March 2019 • Vol.10 No.2
Colorectal Cancer Growing concern among young Americans
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CONTENTS »» MARCH 2019
6 The Pediatrician’s Office: A Good Place to Start Heart disease begins early in life
8 Heart Disease: An Uphill Climb 14 Colorectal Cancer
Growing concern among young Americans
22 Health news and notes 26 Small Guys Finish Last Small practices lag behind big ones under MIPS
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The Journal of Healthcare Contracting | March 2019
3
TRENDS
The Pediatrician’s Office: A Good Place to Start Heart disease begins early in life Gerald Berenson, M.D., professor of cardiology at LSU
mark research because it established a
Health New Orleans School of Medicine, passed away in No-
link between diet, exercise, and genet-
vember. He was 96. Berenson is best known for the Bogalusa
ics and the development of coronary
Heart Study, a multi-decade study of the development of heart
heart disease.”
disease, diabetes and metabolic syndrome.
4
In fact, Berenson believed that school-
A primary finding of the Bogalusa Heart Study, which began
children should be routinely tested for
in 1972, is that the major causes of adult heart diseases begin in
blood pressure, cholesterol and body
childhood – including atherosclerosis, coronary artery disease,
mass. “This internationally acclaimed
hypertension, type 2 diabetes and obesity.
research project is the foundation for
“The impact of the Bogalusa Heart Study cannot be over-
diet and lifestyle interventions that are
stated,” noted Dr. Frank Smart, LSU Health New Orleans chief
commonly employed today,” Smart was
of cardiology, in the LSU Health obituary. “The study was land-
quoted as saying. March 2019 | The Journal of Healthcare Contracting
Better care starts with better patient positioning. Blood pressure inaccuracy is a problem. Many healthcare providers are not aware of current standards and don’t always follow the same process for acquisition. Minor differences can have a major impact on measurement accuracy – and patient health. Only Midmark can offer a fully integrated point-of-care workflow designed to promote proper patient positioning for a more accurate blood pressure measurement with the ability to port data directly into the EMR, eliminating transcription errors. Better BP™ is better care. Learn more at midmark.com/JHCmar
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TRENDS
The pediatrician
“The doctor has to make time to talk
One of the greatest risk factors for heart disease among children
to the child and the parents,” he says.
today is obesity, notes Christopher Snyder, M.D., FAAP, Univer-
Obesity is usually a family affair; that is
sity Hospitals, Cleveland, and chair of the American Academy of
to say, pediatricians seldom see an obese
Pediatrics Section on Cardiology and Cardiac Surgery.
child with two parents of healthy weight.
“Obesity is dangerous, it limits kids’ lives, and it’s a public health issue which we have to recognize,” he says.
“You can’t just walk into the exam room, tell the child and his parents that he’s
Obesity is more common among adolescents today than in
obese, and then leave. You have to help
years past, says Snyder. And even though overweight or obesity
them set goals and continue working to-
may not be the reason a child visits the pediatrician, “it’s what
ward them.”
we see. If we want to move the needle and help people live longer, we have to attack it.”
Again, that is often more easily said than done, he says. Some families can’t
“Pediatricians have to make the time to talk to families about how obesity can affect life expectancy, high blood pressure and diabetes.” – Christopher Snyder, M.D., FAAP, University Hospitals, Cleveland, and chair of the American Academy of Pediatrics Section on Cardiology and Cardiac Surgery Gerald S Berenson, MD, Photo Courtesy of LSU Health
That’s a tall order, given popular culture, which still prizes tasty but unhealthy food, as well as today’s more sedentary lifestyles. In 2011, the American Academy of Pediatrics endorsed guidelines by the National Heart, Lung and Blood Institute
opt for cheaper junk food instead. Some live in unsafe neighborhoods, where kids are unable to play outside with friends.
(NHLBI), part of the National Institutes of Health, which recom-
“Obesity is an epidemic,” says Snyder.
mended universal cholesterol screening at ages 9-11 and 17-21
“We cannot ignore it, even though it can
years, and selective cholesterol screening in children ages 2-21
be really difficult.
years with risk factors.
