The Latest on Physician Burnout in the Time of COVID-19

By Clive Riddle, May 29, 2020

After COVID-19 fully assaulted the United States in March, an article appeared in the April 9^th Harvard Medical School’s Lean Forward: A Double Whammy: The COVID-19 Pandemic and Burnout in Medical Professionals, sharing that “leaders are advising health care workers to think of the pandemic as a marathon, not a sprint. But how long can health care workers hold up in these challenging conditions?” They cited a recent study on China’s physician COVID-19 experience: “researchers in China conducted a cross-sectional study published in JAMA Network Open Journal in March 2020. The study involved 1257 health care workers in China during the coronavirus pandemic and reported troubling results; 50.4% had symptoms of depression, 34.0% reported insomnia, 44.6% reported symptoms of anxiety and 71.5% reported distress.”

A May 17^th Forbes article,  Doctor, Heal Thyself: Physician Burnout In The Wake Of Covid-19 quotes Nisha Mehta, MD, radiologist, physician advocate and keynote speaker: “For many physicians, Covid-19 may be the proverbial straw that breaks the camel’s back as they isolate themselves physically from their family and friends while encountering a surge of sickness and death.” They cite that “physician burnout was an epidemic BEFORE the Covid-19 pandemic. According to a 2018 study, 400 physicians die by suicide each year – double that of the general population. In addition, doctors have the highest suicide rate of any profession in the U.S including combat veterans. From an economic standpoint, studies estimate that physician burnout is costing the health care system approximately $4.6 billion per year.”

An example of a growing trend, at the start of this month Charlotte, N.C.-based Novant Health established a new task force that will screen front-line healthcare workers for burnout.

Without focusing on just COVID-19, The May issue of The Journal of the American Board of Family Medicine featured are series of studies on physician burnout. In Joy in Work for Clinicians and Staff: Identifying Remedial Predictors of Burnout from the Mini Z Survey, Niharika Khanna, Russ Montgomery and Elena Klyushnenkova remind us that “Joy in medical practice is an important marker of clinician satisfaction related to structural and cultural aspects of the practice.”

Their study involved the CMS Transforming Clinical Practice Initiative (TCPI), which provided coaching and learning support to practices during transition to new models of value-based care. Specifically, Maryland practices participated in the Garden Practice Transformation Network (GPTN) as a part of the TCPI. During practices assessment, the authors measured prevalence of burnout and identified its remediable predictors among GPTN-Maryland practices.

 They found “prevalence of burnout symptoms was 22%, with 35% enjoying their work. A 100-point Time Constraints/Teamwork (T/T) score was constructed using factors significantly associated with burnout symptoms. T/T score increase by 1 unit was associated with 10% increase in the odds of moving from the group experiencing burnout or stress to the group who found ‘joy in work’.”

In Indicators of Workplace Burnout Among Physicians, Advanced Practice Clinicians, and Staff in Small to Medium-Sized Primary Care Practices, Debora Goetz Goldberg, Tulay G. Soylu, Victoria M. Grady, Panagiota Kitsantas, James D. Grady and Len M. Nichols remind us that “burnout is defined as a ‘syndrome of emotional exhaustion, depersonalization, and a sense of low personal accomplishment that results in decreased effectiveness at work.’ Numerous studies have concluded that burnout is a serious problem for physicians, advanced practice clinicians, nurses, and other health care professionals. Recent research indicates that primary care physicians experience a higher rate of burnout than most other physician specialties.”

Their study analyzed survey responses from 1273 healthcare professionals from 154 small to medium-sized primary care practices participating in the EvidenceNOW initiative in Virginia. They found “workplace burnout was reported by 31.6% of the physicians, 17.2% of advanced practice clinicians, 18.9% of clinical support staff, and 17.5% of administrative staff. Regardless of burnout status, results show all healthcare professional groups had high levels of anxiety. Providers had significantly higher scores for anxiety than all other healthcare professionals. Providers who experienced higher levels of anxiety and withdrawal were more than three times as likely to report burnout compared to those who experienced low levels in these domains.”

They recommend that “programs should focus on strengthening the work environment of small to medium-sized practices to improve organizational capacity for change and address high levels of anxiety experienced by physicians, advanced practice clinicians and staff.”

Here’s hoping our healthcare heroes can somehow find joy in work, and a strengthened work environment in these COVID-19 times.

Home, Sweet Work

By Kim Bellard, May 21, 2020

If you’re lucky, you’ve been working from home these past couple months. That is, you’re lucky you’re not one of the 30+ million people who have lost their jobs due to the pandemic. That is, you’re lucky you’re not an essential worker whose job has required you to risk exposure to COVID-19.

What’s interesting is that many of the stay-at-home workers, and the companies they work for, are finding it a surprisingly suitable arrangement. And that has potentially major implications for our society, and, not coincidentally, for our healthcare system.

José Cong, a tech talent acquisition advisor, told The Wall Street Journal that, when it comes to increased remote work, the pandemic “is going to be the gasoline on the fire.”

It’s not just corporate benevolence or concerns about public health. It’s also about the money. Short term savings in office energy use/upkeep and business travel, and longer term savings in real estate costs, make work-at-home attractive to companies.

Entrepreneur Hiten Shah told Cat Zakrzewski of The Washington Post: “Everyone’s doing the math. Once you follow the money, it points to the fact that this is inevitable…The cost savings are just ridiculous comparing to have an office and all the things that come with that.”

There are real questions about the shift. “Companies will have to find ways to build culture remotely, which is really tough to do,” tech analyst Gene Munster told the WSJ. Zoom calls are all well and good, but “People like to come in and collaborate with and work with their folks,” said Jennifer Christie, Twitter’s chief human resource officer.

There are further ripple implications. Business Insider reported how suburban office parks were already becoming more deserted, posing problems not just for their commercial real estate owners but also for the cities and municipalities that relied on tax revenue from them — not to mention for the restaurants and other small businesses that served all those workers.

We’ve seen a urban-suburban competition for jobs, but now that fight has a new contender — workers’ homes — and no one yet knows all the implications of that shift.

Healthcare is less able than most industries to work from home, but it is doing its best through increased use of telehealth. Its problem is that its revenues are built around patients coming in for visits/ treatments/ procedures, and most aren’t. As a result, telehealth notwithstanding, hospitals say they are losing billions of dollars, and healthcare workers are, for the first time in decades, undergoing massive layoffs — well over a million in April alone.

When we think about all those deserted office parks and buildings, think also about hospitals and medical office buildings. The healthcare system will need fewer of them both from the demand side — patients preferring to use telehealth — and from the supply side — healthcare professionals able to do more remotely.

This pandemic will not last forever. Perhaps the sudden, massive work-from-home experiment will soon be just a memory, and we’ll all end up back to our offices.

But that’s a sucker’s bet. The prudent business leader would seriously consider, as Mr. Walker said, that this is part of a once-in-a-generation/once-in-a-lifetime, permanent shift. The prudent business leader would evaluate how much of their business could be done from home (or other settings), and how to best support that shift. The prudent business leader would be trying to drive and support the changes, not react to them.

The question is, how many such prudent business leaders there are in healthcare?

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard) 

Surveying COVID-19 Financial Impact on Providers

By Clive Riddle, May 15, 2020

NEPC’s Healthcare Practice Group has just released survey results from a diverse set of healthcare organizations around the country on financial steps they are taking during the pandemic. Here's what NEPC found:

• ·         78% have or will access lines of credit
• ·         96% anticipate additional government assistance
• ·         61% have already, or plan on, furloughing staff
• ·         43% have already, or plan to, suspend or postpone retirement plan contributions (28% of with organizations $2B in assets did so,  compared to 63% with a credit rating of BBB or lower)
• ·         56% said their daily burn rates increased by up to 25%, while 23% of respondents indicated a daily burn increase of more than 25%
• ·         28% of East Coast organizations had 25%+ burn increases, vs 8% of West Coast organizations

In late April, Merritt Hawkins and The Physicians Foundation released national physician survey results that found

• ·         48% are treating patients through telemedicine, up from 18% in 2018
• ·         21% of physicians have been furloughed or experienced a pay cut
• ·         14% plan to change practice settings as a result of COVID-19
• ·         18% plan to retire, temporarily close their practices, or opt out of patient care

Also, the California Medical Association in late April released the results of its COVID-19 Physician Financial Health Survey, which found that "95% of physician practices are worried about their financial health due to the COVID-19 public health emergency. Practice revenue has declined by 64% since March 1, 2020, with 75% of practices experiencing a revenue decline of 50% or greater."

