Wednesday, July 24, 2013

When it Comes to Patient Engagement in Florida, Parrish Medical Center Shines Bright

By Rajiv Leventhal

When it Comes to Patient Engagement in Florida, Parrish Medical Center Shines Bright

Former Biller for RGV DME Gets More Than 11 Years in Federal Prison for His Role in $11 Million Health Care Fraud Scheme

MCALLEN, TX—One of the billers for a now-defunct McAllen area durable medical equipment (DME) business has been ordered to prison for his role in a conspiracy and scheme to defraud Medicare and Medicaid through fraudulent billings, United States Attorney Kenneth Magidson and Texas Attorney General Greg Abbott announced today. Ramon De La Garza, 52, of Mission, was a biller for RGV DME from approximately August 2004 through approximately April 2009. The scheme involved approximately $11.1 million in false claims to Medicare and Medicaid. Today, De La Garza, was handed a sentence of 110 months for conspiracy to defraud Medicare and Medicaid and an additional mandatory 24-month-term for aggravated identity theft that must be served consecutively to the other sentence imposed, resulting in a total sentence of 134 months in federal prison.

He will also serve three years of supervision following his release. In addition to the prison sentence, he was ordered to pay restitution to Medicare and Medicaid in the amount of $5,059,198.96, and a money judgment will be entered against him for that amount. De La Garza and former RGV DME owner Marcello Herrera, 40, along with his wife Carla Cantu Herrera, 32, both from Mission, pleaded guilty on February 21, 2013, to conspiring to defraud Medicare and Texas Medicaid. Beatriz Ramos, 28, of Edinburg, another former biller for RGV DME, pleaded guilty to the conspiracy on October 16, 2012.

Marcelo Herrera and De La Garza also pleaded guilty to one count of aggravated identity theft for unlawfully using the identity of a beneficiary to bill Medicare and Medicaid $5,000 for a power wheelchair that was not requested, prescribed, needed or delivered. Marcelo Herrera was sentenced earlier this month to 120 months for the conspiracy, as well as the mandatory 24 months for aggravated identity theft, for a total of 144 months in federal prison. The court ordered him to pay restitution to Medicare and Medicaid in the amount of $6,103,953.74 and that he forfeit wheelchairs, scooters, and other DME items discovered in his leased storage facility in Alamo, which had been rented by him and ultimately seized by the FBI. From early 2004 through late 2011, Marcello Herrera, who did business as RGV DME in the McAllen area, engaged in and directed a scheme to submit fraudulent claims to Medicare and Texas Medicaid for power wheelchairs, scooters, incontinent supplies, hospital beds, and mattresses, as well as other DME supplies.

At various times, his wife—who admitted to being marketing director, chief financial officer, chief operating officer, office manager, human resources manager, and co-owner of RGV DME—and billers De La Garza and Ramos all participated in the conspiracy and aided Marcello Herrera and each other in the submission of fraudulent billings, wire fraud, and theft of the identities of beneficiaries and doctors. In court on February 21, 2013, De La Garza admitted that during his participation in the conspiracy, the fraudulent billing exceed $9.6 million for which payments exceeded $5 million. Marcelo Herrera acknowledged he submitted or caused the submission of more than $11.1 million in false and fraudulent claims to Medicare and Texas Medicaid for which he illegally received in excess of $6.1 million, while Carla Herrera admitted that during her participation in the conspiracy, the fraudulent billings exceeded $9.9 million for which they received illegal payments exceeding $5.5 million. Marcelo Herrera, his wife, and De La Garza also admitted that approximately 85 percent of their Medicare and Texas Medicaid billings were false and fraudulent.

The three defendants in court on February 21, 2013, also admitted that marketers were used to obtain Medicare and Medicaid identification numbers and other information from beneficiaries, which they in turn used to fraudulently bill Medicare and Medicaid for DME that was either never prescribed or prescribed but never delivered. Ramon De La Garza has been in custody since his arrest on June 28, 2012. He will remain in custody pending transfer to a United States Bureau of Prisons facility to be determined in the near future. Sentencing for Carla Herrera and Ramos are set for September 18 and 26, 2013, respectively.

The investigation leading to the charges was conducted by the FBI, the United States Department of Health and Human Services-Office of Inspector General, and the Texas Attorney General’s Medicaid Fraud Control Unit. Special Assistant United States Attorney Rex Beasley and Assistant United States Attorney Grady Leupold are prosecuting the case. 

