Transcript Document

MIH at 2 –
What’s New?
Matt Zavadsky, MS-HSA, EMT
Public Affairs Director
MedStar Mobile Healthcare
Adjunct Faculty
University of Central Florida
College of Health and Public Affairs
Health survey ranks U.S. last among rich peers
Michael Winter, June 16, 2014
For the fifth time in a decade, the United States is the sick man of the rich
world.
That's according to the latest Commonwealth Fund survey of 11 nations,
which ranked the world's most expensive health care system dead last on
measures of "efficiency, equity, and outcomes." So too in 2010, 2007, 2006
and 2004.
The U.S. ranking reflects poor scores on measures of healthy lives —
"mortality amenable to medical care," infant mortality and healthy life
expectancy at age 60.
The other eight countries surveyed were Australia, Canada, France, Germany,
the Netherlands, New Zealand, Norway and Sweden.
http://www.usatoday.com/story/news/nation/2014/06/16/health-survey-uslast/10638811/
Attention Please!
• $8,600 per capita health expenditures!!
– Due in large part to quantity-based payments
Healthcare Environment
• Accelerated shift from FFS to “something else”
– ACO
– Shared Risk
– Bundled Payments
• Evolution of outcome-based measures
• Continued focus on patient experience of care
– Quality AND satisfaction
• MSPB calculations = 2015
• Medicare Spending Per Beneficiary
– Hospital accountable for some outpatient post acute costs
Hospital Name
ST JOSEPH MED CNTR
State Period
Claim Type
1 through 30 days
After Discharge from
Index Hospital
WA Admission
Outpatient
Avg
Avg
Avg
Spending Spending Spending Percent of Percent of Percent of
Per Episode Per Episode Per Episode Spending Spending Spending
(Hospital) (State)
(Nation)
(Hospital) (State)
(Nation)
$929
$770
$664
4.72%
4.06%
3.39%
UNIV OF WASH MED CNTR WA
1 through 30 days
After Discharge from
Index Hospital
Admission
Outpatient
$1,860
$770
$664
7.94%
4.06%
3.39%
VALLEY MEDICAL CENTER WA
1 through 30 days
After Discharge from
Index Hospital
Skilled Nursing
Admission
Facility
$3,469
$2,903
$3,087
18.27%
15.32%
15.77%
YAKIMA HMA
1 through 30 days
After Discharge from
Index Hospital
Admission
Inpatient
$2,637
$1,929
$2,602
13.75%
10.18%
13.29%
WA
HARBORVIEW MED CNTR WA
During Index
Hospital Admission
Inpatient
$12,663
$9,760
$8,997
51.58%
51.52%
45.96%
HARBORVIEW MED CNTR WA
Complete Episode
Total
$24,552
$18,946
$19,578
100%
100%
100%
National Health Care Spending: What the Numbers Mean for Hospitals
and Health Systems
09.08.14 by Paul Keckley
So, what do these numbers really mean, especially to hospitals and health
systems that have seen average operating margins shrink to 2.1 percent in 2013
from 2.5 percent in 2012?
First, it means hospitals face tough negotiations with health insurers, who will
use the ACA’s trajectory from fee for service to performance-based payments to
providers to aggressively expand bundled payment programs and use narrow
networks and reference pricing to garner better deals for their enrollees.
Second, it means consumers increasingly will shoulder more of the burden of
health costs directly, through premiums, co-payments and deductibles,
accelerating price sensitivity for hospital and physician services, and increasing
bad debt as their bills go unpaid.
http://www.hhnmag.com/display/HHN-newsarticle.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HHN/Daily/2014/S
ep/090814-keckley-healthcare-statistics
Third, it means large employers will become more active as purchasers, seeking
opportunities to contract directly with providers who can accept risk for high-quality,
low-cost guarantees.
Fourth, it means operating margins for doctors, hospitals and post-acute providers will
shrink, accelerating vertical integration into care management organizations that
focus on scale, growth and diversification.
