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Envisioning a range of new roles for the health system

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https://gisthealthcare.com/weekly-gist/

 

 

Over the past few weeks, we’ve been sharing our framework for thinking through the path forward for traditional health systems, as they look to drive value for consumers. We began by describing today’s typical health system as “Event Health”, built around a fee-for-service model of delivering discrete, single-serve interactions with patients. We then proposed the concept of “Episode Health”, which would ask the health system to play a coordinating role, curating and managing a range of care interactions to address broader episodic needs. Finally, last week we shared our vision for “Member Health”, in which the system would re-orient around the goal of building long-term, loyalty-based relationships with consumers, helping them manage health over time. In this broader conception, the health system would curate a network of providers of episodes, and events within those episodes, and ensure that the consumer (and their information) moves seamlessly across a panoply of care interactions over time.

This week we bring those three, distinct visions for the role of the health system together in one framework, shown below. A couple of points are worth mentioning here. To begin, our view is that health systems face a fundamental choice over the near term: either begin to embrace the broader aspiration of evolving toward Episode Health and Member Health or become reconciled to the reality of a future as a subcontractor of events and being part of some other organization’s curated network. There’s nothing wrong with being a subcontractor, as long as your cost and quality positions allow you to win business and thrive. You might be the best acute care hospital choice in the market, or the most efficient surgery provider, or the best diagnostic center. But competition will be intense among those subcontractors and earning the business of those who coordinate episodes and control referrals will be increasingly demanding.

Most health systems have already begun to look beyond Event Health, investing in strategies that allow them to span the full continuum of care. Other systems have pushed even further, into the “risk business”—looking to become Member Health and take on the role of managing a consumer’s care across time. But contrary to common wisdom, this evolution does not require a binary choice. Systems are not moving “from one canoe to the other”; rather, most successful systems will play a combination of all three roles at the same time, in perpetuity. While it’s always worth evaluating whether others might be more efficient providers of some Event Health services (diagnostics, rehab, and so forth), most systems will want to maintain a robust base of providing Event Health, even as they embrace a more comprehensive role.

Finally, there is a space we describe as “Beyond Health”, which comprises all of the additional components of consumer value delivery which may be beyond the ability of most systems to handle on their own. Most notably, these include services that address many of the social determinants of health—housing, nutrition, transportation, and the like. Our recommendation is that health systems look to partner with other organizations at a local and national level to address issues that, however critical, lie beyond their ability to fully solve on their own.

Next week we’ll begin to share some additional implications of our Event-Episode-Member Health framework and discuss the operational challenges that face health systems looking to make this evolution.

Changing Healthcare’s Culture of Overtreatment a Challenge

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https://www.medpagetoday.com/publichealthpolicy/generalprofessionalissues/75402?xid=nl_mpt_DHE_2018-09-29&eun=g885344d0r&pos=&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%202018-09-29&utm_term=Daily%20Headlines%20-%20Active%20User%20-%20180%20days

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More focus on accepting uncertainty is needed, expert says

Medical schools and healthcare workplaces should try harder to change the culture around medical overtreatment, according to Barnett Kramer, MD, MPH.

“Some of the solution may be at the training level of health professionals,” Kramer, director of the cancer prevention division at the National Cancer Institute, in Bethesda, Md., said at a briefing Thursday sponsored by Kaiser Health News. “The number one problem identified by medical historian Kenneth Ludmerer is insufficiency of training for uncertainty in medical school; his thesis was that [this] led to systematic overuse of testing and overtreatment. If neither the physician nor the patient are trained to think [about] and accept uncertainty, then almost always our medical culture is going to lean in one direction, so education in probabalistic thinking [is important].”

Another issue is “knowing when you don’t have to make a decision then and there,” he continued. For instance, “there are situations where we’re learning it’s uncertain what the best way to go is, but there’s pretty good evidence that waiting and seeing what the natural history of the disease is, is acceptable, and sometimes that’s very difficult.”

