Shorter length of stay improves readmission, mortality rates

Shorter length of stay improves readmission, mortality rates:
Despite fears that early discharge will compromise care, new research finds that shorter hospitals stays can actually improve readmission or death rates.
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Study Abstract: Associations Between Reduced Hospital Length of Stay and 30-Day Readmission Rate and Mortality

Study Editorial: Hospital Readmission Rates: Are We Measuring the Right Thing?

6 biggest drivers of healthcare waste

6 biggest drivers of healthcare waste:
A Health Affairs policy brief published yesterday points to care delivery failures, poor care coordination, overtreatment, administrative complexity, pricing failures, and fraud and abuse as the greatest drivers of waste in healthcare.
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Health Affairs Health Policy Brief Reducing Waste in Health Care

Telephone calls from nurses reduce readmissions

Telephone calls from nurses reduce readmissions:
A series of simple phone calls from a nurse can reduce readmissions and cut $1,225 in costs per patient, according to a study in this month's Health Affairs.
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Health Affairs: 
Low-Cost Transitional Care With Nurse Managers Making Mostly Phone Contact With Patients Cut Rehospitalization

Communication failures lead to rampant discharge medication errors

Communication failures lead to rampant discharge medication errors:
Three out of four patients are going home with the wrong prescriptions or don't understand their medications, according to a Yale-New Haven Hospital study.
read more
Connecticut Health I-Team article in the New Hampshire Register
Yale study: Medication errors, confusion common for hospital patients

Hurricane Sandy costs New York $3.1B in healthcare damages

Hurricane Sandy costs New York $3.1B in healthcare damages:
Among the near $40 billion in repairs and prevention costs that New York Gov. Andrew Cuomo requested in federal aid, $3.1 billion of that would go to hospitals and other health facilities.
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NY Governor's announcement: Governor Cuomo Holds Meeting with New York's Congressional Delegation, Mayor Bloomberg and Regional County Executives to Review Damage Assessment for the State in the Wake of Hurricane Sandy

Maps of 2012 Medicare accountable care organizations

Maps of 2012 Medicare accountable care organizations:
More than 150 collaborative groups launched their ACOs through the Center for Medicare and Medicaid Innovation. FierceHealthcare highlights the full lists and maps of Medicare ACOs that launched this year.
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The Influence of Social Environmental Factors on Rehospitalization Among Patients Receiving Home Health Care Services

Lack of home health support linked to readmissions:
New research adds even more fuel to the fire, in which some providers argue they face unfair financial penalties for readmissions outside of their control, with social factors affecting patients returning to the hospital.
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Advances in Nursing Science: The Influence of Social Environmental Factors on Rehospitalization Among Patients Receiving Home Health Care Services

The rising SNFist could curtail readmissions

The rising SNFist could curtail readmissions

Looming readmission penalties force hospitals to improve transitions

Looming readmission penalties force hospitals to improve transitions http://www.fiercehealthcare.com/story/readmission-penalties-push-safe-transitions/2012-08-30

More providers join CMS efforts to reduce readmissions

More providers join CMS efforts to reduce readmissions http://www.fiercehealthcare.com/story/more-providers-join-cms-efforts-reduce-readmissions/2012-08-20

Leaders brace for October readmission penalties

Leaders brace for October readmission penalties http://www.fiercehealthcare.com/story/hospital-execs-react-readmission-penalties/2012-08-20

Association Between Patient-Centered Medical Home Rating and Operating Cost at Federally Funded Health Centers

Better patient-centered medical homes cost more:
Running a better patient-centered medical home (PCMH) may have higher operating costs, according to a study in the Journal of the American Medical Association. Researchers from the University of Chicago found that having an overall score that was 10 points higher than the average performance score was associated with a $2.26 higher operating cost per patient per month, which translates to an annual cost of $508,207.
PCMHs scoring 10 points above the mean for patient tracking and for quality improvement both were associated with higher operating cost per physician full-time equivalent (FTE) and per patient per month.
However, better access/communication was associated with a lower operating cost per physician FTE. For instance, the cost of providing telephone-based clinical advice could be offset if it replaces a more costly in-person visit, the researchers wrote.
Researchers said the larger price-tag is fairly small compared with the potential cost savings from avoided hospitalization and emergency department visits, reported MedPage Today. Previous studies have estimated savings of up to $18 per member, per month from patient-centered medical homes, according to the study.
In fact, patient-centered medical homes already are recouping savings and improving care. CareFirst Blue Cross Blue ­Shield PCMH has saved $40 million in the program's first year, while the first-year results for Horizon Blue Cross Blue Shield of New Jersey's PCMH are a 10 percent decline in the cost of care per member, a 26 percent decline in emergency room visits and a 25 percent decrease in hospital readmissions.
With the trend toward patient-centered medical homes, healthcare organizations can heed the lessons learned shared at the American College of Healthcare Executives' annual congress in March. Laura Etchen, partner at healthcare consulting company The Chartis Group in Chicago, recommended considering National Committee for Quality Assurance accreditation to attract physicians, and John Butterly, executive vice president for medical affairs at Dartmouth-Hitchcock in Lebanon, N.H., advised healthcare leaders to engage physicians and nurses by being honest about implementing the new care model, FierceHealthcare previously reported.
To learn more:

- read the study

- here's the MedPage article
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National Trends in Emergency Department Occupancy, 2001 to 2008: Effect of Inpatient Admissions Versus Emergency Department Practice Intensity

Unsustainable ED crowding grows twice as fast as visits:
Emergency department crowding is growing twice as fast as visits and will rise to unsustainable proportions, according to Jesse Pines, director of the Center for Healthcare Quality at George Washington University and associate professor of emergency medicine and health policy in Washington, D.C.
ED visits increased 60 percent faster than population growth over an eight-year period. Crowding, or occupancy, as it's called, grew even faster, according to an Annals of Emergency Medicine study published online Tuesday. While ED visits increased by 1.9 percent annually from 2001 to 2008, crowding grew by 3.1 percent.
"Visit volume is going up, which is outpacing population group, and patients are staying longer and longer within the ED getting more intense work-ups and treatments," Pines said in a statement to FierceHealthcare. "Together, the 'occupancy,' which is the number of patients in our nation's emergency care system at one time, is rising at a very rapid, unsustainable rate."
Although advanced imaging often receives much of the blame for delays in the ED, researchers found that it had more to do with practice intensity, that is, blood work and x-rays at triage, that's really bogging down the ED.

