Tag Archives: Quality of Care

Shared Savings Program ACOs Reduced Medicare Spending by $1 Billion

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http://www.healthleadersmedia.com/quality/shared-savings-program-acos-reduced-medicare-spending-1-billion?spMailingID=11861186&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1240498373&spReportId=MTI0MDQ5ODM3MwS2

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ACOs under CMS’ largest alternative payment model outperformed fee-for-service providers in quality and cost savings within the first three years of program.

According to findings reported by the Department of Health and Human Services Office of Inspector General (OIG), accountable care organizations (ACOs) participating in the Shared Savings Program are learning how to achieve greater cost savings over time. The Medicare Shared Savings Program is one of the largest alternative payment models implemented by CMS to reward providers for the quality and value of their services in order to keep patients healthy and lower costs.

The OIG’s report suggests many positive outcomes of the program, including that one-third of the ACOs that reduced their spending lowered costs enough to receive a portion of the savings. CMS data on quality measures also shows that ACOs generally improved the quality of care they provided, with a rate of 82% performance improvement on the individual quality measures within the first three years of the program. ACOs also outperformed fee-for-service providers on 81% of the quality measures.

A small portion of ACOs are reported to have gone above expectations, reducing Medicare spending by an average of $673 per beneficiary, including spending reductions for high-cost services such as inpatient hospital care and skilled nursing facility care. The OIG reports that these high-performing ACOs’ frequent use of primary care services, which can lower utilization and costs for other care, and cost reductions for services such as emergency department visits, was a factor in their cost savings. These strategies are compared to other Shared Savings Program ACOs and the national average for fee‐for‐service providers, who showed an increase in per beneficiary spending for key Medicare services.

The OIG concluded that ACOs show promise in reducing Medicare spending while also improving quality. These improvements come at a critical time, as Medicare spending is predicted to grow to $1.4 trillion by 2027. A large portion of Medicare spending has been attributed to overbilling, with the Medicare program losing more money to this error than any other program government-wide.

Public Health Care Programs: Lower Cost but Not Lower Quality

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Public Health Care Programs: Lower Cost but Not Lower Quality

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In recent days, Democrats have stepped into the health policy vacuum created by the Republicans’ failure to repeal and replace the Affordable Care Act. Proposals making the rounds include allowing Americans to buy into Medicare at age 55 or to buy into Medicaid.

Both Medicare and Medicaid pay lower prices to health care providers compared with private market plans offered by employers and in the Affordable Care Act marketplaces. On that basis, you might think these public programs are more cost-efficient. Are they?

Imagine that I take my car to the cheapest mechanic in town, while you take yours to the most expensive. My repairs, though costing less, don’t always fix the problem or last as long. You get what you pay for.

Let’s take a look at whether something similar is happening with public health programs. One study examined claims data for 26 low-value services and found that as much as 2.7 percent of Medicare’s spending is on these services alone, which include ineffective cancer screening, diagnostic testing, imaging and surgery. That sounds pretty bad.

But a paper that appeared in Health Services Research this year suggests that private plans do not perform better. Looking at the years 2009 to 2011, the authors compared the rates at which Medicare and private health plans provided seven low-value services. The services compared were among those identified as unnecessary by national organizations of medical specialists as part of the Choosing Wisely campaign.

The researchers found that four of the seven services they examined were provided at similar rates by Medicare and commercial market plans: cervical cancer screening over age 65; prescription opioid use for migraines; cardiac testing in asymptomatic patients; and frequent bone density scans. Medicare was less likely to pay for unnecessary imaging for back pain, but more likely to pay for vitamin D screening.

This finding might seem counterintuitive. Commercial market plans pay higher rates and confer higher profit margins, meaning there is more financial incentive for physicians to provide privately insured patients more of all types of care, whether low or high value.

But other results from the study suggest a more likely explanation: Doctors tend to treat all their patients similarly, regardless of who is paying the bill.

“What kind of insurance you have does affect your access to health care,” said Carrie Colla, associate professor of the Dartmouth Institute for Health Policy & Clinical Practice and the lead author of the study. “But once you’re in front of the doctor, by and large you’re treated the same way as any other patient.”

One apparent exception found in the study involved the seventh service it examined: cardiac testing before low-risk, noncardiac surgery. This service was provided to 46 percent of Medicare beneficiaries and 26 percent of privately insured patients. The large difference could reflect the fact that cardiac problems are more prevalent among older people. So a doctor with equal concern for all her patients might test Medicare patients at a higher rate for that reason. Nonetheless, such testing is considered low value even for the Medicare population.

