By Jackie Birmingham, RN, MS, vice president, emeritus, of clinical leadership, Curaspan.
The Affordable Care Act calls for provider quality to be publicly reported and widely shared. As a result, the Centers for Medicare and Medicaid Services (CMS) extended star ratings to home health agencies (HHAs) on Home Health Compare (HHC) in 2015 to provide home health care beneficiaries with a summary quality measure in an accessible format.
By supporting consumer choice and encouraging provider quality improvement, public reporting will remain a pillar for improving healthcare quality. Currently, CMS reports 27 process, outcome and patient experience of care quality measures on the HHC website to equip patients and their families with the right tools to make choices about home healthcare.
Calculating the Two Types of Star Ratings
1) The Quality of Patient Care Star Rating – This rating probes nine specific evidence-based process and outcomes measures for each home health agency such as timely initiation of care, improvement in patients’ functional status and hospital readmissions. The measures are calculated into a composite score and star rating, which are typically calculated on a quarterly basis and include:
CMS rankings of all HHA providers reporting which is then divided into 10 ranked deciles for each measure.
Each HHA receives a score (.5 to 5) based on its ranked decile.
Each score is compared to a national agency average on that measure, and if there is a statistical difference, the score will be adjusted.
For each agency, adjusted scores are averaged to reach a composite score which are then translated into stars.
2) Patient Survey Star Ratings –These ratings incorporate the patient experience of care measures based on Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS). These surveys reflect patients’ views on a variety of issues including whether the staff checked patients’ prescriptions for side-effects and properly explained dosing instructions.
Guest post Ken Perez, vice president of healthcare policy, Omnicell.
Soon after passage of the Affordable Care Act (ACA), the Congressional Budget Office, the Obama Administration and private research firms, such as Health Policy Alternatives, concluded that the health reform law would generate budget surpluses over the 10-year period of 2010-2019 of $124 billion to as much as $150 billion.
However, according to the CBO’s report, “The Budget and Economic Outlook: 2016 to 2026,” released in January of this year, the divergence between past rhetoric and current reality has widened, at least in terms of the coverage expansion initiative of health insurance exchange subsidies.
According to an April 22, 2010, memorandum from Richard S. Foster, chief actuary for the Centers for Medicare and Medicaid Services (CMS), the ACA’s health insurance exchange subsidies were projected to total $153 billion from 2014-2019. However, arguably because of the higher-risk pool of individuals participating in the exchanges, the recent CBO report projects $347 billion in federal outlays for health insurance exchange subsidies for 2014-2019, leading to a deficit just for the subsidies of $194 billion for that period, outweighing the previously projected budget surplus.
Even worse, the higher health insurance exchange subsidies aid a significantly smaller exchange enrollment population, down about 40 percent from 21 million to 13 million individuals for 2016, per the CBO. Moreover, the CBO projects exchange enrollment to peak at 16 million in the next decade, a third less than the 24 million it predicted in March 2015.
Guest post by Ken Perez, vice president of healthcare policy, Omnicell.
Under the authority of Section 3021 of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) has launched a variety of accountable care organization (ACO) initiatives, including the Pioneer ACO Model, the Medicare Shared Savings Program (MSSP), the Advance Payment ACO Model, and the Next Generation ACO Model. ACOs continue to be the most aggressive of the healthcare delivery reforms mandated by the ACA.
Notably, none of the aforementioned ACO models has a disease-specific focus. During the past few years, DaVita Inc., the nation’s second-largest dialysis provider, lobbied CMS diligently for a renal-specific ACO or at least creation of a framework that would allow for a disease-specific approach. DaVita formed the Accountable Kidney Care Collaborative to prepare the nephrology community to participate broadly in general ACOs and/or in disease-specific renal ACOs.
An ACO Program Focused on Renal Disease
On Oct. 7, 2015, the Center for Medicare and Medicaid Innovation (the Innovation Center) made a groundbreaking announcement, launching the Comprehensive ESRD Care (CEC) Model, with its sole focus on end-stage renal disease (ESRD), also known as kidney failure. This disease afflicts more than 600,000 Americans. These individuals require life-sustaining dialysis treatments several times each week. In 2012, ESRD beneficiaries comprised 1.1 percent of the Medicare population and accounted for $26 billion or 5.6 percent of total Medicare spending.