Patients are getting more tests, fluids and procedures for a number of reasons, Pines explained. Some providers are practicing defensive medicine, but patients and providers also expect high-technology care, such as requiring CT scans or other advanced test before admitting the patient to the hospital.
"As technology outside the ED improves, such as organ transplantation and cancer care, when patients have complications--and they do--they end up coming in and are sicker and need more ED resources to take care of them," Pines said about the older, sicker population.
Even more, EDs have become rapid diagnostic centers. For example, patients who need X-rays will go to the ED because it's the fastest place to do it, especially when their physicians refer them there, Pines said.

______________________________ "The 'occupancy,' which is the number of patients in our nation's emergency care system at one time, is rising at a very rapid, unsustainable rate." --Jesse Pines, director of the Center for Healthcare Quality at George Washington University ______________________________

"Lengthy work-ups in the emergency department are not always a bad thing if they prevent a costly hospitalization. The problem is that more and more demands are being placed on emergency departments and the mood in the health policy community is to shrink emergency departments, not grow them," Pines said in a research announcement.
Providers can help patients early in the care process, trimming off wasted time in the waiting room. For instance, hospitals can place a physician at triage or eliminate triage altogether when there are empty rooms.
In addition, facilities can use space better to meet patient demands. When the ED is full, patients can wait in the ED, as opposed to outside of it in the waiting room, for tests to be completed.
And lastly, much of the way that ED crowding should be avoided is pinching it off at the source and preventing ED visits altogether with public health measures so patients don't get sick or allowing patients to get "sick visits" at their doctor's office, Pines noted.
For more information:

- here's the research announcement

- see the study (.pdf)
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ACO development grows 38% nationally

ACO development grows 38% nationally:
The accountable care organization (ACO) trend still is rising with more than 200 identified ACOs in the nation, according to intelligence business firm Leavitt Partners. Located in 45 states and the District of Columbia, ACOs total 221 partnerships, up from 160 ACOs in 40 states in November 2011, showing a 38 percent increase in only six months, according to a report released Thursday.

Most of the ACOs are coming from the private sector rather than from the government, outnumbering them four to one. Although the Medicare ACO model is an outgrowth of the accountable care movement, it's not a driving force behind it, Leavitt Partners noted.
Of the 221 ACOs, 148 are single provider ACOs (67 percent), 43 are multiple-provider ACOs (19 percent), 17 are insurer ACOs (8 percent) and 13 are insurer-provider ACOs (6 percent).
"The consistent growth in the number and variety of organizations adopting accountable care demonstrates the momentum of the ACO movement," Andrew Croshaw, a partner and managing director of the healthcare practice at Leavitt Partners and one of the study authors, said in a company statement. "Many providers appear to believe the accountable care model is an important component of the future of American healthcare."

Hospitals are taking the lead as the sponsoring organizations, growing from 99 to 118 ACOs as the primary backers. However, in the past eight months, the number of ACOs sponsored by physician groups has nearly doubled from 38 to 70 ACOs. Insurer-sponsored ACOs remain steady.
Although the number of ACOs continues to grow, it's difficult to determine their success.

"As ACOs become firmly established, it is increasingly important to measure the results of different models," the report noted.
For more information:
- see the company announcement
- check out the white paper (.pdf)

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New York RHIOs and HIEs team up to create 'model for the rest of the nation'

New York RHIOs and HIEs team up to create 'model for the rest of the nation':
The New York eHealth Collaborative (NYeC) and the New York State Department of Health announced Wednesday that three regional health information organizations (RHIOs) and three health information exchange (HIE) vendors will participate in the Statewide Health Information Network of New York (SHIN-NY), which officials say will function much like a public utility.
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3 reimbursement changes for hospital performance

3 reimbursement changes for hospital performance:
Hospitals are bracing themselves for some significant reimbursement changes under health reform that could hit their pocketbooks. The American Hospital Association (AHA) outlined top issues in its 2012 advocacy papers, including how hospitals will be measured for performance this year and beyond.

Value-based purchasing (VBP) - October 2012
Medicare will launch the hospital VBP program, in which pay-for-performance programs will receive incentives for demonstrated excellence and improvements in patient safety and effective care. The Centers for Medicare & Medicaid Services released the final rule in August last year. The AHA had serious concerns about CMS' proposal to include hospital-acquired conditions measures because a separate HAC provision would penalize hospitals, as well as the weighting of patient experiences. CMS will likely propose additional measures over the next several years, AHA said, with certain measures retiring when hospitals reach the maximum performance, that is, when hospitals can improve no further.

Readmissions - October 1, 2012 (FY 2013)
Under the Affordable Care Act provision, hospitals will face penalties for excess readmissions for heart attack, heart failure and pneumonia, starting in October. CMS did account for planned readmissions from heart surgeries following a heart attack, based on the AHA's urging.

The AHA also is pushing the agency to include community factors that could affect readmission reimbursements, which, "thus far, CMS has refused to account for," the association said.
"CMS needs to recognize that readmissions are the result of many factors, some are within a hospital's control, and some are related to the lack of resources elsewhere in the community, such as adequate numbers of primary care clinicians and access to pharmacies," AHA said. "There is compelling evidence that safety-net hospitals and others serving large numbers of low-income individuals will have difficulty reducing readmissions due to the lack of some of these resources in the communities they serve. This creates an unfair system that puts these hospitals at greater risk for substantial readmission penalties."
Hospital-acquired conditions - FY 2015
Hospitals also will face Medicare penalties for hospital-acquired conditions, starting in fiscal year 2015. Those that do well in the top quartile of national rates will receive 99 percent of their Medicare payments for all discharges. Some hospitals, however, will face penalties each year if they fail to progress--a position that AHA strongly opposes.

AHA stated, "Provisions from the Patient Protection and Affordable Care Act (ACA) must be implemented in a way that is fair and equitable for hospitals while seeking to avoid adverse unintended consequences."

