Tuesday, June 18, 2013

Mobile health is touted as affordable, but costs still seen as barrier

By: Brian Dolan | Jun 18, 2013   

GSMA mHealthThe mobile industry’s GSM Association recently funded a survey of 2,000 healthcare providers, patients and consumers in four different countries to better understand the perceptions they had about mobile health. Obviously, a prerequisite for participating in the survey was an understanding or familiarity with mobile health, so those surveyed were a very particular group of providers and consumers.
The survey’s top line metric is that 89 percent of providers, 75 percent of patients, and 73 percent of consumers believe that mobile health offerings can convey significant health benefits.
The group’s concerns about costs associated with mobile health offerings were perhaps the most interesting metrics collected by the pollsters.
“At a time of such current financial concerns and constraints, mHealth solutions will not be accepted if they add to the current costs of healthcare,” the GSMA writes. “…Many HCPs, patients and consumers surveyed by GSMA were concerned about the inaccessibility of mHealth solutions due to costs; 36% of patients believe that mHealth will be expensive, with Brazil and China driving this perception (45% and 41% respectively). Furthermore, almost three quarters of patients and consumers surveyed were concerned that mHealth solutions would not be covered by their insurance company. This is a particular concern in the US, where almost half of HCPs believe they will not be remunerated for mHealth.”
As the GSMA goes on to note, that stands in considerable contrast to one of mobile health’s overarching value propositions: That it is often fairly inexpensive and affordable.
“Of crucial value to regulators is the finding in this research that one third of patients surveyed struggle with affordability of care and half of them believe that mHealth is a solution to this,” the GSMA writes.
The full report is chock full of stats from people familiar with mobile health, read the whole thing here. (PDF)

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BACH transitions remaining primary care services to medical home model

Written by Victoria Tarter For Blanchfield Army Community Hospital Public Affairs
Jun. 14, 2013 | theleafchronicle.com

FORT CAMPBELL, KY. — Blanchfield Army Community Hospital transformed three primary care clinics
into Patient-Centered Medical Homes (PCMH) during an Open House Ceremony Friday, June 7. The
PCMH model offers patient-centered, team-based, holistic care, which places the patient at the center of
the care model.
The Open House Ceremony took place on a windy afternoon on the lawn outside the patient entrance of
“C” building. Ceremony speakers, including hospital commander Col. Paul R. Cordts, chief of primary care
Col. David Brown, and acting senior mission commander for the 101st Airborne Division and Fort
Campbell Brig. Gen. Mark R. Stammer, explained how the Blue, Young Eagle and Byrd Family clinics
have now been reformed into the Air Assault Family Medical Home, the Young Eagle Medical Home and
the Byrd Family Medical Home.
"We are here today to recognize 343 team members and approximately 30,000 patients enrolled to the
three transforming services,” said Cordts.
Cordts also thanked the Family members who partnered with BACH to create an ideal system of care.
Cordts explained that several shifts in services occurred to support the transition to the PCMH model.
The Air Assault Family Medical Home expanded to incorporate the former Well Baby Clinic. This provided
optimal space for the four medical home teams as well as the expanded team members who integrated
into the Air Assault Family Medical Home, including behavioral health, nutrition, clinical pharmacy, case
management and population health providers.
The Emergency Center incorporated the Urgent Care Center, which allowed the Young Eagle Medical
Home to expand into two teams, with Team Soar occupying the former Urgent Care Center.
In addition to honoring the cooperative work of both patients and staff, Stammer highlighted the primary
care team’s success despite financial challenges.
“You have been working to not only improve our Soldiers’ and their Families’ patient care experience, but
also work to maximize healthy outcomes all the while working with a decreased budget,” said Stammer.
Stammer pointed out that Army Medicine is one essential part of the budget, and the relationship between
patients and their caregivers is an essential part of Army Medicine.
There are two major benefits of the PCMH model.
The first is to improve the continuity of care by ensuring patients see their dedicated care team rather than
any available provider. This helps patients build stronger relationships with a care team that understands
their specific medical history and health goals. Expanding personnel within the medical homes, along with
restructuring the workflow within each service, has made this care model possible.
Second, in addition to creating a higher degree of medical care, this new model includes the Army Secure
Messaging System powered by Relay Health. This enables patients to send secure e-mail messages to
their care teams. Patients can e-mail questions to their care team or request appointments, lab results,
medication refills and referrals.
BACH’s noncommissioned officer in charge for the Air Assault Medical Home Sgt. Mark Migala explained
the benefits of creating additional, open lines of communication between patients and caregivers.
“You can do it right there from your iPhone,” said Migala.
To register for this program, patients must simply contact their healthcare team. BACH’s appointment line
Call Center personnel will inform patients about their clinic’s transformation to a PCMH and their assigned


Burke Harvey & Frankowski LLC Announces Investigation of Chemed Corp.

