Community Based Care Models Gaining Momentum with PCMH in Urban Communities
Dr. Young is Ankota's Chief Medical Officer, and serves jointly as Assistant Professor of Medicine at the Welch Center for Prevention, Epidemiology, and Clinical Research, and Core Faculty of Johns Hopkins Bloomberg School of Public Health. In these roles, Dr. Young is involved in population health programs and community based initiatives that are aimed at decreasing readmissions and lowering the overall cost of care. Managing Care Transitions has emerged as a critical element in reducing avoidable readmissions and lowering overall costs, and health care providers are looking for information to guide them in the creation of these programs.
To learn more about how Ankota technology is used to Plan, Coordinate and Deliver care in community based models and PCMH, click here
Improving health outcomes and lowering healthcare costs is challenging and usually requires the effort of a multidisciplinary team of professionals. The Patient-centered Medical Home (PCMH) is a team-based care delivery model that addresses this reality and has been effective in achieving better care in many settings. Early evidence suggests, however, that the PCMH model is not as effective in urban settings, largely due to the inability of clinic-based teams to engage urban residents and to address the social, behavioral, and environmental determinants of health that are prevalent in poor communities.
In response, many programs around the country are beginning to supplement their traditional PCMH model with community-based teams dedicated to urban neighborhoods. As demonstrated by Medicare’s Coordinated Care Demonstration Programs, face-to-face interactions between the PCMH care coordination staff and their patients are an essential element of effective care coordination programs. This may be especially true for low resource, urban communities where trust of the health system can be low. Community-based health workers may also better understand the neighborhood-specific barriers to care that limit access for our urban patients.
Community health teams are defined as community-based, multidisciplinary health staff that support primary care and provide linkages between patients and families, and the medical home and the community. Community health teams wrap-around and enhance the capacity of primary care practice. Core functions of Community Health Teams include patient engagement and assessment, health and social service navigation, mitigation of barriers to care, and self-management support including motivational and emotional support, disease-specific knowledge reinforcement, and on-going monitoring. These functions complement those performed by clinic-based care management staff and together encompass the 6 domains that are critical to chronic disease management as first described by Wagner.1 Conceptualized in 1996, the Chronic Care Model (CCM) addresses these barriers to patient-centered, high-quality, cost-effective care and has become the standard framework guiding efforts to improve care for patients with chronic illness. The CCM includes 6 elements: 1) health care organization, 2) delivery system design, 3) clinical information systems, 4) decision support, 5) self-management support, and 6) links to community resources. These elements support team-based care that promotes and supports activated, informed, and empowered patients.
While enhanced PCMH models have only recently been implemented, the early results are encouraging. As presented in a webinar at the National Academy for State Health Policy and sponsored by the Commonwealth Fund in April 2012, preliminary analysis of programs in Alabama, North Carolina, and Vermont have demonstrated decreases in emergency department utilization, overall health care expenditures, and improvements in HEDIS-based performance measures. Many more programs employing community-based teams have been recently funded through other CMS mechanisms.
Therefore, we can expect to see results from these programs in the coming years.
1. Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Manag.Care Q. 1996;4(2):12-25.
"...new patient-centered population health models will cause more than $1 trillion of value to rotate from the old models to the new and create more than a dozen new $10 billion high-growth markets."
It's already happening: why should you, as a provider, care?
Why should Hospitals, Accountable Care Organizations and post acute providers care about this dramatic shift? After all, you're still going to get paid for delivering services, right? THINK AGAIN! This shift will have a PROFOUND impact on every provider. You will either benefit from participating in new models of care, or you will suffer a painful death by being disintermediated.
Disintermediated? Cut out. Left behind. Irrelevant. Out of business.
As reported in FORBES last month, and detailed in the Oliver Wyman paper you can download here, "Healthcare innovators are already redefining healthcare value, putting patients first and inventing with little regard for current constraints. They have ignited a powerful, self-funding upward spiral by focusing first on healthcare’s big opportunities, transforming the value equation, generating large savings, and fueling smart reinvestment in the next wave of innovation."
Ask yourself this: Am I among the trillion dollars worth of healthcare business that goes away?
Read the FORBES article in its entirety here and link to the Oliver Wyman white paper.
Learn how Ankota is helping Hospitals, ACOs and post acute provders to operate efficiently and be a valued partner in the new healthcare Ecosystem - click the blue button below.
From "The Medical Home: Disruptive Innovation for a New Primary Care Model," Deloitte reports, "Currently, 45 percent of the population has a chronic medical condition. Among the Medicare population the statistics are even worse: 83 percent have at least one chronic condition and almost a quarter have at least five co-morbidities." And, according to CMS data, 3 out of every 4 dollars spent on healthcare is due to chronic diseases." Deoitte's full report can be downloaded using the green button below.
Deloitte Consulting has long been an advocate of innovative healthcare care delivery models and has published signifcant research and opinions around same. Unfortunately, a great many of the providers that make up healthcare delivery channels--particularly outside of primary care settings--fall outside of Deloitte's business focus. Rather, their business is focused on very large, complex institutions where they can make a living for years on end. As Ankota readers know, many post acute providers are small to mid sized operations, typically regional in focus, and have to approach business operations more pragmatically. However, even Deloitte recognizes that the predominant care delivery models & fee for service payment models are limited at best, particularly when it comes to managing chronic conditions. New models of care must rely increasingly on partnerships with post acute providers for care delivery, where outcomes are better, services are less expensive, and patients are happier.