Reported by: FBI

Humana Announces Intent to Acquire American Eldercare

Published: Wednesday, Jul. 24, 2013 / Updated: Wednesday, Jul. 24, 2013 05:14 PM

Humana Inc. (NYSE: HUM) today announced that it has signed a definitive agreement to acquire American Eldercare Inc., the largest provider of nursing home diversion services in the state of Florida (serving frail and elderly individuals in home and community-based settings). Terms of the transaction were not disclosed.
As the only Provider Service Network selected to provide Medicaid long-term care services across the entire state of Florida, American Eldercare complements Humana’s core capabilities and strength in serving seniors and disabled individuals with a unique focus on individualized and integrated care. Annualized revenues for American Eldercare of approximately $75 million are anticipated to increase to over $1 billion in 2015.
The transaction is subject to state regulatory approvals and is anticipated to close by the fourth quarter of 2013.
Cautionary Statement
This news release includes forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995. When used in investor presentations, press releases, Securities and Exchange Commission (SEC) filings, and in oral statements made by or with the approval of one of Humana’s executive officers, the words or phrases like “expects,” “believes,” “anticipates,” “intends,” “likely will result,” “estimates,” “projects” or variations of such words and similar expressions are intended to identify such forward-looking statements. These forward-looking statements are not guarantees of future performance and are subject to risks, uncertainties, and assumptions, including, among other things, information set forth in the “Risk Factors” section of the company’s SEC filings, a summary of which includes but is not limited to the following:
  • If Humana does not design and price its products properly and competitively, if the premiums Humana receives are insufficient to cover the cost of health care services delivered to its members, if the company is unable to implement clinical initiatives to provide a better health care experience for its members, lower costs and appropriately document the risk profile of its members, or if its estimates of benefits expense are inadequate, Humana’s profitability could be materially adversely affected. Humana estimates the costs of its benefit expense payments, and designs and prices its products accordingly, using actuarial methods and assumptions based upon, among other relevant factors, claim payment patterns, medical cost inflation, and historical developments such as claim inventory levels and claim receipt patterns. These estimates, however, involve extensive judgment, and have considerable inherent variability because they are extremely sensitive to changes in payment patterns and medical cost trends.
  • If Humana fails to effectively implement its operational and strategic initiatives, particularly its Medicare initiatives (given the concentration of the company’s revenues in the Medicare business), the company’s business may be materially adversely affected.
  • If Humana fails to properly maintain the integrity of its data, to strategically implement new information systems, to protect Humana’s proprietary rights to its systems, or to defend against cyber-security attacks, the company’s business may be materially adversely affected.
  • Humana’s business may be materially adversely impacted by CMS’s adoption of a new coding set for diagnoses (commonly known as ICD-10).
  • Humana is involved in various legal actions and governmental and internal investigations, any of which, if resolved unfavorably to the company, could result in substantial monetary damages. Increased litigation and negative publicity could also increase the company’s cost of doing business.
  • As a government contractor, Humana is exposed to risks that may materially adversely affect its business or its willingness or ability to participate in government health care programs including, among other things, loss of material government contracts, governmental audits and investigations, potential inadequacy of government-determined payment rates or other changes in the governmental programs in which Humana participates.
  • Recently enacted health insurance reform, including The Patient Protection and Affordable Care Act and The Health Care and Education Reconciliation Act of 2010, could have a material adverse effect on Humana’s results of operations, including restricting revenue, enrollment and premium growth in certain products and market segments, restricting the company’s ability to expand into new markets, increasing the company's medical and operating costs by, among other things, requiring a minimum benefit ratio on insured products (and particularly how the ratio may apply to Medicare plans, including aggregation, credibility thresholds, and its possible application to prescription drug plans), lowering the company’s Medicare payment rates and increasing the company’s expenses associated with a non-deductible federal premium tax and other assessments; financial position, including the company's ability to maintain the value of its goodwill; and cash flows. In addition, if the new non-deductible federal premium tax and other assessments, including a three-year commercial reinsurance fee, were imposed as enacted, and if Humana is unable to adjust its business model to address these new taxes and assessments, such as through the reduction of the company’s operating costs, there can be no assurance that the non-deductible federal premium tax and other assessments would not have a material adverse effect on the company’s results of operations, financial position, and cash flows.
