May 22, 2017
4:16 pm
As the value-based approach to healthcare delivery is gaining momentum, the focus on end-of-life care has moved towards center stage. The benefits of palliative care and advance directives have proven to increase quality of care while decreasing the overall costs. Particularly near the end of life, patients can have a wide range of preferences regarding where they want to be, how much treatment they want to receive, and how comfortable they want to feel. It is important that caregivers and providers are aware of these preferences and have them documented. Health systems and patient advocates alike have been working on educating both sides of the healthcare interaction – the physicians as well as the patients and their families – in order to help with coordination and communication about the patients’ needs and desires.
Premier, Inc ., a member of the Healthcare Leadership Council, has been an acknowledged leader in communicating the vital role palliative care plays within the healthcare system. Its CEO, Susan DeVore, wrote in the Health Affairs Blog about the growth in this area and how Premier has worked to improve the patient experience near end-of-life. This piece is an excellent example of the private sector bringing value and quality to those who need it the most. The post in its entirety can be viewed below, and the link to the original post is here.
The Humanity In End-Of-Life Care
Susan DeVore
May 19, 2017
Health care is personal, especially when it comes to caring for someone as they approach death. However, half of Americans feel they have too little control over end-of-life medical decisions.
As the industry moves toward a more holistic approach to care delivery, health care organizations are beginning to rethink how they treat patients and starting to embed end-of-life care plans into the overall approach earlier on, sometimes before people even become ill. In a recent report on end-of-life care by the Aspen Health Strategy Group, several principles are discussed that take a broader view around caring for seriously ill patients, helping to ensure that care is sensitive, aligned with patient and family wishes, and always working toward enhanced quality of life. One of the top recommendations in the report to achieving that end is increasing emphasis on palliative care.
Deemed the fastest-growing medical specialty in the United States, palliative care is interdisciplinary care (medicine, nursing, social work, chaplaincy, and other specialties when appropriate) that focuses on improving the quality of life for persons of any age with a serious illness, as well as for their families.
While a relatively new concept, palliative care has been increasing in prevalence, in part due to new value-based care incentives that promote an environment in which payment relies on not only treating the illness but keeping patients comfortable and, when possible, at home.
However, there is a significant misunderstanding about what defines effective palliative care among patients and providers. Palliative care is about proactive care, which can be used at any point in an illness. Unlike hospice, palliative care is not just for those who are dying; it can be delivered to anyone with a serious or chronic medical condition from the time of diagnosis, regardless of whether the patient is terminally ill, expected to recover fully, or facing years of chronic or progressive disease. It is often provided at the same time as curative medical regimens to help patients tolerate side effects of disease and treatment, while carrying on with everyday life. This includes social, emotional, and spiritual support, as well as advising families on how to care for their loved ones.
Effective Palliative Care Improves Patient Experience
In dealing with these illnesses at the time of diagnosis through palliative care, caregivers can greatly increase patient satisfaction and outcomes, while reducing costs. For example, one of Premier, Inc.’s (a health care improvement company) members, Presbyterian Healthcare Services, in Albuquerque, New Mexico, launched palliative care outpatient clinics in 2012 and now offers them at three primary-care offices and two oncology offices. In a 2014 cost comparison of patients’ costs in the six months before their first visit to a Presbyterian outpatient clinic to the six months after, hospitalization costs dropped by 19 percent, use of outpatient hospital services went down by 44 percent, and emergency department costs decreased by 79 percent. All of this was done while maintaining quality. And they’ve continued to expand these services by creating a more robust home palliative program with 24/7 access to trained professionals. Acute care hospitalization rates for these patients are now extremely low when compared to national or regional norms.
Research has also shown advantages in administering palliative care. In a randomized trial of patients with metastatic non-small-cell lung cancer, those assigned to early palliative care not only experienced a better quality of life and fewer symptoms of depression than patients receiving standard care, but they also lived more than two months longer.
Health systems in Premier’s quality improvement and population health collaboratives are sharing their best practices in palliative care and implementing effective models across the continuum to make them available in outpatient settings, nursing homes, and at home. They are also driving ongoing educational initiatives to improve cross-specialty generalist palliative care skills and ensure high-risk patients complete advance care directives. At Fairview Health Services, in Minneapolis, Minnesota, nearly all of the oncology clinic sites have interdisciplinary palliative care teams embedded within them. Physicians, social workers, and nurses work together to ensure cancer patients and their families are receiving timely emotional support and are prepared for future decisions using advance care plans.
