Innovation, Technology and Teamwork Lead to Early Opening of Kaiser Permanente’s New State-of-the-Art Hospital in Fontana

FONTANA, Calif. -- 

Patients are now receiving high-quality, affordable healthcare at a new state-of-the-art hospital for Kaiser Permanente in Fontana, Calif. Built by McCarthy Building Companies, Inc. and designed by HMC Architects, the new seven-level hospital boasts a technologically advanced patient-centered design. The project was completed four months ahead of schedule and opened on May 7, 2013.

Located on the southern end of the Kaiser Permanente Fontana Medical Center site, the new 490,000-square-foot tower is one of the largest healthcare facilities in the Inland Empire. The new hospital was built to meet the latest, more rigorous seismic safety standards established by the state of California. It replaces the existing Kaiser Permanente Fontana Hospital tower, some of which will be converted for outpatient use.

Serving as general contractor, McCarthy’s contract entailed construction of a 314-bed hospital, a 50,000-square-foot hospital support building, and a 23,000-square-foot central utility plant. Prior to beginning construction of the hospital in May 2009, McCarthy built a new member and doctor parking lot and relocated utilities at the site.

“Building a major hospital facility on an extremely tight site surrounded by an operational medical center took a great deal of planning and coordination,” said McCarthy Senior Project Manager Lucy Villanueva.

One of the most challenging aspects of the project was the proximity of the new hospital to existing structures, located only 25 feet away from an operational medical office building and 70 feet away from other medical facilities. McCarthy conducted tie-ins to two existing medical office buildings at a second-story pedestrian bridge and an underground pedestrian tunnel as well as various utility tie-ins, all while ensuring operation of existing facilities.

Villanueva says that close collaborating with hospital administration and project subcontractors and suppliers was required to minimize disruption to neighboring facilities. McCarthy also utilized ‘just-in-time delivery,’ staged materials off-site and shuttled construction workers in from a remote parking area.

The new Fontana hospital is based on Kaiser Permanente’s innovative template design that allows for enhanced flexibility to accommodate changing practices and technologies. Kaiser Permanente’s electronic medical record system, sophisticated imaging systems, wall-to-wall wireless computer network and free Wi-Fi for members are some of the technological features in the new hospital. More than 20 specialty services are available in the new tower, including a Cardiac Catheterization Lab, Labor & Delivery and Neonatal and Pediatric Intensive Care Units. Cardiac Surgery Services will be added in 2014. The hospital features: all private patient rooms; a 24-hour, 51-bed emergency department; 24-hour pharmacy; a healing garden and mediation room as well as a cafe. The hospital support building is attached to the new hospital and includes medical offices, radiology, a pharmacy and a specialty clinic.

“The patient-centered design at Fontana is focused on a continuum path to healing throughout three stages of the patient experience: anticipation, transition and healing,” notes John Kouletsis, VP of Facilities Planning & Design at Kaiser Permanente. The facility boasts large windows providing an abundance of natural light to help ease stress and contribute to patient healing. “Warm colors are used throughout the facility to activate the space and presents a more welcoming patient experience,” adds Kouletsis. Each floor features its own accent color that is visible through the main tower to aid in wayfinding. All patient rooms have an acoustic design reducing noise, and the hospital’s labor and delivery suites feature a home-like setting to comfort expectant and new mothers.

The facility also incorporates numerous sustainable design solutions including: energy efficient lighting, electrical, air conditioning and plumbing systems; use of reclaimed water for cooling towers; site bio-retention basins; light colored sustainable roofing; dual pane exterior window glazing and natural day lighting.

Likewise, McCarthy used sustainable building methods such as recycling building materials, minimizing unrecyclable construction waste and maintaining proper indoor air quality. In an effort to streamline the submittal process, as well as dramatically reduce the amount of paper used on the project, McCarthy utilized the Submittal Exchange online service to electronically process over 95% of all submittals.

“According to Submittal Exchange, the use of this software on the Kaiser Permanente Fontana project has saved more than 130 trees,” said Villanueva.

Additionally, a Digital Plan Room with two large monitors for viewing the drawings electronically was used to replace the stacks and rolls of paper drawings. This not only saved space, but significantly reduced the reproduction costs and use of paper for printing the large quantity of drawings required for the project. To encourage the subcontractors to do the same, McCarthy distributed all drawing updates electronically.