  • Humana’s business activities are subject to substantial government regulation. New laws or regulations, or changes in existing laws or regulations or their manner of application could increase the company’s cost of doing business and may adversely affect the company’s business, profitability and cash flows.
  • Any failure to manage operating costs could hamper Humana’s profitability.
  • Any failure by Humana to manage acquisitions and other significant transactions successfully may have a material adverse effect on its results of operations, financial position, and cash flows.
  • If Humana fails to develop and maintain satisfactory relationships with the providers of care to its members, the company’s business may be adversely affected.
  • Humana’s pharmacy business is highly competitive and subjects it to regulations in addition to those the company faces with its core health benefits businesses.
  • Changes in the prescription drug industry pricing benchmarks may adversely affect Humana’s financial performance.
  • If Humana does not continue to earn and retain purchase discounts and volume rebates from pharmaceutical manufacturers at current levels, Humana’s gross margins may decline.
  • Humana’s ability to obtain funds from its subsidiaries is restricted by state insurance regulations.
  • Downgrades in Humana’s debt ratings, should they occur, may adversely affect its business, results of operations, and financial condition.
  • Changes in economic conditions could adversely affect Humana’s business and results of operations.
  • The securities and credit markets may experience volatility and disruption, which may adversely affect Humana’s business.
  • Given the current economic climate, Humana’s stock and the stock of other companies in the insurance industry may be increasingly subject to stock price and trading volume volatility.
In making forward-looking statements, Humana is not undertaking to address or update them in future filings or communications regarding its business or results. In light of these risks, uncertainties, and assumptions, the forward-looking events discussed herein may or may not occur. There also may be other risks that the company is unable to predict at this time. Any of these risks and uncertainties may cause actual results to differ materially from the results discussed in the forward-looking statements.
Humana advises investors to read the following documents as filed by the company with the SEC for further discussion both of the risks it faces and its historical performance:
  • Form 10-K for the year ended December 31, 2012 (as amended by the Form 10-K/A filed on April 12, 2013) ;
  • Form 10-Q for the quarter ended March 31, 2013;
  • Form 8-Ks filed during 2013.
About American Eldercare
American Eldercare Inc. was founded in 1993 as a Home Nursing provider and has evolved into the largest provider of nursing home diversion services, pursuant to a Medicaid waiver program, in the state of Florida.
By beginning as a home health agency American Eldercare understands the challenges faced by its members and providers. The company believes the best way to ensure appropriate care to meet a person’s needs is to constantly work with its members and their providers of choice. Working together, the company develops innovative solutions to help members stay independent. American Eldercare’s experience has also taught it that long-term care requires a different focus than primary care to meet its members’ needs. The social aspect of long-term care can sometimes be missed by organizations not specializing in long-term care. American Eldercare is singularly devoted to long-term care and how it can impact the lives of all Floridians.
About Humana
Humana Inc., headquartered in Louisville, Kentucky, is a leading health care company that offers a wide range of insurance products and health and wellness services that incorporate an integrated approach to lifelong well-being. By leveraging the strengths of its core businesses, Humana believes it can better explore opportunities for existing and emerging adjacencies in health care that can further enhance wellness opportunities for the millions of people across the nation with whom the company has relationships.
More information regarding Humana is available to investors via the Investor Relations page of the company’s web site at, including copies of:
  • Annual reports to stockholders;
  • Securities and Exchange Commission filings;
  • Most recent investor conference presentations;
  • Quarterly earnings news releases;
  • Replays of most recent earnings release conference calls;
  • Calendar of events (including upcoming earnings conference call dates and times, as well as planned interaction with research analysts and institutional investors);
  • Corporate Governance information.