However, an American Journal of Infection Control study this week found that CMS-issued penalties from 2008 did boost infection-control efforts, in which infection preventionists reported increased focus on stopping catheter-associated urinary tract and central line-associated bloodstream infections.

For more information:
- check out the AHA issue papers, including the hospital performance paper (.pdf)
- here's the AHA News Now brief

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NQF endorses readmission measures

NQF endorses readmission measures:
Falling in line with national initiatives, the National Quality Forum endorsed two new measures for all-cause unplanned readmissions Tuesday.

One of the endorsed measures, developed by National Committee for Quality Assurance (NCQA), counts the number of inpatient stays for adult patients to predict the probability of an acute readmission. The second measure is a risk-adjusted readmission rate for surgery/gynecology, general medicine, cardiorespiratory, cardiovascular and neurology. Developed by the Centers for Medicare & Medicaid Services and Yale University, the measure estimates the risk-standardized rate of unplanned, all-cause readmissions.
Many providers have criticized national measures of readmissions as an indicator of quality. For example, at the University of California, San Francisco Medical Center, researchers found that all-cause readmissions inflated rates by 25 percent because they fail to differentiate between planned, scheduled, staged and unplanned surgeries for complications.

NQF said the two newly endorsed measures account for multiple factors that affect readmissions, including the complexity of the medical condition, effectiveness of inpatient treatment and care transitions, patient adherence to treatment plans, patient health literacy and availability of community-based services.
"The recently endorsed NCQA and CMS/Yale measures will focus attention on the multiple patient and system factors which influence re-hospitalizations," Sherrie Kaplan, assistant vice chancellor for healthcare measurement and evaluation and professor of medicine at the University of California, Irvine School of Medicine, said in a statement. "These measures will hopefully encourage increased communication and collaboration among all the stakeholders needed to reduce avoidable re-hospitalizations."
Costing about $15 billion each year, readmissions are the target of federal programs tied to reimbursements. One in every five Medicare beneficiaries ends up back in the hospital within 30 days, according to NQF President and CEO Janet Corrigan.
The U.S. Department of Health & Human Services has set a goal of cutting readmissions across all settings by 20 percent in 2013 compared to 2010 rates as part of its Partnership for Patients campaign.

To learn more:
- here's the NQF statement
- see the NQF-endorsed standards

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Healthcare execs to mentor digital startups in NY 'accelerator' program

Healthcare execs to mentor digital startups in NY 'accelerator' program:
In a move that combines an interest in improving health outcomes with a desire to create jobs and boost the state economy, the New York eHealth Collaborative (NYeC) and the New York State Department of Health (DOH) have partnered with the New York City Investment Fund to launch the New York Digital Health Accelerator (NYDHA). The program will subsidize health IT startups and link them with "senior advisors" from New York healthcare organizations to accelerate the development of useful new products.
Within the next few months, the program will choose 12 "early- and growth-stage companies" that are developing products in the areas of care coordination, patient engagement, data analytics and message alerts for healthcare providers. In addition to the mentoring, each selected company will receive up to $300,000 to help create solutions designed to improve quality of care for the state's Medicaid recipients, according to a NYDHA announcement.
Supported by an initial investment of $4.2 million, the Digital Health Accelerator is expected to create about 1,500 jobs over five years. Additionally, the companies involved in the NYDHA are expected to attract as much as $150 million to $200 million in venture capital.
An investor syndicate has agreed to participate in NYDHA. The syndicate includes Aetna, Milestone Venture Partners, New Leaf Venture Partners, New York City Investment Fund, Quaker Partners, Safeguard Scientifics and UnitedHealth Group. The Empire State Development Corporation, Health Research Inc., and NYeC will provide additional funds and/or services to operate the NYDHA, the announcement said.
Eighteen New York healthcare organizations have agreed to participate, including Maimonides Medical Center, NYC Health and Hospitals Corp., New York-Presbyterian Hospital, and Northshore LIJ Health System in the New York metropolitan area. Upstate New York is also represented by such providers as Albany Medical Center, Finger Lakes Community Health, and Visiting Nurse Service of Schenectady and Saratoga Counties.
New York State has for several years been in the forefront of health IT innovation. The state's HEAL N.Y. program has invested $250 million in developing health information exchanges. In addition, HEAL grants have gone to a number of other quality improvement programs, including New York City's Primary Care Improvement Project, which subsidized EHRs for doctors in underserved areas.
To learn more:
- read the NYDHA announcement
- see a Health Affairs study on the HEAL program
- check out a list of recent HEAL grants
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Readmission rates higher with long stays, heart failure

Readmission rates higher with long stays, heart failure:
As the industry focuses on curbing readmissions, a new a report reveals that roughly 13.5 percent of hospital stays in Pennsylvania in 2010 were followed by at least one readmission within 30 days, while 5.6 percent were followed by a readmission specifically for a com­plication or infection, according the Pennsylvania Health Care Cost Containment Council (PHC4).
The report also found that heart failure patients were responsible for most of the readmissions at 8,846--at a 24.3 percent rate. Mental health disorder patients followed with 6,533 readmissions.
But not all readmissions can be prevented, PHC4 Executive Director Joe Martin said in a statement today, citing follow-up care, patients' willingness or ability to follow post-discharge instructions, patients' access to transportation and insurance coverage as factors that can cause repeat visits. His stance challenges a January study in The Journal of the American Medical Association that found readmissions are indeed preventable.
The PHC4 report also noted that patients were more likely to come back within a month of discharge the longer they stayed in the hospital during the initial visit. In fact, readmission rates more than tripled when length of stay increased from one day (9 percent) to 15 or more days (28.1 percent).
Despite the reason for readmission, the report found that patients' hospital returns led to some hefty Medicare costs. "In 2009, which is the last year for which we have statistics, Medicare just for seniors paid almost half a billion dollars for readmissions," spokesman Gary Tuma told Essential Public Radio. "That doesn't count the original hospital stay, that's just for readmission and treatment associated with it," he said.
For more:
- here's the PHC4 statement and report (.pdf)
- check out the Essential Public Radio piece
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Men have more readmissions, need post-discharge support