A key aspect to delivering this complex healthcare project early and within budget was the design-assist delivery method. “This early collaborative approach among the design engineer and the trade contractor helped reduce costly and time intensive changes during construction,” said Villanueva.

Helping to further the design-assist effort, the project team utilized Building Information Modeling (BIM) coordination technology to manage the hospital facility’s complex structural, architectural, and mechanical, electrical and plumbing systems.

“The project was fully coordinated utilizing Navisworks^TM and its clash detection capabilities. All overhead utilities were completely modeled to assist the project team in efficiently coordinating the extremely complex systems designed for this project,” explained Villanueva. “The ability to resolve design and constructability issues effectively and early in the process, directly attributed to significant cost savings in the field and allowed for a faster, more efficient installation. The largest benefit to the modeling process was the ability to prefabricate the majority of the plumbing, HVAC piping, ductwork and electrical systems. Over 60% of these systems were prefabricated in off-site facilities and shipped to the project just-in-time for installation, helping reduce the project duration and improve quality,” added Villanueva.

Theresa Ashby, transition director, Kaiser Permanente Fontana Medical Center said, “The efficiencies and workflow innovations we were able to leverage during construction of the Fontana Replacement Hospital have allowed us to provide cutting-edge healthcare to the residents of the Inland Empire much sooner than we had initially anticipated.”

About McCarthy

Recognized as one of the nation’s few true builders, McCarthy Building Companies, Inc. is the largesthealthcare facilities builder in California (ENR California, July 2012) and the largest general building contractor in California (ENR California, July 2012). The company is committed to the construction of high performance green buildings; progressive jobsite technology; and safer, faster and more cost-effective execution. More information about the company is available online at www.mccarthy.com.

To download high resolution images, please visit: http://www.mccarthy.com/kaiser-permanente-fontana

http://www.fortmilltimes.com/2013/07/17/2827360/innovation-technology-and-teamwork.html

Capital BlueCross challenges student developers nationwide to create web or mobile applications that improve health care

HARRISBURG, Pa., July 17, 2013 - Capital BlueCross is challenging student developers nationwide to create web-based tools or mobile applications that enrich the health care consumer experience. Winning entries can earn one of three prizes totaling $30,000.

Titled Blue Innovates, the challenge is an opportunity for students 18 years of age or older to bring their innovative ideas to life in one of three categories:

Financial: Applications that assist health care consumers in finding, accessing, organizing, simplifying, understanding or minimizing health care expenditures.

Telemedical: Technology that provides consumers with affordable and high quality health care while saving time and money.

Experiential: Tools that help consumers have a more personalized and satisfying health care experience and that enhance their well-being.

"As a leader in the health care industry, Capital BlueCross is seeking to develop new solutions that will meet the evolving needs of consumers who want to interact with health care like every other retail experience," said Donna K. Lencki, Capital BlueCross chief marketing officer. "We recognize there are a lot of talented people looking for an outlet to showcase their ideas and creativity. Blue Innovates allows us to tap into the minds of'millennials' to drive innovation in a rapidly changing industry to help consumers better understand and navigate the health care system for the best possible outcomes. We are delighted to kick-off this challenge."

Students may use their preferred tools, programming languages and technologies to develop a unique solution. All entries for Blue Innovates must be submitted by Nov. 22, 2013. Winners will be announced by Dec. 20, 2013. Entries must be original work created by the developer who is submitting the application for consideration.

To get started, students can visit Blue Innovates to register and review contest rules. Developers can also use the online forum on the Blue Innovates web site for support and advice throughout the process.

The developer of the first-place winning application will receive $15,000, while the second and third place winners will receive $10,000 and $5,000 respectively.