Burke Harvey & Frankowski LLC Announces Investigation of Chemed Corp.
BIRMINGHAM, Jun 17, 2013 (Menafn - GLOBE NEWSWIRE via COMTEX) --Burke, Harvey & Frankowski, LLC ("BHF") announces the commencement of an investigation into Chemed Corp., ("Chemed" or the "Company") to determine whether the Company's Officers and Directors violated state and federal law in connection with Medicare reimbursement.
Chemed is a company that owns and operates hospice units through its subsidiary Vitas. On May 2, 2013, the U.S. Department of Justice (the "DOJ") filed a lawsuit which alleges that Chemed and Vitas knowingly submitted claims to Medicare for reimbursement for services that were not necessary, not performed, or were not performed in compliance with Medicare guidelines in violation of the False Claims Act. The DOJ's complaint alleges that Chemed's false claims to Medicare cost U.S. taxpayers tens of millions of dollars. When the news of the DOJ's lawsuit became public, Chemed's stock price dropped dramatically, erasing millions of dollars of shareholder equity. We are investigating whether the Officers and Directors of Chemed issued false statements to shareholders or otherwise breached their fiduciary duties owed to the Company and its shareholders by allowing or failing to prevent the actions which gave rise to the DOJ's lawsuit.
What You Can Do
If you are a long term Chemed Corp. shareholder, you may have legal claims against Chemed's Officers and Directors. If you wish to discuss this investigation, or have questions about this notice or your legal rights, please contact attorney Richard Frankowski via email at rfrankowski@bhflegal.com or via toll-free telephone at (888) 930-9091. There is no cost to you.
About Burke, Harvey & Frankowski LLC
Burke Harvey & Frankowski, LLC, is a Birmingham, Alabama law firm that among other things dedicates its practice to the representation of shareholders and investors in litigation, including shareholder class actions, derivative litigation and FINRA arbitrations. More information about the firm is available through its website, www.bhflegal.com and upon request from the firm. Burke Harvey & Frankowski, LLC has paid for the dissemination of this promotional communication and is responsible for its content.
No representation is made that the quality of legal services to be performed is greater than the quality of legal services to be performed by other lawyers.
CONTACT: Burke Harvey & Frankowski, LLC
(888) 930-9091

$112 million claim filed against SD Hospice

Feds cite 2012 whistleblower case but provide few additional details

San Diego Hospice
San Diego Hospice

 — The U.S. Department of Justice, on behalf of the Centers for Medicare & Medicaid Services, has filed a $112 million claim in bankruptcy court, instantly becoming the largest of San Diego Hospice's creditors.
Attorney Lisa K. Samuels accuses the bankrupt hospice, once San Diego's largest, of submitting "false claims for payment" in 2009 and 2010 and cites a whistle-blower lawsuit brought in December 2012 by a nurse who said she was fired after questioning the nonprofit's policies and procedures.
San Diego Hospice filed for Chapter 11 bankruptcy on Feb. 4 after announcing in November of 2012 that it was under scrutiny from Medicare for its billing practices which its chief executive officer said in interviews did not always follow requirements closely enough.
Once with nearly 1,000 hospice patients, the organization had about 430 after declaring bankruptcy. This spring, all of the patients and many of San Diego Hospice's former employees were transferred to Scripps Health and other local hospice operators.
On April 30, Scripps won an auction to purchase the hospice's hospital building in Hillcrest for $16.55 million.
With the organization no longer caring for patients, and its assets sold, all that is left is to divide sale proceeds among creditors like Wells Fargo Bank and former employees. The bankruptcy court lists claims filed by a total of 219 creditors.
Creditors are scheduled to meet on June 26 to vote on a liquidation plan that would pay different amounts based on what types of claim each has filed.
Though hospice officials have said that the government has been reviewing San Diego Hospice records since February 2011, no information has been released to the public on the outcome of the audit. Monday's filing simply cites the claims made in the whistle-blower lawsuit, but provides no additional detail.
The government does, however, leave itself an out to add information later stating in Monday's filing: "The United States continues to investigate the conduct giving rise to this claim and reserves the right to amend it."