The CEC Model’s first three-year agreement period began on Oct. 1, 2015, with 13 ESCOs in 11 states: Arizona, California, Florida, Illinois, New Jersey, New York, North Carolina, Pennsylvania, South Carolina, Tennessee, and Texas. All except one of the 13 ESCOs are owned by a large dialysis organization (LDO), defined as an organization that owns 200 or more dialysis facilities. Dialysis Clinic, Inc. (DCI), the nation’s largest non-profit dialysis provider, owns three of the ESCOs, as does DaVita. Fresenius, the largest dialysis provider, owns six of the ESCOs. The lone non-LDO is the Rogosin Institute in New York City.
As with all Medicare ACO programs, the CEC Model has both quality measures and expenditure-reduction targets which impact the model’s payment arrangements.
The CEC Model features 26 quality measures—14 outcome and 12 process—for both LDOs and non-LDOs. The quality measures span five domains: patient safety, person- and caregiver-centered experience and outcomes, communication and care coordination, clinical quality of care, and population health.
This is the reason that the Affordable Care Act is not going away, despite the continuing conversations about its demise: In its first five years, the Affordable Care Act (ACA) has already left an indelible mark on the $2.9 trillion health sector. By energizing five fundamental shifts, the law has accelerated the rise of a new health economy predicated on value, according to a new report from PwC’s Health Research Institute (HRI), “Five Trends to Watch as the Affordable Care Act Turns Five.”
“Although the ACA will continue to face crosswinds, it has already had a profound impact on the healthcare business,” said Kelly Barnes, PwC’s U.S. health industries leader. “The ACA has catalyzed major changes in an industry historically slow to change. Our report provides a roadmap that outlines what industry leaders should be doing as these shifts continue over the next five years.”
“Most striking, the five trends have led to the creation of more than 90 new companies that have entered the sector since 2010,” said Ceci Connolly, managing director of PwC’s Health Research Institute. “The ACA has opened gates for savvy investors and startups to take a piece of the $2.9 trillion industry.”
According to the report, although much groundwork was laid in advance of the law’s enactment, health industry business models and imperatives will likely never be the same post-ACA. These five key trends fueled by the ACA have ignited sector-wide transformation:
Risk Shift: Raising the stakes for all healthcare players. The ACA added force to new payment models that reward outcomes and penalize poor performance such as high rates of readmission and hospital-acquired conditions.
Primary care: Back to basics. Experimentation in new payment models and expansion of insurance coverage are making primary care once again the critical touch point.
New entrants: Innovators in the New Health Economy. New entrants are rushing into the market to meet the demand for lower-cost, consumer-oriented care options in the post-ACA era. More than 90 new companies have been created since 2010, according to HRI analysis.
Health insurance: From wholesale to retail. Rapid enrollment in the ACA’s public exchanges has demonstrated the potential of retail-style health insurance and spawned renewed interest in private exchanges.
States: Reform’s pivotal stage. States have emerged as key players in the reconfigured healthcare landscape, as the ACA gave states notable discretion in how the law could be implemented.
Guest post by David Cooper, CEO and co-founder, Medical Mime.
As most of us involved in the healthcare industry already know, the Affordable Care Act calls for providers to adopt secure, confidential, electronic health information systems. Why? Because most experts agree that by using these electronic health records, we can collectively reduce paperwork and administrative burdens, cut costs, reduce medical errors and, most importantly, improve healthcare outcomes. But reality has had a funny way of challenging those expectations.
Yes, financial incentives have motivated doctors to get on the bandwagon, and many – if not most – office-based physicians have adopted some form of electronic health records. A study published in the journal Health Affairs reported that 78 percent of doctors working in office-based environments had implemented an electronic health record.
However, only about 48 percent of doctors had an EHR system with advanced functionality, according to the same source. Only 39 percent reported they had used their system to share medical data with other providers, and a stark 14 percent reported sharing data with providers outside their own practice. In short, the adoption of EHRs has not resulted in the promised integration of patient data that we hoped for. In fact, the use of electronic medical records – so far – may actually be having a negative impact on the quality of care doctors deliver.