These efforts are well-aligned with and supported by value-based care delivery and payment models, including accountable care organizations and bundled payment initiatives that require high levels of care coordination. For instance, last year Medicare began paying for voluntary advance care planning. This creates appropriate incentives for physicians, patients, and family members to spend time discussing patients’ health care wishes, which is just as important as having a life insurance policy.
Plan For The Care You Want
Advance care plans can be created even if you’re not ill. In fact, about 90 percent of people say that talking with their doctors and loved ones about their preferred care wishes is important. This includes writing legal instructions on treatments one would or would not want to receive. Patients who have these plans in place report greater satisfaction with their health care, based on how much treatment is desired, and have been shown to have lower costs of care.
Additional efforts dedicated to helping people talk about their wishes for future care, especially care delivered at the end of life, are underway. One that is focused on ambulatory practices and other sites of care is the Institute for Healthcare Improvement’s program, The Conversation Project. It has developed a starter kit to help people have conversations with family members or other loved ones about their wishes, should they become seriously ill.
However, definitions for palliative care standards and remaining fee-for-service incentives can stand in the way. As addressed in Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life, there are too few standards for professional institutions and other organizations to follow regarding advance care planning. In addition, lingering fee-for-service models incentivize volume over value, which can lead to care that may not be in line with patients’ wishes.
Therapies to treat diseases, especially those that are life-threatening, need to be balanced with therapies to relieve suffering or improve the quality of life in the process.
While progress is being made, we need to continue to think about how we fold standards of humanity into caring for the people we love, should they be faced with a devastating illness. Conversations about serious illness can be difficult to have, but they are essential to ensuring the care delivered is compassionate, wanted, and warranted.
May 03, 2017
2:15 pm
I had the privilege of moderating a panel at Datapalooza – the annual gathering of hundreds of leaders in health data innovation — that focused on innovations in genomic science, which are rapidly spurring discoveries in personalized medicine. Clinicians face enormous challenges in keeping pace with evolving best practices in data management and implementing these technologies into routine care. The panelists focused on how genomic sequencing could be utilized with today’s healthcare information technology infrastructure, and the most effective way to do so.
Keith Stewart, the Carlson and Nelson Endowed Director of the Center for Individualized Medicine at the Mayo Clinic, where he is also a professor of medicine at the Mayo College of Medicine, discussed the importance of understanding genomes. He said that 24 percent of people who have their genes sequenced discover new medical findings. Utilizing this information can lead to more precise treatment. Personalized treatment means that patients have the capability of finding out which drugs will give them more or fewer side effects, and which will be more effective overall. Different people react to drugs in different ways, and this advanced knowledge can significantly increase quality of life for those who would otherwise suffer from severe side effects. Dr. Stewart questioned how genome sequencing results can be stored in a way that they can be easily referenced for treatment. Mayo Clinic, he said, is working on a way to bring genomic sequencing directly to the consumer, without the need for a doctor as a middleman.
Emma Huang, associate scientific director for Janssen research and development, said that the entire health continuum — from prevention to interception to cure — can be pushed forward by genomics. Models are being developed for integrating genomic data into predictive models in real time. What the system is lacking is the deep data collection at a population level in order to predict with greater accuracy. There are currently global initiatives linking human genetics and clinical phenotypes. Ms. Huang specified that data needs depend on the stage of a patient’s health. She declared that insights from genomic data need to be available and easily interpreted by patients to achieve results.
A major implementation barrier involves data transfer, flow, and interconnectivity. Genomics data is rarely generated, analyzed, interpreted, and clinically implemented in the same system. Mark Dunnenberger, PharmD, program director of pharmacogenomics at NorthShore University HealthSystem, said genomic data needs to be integrated into the system for true value and should be used alongside clinical data. NorthShore opened the first pharmacogenomics clinic of its kind in 2015, and has recently expanded the offering with an at-home testing program, MedClueRX. Electronic health records were not built to handle the huge volume and complexity of genomic data, and the current method of saving patient information as pdf files does not provide discrete data and tends to get lost in the system. Pharmacogenomics helps clinicians choose between therapeutically equivalent treatments that benefit unique individuals in varying ways. Patients grasp the value of pharmacogenomics, Dr. Dunnenberger said, and are willing to invest money regardless of whether it is covered by insurance.