Men have more readmissions, need post-discharge support:
Men have a higher rate of hospital utilization within 30 days of discharge than women, according to a study in BMJ Open. Men are more likely to return to the hospital post-discharge if they are retired, unmarried, exhibit depressive symptoms or have no primary care provider visit during the month.
"Additionally, men fared more poorly at understanding and attending their follow-up appointments, which also appeared to be an independent risk factor for returning to the hospital for men in this study," researchers state. They also note that men's reduced access to primary care may factor into their additional use of hospital services.
With those risk factors in mind, researchers suggest healthcare organizations can lower the risk for early post-discharge readmissions among men by connecting them to primary care services, addressing social isolation by fostering social support and routinely screening for depressive symptoms.
Researchers acknowledged that the study was limited to an urban safety-net hospital, reported Medscape Today.
Gender disparities can go beyond healthcare utilization, as a study published earlier this year in the journal Health Services Research examined differences in perceptions of care between men and women and found that women were more critical. Women tended to be less satisfied with staff responsiveness, their discussions with nurses, communication about medications and discharge plans, and cleanliness and hygiene issues, FiercePracticeManagement reported.
To learn more:
- here's the abstract and full study
- read the Medscape article
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Patients choose hospitals based on social media

Patients choose hospitals based on social media:
With one-third of consumers using social media for seeking or sharing medical information, 41 percent say tools like Facebook, Twitter, YouTube and online forums influence their choice of a specific hospital, medical facility or doctor, according to Tuesday's report from consulting firm PwC.

In a survey of more than a thousand consumers, more than two-fifths of individuals said social media did affect their choice of a provider or organization. Forty-five percent said it would affect their decision to get a second opinion; 34 percent said it would influence their decision about taking a certain medication and 32 percent said it would affect their choice of a health insurance plan.

The PwC report follows a study last summer by hospital market research firm YouGov Healthcare, which found that 57 percent of consumers said a hospital's social media connections would strongly affect their decision to receive treatment at that facility.

Following the release of the study, YouGov Healthcare Managing Director Jane Donohue told FierceHealthcare, "We were surprised that consumers were going to review sites and blogs as often as they are going to the official hospital sites." She added, "Clearly, any successful social media strategy is going to have to monitor and engage those [review site] conversations because you don't control them. With your own content on Facebook and Twitter, you have a lot of control, but you certainly need to be engaged in those conversations."

However, as one reader noted on the story, "This is the kind of research that ends up misleading healthcare managers to go down a strategic path to nowhere. ... Social media is a valuable and growing tool for communication, but it is nowhere near the usage deciding factor."

Even if the studies overestimate social media's impact on consumer behavior, other experts say it goes beyond marketing.
"Savvy adopters are viewing social media as a business strategy, not just a marketing tool," Kelly Barnes, US Health Industries leader of PwC, said in a company announcement.
Farris Timimi, medical director for the Mayo Clinic Center for Social Media, said social media in healthcare is a "moral obligation," at the ninth annual World Health Care Congress in in National Harbor, Md., on Monday, FierceHealthIT reported.
"Our patients are there. Our moral obligation is to meet them where they're at and give them the information they need so they can seek recovery," Timimi said. "This is not marketing; this is the right thing to do."
For more information:
- check out the PwC report
- here's the accompanying announcement
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Personal touches help patients at risk for readmission

Personal touches help patients at risk for readmission:
Just as the government is ramping up efforts to curb readmissions, hospitals are working to keep discharged patients from bouncing back to the hospital.
Marin General and Novato Community hospitals in California, for example, are part of Advanced Care Transitions, one of the 30 Centers for Medicare & Medicaid Services pilots nationwide, aimed at reducing Medicare costs by $8.2 billion by 2019, Marin Independent Journal reported. The two hospitals target about 700 of the highest-risk Medicare patients with heart failure, pneumonia, diabetes and other chronic conditions.

The county plans to hire two new nurses as transitional coaches, who will meet with patients before discharge and post-discharge at home. Not only are the hospitals improving the discharge process, but they also are making sure patients take their medications during the post-discharge home visit and through patient education.
Having someone the hospital can refer patients to for follow-up after they return home "is something we haven't had in the past," Mary Strebig, a spokesman for Novato Community Hospital, said in the article.
Like the Marin hospitals, Glendale, Calif., hospitals are similarly targeting high-risk patients with heart attack, congestive heart failure and pneumonia, as one in five of those high-risk patients readmit to the hospital within 30 days, according to Glendale News-Press.
The Glendale Healthier Community Coalition created a task force to look at the annual 40,000 patients discharged from area hospitals. The task force not only looks at provider reasons to readmissions but also the patient's situation, such as whether the patient is homeless or foreign-born, which might affect their ability to care for themselves.
"Even going 12 to 18 hours without their medication could already put them on a trajectory for readmission," Bruce Nelson, director of community services at Glendale Adventist Medical Center and cochair of the task force, said in the article.
Nelson said case managers at hospitals are helping with tasks, such as transportation to doctors' offices and refilling prescriptions, as well as coordinating care across the continuum, including skilled nursing facilities.

CMS this month launched two programs, the Community-based Care Transitions Program and Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. CMS has dedicated $500 million to Partnership for Patients funding. The Partnership's two goals are reducing hospital readmissions by 20 percent over a three-year period and reducing harm in hospital settings by 40 percent.

