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Nonessential Care Is Essential

June 16, 2020
12:18 pm

An op-ed appeared in the New York Times entitled, “How Many More Will Die From Fear of the Coronavirus?”  Written by Cleveland Clinic chief executive and president Dr. Tomislav Mihaljevic and Mayo Clinic chief executive and president Dr. Gianrico Farrugia, the message is clear: the longer people avoid healthcare settings and ignore nonessential care, the more people will die preventable deaths.  These two well-respected leaders have made the case for people to return to their doctors with the reassurance that providers have transformed their work environments and are ready to treat people with Covid-19 precautions in place.  The “new normal” is here and may be around to stay for some time.  The full op-ed is available here.

 

Seriously ill people avoided hospitals and doctors’ offices. Patients need to return. It’s safe now.

By Tomislav Mihaljevic and Gianrico Farrugia

More than 100,000 Americans have died from Covid-19. Beyond those deaths are other casualties of the pandemic — Americans seriously ill with other ailments who avoided care because they feared contracting the coronavirus at hospitals and clinics.

The toll from their deaths may be close to the toll from Covid-19. The trends are clear and concerning. Government orders to shelter in place and health care leaders’ decisions to defer nonessential care successfully prevented the spread of the virus. But these policies — complicated by the loss of employer-provided health insurance as people lost their jobs — have had the unintended effect of delaying care for some of our sickest patients.

To prevent further harm, people with serious, complex and acute illnesses must now return to the doctor for care.

Across the country, we have seen sizable decreases in new cancer diagnoses (45 percent) and reports of heart attacks (38 percent) and strokes (30 percent). Visits to hospital emergency departments are down by as much as 40 percent, but measures of how sick emergency department patients are have risen by 20 percent, according to a Mayo Clinic study, suggesting how harmful the delay can be. Meanwhile, non-Covid-19 out-of-hospital deaths have increased, while in-hospital mortality has declined.

These statistics demonstrate that people with cancer are missing necessary screenings, and those with heart attack or stroke symptoms are staying home during the precious window of time when the damage is reversible. In fact, a recent poll by the American College of Emergency Physicians and Morning Consult found that 80 percent of Americans say they are concerned about contracting the coronavirus from visiting the emergency room.

Unfortunately, we’ve witnessed grievous outcomes as a result of these delays. Recently, a middle-aged patient with abdominal pain waited five days to come to a Mayo Clinic emergency department for help, before dying of a bowel obstruction. Similarly, a young woman delayed care for weeks out of a fear of Covid-19 before she was transferred to a Cleveland Clinic intensive care unit with undiagnosed leukemia. She died within weeks of her symptoms appearing. Both deaths were preventable.

The true cost of this epidemic will not be measured in dollars; it will be measured in human lives and human suffering. In the case of cancer alone, our calculations show we can expect a quarter of a million additional preventable deaths annually if normal care does not resume. Outcomes will be similar for those who forgo treatment for heart attacks and strokes.

Over the past 12 weeks, hospitals deferred nonessential care to prevent viral spread, conserve much-needed personal protective equipment and create capacity for an expected surge of Covid-19 patients. During that time, we also have adopted methods to care for all patients safely, including standard daily screenings for the staff and masking protocols for patients and the staff in the hospital and clinic. At this point, we are gradually returning to normal activities while also mitigating risk for both patients and staff members.

The Covid-19 crisis has changed the practice of medicine in fundamental ways in just a matter of months. Telemedicine, for instance, allowed us to pivot quickly from in-person care to virtual care. We have continued to provide necessary care to our patients while promoting social distancing, reducing the risk of viral spread and recognizing patients’ fears.

Both Cleveland Clinic and Mayo Clinic have gone from providing thousands of virtual visits per month before the pandemic to hundreds of thousands now across a broad range of demographics and conditions. At Cleveland Clinic, 94 percent of diabetes patients were cared for virtually in April.

While virtual visits are here to stay, there are obvious limitations. There is no substitute for in-person care for those who are severely ill or require early interventions for life-threatening conditions. Those are the ones who — even in the midst of this pandemic — must seek the care they need.