As our nation’s efforts to bring precision medicine the forefront of clinical care accelerate, we must take care to ensure we incorporate this data in ways that will be usable for clinicians and valuable for patients – without creating additional uncertainly or unsustainable costs. As is often the case, HLC members are forging a path forward for others to follow.
January 26, 2017
3:06 pm
On January 24 at a dinner hosted by the Healthcare Leadership Council for its members, U.S. Representative Greg Walden (R-OR), the new chairman of the influential House Energy and Commerce Committee, spoke of his panel’s goals for the upcoming healthcare overhaul. CQ Roll Call published the following article based upon his prepared remarks.
CQ: Walden Outlines Obamacare Strategy to Health Care Executives By Joe Williams, CQ Roll Call
Energy and Commerce Chairman Greg Walden was poised Tuesday night to outline to health care industry executives his panel’s strategy for repealing and replacing the 2010 health care law, including insights on his plans to overhaul Medicaid.
The Oregon Republican planned to use his closed-door meeting with the Healthcare Leadership Council to discuss several measures his panel would consider in the coming weeks, according to prepared remarks obtained by CQ Roll Call.
A pair of hearings to be scheduled for late next week will center on stabilizing the health insurance marketplaces and on Medicaid. Walden is working with Senate Finance Chairman Orrin G. Hatch of Utah on changes to Medicaid, which provides health insurance to more than 73 million Americans.
Walden planned to confirm during his speech Tuesday night that Republicans will model their legislation largely on a repeal bill President Barack Obama vetoed last year.
“We will use our 2015 reconciliation bill as a starting point in order to repeal major portions of Obamacare, such as the individual and employer mandates, and address the Obamacare Medicaid expansion and the failing exchanges,” Walden’s prepared remarks say. They also say a “stability period” would be included in the legislation.
Walden also is expected to say that Republicans will “maintain protections for those with pre-existing conditions” and permit children to stay on their parents’ insurance plan until age 26, two provisions in the current law (PL 111-148, PL 111-152) that President Donald Trump has voiced support for keeping in a replacement plan.
In his prepared remarks, Walden calls on the Healthcare Leadership Council to engage publicly in the health care debate. The group includes executives from hospitals, insurers, pharmaceutical companies, medical device manufactures and other industries.
“We can’t do this alone. But by working together . . . we can reach our mutual goal of helping people live healthier lives and giving every American a new opportunity to get affordable health care coverage,” Walden will say, according to the prepared remarks.
Changes to Medicaid
Walden’s remarks don’t detail how the GOP would address the 2010 law’s Medicaid expansion, but he confirmed to CQ Roll Call earlier in the day he has had several meetings with Hatch to discuss their legislation on changes to the program.
Earlier this month, Walden organized a meeting between Republican lawmakers on his panel and GOP governors to discuss potential changes to Medicaid. He also attended a separate but similar meeting organized by Senate Finance.
A top aide to Trump said earlier this week the president would propose turning Medicaid into a block grant system. Some GOP governors at the meetings last week, however, suggested a per capita approach that would explicitly require the federal government to incorporate enrollment changes when determining reimbursement rates.
J. Mario Molina, president of Molina Healthcare, told CQ Roll Call both Republican and Democratic governors are likely to push for a per capita approach because it would account for potential increases in each state’s Medicaid population.
“This is going to be a debate between the states and the federal government as to how best to continue this entitlement program while trying to rein in costs,” he said in a recent interview.
Others Republican governors, including Gov. John R. Kasich of Ohio, proposed lowering the Medicaid coverage threshold to 100 percent of the poverty level and allowing people with income above that amount to get exchange coverage. The law’s expansion provides Medicaid coverage for individuals up to 138 percent of the poverty level.
December 05, 2016
3:26 pm
As speculation heats up over how the new Trump administration and Congress will address healthcare in 2017, your time would be well spent viewing this Yahoo Finance video interview with George Barrett, chairman and CEO of Cardinal Health and incoming chair of the Healthcare Leadership Council. In the video, he addresses the uncertainty surrounding the Affordable Care Act (ACA), believing there would be dramatic modifications under any administration but doubting we will see a full repeal of the ACA. Mr. Barrett correctly notes that many aspects of the health law counterbalance one another, making it a challenge to determine who to make changes without creating unwanted and harmful disruptions.