Innovative health care delivery models that are already upon us--those that drive the highest value and best outcomes--are not limited to traditional, large institutions. Programs of care like Patient Centered Medical Home models, while they may often be driven by payors, hospitals and ACOs, will increasingly rely on post acute providers for delivery of services. Post acute care delivery channels are already established, but are typically disconnected and poorly coordinated with programs like Patient Centered Medical Home. That will change rapidly, and Ankota is positioned to accelerate change by enabling highly cooperative, well coordinated care delivery models through better technology. To learn more about how Ankota's technology is used to establsh vitrual "ecosystems" of providers so that they can better Plan, Coordinate & Deliver care, click here
Acute and post-acute providers are already coming together in efforts to better manage care, and chronic conditions are especially well suited for this approach. Chronic conditions demand proactive, integrated approaches that are sustained over long periods of time and utilize best practices of care. Protocol based approaches that are delivered outside of hospital settings and more specifically, in the home, have been proven to be much more effective and dramatically less expensive.
Deloitte reports, "There is widespread recognition that the U.S. health care system falls short in its efforts to effectively manage chronic conditions. Currently, 45 percent of the population has a chronic medical condition. Among the Medicare population the statistics are even worse: 83 percent have at least one chronic condition and almost a quarter have at least five co-morbidities." And, according to CMS data, 3 out of every 4 healthcare dollars spent are due to chronic diseases. Simply waiting for patients to experience enough problems to send them in to the ED is a proven failure.
A good starting point for reducing U.S. health care expenses overall is to implement a long-term strategy to reduce the costs associated with unmanaged chronic conditions. "The Medical Home: Disruptive Innovation for a New Primary Care Model," a paper by the Deloitte Center for Health Solutions, part of Deloitte LLP, offers a strategic perspective on this potential solution to address the challenge of chronic care management.
In a medical home model, primary care clinicians and allied professionals provide conventional diagnostic and therapeutic services, as well as coordination of care for patients that require services not available in primary care settings. The goal is to provide a patient with a broad spectrum of care, both preventive and curative, over a period of time and to coordinate all of the care the patient receives.
"The Medical Home: Disruptive Innovation for a New Primary Care Model" examines medical home models, their savings potential, and the implications for policymakers and key industry stakeholders. The paper also offers compelling arguments in favor of medical home adoption."
To read the full report, please click here
The many great challenges of caring for the elderly also present opportunities, and programs of care like Patient Centered Medical Home (PCMH) may be the vehicles through which patient care is simultaneously improved and costs are reduced. Through better coordinated, more proactive care delivered in the home, and coordinated by primary care, hospitalizations are reduced and patients live more productive and happier lives. Until recently, payment systems have not rewarded these care delivery models, which are almost universally much less expensive than traditional "fee for service" models.
Steven H. Landers is the Medical Director for the Center for Home Care and Community Rehabilitation for the Cleveland Clinic, and describes how health care reform is providing incentives to assure that more poductive models of care are taking hold. Constant themes include care coordination, oversight, and increased utilization of post accute services such as home health care, rehabilitation, and more.
Says Landers, "We may be able to improve the care of these vulnerable patients—and control costs—by taking their primary care to their own homes. To these ends, the Patient Protection and Affordable Care Act (ie, the “health care reform law”) has several provisions for pilot and demonstration projects. In light of the new policies and as part of a grassroots effort to change the delivery of care for patients with chronic conditions, primary care physicians like Dr. Jones are redesigning their practices to provide a patient-centered medical home."
Dr. Landers' article in the Cleveland Clinic Journal of Medicine can also be read in its entirety on the Journal web site.
MRS. SMITH, age 82, has chronic heart failure. She also has difficulty walking because of arthritis in her knee and osteoporosis. Her son has taken the day off work to bring her in to see her primary care physician, Dr. Jones, because of increasing swelling of her legs and feeling tired.
Even on a good day, Mrs. Smith faces challenges getting to the doctor’s office: she has difficulty getting dressed, taking the stairs, and transporting her walker and oxygen, not to mention parking the car, getting out, getting in to the doctor’s office, and then returning home.
After a careful evaluation Dr. Jones concludes that the leg swelling and fatigue are due to an exacerbation of heart failure triggered by excess dietary sodium and uncontrolled hypertension. She decides to increase the dosages of Mrs. Smith’s diuretic and angiotensin-converting enzyme inhibitor and advises her and her son about dietary sodium restriction. She reviews with them the symptoms that should trigger a call to the office, and she says she wants to see Mrs. Smith again in 3 days.
Mrs. Smith and her son do not seem to understand the instructions, and they explain how difficult it will be to make the follow-up visit, so Dr. Jones recommends hospital admission. Mrs. Smith protests, as she has had multiple hospitalizations during the past year and she dreads the idea of returning. And her son explains, “Mom always seems worse after going to the hospital. Last winter when she was there her days and nights got mixed up, and when she called out at night they gave her some drug that knocked her out for 2 days. Doctor, isn’t there any safe way to keep her at home?”