Primary Care Finds a (Medical) Home

Primary Care Finds a (Medical) Home

Primary Care Finds a (Medical) Home

Joe Cantlupe, for HealthLeaders Media , June 13, 2013

This article appears in the June issue of HealthLeaders magazine.
As the nation pushes toward value-based care, there is an explosive demand to launch medical home models among physicians, hospitals, and insurers. From the patient care side, the emphasis is on refining treatment—especially for complex conditions—and on the practice management side, the impetus is to offset costs through accountable care organizations and other mechanisms.
The idea of the patient-centered medical home is a model for strengthening primary care through reorganization of existing practices to provide patient-centered, comprehensive, coordinated, and accessible care. The effort is not only to improve access to care, but also to focus on patients with complex health conditions who need more intensive medical services that are then coordinated among a variety of clinicians.
Healthcare leaders are involved in creating PCMHs in a myriad of ways. Some insurers are partnering with hospitals and physician groups. Some physician groups are developing medical homes on their own. Others are developing ACO structures with incentives for healthcare providers to work together to treat individual patients across care settings, including doctors' offices, hospitals, and long-term care facilities.
Some states are prepping to get these plans in motion within the next few years. It's likely to be a complicated and eventful journey with many potential pitfalls along the way: transitioning to electronic medical records, facing physician shortages, getting a viable patient base, coordinating care, evaluating the need for specialists to care for patients with chronic conditions.
The medical home concept has been around for decades and has gained momentum in recent years as hospitals and healthcare systems focus on value-based quality care, with the primary care practices serving as a significant focal point.
The National Committee for Quality Assurance has recognized nearly 5,000 PCMHs nationwide for coordinating patient care and meeting specific quality standards, and that number is expected to increase significantly. In light of growing concern about primary care physician shortages, many medical homes are offering incentive bonuses for physicians to become involved in their programs.
"What we're seeing now is really a transformative approach," Jonathan Harvey, MD, chief medical officer of Martin's Point HealthCare in Portland, Maine, says of the medical home's role in the transition from fee-for-service to value-based care. Martin's Point includes a health plan and more than 75 primary care providers at nine health centers. "We're seeing a coming together of our ability to manage populations in a delivery system that has enabled primary care to look at communities in a different way," Harvey says. "It's such an exciting time in so many ways."
Like other medical homes, Martin's Point's primary care delivery system provides overall care that includes multidisciplinary teams with care managers and nurses, often focusing on chronic conditions, such as diabetes, coronary artery disease, congestive heart failure, and asthma.
By using electronic medical records and monitoring results, the Martin's Point medical home is improving outcomes and reducing costs. Martin's Point and other healthcare providers are working to engage patients more in their own care, reminding them to take medications, keep their appointments with physicians, and enroll, if necessary, in weight-, exercise-, and stress-management programs.
Martin's Point's patient-centered medical home program has had a noticeable impact, with a 6.2% reduction in hospital readmission rates, with monthly admissions per 1,000 members reduced from 161 in 2011 to 151 in 2012.
There also was a 9.7% decrease in emergency department visits (the rate of ED visits per 1,000 members, 308 in 2011 and 278 in 2012) for patients who were included in the PCMH and Martin's Point insurance program. Those figures compared rates from April and November 2011 to April and November 2012, according to David Stearns, director of informatics at Martin's Point.
Philadelphia-based Independence Blue Cross, which serves 7 million people in 19 states, has established medical homes by collaborating with at least 150 physician practices and other insurers. The program was initiated by the state's Chronic Care Commission in 2007 as a pilot project "intended to change the way care was delivered so we could better manage the chronically ill," says Richard Snyder, MD, chief medical officer for Independence Blue Cross. Over time, it accomplished its mission, he adds.
For years, before working with primary care practices as a team, "we tended to move the needle very slowly—1%, 2%, or 3% a year," Snyder says, referring to improved outcomes. "We had to change the paradigm to better coordinate the care by reducing the number of redundant tests and avoidable admissions, and that coordination started with primary care."
In a review of patients who received care from 20 physician practices, at least 33% of them had patients with poorly controlled diabetes four years ago, says Snyder. By 2013, that figure for those with an A1c of greater than 9% was reduced nearly in half to 18%, he says.
"What we are seeing is that medical homes are moving ahead very substantially, getting to a nearly 20% to 30% improvement year over year," he says. "The kind of coordination and order that is in patient-centered medical homes has resulted in
better outcomes."