There are other interesting aspects to this interview. Mr. Barrett addresses a number of topics including the healthcare system’s difficulty in delivering care in an equitable manner, the social determinants of health and the intertwining of social issues with healthcare delivery, the systemic issue of healthcare access, and steps Cardinal Health is taking to improve health outcomes and curb hospital readmission rates.
October 12, 2016
2:27 pm
In the new era of healthcare in which value-based care is steadily pushing aside the fee-for-service model, outdated rules and regulations continue to hinder the progress of healthcare reform. The Healthcare Leadership Council (HLC) has been focusing on what the barriers to innovation are and how the pathway can be cleared. HLC’s National Dialogue for Healthcare Innovation (NDHI), a platform that builds consensus among the health industry, patient groups, government and academia on issues affecting healthcare progress, hosted a webinar discussing one area considered to be a barrier, the Stark Law and Anti-Kickback Statute.
The Stark Law and Anti-Kickback Statute have been detrimental to the development of alternative payment models. There is agreement that updates are necessary in order for broader collaboration to occur among healthcare providers, without the fear of penalties. This uncertain environment has caused many organizations to hesitate in moving forward, and is delaying the switch from fee-for-service to value based payments. Stephanie Zaremba, of athenahealth, voiced concerns regarding this issue in a recent blog post.
NDHI released a report at the beginning of this year that offered up six viable solutions to transform healthcare, which included the Stark Law. Also earlier this year, the Senate Finance Committee held a hearing to examine possible ways to modernize the law. The interest and focus on this matter is growing, and HLC/NDHI will continue to engage with cross-sectoral stakeholders in developing recommendations. Stay tuned for the whitepaper being released in the near future.
The full athenahealth blog post can be viewed below:
A healthcare law held together by duct tape
By Stephanie Zaremba | August 12, 2016 | Opinion
The drive to fix healthcare is full of big ideas — major overhauls of how physicians are paid, patients are insured, health information is documented, and care is coordinated.
But some of the most important fixes might come from focusing on less exciting details. For example: How outdated fraud and abuse laws are squeezing innovation from the system.
Imagine our existing healthcare laws as a building. Ideally, it is well constructed at the outset, regularly maintained, and remains useful for decades into the future.
But when a law becomes riddled with exceptions — and then with addendums to close the loopholes to the exceptions — its integrity starts to fail. Pretty soon, it’s dilapidated, having exceeded its useful life, held together with a complex web of duct tape and a door that only opens if you know exactly where to kick it.
Our fraud and abuse laws — specifically, the Stark Laws and Anti-Kickback Statute — were written in the era of fee-for-service. They were essential, at the time, to addressing the fundamentally misaligned incentives created by a payment system that rewards physicians for volume.
The basic premise of the laws is simple: A physician can’t receive a financial benefit for referring a patient to another care provider or prescribing a drug, treatment, etc. As patients, we want our providers recommending care based on what is best for our health, not best for their wallets.
But as we shift away from fee-for-service and toward value-based care, Stark and Anti-Kickback are not keeping up. We increasingly see behaviors that are desirable but technically prohibited, such as a hospital paying for the electronic health record used by community physicians. So over time, each law has been subject to a few dozen exceptions and hundreds of advisory opinions carving out specific acceptable behaviors.
Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program receive broad waivers to Stark and Anti-Kickback in recognition of the fact that these laws directly prohibit what is required for ACO success: sharing of costs, infrastructure, and savings.
The Department of Health and Human Services has set aggressive goals for tying payments to value, not volume, and our fraud and abuse laws must be reformed for those goals to be realized. Currently, physicians and hospitals are prohibited from a long list of desirable behaviors under a value-based model: advising patients on the selection of a high quality post-hospital care facility; providing patients with cab rides to appointments or scales to help monitor their weight between visits; and paying for the cost of exchanging patient information electronically, to name a few.
When physicians are financially incentivized to coordinate care, they need a legal framework that encourages innovation around how healthcare providers organize, share costs, exchange information, and engage across the broad continuum of care.
But instead of reform, to date the policy changes necessary to implement this shift are piled on top of a rickety foundation and, as a result, innovation suffers.
The good news is that members of Congress are looking at ways to address problems with the Stark Laws and Anti-Kickback Statute. As they dive in, policymakers need to recognize this crumbling building for what it is: Something that needs comprehensive rebuilding, not another round of patches.
Stephanie Zaremba is director of government and regulatory affairs for athenahealth.
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