For more information:
- read the Marin Independent Journal article
- here's the Glendale News-Press article

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Supreme Court gets to crux of health reform

Supreme Court gets to crux of health reform:
One of the most highly anticipated U.S. Supreme Court cases in recent memory kicked off yesterday. Inside the Court, testimony was often technical and even dense, while, outside the court, the atmosphere was lively with a gathering of protesters, reporters, pundits, politicians and curious spectators. In fact, the fun started on Friday, when folks (including professional line-standers) started lining up outside the court, in hopes of grabbing a coveted seat.
Yesterday's arguments before the Supreme Court centered on whether the Court can rule on the Affordable Care Act and its "individual mandate" provision, which requires all Americans to have health insurance by 2014 to avoid paying a penalty when they file their tax forms in 2015.
The question in yesterday's case: Is the penalty for not having health insurance a fee, or is it a tax?
If it's a tax, the justices could bow out under the 1867 Anti-Injunction Act, which says the court can't hear a case about unconstitutional taxes before plaintiffs actually have paid the tax, which won't happen until 2015.
Both sides agree on this one matter: The case should be litigated now. In fact, the court had to appoint an attorney, Robert Long, to argue the opposite because neither side wanted to do so. Among his arguments: There is no criminal penalty for not paying the fee and, if the court grants exceptions, it will lead to a flood of litigation.
But the litigants will argue that the individual mandate requires people to buy a commercial product and is unconstitutional for that reason.
Justice Ruth Bader Ginsburg said the tax issue is "beside the point" and questioned Long about the "must-buy" aspect of the case. "... All this talk about tax penalty--­it's all beside the point because this suit is not challenging the penalty. This is a suit that is challenging the must-buy provision, and the argument is made that, if, indeed, 'must-buy' is constitutional, then these complainants will not resist the penalty," she said.
"So, what they're seeking is a determination that that the 'must-buy' requirement, stated separately from the penalty, that 'must-buy' is unconstitutional. And, if that's so, that's the end of the case; if it's not so, they're not resisting the penalty."
It is notoriously difficult--if not downright foolish--to try to guess what the Supreme Court will do based on their questions during oral arguments. Even if they often start statements with the phrase, "It seems to me," the justices play the role of devil's advocate frequently and well.
But there's a general consensus that they will rule on the ACA cases scheduled for today and tomorrow. On Monday, justices pointed out that they've put aside or made exceptions to the Act in order to rule on other cases.
"I don't usually make predictions but I thought it was pretty clear that the justices are going to rule on the Affordable Care Act. The only question is what the rationale is going to be," Nina Totenberg, who covers the court for NPR, said in an audio interview yesterday on NPR's Shots blog.
"[Justice Clarence] Thomas was the only justice who didn't ask any questions. He hasn't asked any questions in six years so we don't know what he's thinking," Totenberg said. "But other than that [I saw] a bunch of justices groping for a way to get to the merits of this case and get over this hurdle."
For the gamblers out there, FierceHealthFinance Editor Ron Shinkman is offering 7 to 1 odds on whether Thomas will ask a single question during the three days of arguments. Odds that the Court will strike down the individual mandate are five to six, and it's even money that ACA will prevail in its entirety, he said.
The Supreme Court is set to announce its ruling on the ACA cases later this summer.
In today's case, The Department of Health & Human Services v. Florida, et al, attorneys will get to the real heart of the matter: Can the federal government require U.S. citizens to get health insurance or face paying a penalty?
"[Tuesday] is really the 'main event' from the perspective of many organizations, politicians, businesses and individuals who have been involved with or just have followed the debate over the constitutionality of the new health care law, Marcia Coyle of the National Law Journal told PBS News Hour in a guide to day two of the ACA arguments.
To learn more:
- listen to an audio recording of yesterday's oral arguments or read the transcript (.pdf) of yesterday's session
- see the docket that lists all the ACA cases before the court, including case filings
- read the NPR Shots blog article and listen to Nina Totenberg's recap and analysis of Monday's oral arguments
- see the News Hour roundup of day one and guide to day two of the ACA arguments
- hear from would-be spectators who spent their weekend waiting in line for a seat in the courtroom
- check out the Bettor's guide to health reform at the Supreme Court from FierceHealthFinance

Hospital checklists cut readmissions, Medicare costs

Hospital checklists cut readmissions, Medicare costs:
In another win for in-hospital checklists, new research finds that a simple, one-page checklist can keep heart patients out of the hospital, as well as save Medicare billions of dollars, according to a presentation Saturday at the American College of Cardiology's (ACC) annual scientific session.
After using the 27-question checklist before discharge, 30-day readmissions significantly dropped from 20 percent to 2 percent. The checklist focuses on medications and dosage modification, counseling and monitoring intervention, and follow-up instructions, according to information from the ACC.
"In addition to lowering 30-day and six-month readmissions and the associated costs, we also showed that more patients in the checklist group were likely to be on correct medications and had appropriate drug doses than patients in the control group," study lead investigator Abhijeet Basoor of St. Joseph Mercy Oakland Hospital in Pontiac, Mich., said in a statement.
According to the researchers, the checklist takes only a few minutes to administer and has no costs or side effects, reported USA Today.

Meanwhile, another ACC study of public hospitals in Brazil found that checklists and color-coded signals significantly boosted physician adherence to evidence-based treatment for patients with acute coronary syndrome, MedPage Today reported.
"[I]f patient care can be improved when adoption rates are more in the 'middle range,' then our results are relevant to rest of world and to the U.S. for diseases other than ACS, for which evidence-based medicine uptake is much less common," study authors wrote in the Journal of the American Medical Association.
To learn more:
- read the ACC press release
- here's the USA Today article
- read the MedPageToday article

CMS ramps up efforts to keep patients out of hospital

CMS ramps up efforts to keep patients out of hospital:
The Centers for Medicare & Medicaid Services made two announcements this week with the explicit goal of keeping patients out of the hospital.
One of the programs looks to keep patients from bouncing back after hospitalization. On Wednesday, CMS added 23 sites to its Community-based Care Transitions Program, aimed at preventing high-risk Medicare patients from being readmitted. Community-based organizations work with other providers to transition patients from the hospital to their homes, nursing homes or other facilities. As part of the two-year agreement, each participating organization will get a flat fee for coordinating care.

With this round of agreements, CMS has allocated half of the $500 million of the anticipated program spending over five years to the Community-based Care Transitions Program.
The newly added sites bring the total number of participants to 30 providers, including the seven announced in November. The program will support more than 126 local hospitals and help more than 223,000 Medicare beneficiaries in 19 states, according to CMS.

