Matt Zavadsky, MS-HSA, EMTPublic Affairs Director

MedStar Mobile HealthcareAdjunct Faculty

University of Central FloridaCollege of Health and Public Affairs

MIH at 2 – What’s New?

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Health survey ranks U.S. last among rich peersMichael Winter, June 16, 2014

For the fifth time in a decade, the United States is the sick man of the rich world.

That's according to the latest Commonwealth Fund survey of 11 nations, which ranked the world's most expensive health care system dead last on measures of "efficiency, equity, and outcomes." So too in 2010, 2007, 2006 and 2004.

The U.S. ranking reflects poor scores on measures of healthy lives — "mortality amenable to medical care," infant mortality and healthy life expectancy at age 60.

The other eight countries surveyed were Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway and Sweden.

http://www.usatoday.com/story/news/nation/2014/06/16/health-survey-us-last/10638811/

Attention Please!• $8,600 per capita health expenditures!!

– Due in large part to quantity-based payments

Healthcare Environment

• Accelerated shift from FFS to “something else”– ACO– Shared Risk– Bundled Payments

• Evolution of outcome-based measures• Continued focus on patient experience of care

– Quality AND satisfaction• MSPB calculations = 2015

• Medicare Spending Per Beneficiary– Hospital accountable for some outpatient post acute costs

Hospital Name State Period Claim Type

Avg Spending Per Episode (Hospital)

Avg Spending Per Episode (State)

Avg Spending Per Episode (Nation)

Percent of Spending (Hospital)

Percent of Spending (State)

Percent of Spending (Nation)

ST JOSEPH MED CNTR WA

1 through 30 days After Discharge from Index Hospital Admission Outpatient $929 $770 $664 4.72% 4.06% 3.39%

UNIV OF WASH MED CNTR WA

1 through 30 days After Discharge from Index Hospital Admission Outpatient $1,860 $770 $664 7.94% 4.06% 3.39%

VALLEY MEDICAL CENTER WA

1 through 30 days After Discharge from Index Hospital Admission

Skilled Nursing Facility $3,469 $2,903 $3,087 18.27% 15.32% 15.77%

YAKIMA HMA WA

1 through 30 days After Discharge from Index Hospital Admission Inpatient $2,637 $1,929 $2,602 13.75% 10.18% 13.29%

HARBORVIEW MED CNTR WADuring Index Hospital Admission Inpatient $12,663 $9,760 $8,997 51.58% 51.52% 45.96%

HARBORVIEW MED CNTR WA Complete Episode Total $24,552 $18,946 $19,578 100% 100% 100%

National Health Care Spending: What the Numbers Mean for Hospitals and Health Systems09.08.14 by Paul Keckley

So, what do these numbers really mean, especially to hospitals and health systems that have seen average operating margins shrink to 2.1 percent in 2013 from 2.5 percent in 2012?

First, it means hospitals face tough negotiations with health insurers, who will use the ACA’s trajectory from fee for service to performance-based payments to providers to aggressively expand bundled payment programs and use narrow networks and reference pricing to garner better deals for their enrollees.

Second, it means consumers increasingly will shoulder more of the burden of health costs directly, through premiums, co-payments and deductibles, accelerating price sensitivity for hospital and physician services, and increasing bad debt as their bills go unpaid.

http://www.hhnmag.com/display/HHN-news-article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HHN/Daily/2014/Sep/090814-keckley-healthcare-statistics

Third, it means large employers will become more active as purchasers, seeking opportunities to contract directly with providers who can accept risk for high-quality, low-cost guarantees.

Fourth, it means operating margins for doctors, hospitals and post-acute providers will shrink, accelerating vertical integration into care management organizations that focus on scale, growth and diversification.