And last, it means the gap between household income gains that are substantially lower
than health care spending — 5.6 percent per year — will spark a renewed public debate
about the sustainability of the U.S. health system as it currently operates. The disconnect
hits younger households hardest: the millennials and young Gen Yers might start an
“occupy health care” movement to replace the current system with something else.
http://www.hhnmag.com/display/HHN-newsarticle.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HHN
/Daily/2014/Sep/090814-keckley-healthcare-statistics
Return Visits to the Emergency Department:
The Patient Perspective
Sep 2, 2014
Source: ACEP
Conclusion
Post-discharge factors, including perceived inability to access
timely follow-up care and uncertainty and fear about disease
progression, are primary motivators for return to the ED. Many
patients prefer hospital-based care because of increased
convenience and timely results.
Further work is needed to develop alternative pathways for
patients to ask questions and seek guidance when and where
they want.
http://www.annemergmed.com/article/S0196-0644(14)00622-2/fulltext
Spike in ER, Hospitalization Use Short-Lived After Medicaid
Expansion
By Lisa Aliferis, KQED
October 15th, 2014
While the Medicaid expansion may lead to a dramatic rise in emergency room use and
hospitalizations for previously uninsured people, that increase is largely temporary and
should not lead to a dramatic impact on state budgets.
In July 2011, after being enrolled in California’s Low Income Health Program, the so-called
“bridge to reform,” the group with the highest pent-up demand had a rate of costly
emergency room visits triple — or more — that of the other groups. But from 2011 to
2013, that high rate dropped by more than two-thirds and has remained “relatively
constant,” according to the analysis.
Rates of hospitalization for the “highest pent-up demand” group also started high and
dropped by almost 80 percent over the two-year period.
One factor in helping drive down the higher rates of use, Kominski said, is better efforts
at coordination for Medi-Cal beneficiaries.
http://capsules.kaiserhealthnews.org/index.php/2014/10/spike-in-er-hospitalization-use-shortlived-after-medicaid-expansion/
Number of Americans Without Health Insurance Falls, Survey
Shows
By SABRINA TAVERNISE
SEPT. 16, 2014
Federal researchers reported on Tuesday that the number of Americans
without health insurance had declined substantially in the first quarter
of this year, the first federal measure of the number of uninsured
Americans since the Affordable Care Act extended coverage to millions of
people in January.
The number of uninsured Americans fell by about 8 percent to 41 million
people in the first quarter of this year, compared with 2013, a drop that
represented about 3.8 million people and that roughly matched what
experts were expecting based on polling by private groups, like Gallup.
The survey also measured physical health but found little evidence of
change.
http://www.nytimes.com/2014/09/16/us/number-of-americans-without-healthinsurance-falls-survey-shows.html
Small Firms Start to Drop Health Plans
Many View the Health Law’s Marketplace as Inviting and Affordable
By Anna Wilde Mathews, Angus Loten and Christopher Weaver
Oct. 29, 2014
Small companies are starting to turn away from offering health plans as they seek to
reduce costs and increasingly view the health law’s marketplaces as an inviting and
affordable option for workers.
WellPoint Inc. said Wednesday its small-business-plan membership is shrinking
faster than expected and it has lost about 300,000 people since the start of the year.
Going forward, with the health law’s marketplaces running and functioning well,
small employers will likely re-evaluate exchanges as an option for their employees,
said Wayne DeVeydt, WellPoint’s chief financial officer. “We think [that] will become
even probably a more prominent decision that they’ll make this quarter,” he said.
The law includes subsidies for lower-income workers that can sometimes be as
generous as the amounts small employers were paying toward health benefits.
Indeed, insurers and brokers say small employers in lower-income industries are far
more likely to switch.
http://online.wsj.com/articles/small-firms-drop-health-plans-1414628013
Employers Eye Moving Sickest Workers To Insurance Exchanges
By Jay Hancock - KHN Staff Writer
May 07, 2014
Can corporations shift workers with high medical costs from the company
health plan into online insurance exchanges created by the Affordable Care
Act? Some employers are considering it, say benefits consultants.
"It's all over the marketplace," said Todd Yates, a managing partner at Hill,
Chesson & Woody, a North Carolina benefits consulting firm. "Employers are
inquiring about it and brokers and consultants are advocating for it.“
The concept sounds too easy to be true, but the ACA has set up the ability for
employers and employees on a voluntary basis to choose a better plan in [the]
Individual Marketplace and save a significant amount of money for both!"
says promotional material from a company called Managed Exchange Solutions
(MES).
http://www.kaiserhealthnews.org/stories/2014/may/07/shifting-employees-to-exchanges.aspx
Health Insurers Are Trying New Payment Models, Study Shows
By Reed Abelson
July 9, 2014
The survey, released on Wednesday by the plans’ trade association, estimates that $1
out of every $5 in reimbursements is being paid under an arrangement in which
providers are rewarded for improving care and lowering costs.