Medicare Integrate: A New Benefit Option For Medicare Beneficiaries

July 23rd, 2013 

I. The Need for Medicare Reform
Policy options for making the Medicare program sustainable over the long run will have to identify approaches that reduce costs and improve the quality of care delivered. Effective interventions will be ones that target the key cost drivers in the system, chronic diseases. Since 1987, 10 percent of the growth in Medicare spending is associated with a doubling of obesity among seniors. Moreover, over half the Medicare population receives treatment for five or more chronic conditions during the year, accounting for nearly 80 percent of spending.
My earlier paper, “The Medicare Advantage Experience: Lessons for Reform to Original Medicare,” identified some best-practice approaches for prevention and care coordination derived from Medicare Advantage plans and other private-sector delivery models. Clearly the original Medicare program needs comprehensive care coordination and more effective approaches for reducing the rise in chronic disease incidence and prevalence.
This post outlines a plan to add a new Medicare option featuring evidence-based care coordination and prevention, with the goal of improving the health care outcomes for Medicare beneficiaries while reducing costs for the federal government. Others have set forth related plans, indicating that there is a momentum building behind the goal of more effectively addressing chronic disease in the Medicare program.
II. A New Option for Medicare Beneficiaries: “Medicare Integrate”
Medicare beneficiaries could choose among the original Medicare program; Medicare Advantage; or a new option, Medicare Integrate. The key elements of original Medicare and Medicare Advantage are well known. The key elements of Medicare Integrate would include:
  • Access to Evidence-Based Programs, like the diabetes prevention program (DPP), that reduce the incidence of diabetes and related chronic health care conditions. Today, 50 percent of seniors are pre-diabetic and the DPP intervention has been shown to reduce the incidence of diabetes among these seniors by 71 percent.
  • Access to Care Coordination Services to engage chronically ill patients to keep them healthier and out of the hospital, clinic and emergency room. These services could include comprehensive medication therapy management, transitional care, health coaching, and use of a 24/7 nurse care coordinator. These services and evidence of their effectiveness are detailed in the Appendix.
  • Engaging Beneficiaries. Medicare beneficiaries that select the Integrate option would face no cost sharing for clinically recommended services to manage their chronic health conditions (annual eye exams, HgA1c tests, medications, etc). In addition, overweight and obese seniors who have at least one cardiovascular risk factor (pre-diabetes) would be encouraged to enroll in intensive lifestyle programs like the diabetes prevention program at no charge.
  • Team-Based Care. A clinical strategy designed to provide comprehensive “whole person” care. Care coordination would involve a care plan for all chronic and other medical and behavioral health conditions facing the patient.
  • Provider Choice. Medicare Integrate would remain similar to the original Medicare program in allowing free choice of where to receive health care services. As part of the effort to improve quality, plan vendors could also create networks of high quality providers for beneficiaries to use.
  • Smart Data Application. An important part of effective care coordination is timely collection of utilization data allowing ongoing feedback to providers. Comprehensive utilization data facilitate the development of risk-stratification models for targeting high-use patients. The data also allow real-time information on patients’ health status and the development of health care problems, allowing more effective ongoing medical management.
  • Private-Sector Partnership. The Centers for Medicare and Medicaid Services (CMS) would release a request for proposals for vendors (to include health plans, insurance companies, providers, third party administrators) to provide the full range of prevention and care coordination services. To generate savings and to ensure successful implementation at scale in the marketplace, it is important to allow contractors with past performance and capabilities to participate. CMS could use the current 15 (with future consolidation to 10) Medicare Administrative Contractor (MAC) regions for the contracting process. Contractors would be paid per member per month fee for serving patients throughout each region.
III.  Financing the Integrate Option — Shared Savings
Similar to the financial incentives built into the accountable care organization model, Medicare Integrate plan vendors would split savings with Medicare only once a pre-determined savings threshold is achieved for the Medicare program over a defined time period and quality metrics are met or exceeded. Savings beyond the pre-determined threshold would accrue to the vendor, while savings short of the pre-determined threshold would be paid back by the vendor to CMS.
Quality metrics used in the Medicare Integrate option should be similar to those used by Medicare Advantage and should be extended to include original Medicare. To the extent possible, these metrics should focus on clinical outcomes, be adaptable to new technologies, and act as a counterbalance to short-term cost-saving activities that do not improve health long term.
Adding Medicare Integrate as a third choice for seniors could be accomplished in short order. Having both prevention and care coordination as an integral part of care delivery is what baby boomers entering into the Medicare program expect; indeed it is the type of care they are receiving through private plans prior to Medicare. Adding the option would provide better continuity of care, as those turning age 65 with chronic health care conditions could continue to have their care coordinated.