CHRONIC ILLNESS: A CHALLENGE, AND AN OPPORTUNITY
The growing number of older adults with chronic illnesses poses a serious challenge to the US health care system, placing unprecedented pressures on the financial sustainability and overall effectiveness of the Medicare program.1,2 Of particular concern is the plight of Medicare beneficiaries like Mrs. Smith who have multiple chronic conditions and whose activity and mobility are limited. These patients account for a disproportionate share of Medicare expenses and, despite all the money spent, often struggle without optimal care that is accessible, individualized, and coordinated.
But this challenge is also an opportunity. We may be able to improve the care of these vulnerable patients—and control costs—by taking their primary care to their own homes. To these ends, the Patient Protection and Affordable Care Act (ie, the “health care reform law”) has several provisions for pilot and demonstration projects.3–5 In light of the new policies and as part of a grassroots effort to change the delivery of care for patients with chronic conditions, primary care physicians like Dr. Jones are redesigning their practices to provide a patient-centered medical home.6
Practical considerations for successful physician-home health collaboration in chronic care management
As envisioned, the primary care physician’s office will be the patient’s “medical home.” The primary care physician will lead, coordinate, and oversee the efforts of a multidisciplinary team, referring patients when necessary to specialists and community resources. Primary care practices that become medical homes would potentially be paid care management fees in addition to fees for visits, but with new expectations for care coordination and integration.
The health care reform law also includes the Independence at Home Act, funding a demonstration project in which primary medical care teams will visit patients at home. Beyond the medical home and independence-at-home concepts, the health reform law also promotes “accountable care organizations,” and changes the funding to Medicare Advantage private insurance plans. Both of these initiatives will likely require primary care physicians to redesign how they deliver chronic care to older patients with limited mobility and multiple comorbid illnesses.
The emergence of the medical home, independence-at-home, and related concepts makes it a good time for physicians to explore how they can collaborate with home health providers to better meet the needs of older patients with chronic illness (TABLE 1).
UNDER MEDICARE, WHO IS ELIGIBLE FOR HOME HEALTH SERVICES?
Primary care physicians who are transforming their offices into a medical home must consider how to deliver the care (it must be accessible, team-based, and aimed at the “whole person”), coordinate the care, and measure its quality.7 Many Medicare beneficiaries with serious chronic illness have limited mobility that makes it difficult to regularly travel to medical offices, and thus they need home visits or regular contact by telephone or computer.
Many home health agencies are using new conceptual models, programs, technologies, and services so they can play a supportive role.8 These agencies employ nurses, therapists, social workers, personal caregivers, and nutritionists. In many instances these people can become the physician-directed team responsible for key aspects of caring for patients with chronic illness in their homes, coordinating and integrating the care, and measuring its quality. Additionally, in-home assessment provides a holistic view of patients that potentially promotes patient- and family-centered care options.
To be eligible for home health services, a beneficiary must be “homebound,” must need intermittent skilled nursing care or skilled therapy, and must be under the care of a physician. The health reform law has also mandated that patients have a face-to-face visit with their physician or with certain nonphysician practitioners in order to certify the home health care plan.
Even though the homebound requirement limits the number of people eligible, many older adults like Mrs. Smith who have chronic illness meet this criterion. Others may only be homebound during an exacerbation of a chronic illness that temporarily limits their mobility. However, patients can still be considered homebound for the Medicare benefit even if they leave their home (infrequently) for medical care, religious services, family events, adult day programs, and other reasons.9
The Medicare Home Health benefit covers several services that are especially important for patients with chronic illness. These include nursing visits for observation and assessment, evaluation and management of a care plan, and teaching and training.
How this applies to Mrs. Smith
In the case of Mrs. Smith, Dr. Jones could order home nursing care to make sure she is taking her medications as directed, to teach her about self-management and nutrition, and to assess the impact of medication changes—both the intended effects and adverse effects such as hypotension.
Other team members bring other skills. For example, home health social workers may be able to address complex psychosocial needs that can affect adherence.
The time Dr. Jones spends developing this care plan and reviewing the patient’s condition with home health field staff by telephone or other communication methods is reimbursable under Medicare as “care plan oversight”10 and can substitute for the revenue lost due to less-frequent office visits.10 In the new practice models, a medical home or independence-at-home care-management fee or anticipated revenues from “gain-sharing” could cover nonvisit supervision of in-home services.
Oversight in the computer age
Dr. Jones may be reluctant to rely on a home health agency because she cannot directly oversee what they are doing and may in fact be uncertain as to what they are doing. Home care may seem like a “black box” to physicians, but it shouldn’t in this era of electronic health records and advanced electronic information systems. Seamless communication is possible without playing “telephone tag” and sending multiple faxes. Physicians may prefer to work only with home care providers who use electronic information systems and who can interface their systems with the physician’s electronic systems, or at least offer shared viewing through Web access. Of course, such arrangements must be initiated with respect for the patient’s preference for a home care agency.
Home health providers are also well positioned to help measure and monitor the quality of care. Medicare requires that home health providers track a comprehensive set of quality outcomes, adjusted for risk, and ranging from improvement in function to acute hospitalization rates.11,12 Given that most home care providers are swimming in data about their patients, it would be reasonable for home care agencies to provide physician partners with more nuanced reports for specific subpopulations, such as those from a particular physician practice, or for patients with a particular disease.
NEW CONCEPTS, PROCESSES, AND TECHNOLOGIES
To care for a patient like Mrs. Smith, the home health team must embrace new, chronic-care-oriented concepts, processes, and technologies. Many agencies now have nurses and therapists skilled in chronic illness care, self-management support, and health coaching. Ancillary staff collaborate with the physician by assuming time-consuming but necessary tasks such as patient education, care coordination and integration, and quality measurement and improvement initiatives.