The insurers say they are spending more than $65 billion a year in new “valuebased” payment models, according to the Blue Cross Blue Shield Association, which
looked at 350 programs in nearly every state.
Health insurers have long talked about changing the way they pay for care, but there
have been few tangible signs of just how enthusiastically they are embracing
alternatives.
But the Blue Cross executives say there is no choice but to move away from a system
that rewarded high-cost care over high-quality and efficient treatments.
http://www.nytimes.com/2014/07/10/business/health-insurers-are-trying-new-payment-models-study-shows.html
HCA to close Florida hospital as inpatient volumes dwindle
By Bob Herman
September 24, 2014
For-profit hospital giant HCA said Tuesday it will close one of its hospitals in Florida because
of excess inpatient capacity in the region—a sign that healthcare reform continues to push
patient volumes away from inpatient hospital settings and toward lower-cost outpatient
facilities.
HCA will shut down Edward White Hospital in St. Petersburg, Fla., by Nov. 24. Clinical services
at the hospital—which has 162 licensed beds and 110 staffed beds.
The decline of inpatient utilization began several years ago during the recent recession, and
has intensified as the Patient Protection and Affordable Care Act encourages providers to
use less-costly, preventive measures.
A new report from consulting firm Kaufman Hall backs up those reports from health systems,
finding that in the first half of this year, inpatient volumes were flat or fell for 68% of notfor-profit hospitals.
http://www.modernhealthcare.com/article/20140924/NEWS/309249963/hca-to-closeflorida-hospital-as-inpatient-volumes-dwindle
HCA buying Dallas-based urgent care company, CareNow
Oct 28, 2014
Nashville-based health care giant HCA is buying Dallas-based
CareNow, which owns 24 urgent care centers in Dallas-Fort
Worth.
"CareNow has a strong brand and will add an exceptional
network of urgent care centers and 130 physicians that
complement our hospital, emergency and outpatient services in
Dallas-Fort Worth," said Sam Hazen, HCA president of operations.
"This transaction represents two trusted providers coming
together to deliver a broader and more integrated level of
quality health care services.“
http://www.bizjournals.com/dallas/news/2014/10/28/hca-buying-dallas-based-urgent-care-company.html
Texas Health Resources Pairs With Target For Primary Care
Hospitals 10/2/2014| by Matt Goodman|
Texas Health Resources’ physician organization has teamed with eight Target locations in
North Texas to provide walk-in primary care to customers.
Patients 18 months and older can receive care for minor illnesses and injuries, skin
treatments, vaccinations, tests, and screenings. Texas Health Resources also has an
agreement with CVS locations. Baylor Scott & White Health has a similar deal with
Walgreens and Walmart.
“In a rapidly changing healthcare environment, Texas Health Physicians Group continues
to pursue creative and innovative ways to reach patients and improve patient care,” read a
statement from Shawn Parsley, D.O., the group’s president. “This collaboration advances
Texas Health’s strategy to expand access to convenient, quality primary care close to
where people live and work.”
http://healthcare.dmagazine.com/2014/10/02/texas-health-resources-pairs-with-targetfor-primary-care/
Kindred, Gentiva agree to $1.8 billion merger
By Bob Herman
October 9, 2014
Ending a months-long battle, Kindred Healthcare and Gentiva Health Services
said Thursday they will merge, creating one of the largest post-acute-care
providers in the country.
Kindred said once the deal closes, it will be the fourth-largest healthcare
employer in the U.S. The combined company will have 109,000 employees in
hundreds of long-term acute-care hospitals, inpatient rehabilitation facilities,
skilled nursing facilities and hospices.