About Capital BlueCross

In 2013, Capital BlueCross is celebrating 75 years of serving central Pennsylvania and Lehigh Valley residents and businesses as the region's leading health insurer. Through its family of companies, Capital BlueCross brings innovative services and clinical solutions to the marketplace. Committed to delivering medical value to its communities, Capital BlueCross focuses on improving patient satisfaction, enhancing quality of care and reducing costs. The company continues to lead the change in the industry by meeting the evolving health needs of its customers, most recently by entering the retail market and building a first-of-its-kind health and wellness store called Capital Blue. Headquartered in Harrisburg, Pa., Capital BlueCross is an independent licensee of the Blue Cross and Blue Shield Association, employing more than 1,800 people. More information about Capital BlueCross can be found at capbluecross.com.

http://m.bwwgeeksworld.com/article/Capital-BlueCross-challenges-student-developers-nationwide-to-create-web-or-mobile-applications-that-improve-health-care-20130717

Innovate your Medicare Risk Adjustment Program

In an era of accelerating medical costs and flat payments from CMS, accurately reflecting the health status of your members through proper HCC (Hierarchical Condition Category) management is the only way for your Medicare Advantage plan to remain financially viable.  The secret to successful long-term risk adjustment for your Medicare Advantage plan is to properly educate your providers as to the value of complete and accurate coding of every member, every year. Historically, providers have coded for payment, which simply doesn't work well in the new world of 100 percent risk-based plan compensation, where complete and accurate coding of every patient on an annual basis is imperative.

Compliant Coding = Compliant Documentation

The quality of the documentation is vital to nearly every aspect of health care, and accurate chart documentation and diagnosis reporting determines reimbursement for the CMS Medicare Advantage Plans under the Risk Adjustment Program. However, CMS validation findings indicate that coded conditions are not supported in approximately 30 percent of the records reviewed.

Risk adjustment data validation is the process of verifying that diagnosis codes submitted for payment by the MA organization are supported by medical record documentation for an enrollee. You should assume that—sooner or later—CMS will audit your medical records, and potentially your program.

Explaining the role of clinical documentation and its impact on CMS-HCC will enable everyone to have a good understanding of the big picture.

Important points you should make include:

• Well-documented medical records facilitate communication, coordination, and continuity of care, and promote the efficiency and effectiveness of treatment.
• Accurate coding is the key to prompt reimbursement, practice profiling, and contract negotiations. It is important for both financial and compliance reasons.
• Chronic conditions are important to show not only resource utilization, but also severity of illness for statistical purposes.
• Specificity is important for further research into treatment effectiveness for chronic conditions.
• Showing medical necessity means you are justifying your treatment choice and help support E/M levels.

Evaluate you Program and Process

There may be opportunities within your current process to capture a more appropriate CMS-HCC code. For instance, consider this list of the top Ten Coding Errors for Risk Adjustment published by the AAPC:

1. The records must contain a legible signature including a credential.
2. EMR records must be authenticated, such as “electronically signed by,” followed by the providers name and credential
3. Highest degree of specificity refers to assigning the most precise ICD-9-CM code that fully explains the narrative description in the medical chart of the symptom or diagnosis.
4. Discrepancy between the diagnoses codes being billed versus the actual written description in the medical record. If the record indicates depression, NOS (311), but the diagnosis code written on the encounter document is major depression (296.20) these codes do not match; in addition, they map to a different HCC category. The diagnosis code and the description should mirror one another
5. Documentation does not indicate that the diagnoses are being monitored, evaluated, assessed/addressed, or treated (MEAT).
6. Status of Cancer is unclear, treatment is not documented
7. Chronic conditions such as hepatitis or renal insufficiency not documented as chronic.
8. Specificity: unspecified Arrhythmia coded rather than the specific type of arrhythmia.
9. Chronic conditions or status codes not documented in the medical record at least one per year.
10. Missing linkage or causal relationship for diabetic complication/Failure to report mandatory manifestation code.

Regardless of where you find shortcomings, you’ll want to consider options to improve clinical documentation.

Develop a compliance plan and/or a coding integrity plan.

Limit retrospective reviews and implement proactive policies with ongoing monitoring and feedback.

Many plans use analytics to detect members who might have missing diagnosis codes based on the analysis of pharmacy, claims, and DME data. Analytics are a good tool to point you in the right direction, but they are not a solution alone.  Even if the analytics identify the patient is missing a diagnosis, and the medical record indicates the patient has the condition, often the doctor has not documented the condition in the appropriate manner (MEAT, etc.) which, from a coding guideline perspective, means that code cannot be submitted.

Prospective chart reviews reduce the chances of submitting invalid or non-specific diagnose codes to CMS, and also reduce providers’ compliance risk. Having a review program in place also allows you to identify problem areas quickly, and identify opportunities for provider education and interaction.

