The HHS secretary focused his message on the long-running transformation toward a value-based healthcare delivery system.
Health and Human Services Secretary Alex Azar addressed the World Health Care Congress in Washington, D.C., on Wednesday morning with an optimistic message.
Although policy wonks have been talking for years about healthcare's shift to a value-based delivery system, the time for action has finally come, Azar said.
"Today, we have a president who is unafraid to drive the disruption we need. President Trump is a man of courage and vision," he said in his prepared remarks. "He has seen and heard how the high cost of healthcare is burdening so many Americans; he understands that our system too often fails to deliver value; and he has given us a mandate to do something about it."
Azar outlined four priorities for HHS earlier this year. In his speech Wednesday, he homed in on the first: the long-running transformation toward value-based care.
Here are five notable quotes from his speech:
On free-market forces: "[V]alue is not accurately determined by arbitrary authorities or central planners. The best way to identify and reward value is a marketplace of many players—providers, patients, and, where necessary, third-party payers."
On the need for transparency: "For individuals to drive value, they must have access to data on price and quality. Knowledge is power, and knowing prices and outcomes can enable every American to find better, cheaper healthcare."
On possible new models: "Arrangements like direct primary care have generated tremendous interest from both patients and providers. They can offer the opportunity for seniors to receive convenient, accessible primary care from a physician they know at a predictable and affordable cost. Better access to primary care, as we all know, can prevent more serious and costly ailments."
On overcoming barriers: "[W]e are well aware of the huge burden that regulation places on so many healthcare professionals, and we are working to reduce that burden where we can."
On lowering drug prices: "There’s little difference for a sick patient between a miracle cure that hasn’t been discovered and one that is too expensive to use. I believe we can help lower the cost of medicine while still promoting research that will transform the future of care. Doing both is the only way forward."
An appellate court had sided with Allina Health Services and other hospitals that challenged a 2014 calculation change for disproportionate share hospital payments.
The U.S. Supreme Court could decide a case affecting up to $4 billion in reimbursements to hospitals for uncompensated care.
In a filing last week, Health and Human Services asked the justices to review an appellate court's decision last year to void the way Medicare payments for disproportionate share hospitals (DSH) were being calculated.
The department had interpreted the Medicare Act in mid-2014 as authorizing it to include Medicare Part C claims submissions in its calculation of the so-called "Medicare fraction," which affects DSH payments, for fiscal year 2012, according to the HHS petition.
Minneapolis-based nonprofit Allina Health Services and other health systems challenged HHS in federal district court in 2014, alleging that the department had failed to go through the proper notice-and-comment processes. The district court granted summary judgment to HHS, but the plaintiffs won on appeal last year.
In siding with Allina, the U.S. Court of Appeals for the District of Columbia Circuit departed from decisions reached by other federal appellate courts on this issue, and its decision "threatens to undermine HHS's ability to administer the Medicare Program in a workable manner," the HHS petition argues.
The appellate decision would "significantly impair" the way HHS currently uses Medicare administrative contractors (MACs) to carry out Medicare payments, the department argues.
The total amount of money at issue in this case is $3-4 billion in reimbursements for fiscal years 2005 through 2013, the filing states.
Beyond the specifics of this case, a Supreme Court decision could have broader implications, especially considering how HHS has framed the question at hand: whether it must conduct notice-and-comment rulemaking in situations such as this one.
Hospitals joining Allina in the suit include Florida Health Sciences Center, Mount Sinai Medical Center of Florida, New York Hospital Medical Center of Queens, New York Methodist Hospital, and New York and Presbyterian Hospital.
The executive, who left the organization in March, alleges her termination was tied to her complaints over 'substandard medical care' at the hospital.
Barb McQuillan, BSN, RN, was chief nursing officer and chief operating officer of Sparrow Carson Hospital in Carson City, Michigan, until her departure from the organization was announced in March without explanation.
McQuillan's departure, which came less than a month after the hospital's chief executive officer left over infection concerns, is now the subject of a whistleblower lawsuit in which she claims she was fired for reporting quality concerns at the facility, the Lansing State Journalreported Monday.