Patients who need care at a clinic or hospital or doctor’s office should know they have reduced the risk of Covid-19 through proven infection-control precautions under guidelines from the Centers for Disease Control and Prevention. We’re taking unprecedented actions, such as restricting visiting hours, screening patient and caregiver temperatures at entrances, encouraging employees to work from home whenever possible, providing spaces that allow for social distancing, and requiring proper hand hygiene, cough etiquette and masking.

All of these strategies are intended to significantly reduce risk while allowing for vital, high-quality care for our patients.

The novel coronavirus will not go away soon, but its systemic side effects of fear and deferred care must.

We will continue to give vigilant attention to Covid-19 while urgently addressing the other deadly diseases that haven’t taken a pause during the pandemic. For patients with medical conditions that require in-person care, please allow us to safely care for you — do not delay. Lives depend on it.

Guest Post: The Underutilization of Prevention

March 12, 2020
11:50 am

Robert Popovian is Vice President of U.S. Government Relations at Pfizer

One of the most underutilized ways to reduce medical costs in the U.S. is health care prevention. Unfortunately, politicians choose instead to implement draconian policies such as price controls or utilization management, which focus solely on cost management without any consideration given to patient outcomes or the value of an intervention to society.

The reason policymakers promote these types of measures is twofold. One, these policies are simple to implement and two, they reach their intended results quickly by reducing budgets, whether it be hospital costs or drug expenditures. On the other hand, promotion of preventative measures are complicated and challenging to implement and are thus ignored, despite the fact that the data show that such measures lead to better patient outcomes, including improvements in quality of life and productivity.

The two examples of preventative interventions that have not only shown to reduce costs but also improve outcomes are improving immunization rates and medication adherence.

Vaccines are one of the most cost-beneficial interventions in health care. In the U.S., we have done a great job ensuring our children are protected from various communicable diseases. Vaccination rates for most serious ailments are in the 90th percentile for children. However, the same cannot be said when it comes to adults, as their vaccination rates are abysmal. For example, less than 50% of adults get a flu shot every year.  What’s even more alarming is that approximately 20% of high-risk patients (e.g., patients suffering from lung disease) receive a pneumococcal vaccine. Both measures are well below the Healthy 2020 targets set by the Office of Disease Prevention and Health Promotion (ODPHP).

One approach to encourage adult vaccination is to further expand community-based pharmacist immunization capabilities. The evidence is clear that allowing pharmacists to provide vaccinations is the lowest cost alternative for providing this essential public health service. So it is vital that we expand and harmonize state laws governing pharmacist authority to immunize and to allow pharmacists to administer all Food and Drug Administration (FDA) approved and Advisory Committee for Immunization Practices (ACIP) recommended vaccines.

The second example of a cost-saving preventative intervention is medication adherence. One of the most cost-effective ways to improve patient adherence is through pharmacist-led medication synchronization. Medication synchronization is a service that has been offered for the past several years by pharmacists to patients who take multiple chronic medications.

A pharmacist collaborating with a physician and in consultation with the patient ensures that all of the patient’s medications are refilled on the same day. Pharmacists operationalize the concept by making an appointment with a patient to pick up their prescriptions every month, or at 60 or 90 days — depending on the refill schedule — and to discuss other issues pertinent to their care, such as over-the-counter medicine usage, smoking cessation needs or vaccination requirements. Medication synchronization has not only reduced the number of trips a patient has to take to the pharmacy and lessened the administrative burden for pharmacists and physicians, but most importantly it has led to better patient medication adherence and cost savings overall.

In 2014, for example, the Centers for Medicaid and Medicare Services (CMS) decided that patients enrolled in Medicare Part D plans should have the opportunity to synchronize their medications if they choose to and if it is deemed appropriate by their pharmacist or physician, not only because it improved adherence but also because of the overall health care cost reductions. In their analysis, CMS stated, “while the estimated total 6-year cost of this rule to Part D sponsors is $0.5 million, the savings to Part D sponsors and beneficiaries is $1.8 billion.” More recently, a research article published in Health Affairs suggested that patients with cardiovascular disease whose medications were synchronized were three times more adherent with their medications leading to 9% lower hospitalization and emergency department visits.