And last, it means the gap between household income gains that are substantially lower than health care spending — 5.6 percent per year — will spark a renewed public debate about the sustainability of the U.S. health system as it currently operates. The disconnect hits younger households hardest: the millennials and young Gen Yers might start an “occupy health care” movement to replace the current system with something else.

http://www.hhnmag.com/display/HHN-news-article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HHN/Daily/2014/Sep/090814-keckley-healthcare-statistics

Return Visits to the Emergency Department: The Patient Perspective

http://www.annemergmed.com/article/S0196-0644(14)00622-2/fulltext

ConclusionPost-discharge factors, including perceived inability to access timely follow-up care and uncertainty and fear about disease progression, are primary motivators for return to the ED. Many patients prefer hospital-based care because of increased convenience and timely results.

Further work is needed to develop alternative pathways for patients to ask questions and seek guidance when and where they want.

Sep 2, 2014 Source: ACEP

Spike in ER, Hospitalization Use Short-Lived After Medicaid ExpansionBy Lisa Aliferis, KQEDOctober 15th, 2014

While the Medicaid expansion may lead to a dramatic rise in emergency room use and hospitalizations for previously uninsured people, that increase is largely temporary and should not lead to a dramatic impact on state budgets.

In July 2011, after being enrolled in California’s Low Income Health Program, the so-called “bridge to reform,” the group with the highest pent-up demand had a rate of costly emergency room visits triple — or more — that of the other groups. But from 2011 to 2013, that high rate dropped by more than two-thirds and has remained “relatively constant,” according to the analysis.

Rates of hospitalization for the “highest pent-up demand” group also started high and dropped by almost 80 percent over the two-year period.

One factor in helping drive down the higher rates of use, Kominski said, is better efforts at coordination for Medi-Cal beneficiaries.

http://capsules.kaiserhealthnews.org/index.php/2014/10/spike-in-er-hospitalization-use-short-lived-after-medicaid-expansion/

Number of Americans Without Health Insurance Falls, Survey ShowsBy SABRINA TAVERNISESEPT. 16, 2014

Federal researchers reported on Tuesday that the number of Americans without health insurance had declined substantially in the first quarter of this year, the first federal measure of the number of uninsured Americans since the Affordable Care Act extended coverage to millions of people in January.

The number of uninsured Americans fell by about 8 percent to 41 million people in the first quarter of this year, compared with 2013, a drop that represented about 3.8 million people and that roughly matched what experts were expecting based on polling by private groups, like Gallup. The survey also measured physical health but found little evidence of change.

http://www.nytimes.com/2014/09/16/us/number-of-americans-without-health-insurance-falls-survey-shows.html

Small Firms Start to Drop Health PlansMany View the Health Law’s Marketplace as Inviting and AffordableBy Anna Wilde Mathews, Angus Loten and Christopher WeaverOct. 29, 2014

Small companies are starting to turn away from offering health plans as they seek to reduce costs and increasingly view the health law’s marketplaces as an inviting and affordable option for workers.

WellPoint Inc. said Wednesday its small-business-plan membership is shrinking faster than expected and it has lost about 300,000 people since the start of the year.

Going forward, with the health law’s marketplaces running and functioning well, small employers will likely re-evaluate exchanges as an option for their employees, said Wayne DeVeydt, WellPoint’s chief financial officer. “We think [that] will become even probably a more prominent decision that they’ll make this quarter,” he said.

The law includes subsidies for lower-income workers that can sometimes be as generous as the amounts small employers were paying toward health benefits. Indeed, insurers and brokers say small employers in lower-income industries are far more likely to switch.

http://online.wsj.com/articles/small-firms-drop-health-plans-1414628013

Employers Eye Moving Sickest Workers To Insurance ExchangesBy Jay Hancock - KHN Staff WriterMay 07, 2014

Can corporations shift workers with high medical costs from the company health plan into online insurance exchanges created by the Affordable Care Act? Some employers are considering it, say benefits consultants.

"It's all over the marketplace," said Todd Yates, a managing partner at Hill, Chesson & Woody, a North Carolina benefits consulting firm. "Employers are inquiring about it and brokers and consultants are advocating for it.“

The concept sounds too easy to be true, but the ACA has set up the ability for employers and employees on a voluntary basis to choose a better plan in [the] Individual Marketplace and save a significant amount of money for both!" says promotional material from a company called Managed Exchange Solutions (MES).

http://www.kaiserhealthnews.org/stories/2014/may/07/shifting-employees-to-exchanges.aspx

Health Insurers Are Trying New Payment Models, Study ShowsBy Reed AbelsonJuly 9, 2014

The survey, released on Wednesday by the plans’ trade association, estimates that $1 out of every $5 in reimbursements is being paid under an arrangement in which providers are rewarded for improving care and lowering costs.