Both the diabetes prevention program and care coordination functions are readily scalable and replicable. The capacity for care coordination already exists in the marketplace in the form of home health firms, health plans, and specialty population management vendors, among others. Moreover, the functions performed by the care coordination teams are based on both published randomized trials and actual best-practice experiences from the private sector. These data show that effective care coordination and the use of preventive lifestyle models like the diabetes prevention program reduce spending and improve the quality of care delivered.
However, implementation of these models needs to be particularly sensitive to beneficiaries who are the sickest of the sick — those dually eligible for Medicare and Medicaid. For these patients a slower implementation schedule may be wise to assure that any changes result in better outcomes. In this case, we have much to learn from the best practices of special needs plans in the Medicare Advantage program of how best to design care coordination that is quality improving.
I. Transition Away from Fee-for-Service (FFS) in Medicare
A key to introducing care coordination into traditional Medicare is to transition away from fee-for-service payments and, as a start, replace them with more bundled payments for Part A and B covered services. The incentives to increase the volume of services in FFS run completely counter to the incentives to provide clinically effective care coordination. As FFS is phased out over time, it would be replaced by bundled payments for (most) hospital admissions that include all covered post-acute care services 30 days after discharge.
There is broad agreement that Medicare’s FFS payment model (notably the sustainable growth rate (SGR) physician payment formula) is outdated, drives up the volume of services, and must be replaced to improve health care delivery. Our entire health care system is built around FFS, and updating our current health care delivery structure will set the stage for an innovative, high-quality health care system. However, transitioning away from FFS will not be easy and will not happen overnight; reforming the Medicare system so that it pays for quality will require significant data collection and monitoring, updates to regulations, and testing and scaling of new and innovative payment models and incentives. Advancing these objectives and facilitating a gradual shift from FFS medicine will take time, and will therefore likely occur in stages and lead to a number of new payment model reforms.
The experience from the Medicare Participating Heart Bypass Center Demonstration, which made bundled payments to cover all inpatient hospital and physician services for coronary artery bypass graft surgeries, show the potential for substantial savings. Bundled payments in this case reduced Medicare expenditures on heart bypass surgeries by about 10 percent. Evaluations of the demonstration also found slight improvements in the quality of care provided using measures included in the study.
The Affordable Care Act includes some payment reforms that move in the right direction. The Act includes a bundled payment demonstration that started in January 2013. To date, CMS has outlined four different payment models that include a single payment for an episode of care. To start, CMS has identified 48 different episodes that would be included in a combined bundled payment to 500 different providers. Typically, these bundles include Medicare-covered services (acute inpatient hospital; physician services delivered in and outside the hospital; outpatient hospital services; emergency room services; and post-acute services such as physical therapy) for each of the 48 care episodes. (Part D drug spending around the episode is not included.)
Over the next five years Medicare should expand the bundled payments to virtually all episodes of care. During this time, CMS could quickly evaluate the quality and spending performance of providers for each of the four payment models and recommend adopting either one or two of the most effective ones (ideally the more comprehensive models that include more Part A and Part B services). In the interim, providers would be paid on a mix of FFS and bundled payments.
Building quality metrics into the payment bundles will be essential. These quality metrics should recognize the fact that over half of all Medicare patients are under medical treatment for five or more conditions, accounting for nearly 80 percent of Medicare spending. In addition, quality metrics that are developed should continue to move the Medicare program toward consistent measures throughout the program with a focus on clinical and patient-centered outcomes. Measures will also need to preserve the adaptability needed for the adoption of medical advances and new technologies. Finally, measures should serve as a counterbalance to encourage quality improvements that may be counter to near-term cost savings, such as activities that promote wellness and prevention that reap benefits over time.
Several integrated health centers (Marshfield Clinic, Geisinger), demonstrations, and health teams in Vermont and North Carolina have produced lower spending and improved quality. A common feature of all of the above is the use of team-based care. Team-based care occurs when health care professionals (physicians, nurses, pharmacists, social and mental health workers, and nutritionists, among others) work collaboratively to achieve shared health goals with patients and their families. The health team works in close collaboration with the physician practices, accountable care organizations, and hospitals. In some models a nurse care coordinator is embedded in the teams and in others the teams meet on a regular basis to track quality metrics and outcomes. The teams essentially provide “whole person” care and do not focus on disease specific care. Some of the functions that have proven to improve quality and reduce spending are outlined below.
II. Functions Performed by Health Teams
Health teams would provide the following evidence-based functions when coordinating care.
  • Coordination of care for all covered Medicare services utilizing a team-based approach