The medical record should tell a complete story. Coders need to understand what the physician is thinking and know when the provider isn’t documenting the complete information to assign the most specific diagnosis code. Ensure that all opportunities for documentation improvement are identified.

ICD 10 and Risk Adjustment

2014 is sure to bring a unique set of challenges to the Risk Adjustment Arena.

Currently, there is a 30% shortage of certified coders in the US, and that is expected to jump by 57% with the implementation of ICD-10

What is the potential impact of this transition? Consider these 7 potential risks:

·         ICD-10 requires changes at the core of healthcare business, especially how patient care is documented (Compliance will require far more effort than learning a new code),

·         Inadequate allocation of training and education resources will have a more significant impact with ICD-10 than it ever did with ICD-9,

·         Reimbursement losses due to ineffective, physician clinical documentation will be magnified,

·         Without sustained physician leadership and sponsorship, the possibility for negative political impacts related to poor physician clinical documentation will increase,

·         Training physicians can be a challenging effort,

·          Fraud and abuse is now more aggressively pursued so that poor clinical documentation can pose a higher risk than previously experienced, and

·         Less than appropriate clinical documentation results in a lack of compliance within medical staff by-laws specific to Medicare patients, and is applicable to both out-patient and in-patient settings.

(http://www.kiranconsortium.com/library/whitepapers/TKCG%20White%20Paper%20%2001%202012%20The%20C-Scape%20Series%20Cracking%20the%20Code-Physician%20Clinical%20Documentation%20and%20ICD-10%20FINAL.pdf

RETURN ON INVESTMENT CDI Education

Consider the following ROI example from “Cracking the Code”

A Physician Clinical Documentation Improvement Program is a self-funded initiative.

While each healthcare organization must balance funding numerous concurrent or planned initiatives, a program for Physician Clinical Documentation Improvement is one of a few initiatives that can be self-funded based on the increased revenue that consistently is generated from improved documentation. Why is this true? The cost of a program will initially yield an ROI of a ratio of 1 to 5 or 1 to 4.

Example based on actual returns after a Physician Clinical Documentation

Improvement program has been enacted:

Small Hospital (100 beds): Investment in program (external resource) = $25,000

Increase in Revenue = $ 125,000

RETURN ON INVESTMENT – CODING + CDI + Lean Practice Management

Education Empowers. It empowers physicians, NP’s and PA’s, Receptionist, Nurses, Coders, Medical Records Clerks, Patients and Care Takers.

ERM’s unique Rapid Practice Innovation program routinely returns 300%+, but the greatest gift of all is the desire for something better. In as little as a week, we have successfully “revived” dying practices.

The greatest investment that you can make in yourself, your practice and your employees is education!

Primary care shortfall could be worse than predicted

■ Less than a quarter of recently trained physicians are choosing primary care, and few are heading to underserved rural areas.

By KEVIN B. O’REILLY amednews staff — Posted July 17, 2013

The U.S. appears to be falling behind in its effort to avert an impending primary care physician shortage, according to a recent study published inAcademic Medicine that tracked the specialty choices of residents and fellows as they entered practice (link).

About a third of physicians who deliver patient care are family doctors, internists or pediatricians, according to the American Medical Association’s 2013 Physician Characteristics and Distribution in the U.S. Yet, the Academic Medicine study found that of the new doctors being trained by U.S. physician training programs, only 24% go on to practice primary care.

The Assn. of American Medical Colleges predicts that by 2025 there will be a shortfall of 65,800 primary care doctors to serve the country’s health care needs (link).

For the study in Academic Medicine, researchers mined the AMA Masterfile, the National Provider Identifier database, Medicare claims data and information from the National Health Service Corps and the Accreditation Council for Graduate Medical Education to follow nearly 9,000 doctors who did their training at 759 teaching hospitals between 2006 and 2008.

They then examined what kind of care they delivered three to five years after training. The study said the 24% figure probably overestimates the share of doctors entering primary care because the data sources did not distinguish between internists practicing office-based primary care and those working as hospitalists. The AAMC says 17% of internists self-identify as hospitalists. Meanwhile, just 5% of the tracked residents went on to practice in rural shortage areas, said the study, posted online June 7 (link).