The Centers for Medicare & Medicaid Services threatened to revoke federal funding for Sparrow Carson's services in February after investigators found ongoing infection control problems in the facility.
Here are the key claims raised in McQuillan's suit:
McQuillan alleges she reported "suspected substandard medical care and treatment" by J. David Spencer, DO, FACOOG, at Sparrow Carson. Spencer allegedly performed multiple procedures last year with "negative incidents" other healthcare workers documented and reported.
Despite the incidents, the hospital's Lansing-based medical staff allegedly "without hesitation" allowed Spencer to continue performing surgeries.
During an elective tubal-ligation in December or January, one of Spencer's patients allegedly lost 13.5 ounces (400 cubic centimeters) of blood.
McQuillan claims she pushed for Spencer to be blocked from performing additional surgeries and that Spencer's elective privileges were suspended a few days later.
McQuillan claims she thanked then-CEO Matthew Thompson for the action taken against Spencer then asked for more. "He's all we've got," Thompson allegedly replied, repeatedly.
In a separate incident, last September or October, a 58-year-old man came to the emergency department with appendicitis, then allegedly sat untreated for eight hours or more.
McQuillan claims she was excluded from a Root Cause Analysis review process, despite following up on the matter repeatedly.
McQuillan claims her employment was terminated because of her legally protected work to push for quality controls and improvement at the hospital.
Additionally, McQuillan accuses the hospital of a public policy violation (in case the court determines the whistleblower law does not apply).
Sparrow Carson declined the Journal's request for comment, citing the pending litigation.
The suit was filed in the Circuit Court for Ingham County, where the hospital is located.
The CEO's $3.2 million compensation was 77-times as much as that of the median Quorum employee.
Thomas D. Miller, president and chief executive officer for Quorum Health, made 34% less last year than he did the year before, as the company continues to feud with Community Health Systems, which spawned Quorum two years ago.
After earning more than $4.9 million in 2016, Miller's total compensation fell to $3.2 million in 2017, according to records Quorum filed Friday with the Securities and Exchange Commission. He earned neither a bonus nor incentive pay last year, the records state.
Quorum has a dispute pending before the American Arbitration Association over transition services agreements it signed with CHS in 2016. Both organizations have struggled financially since the spin-off, with Quorum underperforming projections and CHS launching into a hospital-selling spree.
CHS CEO Wayne T. Smith saw his total compensation drop dramatically in recent years, from more than $10.4 million in 2015 to $4.9 million in 2017, according to SEC filings. His declining pay rate was tied largely to CHS stock prices.
Pay ratios
Miller's $3.2 million compensation last year was 77-times as much as the $41,800 earned by the median Quorum employee, the company said in its SEC filing.
Smith's $4.9 million compensation, meanwhile, was 80-times as much as the $61,600 earned by the median CHS employee.
Those two CEO pay ratio disclosures—which are newly required under the Dodd-Frank Act—are markedly lower than those reported recently by other hospital operators:
Tenet Healthcare Corporation Executive Chairman and CEO Ronald A. Rittenmeyer's total compensation was annualized at $5.2 million last year, which was 102-times as muchas the median worker’s compensation of about $50,900.
Encompass Health President and CEO Mark J. Tarr, MBA, earned more than $4.9 million in total compensation last year, which was 134-times as much as the median worker’s compensation of about $36,700.
HCA Healthcare Chairman and CEO R. Milton Johnson earned nearly $17.3 million in total compensation last year, which was 312-times as much as the median worker’s compensation of less than $55,400.
Universal Health Services Board Chair and CEO Alan B. Miller, who founded the company in 1979, earned more than $21.6 million last year, which was 541-times as much as the median worker's compensation of less than $40,000.
These ratios should be taken with a grain of salt, though, because the SEC grants companies flexibility in determining how they will calculate median employee salary and subsequent CEO pay ratio.
The agency wants to know whether it should reduce a face-to-face requirement currently imposed on inpatient rehabilitation physicians.
The use of nurse practitioners and physician assistants in providing inpatient rehabilitation services could expand dramatically if the Centers for Medicare & Medicaid Services reduces the number of face-to-face visits it requires physicians to document.