"I've seen the very real difference that support from organizations like our partners in the Community-based Care Transitions Program can make to people's post-hospital care and their health," CMS Acting Administrator Marilyn Tavenner in the Wednesday announcement.
The other program that CMS touted this week similarly looks at coordinated care. CMS yesterday announced the $128 million Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents.
CMS will partner with independent organizations to improve care for long-stay nursing facility residents on Medicare and Medicaid, facilitating transitions to and from inpatient hospitals and nursing homes. Each organization proposes evidence-based intervention and an improvement strategy, targeted at preventive services and improved communication between providers.
"Being readmitted to a hospital is very difficult for low-income seniors, people with disabilities and their families," Tavenner said in yesterday's statement. "Through this initiative, we will work with nursing facilities and hospitals to provide better, person-centered care. By catching and resolving issues early, we can help people avoid costly and stressful hospitalizations."
About 45 percent of hospital admissions of patients who receive Medicare skilled nursing facility or Medicaid nursing facility services could have been avoided, CMS said. That accounted for 314,000 potentially avoidable hospitalizations and $2.6 billion in Medicare expenditures in 2005.

For more information
- read the CMS announcement and program details on care transitions
- read the statement and program details on nursing homes
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ACOs changing economics

ACOs changing economics:
Could health reform, and more specifically, accountable care organizations be slowing down healthcare spending? That's the hope, and for some, evidenced by recent data, Think Progress noted.
The Congressional Budget Office made a major revision to its 10-year Medicare spending projection by decreasing estimates by $69 billion, Paul Ginsburg and Chapin White at the Center for Studying Health System Change, in Washington, D.C., wrote in the New England of Journal of Medicine last week. "[W]e do not believe that the recent slowdown in Medicare spending growth is a fluke," they wrote. "There has been a long-term trend toward tighter Medicare payment policy, and policy changes that began in the middle of the 2000s have continued that tightening."
Part of the major change under health reform is ACOs, charged with changing the payment models for provider and payer reimbursements, as well as quality care outcomes.

ACOs are a "major game-changer," Karen Davis, president of the Commonwealth Fund, said in The Wall Street Journal.
The New York Times also highlighted the economic shift. However, some critics worry that the ACO change comes with too much risk and administrative burdens.
"The costs are going to accrue to the providers, but the benefits are going to accrue to everyone else," said Joseph Golbus, president of NorthShore University HealthSystem's medical group in Illinois. "What I think killed H.M.O.'s in the '90s was limiting access to patients and telling the doctor he is now worth 17 cents per member, per month. We don't want to see that again."

But ACO advocates insist that accountable care is not a repeat of HMO economics. For instance, ACO members can choose whatever provider they want to receive care from.

"This is not about restricting care, but to proactively coordinate care and to ensure that the patients' needs are met early in the process," Jonathan Blum, deputy administrator at the Centers for Medicare & Medicaid Services, told The Times.
Advocate Health Care, provider of the largest commercial ACO, located in Chicago, said the benefits of ACOs go beyond pure financials. For example, care managers who help patients with appointments, diet, exercise and meals address the ACO's 200,000 members insured by Illinois Blue Cross plans.

"A care manager may care for up to 150 patients, and the savings from keeping these patients healthy, and potentially out of the hospital, pays for their salary several times over," said Lee Sacks, chief medical officer at Advocate, in the article. "But it's more than just the economics. It's the right thing to do."

For more information:
- see the Think Progress blog post
- here's the NEJM article
 - read the NYT article
- here's the WSJ article (subscription required)

Related Articles:
Quality missing from ACO equation?
Atrius CEO Interview: Inside a Pioneer ACO
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ACO models pass on CMS Shared Savings Program

Readmission rates higher with chronic conditions

Readmission rates higher with chronic conditions:
Hospital readmission rates for chronic conditions are substantially higher than rehospitalizations for acute conditions, regardless of payer or age group, the Agency for Healthcare Research and Quality (AHRQ) announced yesterday. For example, conditions such as congestive heart failure or diabetes had higher incidences of patients bouncing back to the hospital than for an acute cases like pneumonia or heart attack.
"Readmission rates were consistently higher for non-surgical hospitalizations," the report states.
In 2008, one in five nonsurgical cases had a 30-day readmission, compared to one in eight surgical cases.
According to AHRQ's latest numbers, readmission rates for nonsurgical hospitalizations for chronic conditions was 23 percent, compared to 19 percent for acute conditions in elderly Medicare patients (over 65). For Medicaid patients age 18 to 44, it was 26 percent for chronic conditions versus 19 percent for acute conditions, that is, about one-third higher. In children under 17, the readmission rate was two-times higher, regardless of whether the initial stay involved surgical treatment, according to the data.
However, in privately-insured adults, ages 45 to 64, the 30-day readmission rate following surgical hospitalizations was similar across chronic and acute conditions.
The numbers which came from inpatient databases for 15 states (Arkansas, California, Florida, Hawaii, Louisiana, Massachusetts, Missouri, Nebraska, New Hampshire, New York, South Carolina, Tennessee, Utah, Virginia, and Washington) represent 42 percent of the U.S. population, according to the report.

Although the report didn't specify why readmission rates were higher for chronic conditions over acute conditions, it did point to associated factors of chronic cases: limitations on self-care, independent living and social interactions, as well as the need for ongoing intervention with medical products, services and special equipment.

As a quality measure with reimbursements on the line, hospitals are certainly keeping a watchful eye on their readmission rates.
For more information:
- read the AHRQ press release
- check out the data

Related Articles:
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Patient-centered care 'flawed' with consumer focus

Patient-centered care 'flawed' with consumer focus:
Despite the trend in the catchphrase, "patient-centered care" is a flawed way of putting it, wrote Charles L. Bardes of New York's Weill Cornell Medical College in a New England Journal of Medicine (NEJM) article, published Thursday.

First coined in 1969 by British psychoanalyst Enid Balint, the term implied taking into account a patient's social context to deal with illness. Patient-centered care, however, in today's environment focuses too much on the consumer, Bardes said. The purpose of the patient shifted from obeying to purchasing, now with a strong emphasis on marketing and branding, he explained.