Success key No. 1: Amassing physician groups
When Independence Blue Cross began a medical home model in the City of Brotherly Love three years ago, it started coordinating care with 32 physician practices. Within a year, it expanded to more than 170 practice groups, which included more than 1,000 physicians, says Snyder. Those numbers also translated into significantly improved patient outcomes, he adds.
Independence Blue Cross is part of the Blue Cross and Blue Shield Association. IBC established its medical home physician incentive program, the Quality Incentive Payment System, in early 2010 to "attract and retain high-performing" primary care physicians in southeastern Pennsylvania. There were 32 multiphysician practices designated to serve 220,000 patients under the governor's Chronic Care Initiative.
Other insurers, including Aetna, UnitedHealthcare, Keystone Mercy Health Plan, AmeriChoice, and CIGNA, participated. Independence Blue Cross had more members in the practices than the other plans.
The IBC-led program focuses on a medical home model to improve care coordination by relying on an electronic tracking system to evaluate outcomes. Care coordinators use the system to keep tabs on patients with diabetes, heart failure, or blood pressure issues, for instance.
The coordination resulted in notable improvements in compliance with reporting health metrics among physician practices participating in the collaborative. "That's the kind of data that turns the heads of chief medical officers at health plans," Snyder says. In a report from 2008 to 2011, Snyder and colleagues found that "adoption of the PCMH model reduced overall cost for diabetic members by 21% within the first year, driven largely by eliminating inpatient costs, which fell by 44%.
A significant element of the program was the insurer's reimbursement changes for treatment by primary care physicians. Doctors were rewarded for improving quality of care and providing that care in a more efficient manner. The program allowed participating primary care doctors who met their goal numbers to double their reimbursement, and Independent Blue Cross paid out nearly $37 million in 2011, though there was not a specific breakdown in doubled reimbursements.
In addition to earning extra pay for running their practices as medical homes, doctors can earn incentives based on measures such as coordinating cost-effective care, delivering effective care, and prescribing generic drugs. Individual bonuses reached over $35,000 annually based on the level of the medical home achievement.
"We learned that practices weren't looking for health plans to help them with clinical management," Snyder says. "They were looking for people who understand the benefit structure to help their staff identify how a patient's benefits work, so they can organize services—such as durable medical equipment, home-care services, and pharmacy prescriptions—in a way that optimizes the patient's health plan benefit."
The care coordination resulted in improved outcomes in areas such as lowering blood pressure, controlling cholesterol, and educating asthma sufferers. Specifically, the blood pressure levels at lower than 140/90 showed a 45% improvement, from 57% of people with acceptable blood pressure in 2008 to 83% in 2012.
High blood pressure is linked to an increase risk of heart attack and stroke, and has been defined as any number higher than 140/90. The test for LDL cholesterol is used to predict the risk for developing heart disease. The elevated levels of LDL cholesterol can indicate a risk for heart disease, with an optimal reading of less than 100 for those at risk.
According to the Chronic Care Initiative, the tests showed a 60% improvement from 2008, when there were 35% in the desired range, to 2012, when 56% had acceptable cholesterol levels.
Asthma is always a concern. The chronic lung disease can be life threatening, but it is usually manageable so people can live a normal, healthy life. The Chronic Care Initiative established an "asthma action plan" as part of its medical home program to help patients self-manage this condition. There has been considerable impact, says Snyder.
While 53% of patients had their asthma under control in 2008, that increased to 76% in 2012. In effect, physicians use the tool to help asthma patients evaluate their own conditions for better care.
For instance, patients are asked to check their peak flow—a measurement of how fast they can exhale—at least daily, and more often when asthma symptoms appear. If the patient has no symptoms and the peak flow is in the expected range, then the patient is in the green zone and simply takes his or her maintenance medications. Patients may enter the yellow zone, in which some medications are needed. If a patient has a lot of trouble breathing—or is in the red zone—then it is time to call 911.
The medical home model and its coordination of care proved to be a successful plan to control healthcare costs compared to other methods the insurer tried, Snyder says. "Over the years, we implemented disease management plans and outsourced them to other companies in an attempt to get better control over chronic conditions. That didn't work well."
One of the biggest flaws in those disease management plans, as Snyder sees it, was the insurer's failure to have providers—not just the insurer—involved from the beginning of care, from the first phone call to follow-up contacts. "Patient education doesn't really work when a nurse is sitting in a different state, calling on behalf of an insurance company," Snyder says. What does work is when the patient gets a call from a medical professional that he or she has personally met. "That patient feels guilty for not listening to the doctor or nurse."
Success key No.2: Accountable care organizations
Large and small healthcare organizations are teaming up with physician groups to initiate the medical home model within ACOs, with patient engagement as a top priority to manage chronic diseases.
In 2012, Summa Health Network—the Akron, Ohio–based physician hospital organization affiliated with Summa Health System Hospitals—launched NewHealth Collaborative, a medical home within its ACO. NewHealth incorporates the practices of 203 physicians who care for 44,000 patients, says James Dom Dera, MD, FAAFP, medical director of the NewHealth Collaborative. For Summa, as with many other medical homes, a primary focus is on diabetes, a chronic disease characterized by a broad range of metabolic abnormalities.
"Diabetes is one of our top priorities, because it's our No. 1 diagnosis, impacting so many people," says Dom Dera, who also is a physician with the Ohio Family Practice Centers Inc. in Fairlawn, which is part of the ACO. "We said, 'Let's try to find a way under the auspices of the accountable care organization to see if we can start to transform patient care."
Under an ACO, physician groups and hospitals leverage their resources to tap into services ranging from case management to nutrition. "We are a group of docs coming together for a shared goal. We view the patient-centered medical home as the center of our ACO," Dom Dera says. With preventive care as a major focus, the physicians group partnered with Emmi Solutions, a Chicago-based patient engagement communications company, to nudge diabetic patients who need yearly retinal eye exams. Physicians made calls to patients to encourage them to obtain eye checkups.
"It was important that these calls were personal and from the physicians, and the patients' feelings were 'Hey, this message is coming from my doctor,' " says David Littlejohn, RN, quality improvement director of the Summa Health Network. "Still, we weren't sure what the impact would be. But we were very surprised and pleased."
Over a six-week period in September and October 2012, the Ohio Family Practice Centers physician group showed a 13% improvement in retinal eye exam rates, based on 523 patients with diabetes. The percentage of patients contacted by Emmi that either updated their records or scheduled appointments was calculated at more than 22% based on responses from 24 of 105 people.