6
afford the price of healthy food, and so
“Pediatricians have to make the time
But long-term change calls for: 1) willingness on the part of
to talk to families about how obesity
the child and his/her parents to adopt a healthy lifestyle, and 2)
can affect life expectancy, high blood
help from professionals, such as dieticians and fitness experts,
pressure and diabetes. If we don’t do it,
says Snyder.
who will?” March 2019 | The Journal of Healthcare Contracting
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PATIENT CARE
ENVIRONMENT OF CARE
INTERVENTIONAL CARE
TRENDS
Heart Disease: An Uphill Climb 8
Despite decades-long improvement, heart disease and stroke remain leading causes of morbidity, mortality, and healthcare costs in the United States. One year ago, the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services launched Million HeartsŽ 2022, a national initiative to prevent a million heart attacks, strokes, and other acute cardiovascular events during 2017–2021. March 2019 | The Journal of Healthcare Contracting
A predecessor program – Million Hearts® – aimed to prevent 1 million heart attacks and strokes in the United States over the course of five years, 2012 to 2016. During the first two years of that initiative, about 115,000 cardiovascular events were prevented, relative to the expected number of events. And although final numbers had not been reported at press time, Million Hearts estimates that up to half a million events may have been prevented from 2012 through 2016.
The economic toll of CVD is high. More than $316 billion each year in the United States, with CVD treatment accounting for about one of every seven dollars spent on healthcare in this country. Million Hearts 2022 focuses on a small set of priorities selected for their impact on heart disease, stroke, and related conditions: • 20 percent reduction in sodium intake • 20 percent reduction in tobacco use • 20 percent reduction in physical inactivity • 80 percent performance on the ABCS Clinical Quality Measures (i.e., (i.e., Aspirin when appropriate, Blood pressure control, Cholesterol management, and Smoking cessation). • 70 percent participation in cardiac rehab among eligible patients. Every 40 seconds, an adult dies from a heart attack, stroke, or other adverse outcome of cardiovascular disease (CVD), reports the CDC. These deaths account for about one third of all deaths in the United States, or more than 800,000 deaths each year. About one in five of these deaths is a person younger than 65. Heart disease and stroke can also lead to other serious illnesses,
Special attention needed Addressing heart disease is important for all Americans, but four groups require special attention, as heart disease and stroke events among them are increasing: • Blacks/African-Americans with hypertension. • 35-to-64-year-olds. • People who have had a heart attack or stroke. • People with mental and/or substance use disorders. In 2016, hospitalization and mortality rates were highest among men (989.6 and 172.3 per 100,000, respectively) and non-Hispanic blacks (211.6 per 100,000, mortality only), and they increased with age, reports the Centers for Disease Control and Prevention. Among adults aged 18-64 years, 805,000 hospitalizations and 75,245 deaths occurred. Without preventive intervention, it is possible that 16.3 million events and $173.7 billion in hospitalization costs could occur from 2017-2021.
Source: Centers for Disease Control and Prevention, https:// www.cdc.gov/mmwr/volumes/67/ wr/mm6735a3.htm?s_ cid=mm6735a3_w
disabilities, and lower quality of life. The Journal of Healthcare Contracting | March 2019
9
TRENDS
Heart disease: Where you live matters Aspirin use, blood pressure and cholesterol control, cardiac rehab and heart-healthy behaviors are effective healthcare strategies to combat heart disease. Nevertheless, adherence is inconsistent throughout the country, resulting in geographic variation in cardiovascular disease (CVD) outcomes, reports the Centers for Disease Control and Prevention. In 2016, state-level mortality was higher in the southeastern United States, which aligns with the findings from previous studies. Rates for emergency-department visits and hospitalizations
were higher in the Southeast and elsewhere, including many Midwestern states. State-level variation in 2016 occurred in heart-disease-related rates of: • Emergency department visits (a low of 56 per 100,000 in Connecticut, to 275 per 100,000 in Kentucky). • Hospitalizations (from 484 per 100,000 in Wyoming, to 1,670 per 100,000 in Washington, D.C.) • Mortality (from 111 per 100,000 in Vermont, to 267 per 100,000 in Mississippi).