The new company is expected to generate about $7.1 billion in annual
revenue, making it larger than the other recent merger in the industry
between Genesis HealthCare and Skilled Healthcare Group.
http://www.modernhealthcare.com/article/20141009/NEWS/310099938/kindred-gentiva-agree-to-1-8-billionmerger
Bundled payments could cut Medicare fraud, experts say
Kelly Kennedy
May 19, 2014
WASHINGTON — Health and policy experts are pushing for a system that pays doctors a
lump sum for medical care or allows them to share in savings, saying it will save millions
of dollars over current fee-for-service payments that can lead to fraud and over-use of
medications.
In the new system, doctors would not be entitled to extra pay should they prescribe
costlier medication.
"CBO projects that applying bundled payment models like Bay State's nationally could
save Medicare about $46.6 billion over the next seven years," Warren said.
Peter Ubel, professor of business administration and medicine at Duke University's
Sanford School of Business, said a third method may also work well: He suggested
changing the payment structure so that a doctor receives the same payment no matter
what he prescribes, rather than receiving a percentage.
http://www.usatoday.com/story/news/nation/2014/05/19/experts-argue-bundled-paymentscould-cut-medicare-costs/8820801/
Employers as Direct Payers
• Shift to self-insured plans
– Including direct contract ACOs
• Drive down utilization
• “Concierge” medicine options
– On-site clinics
– House calls
Employer-Driven Reforms
• Catalyst for Payment Reform
o Coalition of employers (Wal-Mart, Walt Disney,
Boeing, Intel, GE, Delta Airlines, FedEx, 3M…)
o Pushing for value oriented payments to providers
(20% by 2020)
• Aetna – Now paying the same for c-section or
vaginal birth – eliminate incentive for c-section
(H&HN)
• $1,250 for screening colonoscopies – regardless
of in or out of the hospital (H&HN)
http://www.catalyzepaymentreform.org/images/documents/CPR_PBGH_ACO_How_To_Guide_F
INAL.pdf
Accountable Care Organization/Health Plan Questionnaire
The following pages contain a questionnaire CPR and PBGH have created for purchasers to use for assessing their
health plan's ACO strategy as well as their market-specific offerings. We recommend you ask for written responses to
all of the questions.
Throughout this document, CPR-PBGH have written in red where you will need to add specifics about your
organization. We recommend you delete this introduction tab when issuing the Questionnaire.
If you have any questions, please don’t hesitate to contact Shaudi Bazzaz at CPR; [email protected]
Medicare Fines 2,610 Hospitals In Third Round Of Readmission Penalties
By Jordan Rau
KHN Staff Writer
Oct 2, 2014
Medicare is fining a record number of hospitals – 2,610 – for having too many
patients return within a month for additional treatments, federal records
released Wednesday show. Even though the nation’s readmission rate is
dropping, Medicare’s average fines will be higher, with 39 hospitals receiving
the largest penalty allowed, including the nation’s oldest hospital,
Pennsylvania Hospital in Philadelphia.
Under the new fines, three-quarters of hospitals that are subject to the
Hospital Readmissions Reduction Program are being penalized. That means
that from Oct. 1 through next Sept. 30, they will receive lower payments for
every Medicare patient stay — not just for those patients who are
readmitted. Over the course of the year, the fines will total about $428
million, Medicare estimates.
http://www.kaiserhealthnews.org/Stories/2014/October/02/Medicarereadmissions-penalties-2015.aspx
Medicare uses the national readmission rate to help decide
what appropriate rates for each hospital, so to reduce their
fines from previous years or avoid them altogether, hospitals
must not only reduce their readmission rates but do so better
than the industry did overall.
"You have to run as fast as everyone else to just stay even,"
Foster said. Only 129 hospitals that were fined last year
avoided a fine in this new round, the KHN analysis found.
Medicare officials, however, consider the competition good
motivation for hospitals to keep on tackling readmissions and
not to become complacent with their improvements.
http://www.kaiserhealthnews.org/Stories/2014/October/02/Medicarereadmissions-penalties-2015.aspx
The all-cause 30-day hospital readmission rate among Medicare fee-for-service
beneficiaries plummeted further to approximately 17.5 percent in 2013,
translating into an estimated 150,000 fewer hospital readmissions between
January 2012 and December 2013.
This represents an 8 percent reduction in the Medicare fee-for service all-cause
30-day readmissions rate.
http://innovation.cms.gov/Files/reports/patient-safety-results.pdf
Readmission reduction: A losing battle?