According to a Northwestern University study published in the spring of 2014 in the International Journal of Medical Information, doctors who use electronic health records in their exam rooms spend one-third of their time looking at their computer screens. By comparison, physicians who rely on paper charting spend about 9 percent of their time looking at a patient’s records during an encounter. The study also asserts that because physicians spend so much time looking at their EHRs, they miss out on nonverbal communication cues from patients, thus affecting the quality of the care they’re delivering.
Twenty eight states, three territories and the District of Columbia will receive more than $665 million in Affordable Care Act funding to design and test healthcare payment and service delivery models that will try to improve healthcare quality and lower costs, Health and Human Services Secretary Sylvia M. Burwell announced.
Together with awards released in early 2013, more than half of states (34 states and three territories and the District of Columbia), representing nearly two-thirds of the population are participating in efforts to support comprehensive state-based innovation in health system transformation aimed at finding new and innovative ways to improve quality and lower costs.
The State Innovation Models initiative supports states in planning or implementing a customized, fully developed proposal capable of creating statewide health transformation to improve health care. Example initiatives include:
Improving primary care through patient centered medical homes, building upon current Accountable Care Organization models or integrating primary care and behavioral health services.
Providing technical assistance and data to healthcare providers and payers that are working to advance models of integrated, team-based care, or transition to value-based payment models.
Creating unified quality measure score cards that health care payers and providers can use to align quality improvement and value-based payment methodologies.
Expanding the adoption of health information technology to improve patient care.
Fostering partnerships among public, behavioral and primary healthcare providers.
Strengthening the healthcare workforce through educational programs, inter-professional training, primary care residencies and community health worker training.
Health spending continued to grow at a slow rate last year the Office of the Actuary (OACT) at the Centers for Medicare & Medicaid Services (CMS) reported today. In 2013, health spending grew at 3.6 percent and total national health expenditures in the United States reached $2.9 trillion, or $9,255 per person. The annual OACT report showed health spending continued a pattern of low growth—between 3.6 percent and 4.1– percent for five consecutive years.
The recent low rates of national health spending growth coincide with modest growth in Gross Domestic Product (GDP), which averaged 3.9 percent per year since the end of the severe economic recession in 2010. As a result, the share of the economy devoted to health remained unchanged over this period at 17.4 percent.
“This report is another piece of evidence that our efforts to reform the health care delivery system are working,” said CMS Administrator Marilyn Tavenner. “To keep this momentum going, we are continuing our efforts to shift toward paying for care in ways that reward providers who achieve better outcomes and lower costs.”
Total national health spending slowed from 4.1 percent growth in 2012 to 3.6 percent in 2013. The report attributes the 0.5 percentage point slowdown in health care spending growth to slower growth in private health insurance, Medicare, and investment in medical structures and equipment spending. However, faster growth in Medicaid spending helped to partially offset the slowdown.
Other findings from the report:
Medicare spending, which represented 20 percent of national health spending in 2013, grew 3.4 percent to $585.7 billion, a slowdown from growth of 4.0 percent in 2012. This slowdown was primarily caused by a deceleration in Medicare enrollment growth, as well as net impacts from the Affordable Care Act and sequestration. Per-enrollee Medicare spending grew at about the same rate as 2012, increasing just 0.2 percent in 2013.
Spending on private health insurance premiums (a 33 percent share of total health care spending) reached $961.7 billion in 2013, and increased 2.8 percent, slower than the 4.0 percent growth in 2012. The slower rate of growth reflected low enrollment growth in private health insurance plans, the continued shift of enrollees to high-deductible health plans and other benefit design changes, low underlying medical benefit trends, and the impacts of the Affordable Care Act.
Medicaid spending grew 6.1 percent in 2013 to $449.4 billion, an acceleration from 4.0 percent growth in 2012. Faster Medicaid growth in 2013 was driven in part by increases in provider reimbursement rates, some states’ expanding benefits, and early Medicaid expansion.