The Brave New Healthcare Strategic Venture World

By Clive Riddle, May 8, 2020

Strategic investing has escalated as a “thing” with health systems and health plans, and you’ll find the fingerprints of their various venture funds on an increasing number of important healthcare startup and acquisition transactions. Given our new COVID CoronaWorld will is leaving many providers and startups undercapitalized, the potential is there for stakeholders that manage to maintain a healthy venture fund to have an even greater strategic impact in the coming years.

BDC Advisors' Steve Weylandt, Dudley E. Morris, and Alan Trimakas published this April 27th article with HFMA:  8 hallmarks of a successful healthcare venture capital program that begins with "Developing innovative venture capital projects is rapidly becoming an essential element of the U.S. health system’s strategy to ensure long-term financial viability. In the past five years, healthcare venture capital programs and innovation labs have become essential tools for health systems."

Here are the "eight core principles and lessons learned from organizations that have achieved success with value-added venture capital management" that they elaborate on in the article:

1. Make venture capital a health system strategic priority

2. Clearly align corporate and venture capital investment goals

3. Make collaboration and coinvesting key parts of the strategy

4. Separate venture investing from operations

5. Build a culture that is reasonably tolerant of failure

6. Make sure to groom 'venture champions'

7. Focus on scale and implementation from the start

8. Engage health system leadership

A couple of weeks ago, Becker’s Health IT published an article on 15 digital health, telehealth startups that raised millions in the past 3 months that in addition to mentioning typical high-profile VC firms involved in the transactions, also noted involvement of Cigna Ventures and MemorialCare Innovation Fund funding a new round for AristaMD, the e-consult company; and MemorialCare Innovation Fund, LRVHealth, OSF Ventures and UnityPoint Health Ventures funding a new round for SilverCloud Health, a digital mental health platform.

Cigna Ventures in January announced strategic investment with two digital health innovation companies - Buoy Health and RecoveryOne. Buoy Health "brings an unparalleled depth and breadth of experience in leveraging artificial intelligence to facilitate real-time, high-quality and personalized care recommendations based on an individual's symptoms. RecoveryOne "combines the power of digital with the human touch by connecting individuals to one of 180 evidence-based care programs for musculoskeletal conditions ..With this approach, RecoveryOne addresses the significant gap between actual and desired outcomes achieved through traditional care."

Blue Shield of California funded the launch of Altais in August last year, at that time stating “The company, named after a star, has been in discussions with potential partners to launch services and tools to help physicians and their practices reduce administrative burden and spend more time with patients. Altais is also in discussions to eventually provide primary and specialty care services.” Given the strategic objective of many health plans to expand clinical integration, it should come as no surprise that last month Altais and Brown & Toland Physicians announced they have signed a definitive agreement that paves the way for Brown & Toland and its network of more than 2,700 physicians to join Altais Clinical Services, a subsidiary of Altais.

And Commonwealth Care Alliance this week announced their “Winter Street Ventures investment arm has led a $5 million funding round in LifePod® Solutions, Inc. (LifePod). CCA will also distribute approximately 10,000 of LifePod proactive voice units to its members across Massachusetts as part of a broader virtual care program the organization is deploying during the COVID-19 crisis. LifePod’s unique proactive voice capability enables providers and caregivers to check in with and create reminders for individuals with significant health issues, including older adults aging in place and chronically ill patients. Through this expanded relationship with LifePod, CCA will greatly enhance its ability to stay in contact with its members, and to check in on their medical, behavioral health and social needs at a time when home visits are severely reduced to protect public health and safety.”

What changes in healthcare due to COVID-19 will remain after the pandemic is finally in the rear view mirror?

By Clive Riddle, May 1, 2020

The new issue of MCOL ThoughtLeaders asks the question: “What changes in the business of healthcare are taking place during this pandemic that will most likely continue when the pandemic is behind us?” Here’s some highlights of what experts see on the road ahead:

Here are some of the lasting changes Lindsay Resnick, EVP, Wunderman Thompson Health, predicts:

1. Virtual care and telehealth education, acceptance and uptake – from scalability to care management to customer experience, plan for it.
2. Surge in uninsured and COVID-19 as a pre-existing condition will revitalize the push for healthcare reform, and keep healthcare a central 2020 election issue.
3. Changes in consumer spending combined with healthcare’s growing ‘out-of-pocket culture’ will exacerbate delays in care: treatments, prescriptions, elective procedures.
4. New, more prominent roles for nurse practitioners and physician assistants throughout the care continuum are here to stay.
5. Economic downturn and unemployment will be big influencers in insurance product selection
6. Sites of care will continue to move away from hospitals and physician offices to an array of retail clinic options and at-home care alternatives.

Ewa Kisilewicz , Principal, BDC Advisors, Among other things says “COVID-19 has deepened consumer desire to stay away from hospitals. Consumer-centric providers will respond by adding non-hospital ambulatory capacity. Since mid-March, CMS and states released a set of waivers to address anticipated staff shortages caused by COVID-19. While waivers will expire post-COVID, it will be difficult to go back to the ‘pre-COVID norm’ on the changes that improve patient access and expand scope of practice in medically underserved areas – in so far as they do not create patient safety concerns. Once these regulatory barriers are knocked down, there will be little justification to build them back up again.” She also says “physician practice acquisition by non-traditional competitors will also be “fast forwarded” and cause health systems to rethink physician engagement.”

Patrick Horine, CEO, DNV GL Healthcare, noted that “big data, artificial intelligence, and integrated information systems have been evolving for some time in healthcare, but the pandemic has brought about the importance of more timely information being available, connecting providers, tracking & reporting capabilities and the ability to use the data and apply artificial intelligence to it.” He also counsels that a “critical importance to hospitals as well as the government moving forward, is the emergency preparedness, business continuity and contingency planning that will enable a more effective response for any future pandemic,” and that “it will be essential not only within healthcare, but also in companies, and in life, that we have more diligent infection prevention practices in place as well as modification of behaviors to stay healthy.”

Mark Lutes, Chairman, Epstein Becker & Green, PC cautions that “the Public Health Emergency (“PHE”) will leave many health care providers (hospitals, SNFs, hospices, physician groups) seriously weakened…Those providers that are not strongly capitalized will seek new sources of capital and debt relief. In many cases, they will align with better capitalized competitors or new entrants willing to recapitalize the assets. The credit worthiness of patients/consumers has also been impacted by the PHE. The cohort of patients with commercial coverage will shrink lowering providers’ margins. These consumers may find themselves in managed Medicaid or Marketplace options affording less patient choice. Providers will need to be organized in such a way to successfully contract with the organizers of the networks serving these options.

Hank Osowski, Managing Partner, Strategic Health Group  reminds us that the Telemedicine paradigm shift in how care is delivered “will likely impact staffing and real estate models.” He also laments that “what is disturbing however is how reactionary the response has been for many sectors of the healthcare industry.”