Another recent study, published in JAMA Internal Medicine, also found little relationship between insurance status and low-value care. The study found no difference in the rates at which seven of nine low-value services were provided to patients on Medicaid versus those with private coverage. Six were also provided at the same rates for uninsured and privately insured patients.

Moreover, the study found that physicians who see a higher proportion of patients on Medicaid provide the same rate of low- and high-value services for all their patients as other physicians do. This is an important finding because Medicaid pays doctors less than private plans do, raising concerns that higher-quality doctors would tend not to participate in the program.

“Despite concerns to the contrary, Medicaid patients don’t appear to be seeing lower-quality doctors,” said Dr. Michael Barnett, lead author of the study, a physician with the Brigham and Women’s Hospital and an assistant professor at the Harvard T.H. Chan School of Public Health. “Though raising the prices Medicaid pays doctors may increase physician participation, enhancing enrollees’ access to care, it isn’t likely to change the quality of care patients receive once they are in the doctor’s office.”

If insurance status doesn’t influence how much low-value care patients are being offered, what does? In part, it seems related to the history and organization of local health care markets. A big culprit, according to Ms. Colla’s study, is a market’s ratio of specialists, like cardiologists and orthopedists, to primary care physicians. In areas where there are relatively more specialists, there is also more low-value care. That’s not to say that specialists don’t provide valuable services — but it suggests that they tend to provide more low-value care as well.

In a way, this is good news — the medical system doesn’t seem to discriminate by insurance status. It also means that public programs appear to be relatively cost-efficient, spending less than private payers for care of similar quality. That bodes well for Democrats’ proposals to expand Medicare or Medicaid.

But the bad news is that the study results imply that the value of care is hard to influence by adjusting prices. In a normal market, paying less for something would send a message of its low value, prompting people to provide less of it. The fact that price apparently does not influence doctors’ decisions is just another way in which health care does not seem to function like other markets.

Special Report—How to fix the Affordable Care Act

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Click to access FierceHealthcare-HowtofixtheAffordaleCareAct.pdf

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As Congress prepares to get back to business, the industry is holding its collective breath to see if healthcare reform will fall off the agenda. It’s pretty clear that rushing through repeal, replace or repair legislation or letting the Affordable Care Act fail isn’t the answer. In this special report, FierceHealthcare’s editors—experts on the business of healthcare—outline ways to fix the nation’s healthcare system.

Swedish Health’s Cherry Hill campus at risk of losing Medicare, Medicaid funding

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http://www.beckershospitalreview.com/quality/swedish-health-s-cherry-hill-campus-at-risk-of-losing-medicare-medicaid-funding.html

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CMS is threatening to cut off Medicare and Medicaid funding to Seattle-based Swedish Health’s Cherry Hill campus in 90 days unless it resolves patient safety issues, according to The Seattle Times.

The Washington Department of Health inspected Swedish’s Cherry Hill campus after a February Seattle Times investigative report exposed troubles, including staff members feeling intimidated, patient care concerns and surgeons performing overlapping surgeries.

The state surveyors identified numerous patient safety issues at the Cherry Hill campus, including failure to outline the roles of medical fellows, failure to address behavioral concerns, failure to document surgical tasks of medical residents, failure to listen to staff concerns and failure to track when the attending physician was in the operating room.

“Staff members feared punishment and retaliation for voicing concerns,” the regulators wrote, according to the Seattle Times. “Staff members stated they were frequently bullied and intimidated for voicing concerns about the working conditions in the neurosurgical operating area.”

To keep federal funding for the Cherry Hill campus, Swedish Health must submit a corrective action plan to CMS. Regulators will conduct another survey to ensure the hospital is in compliance with Medicare and Medicaid rules.

Swedish Health said that many of the deficiencies cited have been addressed, according to the report. The system implemented a new policy to ban overlapping surgeries. Additionally, Swedish Health CEO Guy Hudson, MD, insured that the culture of intimidation will be addressed

“We are sorry for what occurred at Swedish Cherry Hill on our watch,” Swedish Health board members told the Seattle Times. “As volunteers, we continue to be deeply committed to our critical governance role in overseeing patient quality and safety, as well as physician credentialing.”

Nursing strikes can cause harm well beyond labor relations

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http://www.healthcaredive.com/news/nursing-strikes-can-cause-harm-well-beyond-labor-relations/447627/

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hen officials at Tufts Medical Center in Boston refused to allow nurses just off of a one-day strike return to their jobs, the footage spread across TV news programs and social media. Boston Mayor Martin Walsh, a former labor leader, spoke in favor of the striking nurses and the hospital found itself in an uncomfortable spotlight.