Out-of-pocket spending (which includes direct consumer payments such as copayments, deductibles, spending by the insured on services not covered by insurance, and spending by those without health insurance) grew 3.2 percent in 2013 to $339.4 billion, slightly slower than annual growth of 3.6 percent in both 2011 and 2012.
Among health care goods and services, slower growth in spending for hospital care and physician and clinical services contributed to slower growth in national health care spending in 2013. However, faster spending growth for retail prescription drugs in 2013 partially offset the overall slowdown.
Hospital spending increased 4.3 percent to $936.9 billion in 2013 compared to 5.7 percent growth in 2012. The lower growth in 2013 was influenced by slower growth in both price and non-price factors (which include the use and intensity of services). Growth in private health insurance and Medicare hospital spending decelerated in 2013 compared to 2012.
Spending for physician and clinical services increased 3.8 percent in 2013 to $586.7 billion, from 4.5 percent growth in 2012. Slower price growth in 2013 was the main cause of the slowdown, as prices grew less than 0.1 percent. Growth in spending from private health insurance and Medicare, the two largest payers of physician and clinical services, experienced slower spending growth in 2013, while Medicaid growth accelerated as a result of temporary increases in payments to primary care physicians.
Retail prescription drug spending accelerated in 2013, growing 2.5 percent to $271.1 billion, compared to 0.5 percent growth in 2012. Faster growth in 2013 resulted from price increases for brand-name and specialty drugs, increased spending on new medicines, and increased utilization.
In 2013, households accounted for the largest share of spending (28 percent), followed by the federal government (26 percent), private businesses (21 percent), and state and local governments (17 percent).
As part of its ongoing effort to increase transparency and accountability in healthcare, the Centers for Medicare & Medicaid Services (CMS) released today the first round of Open Payments data to help consumers understand the financial relationships between the healthcare industry, and physicians and teaching hospitals.
This release is part of the Open Payments program, created by the Affordable Care Act, and lists consulting fees, research grants, travel reimbursements and other gifts the health care industry, such as medical device manufacturers and pharmaceutical companies – provided to physicians and teaching hospitals during the last five months of 2013. The data contains 4.4 million payments valued at nearly $3.5 billion attributable to 546,000 individual physicians and almost 1,360 teaching hospitals. Future reports will be published annually and will include a full 12 months of payment data, beginning in June 2015.
“CMS is committed to transparency and this is an opportunity for the public to learn about the relationships among health care providers, and pharmaceutical and device companies,” CMS Administrator Marilyn Tavenner said. “This initial public posting of data is only the first phase of the Open Payments program. In coming weeks, we will be adding additional data and tools that will give consumers, researchers, and others a detailed look into this industry and its financial arrangements.”
Financial ties among medical manufacturers’ payments and health care providers do not necessarily signal wrongdoing. Given the importance of discouraging inappropriate relationships without harming beneficial ones, CMS is working closely with stakeholders to better understand the current scope of the interactions among physicians, teaching hospitals, and industry manufacturers. CMS encourages patients to discuss these relationships with their healthcare providers.
Guest post by Anil Jain, MD, FACP, chief medical officer, Explorys, and staff, Department of Internal Medicine, Cleveland Clinic.
Nearly every aspect of our lives has been touched by advances in information technology, from searching to shopping and from calling to computing. Given the significant economic implications of spending 18 percent of our GDP, and the lack of a proportional impact on quality, there has been a concerted effort to promote the use of health information technology to drive better care at a lower cost. As part of the 2009 American Reinvestment and Recovery Act (ARRA), the Health Information Technology for Economic and Clinical Health (HITECH) Act incentivized the acquisition and adoption of the “meaningful use” of health IT.
Even prior to the HITECH Act, patient care had been profoundly impacted by the use of health informationtechnology. Over the last decade we had seen significant adoption of electronic health records (EHRs), use of patient portals, creation of clinical data repositories and deployment of population health management (PHM) platforms — this has been accelerated even more over the last several years. These health IT tools have given rise to an environment in which providers, researchers, patients and policy experts are empowered for the first time to make clinically enabled data-driven decisions that not only at the population level but also at the individual person level. Not only did the 2010 Affordable Care Act (ACA) reform insurance, but it also has created incentive structures for payment reform models for participating health systems. The ability to assume risk on reimbursement requires leveraging clinical and claims data to understand the characteristics and needs of the contracted population. With this gradual shift of risk moving from health plans and payers to the provider, the need to empower providers with health IT tools is even more critical.