The insurers say they are spending more than $65 billion a year in new “value-based” payment models, according to the Blue Cross Blue Shield Association, which looked at 350 programs in nearly every state.

Health insurers have long talked about changing the way they pay for care, but there have been few tangible signs of just how enthusiastically they are embracing alternatives.

But the Blue Cross executives say there is no choice but to move away from a system that rewarded high-cost care over high-quality and efficient treatments.

http://www.nytimes.com/2014/07/10/business/health-insurers-are-trying-new-payment-models-study-shows.html

HCA to close Florida hospital as inpatient volumes dwindleBy Bob Herman September 24, 2014

For-profit hospital giant HCA said Tuesday it will close one of its hospitals in Florida because of excess inpatient capacity in the region—a sign that healthcare reform continues to push patient volumes away from inpatient hospital settings and toward lower-cost outpatient facilities.

HCA will shut down Edward White Hospital in St. Petersburg, Fla., by Nov. 24. Clinical services at the hospital—which has 162 licensed beds and 110 staffed beds.

The decline of inpatient utilization began several years ago during the recent recession, and has intensified as the Patient Protection and Affordable Care Act encourages providers to use less-costly, preventive measures.

A new report from consulting firm Kaufman Hall backs up those reports from health systems, finding that in the first half of this year, inpatient volumes were flat or fell for 68% of not-for-profit hospitals.

http://www.modernhealthcare.com/article/20140924/NEWS/309249963/hca-to-close-florida-hospital-as-inpatient-volumes-dwindle

HCA buying Dallas-based urgent care company, CareNowOct 28, 2014

Nashville-based health care giant HCA is buying Dallas-based CareNow, which owns 24 urgent care centers in Dallas-Fort Worth.

"CareNow has a strong brand and will add an exceptional network of urgent care centers and 130 physicians that complement our hospital, emergency and outpatient services in Dallas-Fort Worth," said Sam Hazen, HCA president of operations.

"This transaction represents two trusted providers coming together to deliver a broader and more integrated level of quality health care services.“

http://www.bizjournals.com/dallas/news/2014/10/28/hca-buying-dallas-based-urgent-care-company.html

Texas Health Resources Pairs With Target For Primary CareHospitals 10/2/2014| by Matt Goodman| Texas Health Resources’ physician organization has teamed with eight Target locations in North Texas to provide walk-in primary care to customers.

Patients 18 months and older can receive care for minor illnesses and injuries, skin treatments, vaccinations, tests, and screenings. Texas Health Resources also has an agreement with CVS locations. Baylor Scott & White Health has a similar deal with Walgreens and Walmart.

“In a rapidly changing healthcare environment, Texas Health Physicians Group continues to pursue creative and innovative ways to reach patients and improve patient care,” read a statement from Shawn Parsley, D.O., the group’s president. “This collaboration advances Texas Health’s strategy to expand access to convenient, quality primary care close to where people live and work.”

http://healthcare.dmagazine.com/2014/10/02/texas-health-resources-pairs-with-target-for-primary-care/

Kindred, Gentiva agree to $1.8 billion mergerBy Bob Herman October 9, 2014

Ending a months-long battle, Kindred Healthcare and Gentiva Health Services said Thursday they will merge, creating one of the largest post-acute-care providers in the country.

Kindred said once the deal closes, it will be the fourth-largest healthcare employer in the U.S. The combined company will have 109,000 employees in hundreds of long-term acute-care hospitals, inpatient rehabilitation facilities, skilled nursing facilities and hospices.

