Author Archives: henrykotula

Hospital At Home Is Not Just For Hospitals

Posted on by • Posted in Center for Medicare and Medicaid Services (CMS), Consumer Needs, Consumer Preferences, Health Policy, Hospital at Home, Innovation, Medicare, Medicare Advantage • Leave a comment

https://www.healthaffairs.org/do/10.1377/forefront.20220520.712735/#.Yo5Jf1zjH8c.linkedin

Hospital at Home programs deliver needed services to appropriate patients in their homes and can effectively serve patients, payers, and providers. The programs provide physician visits, drugs, monitoring, nursing services, diagnostics, and other services at a level typically reserved for patients in inpatient settings. A typical Hospital at Home patient has features that make home care preferable, for example, they may present to an emergency department with uncomplicated, simple pneumonia, have no significant comorbidities, and live with a partner who can provide basic care, such as preparing meals. Studies have shown these programs have lower readmission rates, lower payer costs, and higher patient satisfaction. Patients prefer their homes, payers prefer having patients get care in the least acute setting possible, and hospital providers want to have beds available for patients who need them.

While Hospital at Home programs have been studied since the 1970s, adoption had been slow until the COVID-19 public health emergency (PHE) prompted the Centers for Medicare and Medicaid Services (CMS) to waive the Medicare Hospital Conditions of Participation to enable the use of this care delivery model for Medicare beneficiaries. In 2020, CMS implemented the Acute Hospital Care at Home Waiver, which establishes Medicare payment for home hospitalizations. The combination of the PHE and CMS’s regulatory response has generated huge demand for Hospital at Home. By July 2021, eight months after the Acute Hospital Care at Home Waiver program was established, more than 140 hospitals across 66 health systems were approved by CMS to provide hospital services in a home setting. Because of COVID-19, patients and providers have quickly embraced telehealth, and that “stay at home” attitude may bring Hospital at Home into the mainstream. In 2019, the Medicare population had more than 800,000 hospitalizations, which could have qualified for Hospital at Home. As the care delivery model grows in the post-PHE, some important questions remain, such as how insurers will reimburse providers for Hospital at Home services and the types of provider organizations that will embrace this novel care delivery model.

Top-Down And Bottom-Up Payment Approaches

Medicare currently pays for Hospital at Home using a top-down (hospital-centered) payment—the payment is made to hospitals, and the amount is based on Medicare’s payment system for acute inpatient admissions. An alternative, bottom-up approach could generate a payment amount on the basis of existing home-based care payment systems, with additions for the expanded services needed for the more acute patients in a Hospital at Home model. Because home care providers are typically reimbursed at lower rates, this approach to payment would be less expensive and could capitalize on the existing in-home care expertise these providers have, while expanding their reach to a higher-acuity patient population. The co-authors have compared payment options for home hospitalization programs under both the top-down and bottom-up approaches.

Transformation Challenges

The Hospital at Home delivery model faces three significant and related challenges to expansion—generating a sufficient volume of patients to keep local programs in business, achieving cost efficiencies, and defining appropriate patients (not so sick that the patients will fail to heal or be in danger but not so healthy that they don’t need Hospital at Home).

Any health care innovation needs patient volume to be viable. A Hospital at Home program requires teams that can immediately access and deliver all needed care, including diagnostics, monitoring, pharmaceuticals, and nursing services. It also requires physicians adept at working with home-based patients while coordinating all aspects of care. Patient intake and discharge must be handled promptly, including care plans for the patient during their Hospital at Home “stay” and transitioning the patient to their regular providers after the acute phase. Much, but not all, of this infrastructure exists in home health agencies, but Hospital at Home patients typically have more time-sensitive and intense needs than the usual home health patient, which will require some staff expansion by a home health agency seeking to run a Hospital at Home program. A few patients a day will not likely generate enough revenue to maintain the staff expertise or the infrastructure needed to deliver all the different services Hospital at Home patients need.

While it might seem logical that Hospital at Home programs would be sponsored and operated by individual hospitals, many hospitals would not generate sufficient volume to support their own program. In 2019, the national average discharge rate per hospital bed was about 33 per year, and about half were Medicare beneficiaries. A large hospital with 1,000 beds might have 15,000 Medicare discharges per year. On average, we found about 5 percent of Medicare discharges would be eligible for Hospital at Home—only about 15 per week for a 1,000-bed hospital. A program sponsored by a particular hospital might not receive referral patients from competing hospitals because the competing hospitals would be losing patient volume and revenue, and except for extremely large hospital systems, most hospitals would not generate sufficient volume to support the program. A program that serves multiple hospitals will likely have advantages of scale.