About 1,200 nurses went on a one-day strike after their union, the Massachusetts Nurses Association, and Tufts couldn’t come to a new contract agreement after more than a year of negotiations. Tufts, in turn, locked out the nurses when they attempted to return to work the next day.

Officials said the lockout was required because they needed to give at least five-day contracts to 320 temporary nurses brought in to fill the gap. The nurses are back on the job now without a new contract, but the strike and subsequent lockout got the public’s attention.

Hospital strikes aren’t that common — usually, the sides agree to a new contract. Strikes or threatened strikes in recent years have typically involved conflicts over pay, benefits and staff workloads.

When strikes do happen, however, they can hurt a hospital’s reputation, finances and patient care.

Strike’s effect on patient safety

A study on nurses’ strikes in New York found that labor actions have a temporary negative effect on a hospital’s patient safety.

Study authors Jonathan Gruber and Samuel A. Kleiner found that nurses’ strikes increased in-patient mortality by 18.3% and 30-day readmission by 5.7% for patients admitted during the strike. Patients admitted during a strike got a lower quality of care, they wrote.

“We show that this deterioration in outcomes occurs only for those patients admitted during a strike, and not for those admitted to the same hospitals before or after a strike. And we find that these changes in outcomes are not associated with any meaningful change in the composition of, or the treatment intensity for, patients admitted during a strike,” they said.

They said a possible reason for the lower quality is fewer major procedures performed during a strike, which could lead partially to diminished outcomes. The study authors found that patients that need the most nursing care are the ones who make out worst during strikes.

“We find that patients with particularly nursing-intensive conditions are more susceptible to these strike effects, and that hospitals hiring replacement workers perform no better during these strikes than those that do not hire substitute employees,” they wrote.

Allina Health’s Abbott Northwestern Hospital in Minneapolis faced a patient safety issue during a strike last year that resulted in the CMS placing the hospital in “immediate jeopardy” status after a medication error. A replacement nurse administered adrenaline to an asthmatic patient through an IV rather than into the patient’s muscle. The patient, who was in the emergency room (ER), wound up in intensive care for three days because of the error. Allina said the error was not the nurse’s fault, but was the result of a communication problem.

The CMS accepted the hospital plan of correction, which included having a nurse observer when needed and retraining ER staff to repeat back verbal orders.

A strike’s financial impact

Hospitals also take a financial hit during strikes. Even the threat of a one- or two-day nurse strike can cost a hospital millions.

Bringing in hundreds or thousands of temporary nurses from across the country is costly for hospitals. They need to advertise the positions, pay for travel and often give bonuses to lure temporary nurses.

The most expensive recent nurse strike was when about 4,800 nurses went on strike at Allina Health in Minnesota two times last year. The two strikes of seven days and 41 days cost the health system $104 million. The hospital also saw a $67.74 million operating loss during the quarter of those strikes.

To find temporary replacements, Allina needed to include enticing offers, such as free travel and a $400 bonus to temporary nurses.

Even the threat of a strike can cost millions. Brigham and Women’s Hospital in Boston spent more than $8 million and lost $16 million in revenuepreparing for a strike in 2016. The 3,300-nurse union threatened to walk out for a day and much like Tufts Medical Center, Brigham & Women’s said the hospital would lock out nurses for four additional days if nurses took action.

At that time, Dr. Ron Walls, executive vice president and chief operating officer at Brigham and Women’s Hospital, said the hospital spent more than $5 million on contracting with the U.S. Nursing Corp. to bring on 700 temporary nurses licensed in Massachusetts. The hospital also planned to cut capacity to 60% during the possible strike and moved hundreds of patients to other hospitals. They also canceled procedures and appointments in preparation of a strike.

The Massachusetts Nurses Association and Brigham & Women’s were able to reach a three-year agreement before a strike, but the damage was already done to the hospital’s finances.

Richard L. Gundling, senior vice president of healthcare financial practices at Healthcare Financial Management Association, told Healthcare Dive that healthcare organizations need to plan for business continuity in case of an event, such as a labor strike, natural disaster or cyberattack.

“Business continuity is directly related to the CFO’s responsibility for maintaining business functions. The plan should include having business continuity insurance in place to replace the loss associated with diminished revenue and increased expenses during the event,” Gundling said.

These plans should provide adequate staffing, training, materials, supplies, equipment and communications in case of a strike. Hospitals should also keep payers, financial agencies and other important stakeholders informed of potential issues.

“It’s also key to keep financial stakeholders well informed; this includes insurance companies, bond rating agencies, banks, other investors, suppliers and Medicare/Medicaid contractors,” he said.