Fortunately, most states except for California and a handful of smaller ones have taken the lead from CMS to allow all patients in need to benefit from medication synchronization. It is now up to the pharmacists to offer this service universally to their patients.

No one denies that saving health care costs is a noble cause, and everyone agrees that it is not an easy task. However, policymakers are only focusing on the side of the ledger marked “cost”.  Instead, they should be implementing policies that guide us towards the goal of disease prevention to achieve the ultimate endpoint of reducing health care costs while improving patient outcomes.

National Obesity Care Week: Behind the Scenes of Obesity

September 19, 2019
4:19 pm

September 16-20 is National Obesity Care Week (NOCW).  NOCW is a source for science-based information on obesity.  More than 93 million Americans are affected by obesity, with an estimated cost of $480 billion to the healthcare system.  The Healthcare Leadership Council (HLC) has joined as a partner of NOCW, advancing our conviction that people who struggle with obesity deserve access to quality care and must be treated with dignity and respect.

Recently, HLC has been focused on how the healthcare system can utilize research on social determinants of health so that essential socioeconomic and environmental factors can be considered and addressed in addition to one’s clinical care.  At the beginning of this week, HLC hosted a Hill briefing that had an expert panel present on reducing disparities in health.  While this particular briefing looked at the whole patient from a pediatric and senior perspective rather than zeroing in on obesity, there is a strong relationship between obesity and low socioeconomic status that cannot be ignored.

Many HLC members have recognized the need to reach out and invest in the well-being of surrounding communities:

  • BlueCross BlueShield of Tennessee has taken many avenues to encourage healthy lifestyles of Tennesseans, such as revitalizing neighborhoods with parks, and repaving the roads with bike lanes.
  • The Bristol-Myers Squibb Foundation provided resources to establish one of New Jersey’s largest and most comprehensive children’s hospitals which includes a clinical center of excellence dedicated to the study and treat childhood obesity.
  • Fairview Health System launched a new 24-week Healthy Lifestyle Plan that combines evidence-based weight loss strategies with one-on-one lifestyle coaching.  This approach can address medical issues that make it hard for someone to lose weight on their own, such as hormone levels, the side effects of prescription drugs, or chronic conditions like sleep apnea.
  • Teladoc Health has invested in a personalized virtual care platform for physical and behavioral health, addressing the root of the problem for chronic disease with digital therapeutic interventions and sustainable behavioral change.

It is promising that across the healthcare spectrum there have been a variety of solutions offered to address obesity, but much progress must still be achieved to make a lasting impact on the health of millions of Americans.  Many people do not know that obesity is a disease, and education is the just the first step to achieving NOCW’s goal of access to comprehensive obesity care.  More voices are needed to enact change.  Additional information about ways to take action is available on ObesityCareWeek.org/ACTION.

Quantifying the Medicare Advantage advantage

July 25, 2018
2:51 pm

In the 15 years since its inception, the increase in popularity of Medicare Advantage (MA) – health coverage provided by private plans in contrast to traditional fee-for-service (FFS) Medicare – has been undeniable.  Roughly half of all Medicare-eligible seniors are enrolled in Medicare Advantage plan and that proportion keeps rising.

Now there is a new addition to the growing body of evidence that MA plans are not only serving their enrollees well, but is bringing greater overall value to the Medicare program than that generated by the FFS approach.

A newly-released study by Avalere Health, Medicare Advantage Achieves Better Health Outcomes and Lower Costs for Beneficiaries with Chronic Conditions Compared to Fee-for-Service Medicare, finds that Medicare Advantage is outperforming traditional FFS Medicare with higher rates of preventive screenings, fewer avoidable hospitalizations, and fewer emergency room visits.  In other words, healthier patients and significant dollar savings.