"If the patient is reconceived as a consumer, new priorities take center stage: customer satisfaction, comparison shopping, broad ranges of alternatives, choice, and unimpeded access to goods and services," he wrote.
Bardes's position is much like an earlier NEJM article by two Beth Israel Deaconess Medical Center physicians who voiced concerns about industrialized patient care. Pamela Hartzband, assistant professor of medicine at Harvard Medical School, and Jerome Groopman, chair of medicine at Harvard Medical School and chief of experimental medicine at the Beth Israel, described hospitals like "factories" and patient encounters like "economic transactions," further explaining that the "consumer" term was inappropriate.

However, others see the trend of patients as the focus as undeniable. Patient-centered care could mean simply looking at the individual, perhaps more appropriately (or inappropriately) named "personalized medicine."

Kent Bottles, senior fellow at the Thomas Jefferson University School of Population Health, said personalized medicine is a trend that healthcare executives can't ignore, in today's Hospital Impact blog post. The important trend is personalized medicine that concentrates on the individual not the population, Bottles said. For example, cancer screening by mammography after age 40 in women and colonoscopy after age 50 in men and women does not take into account the different genetic predispositions for breast cancer and colon cancer in individual patients.

As the debate rages on about patient- versus physician-centered care, Bardes suggested a better term that combines the shared investment in care.

"The flaw in the metaphor is that the patient and the doctor must coexist in a therapeutic, social, and economic relation of mutual and highly interwoven prerogatives. Neither is the king, and neither is the sun," Bardes said. He continued, "Patient and physician must therefore meet as equals, bringing different knowledge, needs, concerns, and gravitational pull but neither claiming a position of centrality."

For more information:
- read the NEJM article

Geisinger plan reduces readmissions 44% with telemonitoring

Geisinger plan reduces readmissions 44% with telemonitoring:

Geisinger Health Plan, based in Danville, Pa., reports that its use of a home telemonitoring program for patients with congestive heart failure reduced their readmission rate by 44 percent, compared to a control group. The success of the telehealth program, which incorporated technology from AMC Health, has prompted Geisinger to expand it to include patients with hypertension and diabetes.

The core of the heart failure program is an interactive voice response (IVR) system that asks discharged patients a series of questions about their symptoms after they have submitted their weight.

In the two-year study, Geisinger compared the 30-day readmission rates of patients who received only case management with those who both had a case manager and used the telemonitoring system. Eighty-five percent of the patients in the study used this system regularly.

Today, about 1,000 patients with congestive heart failure are utilizing the telemonitoring system at any given time. According to Geisinger, the technology has allowed the case management program to accommodate more patients than it previously could.

A survey of Geisinger case managers found that most believed the telehealth program helped keep their patients out of the hospital. Nearly all of them found that the system enabled them to monitor the patients more efficiently.

A large-scale 2008 study by the Veterans Health Administration (VHA) of several telehealth technologies found that they reduced the number of hospital bed days by 25 percent and hospital admissions by 19 percent. A recent report prepared for the U.K. National Health Service said the U.K. should follow the VHA's example.

To learn more:
- read the Geisinger announcement
- see the VHA study

Related Articles:
UK report says NHS should follow VA's approach to telehealth
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Transitional care life coaches, clinics save hospitals thousands

Transitional care life coaches, clinics save hospitals thousands:
Hospitals in Virgina are trying to keep patients from returning to the hospital by bolstering the shift to outpatient care, reported The Virginian-Pilot. For instance, Bon Secours Hampton Roads Health System in Norfolk, Va., has found that using hospital "life coaches" reduces preventable readmissions and saves money.
The life coaches--or medical life coach navigators--connect low-income and uninsured patients with free or reduced-price care at nearby clinics. Of the 1,000 patients seen by the hospital's two life coaches in 2010, only two came back to the emergency room for the same complaint that year. Meanwhile, 90 percent followed through with the coaches' plans for ongoing care.
The life coaches, both licensed practical nurses, also saved the hospital about $150,000 in 2010, according to Catholic Health World.
As the life coach program expands, Bon Secours Hampton Roads is examining whether coaches paid by the hospital or an external agency are more successful, hospital spokeswoman Lynne Zultanky told Catholic Health World.
With similar goals in mind, Chesapeake (Va.) Regional Medical Center has launched a transitional care clinic, which costs about $102,000 to run, noted the Virginian-Pilot.
Providers examine uninsured chronically ill patients within two weeks of their hospital stays. And within two months, they arrange ongoing primary care, usually at a free clinic. Despite the operational costs, the transitional clinic could save Chesapeake Regional about $400,000 a year, according to an analysis of the first seven months.
For more information:
- read the Virginian-Pilot article
- check out the Catholic Health World piece
Related Articles:
Readmissions are preventable, JAMA study says
Researcher: Socioeconomics not to blame for readmission rates
Readmission rate culprits remain elusive
Nursing homes offer solution to curb hospital readmissions

Joint Commission: Palliative care should be open to all; first certifications announced

Joint Commission: Palliative care should be open to all; first certifications announced:

As interest in palliative care grows among the public and the healthcare profession, The Joint Commission has acknowledged the field's importance by creating a new recognition program. Hospitals that demonstrate a focus on patient-centered inpatient care during all stages of a serious illness can now apply to receive The Joint Commission's Advanced Certification for Palliative Care.

The Joint Commission yesterday announced its first palliative care certifications to five hospitals: Regions Hospital in St. Paul, Minn.; Strong Memorial Hospital in Rochester, N.Y.; Mt. Sinai Medical Center in New York City; St. Joseph Mercy Oakland in Pontiac, Mich.; and Connecticut Hospice, Inc., in Branford.

Palliative care is the field of medicine dedicated to improving patients' quality of life by focusing on pain control, symptom management and stress relief. This treatment model is designed for patients of all ages at any stage of a serious illness.

Michele Sacco, executive director of palliative care certification at The Joint Commission, hopes the certification program will clear up some misconceptions about palliative care while inspiring hospitals to formalize policies for good care they may be providing already.

"Palliative care is not synonymous with hospice care for the terminally ill," Sacco told FierceHealthcare. "We think hospitals should make palliative care available to any patient with any diagnosis of a serious illness, regardless of prognosis." Even providers may not always understand the distinction between palliative care and hospice, though awareness is growing, she said.