The agency floated the idea Friday, when it announced $1.3 billion in proposed rate increases and several operational tweaks for four post-acute programs in fiscal year 2019, including an estimated $75 million increase for the Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS).
Under the proposed changes, rehabilitation physicians would no longer be required to perform one post-admission evaluation plus three face-to-face visits per week for each patient. Instead, each patient's initial evaluation would count toward the three face-to-face visits, beginning October 1.
"While we continue to believe that the post-admission physician evaluation and the face-to-face physician visits are two different types of assessments," the CMS proposal states, "after reevaluating these coverage criteria, we believe that the rehabilitation physician should have the flexibility to assess the patient and conduct the post-admission physician evaluation during one of the three face-to-face physician visits required in the first week of the IRF admission."
The change, which is part of an effort to reduce certain documentation requirements CMS officials believe to be overly burdensome, could foretell even more dramatic changes to come.
Officials are asking stakeholders whether they should allow non-physicians, such as NPs and PAs, to fulfill some of the requirements currently being imposed exclusively on physicians. To this end, the CMS proposal includes four specific questions:
Do non-physician practitioners have the specialized training in rehabilitation that they need to have to assess IRF patients both medically and functionally?
How would the non-physician practitioner’s credentials be documented and monitored to ensure that IRF patients are receiving high quality care?
Are non-physician practitioners required to do rotations in inpatient rehabilitation facilities as part of their training, or could this be added to their training programs in the future?
Do stakeholders believe that utilizing non-physician practitioners to fulfill some of the requirements that are currently required to be completed by a rehabilitation physician would have an impact of the quality of care for IRF patients?
In addition to floating the idea of permitting NPs and PAs to step into the physician's current role, CMS is also seeking feedback on the possibility of allowing rehabilitation physicians to do their work remotely, such as via videoconferencing. To this end, the CMS proposal includes six specific questions:
Do stakeholders believe that the rehabilitation physician would be able to fully assess both the medical and functional needs and progress of the patient remotely?
Would this assist facilities in rural areas where it may be difficult to employ an abundance of physicians?
Do stakeholders believe that assessing the patient remotely would affect the quality or intensity of the physician visit in any way?
How many and what types of visits do stakeholders believe should be able to be performed remotely?
From an operational standpoint, how would the remote visit work?
What type of clinician would need to be present in the room with the patient while the rehabilitation physician was in a remote location?
"Given the level of complexity of IRF patients, we have some concerns about whether this approach would have an impact on the quality of care provided to IRF patients," the CMS proposal notes.
"To maintain the hospital level of care that IRF patients require, we would continue to expect that the majority of IRF physician visits would continue to be performed face-to-face," it adds. "However, we are interested in feedback from stakeholders on whether we should allow a limited number of visits to be conducted remotely."
Comments on the proposal, which is slated for publication May 8 in the Federal Register, will be accepted through June 26.
The Medicare rate increases are slated for SNFs, hospices, and two categories of inpatient care.
Skilled nursing facilities, hospices, and inpatient facilities for rehabilitation or psychiatric care will receive $1.3 billion more in fiscal year 2019 than they did this year, if the Centers for Medicare & Medicaid Services finalizes a set of proposals announced Friday.
The annual update affects Medicare policies for four separate payment systems:
Skilled Nursing Facility Prospective Payment System (SNF PPS)
Update: +2.4%, as required by the Bipartisan Budget Act of 2018
Note: Without the statutory requirement, the market basket update factor would have been 1.9%, which would have resulted in an estimated increase of $670 million.
Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS)
Researchers are being granted access to detailed claims data for the large and growing segment of the Medicare beneficiary population.
For the first time, the federal government is granting researchers access to Medicare Advantage claims data with the stated goal of driving innovation and competition.
Centers for Medicare & Medicaid Services Administrator Seema Verma announced the change Thursday during a speech at Health Datapalooza in Washington, D.C., touting the move as part of the agency's MyHealthEData initiative.
"We recognize that the MA data is not perfect, but we have determined that the quality of the available MA data is adequate enough to support research," Verma said in her prepared remarks. "And although this is our first release, going forward, we plan to make this data available annually. And we’re not stopping with MA data."