Overall, the Avalere study found that MA beneficiaries had 23 percent fewer emergency stays and 33 percent fewer emergency room visits than their peers in FFS coverage.  This wasn’t the result of MA plans enrolling healthier individuals at the outset.  Rather, the study found that a greater percentage of MA beneficiaries were in clinical and social risk categories that traditionally drive up costs in FFS Medicare.

Avalere found that MA outperformed FFS on a range of cost, utilization, and outcome metrics in caring for individuals with one or more chronic health conditions.  Among patients with diabetes, for example, those enrolled in MA experienced 73 percent fewer serious clinical complications than FFS beneficiaries.  And patients dually eligible for Medicare and Medicaid – who generally have more complicated and serious health conditions – had 49 percent fewer hospital visits and a 17 percent lower average-cost-per-beneficiary in MA plans.

Former Congresswoman Allyson Schwartz, president and CEO of the Better Medicare Alliance (of which the Healthcare Leadership Council is a member) said “this study adds to the growing body of evidence showing the ability of Medicare Advantage to align incentives to better manage the care for a high-need population with multiple chronic conditions.”  These patients, of course, account for the most significant portion of our country’s healthcare spending.

This study adds fuel to the argument that we can enhance healthcare quality and better contain spending through improved patient health when healthcare entities compete on the basis of value.

An Expert Look at 2018 Healthcare Trends and Their Potential Impact

February 08, 2018
6:05 pm

President and CEO of Premier healthcare alliance, Susan DeVore, discusses her predictions of what 2018 will bring in a Health Affairs article.  Ms. DeVore, a member and former chair of the Healthcare Leadership Council, shares her optimism regarding the commitment to innovation and competition that is driving the industry towards value-based care and the increased utilization of actionable data.  Her assessment of current trends focuses on how growth and changes in all healthcare sectors have an impact on providers, and further solidifies the importance of the work being done to improve access to care as well as outcomes.

The article is copied below and the original publication can be found here.


What To Watch In Health Care In 2018: Six Key Trends

At the start of 2018, the health care industry is on the cusp of more significant change. The GOP Congress has moved health care away from the center of their public policy agenda, creating more certainty and a clearer view. Of course greater certainty doesn’t mean total certainty, especially as market trends and business realities continue to shift. As providers move into 2018, we still feel confident in making some predictions as to what the future holds.

Clearer Skies Ahead, Pockets Of Turbulence

Uncertainty is expected during any major political transition, but it reached an all-time high for health care leaders in 2017. The fog has largely cleared, and 2018 will be a year of health care leaders starting to place their bets. Here’s what health care leaders see.

Instead of a sweeping set of legislative changes to the Affordable Care Act, the elimination of the individual insurance mandate is now the symbolic emblem of “repeal.” While some project that the mandate’s demise will lead to a decline in the private insurance market, it remains to be seen how the elimination will ultimately play out given the mandate’s relatively weak incentive for individuals to purchase coverage. The strong economy is causing employers to offer health coverage to compete for talent, and the probable enactment of the exchange market stabilization legislation should serve to calm the exchange market, potentially lowering premiums. Going forward, focusing on states will likely become the “replace” strategy for Republicans in 2018, with a larger number of waivers granted to experiment with programs, giving states greater control and reason to consider expanding Medicaid coverage. Health care leaders are viewing 2018 as a year of greater insurance market stability, with the number of insured Americans holding steady or possibly increasing over the latest numbers.

There is also more certainty around the movement to value-based care. Last year’s raging health care debate caused health care leaders to question the movement to alternative payment models (APMs). That momentum, however, is returning, and the experienced and more transparent leadership in the Department of Health and Human Services (HHS) by Alex Azar should provide significant reassurance to providers on both insurance market certainty and the movement to value-based care.