“Business continuity is directly related to the CFO’s responsibility for maintaining business functions. The plan should include having business continuity insurance in place to replace the loss associated with diminished revenue and increased expenses during the event.”

Richard Gundling

Senior vice president of healthcare financial practices, Healthcare Financial Management Association

Impact to a hospital’s reputation

Hospital strikes, particularly nurses’ strikes, can also wreak havoc on a hospital’s reputation. Nurses are a beloved profession. They work hard, often long hours and don’t make a fortune doing it. The median registered nurses’ salary is about $70,000, according to the Bureau of Labor Statistics.

Nurses’ contract disputes involving staffing levels are a sticky situation for hospitals. Nurses will almost always win the PR battle against hospital executives.

If a hospital can’t avoid a strike, Seitel said two keys for the organization are telling the truth and not being passive about untrue statements from the other side. They don’t want to be adversarial and escalate the situation, but go with a more measured approach.

Fraser Seitel, president of Emerald Partners, a communications management consulting company, told Healthcare Dive there are two ways that hospital leadership can avoid a strike.

“The best way to prevent a strike is by the management of the hospital having a robust communications program with the staff of the hospital as well as keeping competitive in terms of salaries and benefits,” said Seitel, who has helped hospitals during times of labor strife.

Seitel said labor issues often crop up when management isn’t communicative. Communication, transparency and competitive compensation are the best preventative medicine for a strike, he said.

Dirty, Dingy Hospitals: Doctors Blame Debt-Fueled Takeovers

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https://www.bloomberg.com/news/articles/2017-06-01/dirty-dingy-hospitals-doctors-blame-debt-fueled-takeover-boom

There are two groups Community Health Systems Inc. can’t push too far: the doctors at its hospitals, and the debtholders it owes billions of dollars. Right now, the creditors are winning, and the doctors aren’t happy.

In Fort Wayne, Indiana, the rancor about Community’s neglect of a local health system has gotten so bad that a group of doctors tried to get rid of corporate ownership and buy the company out. And 1,500 miles away on the island of Key West, Florida, doctors say patients are being overcharged so that Community, sometimes called CHS, can rake in cash.

The two locations are among Community’s most lucrative, and their conflicts are part of the flip side of an industrywide acquisition binge over the last decade. For-profit hospital chains like Community borrowed billions to snap up rivals, facing massive debt reimbursements just as the benefits of the Affordable Care Act, known as Obamacare, began to wane.

“I understand that they have billions in debt and may need to take money from this chain to service it,” said William Pond, an anesthesiologist at one of the Fort Wayne hospitals and president of the county health department’s executive board. “But it’s very disappointing to see the course that CHS is taking and the devastating effect they’re having on our community.”

Once the biggest U.S. for-profit hospital chain, Community is selling off other, poorly performing facilities to pay off $2 billion of its $15 billion in debt. Yet even as the company skimps on spending and patient satisfaction lags at key facilities like Fort Wayne, its bonds are rising in value — an indication that debtholders are betting that the chain will make a financial turnaround.

The company’s $3 billion of 6.875 percent bonds due February 2022 have gained almost 30 percent this year and were changing hands at 89 cents on the dollar, according to Trace, the bond-price reporting system of the Financial Industry Regulatory Authority. The debt still trades at yields about 8 percentage points more than government debt.

If the chain can’t subdue the unrest at its most profitable locations, it’s not clear how successful the turnaround will be. Indiana and Key West represent just nine of Community’s about 150 hospitals, yet they contribute an estimated 16 percent of the company’s adjusted earnings before interest, taxes, depreciation and amortization, according to Mizuho Securities analyst Sheryl Skolnick.

CDC Flags Hospitals’ Stubborn Problem with Legionnaires’ Disease

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http://www.medpagetoday.com/hospitalbasedmedicine/generalhospitalpractice/65825

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Most outbreaks preventable with properly designed and maintained water systems.

Most of the country has seen cases of Legionnaires’ disease associated with healthcare facilities, CDC officials said Tuesday.

This is “a concerning finding,” a CDC statement said, because of the illness’s increased severity when contracted in hospitals and long-term care facilities. The fatality rate for definite healthcare-associated Legionnaires’ disease was 25% in a new CDC analysis.

Surveillance data from 20 states and one large city identified 2,809 Legionella infections.

Although the analysis found that only 3% of confirmed cases were definitely acquired in healthcare institutions, officials said they believe that a much larger fraction were contracted in such facilities but were diagnosed only after discharge. The CDC’s Vital Signs report indicated that another 17% of infections were suspected to have originated in healthcare facilities, in that the patients had been in such a facility within 10 days of symptom onset.