A third consideration “is to try to keep the discussion focused on what is known about the particular disease,” Kramer said. “There’s a famous saying that ‘If thought corrupts language, the opposite is certainly the case.’ So as soon as you have an entity with the word ‘cancer’ or ‘carcinoma’ in it, sometimes that shuts off the ability to really understand and get informed about what the disease really is.”

“There is some movement … to change the name of some of the things we call cancer,” he added. “If we have enough biological information to know they don’t act like a routine cancer, that at least moves the word off the table and you can focus on what’s known and what’s not known, and try to handle the uncertainties.”

Malpractice liability concerns, especially when combined with clinical uncertainty, also can contribute to overtreatment, said Ranit Mishori, MD, MHS, a family physician and professor of family medicine at Georgetown University here. “There are days when I go home and ask myself again and again and again, ‘Should I have ordered that test? I think I probably shouldn’t have, but is that patient going to sue me?’ God forbid they’ll be the one patient in 1,000 coming down with that rare form of prostate cancer.”

That situation happened to a physician friend of Mishori’s. “He followed all the guidelines about PSA [prostate-specific antigen] testing, and this one person was the person he didn’t test who ended up having prostate cancer and sued the heck out of him,” she said. “Do you think my friend continued with not offering PSA testing to all his other patients? For a while it was a very difficult decision for him.”

Although critics have complained for decades about the problem of physicians overtesting and overtreating because they’re afraid of malpractice suits, not much has changed, Mishori told MedPage Today. She added that the probability of being sued seems to be geographically dependent. “If you’re in rural Arkansas, you’re less likely to be sued, but if you’re in Washington, D.C., and everybody and their sisters are lawyers, it’s something that goes through your mind a little bit more.”

Another problem is that one test often triggers a cascade of testing, said Saurabh Jha, MD, a radiologist and associate professor of radiology at the University of Pennsylvania. He cited a case in which a woman came into the hospital with a suspected pulmonary embolism. A CT scan ruled out that possibility, “but then I did something else which led to cascade of investigations: I measured the main pulmonary artery, and it was 3.3 cm.” Since the threshold for suspecting pulmonary hypertension is 3.1 cm, Jha said in his report that the patient possibly had pulmonary hypertension, and also added the limitations of his conclusion. Because Jha was a resident at the time and most patients passed into others’ care, he then forgot about the case.

Later on, however, another hospital staff member told him that his diagnostic conclusions had resulted in a “cascade of investigations” for that patient. “What I began to realize later on was that the chances of actually picking somebody up with pulmonary hypertension using that number is overwhelmed by causing false positives and putting somebody through a train of investigations,” he said. “Since then, I have begun to be more judicious with measuring, realizing that anything printed in a report can be like a Greek tragedy — very difficult to reverse afterwards.”

Jacqueline Kruser, MD, a pulmonologist and critical care physician at Northwestern Memorial Hospital, in Chicago, called the phenomenon of this testing cascade “clinical momentum.” “We see this for acutely ill patients,” she said. “When they come to the hospital and are admitted to the intensive care unit (ICU), everyone who takes care of you is laser-focused on the acute problems that brought you there … Most importantly, they want to act quickly to fix them, and the environment is designed to fix things rapidly — we can get lab tests back in minutes and rush someone to the operating room in an hour.”

However, although that works well for most patients, “what we worry about is, what about the patients who have different goals [than just getting things fixed] — they want to avoid invasive procedures or burdensome treatment, or they want to be with family, eating what they want to eat?” she said. “All those cascading interventions might not accomplish those goals for that patient.”

The hospital isn’t necessarily designed to focus on those issues, Kruser said. In an ICU, for example, it’s hard to find “enough chairs for everyone to sit down with the patient in the room — with their family, their doctors — and talk about what’s most important to them.”