October 16, 2014
Readmissions may be "beyond a hospital's control," according to a new study published
in the American Journal of Managed Care.
They gave half the patients an intervention featuring pre-discharge education and
planning, post-discharge follow-up, an available hotline and "bridging" techniques such
as daily symptom checks.
Linden and his coauthor, Susan W. Butterworth, Ph.D., found no statistical difference in
readmissions between the two groups after both 30-day and 90-day periods, although
mortality was lower in the intervention group than the control group.
The research found only a single instance where a patient received same-day care from a
PCP, and in that case the issue was dealt with without requiring emergency care. Linden
and Butterworth cited several cases in which patients sought an appointment with their
PCPs for non-emergency conditions but were sent to the emergency room or unable to
make an appointment for weeks.
http://www.ajmc.com/publications/issue/2014/2014-vol20-n10/a-comprehensive-hospital-based-intervention-toreduce-readmissions-for-chronically-ill-patients-a-randomized-controlled-trial/3
Take-Away Points from the Research:
• Our results suggest the need to continue experimenting with new
interventions targeting readmissions, especially for severely ill patients.
• Our addition of interactive voice response and motivational interviewing–
based health coaching to the transitional care model did not improve
outcomes.
• Our findings suggest that correcting improper use of the inhaler and
increasing adherence to inhaled medications may reduce 90-day mortality
for chronic obstructive pulmonary disease patients.
• Hospitals, without collaborative relationships with community-based
providers, may have limited ability to reduce readmissions, as they cannot
ensure timely and continuous care for patients after discharge.
• A challenging road lies ahead for stand-alone community hospitals seeking
to decrease readmissions and avoid financial penalties.
Name
City
Tristar Skyline Med Cntr
Tristar Southern Hills Med Cntr
Vanderbilt University Hospital
Baptist Memorial Hospital
Delta Medical Center
Fort Sanders Regional Med Cntr
Parkwest Medical Center
Nashville
Nashville
Nashville
Memphis
Memphis
Knoxville
Knoxville
THR - Fort Worth
JPS Fort - Worth
Plaza Med Cntr - Fort Worth
Baylor - Fort Worth
North Shore University Hospital
Wakemed, Raleigh Campus
Legacy Emanuel Med CNtr
Legacy Meridian Park Med. Cntr.
Fort Worth
Fort Worth
Fort Worth
Fort Worth
Manhasset
Raleigh
Portland
Tualatin
State
TN
TN
TN
TN
TN
TN
TN
TX
TX
TX
TX
NY
NC
OR
OR
FY2013
FY2014
FY2015
Readmission Readmission Readmission
Penalty
Penalty
Penalty
0.33%
0.15%
0.61%
0.00%
0.28%
0.00%
0.20%
0.59%
0.08%
0.30%
0.00%
1.00%
0.28%
0.10%
0.28%
0.23%
0.20%
0.11%
0.00%
0.38%
0.20%
0.09%
0.32%
0.03%
0.12%
0.00%
0.98%
0.42%
0.19%
0.39%
0.47%
0.48%
0.10%
0.00%
0.95%
0.47%
0.82%
0.19%
0.03%
0.00%
0.00%
0.55%
0.38%
0.19%
0.03%
Patients Seeking Cheaper Care Are Soliciting Bids From Doctors Online
By Sandra G. Boodman
Aug 05, 2014
Francisco Velazco couldn't wait any longer. For several years, the 35-year-old Seattle
handyman had searched for an orthopedic surgeon who would reconstruct the torn
ligament in his knee for a price he could afford.
Out of work because of the pain and unable to scrape together $15,000 – the cheapest
option he could find in Seattle – Velazco turned to an unconventional and controversial
option: an online medical auction site called Medibid, which largely operates outside
the confines of traditional health insurance.
After accepting the lowest bid -- $7,500, a fee that covered anesthesia and related costs
-- he learned that his surgeon would be William T. Grant, a Charlottesville orthopedist. A
few weeks later, after several online discussions with Grant, Velazco arrived in
Charlottesville, where he had rented a $50-a-night room and would spend two weeks
recuperating. On Dec. 4, 2013, he underwent knee surgery, performed in an outpatient
surgery center that Grant co-owns.