And finally, Terri Welter, Principal, ECG Management Consultants, discusses in more detail the following:

• Financial positions are compromised, prompting market repositioning.
• Strategy One: Aggressively renegotiate health plan contracts
• Strategy Two: Reshape service lines to bolster margins.
• Outpatient growth will accelerate.
• Strategy Three: Invest in building the ambulatory network.
• Strategy Four: Revisit capital investment plans.
• Strategy Five: Change the economic and service relationship between physicians and consumers
• Health plan networks will become bigger competitors for health systems and their physician networks.
• Strategy Six: Partner with independent medical groups.
• Strategy Seven: Restructure health system physician enterprise organizations

Hiding Our Heads in the Sand

By Kim Bellard, April 24, 2020

There are so many stories about the coronavirus pandemic — some inspiring, some tragic, and all-too-many frustrating. In the world’s supposedly most advanced economy, we’ve struggled to produce enough ventilators, tests, even swabs, for heaven’s sake. I can’t stop thinking about infrastructure, especially unemployment systems.

The U.S. is seeing unemployment levels not seen since the Great Depression, and occurring in a matter of a couple months, not several years. Many unemployment systems could not manage the flood of applications.

The word that has been repeatedly used to describe unemployment systems is “antiquated.” Many are still mainframe systems based on COBOL, dating as far back as the 1960’s. New Jersey Governor Phil Murphy lamented: “We have systems that are 40 years-plus old, and there’ll be lots of postmortems. And one of them on our list will be how did we get here where we literally needed COBOL programmers?”

And, let’s be fair: it’s not just state unemployment systems dependent on COBOL; many key federal systems are as well, including some used by the IRS, HHS, Treasury, and DoD, not to mention many banking systems.

There had been precious little money spent on upgrading the systems to more modern architectures, or even to retaining the programmers who could keep them running. When making budget decisions, it often seems like there will always be time to modernize…until there isn’t. Like in a pandemic.

We’re a nation that tends to underfund public pensions, at the local, state, and federal levels. We’re a nation whose infrastructure — e.g., roads, bridges, railroads, dams, water and sewer systems — is rated D+ by the American Society of Civil Engineers. And, as the COVID-19 pandemic is making so very evident, we’re a nation that has been extremely shortsighted in funding public health.

A new report from the Trust for America’s Health minces no words. President and CEO John Auerbach charges: COVID-19 has shined a harsh spotlight on the country’s lack of preparedness for dealing with threats to Americans’ well-being. Years of cutting funding for public health and emergency preparedness programs has left the nation with a smaller-than-necessary public health workforce, limited testing capacity, an insufficient national stockpile, and archaic disease tracking systems — in summary, twentieth-century tools for dealing with twenty-first-century challenges.

Tom Frieden, formerly of the CDC, warns: “We need an army of contact tracers in every community of the US to be ready to find every contact and warn them to care for themselves and stop spreading it to others.” Unfortunately, as Brian Castrucci of the de Beaumont Foundation told Time: “We waited until the house was on fire before we started interviewing firefighters.”

Oh, now we’re seeing why we need to invest in public health. Now we see why we need to invest in better UI systems. Now we see why things like the federal emergency stockpile and the Defense Production Act are important. It’s not like we didn’t know that pandemics could happen and how devastating they could be; we just chose to not be prepared.

We’ve been hiding our heads in the sand.

We’ll get through this pandemic. Not all of us, and not without too many of the rest us suffering in many ways. We’re told that we’re probably not going back to “normal,” at least not anytime soon, that we’ll have to adjust to a “new normal.” I just hope that the new normal includes a more clear-eyed perspective on being prepared for when pandemics and other catastrophes do strike.

We may never be fully prepared for when emergencies do hit, but we certainly can do better than we’ve done so far with this one.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard) 

Four Questions for The Whyzen Team at Health Intelligence Company on Solving the Rubix Cube of Health Plan Benefit Design with Analytics

By Claire Thayer

Drs Mary Henderson and Russell Robbins from The Whyzen Team at Health Intelligence Company participated in a Healthcare Web Summit webinar: Solving the Rubix Cube of Health Plan Benefit Design with Analytics.  The discussion highlighted the greater need for near real-time, population-specific health benefits analytics.  The speakers addressed how Whyzen is helping health benefits stakeholders spot outliers and track variations from benchmarks over time with quick views of cost, quality, and utilization.

Additionally, with COVID-19 being top of mind for so many, Whyzen has added reporting capabilities that allow health plans, employers, brokers/consultants identify who and where their most vulnerable employees/members are. This targeted information empowers all users to better allocate care management resources for targeted and impactful interventions.

If you missed this engaging webinar presentation, you’ll want to be sure to watch the Webinar Video. After the webinar, we interviewed the speakers on four key takeaways: 

1. What are some of the ways that employers are mitigating out-of-network costs?

The Whyzen Team at HIC: While out-of-network costs are not the biggest driver of healthcare trends, they are definitely substantial – and largely avoidable. Employers are looking for solid data to provide support for alternatives and programs that comprise key elements of benefit design. Whyzen provides the analysis and justification for appropriate programs.

For starters, employers need to assess the extent to which out-of-network costs drive overall trends. Whyzen – from Health Intelligence Company (HIC) – can help them quantify the scope of the problem and identify where the saving opportunities lie.

For example, for elective surgeries (e.g., bariatric surgery, orthopedic surgery), Whyzen can identify the types of procedures that were performed, the volume of procedures, and whether they were done in or out of network. To avoid high rates charged by out-of-network providers, Whyzen enables employers to guide employees to Centers of Excellence or to align patients’ needs with more appropriate sites of service.

2. You mention that employers are telling you that only "data nerds" can get value out of reporting and analytics solutions. Can you tell us more?

The Whyzen Team at HIC: Frequently, companies that use analytics solutions find them to be cumbersome to navigate, time-consuming  to get to a decision point, and lacking  actionable recommendations at the end of the analysis. As a result, plans, employers, and brokers tend to hand that work off to data experts, thereby distancing their clinical, care management, and benefit design staff from data-driven insights. And data analysts may not understand the clinical, quality, or financial implications of their findings.

Solutions that are accessible, intuitive, and inclusive of many data sources allow users to spend less time analyzing and more time developing strategies and interventions. Health Intelligence Company designed its Whyzen employer reporting solution with those features in mind.

3. How does Whyzen differentiate itself from competing solutions? What are its key strengths and differentiators?

The Whyzen Team at HIC: Whyzen stands out as the industry leader for employer reporting and analytics for a number of reasons:

•    Standard and Customized Reporting:
•    Interactivity
•    National Benchmarks
•    Flexible Analytics
•    Deep External Data Integration
•    Flexibility / User Configurability

4. What types of  benchmarks can Whyzen produce?

The Whyzen Team at HIC: Whyzen utilizes HIC’s National Benchmarking Module (NBM) to provide a rich set of benchmarks. HIC draws on a dataset that contains over 200 million unique lives and over 20 billion healthcare claims. Employers, brokers, and third-party administrators can compare relevant, HIPAA-compliant healthcare performance metrics. Whyzen can examine and compare cost and utilization performance by: 

Geography

•          National vs. regional vs. local
•          Census region and division
•          Region type (urban, suburban, rural, exurban, etc.)
•          State, city, or ZIP Code

Industry

•          Industry category
•          Standard Industrial Classification (SIC) codes

Product

•          Preferred Provider Organization (PPO)
•          Health Maintenance Organization (HMO)

Account Size

•          Small
•          Mid-Market
•          Large

By viewing data through geographic, industry, product, and account size lenses, users can easily:

•          Compare employer accounts
•          Drill into cost and utilization data
•          Explore quality measures, health risk scores, and clinical episode components

HIC’s unmatched data set and rigorous analytic model offer customers the single best view into how their spending compares on any number of dimensions.

For more information on Whyzen or Health Intelligence Company – or to view our recent webinar, “Solving the Rubix Cube of Employee Benefit Design” – click here.