  • Approaches that provide a “whole” person focus on preventing disease and managing acute, chronic, and mental health services
  • Medical advice from a care coordinator available 24/7
  • Assessment of patient risk and development of an individualized care plan
  • Comprehensive medication management
  • Transitional care and health coaching
  • Regular contact with enrollees
  • Close integration of the care coordinator nurse and primary care (and specialist) physicians
  • Evidence-based health coaching to train patient self-management skills and facilitate behavior change.
Each of the major functions outlined above (transitional care, medication adherence, health coaching) have several published randomized trials showing they individually result in improved health outcomes at lower levels of health care spending. Collectively they serve as a powerful, team-based approach to generate substantial proven savings and improved quality of care.
Team-based care has been introduced at the state level (Vermont and North Carolina) and increasingly plays a major role in most delivery systems. There is emerging evidence from these states and individual practices that team-based care can produce better quality at lower cost. Milliman estimates savings to North Carolina’s Medicaid program of up to 15 percent. Recent evaluations of the community health teams in Vermont also are showing promising reductions in costs. A brief summary of some of the randomized trials highlighting the clinical effectiveness and cost savings associated with these care coordination functions is presented below.
Transitional Care
Two of the best known models of transitional care have been developed by Eric Coleman at the University of Colorado and Mary Naylor at the University of Pennsylvania. The team at Penn defines transitional care as providing “comprehensive in-hospital planning and home follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions.” The heart of the model is the Transitional Care Nurse (TCN), who follows patients from the hospital into their homes and provides services designed to streamline plans of care, interrupt patterns of frequent acute hospital and emergency department use, and prevent health status decline.
While TCN is nurse led, it is a multidisciplinary model that includes physicians, nurses, social workers, discharge planners, pharmacists, family caregivers, and other members of the health care team in the implementation of tested protocols with a unique focus on increasing patients’ and family caregivers’ ability to manage their care. For the millions of Americans who suffer from multiple chronic conditions and complex therapeutic regimens, TCM emphasizes coordination and continuity of care, prevention and avoidance of complications, and close clinical treatment and management — all accomplished with the active engagement of patients and their family and informal caregivers and in collaboration with the patient’s physicians. More information is available here.
A second model, developed by Eric Coleman, uses transition coaches to train patients and family caregivers how to manage their care. Transition coaches are generally not physicians but are nurse practitioners, nurses, or community health workers. To smooth transitions from hospital to home, the Care Transitions Intervention (CTI) uses coaching and home visits by trained care coordinators. The coach makes one home visit and several phone calls to the patient over a 30-day window. More information on this program is available here.
According to randomized trials, both programs reduce dramatically hospital readmission rates. Among Medicare patients, the CTI program reduced 30-day readmissions by 30 percent and hospital costs at 90 days by 25 percent. Randomized trials of the TCN model have demonstrated reductions in readmissions of 56 percent, with similar reductions in total Medicare spending after one year.
Comprehensive Medication Management
Poor medication management adds substantially to the overall cost of health care, by some estimates adding over $200 billion per year in additional hospital and other spending.  Comprehensive medication management provided as part of an integrated health team has shown to save $1.29 in health care spending for every $1 spent to administer the program.  Moreover, a recent summary of the published research literature by the Congressional Budget Office (CBO) found that adherence and persistency in taking medications reduces spending. Specifically the CBO found that every 1 percent increase in prescriptions filled would reduce Medicare spending by roughly 0.20 percent.
Under the Part D program, drug plans must offer medication therapy management program (MTM). However, the criteria for targeting Medicare beneficiaries enrolled in Part D plans are those with multiple chronic conditions (maximum of 3 required for targeting) and expected annual drug spending for 2013 of $3,144. However, the current MTM program would not include patients with high Part A and B medical costs who may not be appropriately taking medications (non-adherent, etc) and would not hit the $3,144 spending threshold.
Indeed, poor medication management has been linked to 32 percent of all adverse events leading to hospitalizations and is a key cause of preventable adverse events among Medicare patients. Recent studies have demonstrated that team-based medication management care, as part of an overall care coordination clinical strategy, reduced the growth in spending by 11 percent.
As part of the new care coordination services in traditional Medicare, the current MTM program should be broadened and integrated into the overall set of care coordination services provided. A pharmacist working as part of the care coordination team would work with patients who have high prior-year total Medicare spending (not just those with high Part D spending) to resolve drug therapy issues (drug effectiveness, dosage, compliance, and adherence). This broader approach would, as part of the overall care coordination team, link medication management and resolving drug therapy problems to clinical improvements in seniors. Substantial work has already been completed on the design of such a benefit from the Patient-Centered Primary Care Collaborative and the Agency for Healthcare Research and Quality Innovation Exchange Quality Toolkit.