Success key No. 3: Improved patient satisfaction
Physician groups are developing their own medical home programs and increasing patient satisfaction.
 That is happening at Cornerstone, a High Point, N.C.–based physician-owned multidisciplinary practice of more than 360 doctors and midlevel health professionals in more than 85 locations in central North Carolina, serving a population of 200,000.
 For Cornerstone, improved patient satisfaction has been the result not only of coordinated care but also homing in on patient response to that care. Cornerstone's medical home focuses on recruiting more adult Medicaid and low-income Medicare patients, most of them with complex and costly illnesses.
 Like physician medical home teams elsewhere, Cornerstone employs a support team that ensures longer one-on-one appointments with patients. With the extra time, the health professionals provide in-depth disease education or stress counseling as part of their services, if needed, according to Michael Ogden, MD, chief clinical integration officer at Cornerstone.
 Using electronic medical records, primary care physicians on the support team receive periodic updates about all their patients, enabling the doctors to quickly identify aberrations in blood pressure, blood sugar, or medication reconciliation that might be a concern. Cornerstone also operates what Ogden terms "transformational models" that include the clinics that serve the polychronic patients and provide dietary or social work specialists and psychologists who coordinate care with nurse navigators. "A psychologist spends a lot of time figuring out ways to overcome barriers to good health," he adds.
Cornerstone made its improvements after several failed attempts at boosting patient satisfaction scores, realizing it needed a more concentrated approach to ensure success. So, several years ago, Cornerstone first surveyed patients to understand how they viewed their patient experiences, examining responses from 360 providers in 85 locations, serving a population base of 200,000. They set a goal of improving patient satisfaction scores by 10% each year, he says.
The sample size for the patient satisfaction surveys has been from 250 to 400, Ogden says. "We have been paying attention to patient satisfaction especially the past two years," he adds. "For the entire team the focus is to have the best experience possible."
 Attaining good patient satisfaction only results with continued improvements in the "culture of the primary care practice," Ogden says. That culture focuses on follow-up care, such as "identifying patients who have gaps in care, the diabetic who doesn't have the eye exam or foot exam."
 Cornerstone committed to improving patient relations by paying attention to what may seem like small customer service details. Scripts for phone messages to patients were rewritten. When patients waited in physician offices, employees would come out from behind their desks to notify patients periodically about the delays. New name badges were distributed that prominently showed the first name of a provider.
Ogden says Cornerstone also uses a standardized method developed by Press Ganey to assess patient experience, with the intent of boosting patient satisfaction scores. It established a PEAK (Patient Expectations Are Key) team that continually reviews patient satisfaction scores and aims for improvement, he says.
The PEAK team includes representatives from clinical operations, medical staff, nursing, and "focuses on enhancing the patient experience," Ogden says. As an example, nurse navigators made repeated phone calls to patients to ensure they were taking their medications and keeping their appointments. In one instance, a nurse navigator's persistent questioning of a breast cancer patient who said she wasn't hungry revealed that the patient hadn't eaten for several days. As a result, the nurse immediately assembled a team to collect food to give her.
Physician champion Yates Lennon, MD, heads the PEAK team. Each month, written communications are sent to staff to provide what they term "wow stories, [patient satisfaction] score updates, and constant reminders about the goals," according to Ogden.
Over the past three years, the PEAK team has worked with staff to oversee a continual improvement in patient satisfaction scores. Three years ago, Cornerstone was in the 76th percentile of patient satisfaction, and it reached 90% in 2013, Ogden says. Cornerstone officials saw the need for change after several failed attempts to boost patient satisfaction scores.
Ultimately, to obtain sufficient patient satisfaction, it's important to have the patients engaged, Ogden says. "Folks aren't used to being reached and touched by a healthcare delivery system," he says. "It's engagement when the healthcare navigator helps patients achieve their healthcare goals."
Success key No. 4: Bridging community gaps
In western North Carolina, air quality issues are producing some of the highest rates of asthma in the state, particularly among children, says Susan Mims, MD, MPH, vice president and medical director of the 135-staffed-bed Mission Children's Hospital in Asheville, N.C.
Through Mission Children's Hospital Regional Asthma Disease Management Program, the hospital uses its regional network to provide intensive case management by respiratory therapists to children suffering from asthma. As a result, the hospital has made inroads in bridging care in the community—thereby reducing emergency department use and all-too-frequent hospitalizations among asthma patients, Mims says.
Mission began its program after evaluating hospital admissions and school absences, and calculated the cost estimate for ED visits.
The asthma program uses a multifaceted educational approach to help families understand the causes, signs, and symptoms of asthma attacks and the proper use of medications, and connects families with community resources that can help.
The hospital's program focuses on children who may not have received intervention on a regular basis, Mims says. The children targeted for these interventional services are those with moderate and severe asthma, and they receive clinical services in a doctor's office, at home, or at school or daycare.
 "This work is vitally important, because we target the highest–risk children whose asthma has not been controlled," Mims says.
RADMP activities have contributed to the reduction of asthma-related emergency visits by 85% and hospitalizations by 95%, equaling a total savings of more than $800,000. The estimated cost savings from the ED visits alone was $142,000, and for hospitalizations, it was $687,477, Mims says.
With coordination under the medical home, ED utilization and hospitalizations declined dramatically, Mims says. Before the program was launched, there were 158 visits reported in 2011; postintervention, there were only nine in one cohort of patients, she says. As for hospitalizations, there were 60 pre-intervention and only three after the program started.
To accomplish these clinical and financial results, the hospital coordinated with Community Care of North Carolina, a Medicaid-run program, and area pediatric primary care practices. "There was a big focus to make sure that kids were getting care addressed in primary care offices and to make sure their asthma was being addressed, and that they would not end up in the ED or admitted to the hospital," Mims says.
Primary care medical homes are involved in ensuring that children continue to receive care for asthma—outside the hospitals. Respiratory therapists coordinate with the program to "visit the schools, the child care centers, meet parents, and talk with families," Mims says. "We're trying to prevent asthma attacks by educating and changing the environment so the disease can be managed more effectively."
Reprint HLR0613-7

