is part of a nationwide effort to find a better way to treat elderly patients. The first geriatric ER opened in New Jersey in 2008, and now there are more than 100 such units nationwide. Several others are being planned, including in California, North Carolina, Connecticut and Texas.

Geriatric ERs vary widely. Some are separate units with trained staff; others are merely sections within traditional emergency rooms with extra hearing aids and other senior supplies. But professional medical organizations have developed guidelines to standardize design, staffing and patient screening.

The boomlet in geriatric emergency rooms stems in part from an increase in older patients with complex conditions who are seeking care in regular ERs. That has caused some providers and hospitals to seek more effective and efficient ways to treat them.

About 20.4 million patients over the age of 65 were treated in emergency rooms in 2011, up from 15.9 million a decade earlier, according to a national hospital survey conducted by the Centers for Disease Control and Prevention. As the population ages, older patients are expected to make up an increasing share of ER patients.

The Affordable Care Act also has fueled the expansion of senior emergency rooms. The law assesses penalties when too many patients return to a hospital too soon after discharge. Facilities have tried to reduce readmissions in part by providing better emergency care and triage.

Now, that growth could continue as hospitals face additional pressure to provide more efficient and less costly care to their Medicare patients. The Centers for Medicare and Medicaid Services announced in January that within two years, half of all traditional Medicare payments will go to providers based on quality of care rather than quantity of services.

Emergency departments are the perfect places to make changes that could help control spending, because they are gateways between home and costly hospitalizations, Hwang said. About 60 percent of elderly patients who get hospitalized come through the emergency room, according to a 2013 Rand Corporation study. A quarter of those hospitalizations are preventable, according to one 2012 federal study.

"Hospitals that before didn't think there was any need for this are saying, 'Can you help us create a geriatric ED?'" Hwang said.

Hospitals also may view specialized emergency departments as a marketing tool to reach the growing elderly population.

The geriatric emergency room at Mount Sinai is set up differently than traditional emergency rooms. It has thicker mattresses to help reduce the chance of bed sores, raised toilet seats, hand rails in the hallways and reduced-noise curtains.

The department is allotted 20 beds, but the main hospital sometimes steals them for other patients. That leaves some older ER patients waiting in the hallway.

Over a two-day period in May, dozens of older patients were treated for falls, dizziness, severe pain and shortness of breath.

John Fornieri, 80, came in after falling on his floor at home. Fornieri, an artist with arthritis and a heart condition, said he nearly lost consciousness. An x-ray showed he had broken a hip.

Fornieri said he was grateful that the geriatric emergency room staff was trained to care for the elderly. "Seniors need a different kind of attention," he said. "We can't see and we can't hear like we used to. We can't even talk the same."

Denise Nassisi, a physician who runs the geriatric ER, said her patients are at greater risk of falling, medication errors and infections than younger patients. Seemingly routine injuries can have devastating effects. Broken arms, for example, can make it difficult for elderly people to care for themselves.

Many also have dementia or other cognitive impairments that make it harder to get an accurate account of their medical history and the reason for their ER visit, she said. About half of the patients arrive unaccompanied by relatives or caregivers.

In the past, Nassisi said, doctors frequently just admitted the patients, leaving it to the hospital staff to do a more complete workup. But now, Nassisi and her team of social workers, therapists, nurses and others try to screen, diagnose and treat patients more thoroughly in the ER, she said.

Part of their job is to determine whether older patients can be safely discharged. That means they aren't automatically admitted to the hospital, which would raise their risk of confusion and loss of independence. "We are trying to change the culture of just admitting," Nassisi said.

A patient doesn't need a clean bill of health to be discharged. One 81-year-old patient came in for a toothache but also had a long list of illnesses: coronary artery disease, chronic pulmonary disease, arthritis, high blood pressure, prediabetes and high cholesterol. She was released with pain medication, antibiotics and an appointment with a surgeon.

Another patient, who was 83 and had high blood pressure, anxiety and cancer, had fallen in her kitchen. She, too, was discharged after staff ensured she could walk on her own and had help at home.

As providers determine where the patients should be treated, they also try to prevent them from becoming delirious, developing additional problems or taking potentially harmful medications.

Physician assistant Jaclyn Schefkind evaluated Hill, the 105-year-old patient.