Four Key Takeaways About Stroke Program Certification

By Claire Thayer

Tim Hehr, Stroke Technical Advisor, Stroke Program Development, DNV GL Healthcare and Debbie Camp, Stroke Program Manager, Piedmont Newnan Hospital, participated in a recent Healthcare Web Summit webinar: Stroke Program Certification: Positive Impacts on Safety and Quality Care in the Piedmont Healthcare System.  Piedmont Healthcare is a large hospital system in the Atlanta area, four of their hospitals are DNV GL Healthcare certified stroke centers – a designation they have held for the last 5 years. The discussion offered an overview of the process to achieve a DNV GL Stroke Program Certification as well as focused on how certification has positively impacted the Piedmont Healthcare System.   If you missed this engaging webinar presentation, you’ll want to be sure to watch the Webinar Video. After the webinar, we interviewed the speakers on four key takeaways: 

1. How many levels of stroke certification are offered by DNV GL Healthcare? 

Tim Hehr: There are 4 levels of stroke certification offered by DNV-GL Healthcare:  Acute Stroke Ready, Primary Stroke Center, Primary Stroke Center Plus, and Comprehensive Stroke Center

2. What are a few of the sources and guidelines utilized in the development of the DNV GL Healthcare stroke certification standards? 

Tim Hehr: There are several sources utilized in developing DNV-GL Stroke Center Certification standards including The American Stroke Association, The Brain Attack Coalition, The American Association of Neuroscience Nurses, and The Society of NeuroInterventional Surgery.

3. Describe some of the advantages of DNV GL stroke certification for an organization like Piedmont Healthcare.

Debbie Camp: The biggest advantage is the annual on-site surveys and the collaborative/partnership that is provided by subject matter experts (surveyors’) who truly understand the job we do. The surveyors share best practices from around the country with our Team which has greatly improved our stroke program throughout our system.

4. Can you share examples of specific guidelines that were reviewed at Piedmont and describe how they positively impacted stroke care in that organization?

Debbie Camp: The ppt went through some of the process improvement (PI) initiatives for the non-conformities (NC1-2) and/or opportunities for improvement (OFI’s) that we received from our survey’s.

Because of the PI process being implemented at a system level we are able to ensure best practices across the system.

Below are examples of some of the Standards that matched the PI initiatives that were presented on the webinar.

NC-1 QM.7 (CR.2i) (Door to Monitored Bed)/Code Alteplase

NC-2-1 PC.10 Patient Care Plan of Care (CR.1) /(CR.1g)/Stroke Bleeding Precautions & Documenting Modifiable Risk Factors

NC-2-2 PC.8 Patient Care Protocols/Pre & Post Alteplase Parameters met

NC-2-3 PC.12 Patient Care Diagnostic Testing /Development of the Stroke Narrator to capture MD @ BSD prior to CT

NC-1-2 QM.7 (Quality Mgt Systems) Measurement, Monitoring, Analysis, PC.12 (Pt Care Services), Diagnostic Test, MS.1 (Medical Staff) Admissions Requirements/Development of Stroke Narrator

NC-1-1 PC.4 Patient Care Services Emergency Department/Developing Alteplase Audit Handoff Tool

NC-1-1 Protocols PC.8/CR.3a   &   Required Documentation (MR.4)/(CR.6b)/Standardized S/P CEA order sets and Documentation of V/S & Neuro Checks  

To view the full webinar, Stroke Program Certification: Positive Impacts on Safety and Quality Care in the Piedmont Healthcare System  – click here.

Deploying SDoH Factors in the COVID Battle

By Clive Riddle, April 3, 2020

PWC’s Health Research Institute recent released: COVID-19: Six things health organizations should be considering (but might not be) offering six strategies that could be deployed in the fight against the pandemic. Number five on that list was SDoH:

“Strategies on social determinants of health can be an advantage in pandemic response. Trust-based relationships are important when people and communities are scared and unsure of what to do. Coalitions developed for pandemic response, much like social determinants of health interventions, should include trusted community organizations and providers that have access to hard-to-serve or underserved communities that may not be able to get information and support from traditional sources such as their employer or local government.”

A companion graphic noted "Less than 50% of primary care physicians said their practices coordinate with the right social service agencies.”

Health plans have come to embrace the SDoH component of removing economic barriers in treatment of COVID-19. While initially announcing waiver of any out-of-pocket costs for testing, more recently many health plans have issued announcements of waiving all treatment costs to consumers, including Aetna’s announcement on March 25^th,   Humana’s announcement and Cigna’s announcement on March 30^th, followed by UnitedHealthcare on March 31^st and Anthem on April 1^st.

Also, numerous health plans are making sizeable donations to COVID-19 relief efforts in their markets, including these:

Harvard Pilgrim Health Care Foundation Gives More Than $3 Million for Covid-19 Relief Efforts

Medica Donates $1 Million to Minnesota Non-Profits to Meet Emergency Needs from the Coronavirus

21 Organizations to Receive First $500K of $1M Committed by the Tufts Health Plan Foundation

Health Net Rolls Out $5.9 Million in COVID-19 Assistance for Those Serving Medi-Cal Members

But a more proactive approach in leveraging SDoH in the COVID-19 battle is being offered by analytics technology companies. Two such approaches were profiled in the April Care Technology Edition of Care Analytics News, discussing Jvion’s new COVID Community Vulnerability Map and Clarify’s COVID-19 Elderly Vulnerability Population Index (EVI) and the Clarify COVID-19 Patient Risk Profile

Jvion’s  COVID Community Vulnerability Map is built on Microsoft Azure maps, and enables healthcare providers and communities to identify the social determinants of health (SDoH) that put populations at greater risk during the COVID pandemic. Jvion states the map’s purpose is to inform “community planning and resource allocation to proactively mitigate the risk to vulnerable populations.” The Jvion COVID Community Vulnerability Map is available at https://covid19.jvion.com,

The interactive map identifies populations down to the census block level that are at risk for severe outcomes upon contracting a virus like COVID. Severe outcomes include hospitalization, organ failure and mortality. Additionally, the map surfaces the socioeconomic and environmental factors, such as lack of access to transportation or nutritious food, that put patients at greater risk. The map is also overlaid with points of interest, such as hospitals, food sources and transportation, in relation to the at-risk communities. These insights can help inform providers, public health organizations and community support agencies as they look to deploy interventions, outreach and other services to keep individuals from contracting the virus and, once infected, manage their care towards a positive outcome.

The map can quickly help local health departments prioritize their limited resources for response planning and adapt their tactics to the needs of neighborhoods and communities. By understanding the differentiated needs within their population, health systems can more adequately plan for healthcare utilization, deploy preventive or mitigating care resources, and anticipate the short-, mid- and long-term impacts of public health decisions, such as school and business closures.

Clarify Health announced that it launched two new critical applications in response to the needs of customers at the forefront of providing care to the communities impacted by COVID-19. The company is deploying the Clarify COVID-19 Elderly Vulnerability Population Index (EVI) and the Clarify COVID-19 Patient Risk Profile to healthcare organizations across the US to equip them with the patient risk insights that are needed to inform resource planning, interventions, and community initiatives.

The two applications leverage Clarify’s patient dataset, covering over 300 million lives, and AI capabilities. The solutions will reduce blind spots in patient risk by giving healthcare organizations access to an actionable COVID-19 vulnerability score for their elderly patients and a drill-down view into individual risk profiles and comorbidities at the point of care. Clarify’s COVID-19 EVI measures ZIP codes on relative vulnerability of seniors to severe coronavirus infection and delivers insights into their comorbidities, such as, cardiac diseases, respiratory diseases (including COPD), and cancer. The EVI provides hospitals, emergency services, health plans, and government agencies with the ability to identify neighborhoods which could benefit from greater testing or support services and prepare to take action quickly in high risk areas.

Clarify’s COVID-19 Patient Risk Profile is a web-based interface that highlights known risk factors for severe illness related to COVID-19. This capability is critical as frontline care providers struggle to proactively manage capacity and care for COVID-19 suspicious patients.