“If residency programs do not ramp up the training of these physicians, the shortage in primary care — especially in remote areas — will get worse,” said Candice Chen, MD, MPH, the study’s lead author. A pediatrician, she also is assistant research professor of health policy at the George Washington University School of Public Health and Health Services in Washington.

Wide gaps in residency programs

Behind the low share of trainees entering primary care lies great variation among residency programs, the study found. For example, 158 of the 759 training sites studied produced zero primary care physicians, while 184 saw 80% or more of their residents go on to practice in primary care.

“We talk about the primary care shortage a lot in the aggregate,” Dr. Chen said. “The reality is, it’s the decisions that each of these programs make on their own that makes up the aggregate. It’s worth looking at what each of these programs does on its own that affects the big picture on this.”

A teaching hospital medical culture that prizes primary care practice can persuade more internal medicine residents to enter primary care instead of subspecializing, Dr. Chen said. Further research should be done to determine the factors associated with the training sites that produce higher shares of primary care doctors, she added.

Nearly $13 billion in Medicare and Medicaid dollars go to graduate medical education annually. President Obama’s fiscal 2014 budget proposes to reduce Medicare’s contribution to GME by about 10% for a total cut of $11 billion during the next decade. The AMA opposes the cuts and has argued that the restrictions on Medicare GME funding that took effect in 1997 ought to be reversed.

http://www.amednews.com/article/20130717/profession/130719995/8/?utm_source=rss&utm_medium=&utm_campaign=20130715

Medicare Program; Comprehensive ESRD Care Initiative; Extension of the Submission Deadlines for the Letters of Intent and Applications

ACTION

Notice Of Extension Of Deadlines.

SUMMARY

This notice reopens the Letter of Intent submission period for the Comprehensive ESRD Care initiative letters of intent. Letters of Intent are now due on or before July 19, 2013. All potential applicants must submit a Letter of Intent to be eligible to submitan application. The submission deadline for the application has been extended to August 1, 2013.

TABLE OF CONTENT

·         DATES:

·         FOR FURTHER INFORMATION CONTACT:

·         SUPPLEMENTARY INFORMATION:

·         I. Background

·         II. Provisions of the Notice

DATES:

Letter of Intent Submission Deadline: Interested organizations must submit a non-binding letter of intent on or before July 19, 2013, by an online form at: https://cmsgov.secure.force.com/cec.

Application Submission Deadline: Interested organizations must submit an application on or before August 1, 2013, as described on the Innovation Center Web site at: http://innovation.cms.gov/initiatives/comprehensive-ESRD-care/apply.html. Interested organizations should also continue to check the Web site for updates on this initiative.

FOR FURTHER INFORMATION CONTACT:

Melissa Cohen, (410) 786-1829 or ESRD-CMMI@cms.hhs.gov.

SUPPLEMENTARY INFORMATION:

I. Background

The Center for Medicare and Medicaid Innovation (Innovation Center) is interested in identifying models designed to improve care for beneficiaries with end-stage renal disease (ESRD). To promote seamless and integrated care for beneficiaries with ESRD, we are developing a comprehensive care delivery model to emphasize coordination of a full-range of clinical and non-clinical services across providers, suppliers, and settings. Through the Comprehensive ESRD Care Model, we seek to identify ways to improve the coordination and quality of care for this population, while lowering total per-capita expenditures under the Medicare program. We anticipate that the Comprehensive ESRD Care Model would result in improved health outcomes for beneficiaries with ESRD regarding the functional status, quality of life, and overall well-being, as well as increased beneficiary and caregiver engagement, and lower costs to Medicare through improved care coordination.

On February 6, 2013, we published a notice in the Federal Registerannouncing a request for applications from organizations to participate in the testing of the Comprehensive ESRD Care Model, for a period beginning in 2013 and ending in 2016, with a possible extension into subsequent years.

Lean Thinkers and Practitioners from Around the World Invited to Connect at The Lean Post, a New Blog from the Lean Enterprise Institute

Cambridge, MA (PRWEB) July 15, 2013

The nonprofit Lean Enterprise Institute (LEI) has launched The Lean Post, an ambitious community blog platform where leading thinkers and practitioners in the business world’s various continuous improvement communities can connect, share, and learn together.

