Tuesday, October 8, 2013

Patient-centered medical home philosophy boosts patient, physician satisfaction

UCLA-USC intervention could encourage more new docs to enter primary care

The common refrain about health care is that it's a broken system. A new joint program between UCLA and USC demonstrates a way to mend the system with a new patient-centered program that is getting rave reviews from patients and from the residents and nurses who provide their care.
The program, Galaxy Health, debuted at Los Angeles County+USC Medical Center in 2012 with the goal of substantially improving an on-site clinic for residents and demonstrating to county officials that intuitive and inexpensive interventions can dramatically improve patient care and physician and staff morale.
A new UCLA–USC study published online in the JAMA Internal Medicine, a peer-reviewed journal of the American Medical Association, outlines how the Galaxy model works in a public setting, with a favorable effect on both patients and medical residents.
"We all know that fewer and fewer young physicians are choosing careers in primary care because of the difficult work schedules, lack of support and lower salaries," said lead study author Dr. Michael Hochman, who conducted the research as a Robert Wood Johnson Clinical Scholar in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA. "What we did here was to move in the direction of a team-based approach, and it resulted in improved satisfaction for physicians-in-training with their primary care experiences."
Dr. David Goldstein, an associate professor of clinical medicine at USC's Keck School of Medicine and chief of the division of geriatric, hospital, palliative and general internal medicine at LAC+USC Medical Center, was the study's senior author. He conceived the Galaxy Health program.
"My hope was that Galaxy would reveal that a minimal investment and reorientation in delivery focused on the patient and enhanced access to care could improve the satisfaction of patients, staff and physicians, even in an underfunded public environment," he said. "I think it worked out well. It's not rocket science."
The Galaxy model established round-the-clock, seven-day-a-week access to physicians, made urgent clinic appointments available within hours and coordinated care in the ambulatory environment. It was based in part on increasing interest in a concept known as the patient-centered "medical home," which provides a team-based, coordinated approach to care that aims to make the primary care team central to the patient’s health needs. While the concept may not sound that different from the traditional vision of high-quality primary care, Galaxy's innovation is making this vision a reality in a complex, disconnected health care system.
"Galaxy Health has proven its value and effectiveness, as measured by patient satisfaction, access to care and provider satisfaction, in an incredibly challenging clinical environment," said Christina Ghaly, interim CEO of LAC+USC Medical Center. "Its remarkable success is to the benefit of our patients at LAC+USC Medical Center and can be a model for other safety-net, resident-run clinics struggling with implementing patient-centered medical homes."
The project was funded primarily by a three-year, $750,000 grant from UniHealth Foundation.
The study findings also support further investment in primary care, particularly in teaching settings, where the next generation of primary care leaders will be developed, said Hochman, now medical director for innovation at AltaMed Health Services, a large federally qualified health center in Southern California. There is currently a shortage of primary care physicians, and the situation is expected to become more acute as baby boomers continue to reach retirement age.
The researchers conducted their study at three primary-care internal medicine clinics at LAC+USC, an urban academic medical center serving a safety-net population. They focused on expanded access to care, enhanced care coordination and team-based care. Galaxy Health included the creation of a call center staffed by two care coordinators, telephone renewal of prescriptions and the availability of up to five urgent care appointments each day.
Input from patients and staff during prior focus groups was incorporated into the study. The researchers surveyed patients and residents before the intervention and again one year later. They also analyzed emergency room and hospital visit rates.
Though the clinics did not satisfy all the elements needed to qualify as a patient-centered medical home, overall their score jumped from a previous 35 to 53 out of 100 possible points. The satisfaction rating from patients increased from 48 percent to 65 percent in the intervention clinic, compared with a jump from 50 percent to 59 percent in the controls. Patients were particularly pleased with access. Satisfaction with urgent appointment scheduling increased from 12 percent to 53 percent in the intervention clinic, compared with an increase from 14 percent to 18 percent in the control clinic. 