Several groups and authors have proposed a “home-based chronic care model,” built upon the well-studied “chronic care model,” 13–16 as a framework to help home care providers change their approach to patients with chronic illness. This model offers a standardized curriculum and certification program, as well as practice guidelines, which standardize best-practice care delivery from agency to agency.
A core tenet of this model is a strong focus on teaching clinicians how to teach their patients to care for themselves, since bad outcomes are often due to patients not following physicians' recommendations. Since successful chronic care management requires adherence to specific self-care behaviors, the focus on behavior change must not be neglected if positive outcomes are to be realized.
New technologies are also emerging. Some home health providers are using in-home telemetry with remote call centers to track the patient’s health status on a daily basis. Physicians and patients can follow the data, allowing for quick intervention, if necessary, and reinforcement of self-management learning.17–20Some home care agencies could monitor, via telemetry, Mrs. Smith’s weight, blood pressure, oxygen saturation, heart rate, and dyspnea symptoms. This information could be fed back to call-center clinicians who have predetermined parameters for titrating the diuretic dose and for notifying the physician.
Some monitoring technology allows for interactive assessment and teaching via live videoconferencing. Some home health agencies also use telephone-based health coaching.21 Information system interfaces between the home health agency and the medical home coordinator could make the content of this in-home monitoring and care management visible in the physician’s record.
TOWARD ONGOING CARE MANAGEMENT
In spite of these opportunities, the Medicare home health benefit rarely permits uninterrupted ongoing home care. Thus, the home health collaboration developed around Mrs. Smith’s heart failure exacerbation is likely to be temporary, and when her condition stabilizes she may no longer meet the criteria for home health services.
This episodic-payment model contrasts with the ongoing needs of the typical high-risk older patient with chronic illness. Changing the home health benefit to allow for ongoing home health care for beneficiaries like Mrs. Smith may be an opportunity for patient-centered reform. Although ongoing home health care for a given patient may not be possible, the medical home model offers the opportunity for ongoing physician-home health collaboration because at any time a physician’s practice is likely to have patients requiring these services. The independence-at-home model does provide for uninterrupted ongoing in-home physician and mid-level care for some patients, but it may require changing primary care physicians, and this may be undesirable to some patients. If a viable financing model is established for medical homes and independence-at-home practices, they may choose to contract with home health agencies to provide ongoing telephone or telemetric care management between (or outside of) episodes of eligibility for traditional home health care. All of these potential arrangements would need legal review and would need to be structured to avoid violation of the letter and spirit of laws prohibiting self-referrals and kickbacks.
PHYSICIAN HOME VISITS
In the case of Mrs. Smith, Dr. Jones has the option of making a follow-up home visit, or even ongoing home visits.
Granted, home visits may be impractical due to the time involved and the impact of that downtime on the physician’s medical practice and responsibilities to other patients. However, larger practices may employ a specific physician, nurse practitioner, or physician’s assistant to provide in-home care to patients in need.
Some communities have house-call practices to which Dr. Jones could refer Mrs. Smith for in-home physician care, and, where available, this may be a preferred care model— somewhat analogous to how a primary care physician might collaborate with a hospitalist for inpatient care of a specific patient.22 These homecare physician practices will likely become more prevalent if the independence-at-home Medicare demonstration project is successful.
In the future, even if Mrs. Smith needed more intensive inpatient care, an emerging concept called “hospital at home” may be able to provide this acute care in her home.23,24 These in-home physician services are increasingly supported by new mobile diagnostic technologies.25
However, adding or changing physicians may not be possible or desirable for Mrs. Smith and could lead to further fragmentation of care. In the future, teleconferencing may provide options for “virtual visits” that would partially solve this problem.
Whether the physician care is provided in the office, in the home, or as a virtual visit, much of the care Mrs. Smith needs can and should be done by nonphysician home health care providers in partnership with informal caregivers.
MRS. SMITH GETS BETTER AT HOME
Dr. Jones decided to refer Mrs. Smith for home health nursing and maintained close telephone contact with her and the home health nurse during the first 2 weeks. Mrs. Smith responded well to the changes in medication and diet, her leg swelling decreased, and she was feeling more like her usual self. At a follow-up office visit 3 months later, Mrs. Smith hugged Dr. Jones and thanked her profusely for helping her get better at home.
- Copyright© 2010 The Cleveland Clinic Foundation
Aetna CEO Bertolini: Fix the Waste in Health Care and Reduce the Deficit by Half in 10 years
"Washington lawmakers are still working to avoid the fiscal cliff. That's the expiring of tax cuts at the end of the year and deep spending cuts that could throw the economy into recession. A group of top CEOs has been urging lawmakers to reach a deal. Renee Montagne talks to Aetna CEO Mark Bertolini about the fiscal cliff and health care."
In a program that sounds a lot like Patient Centered Medical Home (PCMH), Aetna CEO Mark Bertolini shows that programs like this have been shown to reduce hospital admissions in Congestive Heart Failure (CHF) patients by 43%. Bertolini describes a rather simple approach that coordinates remote monitoriong and home care nursing with CHF patients. The results are compelling in this most expensive patient population, which costs as much as $80,000 per admission.