Each state would need to realize an approximate 6 percent decrease in its expected event totals during 2017–2021 to collectively prevent 1 million events at the national level. For that to occur, the participants in Million Hearts® 2022 believe an 80 percent or greater performance on the ABCS (i.e., aspirin use, blood pressure control, cholesterol control and cessation of smoking) and at least a 20 percent reduction in physical inactivity, tobacco use, and sodium consumption are necessary.
Source: Centers for Disease Control and Prevention, https://www.cdc.gov/mmwr/volumes/67/wr/ mm6735a3.htm?s_cid=mm6735a3_w
The economic toll of CVD is high. More than $316 billion each
The CDC reports that acute myocar-
year in the United States, with CVD treatment accounting for about
dial infarctions and strokes accounted
one of every seven dollars spent on healthcare in this country.
for approximately half (47 percent) of
And while cardiovascular deaths have been declining for the
hospitalizations (rates = 204.5 and 199.1
past 40 years, the reduction in these deaths has slowed since
per 100,000, respectively) and approxi-
2011, indicating the need for focused, sustained action by pub-
mately two thirds (61 percent) of deaths
lic and private partners to improve our nation’s cardiovascular
(42.2 and 53.7 per 100,000, respectively).
health, says the CDC. Managing blood pressure and cholesterol
Other cardiovascular events, which in-
levels is more important than ever. Cardiac rehabilitation pro-
clude those related to heart failure, con-
grams, increased physical activity and healthy eating habits are
tributed to 46 percent of hospitalizations
other priorities.
and 38 percent of deaths (rates = 394.6 and 59.8 per 100,000, respectively).
In 2016, heart disease caused:
10
• 2.2 million hospitalizations (850.9 per 100,000 population).
Editor’s note: Refer your clinical cus-
• $32.7 billion in costs.
tomers to the Million Hearts website at
• 415,480 deaths (157.4 per 100,000).
www.millionhearts.hhs.gov March 2019 | The Journal of Healthcare Contracting
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TRENDS
The cost of heart disease, 2016
By gender
Hospitalization/mortality rates
Hospitalization cost ($)
Men (total)
1.18 million
$18.6 billion
Women (total)
1.06 million
$14.1 billion
Men by age
Hospitalization/mortality rates
Hospitalization cost ($)
18-44 years
73,000
$1.3 billion
45-64 years
426,000
$7.4 billion
65-74 years
286,100
$4.8 billion
75 years and over
395,000
$5.1 billion
Women by age
Hospitalization/mortality rates
Hospitalization cost ($)
18-44 years
46,900
$0.8 billion
45-64 years
258,700
$4.1 billion
65-74 years
231,100
$3.3 billion
75 years and over
520,500
$5.9 billion
Race/ethnicity
Hospitalization/mortality rates
Hospitalization cost ($)
White, non-Hispanic
320,200
NA
Black, non-Hispanic
52,200
NA
Hispanic
25,400
NA
Other, non-Hispanic
12,600
NA
Asian/Pacific Islander
10,600
NA
Alaskan native
2,000
NA
Sources: Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS); National Center for Health Statistics’ National Vital Statistics System Mortality Data. (https://www.cdc.gov/mmwr/volumes/67/wr/mm6735a3.htm?s_cid=mm6735a3_w)
12
March 2019 | The Journal of Healthcare Contracting
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March 2019 | The Journal of Healthcare Contracting
Colorectal Cancer Growing concern among young Americans
Rates of colorectal cancer are rising for the under-50 crowd, but declining for those over 50 to 55. Those findings, reported by the American Cancer Society in its May 2018 Colorectal Cancer Screening Guideline, caused ACS to recommend that average-risk adults aged 45 years and older undergo regular screening with either a high-sensitivity stool-based test (e.g., iFOBT) or a structural – visual – exam, based on personal preferences and test availability. As a part of the screening process, all positive results on non-colonoscopy screening tests should be followed up with timely colonoscopy, according to ACS. True, the Society calls its most recent guideline a “qualified recommendation,” whereas its prior recommendation for regular screening in adults aged 50 years and older remains a “strong recommendation.” Nevertheless, ACS issued its recommendation based on a systematic evidence review of colorectal cancer screening literature and modeling analyses. Not every professional group is completely on-
“ Young onset rates of colorectal cancer are absolutely rising, and we as clinicians need to be cognizant of that when we see our young patients in the office who present with digestive complaints of concern.”
board with the ACS recommendation. The U.S.