During a press call with reporters, CDC Acting Director Anne Schuchat, MD, said the study highlights the important work that hospitals and long-term care facilities must do with regard to their water systems. Legionella organisms live in water and outdated systems allow them to spread.

Proper water management “could have prevented four out of five Legionnaires’ disease outbreaks,” Schuchat said. “This means tending to the buildings’ water infrastructure,” she added, particularly in older facilities.

The chief of CDC’s respiratory diseases branch, Cynthia Whitney, MD, MPH, noted on the press call that the agency has developed a water-management toolkit for hospitals and other facilities to minimize Legionnaires’ disease. As important as having a program, she emphasized, is assigning “a dedicated team to execute the program.”

Whitney and Schuchat also said they believe many, perhaps most, Legionnaires’ cases go undiagnosed. Whitney said it’s vital that patients with symptoms consistent with the condition undergo specific testing for Legionnaires’ disease, so that outbreaks can be curtailed at their outset.

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Hospitals that spend more on emergency care, inpatient care yield better outcomes

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http://www.fiercehealthcare.com/healthcare/study-investments-patient-care-lead-to-better-outcomes

An MIT study suggests hospitals get more bang for their buck when they spend money on emergency care versus long-term care.

The study, which was published in the current issue of Journal of Health Economics, compared data on outcomes between hospitals that make a substantial upfront investment in inpatient care after a patient experiences an emergency with those that rely more heavily upon skilled nursing facilities and other long-term care options postdischarge.

“We find that patients who go to hospitals that rely more on skilled nursing facilities after discharge, as opposed to getting them healthy enough to return home, are substantially less likely to survive over the following year,” says Joseph Doyle, Erwin H. Schell Professor of Management at the MIT Sloan School of Management, in an article posted on MIT’s news site.

The study sought to weed out inefficiencies in hospital spending that contribute to the higher per capita cost of healthcare in the United States compared to the rest of the world. Statistics from the Organisation for Economic Co-operation and Development peg spending in the United States at 40% higher than the next-highest spender, which MIT notes has led to questions about “significant inefficiencies” in terms of where all that money gets spent.

When the high costs of care get passed along to patients, they can cause a ripple effect in terms of overall population health. In one survey, as many as one in four Americans said they chose to forgo medical care because of prohibitive costs.

The MIT study found that hospitals that spent approximately $8,500 above the average 90-day spend of $27,500 per patient saw a two-percentage-point decrease in their patients’ mortality risk. That compares to findings of a five-percentage-point increase in mortality when hospitals focus their spending on postdischarge nursing facilities.

Doyle suggests these results could form the basis of a new quality metric looking at hospitals with worse outcomes and a higher proportion of downstream spending.

Multiple Recurring C. Diff. Infections on the Rise

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The incidence of Clostridium difficile infections rose by 43% from 2001 to 2012, while the incidence of multiple recurring CDI rose by 189% over the same period.

The incidence of Clostridium difficile infections rose by 43% from 2001 to 2012, while the incidence of multiple recurring CDI rose by 189% over the same period.

Multiple recurring Clostridium difficile infections are becoming more common in the nation’s hospitals and researchers aren’t sure why. In an analysis of a large, nationwide health insurance database, researcher’s at the University of Pennsylvania’s Perelman School of Medicine found that the annual incidence of multiple recurring C. difficile (mrCDI) increased by almost 200% from 2001 to 2012.

During the same period the incidence of ordinary CDI increased by only about 40%. The study results were published this week in the Annals of Internal Medicine.

Related: C. Diff Infection Raises Hospital Costs by 40% per Case The reasons for the sharp rise in mrCDI incidence is unknown.

Researchers said the finding points to an increased burden on the healthcare system, including increased demand for new treatments for recurrent CDI. The most promising of these new treatments, fecal microbiota transplantation—the infusion of beneficial intestinal bacteria into patients to compete with C. difficile—has shown good results in small studies, but hasn’t yet been thoroughly evaluated. “The increasing incidence of C. difficile being treated with multiple courses of antibiotics signals rising demand for fecal microbiota transplantation in the United States,” said study senior author James D. Lewis, MD, professor of gastroenterology and senior scholar in the Center for Clinical Epidemiology and Biostatistics.

Related: Intractable C. Diff Infection Linked to Multiple Care Settings “While we know that fecal microbiota transplantation is generally safe and effective in the short term, we need to establish the long term safety of this procedure.” In their analysis of CDI trends, the researchers examined records on more than 40 million patients enrolled in private health insurance plans. Cases of CDI were considered to have multiple recurrences when doctors treated them with at least three closely spaced courses of CDI antibiotics.