When it comes to cost, hospital-based services are well-known to bear facility overhead expenses, which can make hospital-based services more expensive than services delivered from other sites. Medicare pays for hospital inpatient services mostly using diagnosis-related groups. Medicare pays a pre-set amount for each kind of admission, regardless of the actual cost accrued by the provider for a particular patient. But as our analysis shows, starting with Medicare’s home care reimbursement saves the payer more than 50 percent of an acute patient stay, when considering all facility, professional, and ancillary services. Of course, the lower price is appealing to a payer, such as a Medicare Advantage plan, but it could also save a patient money in reduced cost sharing.

Identifying the right patients for medical interventions has been a challenge for decades. The goal is to strike the right balance: avoiding unnecessary care but not skimping on needed care. To promote efficiency and outcomes, private payers and Medicare apply utilization management reviews and quality monitoring. Even for patients appropriate for Hospital at Home, hospitals may dislike the programs, as they fail to see the value of home-based care delivery in the face of many unfilled inpatient beds. On the other hand, home health agency-based Hospital at Home programs could see financial gains and tend to over-use such programs. All of this must be balanced with patient perceptions and acceptance of such programs. Participants who have piloted both top-down and bottom-up models have found substantially higher patient acceptance in models that allow entry to a Hospital at Home admission without an emergency department visit, which is typically required of top-down models. Clearly, use and quality management programs will be needed to achieve the right balance of these competing interests, and value based programs can help align incentives as well.

Bottom Line

Most research and proposals for implementing home hospitalization programs assume they are an extension of hospital operations and assume hospital costs and reimbursement. But there are cost and other advantages to building home hospitalization on the foundation of home-based care providers, whose expertise includes keeping patients safe and healthy at home. Policy makers who design reimbursement for home hospitalization programs and set conditions for providers to participate in them should consider whether home-based care providers should be eligible to manage, or play a foundational role in, these programs. This could simultaneously save payers money, create operational efficiencies, and increase patient access. Physicians and hospitals sponsoring these programs should similarly consider the roles home-based care providers could play within current home hospitalization programs. Simply extending the reach of hospitals into patients’ homes is unlikely to allow the promising scale or cost savings stakeholders hope for from home hospitalization programs. Each year, hundreds of thousands of Medicare patients could benefit.

Inpatient volumes poised to grow 2% over next 10 years

Posted on by • Posted in Emergency Care, Health System, Home Care, Home Health, Hospital, Hospital Industry, Inpatient Care, Market Trends, Outpatient Care, Telemedicine, Utilization Trends • Leave a comment

https://www.beckershospitalreview.com/patient-experience/inpatient-volumes-poised-to-grow-2-over-next-10-years.html

Adult inpatient volumes will recover to pre-pandemic numbers but grow only 2 percent over the next decade, a new report from Sg2 forecasts.

At the same time, adult inpatient days are expected to increase 8 percent and tertiary inpatient days are poised to increase 17 percent, fueled by an increase in chronic conditions. 

“While case mix varies by hospital, it is likely this combination of increased inpatient volume, patient complexity and length of stay may require healthcare organizations to rethink service line prioritization, service distribution and investment in care at-home initiatives,” Maddie McDowell, MD, senior principal and medical director of quality and strategy for Sg2, said in a June 7 news release for the report. 

Five other key takeaways from Sg2’s forecasts: 

1. Outpatient volumes are projected to return to pre-pandemic levels in 2022 and then grow 16 percent through 2032, three percentage points above estimated population growth.

2. Surgical volumes are projected to grow 25 percent at ambulatory surgery centers and 18 percent at hospital outpatient departments and physician offices over the next decade. 

3. The pandemic-driven decline in emergency department visits is expected to plateau with a decline in demand projected at -2 percent over the next 10 years.

4. Over the next five years, home care is expected to gain traction, with home evaluation and management visits seeing 19 percent growth, home hospice at 13 percent growth and home physical and occupational therapy at 10 percent growth.

5. Telehealth is expected to resume its climb and by 2032 account for 27 percent of all evaluation and management visits.

COVID-19 cases are on the rise. Does it matter anymore?

Posted on by • Posted in Coronavirus, Coronavirus BA.2 variant, Coronavirus BA.2.12.1 variant, Coronavirus Delta Variant, Coronavirus Long-Term Complications, Coronavirus Mutation, Coronavirus Omicron Variant, Pandemic, Public Health, Public Inaction, Public Opinion, Public Perception, Vulnerable Populations • Leave a comment
COVID-19 cases are on the rise. Does it matter anymore?

COVID-19 cases have risen in the U.S. to around 100,000 per day, and the real number could be as much as five times that, given many go unreported.  