According to David Eickemeyer, associate director of certification at The Joint Commission, hospital interest in palliative care certification has been high. "We thought the program would take longer than it did to launch, but these five hospitals could receive certification quickly because they have been doing palliative care for a long time," he said in a FierceHealthcare interview.

At Regions Hospital, the palliative care program started in 2005 as an outgrowth of the hospital's hospitalist program. "We developed a systematic but compassionate strategy for the many patients coming in with significant morbidity," Jim Risser, medical director of the Regions palliative care team, told FierceHealthcare. "We felt good about our program and now have had that confirmed by the Joint Commission's outside review."

The Joint Commission has 21 palliative care applications in house from 13 different states, Eickemeyer said. Additionally, he expects 20 more applications in April as part of a Livestrong Foundation grant program that will offer financial assistance to applicants. He estimates that more than 1600 U.S. hospitals currently have palliative care programs

For more information:
- read the Joint Commission's announcement
- see the Joint Commissions certification requirements (.pdf)
- check out the Livestrong Foundation's grant program

Nursing care moving to outpatient model

Nursing care moving to outpatient model:

The number of skilled nursing facilities and nursing homes is on the decline with the introduction of in-home care, which is aimed at cutting costs, according to The New York Times.

Despite the aging population, the number of nursing homes--which have relied heavily on Medicare and Medicaid dollars--has shrunk by almost 350 during the past six years. Meanwhile, the number of in-home nursing programs nationwide has doubled since 2007, from 42 programs in 22 states in 2007 to 84 programs in 29 states today, the article noted.

"It used to be that if you needed some kind of long-term care, the only way you could get that service was in a nursing home, with 24-hour nursing care," Jason A. Helgerson, who directs New York's Medicaid program, told the Times. "That meant we were institutionalizing service for people, many of whom didn't need 24-hour nursing care. If a person can get a service like home healthcare or Meals on Wheels, they can stay in an apartment and thrive in that environment."

The move from institutionalized care, as Helgerson called it, to managed care is one that stems from nationwide initiatives to cut costs while improving care.

In the newer model of care, a team of doctors, social workers, physical and occupational therapists and other specialists provides managed care for patients in the comfort of their own home or at adult day-care centers. Studies indicate that the managed care model can not only save money over the traditional nursing home approach but also improves patient outcomes.

With fixed monthly fees for each participant, center operators of the Program of All-Inclusive Care for the Elderly--better known as PACE--are incentivized to offer preventative care rather than fee-for-service care that have traditionally relied on hospitalizations for payments. The idea is simple: keep patients out of the hospital and save some money and keep the patients happy.

As Gene Lindsey, president and CEO of Atrius Health, noted, managed care with global payments is a "big experiment." As the nation's healthcare system tests out at-home care, adult day center programs and Pioneer Accountable Care Organizations, like Atrius Health, only time will tell if the experiment with work.

For more information:
- read the New York Times special report
- check out the FierceHealthcare interview with Atrius Health

CMS releases Stage 2 Meaningful Use proposals

CMS releases Stage 2 Meaningful Use proposals:
Officials with the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) today announced the proposed requirements for Stage 2 Meaningful Use and 2014 certification of electronic health records at the Healthcare Information and Management Systems Society's annual conference in Las Vegas.
The officials said they expected the notices of proposed rulemaking (NPRM) for the two sets of regulations to be published this week in the Federal Register. Following a 60-day comment period, the final rule is scheduled for release this summer.
The Stage 2 Meaningful Use rules and EHR certification standards largely reflect the recommendations made last year by the Health IT Policy Committee and the Health IT Standards Committee, said National Coordinator for Health IT Farzad Mostashari, speaking to an overflow crowd.
The proposed regulations, he said, emphasize the need for greater interoperability among systems and health information exchange. "We can't wait five years to get standards-based exchange," he said. On the Meaningful Use side, this means that organizations will have to exchange data across organizational boundaries and disparate EHRs.
According to Mostashari, other areas that receive enhanced focus in these NPRMs include patient engagement, patient safety and increased flexibility in the design of applications.
Overall, the proposals continue to push both hospitals and physicians to improve quality and efficiency through the use of health IT. "We've stayed the course," Mostashari said. "We're continuing what was in Stage 1 [of Meaningful Use] and making it better."
The proposed Stage 2 regulations will keep some Stage 1 criteria unchanged, revise others, and include new requirements. Some highlights cited include:

• Patients must be given the opportunity to view, download and transmit their medical records online.
• The number of decision support elements that must be used will increase.
• Data must be submitted to public health agencies, where possible.
• Viewing of images will be on the optional menu of criteria.
• Clinical quality measures for Meaningful Use will be aligned with those in other programs that involve quality reporting, including Medicare's Physician Quality Reporting System, the shared savings program for accountable care organizations, medical homes and the Joint Commission's quality program.
• Eligible professionals will be able to report data in batches.
• Physician groups of a certain size can report quality data for their groups.
• Connections to registries will be required, including cancer registries
• CMS will do prospective reporting of "payment adjustments" for those who don't show Meaningful Use by 2015.

On the EHR certification side, some of the proposals included:

• EHRs must include the Direct protocol for secure clinical messaging.
• Vendors will have to begin incorporating standard clinical terminologies into their products. Mostashari cited SNOMED, LOINC, and RXNorm, as examples, but it was unclear whether EHRs must have all of those for 2014 certification. RXNorm for medications must be included, said Steve Posnack, the director of ONC's federal policy division.
• There will be new vendor requirements for usability, partly to give more flexibility to specialists who need "scope of practice" exclusions to meet the Meaningful Use criteria.
• The definition of a certified EHR no longer will be based on meeting 100 percent of a set list of criteria. Instead, the criteria will be revised so that they enable providers to meet the requirements they have chosen to meet for Meaningful Use. That means that specialists who don't use certain aspects of primary care EHRs can qualify for Meaningful Use by using EHRs that are certified to meet the needs of their specialties.
• Beyond satisfying "base EHR" requirements, such as patient demographics, problems, clinical decision support, and computerized physician order entry, EHRs or EHR modules can be certified if they have the capability to help providers achieve the core criteria for their stage of Meaningful Use (with exclusions for specialists) and only those optional menu items that the providers who use those applications have chosen.