This article appears in the June issue of HealthLeaders magazine.

Joe Cantlupe is a senior editor with HealthLeaders Media Online.

Summit Focuses on Lower Health Care Costs, Success of New Models

June 17, 2013 12:19 pm James Arvantes Washington –
 According to presenters at a June 6 policy summit(fora.tv) on health care innovation here, the lower health care costs the United States is experiencing may be due, in part, to the growing use of innovative payment and delivery models of health care. This is backed up by results from at least one pilot program testing the patient-centered medical home (PCMH) model of care that has seen a large decrease in costs.
Bruce Bagley, M.D., right, TransforMED interim president and CEO, talks about the patient-centered medical home with Chet Burrell, president and CEO of CareFirst BlueCross BlueShield, and Marci Nielsen, M.P.H., Ph.D., CEO of the Patient-Centered Primary Care Collaborative after participating in a policy summit on health care innovation.
During the summit, CareFirst Blue Cross Blue Shield, a sponsor of the summit, which was held by theNational Journal Live, announced that its medical home program in Maryland, Northern Virginia and Washington, D.C., had achieved dramatic cost savings and improvements in the quality of care for the second straight year. In 2012, the PCMH project, the largest of its kind in the nation, saved $98 million, according to CareFirst.
In addition, two reports issued by the Congressional Budget Office earlier this year projected billions in federal budgetary deficit savings as a result of lower health care costs. "CBO has issued two reports in which the data points around health care costs are dramatically changing," said Neera Tanden, J.D., president of the Center for American Progress and a former senior adviser for health reform at HHS, who delivered the summit's keynote address.
Tanden attributed at least part of the slowdown in health care costs to the growing use of PCMHs, accountable care organizations and bundled payments. "These innovations are driving the changes," she said.
  • The move to team-based, coordinated care has created a greater need for the patient-centered medical home and other innovative payment models that rely on a foundation of primary care, according to a recent policy summit held in Washington.
  • The forum highlighted the accomplishments of the CareFirst medical home program, which achieved cost savings and improvements in the quality of care for the second straight year.
  • Bruce Bagley, M.D., interim president and CEO for TransforMED, said the prevailing fee-for-service payment system discourages innovation and change in the health care arena.
The Health Care Environment
Tanden's keynote address was followed by an expert panel that included Bruce Bagley, M.D., TransforMED interim president and CEO; Chet Burrell, president and CEO of CareFirst; Marci Nielsen, M.P.H., Ph.D., CEO of the Patient-Centered Primary Care Collaborative; and Kavita Patel, M.D., fellow and managing director of delivery system reform and clinical transformation at the Center for Health Care Reform at The Brookings Institution.
Bagley told the audience of about 200 policymakers and other stakeholders that the health care environment has changed, becoming much more oriented toward primary care. "I have never seen this much attention to primary care in the policy arena and the political arena," he said.
There is a general acknowledgement that health care spending and costs are not sustainable, creating a need for innovative payment and delivery models to slow health care costs and improve quality. The prevailing fee-for-service payment system has discouraged innovation and change in the health care arena because the model is based almost entirely on office visits as the central commodity, Bagley said. "Until we get unshackled from that, it is very hard to do things that are not visit-based."
When Bagley asked how many people in the audience could e-mail their physicians for a consultation, only two hands went up. "That is sparse," Bagley said. "That is sad."
He called for a blended payment model to compensate physicians for care coordination and other services that fall outside face-to-face visits. One of the goals of the AAFP and TransforMED, said Bagley, is to create an environment where physicians can deliver continuing, comprehensive and personal care in more consistent and reliable ways using tools, such as registries, for patients with chronic diseases.
In recent years, said Bagley, it has become increasingly clear that practices need an infrastructure to implement and sustain the PCMH model. "It is not only about paying doctors more," he said. "It is about creating an environment in which the work of primary care can be done in an effective and efficient way."
The CareFirst Pilot
That environment is demonstrated in the CareFirst PCMH pilot project, which relies on a network of primary care practices, known as medical care panels, to deliver and manage care through a team-based approach. The program comprises 420 physician panels, and each panel is responsible for taking care of about 3,000 CareFirst members. The panels are accountable for aggregate patient costs and quality across all settings.
"Every single thing that is done for those patients in any setting, by any provider, is the responsibility of that panel," said Burrell. "We debit every single item and service against that panel."
The message to the physician practices is unmistakable: "Don't let your patients break down, don't let your patients get excess services, and don't ignore things that need to be tended to," Burrell said. "The job is to take care of the (patients) better, and for that we need a team, not just the physician."
CareFirst provides each panel with an overall budget for the coming year and then challenges the panel to beat that budget, allowing it to share in the savings if it comes in below the target. The panels are able to beat the budgets by reducing hospital readmission rates, emergency room visits and complications from drug interactions, effectively taking better care of their patients, said Burrell.
CareFirst has 2.5 million members in Maryland, Virginia and Washington, D.C. More than 1 million are included in the pilot. The inpatient medical costs for members within the PCMH pilot were 15 percent lower in 2012 than for those who were not in the pilot. PCMH patients also had drug costs that were 4 percent lower, and their cost per admission was 8.3 percent lower than the non-PCMH patients.
Burrell said elements of the CareFirst model can be replicated in other parts of the country. He pointed out, however, that health care intrinsically is local. "There are meaningful differences in the way it is provided in difficult localities," said Burrell. "You should build on that and not try to ignore that and make everything one common model. There is no one right way."
According to Bagley, the ultimate goal is to achieve the triple aim of health care: better care for the individual, better population health and lower costs on a per capita basis. "That should be common everywhere," Bagley said. "That is the goal of our system."