The new company is expected to generate about $7.1 billion in annual revenue, making it larger than the other recent merger in the industry between Genesis HealthCare and Skilled Healthcare Group.

http://www.modernhealthcare.com/article/20141009/NEWS/310099938/kindred-gentiva-agree-to-1-8-billion-merger

Bundled payments could cut Medicare fraud, experts sayKelly KennedyMay 19, 2014

WASHINGTON — Health and policy experts are pushing for a system that pays doctors a lump sum for medical care or allows them to share in savings, saying it will save millions of dollars over current fee-for-service payments that can lead to fraud and over-use of medications.

In the new system, doctors would not be entitled to extra pay should they prescribe costlier medication.

"CBO projects that applying bundled payment models like Bay State's nationally could save Medicare about $46.6 billion over the next seven years," Warren said.

Peter Ubel, professor of business administration and medicine at Duke University's Sanford School of Business, said a third method may also work well: He suggested changing the payment structure so that a doctor receives the same payment no matter what he prescribes, rather than receiving a percentage.

http://www.usatoday.com/story/news/nation/2014/05/19/experts-argue-bundled-payments-could-cut-medicare-costs/8820801/

• Shift to self-insured plans– Including direct contract ACOs

• Drive down utilization• “Concierge” medicine options

– On-site clinics– House calls

Employers as Direct Payers

Employer-Driven Reforms• Catalyst for Payment Reform o Coalition of employers (Wal-Mart, Walt Disney,

Boeing, Intel, GE, Delta Airlines, FedEx, 3M…)o Pushing for value oriented payments to providers

(20% by 2020)• Aetna – Now paying the same for c-section or

vaginal birth – eliminate incentive for c-section (H&HN)

• $1,250 for screening colonoscopies – regardless of in or out of the hospital (H&HN)

http://www.catalyzepaymentreform.org/images/documents/CPR_PBGH_ACO_How_To_Guide_FINAL.pdf

Accountable Care Organization/Health Plan Questionnaire The following pages contain a questionnaire CPR and PBGH have created for purchasers to use for assessing their health plan's ACO strategy as well as their market-specific offerings. We recommend you ask for written responses to all of the questions. Throughout this document, CPR-PBGH have written in red where you will need to add specifics about your organization. We recommend you delete this introduction tab when issuing the Questionnaire. If you have any questions, please don’t hesitate to contact Shaudi Bazzaz at CPR; sbazzaz@catalyzepaymentreform.org

Medicare Fines 2,610 Hospitals In Third Round Of Readmission PenaltiesBy Jordan RauKHN Staff WriterOct 2, 2014

Medicare is fining a record number of hospitals – 2,610 – for having too many patients return within a month for additional treatments, federal records released Wednesday show. Even though the nation’s readmission rate is dropping, Medicare’s average fines will be higher, with 39 hospitals receiving the largest penalty allowed, including the nation’s oldest hospital, Pennsylvania Hospital in Philadelphia.

Under the new fines, three-quarters of hospitals that are subject to the Hospital Readmissions Reduction Program are being penalized. That means that from Oct. 1 through next Sept. 30, they will receive lower payments for every Medicare patient stay — not just for those patients who are readmitted. Over the course of the year, the fines will total about $428 million, Medicare estimates.

http://www.kaiserhealthnews.org/Stories/2014/October/02/Medicare-readmissions-penalties-2015.aspx

Medicare uses the national readmission rate to help decide what appropriate rates for each hospital, so to reduce their fines from previous years or avoid them altogether, hospitals must not only reduce their readmission rates but do so better than the industry did overall.

"You have to run as fast as everyone else to just stay even," Foster said. Only 129 hospitals that were fined last year avoided a fine in this new round, the KHN analysis found.

Medicare officials, however, consider the competition good motivation for hospitals to keep on tackling readmissions and not to become complacent with their improvements.

http://www.kaiserhealthnews.org/Stories/2014/October/02/Medicare-readmissions-penalties-2015.aspx

The all-cause 30-day hospital readmission rate among Medicare fee-for-service beneficiaries plummeted further to approximately 17.5 percent in 2013, translating into an estimated 150,000 fewer hospital readmissions between January 2012 and December 2013.