The composite satisfaction score for residents went up from 39 percent to 51 percent in the intervention clinic but fell in the control clinic from 46 percent to 42 percent.
The study noted that emergency room and hospital visits were not reduced.
"This was an anticipated finding, because we expanded access to care to an underserved patient population, and frequently when this happens, there's a spike in emergency and hospital room utilization," said study co-author Dr. Arek Jibilian, assistant professor of clinical medicine in the Keck School's division of geriatric, hospital, palliative and general internal medicine. "However, we believe that a sustained commitment to primary care will ultimately reduce emergency and hospital utilization, and this is something we hope to see as the program continues."
Study co-authors are Steven Asch, Arek Jibilian, Bharat Chaudry, Ron Ben-Ari, Eric Hsieh, Margaret Berumen, Shahrod Mokhtari, Mohamad Raad, Elisabeth Hicks, Crystal Sanford, Norma Aguirre, Chi-hong Tseng, Sitaram Vangala and Carol M. Mangione. Additional contributors include Becky O'Neal and Roman Corral.
The demonstration was primarily funded by the UniHealth Foundation in Los Angeles. In addition, the study was funded by grants from the Robert Wood Johnson Clinical Scholars Program; the U.S. Department of Veterans Affairs (grant 67799 to UCLA); the UCLA Resource Centers for Minority Aging Research Center for Health Improvement of Minority Elderly (RCMAR/CHIME) under NIH/NIA Grant P30-AG021684; and the NIH/NCATS UCLA CTSI (grant UL1TR000124).
The Keck School of Medicine of USC , founded in 1885, is among the nation's leaders in innovative patient care, scientific discovery, education and community service. It is part of Keck Medicine of USC, the university's medical enterprise, one of two USC-owned academic medical centers in the Los Angeles area. This includes the Keck Medical Center of USC, composed of the Keck Hospital of USC and the USC Norris Cancer Hospital. The two world-class, USC-owned hospitals are staffed by more than 500 physicians who are faculty at the Keck School. The school today has more than 1,500 full-time faculty members and voluntary faculty of more than 2,400 physicians. These faculty direct the education of approximately 700 medical students and 1,000 students pursuing graduate and postgraduate degrees. The school trains more than 900 resident physicians in more than 50 specialty or sub-specialty programs and is the largest educator of physicians practicing in Southern California. Together, the school's faculty and residents serve more than 1.5 million patients each year at Keck Hospital of USC and USC Norris Cancer Hospital, as well as the USC-affiliated Children's Hospital Los Angeles and Los Angeles County+USC Medical Center. Keck School faculty also conduct research and teach at several research centers and institutes, including the USC Norris Comprehensive Cancer Center, the Zilkha Neurogenetic Institute, the Eli and Edythe Broad Center for Stem Cell Research and Regenerative Medicine at USC, the USC Cardiovascular Thoracic Institute, the USC Eye Institute and the USC Institute of Urology.
General Internal Medicine and Health Services Research is a division within the department of medicine at the David Geffen School of Medicine at UCLA. It provides a unique interactive environment for collaborative efforts between health services researchers and clinical experts with experience in evidence-based work. The division's 100-plus clinicians and researchers are engaged in a wide variety of projects that examine issues related to access to care, quality of care, health measurement, physician education, clinical ethics and doctor–patient communication. The division's researchers have close working relationships with economists, statisticians, social scientists and other specialists throughout UCLA and frequently collaborate with their counterparts at the RAND Corp. and Charles Drew University.
The Robert Wood Johnson Foundation Clinical Scholars program has fostered the development of physicians who are leading the transformation of health care in the United States through positions in academic medicine, public health and other leadership roles. Through the program, future leaders learn to conduct innovative research and work with communities, organizations, practitioners and policymakers on issues important to the health and well-being of all Americans. This program is supported in part through a collaboration with the U.S. Department of Veterans Affairs.