But the situation is far different from the early months of the pandemic. There are now vaccines and booster shots, and new treatments that dramatically cut the risk of the virus. So how much do cases alone still matter?

That question has prompted debate among experts, even as much of America goes on with their lives, despite the recent surge in cases.  

How much concern high case numbers alone should prompt is “the trillion-dollar question,” said Bob Wachter, chair of the department of medicine at the University of California-San Francisco.  

In the early days of the pandemic, dying of COVID-19 was a concern for him, but now, in an era of vaccines and treatments, “it doesn’t even cross my mind anymore,” he said.  

But he noted there are other risks, including long COVID-19: symptoms like fatigue or difficulty concentrating that can linger for months.  

“I think long COVID is pretty scary,” he said.  

While cases have risen to around 100,000 reported per day, deaths have stayed flat, a testament to the power of vaccines and booster shots in preventing severe illness, as well as the Pfizer treatment pills Paxlovid, which cut the risk of hospitalization or death by around 90 percent.  

Hospitalizations have risen, but only modestly, to around 27,000, one of the lowest points of the pandemic, according to a New York Times tracker.  

Cases have now been “partially decoupled” from causing hospitalizations and deaths, said Preeti Malani, an infectious disease expert at the University of Michigan, such that hospitals are no longer overwhelmed. 

“[Cases are] not without any consequence, but in terms of pressure on the health system, so far we’re not seeing that, which is really what drove all of this,” she said.  

The behavior of much of America reflects a lessened concern about the risk of being infected. Restaurants and bars are packed. Many people do not wear masks even on airplanes or on the subway.  

An Axios-Ipsos poll in May found just 36 percent of Americans said there was significant risk in returning to their “normal pre-coronavirus life.” 

In the Biden administration, health officials are still advising people to wear masks in areas the Centers for Disease Control and Prevention classifies as at “high” risk. But President Biden himself is talking about the virus far less than he did at the start of his administration, and is not making sustained calls for people to wear masks.  

White House COVID-19 response coordinator Ashish Jha touted progress in defanging cases on Thursday.  

“We see cases rising, nearly 100,000 cases a day, and yet we’re still seeing death numbers that are substantially, about 90 percent lower, than where they were when the president first took office,” he told reporters.  

Some experts are pushing back on the deemphasis of case numbers, saying they still matter.  

“The bunk that cases are not important is preposterous,” Eric Topol, professor of molecular medicine at Scripps Research, wrote last month. “They are infections that beget more cases, they beget Long Covid, they beget sickness, hospitalizations and deaths. They are also the underpinning of new variants.” 

Even if one does not get severely ill oneself, more cases mean more chances for the virus to spread on to someone who is more vulnerable, like the elderly or immunocompromised.  

While deaths are way down from their peak earlier in the pandemic, there are still around 300 people dying from the virus every day, a number that would have proved shocking in a pre-COVID-19 world.  

Leana Wen, a public health professor at George Washington University, recommended that people take a rapid test before visiting a more vulnerable person, as a safeguard that avoids more burdensome restrictions.  

“Cases alone do not tell the whole story,” she said, adding, “As a policy matter we need to stop using the same comparisons we were in 2020 and 2021.” 

There is still much that is unknown about long COVID-19, one of the biggest risks remaining for healthy, younger people who are vaccinated.  

A recent article in the Journal of the American Medical Association estimated 10 percent to 30 percent of COVID-19 infections result in long COVID-19 symptoms, but there is no precise estimate. 

Experts also urge people who have not gotten their booster shots, or not been vaccinated at all, to do so, given that many are more vulnerable to the virus if they are not up-to-date on their shots.  

A new variant also always holds the risk of upending the current risk-benefit calculations. The virus has continued to evolve to spread more easily, and a future mutation could cause more severe illness or more greatly evade vaccines.  

Pfizer and Moderna are working on updated vaccines to better target the omicron variant, but the Biden administration warns it will not have enough money to purchase those new vaccines for all Americans this fall unless Congress provides more funding. The funding request has been stalled for months, though, itself a sign of the reduced sense of urgency around the virus fight. 

At least for now, though, while many people are getting COVID-19, fewer are getting extremely sick.  

“It’s a very risky time if you don’t want to get COVID [at all],” Wachter said. “But a relatively less risky time if your goal is to not get severe COVID or die.” 