November Offers Major Test of Medicaid Expansion’s Support in Red States

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http://www.governing.com/topics/health-human-services/gov-medicaid-expansion-voters-ballot-november-states.html?utm_term=November%20Offers%20Major%20Test%20of%20Medicaid%20Expansion%27s%20Support%20in%20Red%20States&utm_campaign=A%20Major%20Test%20of%20Medicaid%20Expansion%27s%20Support%20in%20Red%20States&utm_content=email&utm_source=Act-On+Software&utm_medium=email

Several states will hold the first referendum on Obamacare since Congressional Republicans tried and failed to repeal it.

SPEED READ:

  • Four states are voting on Medicaid expansion in November — Idaho, Montana, Nebraska and Utah. 
  • Medicaid expansion is a central tenet of President Barack Obama’s Affordable Care Act. It makes people living up to 138 percent of the federal poverty line eligible for Medicaid, the government-run health insurance program for the poor.
  • Only one state, Maine, has approved Medicaid expansion through the ballot box.
  • It is the first time voters will directly weigh in on provisions of the ACA since Congressional Republicans tried to repeal it.

It started with Maine. After years of failed attempts to get Gov. Paul LePage to sign off on Medicaid expansion, residents took to the ballot box and made it the first state where voters passed the health care policy.

It hasn’t been smooth sailing. Maine’s Republican governor has taken every opportunity to block the expansion — even asking the federal government to reject the state’s Medicaid expansion application that the courts made him send.

But the passage alone galvanized health care advocates who wish to see Medicaid expansion in the 14 states that have declined federal money to offer health insurance to the people who fall in a “coverage gap,” where they make too much money to qualify for Medicaid but can’t afford private insurance.

In November, four states are voting on the issue — Idaho, Montana, Nebraska and Utah. The ballot measures will test support for a central tenet of President Barack Obama’s Affordable Care Act (ACA) in red states, which make up the bulk of the 14 holdouts. It will be the first referendum on provisions of the ACA since Congressional Republicans tried and failed to repeal it last year.

Supporters of Medicaid expansion see it as a vital part of the social safety net, especially because qualifying for Medicaid in nonexpansion states can be tough. Opponents, however, see expansion as fiscally irresponsible since states will start picking up 10 percent of the costs in 2020.

While the price tag of Medicaid expansion can come with some sticker shock, independent analyses have found that states often save money by insuring people — there are fewer instances of uncompensated care, and people are healthier when they have insurance. According to a 2016 report from the Robert Wood Johnson Foundation, 11 states experienced some savings from Medicaid expansion.

In Idaho and Nebraska, there has been no major movement on Medicaid expansion from either the executive or legislative branches for years. Because of Idaho’s historic opposition to Medicaid expansion, and the fact that the ballot measure doesn’t mention how it would be funded, advocates could experience a bit of déjà vu there.

While the federal government initially pays 100 percent of the costs of Medicaid expansion, it eventually hands states a bill for 10 percent. The funding issue is what LePage has been using as a reason to refuse to implement Medicaid expansion in Maine. For his part, Idaho Lt. Gov. Brad Little, the Republican expected to succeed Gov. Butch Otter in November, is against Medicaid expansion but has said he would accept it if it passes.

“Proponents insist that it’ll pay for itself, but entitlement programs are historically costlier than anticipated. I imagine there are going to be some really tough discussions if it passes,” says Fred Birnbaum, vice president of the Idaho Freedom Foundation, which opposes the measure.

Nebraska’s measure also doesn’t have a provision that explicitly says how the state share would be paid for, but supporters don’t believe that should make a difference.

“We modeled our language based on the Maine initiative, so it’s clear and unequivocal,” says Democratic state Sen. Adam Morfeld, who introduced Medicaid expansion bills in the past. “The governor can say he won’t implement it, but we’ll have a court tell him otherwise.”

Republican Gov. Pete Ricketts, who is expected to win reelection in November, has opposed Medicaid expansion since the beginning but said that if it made the ballot, it’s up to the voters to decide.