Mobile health vans' value proposition

Posted on Sep 13, 2013

ASC: 100 Surgery Center Benchmarks & Statistics to Know

Here are 100 benchmarks and statistics for ambulatory surgery centers based on reports from Accreditation Association for Ambulatory Health Care, Ambulatory Surgical Centers of America, Ambulatory Surgery Center Association, HealthCare Appraisers, Provista, RemitData, MedPAC, Objective Health and VMG Health. 

All benchmarks and statistics on this list are averages gathered by compiling data from multiple ASCs.

Operational benchmarks

1. Administrator salary is $109,184. 1

2. Administrators in the west receive the highest salary, at $114,109 while administrators in the Midwest receive the lowest salary at $104,317.

3. Staff hours per case at ASCs is 12.8 hours.

4. Administrative hours per case is four hours.

5. Nurse hours per case in one- to two-OR centers is 5.2 hours.

6. Administrative hours at one- to two-OR centers is 3.8 hours.

7. Nurse hours at ASCs with three- to four-ORs is 6.3 hours.

8. Administrative hours at ASCs with three- to four-ORs is 4.1 hours.

9. ASCOA surgery centers have a per room goal of 10 cases per day to encourage compressed schedules. 2

10. GI and pain-driven centers with less than five clinical hours would have a total of around eight staff hours per case.

11. Centers with more complicated cases such as orthopedics and spine would have clinical hours around seven to eight hours per case and total staff hours around 10 to 12 hours per case.

12. Average room turnover time goal is seven to 10 minutes at ASCOA surgery centers, depending on the case mix.

13. 53 percent of ambulatory surgery centers maintain paper records and 23 percent track their supply chain on spreadsheets. 3

14. Typical surgery centers have 19 cases per day. 4

15. 74 percent of the cases are performed by the top five physicians at the ASC.

16. ASCs have of three surgical cases per operating room per day.

17. Total operating expenses per OR is $1.2 million.

18. Employee salary and wages per operating room is $421,820.

19. Medical and surgical expenses per OR are $375.37.

20. General and administrative expenses per OR are $259.38.

21. Total cases per center is 4,714 per year.

22. Average number of non-surgical cases per year is 1,146.

23. 765 cases are performed per operating room annually, with 4.6 cases per day.

24. ASC procedure rooms see around 1,144 non-surgical cases per room annually, with 4.6 procedures per day.

25. The top five physicians performed 54 percent of the ASC's case volume.

26. Surgery centers with more than four operating rooms performed 24 cases per day, while those with one to two operating rooms performed 12 cases per day.

27. Surgery centers with one to two operating rooms had the highest annual surgical case rate per operating room, at 782, while those with more than four operating rooms hosted 744 cases annually per operating room. 

28. Non-surgical case volume per year at facilities with one to two operating rooms is 1,017 cases per procedure room.

29. Surgery centers with three to four ORs reported 769 non-surgical cases per procedure room annually, which dropped to 705 cases in centers with more than four ORs.

30. In surgery centers with more than four ORs, only 22 percent of the cases were performed by the top two physicians, while 62 percent were performed by the top 10 physicians.

31. Median operating room time per patient encounter: 50.2 minutes. 5

32. Procedure room time per patient encounter: 34.2 minutes.

33. Median rate of unscheduled direct transfers: .6 transfers per 1,000 patient encounters.

34. 34 percent of ASC leaders plan to standardize products used in their center. 6

35. 24 percent plan to evaluate their GPO.

36. 19 percent plan to implement an order management system.

37. 6 percent plan to change or join a GPO.

38. 6 percent plan to change distributors.

Revenue cycle benchmarks

39. 79.9 percent of ASCs collect between 0 to 30 days from the date of service to the check date. 7

40. 13.3 percent of ASCs receive cash collection between 31 and 60 days from the service date to the check date. 

41. 20 percent of ASC claims are not collected for more than 30 days. 8

42. The top reason for ASC procedures to receive an unexpected denial is "claims or service lacks information which is needed for adjudication." The second most common reason is "duplicate claim or service" followed by "procedure or treatment is deemed experimental or investigational by the payer." 

43. Commercial insurance companies have a 12 percent unexpected denial rate for the top 10 CPT codes that have unexpected denials at ASCs.

44. Medicare's unexpected denial rate is 6 percent for the top 10 CPT codes that have unexpected denials at ASCs.

45. Medicaid has a 26 percent denial rate for the top 10 CPT codes that have unexpected denials at ASCs.

46. Around 47 percent of ASCs with fewer than 3,000 cases have 0 to 30 A/R days, while 18.7 percent have 31 to 60 A/R days. 9

47. Most ASCs with at least 6,000 cases annually have 0 to 30 A/R days.

48. Of all ASCs, about 15.9 percent have more than 120 A/R days.

49. For ASCs with three to four ORs, average ENT revenue is $1,734 per case.

50. Average GI/endoscopy revenue per case for medium-sized ASCs is $776.

51. Orthopedics revenue per case for three- to four-OR ASCs is $2,617.

52. Average general surgery revenue per case for medium sized ASCs is $1,721.

53. For ASCs with three to four ORs, average ophthalmology revenue is $1,249 per case.

54. Average plastic surgery revenue per case for medium-sized ASCs is $1,516.

55. Podiatry revenue per case for three- to four-OR ASCs is $2,021.

56. For medium sized ASCs, average OB/GYN revenue per case is $1,958.

57. Average pain management revenue per case for three- to four-OR ASCs is $890.

58. Revenue per case for urology procedures in medium-sized ASCs is $1,476.

59. ASCOA centers have a goal of low-to-mid 30s for A/R days out. 10

Clinical benchmarks

60. 89 percent of patients wait at least a month after scheduling cataract surgery before undergoing the procedure.11

61. 96 percent of patients are able to schedule their cataract surgery at their desired time in the ASC.