How other industry players are expanding their healthcare platforms  

Posted on by • Posted in Access, Accessible Care, Care Ecosystem, Care Supplier, Consumer Engagement, Consumer Loyalty, Consumer Needs, Consumer Preferences, Consumer-Centric, Consumerism, Healthcare Platform, Managing Health Spending, Managing the Total Cost of Care, Platform of Choice, Population Management Platform, Population Manager, Premium Owner, Promote Health, Strategic High Ground, Strategy, Strategy Framework, Value Creation, Value Proposition, Value-Based Healthcare • Leave a comment

https://mailchi.mp/31b9e4f5100d/the-weekly-gist-june-03-2022?e=d1e747d2d8


Last week, we introduced our framework for value delivery as a “healthcare platform”, in which an organization’s proximity to both the consumer and to the premium dollar determines how it competes as a “care supplier,” a “care ecosystem,” a “premium owner,” or a “population manager.” Traditionally, different healthcare companies have operated primarily in one of these four domains. However, as shown in the graphic below, we’ve recently seen many shift their business into one or more additional quadrants, as they seek to expand their value propositions. UnitedHealth Group is an obvious example: it has moved well beyond the traditional insurance business, via numerous provider and care delivery acquisitions across the continuum.

Other players have shifted from their own “pure play” positions toward more comprehensive “platform” strategies as well: One Medical adding Iora Health to enhance population health capabilities; Walmart moving beyond retail and pharmacy services, partnering with Oak Street Health to expand its ability to manage Medicare patients; Amazon getting into the employer health business. 

There’s a clear pattern emerging—value propositions are converging on a “strategic high ground” that encompasses all four dimensions of platform value, creating a comprehensive set of solutions to deliver accessible care, promote health, and grow consumer loyalty, with an aligned financial model centered on managing the total cost of care. Health systems looking to build platform strategies will find many of these competitors also vying for pride of place as the “platform of choice” for healthcare consumers and purchasers.

Eyeing a rebound in emergency department volumes

Posted on by • Posted in Coronavirus, Coronavirus Mutation, Emergency Care, Health System, Hospital, Hospital Industry, Inpatient Care, Market Trends, Pandemic • Leave a comment

https://mailchi.mp/31b9e4f5100d/the-weekly-gist-june-03-2022?e=d1e747d2d8

This week we heard from three healthcare executives that they’ve seen a recent uptick in emergency department (ED) volumes. As we’ve discussed before, ED visits plummeted at the beginning of the pandemic, and were the slowest class of care volume to rebound. Over the past year, many systems reported that ED volume had remained persistently stuck at 10 to 15 percent lower than pre-COVID levels, leading us to question whether there had been a secular shift in patient demand, with consumers choosing alternative options like telemedicine or urgent care as a first stop for minor acute care needs. 
 
An uptick in ED volume would be welcome news to many hospital executives, as the emergency department is the source of half or more of inpatient admissions for many hospitals. But according to what we’re hearing, the recent rise in emergency department patient volume has not resulted in an expected bump in inpatient volume.

“We’ve dug into it, and it seems like the jump in ED visits is a function of COVID,” one leader shared. “There’s just so much COVID out there now…even though the disease is milder, there are still a lot of patients coming to the ED. But unlike last year, most aren’t sick enough to be admitted.”

And ED visits for other causes have not rebounded in the same way: “We’re hoping patients aren’t still staying away because they’re afraid of catching the virus.” We’ll be watching closely across the summer to see how volumes trend as the pandemic waxes and wanes across the country—we’d still bet that many consumers have changed their thinking on where and how they will seek care when the need arises.   

Surprise billing ban leads to cuts at PE-backed staffing firms

Posted on by • Posted in Emergency Care, Health Policy, Health System, Hospital, Hospital Industry, Physician Staffing, Physician Staffing - Private Equity Backed, Private Equity, Quality of Care, Surprise Bills • Leave a comment

https://mailchi.mp/31b9e4f5100d/the-weekly-gist-june-03-2022?e=d1e747d2d8

 When Congress passed the “No Surprises Act” in 2021, credit rating agencies like Moody’s warned that the bill would hurt physician staffing firms, especially those that provide emergency department (ED) services, which result in a surprise bill in roughly one in five visits. A piece from investigative outlet The Lever highlights how one private equity-backed physician staffing firm, Nashville-based American Physician Partners, is responding to the resultant cash flow challenges by cutting ED physician pay, after already reducing staffing levels. As the article describes, this is possible in an otherwise tight labor market because, unlike many other specialties, there’s an oversupply of ED physicians, due to the rapid growth in emergency medicine residency programs over the last decade.  

The Gist: With two-thirds of hospitals outsourcing at least some ED physician labor, the potential insolvency of large physician staffing firms could bring a crisis in access and coverage. 

In addition to revenue cuts tied to the surprise billing ban, rising interest rates also mean that PE firms may soon find it more difficult to fund their aggressive growth strategies. 

Health systems should proactively evaluate their partnerships with PE-backed physician staffing groups, with an eye toward anticipating potential staffing problems and service quality shortfalls.