Listen to the entire story by clicking the link above, or you can read the transcript below or directly on NPR's web site.
How does Ankota help manage Patient Centered Medical Home and similar programs? Click the blue button above to find out.
RENEE MONTAGNE, HOST:
In Washington, lawmakers are trying to work out a deal to keep the economy from going over the fiscal cliff. Many economists predict those automatic tax hikes combined with deep spending cuts set to go into effect on New Year's Day would throw the economy back into recession.
A group of top CEOs has been urging lawmakers to reach a deal to keep that from happening. Mark Bertolini is one of them. He's CEO of the health insurer Aetna and he said tax increases are as important as spending cuts. We called him to talk more.
MARK BERTOLINI: Good morning.
MONTAGNE: So let's begin with something you have made public recently. And that's that Aetna is preparing for layoffs if the government does go over this fiscal cliff. Is that your way of sounding the alarm to both sides of Congress?
BERTOLINI: Well, you know, I think that connotation to my words is overblown. What I did say is that when companies go into a recession, one of the consequences of that recession are layoffs. And to the degree we go into a deep recession as a result of going over the fiscal cliff, that is an option that we would be prepared to exercise, as well as many other employers.
MONTAGNE: I'm interested in knowing where you see talks going.
BERTOLINI: Well, I think the talks are hopeful right now. I've been, you know, involved in a meeting that we had at the White House last week. But I've also have been very involved with the Fix the Debt Campaign for the last couple of years, and we do have a bipartisan approach. And that balanced approach is both taxes and entitlement reform.
MONTAGNE: Would you consider yourself an outlier among CEOs, that tax increases is not just inevitable but a good thing?
BERTOLINI: No, I think I'm actually in a majority of people in my socio-economic class and in my position. I would tell you that as long as we work on working down the debt, and the cost of working down the debt is really to pay more taxes, I get that. That's important. That invests for the future.
Think of it like war bonds. You know, we're paying for the future when we're helping the country get through a difficult time.
MONTAGNE: I'm speaking with Mark Bertolini, CEO of the big insurer Aetna.
Let's turn now to the fundamental issue, the ballooning government debt. One of the main causes is rising health care costs. It would be something you know quite a bit about. What do you see as key ways to lower health care?
BERTOLINI: I think the fact that we waste $750 billion a year on the health care system, about 30 percent of what we spend. So if we just fix the waste in the health care system, over 10 years that would pay back half of the nation's deficit. So, for example, today there is no data connection about Mark Bertolini across multiple providers, and if I'm having a significant health event, I see one doctor now and then I see another doctor in a few weeks from now - they may order the same tests.
Why shouldn't that information be widely available on the tests that I've had done? Why shouldn't there be a profile on recent exams that I've had? Why shouldn't that information be available in some way? And if it's available, then physicians begin with a better base of information and can move forward versus having to reinvent the history.
MONTAGNE: Let me ask you about fixing the delivery system so that costs and payments are based on outcomes, not procedures done.
BERTOLINI: I think that is a very important step. In today's system we pay for each unit of service provided and there is an incentive then to do more units of service, particularly when the government cuts back on the reimbursement for units of service. Medicare and Medicaid pay well below physician's costs for reimbursement. So to the degree we change the system to where we pay for better outcomes, improving their health, then I think the system changes its focus.
MONTAGNE: But if you somehow manage to get a system where it's based on better outcomes, wouldn't many doctors, given a choice, choose patients that are healthier so that they offer that physician an opportunity at achieving a better outcome?
BERTOLINI: I would argue that people with multiple chronic diseases in the Medicare population, the opportunity to improve their care and make headway is much more dramatic than dealing with a healthy person. What we need to do is set up a system where we're reimbursing based on the underlying illness of the individual. So in the Medicare population the premium is $1,200 a month. In the healthy population it's $300 a month.
If we can improve care by 10 percent in the elderly population, that's $120 a month of opportunity versus $30 a month in the commercial population. So I think those are dramatic impacts, and we've seen 10 percent of the Medicare fee for service population driving 50 percent of the health care costs in Medicare, which is 50 percent of the nation's health care costs. And if we can have an impact there, we can make much better progress.
MONTAGNE: Could you give us an example?
BERTOLINI: I'll give you a great example. Congestive heart failure patients are the most expensive patients to take care of. We have given them a scale with Bluetooth technology and we told them to go home, stand on the scale in the morning and take your medication. And we monitor their weight over time. If their weight goes out of tolerance, because that means they're putting on water weight, which causes the congestive heart failure, then what we do is we send a nurse to the house.
The nurse makes sure their taking their medications. If they're taking their medications, they call the doctor to update them because they're not working as well as they should, and before they leave, they roll up the loose rugs in the house 'cause people shuffle when they walk when they've got water weight. We've reduced congestive heart failure readmissions by 43 percent. That's huge.
MONTAGNE: Roll up the rugs because people shuffle, so have also eliminated some percentage of falls?
BERTOLINI: That's right, 'cause they break their hips. And so there are example after example after example of having an impact there. You know, congestive heart failure admission can cost $80,000. And so if we can avoid one, we've not only improved the patient's quality of life dramatically, because they're still at home, but they're not in a hospital where they could get sicker, which is often what happens.
MONTAGNE: But of course would you have been saying this, or some of your colleagues in related industries, even 10 years ago?