62. 94 percent of patients resume daily living within a week of undergoing cataract surgery.

63. 94 percent of patients reported improved vision after cataract surgery in an ASC.

64. 98 percent of patients say they're comfortable while undergoing cataract surgery in the ASC and 99 percent are comfortable after discharge.

65. 99 percent of patients report they would recommend cataract surgery after undergoing the procedure in an ASC.

66. Pre-procedure time is 81 minutes for cataract surgeries.

67. Procedure time for cataract surgeries in ASCs is 14 minutes.

68. Discharge time for cataract surgeries is 21 minutes.

69. 77 percent of colonoscopy patients report little or no discomfort during bowel preparation. 12

70. 81 percent of colonoscopy patients wait less than a month between scheduling their colonoscopy and having the procedure.

71. 98 percent of colonoscopy patients report being comfortable after discharge.

72. 99 percent of colonoscopy patients report little or no discomfort during the procedure and would recommend it to others.

73. 100 percent of colonoscopy patients report understanding the procedure.

74. Colonoscopy procedure time is nine to 29 minutes.

75. Pre-procedure time for colonoscopy is 17 to 129 minutes, covering patient check-in to scope insertion.

76. Colonoscopy discharge time is 15 to 75 minutes for ASCs.

77. Pre-procedure time for knee arthroscopy is 88 minutes, and organizations with shortest times attribute results to calling patients the day before to remind them of the appointment and pre-procedure requirements.13 

78. Knee arthroscopy procedure time is 28 minutes in the ASC.

79. Discharge time for knee arthroscopy is 75 minutes in the ASC, and organizations with short discharge times attribute results to having patients leave the operating room as they are waking up to assess their comfort level as soon as possible.

80. 75 percent of knee arthroscopy patients wait less than a month for their procedure after scheduling.

81. 89 percent of knee arthroscopy patients are able to schedule the procedure as soon as they wanted in the ASC.

82. 99 percent of knee arthroscopy patients say they are comfortable post-discharge in the ASC.

83. Pre-procedure time for low back injections is 43 minutes, and organizations with the shortest discharge times attribute results to not using or using low levels of sedation or controlling the type and amount of medication administered. 83

84. Procedure time is seven minutes for low back injections in the surgery center.

85. Discharge time after low back injections in the ASC is 22 minutes, with a range of one to 42 minutes.

86. 90 percent of patients wait less than a month from scheduling their low back injection to undergoing the procedure in the ASC.

87. 93 percent of patients say they are able to schedule their low back injections in an ASC within a "reasonable" period to time.

88. 85 percent of patients report returning to daily activities after undergoing low back injections in ASCs.

89. 80 percent of patients say they experienced less pain after the low back injections, and 50 percent reduced pain medications after the procedure.

Growth benchmarks

90. 100 percent of surgery center management companies in the HealthCare Appraisers 2013 ASC Valuation Survey found orthopedics/sports medicine a desirable specialty. 15

91. 94 percent of ASC management companies find orthopedic spine a desirable specialty in 2013.

92. 94 percent of ASC management companies find ENT desirable in 2013.

93. 88 percent of ASC management companies find general surgery desirable in 2013

94. 88 percent of ASC management companies find pain management desirable in 2013.

95. 82 percent of ASC management companies find gastroenterology a desirable specialty in 2013.16

96. There were 113 new Medicare-certified ambulatory surgery centers in 2012. 

97. Medicare made $3.5 billion in payments to ambulatory surgery centers in 2011.

98. There were 5,344 Medciare-certified ambulatory surgery centers in 2011, up 1.8 percent over the previous year.17

99. Between 2001 and 2011, the number of ambulatory surgery center operating rooms doubled in the United States and in 2011, 60 percent of hospitals had an ASC within five minutes of their facility. 18 

100. Objective Health predicts that procedure volumes for cases such as shoulder arthroscopy, which Medicare paid ASCs 42 percent lower than hospital outpatient departments in 2012, will continue to increase in ASCs.