– Sophie M. Balzora, MD, FACG
Multi-Society Task Force (MSTF) on Colorectal Cancer – which represents the American Gastroenterological Association, American College of Gastroenterology, and the American Society for Gastroenterological Endoscopy – is standing by its 2017 recommendations, The Journal of Healthcare Contracting | March 2019
15
COLORECTAL CANCER
which call for screening for colorectal cancer be-
diet, including high consumption of alcohol and
ginning at age 50 years in average-risk people, ex-
red and processed meat and low consumption of
cept in African-Americans, in whom some evidence
fruits/vegetables, dietary fiber, and dietary calci-
supports screening at 45 years. Nevertheless, MSTF
um; and physical inactivity, says ACS. The risk for
recognizes that earlier screening may improve ear-
developing colorectal cancer is associated with
ly detection and prevention of colorectal cancer.
several identified hereditary conditions, includ-
At the very least, the Task Force acknowledges that
ing family history; medical conditions, including
the ACS recommendation will stimulate discussion
chronic inflammatory bowel disease and type 2
and further research on the risks and benefits of
diabetes; and a history of abdominal or pelvic ra-
earlier screening.
diation for a previous cancer. Among adults younger than 55 years, the incidence of colorec-
By the Numbers
tal cancer increased 51 percent from 1994 to 2014, and mortality increased 11 percent from 2005
Colorectal cancer (CRC) is the fourth most commonly diagnosed cancer among adults in the United States, reports the ACS. Over 140,000 Americans were expected to be diagnosed with it in 2018. It is the second leading cause of cancer death, leading to over 50,000 deaths annually.
to 2015. “Young onset rates of colorectal cancer are absolutely rising, and we as clinicians need to be cognizant of that when we see our young patients in the office who present with digestive complaints of concern,” says Sophie M. Balzora, MD, FACG, who
16
is chair of the American College
Onset among the young
of Gastroenterology’s Public Relations Committee
Colorectal cancer (CRC) is the fourth most com-
and of the NYU School of Medicine. It is not clear
monly diagnosed cancer among adults in the Unit-
why colorectal cancer is increasing in this popula-
ed States, reports the ACS. Over 140,000 Americans
tion, she adds.
were expected to be diagnosed with it in 2018. It is
While Balzora could not comment on ACG’s
the second leading cause of cancer death, leading to
behalf on the American Cancer Society’s newest
over 50,000 deaths annually. The highest incidence
recommendations, “what I can say is that the rec-
and mortality rates are among African-Americans,
ognized increased rate of rectal cancer in those
American Indians, and Alaska Natives.
under age 50 has sounded an alarm, and height-
Risk factors associated with a Western life-
ens the importance of informing patients in this
style that have been shown to increase CRC risk
age group to not ignore their digestive symptoms
include: cigarette smoking; excess body weight;
and to seek the care of their physician sooner, March 2019 | The Journal of Healthcare Contracting
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COLORECTAL CANCER
rather than dismissing symp-
American Cancer Society Guideline for CRC Screening, 2018
toms. This is something we have
The American Cancer Society recommends that adults aged 45 years and older with an average risk of colorectal cancer (CRC) undergo regular screening with either a high-sensitivity stoolbased test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on non-colonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends that average-risk adults in good health with a life expectancy of greater than 10 years continue CRC screening through the age of 75 years (qualified recommendation). The ACS recommends that clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history (qualified recommendation). The ACS recommends that clinicians discourage individuals over age 85 years from continuing CRC screening (qualified recommendation).
The good news
Options for CRC screening Stool-based tests: • Fecal immunochemical test every year. • High-sensitivity, guaiac-based fecal occult blood test every year. • Multitarget stool DNA test every 3 years.
increased screening, with im-
always stressed, but this message is more important now than ever.”