"How are you doing?"

"Bad," Hill said, wincing in pain.

Schefkind looked at Hill's leg, red and swollen. She said they were going to get her some stronger antibiotics and something to relieve the pain.

"Let's start with Tylenol," Schefkind said. "I don't want to give you something too strong because it's not safe when you're older."

Shortly afterward, the team decided the best place to admit Hill so doctors could get her infection under control. A nurse pulled Hill's blanket up to her chin, packed up her belongings and rolled her through the door toward the main hospital.

AORN: Evidence Supporting ACS Surgical Attire Guidelines is Lacking

Interpreters Key To Easing Patients' Final Days

KFF Health News, August 22, 2016

Interpreters routinely help people who speak limited English understand what's happening in the hospital. They become even more indispensable during patients' dying days. But specialists say interpreters need extra training to capture the nuances of language around death.

This article first appeared August 22, 2016 on the Kaiser Health News website

By Eryn Brown | Photos by Heidi de Marco

MORENO VALLEY, Calif. — Alfredo David lay in bed, looking deflated under an Avengers blanket, as a doctor, two nurses, and medical interpreter Veronica Maldonado entered his hospital room. He wrapped up a call from his wife, then fiddled idly with his phone.

He had received distressing news from the team at the Riverside University Health System Medical Center: His sharp abdominal pains and difficulty eating, previously diagnosed at another hospital as gastritis, were actually caused by metastatic cancer. The tumor was growing. David, 45, was not going to recover.

Maldonado pulled up a chair for herself and another for palliative care specialist Dr. Faheem Jukaku, and the two sat at David's eye level. Pointing to an MRI image of David's abdomen, Jukaku explained in English how surgeons would attempt to ease his symptoms the next day. Maldonado translated Jukaku's words into Spanish, modulating her tone of voice to match the doctor's delivery.

David listened — seeming resigned, but grateful that some relief might be on the way. Occasionally he'd ask a question in Spanish about the procedure, which Maldonado translated back to Jukaku. Asked about his earlier misdiagnosis, he rolled his eyes.

David, a mechanic and father of three teenagers, understands some English. But he said Maldonado's help had been crucial to deciding on his new course of treatment. Thanks to her, he said in Spanish as she translated, "I don't have any misunderstandings. I'm more at peace."

Interpreters routinely help people who speak limited English — close to 9 percent of the U.S. population, and growing — understand what's happening in the hospital. They become even more indispensable during patients' dying days. But specialists say interpreters need extra training to capture the nuances of language around death.

Many doctors and nurses need the assistance of interpreters not only to overcome language barriers but also to navigate cultural differences. Opportunities for miscommunication with patients abound. Words don't always mean the same thing in every language.

Medical staff, already nervous about delivering bad news, may speak too quickly, saying too much or too little. They may not realize patients aren't comprehending that the team can no longer save their lives.

"That's when it gets interesting," Maldonado said. "Does the doctor understand that the patient isn't understanding?"

At Riverside and some other hospitals, interpreters have completed special training and work closely with palliative care teams to help patients and their families decide when the time has come to stop trying to cure a disease and start focusing on comfort and quality of life.

Palliative care is unusual among medical specialties, said Dr. Neil Wenger, an internist who is chair of the ethics committee at the UCLA Medical Center. Rather than curing or eliminating disease, its purpose is to manage symptoms for patients who are not expected to recover.

Physicians and nurses talk at length with dying patients and their families about their wishes, collaborating with social workers, chaplains and hospice workers. Under any circumstances, the clinical shift from curing disease to treating symptoms can be difficult for doctors and patients. Advance care planning — a process used to help patients understand their prognoses and explore preferences for future care — is more like psychotherapy than a routine medical consult, Wenger said.

"This is not a straightforward set of questions," he said. "You ask a question, and the next question is dependent on the response. It's very easy to use the wrong words and startle the person and put them off. It's a dangerous conversation."

When there's a language or culture gap, Wenger added, the interaction becomes much more difficult. Both sides can fail to recognize important nuances, such as body language and variations in the meaning of words.

Wenger said that he finds it hard to speak with patients about palliative care through an interpreter because, in his experience, unexpected turns in the conversation and difficult emotions can literally get lost in translation.