Humana Teams with VRI to Pilot Enhanced Medical Alert Systems for its Medicare members

DAYTON, Ohio & ST. PETERSBURG, Fla.--(BUSINESS WIRE)-- Humana Inc.(NYS: HUM) , one of the nation's leading health and well-being companies, andValued Relationships, Inc. (VRI), a leading provider of home health monitoring services, are partnering on a national pilot aimed at preventing the serious long-term effects of medical emergencies and falls, and reducing unnecessary hospital admissions, readmissions and emergency room visits.

Beginning in late July, Humana began providing a free personal emergency response system, called a "PERS," to Medicare Advantage members identified by the company's national chronic care management division, Humana Cares / SeniorBridge. Plans are for 500 Humana Medicare members nationwide to participate in the six-month pilot.
"We know that a third of people over age 65 fall at least once a year, and nearly half cannot get up without help," said Humana Cares / SeniorBridge Vice President of Telephonic Clinical Operations Gail Miller. "Our goal is to continue to find ways to help our Medicare members stay longer and safer in their homes. Humana believes a medical alert system can help our members who are at risk of falls, and give their caregivers and family members peace of mind at the same time."
The VRI medical alert system is easy to use. When help is needed, the member simply pushes a button on the device and a Care Center representative answers the call and gets the help needed, 24 hours a day, seven days a week. VRI also uses the device to track motion and is alerted if the device senses a lack of activity that may signal a health emergency.
"We are excited to work with Humana to show that when proven, low-cost Medical Alerts are combined with innovative monitoring processes and fall technologies, health care organizations can improve care and reduce costs associated with hospitalizations," said Andy Schoonover, President of VRI.
Using state-of-the-art technology, the PERS device:
  • Automatically detects when someone wearing the device falls and calls them to see if they're okay.
  • Uses GPS-tracking to help find the member if he/she can't call out or doesn't answer calls.
  • Can work like a two-way, hands-free radio anyplace where AT&T's cellular network is active.
  • VRI is providing the monitoring of the systems through trained responders at its call center located in Franklin, Ohio.
Humana Cares / SeniorBridge, Humana's national chronic care management division, supports more than 300,000 individuals who have chronic conditions, struggle with daily activities and are frequently hospitalized, as well as their family members and caregivers.

Humana bought Healthrageous to build out Vitality

Humana was the mystery buyer of Boston-based health engagement company Healthrageous, MobiHealthNews has learned. Healthrageous sold its assets to Humana and a number of Healthrageous employees who supported the platform will also be joining the insurance company. 
MobiHealthNews first reported last week that Healthrageous had shut down and had its assets acquired. The financial details of the deal remain undisclosed.
Healthrageous also had a handful of other customers and pilot deals that had been previously unannounced — including three of the regional Blue Cross Blue Shields and a large IDN in Indiana.
Humana’s acquisition of Healthrageous will likely mean considerable changes to Humana Vitality, a competitive offering to Healthrageous. Humana first launched Humana Vitality in mid-2011 as a program that used a points-based rewards system to encourage healthy behavior and wellness education among employee populations. HumanaVitality is a joint venture between Humana and the Vitality program parent company, South Africa-based Discovery Holdings.
When Humana first launched Vitality the platform offered members an initial health assessment to determine their “Vitality Age,” a “scientifically calculated” number that offered a representation of their risk-adjusted “true” age, and taught members how their current behaviors are impacting their health. Vitality users were then given “personal pathways, recommended goals to help improve their health based on their individual health needs.” They could choose from more than 30 activities, divided between four categories: Fitness, Healthy Living, Prevention, and Education. In addition, children could earn Vitality Points by receiving immunizations, flu shots and participating in team sports. Vitality was included as a part of Humana’s commercial members but not its Medicare members.
As of May 2013, Humana Vitality integrated with a number of activity and biometric tracking devices including all Fitbit devices, some Garmin heart rate monitors, Polar heart rate monitors, and Timex heart rate monitors, as well as apps like Nike+ and Humana’s own Fit apps for iPhone, Android and BlackBerry. Humana also offers two white-labeled devices called HumanaGear Pedometers — one requires a USB connection and the other is wireless-enabled.
While it may not be related to the Healthrageous buy, Humana’s CEO was slated to serve as a keynote at Health 2.0 in Santa Clara last week but cancelled shortly before the event.