Health Coaching and Patient Literacy
Coaching empowers patients with one or more chronic conditions to understand and follow through on their care plan, participate in shared decision making with their health care providers, and more effectively navigate the health care system. Understanding the care plan and working to consistently execute it are elements critical to reducing unnecessary utilization of health care services. Effective coaching empowers individuals with a wide range of conditions, including but not limited to chronic conditions, to participate in medical treatment decisions with their doctors.
Coaching would be another key component of care coordination services provided in Medicare Integrate.A large randomized trial conducted by Health Dialog and published in the New England Journal of Medicine utilized telephonic health coaching to work with a large population (more than 174,000—7,000 of whom were Medicare patients) of patients. This recent randomized trial showed that total health care spending was 3.6 percent lower in the treatment group (yielding about a 3 percent net savings after accounting for the cost of the intervention). This single component of care coordination alone reduced hospitalizations in the trial by 10 percent and total spending by more than 3 percent.
There is considerable evidence that these care coordination functions improve outcomes and reduce spending. Randomized trials evaluating transitional care models have found 50 to 60 percent reductions in 30-day hospital readmission rates among Medicare patients. A recent randomized trial found that comprehensive medication therapy management in Minnesota produced lower total healthcare costs (over 31 percent in one year) while significantly improving clinical outcomes with a 12:1 return on investment.
States could also use the health teams to manage Medicaid patients and those dually eligible for both Medicare and Medicaid. Section 2703 of the Affordable Care Act provides states a 90 percent match for eight quarters toward the cost of establishing community health teams that provide the care coordination services above.
Adding evidence-based lifestyle programs and health teams to provide care coordination services would target two of the major issues facing Medicare: rising rates of chronic disease prevalence and the need to coordinate care for chronically ill patients throughout the Medicare program. The DPP (discussed below) and community health teams could be replicated and scaled quickly throughout the country. Both changes would improve health outcomes and have tremendous potential to reduce health care spending.
Diabetes Prevention Program
The diabetes prevention program is an intensive lifestyle protocol that includes a 16-lesson curriculum covering diet, exercise, and behavior modification delivered over a 24-week period. The program targets overweight and obese pre-diabetic adults. The goal of the intervention is to achieve and maintain weight loss of 7 percent of starting body weight. Large randomized trials have shown that the intervention reduced the incidence of diabetes by 58 percent and among seniors by 71 percent. Even with some weight regained, recently published results of a 10-year follow-up study of the original trial found that adults in the intensive lifestyle program continued to maintain around five pounds of weight loss and those aged 60 and older maintained longer term weight loss of just under 11 pounds. Diabetes incidence in the 10 years since DPP started was reduced by 34 percent.
Community-based adaptions of the DPP protocol by the YMCAs and other groups have found, in initial studies, similar reductions in weight, approximately 6 percent. The community based adaptation of the model reduces the per enrollee costs substantially to around $350 for each 16-week class. As a result, tabulations show, on the conservative side, that adopting the DPP into the Medicare program would produce net budget savings totaling several billion dollars within the 10-year scoring window.
III. Key Design Issues in Incorporating Care Coordination into Medicare through Medicare Integrate
Shared Savings
CMS would develop a request for proposals, and contractors that can provide the full range of care coordination functions would be eligible to bid. Bidders would be expected to complete a needs assessment of service gaps facing patients and primary care providers, as well as addressing how to coordinate existing services (public health nurses, etc) with the new care teams and how to provide the full range of care coordination services outlined above. Eligible entities would have to meet certain financial reserve/capacity tests and would carry medical malpractice liability insurance. The awards would be for three years to parallel the Medicare Shared Savings Program.
Bids would be on a per-member per-month basis based on initial estimates of Medicare patients receiving care coordination and reconciled at year end. As such, contractors would not be risk-bearing entities and would not face state insurance rules and regulations. Contracts would be renewed every three years based on meeting quality and spending targets similar to those outlined under the shared savings program for accountable care organizations.
Firms providing care coordination services could be the same administrative contractors that process claims or other firms (i.e. home health and population health management firms) that would partner with the Medicare Administrative Contractors.
IV. Collaboration
Any Medicare provider could contract with the health teams at no fee or charge. Provider practices, accountable care organizations, hospitals, health systems, or other providers using the teams would be expected to report quality metrics similar to those expected of Medicare Advantage plans. Participating providers would receive a small $2-$3 per-member per-month payment for each patient using the health teams.