The New Scarlet Letter

By Kim Bellard, March 26, 2020

If you live in one of the jurisdictions that have imposed stay-at-home requirements, you’re probably making your essential excursions — grocery store, pharmacy, even walks — with a wary eye towards anyone you come across. Do they have COVID-19? Have they been in contact with anyone who has? Are they keeping at least the recommended six feet away from you? In short, who is putting you at risk?

Well, of course, this being the 21st century, we’re turning to our smartphones to help us try to answer these questions. What this may lead to remains to be seen.

Last week Israel granted its domestic security agency emergency powers to track the mobile phone data of people who have (or may have) coronavirus. The intent is for the health ministry to track whether such persons are adhering to quarantine rules, and possibly to alert others who had previously come in contact with them.

China is using the AliPay Health Code to assign color codes to individuals based on their known health status — green, yellow, red. The system is used in real time to determine, for example, who can board mass transit or use public housing. It is being rolled out nationwide, despite the lack of transparency about how the codes are determined, used, or updated.

Singapore has developed a tool — TraceTogether — that uses Bluetooth to track whose phones have been in close contact, and for how long. If someone then tests positive for COVID-19, the health ministry can easily determine who has been in contact with them.

South Korea is using smartphone data to create a publicly available map of movements of known coronavirus patients, and aggressively message those who might have come in contact with them.

Unfortunately, the information about their movements is having significant ripple effects, disclosing destinations users might have preferred not be public, or attaching a stigma to places they frequented.

In the U.S., volunteers from several big tech companies built covidnearyou, which allows people to self-report such facts as any symptoms, travel history, or exposure to people who have tested positive. Anyone can then use their map to determine if there are affected individuals near them.

MIT’s Media Lab has developed Private Kit: Safe Paths, “An app that tracks where you have been and who you have crossed paths with — and then shares this personal data with other users in a privacy-preserving way.” Unlike efforts in some other countries, the data is encrypted and does not go through a central authority. MIT Technology Review says:

Going one step further, two San Francisco hospitals have developed a smart ring that is “able to detect body temperature and pulse.” It is aimed at health care professionals and workers, such as ER doctors, as an early indicator of COVID-19 exposure. It’s probably only a matter of time before laypersons demand a version.

One can easily imagine such a smart ring being connected to a smartphone app, perhaps even generating a color code, and broadcasting the individual’s status and location to others worried about potential exposure. I bet Alibaba would be happy to help.

Tagging people and then broadcasting that tag, along with location and even identity, could put people at risk of discrimination (e.g., refused service or contact) and even attacks.

And we need to bear in mind that whatever technology we bring to bear on this public health problem could subsequently be used for other problems, public health or other. We increasingly live in a surveillance society, and that can be to our benefit — or to our detriment. We don’t always realize the slippery slope we’re on until the slide has become irreversible.

I’m all for using technology to address public health crises. I’m just not clear what the ultimate price we’re going to have to pay for that, and that makes me nervous.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

Seven Indirect COVID-19 Healthcare Business Implications, and Nostalgia for a 2020 Top Ten Healthcare Issues Infographic

By Clive Riddle, March 20, 2020

The HealthCare Executive Group (HCEG) recently released their 2020 HCEG Top 10 Infographic​ with summary data and insights garnered from the 10​th​ Annual  Industry Pulse Research Survey, which is shared below.

Of course, HCEG prepared the infographic based on their survey conducted well before COVID-19 sucked all the current oxygen out of the room in which most other healthcare issues are being discussed. Their survey results would undoubtedly look much different today, and almost feels nostalgic in a way.

Which poses the question – so how is COVID-19 impacting other key aspects of the business of healthcare.  Boundless information and discussion from true experts is coming forth daily on the public health implications and matters related directly to the pandemic. But what about the indirect implications, that will emerge as the year progresses?

Here’s a short list of seven items that come to mind, beyond the oft-stated concerns that the available healthcare clinician and support labor pool is at risk of being diminished from applicable quarantines, lack of personal protective equipment, and sickness within the healthcare workforce; as well as major concerns about hospital bed capacity:

1. RePrioritization: The strain on healthcare organizations while addressing COVID-19 issues, both as a provider and as an employer, will continue to cause other aspects of delivery of services to suffer as resources and attention are re-prioritized.
2. Deferral Cost: This will cause mounting deferral of non COVID-19 related care. Initially non COVID-19 healthcare costs and utilization will be lower than average, but after COVID-19 hopefully runs its course, these costs will escalate well above benchmark levels both due to pent-up demand plus increased services and costs with applicable worsening conditions resulting from deferral of care.
3. Uninsured: The uninsured population will increase significantly due to the economic slowdown driven by the pandemic and required response. Various past legislative and administrative measures to chop away at the ACA during the past three years will result in a weakened safety net.
4. Uncertainty: Uncertainty will reign in the short term for the general, and healthcare business environment, causing longer range business strategic initiatives to be paused.
5. Recession: Healthcare capital spending, M&A activity, and long-range initiative funding such as SDOH investments will thus slow down as this new Recessions escalates.
6. Policy: Healthcare election year policy reform issues will morph, both addressing public health policy issues, as well as coverage issues as the uninsured population increases.
7. Permanent Changes: Some required changes to clinical and business practices during this pandemic will evolve into longer range changes in clinical practices and how healthcare organizations do business.

Successful healthcare organizations in 2020 will somehow juggle and balance navigating the COVID-19 landscape while still keeping an eye on the ball of all the other issues that remain or result after COVID-19 hopefully subsides.

Speaking of keeping an eye on the other balls being juggled, and thus getting back to the HCEG infographic, here’s a reminder of their top ten items 2020 listed in the infographic, which we someday, somehow need to find our way back to, when we’re ready to move forward:

1. Cost& Transparency
2. Consumer Experience
3. Delivery System Transformation
4. Data & Analytics
5. Interoperability / Consumer Data Access
6. Holistic Individual Health
7. Next Generation Payment Models
8. Accessible Points of Care
9. Healthcare Policy
10. Privacy / Security

 

Five Questions for Rachel Sokol with Advisory Board on Frictionless Healthcare Experiences

By Claire Thayer

Rachel Sokol, Managing Director, Payer Research, Advisory Board participated in a Healthcare Web Summit webinar on The Financial Case for a Frictionless Experience.  The discussion highlighted several areas of frictions that highly impact cost of care use, satisfaction and retention efforts and where payers and health systems might think about prioritizing their experience improvement initiatives. If you missed this engaging webinar presentation, you’ll want to be sure to watch the Webinar Video. After the webinar, we interviewed Rachel on five key takeaways: 
 

1. What are a few of the common consumer experience initiatives that health plans are investing in?

Rachel Sokol: The biggest investments we see from plans center around the digital experience – so many plans building new websites, member-only portals, and apps.

2. Your focus of the presentation is on member friction and how this correlates with costly care use. How do you define “friction” from the consumer’s perspective?

Rachel Sokol: We define a “friction” as anything that prevents a consumer from easily and intuitively achieving their goals causing the consumer to hesitate or abandon the health care interaction altogether.

3. Continuing with the discussion on "friction" - what are some of the friction points that would result in a health plan member choosing to go out of network for care services?

Rachel Sokol: The biggest frictions we see leading to out of network use are discrepancies between what the insurer and what the provider say regarding service or physician coverage.

4. Your study points out that members aren't willing to wait for care, even at convenient sites like urgent care and telehealth.  What insights or suggestions do you have for health plans to improve member access?

Rachel Sokol: We’d suggest that plans make it easier for members to access these sites by pre-registering them wherever possible and making the process as familiar as they can with training and promotional materials.

5. To best manage the full member experience cycle, do health plans need to own physician practices in order to reach high levels of member service standards?

Rachel Sokol: Plans don’t have to own practices to offer a seamless experience – but if they don’t, they’ll need a strategy to compete with the expectations set by those that do.  If not ownership, close partnership will be essential to making sure that members have access to high value physicians ready to provide personalized care.