Health care leaders still face major financial threats. Bad debt continues to grow, reaching $38.3 billion in large part due to the rise of high-deductible health plans. Hospitals have taken $148 billion in Medicare payment cutssince 2010, and these cuts are scheduled to continue. Some states are cutting Medicaid reimbursement. 82 rural hospitals, as well as many urban hospitals, have closed since 2010. This year’s $1.6 billion cut in 340B payments will crush some of the most financially challenged hospitals treating the most vulnerable patient populations. Hospitals continue to be disadvantaged in the design of many of the Centers for Medicare and Medicaid Service (CMS)’s pay for performance and alternative payment models. As a result, hospital margins remain in low single digits, and the Medicare Payment Advisory Commission projects that the Medicare margin will fall to negative 11 percent in 2018.

Attention, Value Shoppers: The New Health Care Market

2018 will be a year of a renewed focus by CMS on paying for value, particularly with the continued ramp up of the Medicare Access and CHIP Reauthorization Act of 2015 that incents clinicians to take risk, and new APMs that create attractive alternatives for fence sitting providers.

Perhaps more notable today are private sector actions to expand and accelerate the value-based payment movement and disrupt the status quo. Given the clear signals, health care leaders are focused on gaining scale and/or vertical integration to position themselves favorably for an expansion of value-based care. Unlike past merger efforts to command greater market power, today’s consolidation is often more driven by the goal to integrate care delivery and achieve savings.

There is a new form of competition emerging. Providers and payers are organizing themselves into vertically-integrated, high-value care and financing networks. Health care leaders are actively exploring commercial, employer, and Medicare Advantage risk-based programs through either ownership models or partnerships. The most recent mega-deals by CVS and Aetna, Humana and Kindred, Ascension Health and Providence Health, Aurora Health Care and Advocate Health Care, as well as the ongoing provider acquisitions by insurance goliath UnitedHealthcare, all send a clear message: insurers, physician groups, health systems, and even retail organizations are each seeking to compete as high value care and financing networks.

The CVS/Aetna merger, for instance, is based on a strategy that they will be able to disrupt the system with a retail pharmacy and e-enabled high value provider network. The Advocate/Aurora merger is seeking to achieve regional scale by combining two of the nation’s leading clinically integrated physician networks, hospitals and other provider settings, and pharmacy capabilities in the greater Chicago-Milwaukee region. UnitedHealthcare appears to acquire more physician practices each day. We anticipate more mergers and acquisitions in 2018. As the merger and acquisition activity heats up, the question remains: Who will be best at capturing and engaging patients and customers?

Washington must be careful not to undermine this movement by confusing integration to deliver efficient, high-quality care with consolidation to reduce competition. This emerging model needs to be supported by continuing the movement by public payers to APMs and careful thought by anti-trust regulators.

Episode 2018: The Consumer Strikes Back

For providers to succeed as stewards of new care delivery networks, they need to play the game differently. This means a number of new capabilities, including creating clinically integrated physician networks, collecting and integrating data, and applying analytics to find cost, work flow, and quality improvement opportunities. It also means providing more outpatient clinics and offering additional access points, establishing preferred post-acute care networks, creating new incentive and payment arrangements, building physician measurement systems to assess performance, and negotiating successful alternative payment models with public and private payers.

To ultimately succeed, however, health leaders realize that they need to, above all else, excel at attracting and engaging patients, families, caregivers, and consumers. 2018 will be the year of focus on patient capture and engagement. Providers will work with their patients, families, and caregivers to develop approaches so they more actively manage their health and health care.

This means engaging the patient in their health and health care outcomes from the beginning. This involves providing prevention, diagnosis, and monitoring services that support the total care experience. Done well, it creates stickiness to a high value care network. Organizations are focusing more on this from a human resources training and measurement vantage point. They are also establishing patient portals, providing wearable devices, implementing patient educational programs, screenings, and pushing targeted materials to patients based on their current and anticipated needs.

For example, one of our members is providing home monitoring tools as well as tablets for video consults to help patients meet their health goals. The program focuses on total patient care from prevention to recovery. Few people leave the program, and the organization has reduced overall costs by 34 percent per year and hospitalizations by nearly 50 percent.

Financial Imperative, Meet Actionable Data

A certainty for health system leaders is the need to improve productivity and efficiency. The approach, however, is going beyond the past’s focus on reducing head count and cost of supplies.