The agency expects to release data from Medicaid and the Children's Health Insurance Program (CHIP) next year as well, she said.
Researchers already have access to detailed data from the fee-for-service program, but they have pushed for the MA data as well because it represents a large and growing segment of the beneficiary population: about 19 million people, or one-third of all Medicare beneficiaries, last year.
In an opinion piece for the Journal of the American Medical Association, researchers Niall Brennan, MPP, of the Health Care Cost Institute; Charles Ornstein of ProPublica; and Austin B. Frakt, PhD, of the Department of Veterans Affairs and Boston University, wrote last month that MA plans have more flexibility than traditional Medicare, making them more popular.
"Despite the important and increasing role of Medicare Advantage plans, there is fairly little insight into the relative value Medicare Advantage provides to beneficiaries or the funder, the US taxpayer," they wrote.
With this newfound access to detailed MA data, the researchers may be able to better assess how well MA modifications are working.
In a written announcement, CMS said the agency will begin with a preliminary version of the 2015 Medicare Advantage Encounter Data, followed later this year by a final version.
Anyone seeking additional information or looking to request encounter data can do so online at the CMS Research Data Assistance website.
Patient safety leaders slashed the number of overridden medication safety alerts by 60% in the first month of targeted interventions.
A nursing home patient with dementia who was admitted last October to DeKalb Medical in Decatur, Georgia, died after the hospital gave her 10 times the maximum daily dose of a calcium channel blocker.
The overdose death resulted in a finding of immediate jeopardy by the Centers for Medicare & Medicaid Services and spurred a series of patient safety reforms, many of which seek to reduce overreliance on technology.
"Our staff, physicians, pharmacists, nurses, other healthcare team members—and I don't think this is unique to our hospital system—have become very task-oriented in their actions as it relates to working with an electronic medical record," said Sharon Mawby, MSN, RN, NEA-BC, vice president of patient care services and chief nursing officer for DeKalb.
"Many hospitals, in an effort to decrease keystrokes for a practitioner, have developed order sets and systems which allow our practitioners to simply check boxes or choose from dropdown screens," she said.
That efficiency, without proper safeguards, can make it easier for healthcare workers to carry out unsafe orders methodically, without a second thought, Mawby said.
"Why aren't we asking questions?" she added. "Why aren't we stopping to listen to our gut when something doesn't feel right?"
What went wrong
The doctor who ordered 100 mg of amlodipine besylate tablets failed to second-guess an existing error made by another physician in the patient's file. A pharmacist tasked with reviewing the order missed the error as well, even though DeKalb's medication management system alerted the pharmacist to the unsafe dosage.
Pharmacists may mistakenly override a medication safety alert because they are inundated with false alarms, DeKalb's pharmacy director told inspectors after the fatal incident, according to an inspection report CMS released to HealthLeaders Media in response to a public records request.
The rate of adverse drug events originating during an inpatient stay at U.S. hospitals declined 23.8% from 2010 to 2014, falling most dramatically among patients ages 65 and older, according to a study released in January by the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project.
But the quality concerns over "alert fatigue," which can make it more difficult to catch medication errors before they harm patients, continue to plague hospitals and health systems nationwide.
Research conducted by Adrian Wong, PharmD, MPH, BCPS, BCCCP, an outcomes research and pharmacy informatics fellow at Brigham and Women's Hospital in Boston, found that nearly three-quarters of medication safety alerts were overridden over a three-year period at a large teaching institution he studied. About 40% of the overrides were deemed inappropriate.
Despite the numbing effects of alert fatigue, a second DeKalb pharmacist caught the doctor's error last October, notified the first pharmacist of the problem, and kept the unsafe order from being processed, according to the CMS documents.
But the pharmacists failed to contact the doctor to modify the mistaken order.
When the patient was transferred from the Express Admission Unit to a medical wing, a registered nurse followed the unmodified order. The nurse scanned the patient's wristband and the medication packaging to verify the proper dose, then the nurse helped the patient take all 10 amlodipine tablets.
The patient's blood pressure dropped sharply, and she was transferred to the ICU, where she was placed on a ventilator until her death two days later.