Will COVID-19 Create a Tipping Point For TeleHealth and Mobile Apps?

by Clive Riddle, March 6, 2020

mHealthIntelligence reminds us that the emergency spending now passed by Congress "will waive Medicare’s geographical restrictions on telehealth during a public health emergency, enabling providers to use telehealth in urban and rural areas as well as in the patient’s home" and "also loosens restrictions on the use of a telephone to deliver care, as long as that phone has audio-visual capabilities."

The Wall Street Journal notes that "doctor groups, hospitals and health insurers are increasingly steering people with mild or no symptoms toward initial visits conducted by phone, interactive video or secure messaging. They are also starting to use the technology to care remotely for people with suspected or confirmed cases of Covid-19, the respiratory disease caused by the virus."

CNBC reports, from a market perspective, that “Coronavirus could be a boon for telemedicine, as health industry hopes to keep ‘worried well’ out of the hospital” and that “the coronvirus outbreak could provide a bright spot for one sector of the health industry that has struggled to gain widespread acceptance: Telemedicine. Health insurer Anthem, for instance, is staffing up more doctors for its  service, LiveHealth Online, in case there are more cases in the United States. Telemedicine start-ups are also bracing for a rush of customers.”

But StatNews tell us that "Telehealth can help fight the novel coronavirus, but U.S. challenges could limit its potential," noting that "there are obstacles to telehealth in the U.S., since its health care system is not well-suited to widely adopt digital health tools. The biggest challenges stem from factors that don’t exist in China, like our vast array of private, state, and federal payers with varying reimbursement policies and state-based medical licensing."

These U.S. obstacles also impact adoption rates for mobile apps – which are evident not just with the urgent issue of COVID-19, but with the increased prevalence of chronic disease. Avalere has just released a report “Chronic Disease Mobile Health Apps Need Better Value Propositions and Evidence” that tells us this “increased prevalence of chronic disease in the US are incentivizing stakeholders to develop new solutions to tackle these issues. Many have turned to digital health innovations like mobile health applications to facilitate care prevention and management for chronic disease, but significant gaps remain in their ability to be used in real-world practice.”

The crux of the problem? Avelere says “mobile health apps are difficult to sell directly to patients, introducing additional complexity for how to fund the provision and maintenance of these technologies. With relatively few patients willing to pay for digital tools, health care organizations – providers (health systems or primary care practices) and payers (self-insured employers or health insurers) – often assume the costs. To date, little evidence demonstrates improved health outcomes or lowered costs that can justify the cost of development and adoption. However, some promising examples demonstrate clinical efficacy and cost savings in digital chronic disease management solutions”

Avalere advises that “to drive broader use and adoption of digital solutions in chronic disease, app developers need a strong value proposition that can demonstrate improved outcomes and cost efficiency to organizations that can both pay for apps and incentivize providers and physicians to use them.”

Perhaps COVID-19 might be an impetus with value proposition that could stimulate greater overall adoption that would benefit chronic disease initiatives as well.

Time Really Can Be Money

By Kim Bellard, February 26, 2020

If you are not an IKEA fan, or haven’t been spending any time in Dubai, you may have missed the chain’s marketing campaign to help promote its second store in the area. Titled “Buy With Your Time,” customers got store credits for how long they spent getting to the store.

Gosh, that’s something that should make any self-respecting critic of the U.S. healthcare system perk up. Count me as intrigued.

The campaign involved checking the customer’s Google Maps’ Trip tab to determine how long it took them to get to the store. IKEA benchmarked the average hourly wage in Dubai, and converted the travel time into how much credit they’d generated. It works out to about $29/hour, or $0.48 per minute. Spend long enough getting there and you could get a free coffee table or even a bookcase. Prices in the store include the equivalent time currency.

It is believed to be the first time a retailer is letting customers use their time as a means of payment. The program seems to have been a success.

I love this campaign for a couple reasons. One is the concept that it recognizes that, yes, our time is valuable, and not just in a lip service sort of way. The second is that “money” is a broader, more elusive, concept than the formal forms of currency that we usually use.

Healthcare should be thinking about both of those.

Travel is often not a prime consideration in healthcare, with medical tourism and centers of excellence still not achieving mainstream status. We like our healthcare local, failing to recognize that, for most of us, local is far from the best care we could get. But what if, taking a page from Ikea’s campaign, the time we spend traveling to — and taking off work for — sources of higher quality care translated into credits that we could use to pay for that care?

More important than travel time is the waiting. I have railed before about how the healthcare system often treats our time almost contemptuously. As I put it previously, we wait to get appointments, we wait at appointments, we wait during appointments, we wait for results after appointments, and, if we’re in a hospital or nursing home, we spend most of our time waiting.

Healthcare should be valuing the time we spend in the system waiting for something to happen. Some parts of the healthcare system seem to track and report waiting time — e.g., urgent care centers or emergency departments come to mind — but they don’t seem to do much with that information.

Imagine instead of paying health insurance premiums we accrue credits for our good health behaviors, which can be redeemed when we need some sort of intervention to maintain or improve our health. Ikea couldn’t have done its campaign without Google Maps, and we’re getting close to the kind of 24/7 tracking options that would allow for us to determine and manage such credits.

The problem will be that no existing entities in the healthcare system are really equipped (or incented) to administer such an approach, opening the door to new types of market entrants. Maybe we should ask the people at IKEA…

IKEA’s effort may just have been a clever gimmick to promote a new store in an isolated location, but there are lessons to be learned from it nonetheless. As Mr. Aten suggested, turning pain points for the customer into a win for the customer is, in fact, a win. If there is something that we can all agree on, it is that healthcare has too many pain points for its customers. The question is: how can we turn them into wins for those customers?

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

Ten Things to Know from HCCI's Health Care Cost and Utilization Report

by Clive Riddle, February 21, 2020

The Health Care Cost Institute has released its annual Health Care Cost and Utilization Report, now addressing 2018 data. The report "analyzes 2.5 billion medical claims to inform the public about trends affecting approximately 160 million U.S. individuals with employer-sponsored insurance." 

Here's ten takeaways from the 29-page report:

1. Health care spending grew 4.4% in 2018, slightly above growth in 2017 of 4.2%, and the third consecutive year of growth above 4.0%.
2. Total annual spending per person increased by 18.4%, from $4,978 to $5,892, between 2014 and 2018.
3. Between 2014 and 2018, average prices rose by 15%. Growth in average prices was 2.6% between 2017 and 2018, the slowest rate over the period.
4. Higher prices accounted for 74% of total spending increases above inflation over the 5-year period - an average of $453 per person.
5. Increased utilization of medical services accounted for 21% of spending growth after inflation - an average of $130 per person. Utilization of medical services rose by 3.1% between 2014 and 2018. Most of that increase, 1.8%, occurred between 2017 and 2018.
6. Professional Services averaged $1,985 per person, consuming 33.7% of spending. Outpatient Services averaged $1,662 per person, or 28.2% of spending. Inpatient Services averaged $1,128 per person, accounting for 19.1% of spending. Prescription Drugs averaged $1,118 per person, with 19.0% of spending.
7. Of the four major categories, outpatient visits and procedures saw the highest 2018 spending increase (5.5%), followed by prescription drugs (4.7%), professional services (4.5%) and inpatient services (2.2%)
8. Demographic shifts in the employer-insured population accounted for 4% of post-inflation spending growth over the 5-year period - an average of $27 per person.
9. People with job-based insurance saw their out-of-pocket costs rise by an average of 14.5%, or $114, between 2014 and 2018. The average out-of-pocket spending increased to $907 per person.
10. On average, Americans with employer-sponsored insurance spent $155 out-of-pocket on prescription drugs in 2018. Generic drugs accounted for 88% of all prescriptions. The average out-of-pocket price for generic drugs was less than 1/5 the average for brand-name drugs

SDoH, Chronic Care, Reinsurance, Pools and Doughnuts

By Clive Riddle, February 13, 2020

I gave a presentation recently to a healthcare group on the state of the business of healthcare in 2020, and in the ensuing reactor panel discussion, the topic of return on health plan investment in longer range initiatives such as in SDoH or applicable chronic care management programs came up.

