Guest post by Jennifer Holmes, chief executive officer, Central Logic.
Healthcare systems gather a lot of patient data as care providers, but a surprising lack of coordination too often puts patients at risk.
Tragically, that is exactly what happened to my father nine years ago. A week before his 70th birthday, he passed away due to the lack of care coordination. His risk factors were high and his care provider had all his health records and history documented in his chart. Over the course of 15 years, my father had been admitted and treated six times at the same hospital. He was an open heart surgery patient, had multiple coronary artery stents placed 10 years post surgery, and he was diagnosed with cancer eight years before his death.
His primary care physician admitted him to the Emergency Room after finding a lump on his leg. Later that evening, we learned he had Stage 4 non-Hodgkin’s Lymphoma. The coordination care breakdown started with his oncologist who, although armed with most of my father’s health information, he missed one critical piece to the puzzle. Our family later learned the physician never reached out to my father’s interventional cardiologist to better understand his percent of heart function. If he had, they would have learned his left ventricular function was only 45-percent. Due to this lack of care coordination, the wrong drug cocktail was prescribed to treat his cancer, ultimately resulting in heart failure. He was gone in six weeks.
Finding the Good in the Bad
The good news is that EHR technology adoption and compliance certifications around Meaningful Use is driving improvement for quality, safety, efficiency, and reduced health disparities. I believe these efforts to enhance care coordination will result in improved population and public health so that fewer and fewer families will experience what mine did.
According to the Health and Human Service’s Agency for Healthcare Research and Quality (AHRQ), the Institute of Medicine identifies patient centeredness as “a core component of quality health care.” The agency tracks and analyzes the number of incidences of avoidable hospital-acquired conditions along with adverse events. While progress has been made over the years, more work is necessary to improve care coordination.
To be fair, enormous demands have been placed on healthcare systems for profitability, efficiency, compliance, safety and overall excellence. However, excellent quality healthcare is inextricably connected to a patient care centered strategy. Our current systems must get back to that root focus through improved communication and sharing data transparently across all facets of the patient’s health spectrum. The key is finding user-friendly solutions to collect and analyze the right data, and warehouse and share all this data in a compliant way.
How to Engage – Transparently
Sharing all of that data sounds like a tall order and the technicalities of exactly how it gets accomplished seem daunting. We must follow patients from their first office visit to hospitalization, to discharge, to outpatient care, to patient-centered medical home (PCMH) care, and even at-home care. Lives can depend on it. The rub for patients and providers comes when collecting information becomes cumbersome, time-consuming and inefficient.
Recent tech and software solution advances portend smoother sailing ahead. Powerful tools are now available to collect, connect, communicate and share data from inside and outside a hospital’s four walls, directing real-time, actionable health decisions to improve patient-centered care. Providers realize efficiencies of scale when they use systems and software solutions that aggregate a patient’s total record. Optimal tools collect data from the patient’s complete health history and the best solutions can synthesize that data across all platforms and providers. This connected data roadmap then acts as a support and monitoring tool, as well as a yardstick to measure business intelligence goals.
What to Engage – Complete Data for Excellence
Patient-centeredness must then be a partnership among systems, practitioners, patients, and their families (when appropriate) to ensure that decisions respect the wants, needs, and preferences of patients. Such partnerships ensure patients have the education and support they need to make decisions and participate in their own care.
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.
Under the traditional fee-for-service reimbursement model, providers and payers are natural adversaries. To maintain a steady source of revenue, providers are incentivized to render as many services as possible without running afoul of controls designed by payers to keep utilization in check. When healthcare costs inevitably creep up, providers demand higher reimbursements from payers. Payers, trying to keep claim in check and health insurance premiums competitive, respond by restricting members’ access to certain providers.
It’s this tension between payers and providers that forms the backbone of the U.S. healthcare system. At least, it has until recently. Policy and political leaders have come to realize that, absent of other factors such as quality, efficiency and patient satisfaction, healthcare costs will continue to rise, creating a weight under which the system will eventually collapse.
Enter the accountable care organization, a new model for healthcare delivery and reimbursement that exemplifies the key tenants of the Affordable Care Act and the healthcare Triple Aim: improving the patient experience of care, improving the health of populations and reducing per capita costs. Unlike the fee-for-service reimbursement model that rewards providers based on volume of services, the ACO model rewards providers for achieving specified quality objectives and constraining costs.
On their face, ACOs would seem to encourage cooperation between payers and providers. After all, to improve population health, providers need claims data and the type of technology solutions that payers have been investing in for decades. And to reduce healthcare costs, payers need to partner with quality providers with proven track records for keeping patients healthy. Ask any patient who has bounced back and forth between doctors’ offices and their health insurance company trying to sort out a medical bill, and the opportunity for improving the patient experience of care is tremendous.
So far, many ACOs are doing just that. Of the nearly 1,100 ACO contracts that Decision Resources Group is tracking today, more than half are commercial agreements involving 70 private payers. The largest private-payer ACO initiative in the country is led by Cigna, whose Collaborative Accountable Care program has 124 ACO agreements in 29 states encompassing more than 24,000 primary-care physicians and 27,000 specialists.
However, other aspects of healthcare reform are adding fuel to the payer-provider fire—and ACOs are a flashpoint. To keep health insurance premiums competitive, payers are excluding high-cost providers from their networks. Many of these narrow or exclusive provider networks also function as an ACO, with attached health plan products that are proving popular in public health insurance exchanges.
Managing medications throughout several facilities within an integrated delivery network (IDN) or accountable care organization (ACO) is challenging. Recent Joint Commission surveys show that appropriate medication storage is the most common regulatory standard hospitals struggle with. As director of pharmacy at ProHealth Care Inc. (ProHealth), a regional integrated health network in Wisconsin with about 400 hospital beds, this is a challenge that I am all too familiar with.
One of my primary responsibilities is ensuring that all medications are well-managed throughout our facilities. As ProHealth has expanded to include a wider array of care delivery sites, medication management has increasingly become associated with high financial stakes. If medications are not well managed, hospitals lose money. Every pill that is unaccounted for translates to dollars lost for a provider. And when facilities fail to meet Joint Commission medication management standards, they risk valuable Medicare reimbursement funds.
Guest post by Ken Perez, healthcare policy and IT consultant.
Don’t say we had no warning. In late February of this year, 30 of the 32 Pioneer ACOs sent a letter to CMS that expressed concern about the program’s quality benchmarks and requested reporting-based, as opposed to performance-based, payments for performance year 2013.
On July 16, CMS shared the results of the first year of the Pioneer ACO program, which were rather checkered. On the positive side, all 32 Pioneer ACOs successfully reported the required quality measures, and costs for the more than 669,000 Medicare beneficiaries in Pioneer ACOs grew by 0.3 percent in 2012 versus 0.8 percent for similar beneficiaries in the same year.