“That’s honestly the best I could hope for,” says Morfeld.

In Montana and Utah, the questions before voters are a little more complicated.

Montana expanded Medicaid in 2015, but under the deal struck in the state legislature, it is set to expire June 30. Residents will be voting on whether to extend it, and how the state would fund their portion of it. The ballot measure proposes hiking taxes on tobacco products to $2 per pack.

Utah also already passed a bill to expand Medicaid, but it is awaiting federal approval. It would require nondisabled people to work, volunteer or participate in a job training program; the expansion would automatically end if the federal match dipped below 90 percent; and eligibility stops at the poverty line, which is $12,140 for a single person. (The federal government has rejected other states’ requests to limit expansion to people at the poverty line.)

The ballot measure, meanwhile, asks voters to expand Medicaid traditionally — without work requirements or eligibility limits past the federal poverty line. It also asks voters to increase the sales tax to fund the state’s share. It’s unclear what would happen if the ballot measure passes and the federal government approves Utah’s competing Medicaid waiver.

In three of the four states — Nebraska, Montana and Utah — more than $11 million has been spent to sway voters one way or the other. In Nebraska and Utah, supporters have spent $1 million to 2 million while opponents have spent a reported zero dollars. In Montana, the balance is just the opposite: opponents have raised $8 million while supporters have raised just $2 million. In Idaho, the issue has attracted just has $37,067 — all from the supporters’ side.

Only Utah has conducted polling on the issue, which was done in June. The Salt Lake Tribune and the Hinckley Institute of Politics found that 54 percent of voters support the measure, 35 percent oppose it, and the rest are undecided.

“There’s been a lot of discussion in Utah about this, we’ve been having this debate for a couple of years now,” says Danny Harris, associate state director of advocacy at AARP Utah, which is in favor of the ballot measure. “The polling has always been consistently in favor. People are ready for this issue to move forward.”

 

23-hospital system rolls out student loan repayment program to attract nurses

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https://www.beckershospitalreview.com/workforce/23-hospital-system-rolls-out-student-loan-repayment-program-to-attract-nurses.html?origin=cfoe&utm_source=cfoe

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Mercy Health, a 23-hospital system based in Cincinnati, has launched a student loan repayment program to attract and retain nurses in hard-to-fill roles, according to WVXU.

Due to tough competition for nurses and an increase in voluntary turnover, Mercy Health typically has between 1,500 and 2,000 openings for nursing positions. “We’ve seen voluntary turnover of almost 18 percent,” Allan Calonge, Mercy Health’s human resources vice president, told WVXU. “That’s quite a bit higher than it has been historically.”

Officials hope the new student loan repayment program will help address the problem. Mercy will make monthly contributions toward outstanding student loan debt for nurses who qualify. The system will contribute up to $20,000 to each nurse’s loans, according to WLWT.  

“Talented nurses are vital to ensuring the health and well-being of our patients,” Mr. Calonge told WLWT. “Our new student loan repayment program is a win-win for us and our nurses.”

 

 

Trinity Health forms new 5-hospital system

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https://www.beckershospitalreview.com/hospital-transactions-and-valuation/trinity-health-forms-new-5-hospital-system.html?origin=cfoe&utm_source=cfoe

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Livonia, Mich.-based Trinity Health, which includes 93 hospitals in 22 states, has formed a new regional health system called Trinity Health Mid-Atlantic.

The new system will include the following hospitals: St. Mary Medical Center in Langhorne, Pa.; St. Francis Healthcare in Wilmington, Del.; Mercy Philadelphia Hospital; Mercy Fitzgerald Hospital in Darby, Pa.; and Nazareth Hospital in Philadelphia. Clinics, medical offices and other facilities associated with the hospitals will also be part of Trinity Health Mid-Atlantic.

Trinity said the formation of the new regional health system will streamline operational efficiencies, improve clinical collaboration by physicians, and lead to a more comprehensive outpatient strategy.