“Long-time adjacent communities such as lean management, organizational learning, systems thinking, operations research, and the lean startup movement are intersecting, colliding, and converging, which is as it should be,” said John Shook, LEI chairman and CEO. “We decided to create The Lean Post as one means of boosting global communication among all communities thinking deeply about continuous innovation.”

Current posts cover lean healthcare, startup lessons learned, model lines, leadership, capability development, design thinking, and senior leadership involvement, among other topics. The blog has a list of guidelines for prospective contributors.

“Essentially The Lean Post is a blog curated by LEI editors for the global business and organizational change communities,” explained Lex Schroeder, LEI managing editor. “It’s a place where thought leaders, coaches, practitioners, and people at any stage of their improvement journeys can share stories, lessons learned, and be in conversation about making things better through lean.”

Invitation to Participate
Schroeder said articles should present a new idea, discuss an old idea from a new angle, or raise a question related to the value of lean thinking and practice in the world today. “Everyone is invited to participate, either by submitting an article, joining the dialogue, sharing articles with colleagues, or just reading and learning,” she said. “We’re aiming to create a unique mix of voices and perspectives on The Lean Post, and we really want to invite people to submit posts.”

To stay updated on the latest posts, readers can subscribe to the blog by an RSS feed that is customizable by topic and author. The Lean Post can be viewed at: http://www.lean.org/LeanPost

Lean Enterprise Institute
Lean Enterprise Institute Inc., a 501(c)(3) nonprofit, makes things better through lean research, education, publishing, and conferences. Guided by a mission to advance lean thinking and practice around the world, LEI also supports other lean initiatives such as the Lean Global Network, the Lean Education Academic Network, and the Healthcare Value Network. Visit LEI at http://www.lean.org for more information.

For the original version on PRWeb visit: http://www.prweb.com/releases/2013/7/prweb10924955.htm

Read more: http://www.virtual-strategy.com/2013/07/15/lean-thinkers-and-practitioners-around-world-invited-connect-lean-post-new-blog-lean-ente#ixzz2ZIyAGH10

CareOregon releases 2012 Annual Report

By: 

 CareOregon

July 15, 2013 —2012 was a revolutionary year for health care in Oregon, with the advent of Coordinated Care Organizations, the genesis of the Cover Oregon health insurance exchange, and the launch of new Consumer-Oriented and Operated Plans. All these changes, and more, are featured the 2012 Annual Report from CareOregon.

Through that change, CareOregon has reinvented itself as an agent of innovation.

“It is a bold statement to proclaim that health care can be more affordable and achieve better results,” notes CareOregon CEP Patrick Curran. “It is far bolder still to actually turn those statements into action.”

Underscoring that objective is CareOregon’s commitment to the people we serve, including members, providers, partner organizations and our communities. This informs new and ongoing initiatives, including:

• Providing services to five Coordinated Care Organizations (CCOs), Oregon’s Health CO-OP and Neighborhood Health Center, and administering Multicare Dental, now called CareOregon Dental.
• Widening focus on bottom-up, top-enabled quality improvement on the front lines of health care through: primary care transformation (our initial Primary Care Renewal and the second generation Patient and Population Centered Primary Care programs); applying lean methodology to hospital operations in the Releasing Time to Care and the pilot Productive Operating Theater program.
• Expanding the operations of the Community Care Team’s non-traditional health workers and the Health Commons Grant, as well as supporting the principles of community-based care and transformation in the CCOs.
• Broadening community engagement through our CareOregon’s Member Advisory Council and support of CCO Community Advisory Councils.
• Enhancing Medicare support and services.

The report also features stories of those who are helped by community efforts and those who, as providers or active citizens, are helping others.

The annual report is available online at http://www.careoregon.org/Res/Documents/AnnualReport.pdf.

For more information or to arrange an interview, please contact Jeanie Lunsford.

http://www.thelundreport.org/resource/careoregon_releases_2012_annual_report

Rates of major CV procedures differ between Medicare Advantage and fee-for-service beneficiaries

In a study that included nearly 6 million Medicare Advantage and Medicare fee-for-service beneficiaries from 12 states, rates of angiography and percutaneous coronary interventions were significantly lower among Medicare Advantage beneficiaries and geographic variation in procedure rates was substantial for both payment types, according to a study in the July 10 issue of JAMA.