BERTOLINI: No. And I think, you know, as time goes on, as we see the impact on health care, not only on this country's deficit, but on nations around the world, health care is central to the economic vibrancy around the globe. So I think we've come to the realization that this is very, very important. How do we do it better? Because it's unsustainable on its current path.
MONTAGNE: Mark Bertolini is the CEO of Aetna. Thanks very much for joining us.
BERTOLINI: Thanks, Renee.
NPR transcripts are created on a rush deadline by a contractor for NPR, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of NPR's programming is the audio.
In today's Crain's Cleveland Business, Author David Schweighoefer of the Cleveland-based law firm Walter & Haverfield offers a common sense "User's Guide" for those trying to figure out Healthcare Reform and what it means. I'll call it "Take a Deep Breath and Keep These 7 Things In Mind..." I especially like #1:
Separate: Strive to separate politics from the law.
These 7 points are a quick read - It is so good and so simple, in fact, that I'll run it verbatim on Ankota's blog. Enjoy!
No one should underestimate the scope and complexity of the recently upheld Accountable Care Act. Everyone wants to know, “what does it mean?” and “what happens now?” Readers are being bombarded with explanations and projections and hypotheses. Exactly what it means depends on your age, gender, current health status and if your questions are from the standpoint of an individual or a business owner. Here are a few simple rules to keep in mind as you proceed with your analysis:
1. Separate: Strive to separate politics from the law. This legislation has become enormously politicized, and that clouds understanding of what exactly the legislation attempts to accomplish.
2. Observe: Our present health care system, in comparison to other civilized nations, costs too much, is too complex and delivers sub-optimal results. This legislation is an ambitious attempt at reform and repair. Change is difficult.
3. Analyze: It has become a political issue because we as citizens do not agree on the proper size of the role government should play in our lives, and in this instance, our health care.
4. Contemplate: We have a moral dilemma. What is our responsibility to care for our fellow citizens? Should health care be a human right? In this regard, why are we so different from other civilized nations? Many European nations have successfully implemented the changes contemplated by this legislation, a task made easier by fundamental differences between those societies and ours. Many other societies have a belief that their members have an obligation to each other rather than a belief that individuals are only responsible for themselves.
5. Ask: Ask: What does this legislation propose to do? It provides for insurance reform: (i) more people are covered with insurance; (ii) insurance becomes more accessible through the expansion of Medicaid and insurance exchanges; (iii) coverage is better (young adults covered until age 26, preventative care is covered, your insurance company must spend a certain amount of your health care premium dollar on your care) AND…..
The legislation proposes delivery system reform: (i) care will be better integrated and coordinated through a variety of new structures, one of which is named an Accountable Care Organization; (ii) this new care system will be paid differently -- rather than a fee for every service provided to you, the providers will receive a bundled payment to split among themselves, the amount of which will not depend on their respective fees, but rather on the outcome of your care; (iii) an increase in attention to the quality of your care; and (iv) increased efforts at developing innovation in the health care system.
6. Calculate: This legislation has dozens and dozens of moving financial parts and pieces. Some costs will go up, others down. Still others will shift. Political explanations of these changes are political explanations of these changes. In order to understand the financial impact on you, you will need to carefully investigate the changes as they apply to your situation.
7. Examine: It is tempting to believe that the simple operation of the marketplace can be relied upon to correct these many ills. To date, this has not been the case. Markets function best when they operate under certain conditions, one of which is when a large number of sellers compete with each other over prices that reflect the true resource costs. The other necessary condition is when the consumer has good information about the characteristics of products and their prices – information that is most easily obtained if products are well defined and standardized and if prices can be readily ascertained without excessive search. Our current market for health care does not meet these conditions.
Watch for additional blog postings in coming weeks as we endeavor to explore these guidelines in more detail. Until then, consider just one aspect that seems particularly riveting: In the long run, can the states really afford the expansion of Medicaid?
Ankota's technology is used to organize providers of all types into "ecosystems," enabling Accountable Care models with technology that helps organizations Plan, Coordinate, and Deliver services in a highly coordinated and efficient manner. To learn more about Ankota technology for ACOs or to manage Care Transitions, click on this really cool orange button!
Better Care at Lower Costs: Clearly explaining Accountable Care. Learn how ACOs are organized, what the incentives are, and how patients ultimately benefit.
Former CMS Administrator Don Berwick does an excellent job of clearly explaining Accountable Care. Learn how ACOs are organized, how they are incentivized, and how patients lives are ultimately improved. Berwick is well known as a big thinker and as the policy wonk who coined the phrase "Triple Aim," which he used to describe the goals of health care reform: improving patient experience, improving population health and reducing costs.
Berwick has been openly critical of the healthcare system and a strong proponent of reform, saying, "20-30% of health spending is 'waste' with no benefit to patients, because of overtreatment, failure to coordinate care, administrative complexity and fraud." He lays part of the blame on CMS regulations.
Fundamentally, hospitals have been paid to keep beds full and provide lots of services. "Fee for Service" means "provide more services...earn more fees." Now, under Accountable Care, hospitals and other providers are paid to keep beds empty! ACOs, hospitals, and the rest of the providers that make up the healthcare ecosystem are paid more to provide the right types of services that keep patients healthier and out of the hospital.
Accountable Care Organizations, Hospitals, Primary Care Physicians, Post-acute care providers such as home health care, physical therapy, infusion nursing and more are engaging in programs such as Patient Centered Medical Home (PCMH), Aging in Place, and Care Transitions Initiatives to achieve the Triple Aim.