Many companies such as Explorys, a big data health analytics company spun-out from the Cleveland Clinic in 2009, experienced significant growth because of the need to be able to integrate, aggregate and analyze large amounts of information to make the right decision for the right patient at the right time. While EHRs are the workflow tool of choice at the point-of-care, an organization assuming both the clinical and financial risk for their patients/members needs a platform that can aggregate data from disparate sources. The growth of value-based care arrangements is increasing at a staggering rate – many organizations estimate that by 2017, approximately 15 percent to 20 percent of their patients will be in some form of risk-sharing arrangement, such as an Accountable Care Organization (ACO). Already today, there are currently several hundred commercial and Medicare-based ACOs across the U.S.
There is no doubt that there are operational efficiencies gained in a data-driven health system, such as better documentation, streamlined coding, less manual charting, scheduling and billing, etc. But the advantages of having data exhaust from health IT systems when done with the patient in mind extend to clinical improvements with care as well. We know that data-focused health IT is a necessary component of the “triple-aim.” Coined by Dr. Donald Berwick, former administrator of the Centers for Medicare and Medicaid Services (CMS), the “triple-aim” consists of the following goals: 1) improving health and wellness of the individual; 2) improving the health and wellness of the population and 3) reducing the per-capita health care cost. To achieve these noble objectives providers need to use evidence-based guidelines to do the right thing for the right patient and the right time; provide transparency to reduce unnecessary or wasteful care across patients; provide predictive analytics to prospectively identify patients from the population that need additional resources and finally, use the big data to inform and enhance net new knowledge discovery.
Eric Munz, vice president of business process crowdsourcing at Lionbridge Technologies, where he manages and leads the delivery of in-person, telephonic and video crowd-enabled interpretation solutions to meet the unique needs of customers across a broad range of industries, discusses here the need for interpretation services in health systems.
He also touches upon interpretation mandates for hospitals, the struggles large and small health systems face with interpreting to ensure the best patient care; he discusses the benefits of using a secure interpretation solution; and provides advice for implementing such a solution.
What are interpretation mandates for hospitals? How has equal access to language changed recently with ACA?
There are about 10 different places in the Affordable Care Act (ACA) that require hospitals to develop and implement a system that provides interpretation services to patients with limited English proficiency (LEP), to have equal access to healthcare. For example, Section 1557 of the Patient Protection and Affordable Care Act focuses on non-discriminatory policies and procedures, including those based on the grounds of language and national origin.
Now, healthcare facilities are facing a renewed struggle to provide such interpretation services because of the influx of LEP patients newly enrolled in insurance plans under the ACA. According to the UCLA Center for Health Policy Research, 36 percent of newly insured individuals under the ACA in the state of California are LEPs — compared to only 9 percent of LEP patients prior to the ACA enactment. That is a dramatic increase in non-English speaking patients to serve.
Other states facing a jump in patients speaking foreign languages include Texas, Arizona and Florida. Across the nation, healthcare providers must be at the ready to interpret more than 300 languages to remain compliant. Otherwise, they risk incurring monetary penalties.
Why is it often a struggle to deliver interpretation for patients in large and small hospitals alike?
A big city hospital could serve patients representing a dozen different languages or more on any given day. That presents a very practical logistical problem for facilitating so many different conversations in so many different languages. This is why many facilities partner with vendors to provide on-site interpretation, but these interpreters often work on an on-call basis, delaying treatment. They also often charge two-hour minimum rates for their service even if it’s a 30-minute conversation. In a rural hospital, there simply may not be someone with the skillset to speak a particular language within the geographic area.
For these reasons, the biggest challenge for hospital management is determining how to efficiently meet the demand for interpretation services, which are required by law, while remaining cost conscious throughout the process.