After years of avoiding care efficiency and standardization initiatives due to the difficulty of persuading clinicians to embrace them, health care leaders now have a larger and more urgent financial imperative to identify and isolate wasteful practices, cost outliers, and the root causes for the inefficiencies. The keys to success are a strong case for change and a prioritization of efficiencies that yield both cost and quality improvements. This is, therefore, all about data and analytics.

Recent cost containment efforts we have pursued with our members provides a sense of scale.  These health care systems range in size from 6 to 19 hospitals and their care transformation work has achieved savings ranging from $180 to $250 million over two years. Another specific example is a health system member of ours that realized $13 million in savings by driving care process standardization across their departments that touch just ICU and blood utilization. In addition to the savings they also improved their quality scores and reduced patient complications and readmissions. Premier data found a lot of opportunity for other hospitals around ICU stays, potentially reducing expensive ICU stays by 200,000 days across 786 hospitals. This is precisely where providers are now focusing their efforts.

2018 will be the year of delivering efficient, highly reliable care. With today’s financial imperative and actionable data, health care leaders are achieving a new level of efficiency and productivity.

America’s Other Drug Problems: Cost And Competition

Rising drug prices continue to be a dominant concern to health care leaders. Pharmaceutical innovation holds great promise for helping providers achieve their mission to improve and sustain patient lives, but it’s also a Catch-22. As providers are increasingly assuming accountability for the health outcomes of a population, six figure drug price tags and unpredictable price increases threaten financial planning and cool the enthusiasm for taking risk. 2018 will be a year of increased legislative and regulatory policymaking to foster increased drug market competition.

The FDA has and will continue to step up its game with new initiatives designed to unleash more competition that can moderate drug price trends. These include encouraging new market entrants to rapidly start developing generics in classes where there is no competition, streamlining the generic drug approval process, promoting biosimilars and taking steps to prevent branded drug makers from exploiting programs like the Risk Evaluation and Mitigation Strategy and citizens’ petitions.

Congress will also be getting into the act this year. We expect the Fair Access for Safe and Timely (FAST) Generics Act and the Creating, Restoring Equal Access to Equivalent Samples (CREATES) Act, among other legislation, will help eliminate loopholes that can slow the introductions of competitor products.

Finally, manufacturers are developing new ways to demonstrate product return on investment in response to provider demands. There is increasing use of real-world evidence to demonstrate value as well as use of outcomes measures to quantify results. While value-based contracting is still in the early stages, manufacturers are looking to measure and launch these programs.

Emerging And Converging Digital Health

In every single aspect of health care, the digital revolution is making itself felt: new apps are getting patients more engaged; health sensors and wearables are creating terabytes of new, granular data, and machine learning, natural language processing, and artificial intelligence techniques and tools are all emerging new technologies. What’s more, precision medicine, telehealth, blockchain technology, and new personalized digital devices are being infused into all parts of the workflow and consumer experience.

The biggest impediment to effective use of data continues to be the lack of interoperability, especially among the electronic health records, which impedes care coordination and efficiency. While providers are waiting on HHS to implement the interoperability provisions of the 21st Century Cures Act, they are wasting no time in building data warehouses that assemble the multiple sources of data necessary to provide quality care and make informed decisions across the continuum of care. Growth of data warehouse systems and data analytics is one of the fastest growing technology areas as health systems seek actionable information to help them manage the total cost of care at a site and across sites of care.

Consequently, there is a growing and acute need for a trained workforce able to deploy, implement, and maintain health information technologies and systems and increasingly complex medical devices.  Today’s electronically connected, data-and evidence-driven health care system requires staff with data science and data analysis skills. These skills are essential in gathering, interpreting, protecting, and analyzing large and complex data sets. Data management, cyber security, and governance is essential to precision medicine, value-based care and payment and population health.

These are the big trends we see impacting health care providers in 2018.

We are encouraged by the outlook. We are hopeful Congress and the Trump administration will encourage and not impede this progress to high value networks, increased competition among pharmaceutical manufacturers, and increased access to health information.