Medicare program eliminates 30 out-of-state suppliers

7:33 AM, Jun 18, 2013 
The federal Medicare program has dropped nearly a third of the companies chosen to continue supplying home medical equipment to beneficiaries statewide, leaving even fewer suppliers as part of its controversial competitive bidding program set to kick off in Tennessee in less than two weeks.
The contracts were voided because those 30 out-of-state suppliers that had won didn't meet Tennessee licensing requirements when they submitted bids, said Marilyn Tavenner, administrator of the Centers for Medicare and Medicaid Services.
Her disclosure in a letter to the state's congressional delegation is a small win for many Tennessee-based vendors that lost bidding contracts and won't be reimbursed for any supplies sold to Medicare beneficiaries starting July 1.
But Tavenner stopped short of agreeing with ATHOMES, the statewide industry trade group, that the entire results of the competitive bidding process should be scrapped and restarted. The group had argued that CMS violated its own rules by not ensuring that applicants were properly licensed in the states where they were trying to do business.
"This is government at its worst," said Ben Shapiro, chief operating officer of Ed Medical, a Hendersonville-based supplier bracing to lose a quarter of its revenue because it didn't win a local contract. "It will create a real access problem. It's just going to disrupt the whole competitiveness that now exists in the marketplace."
But in her response to the lawmakers, Tavenner said given the large number of in-state suppliers remaining, she was confident beneficiaries will continue to have access to a variety of quality items and services and that her agency might consider making newawards in the future.
"We will continue to examine this issue and closely monitor the situation in the state," Tavenner said.
Through the competitive bidding program, which is being expanded to 91 metro areas including Nashville, federal officials expect billions of dollars in savings from dealing with fewer vendors. According to results from other cities in the program, Medicare was able to cut prices for many offerings - including wheelchairs, crutches and blood pressure monitors - in half.
Lawmakers express their concerns
Last week, more than 200 members of Congress wrote CMS urging a delay in implementing the latest round of the program amid concerns about its structure and licensure issues, such as the one raised in Tennessee.
"The Tennessee delegation wants to make absolutely certain that patients have reliable access to the durable medical equipment supplies that they need, that the law is followed, and that Tennesseebusinesses are given a level playing field," said U.S. Rep. Phil Roe, R-TN. He was among the lawmakers urging the delay and is a co-sponsor of legislation that seeks to replace the competitive bidding program with a market pricing program.
Roe and other lawmakers said they were encouraged by some actions CMS has taken, but added that there's more to be done.
"I fear that the winning bid rates have been inaccurately calculated given the inclusion of now voided bids, and I worry that Medicare beneficiaries in Tennessee will not have sufficient options to receive necessary durable medical equipment given the large number of voided bids," said U.S. Rep. Marsha Blackburn, R-Brentwood. "Patients in Tennessee could suffer the access-to-care issues that may arise given the volume of voided bids. Finally, I continue to have reservations about this program going live in less than two weeks with potentially similar problems in other states."
CMS also was made aware of legitimate licensing issues in Maryland and is reviewing the situation to determine the appropriate action to take, said Tami Holzman, a spokeswoman.
"Competitive bidding is working and is saving taxpayers and beneficiaries billions of dollars," she said. "We remain confident that seniors will have access to their equipment, (and) savings will continue."


Report: Sacred Heart's 'Physician D' is Chicago pulmonologist

Report: Sacred Heart's 'Physician D' is Chicago pulmonologist

A Chicago pulmonologist has been identified as holding the same position at Sacred Heart Hospital as “Physician D,” the doctor federal authorities say performed medically unnecessary tracheotomies at the West Side hospital, according to a report.
Dr. Venkata Buddharaju has not been formally accused in any aspect of the federal investigation at Sacred Heart, where the FBI and the U.S. attorney's office in Chicago have alleged that administrators and doctors engaged in various schemes, including kickbacks to physicians, intended to defraud the Medicare program.
In a 90-page complaint released in April, federal authorities say Physician D deliberately oversedated patients so they would not be able to breath on their own. Once a patient was deemed dependent on a ventilator, the doctor would order a tracheotomy, the complaint alleges.
Physician D is described in the complaint as the chair of the critical-care committee of Sacred Heart's medical staff. According to a story published by Bloomberg on Friday, Dr. Buddharaju holds that position.
Dr. Buddharaju's lawyer, Thomas Breen, confirmed to Bloomberg that his client holds the critical-care chairmanship but told the news service the allegations in the federal complaint are “untrue.”
“While it would appear that Dr. Buddharaju is Physician D in the complaint based on his job title and his chairmanship of the Critical Care Committee, the rest of the description and allegations do not conform to the medical care or decisions made by Dr. Buddharaju,” Mr. Breen told Bloomberg.
In the complaint, the FBI alleges that Sacred Heart CEO Edward Novak called tracheotomies, in which a hole is made in a patient's throat to insert a breathing tube, the hospital's “biggest money maker,” bringing in $160,000 if the patient stays 27 days.
Mr. Breen did not immediately respond to a call from Crain's to comment.
Federal law enforcement officials on April 16 arrested Mr. Novak, Chief Financial Officer Roy Payawal, and Drs. Venkateswara Kuchipudi, Percy Conrad May, Subir Maitra and Shanin Moshiri in connection with the alleged kickback scheme. They arrested a fifth doctor, Kenneth Nave, the next day, alleging he prescribed painkillers without authorization.
Lawyers for each defendant have denied the accusations.