If there is good news to report, it is this: Colorectal cancer incidence and mortality among adults aged 55 years and older have shown a decline for several decades, which accelerated around 2000, particularly among adults aged 65 years and older, according to ACS. Although changes in exposure to risk factors account for an estimated one-half of the reduction in incidence and one-third of the reduction in mortality before 2000, subsequent accelerated declines in incidence and mortality since 2000 are largely attributable to proved treatment also contributing to mortality reduction. “Screening saves lives, and this group [those aged 55 and over]
Structural examinations • Colonoscopy every 10 years. • CT colonography every 5 years. • Flexible sigmoidoscopy every 5 years.
has been heavily targeted, which is fantastic to see,” says Balzora. “The ‘Katie Couric Effect’ was a true phenomenon that increased
Source: Colorectal cancer screening for average-risk adults:
colorectal cancer screening rates
2018 guideline update from the American Cancer Society, CA: A Cancer Journal for Clinicians, https://onlinelibrary.wiley.com/doi/ full/10.3322/caac.21457#caac21457-tbl-0001
tremendously,” she says, referring to the efforts of the journalist and author. “Having her colonoscopy nationally broadcast on
18
March 2019 | The Journal of Healthcare Contracting
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COLORECTAL CANCER
live television in March 2000 was an innovative
U.S. Multisociety Task Force on Colorectal Cancer: Statement regarding new recommendations
and extremely successful method of driving home the importance of colorectal cancer screening. “As gastroenterologists, we strive to prevent colorectal cancer over detecting it, which is why we feel colonoscopy is the best test, as it can
The MSTF has previously recommended that colorectal cancer screening for average-risk persons (persons who do not have a family history of colorectal cancer in a first-degree relative) begin at age 45 years in African Americans and age 50 in other groups. The MSTF has reviewed the recent recommendation from the American Cancer Society (ACS) to lower the age to begin screening from 50 to 45 years in all Americans. This change was a qualified recommendation based largely on a modeling study utilizing updated data on the incidence of colorectal cancer in younger people. Evidence from screening studies to support lowering the screening age is very limited at this time. Based on the modeling study used to support the ACS recommendation, the MSTF recognizes that lowering the screening age to 45 may improve early detection and prevention of CRC. The MSTF expects the new ACS recommendation to stimulate investigation that will clarify the benefits and risks of earlier screening. As the MSTF has previously noted and discussed, rates of colorectal cancer are increasing in Americans down to age 20 years. Beginning screening at 45 years addresses only part of the increasing risk of colorectal cancer in young persons. For all persons under 50 years, it remains critical to promptly assess symptoms consistent with colorectal cancer. In particular, rectal bleeding and unexplained iron deficiency anemia have substantial predictive value for colorectal cancer and should be thoroughly evaluated.
truly prevent colorectal cancer, as well as detect
Source: U.S. Multisociety Task Force on Colorectal
Recommendations for Physicians and Patients
Cancer, June 14, 2018, https://www.gastro.org/ press-release/statement-from-the-u-s-multisocietytask-force-on-colorectal-cancer
From the U.S. Multi-Society Task Force on
it,” says Balzora. Stool-based, noninvasive testing – such as iFOBT, or FIT – does not prevent colorectal cancer, because its primary goal is to detect colorectal cancer, and not precancerous polyps, she says. “But ultimately, the best test is the one that gets done (properly)!” FIT testing is an excellent noninvasive alternative to colonoscopy, assuming that patients follow through by getting a colonoscopy should the FIT test return positive, says Balzora. “FIT has a significant advantage over FOBT testing, as it is specific to lower intestinal bleeding, and is a better, more accurate test overall compared with FOBT testing.”
Resources: American Cancer Society Colorectal Cancer Screening Guideline (2018), https://www.cancer.org/health-careprofessionals/american-cancer-societyprevention-early-detection-guidelines/ colorectal-cancer-screening-guidelines.html Colorectal Cancer Screening:
Colorectal Cancer, July 2017, Gastroenterology (https://www.gastrojournal.org/article/S00165085(17)35599-3/fulltext)
20
March 2019 | The Journal of Healthcare Contracting
Rx Only ©2016 B. Braun Medical Inc. Bethlehem, PA. All rights reserved. 16-5430_JHC_5/16_RTS3
HEALTH NEWS
Health news and notes Get happy
said Petra Hanson, MBChB, MRCP, AFHEA,
Being active can help you improve your health and feel better,
a clinical research fellow at Clinical Sci-
says the Department of Health and Human Services. It can low-
ences Research Laboratories, University
er your blood pressure and reduce your risk of chronic diseases,
Hospitals Coventry and Warwickshire, U.K.