Ankota's technology is used to organize providers of all types into "ecosystems," enabling Accountable Care models with technology that helps organizations Plan, Coordinate, and Deliver services in a highly coordinated and efficient manner. To learn more about Ankota technology for ACOs or to manage Care Transitions, click on this really cool orange button!
New Care Coordination Payments for Managing Care After Discharge
CMS will pay community physicians and other care coordinators for the care required to help a patient transition back to the community following discharge from a hospital. This is consistent with CMS objectives of aligning incentives to drive the right kind of care that reduces avoidable readmissions, improves quality of care and lowers healthcare delivery costs.
As described in the Remington Report, "Under the proposed rule, CMS would make a separate payment to a patient’s community physician to coordinate care during the first 30 days after a patient’s hospital stay. Research shows that patients who receive timely physician follow-up care after being discharged are significantly less likely to be readmitted.
The proposed rule would increase payments for family physicians by 7 percent and other practitioners providing primary care services by 3 to 5 percent under the Medicare Physician Fee Schedule for 2013. The proposed rule, which will appear in the July 30 Federal Register, also seeks public comment on how Medicare can better recognize the services community physicians provide in office visits and in coordinating care outside of the office."
Why is CMS Paying for Care Coordination?
That's easy: by creating this role and providing incentives for those who provide Care Coordination following discharge, hospital readmissions will be greatly reduced. And more care will be provided proactively to prevent episodes that cost more later if not addressed. And that lowers costs and improves patients lives. It's really that simple.
From a recent Community Catalyst paper titled Special Delivery: How Coordinated Care Programs Can Improve Quality and Save Costs, published jointly with U Mass Medical School,
"The delivery of health care in the United States is fragmented and uncoordinated. This adds
unnecessary risks and costs to people’s health care experience.
• Lack of coordination can be unsafe, even fatal, when abnormal test results are not
communicated correctly, prescriptions from multiple doctors conflict with each other
or primary care physicians do not receive hospital discharge plans for their patients.
• Uncoordinated care is also costly because of duplicated service
Healthcare professionals are well aware now that 20% of patients are readmitted within 30 days of discharge from the hospital, and that number increases to 30% within 60 days. It is widely accepted that this is both a cost and quality problem. In fact, Medicare figures alone peg the cost of readmissions that could have been avoided at more than $25 BILLION annually. Further, chronic diseases account for $3 out of every $4 spent on healthcare in the US. Many chronic conditions are manageable, but when left unmanaged--which is common in the fee for service model--they result in needless ER visits and hospital stays.
So How Is This Going to Work?
It may help to understand where Ankota's focus is. Ankota's technology is sharply focused on managing Care Transitions, a strategy that is shown to improve outcomes, reduce hospital admissions, and lower the overall cost of care. Ankota's customers are doing this today and are well positioned to take advantage of new opportunities such as these Care Coordination payments that are available.
Ankota's customers make up much of the healthcare ecosystem and are those that Plan, Coordinate, and Deliver services to patients. They are a diverse crowd, including
1) Hospitals, ACOs, CCTPs: using Ankota technology to Coordinate Care and manage Care Transitions under models like Patient Centered Medical Home and Community Based Care Transitions programs (CCTP), and
2) Post-acute Care Providers: delivering services outside of hospitals and primary care settings. These services are growing rapidly and are provided by post-acute providers that include home health, HME or DME providers, Infusion nursing, Physical Therapy (PT/OT/ST), Geriatric Care Managers, Non-medical Home Care, Behavioral health specialists, and more.
These are the organizations that actually provide the services for patients after discharge from the hospital. In our terms, this is the Healthcare Ecosystem. Ankota helps organizes providers into a single, integrated service model in order to Plan, Coordinate, and Deliver needed services.
For more information about Ankota's technology for managing Care Transitions, please click on the really cool orange button immediately below
"If there was ever any doubt about the importance of managing care transitions – it's gone now."
-- Daniel Day, Care Transitions Journal
The article below recently ran in Sirona Health's Care Transitions Journal, and discusses the Supreme Court's ruling on the Patient Protection and Affordable Care Act, the rise of Accountable Care Origanizations (ACOs) and Patient Centered Medical Home models (PCMH), and what the ruling does and does not do for healthcare providers.
As Daniel Day points out, "While The Patient Protection and Affordable Care Act has created incentives for organizations like yours to focus on providing high-quality patient care, they haven't provided any instructions on how, exactly, to do that."
This, appropriately enough, has been left to the best market driven economy in the world. Payment incentives are aligning around clear objectives--better outcomes at lower overall costs--and innovation will accelerate dramatically to enable new, highly efficient models of care to emerge.
Ankota is leading the way with technology that enables the formation of Healthcare Ecosystems: collaborations of providers that coordinate care seamlessly, across all disciplines, while achieving unprecedented levels of operational efficiency. It all translates immediately into better outcomes for patients and lower overall cost of care. To learn more about Ankota's Care Coordination technology to manage Care Transitions, click on this orange button. And be sure to read the article below!
It's settled. The Supreme Court has ruled to uphold the Patient Protection and Affordable Care Act.
As the nation absorbs and reacts to this landmark case, healthcare insurers and practitioners like you will be rolling up their sleeves and getting back to work.