This represents an 8 percent reduction in the Medicare fee-for service all-cause 30-day readmissions rate.

http://innovation.cms.gov/Files/reports/patient-safety-results.pdf

Readmission reduction: A losing battle?October 16, 2014

Readmissions may be "beyond a hospital's control," according to a new study published in the American Journal of Managed Care.

They gave half the patients an intervention featuring pre-discharge education and planning, post-discharge follow-up, an available hotline and "bridging" techniques such as daily symptom checks.

Linden and his coauthor, Susan W. Butterworth, Ph.D., found no statistical difference in readmissions between the two groups after both 30-day and 90-day periods, although mortality was lower in the intervention group than the control group.

The research found only a single instance where a patient received same-day care from a PCP, and in that case the issue was dealt with without requiring emergency care. Linden and Butterworth cited several cases in which patients sought an appointment with their PCPs for non-emergency conditions but were sent to the emergency room or unable to make an appointment for weeks.

http://www.ajmc.com/publications/issue/2014/2014-vol20-n10/a-comprehensive-hospital-based-intervention-to-reduce-readmissions-for-chronically-ill-patients-a-randomized-controlled-trial/3

Take-Away Points from the Research:

• Our results suggest the need to continue experimenting with new interventions targeting readmissions, especially for severely ill patients.

• Our addition of interactive voice response and motivational interviewing–based health coaching to the transitional care model did not improve outcomes.

• Our findings suggest that correcting improper use of the inhaler and increasing adherence to inhaled medications may reduce 90-day mortality for chronic obstructive pulmonary disease patients.

• Hospitals, without collaborative relationships with community-based providers, may have limited ability to reduce readmissions, as they cannot ensure timely and continuous care for patients after discharge.

• A challenging road lies ahead for stand-alone community hospitals seeking to decrease readmissions and avoid financial penalties.

THR - Fort Worth Fort Worth TX 0.59% 0.32% 0.19%JPS Fort - Worth Fort Worth TX 0.08% 0.03% 0.03%Plaza Med Cntr - Fort Worth Fort Worth TX 0.30% 0.12% 0.00%Baylor - Fort Worth Fort Worth TX 0.00% 0.00% 0.00%North Shore University Hospital Manhasset NY 1.00% 0.98% 0.55%Wakemed, Raleigh Campus Raleigh NC 0.28% 0.42% 0.38%Legacy Emanuel Med CNtr Portland OR 0.10% 0.19% 0.19%Legacy Meridian Park Med. Cntr. Tualatin OR 0.28% 0.39% 0.03%

Name City State

FY2013 Readmission

Penalty

FY2014 Readmission

Penalty

FY2015 Readmission

PenaltyTristar Skyline Med Cntr Nashville TN 0.33% 0.23% 0.47%Tristar Southern Hills Med Cntr Nashville TN 0.15% 0.20% 0.48%Vanderbilt University Hospital Nashville TN 0.61% 0.11% 0.10%Baptist Memorial Hospital Memphis TN 0.00% 0.00% 0.00%Delta Medical Center Memphis TN 0.28% 0.38% 0.95%Fort Sanders Regional Med Cntr Knoxville TN 0.00% 0.20% 0.47%Parkwest Medical Center Knoxville TN 0.20% 0.09% 0.82%

Patients Seeking Cheaper Care Are Soliciting Bids From Doctors Online By Sandra G. Boodman Aug 05, 2014

Francisco Velazco couldn't wait any longer. For several years, the 35-year-old Seattle handyman had searched for an orthopedic surgeon who would reconstruct the torn ligament in his knee for a price he could afford.

Out of work because of the pain and unable to scrape together $15,000 – the cheapest option he could find in Seattle – Velazco turned to an unconventional and controversial option: an online medical auction site called Medibid, which largely operates outside the confines of traditional health insurance.

After accepting the lowest bid -- $7,500, a fee that covered anesthesia and related costs -- he learned that his surgeon would be William T. Grant, a Charlottesville orthopedist. A few weeks later, after several online discussions with Grant, Velazco arrived in Charlottesville, where he had rented a $50-a-night room and would spend two weeks recuperating. On Dec. 4, 2013, he underwent knee surgery, performed in an outpatient surgery center that Grant co-owns.