For Medicare programs, plans can have the motivation to invest in programs that may take years to generate material improved outcomes and resource savings for individual patients – as they potentially can keep these patients enrolled for the duration. But with Medicaid and commercial programs, there is ongoing turnover – employees change jobs and individual Medicaid eligibility is subject to change.

Thus a plan that invests in long range programs for their covered Medicaid and commercial populations, may not retain specific individual members long enough to reap the improved outcomes and savings for those specific individuals. An SDoH investment might get a specific member on a better footing to improve their health, but then the member loses eligibility with that plan for a variety of reasons – loss of Medicaid eligibility, loss of a plan’s Medicaid contract, change of employer, change of plan during open enrollment, etc. Programs to improve certain chronic conditions or effect lifestyle or behavioral changes have the same challenge.

Many plans are investing in SDoH at least partly through a philanthropic perspective – typically providing funding through their plan’s affiliated foundation to designated Community Based Organizations that may serve some of the plan’s members, but also serve other segments of the population as well. Here’s some headlines during the past month in this regard:

• Anthem Blue Cross and Blue Shield Activates $3.6 Million Across Ohio in 2019
• CareFirst Contributed $43 Million To Health Initiatives in 2019
• Kaiser Permanente pledges $5.1M in 2020 to reduce homelessness
• Blue Shield of California Promise Health Plan Awarded $1.1 Million

But what if there was pooled funding mechanism for SDoH and eligible long-range chronic care management programs for pre-Medicare populations, Plans could refer members into applicable programs, and uninsured patients could participate as well. Plans could have allocated contribution requirements, along with other sectors providing funding.

Think of it as reinsurance pooling on the other end of the spectrum. In fact, a case can be made for advancement of pooling on both ends of the spectrum. Patients meeting catastrophic case criteria would transfer to coverage by kind of catastrophic “Medicare for All” plan. Plans would provide funding for the pooled plan, along with public funding, and uninsured could qualify as well if they met the criteria.

Between the pooled SDOH/Chronic Care programs, and pooled Catastrophic program, would be the doughnut hole filled by our quilt of current health care coverage.

Reinsurance pooling, while not as for along as a catastrophic Medicare for All program, does exist. Much of such efforts focus on the state ACA individual coverage markets. The Center on Budget and Policy Priorities published this paper last April covering the topic:  Reinsurance Basics: Considerations as States Look to Reduce Private Market Premiums. And for example, last August, CMS “approved Montana’s plan to create a reinsurance pool that aims to help lower individual health insurance premium costs.”

Pooled funding for SDoH programs is also not a new idea.  Back in 2016, the Public Health Institute published this paper: When Tackling the Social Determinants of Health, Pooling Funding Streams Is the Wise Course, stating “It seems like a logical approach to tackling tough social problems: coordinate across agencies, pool funds, and take aim at the issues from all angles. In practice, that rarely happens, but not for want of trying.”

You’ll also find the topic addressed in this February 2015 paper from the Center for Health Care Strategies: State Payment and Financing Models to Promote Health and Social Service Integration, and in this Institute for Medicaid Innovation January 2019 paper:  Innovation and Opportunities to Address Social Determinants of Health in Medicaid Managed Care.

In fact, while a December Health Affairs Blog piece Health Conundrum: How State Budgets Can Find The Balance Between Social Versus Medical Services  by Shannon Brownlee, Vikas Saini, and Benjamin F. Miller is skeptical that SDoH investment can lower spending – “there are several reasons to doubt this argument, if only because rising prices for medical services are driving national health care expenditures more than rising medical need” – they do go on to advocate pooled funding.

They authors state “in our report, we recommend that the California state government, and by implication all state governments, serve as a catalyst for multiple co-ventures of this type. States can convene all stakeholders, including health care institutions, health plans or payers, social service providers, community development financing institutions, and public health officials. They can also commission research, create the infrastructure for pooled funds for investing in community conditions, and draft new community benefit regulations for hospitals that would bring nonprofit health care providers to the table with funds to offer.”

So – food for thought - about programs that think about food as part of the solution, and doughnut holes between pools.

The Visits, They Are A-Changing

By Clive Riddle, February 7, 2020

Many facets of daily American life woven into the fabric of the Greatest Generation and Boomers have been gradually unraveling -  Attending church regularly, Belonging to service clubs, and Golfing for example. Is having a primary care doctor another?

The February issue of the Annals of Internal Medicine features the research article: Declining Use of Primary Care Among Commercially Insured Adults in the United States, 2008–2016.  The authors pose the issue, that despite well documented value to primary care visits and relationships, "there is early evidence of a decline in per capita primary care visit rates, and little is understood about what is contributing to the decline." They conclude: "commercially insured adults have been visiting PCPs less often, and nearly one half had no PCP visits in a given year by 2016. Our results suggest that this decline may be explained by decreased real or perceived visit needs, financial deterrents, and use of alternative sources of care."

 

Their study of 142 million primary care visits among 94 million member-years found that PCP visits declined 24.2%, from 169.5 to 134.3 visits per 100 member-years, while the proportion of adults with no PCP visits in a given year rose from 38.1% to 46.4%. Yet visit rates to specialists remained stable and visits to urgent care, retail clinics, and telehealth increased by 46.9%. They also found that the decline was largest among the youngest adults (−27.6%), healthier patients - those without chronic conditions (−26.4%), and lowest-income area residents (−31.4%).

Prior studies prompted the authors to examine this trend. Some previous indicators include:

• The Kaiser Family Foundation Health Tracking Poll in July 2018 found that 26% of all adults don’t have a primary care doctor – and that rate grows much higher for younger age groups: 45% without a PCP for age 18029; 28% for age 30-49; 18% for age 50-64 and 12% for age 65+.

• A study published in the November/December 2019 issue of the Annals of Family Medicine: National Trends in Primary Care Visit Use and Practice Capabilities, 2008-2015, found that PCP visits per capita declined 20% during this time period, while visit duration increased 2.4 minutes per visit, and visits addresses 0.3 more diagnoses and 0.82 more medications per visit. The authors offered the hypothesis that “the decline in primary care visit rates may be explained in part by PCPs offering more comprehensive in-person visits and using more non–face-to-face care.”  But perhaps this could also be explained by an aging case mix (fewer younger people seeking visits) that require more visit intensity.

• A study published in the EBRI March 2018 Issue Brief Consumer Engagement in Health Care Among Millennials, Baby Boomers, and Generation X Findings from the 2017 Consumer Engagement in Health Care Survey, reported that "Eighty-five percent of Baby Boomers have a PCP, compared with 78 percent among Gen Xers and 67 percent among Millennials."

Further studies and time will tell how much of this generational shift away from PCP visits is due to alternative points of care,  vs. cost issues, vs. changes in perception of the value of primary care, or perhaps – just maybe – PCPs are doing too good a job with younger generations in communicating electronically via patient portals and other means, and participating in plans with nurse call line options and web based care information that renders the lowest level of primary care physician visits unnecessary.

Quantum Theory of Health

By Kim Bellard, January 30, 2020

We’re pretty proud of modern medicine.  However, there has been increasing awareness of the impact our microbiota has on our health, and I think modern medicine is reaching the point classical physics did when quantum physics came along.  

Classical physics pictured the atom as kind of a miniature solar system, with well-defined particles revolving in definite orbits around the solid nucleus.  In quantum physics, though, particles don’t have specific positions or exact orbits, combine/recombine, get entangled, and pop in and out of existence.  At the quantum level everything is kind of fuzzy, but quantum theory itself is astoundingly predictive.  We’re fooled into thinking our macro view of the universe is true, but our perceptions are wrong.   