Mawby said individual workers were held responsible for the actions they took with "reckless disregard" for safe medication administration procedures. She declined to say whether anyone was fired.
Seeking systemic solutions
When serious medication mistakes occur, it may be tempting to place blame squarely on the shoulders of the doctors, pharmacists, and nurses who erred. But beyond holding individuals responsible for their actions, DeKalb's leadership team also identified several systemic problems it could solve.
Below are five key steps DeKalb took to shore up patient safety at its organization:
1. Medication safety team restructured
The three-hospital system already had a standing team tasked with addressing medication safety concerns. But the fatal error last October prompted DeKalb to restructure, revamp, and revitalize the initiative, Mawby said.
"The problem with the previous team was that it was not robustly overseen, so even though they reported directly to the pharmacy and therapeutics committee, there was no link to the board for information," she said. "There was really no direct link to me for patient care to help them solve issues."
The restructured team—which rewrote its charter—now reports to the board quality committee, linking it directly to C-suite leadership for more consistent communication.
2. Data points identified, tracked
To quantify DeKalb's problems and progress, the medication safety team identified key data points it will track in an effort to trend all medication safety errors and adverse drug events that rise above a defined level of severity.
The team will keep an especially close eye on one metric, Mawby said: the number of overridden medication safety alerts.
After months of planning and technical EMR adjustments, the team began formally tracking these overridden alerts in February. At the beginning of the month, there were 433 alerts overridden in a single day. By the end of the month, DeKalb slashed that number by 60%, to 175 alerts overridden in a single day.
"It's a definite improvement, but the fix is going to take a long time," Mawby said.
For starters, the EMR and related systems require that every medication be mapped individually to identify its safe dosage parameters. If the parameters are too strict, then healthcare workers will be bogged down with unneeded alerts; if they're too lax, then those who prescribe and administer medication will be driving without guardrails.
"You can't just turn the button on and say, 'OK, we've got these dose quantity alerts on for everything,' " Mawby said. "It just doesn't work that way."
The goal should not be to reach zero overridden alerts, Mawby noted. The goal should be to track and verify that the alerts are being overridden for the right reasons.
3. Changes to EMR systems implemented
As the medication safety team has begun to track overridden alerts more closely, the DeKalb team has pinpointed which medications and providers need the attention of a fine-toothed comb.
"We've been able to go in and readjust order sets so they're not alerting inappropriately," Mawby said. "We've been able to go in and teach physicians and pharmacists and show them what they're doing wrong."
Arguably the most significant systemic problem that contributed to last October's incident was rooted in DeKalb's EMR setup. Although the pharmacists who were tasked with reviewing and filling the unsafe medication order received an automated safety alert from the system, the physician did not.
That setup has since been changed. DeKalb turned on medication safety alerts for prescribing physicians as well, offering immediate feedback when an order appears to contradict safe practices.
"The only way that a physician, or person ordering the medication, can get past the alert now is by choosing the appropriate override comment as to why the order is given outside of the normal parameters," Mawby said.
"When the medication order gets to the pharmacist, they will be able to see why the medication was overridden. They will be the second line of defense to make sure that that's an appropriate reason as well to override an alert."
4. Policies and training updated
In addition to targeted training for physicians, pharmacists, and others involved in medication administration, DeKalb implemented more general safety training and information-sharing initiatives on a regular basis. These initiatives include daily safety briefings.
"Those are led by our senior leaders, which is somebody from the C-suite," Mawby said. "And at these daily safety briefings, we report out on safety events that may have occurred in the past 24 hours or issues that we are concerned might be an event in the next 24 hours."
Attendees include hospital leaders from across the DeKalb system, including representatives from facilities services, sanitation, and other teams not directly involved in patient care.
5. Transparency practiced
In the immediate aftermath of the medication safety error, DeKalb hosted town halls that were mandatory for all patient care services staff and optional for the rest of the system's employees.
"One of the best things that we did as an organization was be completely transparent about the event that occurred," Mawby said, noting that nearly 800 people attended.
Leaders stood in front of DeKalb staff, outlined what went wrong, and identified eight missed opportunities that could have stopped the error from harming the patient.
"It brought a lot of caregivers to tears," Mawby said.