"I'm back working four days per week and climbing ladders," Velazco said recently. "I'm doing great." http://

www.kaiserhealthnews.org/Stories/2014/August/05/Patients-Seeking-Cheaper-Care-Are-Soliciting-Bids-From-Doctors-Online.aspx

Doctors begin to practice "web-side" mannerOctober 19, 2014

With waits at doctors' offices increasing, online visits are becoming the new house calls. Google is testing such a service. Other companies already offer it. Taking medicine from "the doctor is in" to "the doctor is online."

CBS News reporter Vladimir Dutheirs showed his wrist to Dr. Peter Antall over a web camera, asking about a lump on it. "Can you see that, doctor?"

That doctor works for a company called AmWell, which has grown 1,000 percent in two years.

Right now, 22 percent of employees offer video consults through health plans. About 71 percent say they will offer it by 2017. Any serious medical conditions are flagged immediately for in-person care.

Another company, Teladoc, offered only through employee benefit plans, covers 8 million people.

http://www.cbsnews.com/news/doctors-begin-to-practice-web-side-manner/

Around the Nation

• 2013 NAEMT MIH/CP Survey– 3,781 total responses were received

• Total responses were evenly dispersed across all types of EMS delivery models.

– 232 unique MIH/CP programs were reported• (6% of responses).

– 566 respondents (15%) indicated that their EMS agencies were in the process of developing a MIH/CP program.

• Round 2 in process now– 232 surveys + new one’s known– ~150 completed surveys!

‘Maturing’ Programs

• Reno, NV (CMS HCIA Grantee)– REMSA– Community paramedicine

• High Utilizers & CHF– Ambulance transport alternative destinations– 9-1-1 Nurse Triage

• Dallas, TX– Dallas Fire– Community paramedicine

• High Utilizers & CHF

• Pittsburgh, PA– UPMC/Emed Health Community Connect– Community paramedicine

• High Utilizers & CHF– Partnership between Highmark and UPMC

‘Maturing’ Programs

• Mesa, AZ– Mesa Fire and Medical Dept.

• Transitional Response Vehicle– NP/Behavioral Health specialist & Paramedic

• Eagle County, CO– Eagle County Paramedics

• Primary Care/Rural Model

• Wake County, NC– Wake EMS– Community paramedicine

• High Utilizers, CHF, Behavioral Health and Substance Abuse• ALF/SNF falls alternative destination

‘Maturing’ Programs

• MedStar– High utilizer– 9-1-1 Nurse Triage– CHF– Obs Admission Avoidance– Hospice– Home Health Partnership– Call Center Services (Jan. 2015)

On the Horizon

• 3 new HCIA EMS MIH Grants in Round 2– Mt. Sinai Medical Center, NY– Yale New Haven Hospital, CT– Mesa, AZ Fire & Medical Dept.

• California CP Pilots– 12!– Waiver project

Regulatory Landscape

• Still evolving– TN, ME, MN, WA, AR efforts– California project

MIH – Federal Payer View

• Discussion with CMS CMO– Great outcomes - more patients!

• Legislative initiative– Field EMS Bill

• Test new payment models for EMS

• Workgroup for new EMS economic model– Reduce fraud and abuse– Use $ to fund permanent ‘extenders’– Additional $ to incentivize bonuses for reporting

quality metrics

Measures Project

Accreditation

• NCQA or others…

“Mobile Integrated Healthcare is an innovative and patient-centered approach to meeting the needs of patients and their families. The model does require you to “flip” your thinking about almost everything – from roles for health care providers, to what an EMT or paramedic might do to care for a patient in their home, to how we will get paid for care in the future. The authors teach us how to flip our thinking about using home visits to assess safety and health. They encourage us to segment patients and design new ways to relate to and support these patients. And they urge us to use all of the assets in a community to get to better care. This is our shared professional challenge, and it will take new models, new relationships, and new skills.”

Maureen BisognanoPresident and CEO

Institute for Healthcare Improvement

Questions/Comments?

http://www.emsworld.com/article/11446135/performance-metrics-for-value-based-purchasing