"Treatment of cardiovascular disease is one of the largest drivers of health care cost in the United States, accounting for $273 billion annually. Cardiovascular procedures are major contributors to this high cost," according to background information in the article. "Little is known about how different financial incentives between Medicare Advantage and Medicare fee-for-service (FFS) reimbursement structures influence use of cardiovascular procedures."

"Under the Medicare FFS reimbursement structure, physicians are paid more for doing more procedures. In contrast, integrated delivery systems that provide care for Medicare Advantage beneficiaries receive a capitated payment, and physicians working in these settings are not paid more for doing more procedures," the authors write.

Daniel D. Matlock, M.D., M.P.H., of the University of Colorado School of Medicine, Aurora, and colleagues conducted a study to compare the overall rates and local area rates of coronary angiography, percutaneous coronary intervention (PCI; procedures such as balloon angioplasty or stent placement used to open narrowed coronary arteries), and coronary artery bypass graft (CABG) surgery between Medicare Advantage and Medicare FFS beneficiaries living in the same communities. The study, which included 878,339 Medicare Advantage patients and 5,013,650 Medicare FFS patients older than 65 years of age, compared rates of these procedures between 2003-2007 across 32 hospital referral regions (HHRs) in 12 states.

The researchers found that compared with Medicare FFS patients, Medicare Advantage patients had lower age-, sex-, race-, and income-adjusted procedure rates for angiography and PCI but similar rates for CABG surgery. There were no differences between Medicare Advantage and Medicare FFS patients in the rates of urgent angiography. When examining procedure rates across HRRs, there was wide geographic variation among Medicare Advantage patients and Medicare FFS patients.

Across regions, the authors found no statistically significant correlation between Medicare Advantage and Medicare FFS beneficiary utilization for angiography and modest correlations for PCI and CABG surgery. Among Medicare Advantage beneficiaries, adjustment for additional cardiac risk factors had little influence on procedure rates.

"The finding that Medicare Advantage patients have lower rates of angiography and PCI underscores the need for additional research to determine the extent to which this is attributable to differences in population characteristics, more efficient utilization of procedures among Medicare Advantage patients (i.e., overutilization in Medicare FFS), or harmfully restrictive management of utilization among Medicare Advantage patients (i.e., underutilization in Medicare Advantage). One explanation for the differences in rates seen in this report could be that Medicare Advantage beneficiaries are healthier and require fewer cardiovascular procedures than Medicare FFS beneficiaries," the authors write.

"Geographic variation in health services in the Medicare FFS population has fueled the perception of an inefficient, ineffective U.S. health care system. Until the causes of geographic variation are understood, shedding light on the sources of variability remains an important research and quality improvement endeavor. Indeed, comparing 'the effectiveness of accountable care systems and usual care on costs, processes of care, and outcomes for geographically defined populations of patients' is one of the Institute of Medicine's 100 priorities for comparative effectiveness research. Capitation in various forms is anticipated to be an effective means of reducing future health care cost growth, particularly cost growth resulting from unnecessary care. Although in this study capitation was associated with lower procedure rates for angiography and PCI, the substantial geographic variation that remained despite the reimbursement structure suggests that capitation alone may not lead to reductions in the wide variations seen in use of cardiovascular procedures."

"Scientists have documented variation in health care and have identified nonpatient factors that influence practice," writes Harlan M. Krumholz, M.D., S.M., of the Yale University School of Medicine, New Haven, Conn., in an accompanying editorial.

"However, too little attention, for too long, has been directed toward ensuring the quality of preference-sensitive patient decisions. Moreover, if high-quality decisions, under the wide range of circumstances in medicine, are a worthy goal, investment is necessary to advance the science of clinical decision making, including increasing the understanding of the vulnerabilities of current approaches and developing ways to improve performance and ensure that the patient's interests are best served. Ultimately, the goal is not to eliminate variation but to guarantee that its presence throughout health care systems derives from the needs and preferences of patients."

More information: JAMA. 2013;310(2):155-162.
JAMA. 2013;310(2):151-152.

Provided by The JAMA Network Journals

http://m.medicalxpress.com/news/2013-07-major-cv-procedures-differ-medicare.html