"I'm back working four days per week and climbing ladders," Velazco said recently. "I'm
doing great."
http://www.kaiserhealthnews.org/Stories/2014/August/05/Patients-Seeking-Cheaper-Care-AreSoliciting-Bids-From-Doctors-Online.aspx
Doctors begin to practice "web-side" manner
October 19, 2014
With waits at doctors' offices increasing, online visits are becoming the new house calls.
Google is testing such a service. Other companies already offer it. Taking medicine from
"the doctor is in" to "the doctor is online."
CBS News reporter Vladimir Dutheirs showed his wrist to Dr. Peter Antall over a web
camera, asking about a lump on it. "Can you see that, doctor?"
That doctor works for a company called AmWell, which has grown 1,000 percent in two
years.
Right now, 22 percent of employees offer video consults through health plans. About
71 percent say they will offer it by 2017. Any serious medical conditions are flagged
immediately for in-person care.
Another company, Teladoc, offered only through employee benefit plans, covers 8
million people.
http://www.cbsnews.com/news/doctors-begin-to-practice-web-side-manner/
Around the Nation
• 2013 NAEMT MIH/CP Survey
– 3,781 total responses were received
• Total responses were evenly dispersed across all types of
EMS delivery models.
– 232 unique MIH/CP programs were reported
• (6% of responses).
– 566 respondents (15%) indicated that their EMS
agencies were in the process of developing a MIH/CP
program.
• Round 2 in process now
– 232 surveys + new one’s known
– ~150 completed surveys!
‘Maturing’ Programs
• Reno, NV (CMS HCIA Grantee)
– REMSA
– Community paramedicine
• High Utilizers & CHF
– Ambulance transport alternative destinations
– 9-1-1 Nurse Triage
• Dallas, TX
– Dallas Fire
– Community paramedicine
• High Utilizers & CHF
• Pittsburgh, PA
– UPMC/Emed Health Community Connect
– Community paramedicine
• High Utilizers & CHF
– Partnership between Highmark and UPMC
‘Maturing’ Programs
• Mesa, AZ
– Mesa Fire and Medical Dept.
• Transitional Response Vehicle
– NP/Behavioral Health specialist & Paramedic
• Eagle County, CO
– Eagle County Paramedics
• Primary Care/Rural Model
• Wake County, NC
– Wake EMS
– Community paramedicine
• High Utilizers, CHF, Behavioral Health and Substance Abuse
• ALF/SNF falls alternative destination
‘Maturing’ Programs
• MedStar
– High utilizer
– 9-1-1 Nurse Triage
– CHF
– Obs Admission Avoidance
– Hospice
– Home Health Partnership
– Call Center Services (Jan. 2015)
On the Horizon
• 3 new HCIA EMS MIH Grants in Round 2
– Mt. Sinai Medical Center, NY
– Yale New Haven Hospital, CT
– Mesa, AZ Fire & Medical Dept.
• California CP Pilots
– 12!
– Waiver project
Regulatory Landscape
• Still evolving
– TN, ME, MN, WA, AR efforts
– California project
MIH – Federal Payer View
• Discussion with CMS CMO
– Great outcomes - more patients!
• Legislative initiative
– Field EMS Bill
• Test new payment models for EMS
• Workgroup for new EMS economic model
– Reduce fraud and abuse
– Use $ to fund permanent ‘extenders’
– Additional $ to incentivize bonuses for reporting
quality metrics
Measures Project
Accreditation
• NCQA or others…
“Mobile Integrated Healthcare is an
innovative and patient-centered approach
to meeting the needs of patients and their
families. The model does require you to
“flip” your thinking about almost everything
– from roles for health care providers, to
what an EMT or paramedic might do to care
for a patient in their home, to how we will
get paid for care in the future.
The authors teach us how to flip our thinking
about using home visits to assess safety and
health. They encourage us to segment
patients and design new ways to relate to
and support these patients. And they urge
us to use all of the assets in a community to
get to better care. This is our shared
professional challenge, and it will take new
models, new relationships, and new skills.”
Maureen Bisognano
President and CEO
Institute for Healthcare Improvement
Questions/Comments?
http://www.emsworld.com/article/11446135/performance-metrics-for-value-based-purchasing