NextGen Healthcare and Availity Introduce Health Plan/Physician Data Sharing Program

NextGen Healthcare and Availity Introduce Health Plan/Physician Data Sharing Program
Integrated EHR Environment to Foster Collaborative Coordinated Care
HORSHAM, Pa.--(BUSINESS WIRE)-- NextGen Healthcare Information Systems, LLC., a wholly owned subsidiary of Quality Systems, Inc. (NAS: QSII) and a leading provider of health care information systems and connectivity solutions, today announced the introduction of a collaborative care project with Florida's largest health insurer, Florida Blue, and Availity, a top health information network to improve health care delivery for Florida residents.

The program enables physicians to exchange clinical data and patient care summaries with the health plan through integration with the NextGen®Ambulatory EHR. The organizations are joining to make patient-specific clinical information accessible at the point of care to both providers and payers concurrently, helping them more effectively coordinate care for patients by flagging potential care gaps and care opportunities.
Three provider groups—Family Care Partners (Jacksonville), HeartWell, LLP (Miami) and Baptist Health South Florida—have agreed to implement the joint project to improve health care delivery and foster collaborative coordinated care for all Florida residents.
The goal of this program is to help providers better coordinate care for their patients by identifying potential gaps in care, lack of coordination among providers that might lead to less-than-effective provision of care, and the identification of other opportunities that would mitigate unnecessary care if certain pro-active measures are taken earlier in the plan of care for a particular patient.
Physicians will access the NextGen Ambulatory EHR to view patient care summaries and care reminders from Availity—information that gives physicians a more holistic view of the patient's medical history, at an opportune time in the patient encounter.
Additionally, the program will automate the exchange of care summaries back to the health plan for quality improvement reporting. The two-way integration at the EHR level automates the costly, manual exchange between providers and payers of critical clinical information necessary to support today's care delivery, as well as revenue cycle and emerging payer driven value-based payment models and quality improvement programs.
"Together with NextGen, Availity enables health plans and physicians to easily meet the dynamic clinical information exchange requirements for new value-based care models, while reducing the administrative cost of business between providers and health plans. Our strong partnership with NextGen will focus on delivering value to Florida Blue, physicians, hospitals, and most importantly, patients, while driving sustainable innovation in the delivery of health care, said Russ Thomas, chief executive officer for Availity."
"This project is an important step toward meaningful payment reform for both providers and commercial insurers. Together with NextGen and Availity, we are working to provide more cost-effective, better quality, patient-centric care to our patient population," said Daniel Choquette, director of information technology for Family Care Partners.
"Baptist Health South Florida is very pleased to be partnering with NextGen and Florida Blue to explore and assist in architecting what may be the future of health care with regards to patient management and data sharing," said Mimi Taylor, corporate vice president and chief information officer, information technology for Baptist Health South Florida.
"This program is a truly integrated, collaborative and strategic approach to providing more efficient, cost-effective care to our patient population," said Jeffrey Kaplan, chief operating officer for the Miami multi-site cardiology practice HeartWell, LLP. "We are pleased to be one of the medical groups chosen by Florida Blue to participate and look forward to working with NextGen Healthcare in this joint program to better identify a patient's health care needs while eliminating duplicative testing."
"We are very pleased to be supporting our clients in a path-breaking strategy to share data between payer and provider in an automated manner. Our hope is that patient care will be improved and providers' professional lives will be more organized," said Charlie Jarvis, Senior Vice President, Health Reform for Quality Systems Inc., NextGen Healthcare. "We are anxious to quickly move this demonstration into a network-wide and a future nation-wide strategy with all payers who support our client base."