So it may be with modern medicine.  Our microbiota (including both the microbiome and mycobiome) both provide the fuzziness and dictate a significant portion of our health.   

Two articles in Science illustrate how we’re still just scratching our understanding of their impact.  The first, from Rodrigo Pérez Ortega, reports on two new studies. 

The first study found that the genetic structure of gut microbiome was more predictive of health than one’s own genes.  It was especially better for “complex” diseases that are attributed to both environmental and genetic factors.  Gut microbes are impacted sooner by environmental factors and thus serve as better predictors for such diseases. 

The second study found that a person’s microbiome could be used to predict their death 15 years later.  Presence of a certain family of bacteria led to a 15% higher mortality rate in the next 15 years.  Whether the bacteria are the cause of the mortality or a side effect of other factors is not clear. 

The second article was a study from B.B. Finlay, et. alia, that speculated that so-called non-communicable diseases (NCD) might actually be communicable, via the microbiome.  Their paper concludes:  “These findings could serve as a solid framework for microbiome profiling in clinical risk prediction, paving the way towards clinical applications of human microbiome sequencing aimed at prediction, prevention, and treatment of disease.”

Dr. Finlay says: “If our hypothesis is proven correct, it will rewrite the entire book on public health.”

Still, it is too early to get overly excited.   Everyone agrees more research is necessary.  Timothy Caulfield, the Research Director of the Health Law Institute at the University of Alberta, warns: “Gut hype is everywhere.”  He acknowledges that this is an exciting field with great promise, but cautions “it is still early days for microbiome research.”  

Think of modern medicine, with its germ theory of disease and its understanding of our body’s biomechanics, as classical physics.  Our recent discoveries about our microbiota are upending our notions about what disease is, what causes it, and how we should best deal with it.  Our supposed precision in medicine is illusionary.  

Modern medicine loves its antibiotics, despite the devastating impact they wreak on our microbiome.  It is fascinated with our genome, despite the fact that our microbiota’s genes greatly outweigh our own, and have more diversity.  Our microbiota change in ways that we don’t understand and, as yet, can’t even really track, much less predict the effect of. 

We need the equivalent of a quantum theory of health.  

Modern medicine is in the stage physics was in the early part of the 20th century, when the concept of quanta was known but the consequences of it were yet to be discovered.  

Modern medicine has had its Newtons, maybe even its Einsteins, but now it needs a new generation of scientists to develop more accurate theories of our health, no matter how counter-intuitive they might be.  

Welcome to a quantum theory of health.

This post is an abridged version of the original posting in The Health Care Blog.

The Yellow Brick Road to Savings $13B In Further Automated Healthcare Administrative Transactions

By Clive Riddle, January 24, 2020

CAQH has released their seventh annual report  - the 2019 CAQH Index - which measures "the progress made by the healthcare industry in reducing the costs and burden associated with administrative transactions through automation. Their 49-page report found that "of the $350 billion dollars widely cited as the cost of administrative complexity in the US healthcare system, $40.6 billion is spent on eight administrative transactions. Of that, the industry can save $13.3 billion, or 33 percent of existing annual spend, by transitioning to fully electronic processes." 

Regarding the $13.3 billion in potential savings through automation, the report tells us “$9.9 billion can be saved by the medical plans and providers, while $3.4 billion can be saved by the dental industry. In both industries, the greatest savings exist for providers as compared to plans.”

The Index report “analyzes levels of automation, spending and savings opportunities for eight administrative transactions related to verifying patient insurance coverage and cost sharing, obtaining authorization for care, submitting claims and supplemental information and sending and receiving payments.”

What are these eight transaction categories, and what were their corresponding rates of full electronic transaction processing in 2019 vs. 2015?

1. Eligibility and Benefit Verification:  84% 2019 | 71% 2015
2. Prior Authorization  13% 2019 | 10% 2015
3. Claim Submission  96% 2019 | 94% 2015
4. Attachments  20% 2019 | NA 2015
5. Coordination of Benefits  86% 2019 | 49% 2015
6. Claim Status Inquiry  70% 2019 | 57% 2015
7. Claim Payment  70% 2019 | 61% 2015
8. Remittance Advice  50% 2019 | 51% 2015

Of these eight transaction categories  - the term “Attachments” might be a little generic and require further definition. CAQH defines Attachments as "the exchange of patient-specific medical information or supplemental documentation needed to support administrative transactions and clinical decisions." They go on to say "serving as a bridge between clinical and administrative data, attachments are also critical to the success of value-based payment models" and that the majority of attachments are exchanges through mail and fax as opposed to electronically.

The largest remaining estimated savings opportunities from further automation are with:

• Eligibility and Benefit Verification:  $4.24 Billion
• Claim Status Inquiry: $2.16 Billion
• Remittance Advice: $1.85 Billion

CAQH’s call to action for the industry to achieve these savings centers around:

• Focusing efforts to reduce provider burden
• Accelerating standards and operating rule development to support harmonization of administrative and clinical data exchange
• Needing vendor adoption of all standards and operating rules; and
• Expanding research related to the administrative workflow

The CMS Innovation Center: Innovative Savings Projections?

Avalere has released a report: CMMI’s Financial Impact on Medicare Spending Challenging to Project, which concludes “CMMI’s impact on Medicare spending has not reached earlier projections by the Congressional Budget Office (CBO), demonstrating the difficulty in projecting savings from untested and future unknown alternative payment models.”

Before we delve into the details of Avalere’s findings, let’s take a step back and peek into what goes on these days at The Center for Medicare & Medicaid Innovation (CMMI), which they now like to refer to as the CMS Innovation Center.

The CMS Innovation Center tells us they develop new payment and service delivery models brought about by the Affordable Care Act and other legislation, overseeing a number of specific demonstrations to be conducted by CMS; and implement the Quality Payment Program brought about by MACRA. The demonstrations and QPP were developed with an underlying assumption of savings to be accrues, and Avalere is now finding the savings have missed their targets.

The CMMI site provides tables itemizing the Alternative Payment Models in the Quality Payment Program, which list 50 specific Alternative Payment Models (APMs), plus Other Payer Advanced APMs including 7 Medicaid Other Payer Advanced APMs; 59 Medicare Health Plan Payment Arrangements; and 2 CMS Multi-Payer Payment Arrangements.

The CMMI Site indicates 90 specific demonstration models, which fall under seven categories:

1. Accountable Care
2. Episode-based Payment Initiatives
3. Primary Care Transformation
4. Initiatives Focused on the Medicaid and CHIP Population
5. Initiatives Focused on the Medicare-Medicaid Enrollees (dual eligible)
6. Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models
7. Initiatives to Speed the Adoption of Best Practices

Given this scope, Avalere tells us that "CBO’s 2010 projection was $1.3 billion in net federal government savings from CMMI over the 2010-2019 budget window. In 2015, CBO began projecting more substantial savings from CMMI: $27 billion in net federal government savings over the 2016-2025 budget window; and then in 2016, $34 billion in net federal government savings over the 2017–2026 budget window."

Avalere however “estimates net Medicare savings of $18.0 billion from CMMI for the 2017-2026 budget window, lower than the $34 billion projected by the CBO in 2016. Net Medicare savings reflects expected reduced Medicare program expenditures net of CMMI outlays.” They break down their projection as follows:

1. The continuation and expansion of already-existing CMMI demonstrations generate $4.4 billion in gross Medicare savings between 2017 and 2026. 
2. Proposed demonstrations generate $21.4 billion in gross Medicare savings for 2017–2026. 
3. CMMI will launch new, not yet proposed demonstrations that generate $3.3 billion in gross Medicare savings for 2017–2026.

Of course, the aftermath of a Presidential election year could bring about any number of scenarios that could spin CBO or Avalere projections sideways.