Others say that interpreters are key for helping patients make sense of palliative care — that they just need extra training to be good at it.

Kate O'Malley, a senior program officer at the California Health Care Foundation, said she started thinking about interpreters when the Oakland, Calif.-based foundation funded new palliative care programs in safety net hospitals throughout the state. It found that vast numbers of patients did not speak English as their primary language.

At Los Angeles County-USC Medical Center, for instance, 68 percent of palliative care patients in 2011 spoke a first language other than English. At San Francisco General Hospital, that number was 45 percent; at Riverside County Medical Center, 33 percent.

"One of the key tenets of palliative care is to have goals-of-care discussions," O'Malley said. So when patients speak a different language, "How do you do that?" Her team found that palliative care providers sometimes brought in interpreters to assist, but that many of them didn't have the knowledge, training, or vocabulary to convey key concepts.

Take the idea of hospice, the comprehensive palliative care services available to patients in their last months, often at home. For people from Mexico, the Spanish equivalent hospicio "conjures up the image of the worst nursing home you could ever imagine, where people are disabled and left for dead," said Dr. Anne Kinderman, who runs the palliative care service at Zuckerberg San Francisco General Hospital. "If I come into the room and say, 'I'm here to tell you about this great thing called hospicio,' there's a cognitive disconnect," she said.

Interpreters have to learn how to bridge that gap. "You have to know how to present [hospice] in Spanish," said Viviana Marquez, supervisor of the department of language and cultural services at Riverside, and Maldonado's boss. "It's not a matter of finding an equivalent word, because there is none. You have to get into a deeper explanation."

Without that kind of clear communication, many Latino families never understand that hospice isn't a place but rather a suite of comfort-focused extra services, available at home, that relatives usually can't provide on their own, said Beverly Treumann, a medical interpreter in Los Angeles who now works as head of quality assurance for the Health Care Interpreter Network, an Emeryville, Calif.-based cooperative that lets member hospitals share interpreters through videoconferencing.

Treumann said she once trained an interpreter who had refused hospice for her own mother because of such a misunderstanding. "This interpreter, she was heartbroken," Treumann said. "The family took care of the mother — but without the extras that hospice could provide. The mother suffered because the concept wasn't explained adequately."

Cultural differences can breed other misunderstandings too, Kinderman said. Families from many parts of the world approach health care decisions as a group. That can make a palliative care concept like a health care proxy — a person who makes medical decisions when a patient becomes incapacitated — hard for them to grasp.

Hoping to bypass all these potential minefields, the California Health Care Foundation recruited Kinderman and other experts to help develop a palliative care curriculum for interpreters.

It introduces the palliative care concept, defining terms and providing vocabulary to help interpreters accurately convey key ideas. It encourages interpreters to alert physicians when they suspect a patient and his family don't understand what they are told. It also includes materials to help interpreters deal with their own complicated emotions during palliative care encounters.

Marquez said that all 10 of the Riverside medical center's interpreters have completed some version of the curriculum, which is taught in person or on the web.

For Maldonado, who has been interpreting for about five years, working with palliative care patients has become a passion.

She attends the palliative care team's weekly meetings, working closely with staff and patients. If Maldonado is around when a difficult conversation arises, she's the first person Marquez sends to interpret. If Maldonado or another interpreter who is comfortable with palliative care work is not available, Jukaku said, "we try to postpone the talk."

Last year, Maldonado taught a palliative care training course for interpreters. The session, held at the Moreno Valley hospital, attracted around 50 participants from throughout Southern California.

The participants wanted to talk about terminology and "vicarious trauma" — the emotional toll that interpreting for palliative care patients can take. They shared self-protection techniques. Marquez recommended using the third-person voice instead of the customary first person: rather than directly translating the doctor's words and saying "I recommend," an interpreter might create emotional distance for herself in difficult moments by saying, "your doctor recommends."

Maldonado said she, too, has trouble sometimes containing her feelings when families are distraught or have trouble accepting that a patient may soon die. "Later in the day I say, 'Oh my God … can I vent?' I have to vent."

But Maldonado also noted that raw emotion from the families means she is doing her job well.

"When we get the tears and the reactions," she said, "we know we've rendered the message."

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