You'll continue to improve the delivery of care to your patients – focusing on service quality over quantity – ensuring your patients receive safer, more appropriate healthcare.
If there was ever any doubt about the importance of managing care transitions – it's gone now.
Implementing Patient-Centered Models Of Care
At the very heart of reform are patient-centered organizations like yours. Organizations that view healthcare as something that occurs across the entire continuum of care – not just during acute or chronic illness.
You understand that being accountable for the quality of care a patient receives is the path to improved population health and financial security. Many of you will continue on this path and implement new models of care, such as Accountable Care Organizations and Patient Centered Medical Homes.
In order for these new care models to succeed, you'll be required to coordinate your patient's movement between local and national healthcare resources as their needs change.
This means you need to have an infrastructure in place that:
- Provides patients with 24x7 access to clinical support.
- Coordinates clinical and administrative resources.
- Enables continuous feedback to each patients entire care team.
- Has relentless quality oversight; allowing for continuous improvement.
Preventing Unnecessary Use Of Healthcare Resources
If you've been in a blissful state of denial, it's time to shake it off. CMS penalties are coming.
As a result of the Affordable Care Act, the Centers for Medicare and Medicaid Services will now be withholding payments for excessive hospital readmissions. In short, hospitals are now financially at risk for patients re-hospitalized for reasons considered to be preventable.
While CMS has implemented financial penalties for hospitals with excessive readmissions, they haven’t provided any instructions on how to successfully reduce them.
This leaves many hospitals wondering what the right approach is. And while there are indeed many solutions to consider, managing how patients transition in and out of the hospital is critically important to impacting readmission rates.
This requires that you focus on improving:
Improving The Patient Experience Through Quality Care
In addition to financial incentives targeting preventable readmissions, CMS will reward hospitals that provide high-quality patient care through the hospital Value-Based Purchasing Program (VBP).
The goal of the VBP program is to motivate hospitals to focus on the quality of care delivered, rather than the quantity of services they provide – outlined by:
- 12 Clinical Process of Care Measures, and
- 8 Patient Experience of Care Measures.
Transitional care plays an important role in experience management.
To receive appropriate care, a patient will likely require services from a variety of healthcare practitioners and settings across the healthcare system. Transitional care programs provide consistent, personally relevant guidance to patients, enabling them to successfully find and utilize these resources.
By supporting patients as they move along the continuum of care, you reduce the likelihood a gap in care will occur – simultaneously building the patient's trust in the care they are receiving.
The Way Forward For Building A Transitional Care Program
No transitional care program will be exactly the same.
That's because, while The Patient Protection and Affordable Care Act has created incentives for organizations like yours to focus on providing high-quality patient care, they haven't provided any instructions on how, exactly, to do that.
What is clear is that to be successful, you'll need to create a patient-centered infrastructure that facilitates the delivery of care through customized patient interactions, guideline driven processes, clinical escalation, dynamic referrals, and real-time notifications.
Contact Ankota today to learn more about why some of the nations best respected healthcare organizations are turning to Ankota for technology to help manage Care Transitions.
A relatively small percentage of cases make up the bulk of expenses in healthcare--and that is true among all payor sources. There is much that can be done to mitigate avoidable readmissions, take care of patients more proactively in their homes, and lower the total overall cost of care. Here is a compelling story as backdrop for the conversation.
This Wall Street Journal article The Crushing Cost of Care illustrates this point dramatically. Using the case of Scott Crawford, who, in 2009, consumed $2.7M in Medicare funded services until he died at the age of 41, author Janet Adamy tells the tragic story of one of Medicare's most expensive beneficiaries in that year. Crawford was only in his 20's when he became sick, qualified for Medicare coverage through the disability, and ultimately received a transplanted heart at Johns Hopkins in Baltimore.
"We're always going to have patients in the Medicare program that need a disproportionate number of resources," said Jonathan Blum, deputy administrator and director for Medicare. Blum observed about Crawford's case, "A lot of the costs were driven by complications that could have been avoided," and cited an infection that Mr. Crawford aquired as an example.
I am deliberately ignoring any ethical discussion about Mr. Crawford's casefor a number of reasons, including:
1. I am a proponent of organ donation. My own wife's life was extended significantly by a liver transplantation made possible by the generosity of the donor and his surviving family.
2. Mr. Crawford's case is simply an illustration for a disussion about how we care for the sickest and costliest of patients -- and how we can improve both the outcomes and the cost at which we deliver that care.
3. As the leader of a software company that develops technology that helps providers coordinate better care, I am focused on dramtically improving healthcare delivery models.
Mr. Crawford's case is extreme, but is a good catalyst for discussion. There are millions more patients consuming healthcare services that are poorly organized and delivered. Whether it is a patient's failure to manage his own medications or chronic condition that results in an emergency room visit, or better coordinated therapy plan following knee replacement surgery that would rehabiliate the patient faster and stronger, it is clear that more can be done. What I find more interesting than the article itself is the interview with the author, Janet Adamy of the Wall Street Journal, which you can see in the video above. Maybe this is the real discussion and Mr. Crawford simply serves to make the lesson more personal.
Aknota's technology is used by providers of all types, including hospitals, ACOs and post acute care providers to better coordinate and deliver care upon discharge, and enable programs like Patient Centered Medical Home, Care Transitions Initiatives, and Community Based Care. To learn more about Ankota's technology click here