This transparency in the wake of a tragedy that stemmed from individual and systemic blunders alike is necessary to foster a culture of safety.
"You've got to have a culture of safety in the hospital that is supportive of asking questions and bringing concerns forward," Mawby said.
"This horrible event actually has changed us in so many ways that we've expanded our focus beyond medication administration to include other items around patient safety," she added.
The public-private partnership will include prize competitions and other efforts to 'accelerate the commercialization' of therapies.
Health and Human Services announced an initiative Thursday, in partnership with the American Society of Nephrology, with the goal of helping the more than 40 million Americans living with kidney disease.
The project, dubbed the Kidney Innovation Accelerator, or KidneyX, will encourage public-private coordination and a series of prize competitions "to enable and accelerate the commercialization" of therapies, HHS said in its announcement.
HHS Chief Technology Officer Bruce D. Greenstein signed a memorandum of understanding Thursday with ASN President Mark D. Okusa, MD, FASN.
"Over the last decade, patients with cancer and heart disease have benefitted from innovative improvements in therapies, drugs, devices and digital health tools. Patients suffering from kidney disease deserve the same opportunity," said Greenstein in a statement.
"With KidneyX, HHS sends an important message to innovators and investors regarding the desire and demand to help patients suffering from chronic kidney disease," Greenstein added.
Okusa said KidneyX will encourage venture capitalists—who have been reluctant to invest in innovative therapies for kidney diseases in the past—to give kidney-related investment opportunities another chance.
The plan is to focus on three main areas:
Conducting competitions to identify the most promising innovators, funding their work with prize money;
Improving coordination across several relevant federal agencies "to help clarify the path toward commercialization"; and
Fostering a sense of urgency to develop new therapies.
Applications for the first round of KidneyX prize funding will be accepted in the late summer of this year, HHS said.
Here's hoping that #KidneyX is a game-changer. Together we can innovate beyond dialysis and transplantation! https://t.co/wPwCZmC3NJ
The company fell short of its 2017 financial performance expectations, as the industry has been under pressure.
While continuing to project confidence in the company's future, LifePoint Health's top executive delivered a frank message to investors Wednesday ahead of the company's annual shareholder meeting: 2017 was rough.
William F. Carpenter III, chairman and chief executive officer for the for-profit rural hospital operator based in Brentwood, Tennessee, admitted the company failed to achieve its financial performance expectations last year, as headwinds have made the business of healthcare increasingly difficult industrywide.
"We are navigating a shifting payer mix, uncertainty in Washington, increasing consolidation of existing providers, a movement toward consumerism, in which our patients are exercising more choice in where and how they receive their care, and the entry of non-traditional providers into the healthcare environment," Carpenter said.
His message was submitted to the Securities and Exchange Commission as part of a proxy statement ahead of LifePoint's annual shareholder meeting, scheduled for June 5.
The company's stock price slumped when fourth-quarter and 2017 year-end earnings numbers were released in February. Same-hospital revenues were about $5.9 billion in 2017, down 0.8% from the year before.
Although the hospitals LifePoint acquired in 2014 and 2015 performed according to plan last year, the hospitals it acquired in 2016 "did not improve at the pace we had expected," Carpenter noted. The company responded by pausing its acquisitions activity in 2017 to focus on integrating the new facilities into the company's overall operation.
"We believe that the transition of ownership of these hospitals will position them more effectively to service their local communities as well as benefit [LifePoint] and its shareholders in the long term," Carpenter said.
Executive compensation
Although the company exceeded its quality goals, missing the mark on revenue and other financial goals resulted in below-target incentive payouts. Those eligible for annual cash incentives earned 68% of that target.
Carpenter's total compensation was more than $13.6 million last year, including $1.2 million in incentive pay and more than $10.8 million in stocks and options. He earned $12.6 million in 2016 and $15.2 million in 2015.
Carpenter's total compensation last year was about 262-times as much as the $52,100 earned last year by LifePoint's median employee. The CEO pay ratio disclosure is newly requiredas a result of the Dodd-Frank Act.
"The majority of our employees are located in relatively small, non-urban markets," the company noted in its filing.