Federal Jury Finds Brookfield Podiatrist Guilty of Medicare Fraud

U.S. Attorney’s OfficeJune 14, 2013
  • District of Connecticut(203) 821-3700
Deirdre M. Daly, Acting United States Attorney for the District of Connecticut; Susan J. Waddell, Special Agent in Charge of U.S. Health and Human Services, Office of Inspector General for New England; and Kimberly K. Mertz, Special Agent in Charge of the Federal Bureau of Investigation, today announced that a federal jury in Hartford has found Samir Zaky, 38, of Brookfield, guilty of 14 counts of health care fraud and 14 counts of making false statements relating to health care matters. The trial before Senior U.S. District Judge Alfred V. Covello began on June 10 and the jury returned its verdict this afternoon.
“Health care fraud is a serious crime that undermines our ability to provide care to those who need it most,” stated Acting U.S. Attorney Daly. “Our office is committed to protecting Medicare beneficiaries and taxpayers from all unscrupulous health care providers in Connecticut.”
“When health providers put personal greed ahead of the provision of quality patient services, they should expect intense scrutiny by law enforcement officials,” stated HHS-OIG Special Agent in Charge Waddell. “Dr. Zaky recklessly ignored the consequences, insisting on cheating taxpayers, patients, and the Medicare program. Now, he is paying the price.”
“Medicare is in place for our nation’s elderly to receive important and often vital health care services,” stated FBI Special Agent in Charge Mertz. “It is not for unscrupulous doctors and health care professionals to use as a personal slush fund. The FBI is committed to investigating fraud in both government-sponsored and private health insurance programs and urges anyone with information on a health care fraud to report it their local FBI office.”
According to the evidence at trial, Zaky is a podiatrist who operated Affiliated Podiatrists LLC in Brookfield. From August 2010 to July 2011, Zaky submitted numerous claims to the Medicare program stating that he had performed nail avulsions, a surgical procedure that requires use of an injectable anesthetic and removes the entire border of a patient’s toenail. In fact, Zaky had only clipped or trimmed the patient’s toenails.
Judge Covello has scheduled sentencing for September 10, 2013, at which time Zaky faces a maximum term of imprisonment of 10 years on each count of health care fraud and a maximum term of imprisonment of five years of each count of making a false statement.
The government also is seeking to forfeit more than $29,000 in cash found during a search of Zaky’s residence in August 2010.
Zaky has been released on bond since his arrest on November 29, 2012.
This matter is being investigated by the U.S. Department of Health and Human Services-Office of the Inspector General (HHS-OIG) and the Federal Bureau of Investigation. The case is being prosecuted by Assistant United States Attorneys David J. Sheldon and Christopher W. Schmeisser and Auditor Kevin Saunders.

From HFMA: ICD-10 Vets Offer Guidance

The clock is ticking louder for the ICD-10 go-live date in October 2014. As it does, health systems are beginning to fret about the likely financial impact on operations. Speakers at the Healthcare Financial Management Association conference in Orlando described the journey to ICD-10 as both arduous and full of uncertainties.

Sutter Health, a $9.1 billion health system with 24 acute care hospitals across northern California, began its transition program in 2013, noted HFMA panelist Danielle Reno, ICD-10 program director. Sutter’s 14 transition teams--which report up to a senior level executive sponsor--represent the breadth of the challenge, which impacts information systems, revenue cycle, contract management and multiple other areas. Sutter is about three-quarters of the way through its financial analysis of ICD-10’s likely impact--a key consideration in determining where to focus clinical documentation improvement and coding training resources, Reno said.
Using claims grouping and cross-walking tools from CMS, Sutter determined that about 8 percent of its claims mapped to Medicare DRGs would shift to another DRG under ICD-10. Medicare offers a cross-walk tool known as GEMs, or general equivalency mappings. Using the cross-walk, health systems can identify which cluster of codes in ICD-10 would correspond to a counterpart in ICD-9. Reno noted that the GEMs tool, while a good starting point, still requires a great deal of manual review due to the one-to-many relationship between versions 9 and 10--which includes tens of thousands of new codes.
Sutter is also conducting “table top testing” of ICD-10 with two commercial payers. Rather than submitting test data through its billing system, the process involves sending raw ICD-10 data on a spread sheet, which the payer can parse and analyze for errors and omissions. The effort requires pulling coders from their normal duties however and Reno cautioned that as health systems go through the exercise, they may discover a correspondent drop in cash flow as it could take longer to get real claims out the door. Sutter budgeted for additional coding support during the initiative, she noted.
Panelist Brett Kelsey, chief revenue officer at Lucille Packard Children’s Hospital, serves as executive sponsor of the pediatric facility’s ICD-10 transition team. Part of Stanford Health System in California, Lucille Packard has mostly completed its information systems and financial impact analysis. It’s now renegotiating payer contracts in areas most likely to be heavily affected by ICD-10.
But Kelsey and other panelists sounded one common theme: there is a great deal of uncertainty inherent to the transition to ICD-10. Packard, for example, is looking for a vendor partner to assist with cross-walking data from ICD-9 to ICD-10, noted Kelsey. And as Reno pointed out, even after training, coders may not agree on which particular ICD-10 code to apply to a given case--even if physician documentation is thorough.