like type 2 diabetes and certain cancers. Physical activity can
“Mindfulness taught in such a setting can
also boost your mood and help sharpen your focus. In its new
also improve patients’ confidence and
Physical Activity Guidelines for Americans, HHS says that adults
ability to manage weight in the long term.
need at least 150 minutes of moderate-intensity physical activ-
It is a very scalable intervention that can
ity per week. You can start with just 5 minutes at a time. Swim,
be applied to everyone.”
garden, walk the dog, dance, or bike your way to feeling better. Strengthening your muscles is important too. At least two days
Housework for brainiacs
each week, do some push-ups or lift weights. Children ages
Now there’s no excuse for not doing more
three to five should be physically active for at least three hours
housework. Even simple housework,
throughout the day. Kids six through 17 need at least one hour
like cooking and cleaning, may make a
per day. All of your physical activity adds up. Moving more often
difference in brain health, according to
throughout the day can help you get enough activity.
researchers at Rush University Medical Center in Chicago. In the last years of re-
22
Pay attention
search before death, each participant in
Adults with obesity who attended group sessions teaching mind-
the Rush study wore an activity monitor
fulness-based eating techniques lost an average of 2.85 kg more
called an accelerometer, similar to a Fitbit,
than similar adults who attended group classes without mindful
which measured physical activity around
eating strategies, according to findings published in The Journal
the clock – everything from small move-
of Clinical Endocrinology & Metabolism and reported by Helio.
ments, such as walking around the house,
com. “Our study has shown that mindfulness techniques can
to more vigorous movements, like exer-
improve eating behavior and facilitate weight loss in patients
cise routines. Researchers collected and
with obesity attending specialist weight management service,”
evaluated 10 days of movement data for March 2019 | The Journal of Healthcare Contracting
Better, faster. It’s what we want for patients.
What about your clinicians?
Connecting vital signs monitors to the EMR has been shown to: Y
Reduce errors caused by manual processes1
Y
Save clinicians time by removing manual documentation steps2
Y
Increase clinical time spent on value-added care3
40
1
Reduction in minutes of vital signs data latency in the EMR after connecting vital signs4
Welch Allyn partners with leading EMRs to send data from the Connex® family of vital signs devices directly to the patient’s record. Our goal is simple: help your clinicians work better, faster so they can focus on getting patients better, faster.
Start today at www.welchallyn.com. 1 CIN: Computers, Informatics, Nursing: Eliminating Errors in Vital Signs Documentation, FIELER, VICKIE K. PhD, RN, AOCN; JAGLOWSKI, THOMAS BSN, RN; RICHARDS, KAREN DNP, RN, NE-BC, 2013. The paper vital signs recording had an error rate of 18.75%. 2 JHIM FALL 2010 Volume 24:Number 4, Vital Time Savings: Evaluating the Use of an Automated Vital Signs Documentation System on a Medical/Surgical Unit 3 Going One Step Further at Scott & White Medical Center—Temple: Eliminating manual vital signs documentation to prioritize value-added care. 2017 Welch Allyn. www.welchallyn.com 4 CareAware® VitalsLink: Eliminating Data Latency & Manual Documentation at Naples Hospital. Prepared by Cerner, 2013. © 2017 Welch Allyn
MC14605
HEALTH NEWS
each participant and calculated an average daily activity score.
less. The report from a panel of nutrition,
The findings showed that higher levels of daily movement were
agriculture and environmental experts
linked to better thinking and memory skills, as measured by the
recommends a plant-based diet, and en-
yearly cognitive tests. And when researchers analyzed brain tis-
courages whole grains, beans, fruits and
sue under a microscope, this finding turned out to be the case
most vegetables. Added sugars should
even for individuals with at least three signs of Alzheimer’s dis-
be limited, as should refined grains, such
ease, such as amyloid plaques and neurofibrillary tangles. Even
as white rice, and starches, like potatoes
though these individuals might have been diagnosed with Al-
and cassava. It says red meat consump-
zheimer’s, 30 percent of them had “normal” cognition at death.
tion on average needs to be slashed by
What to do about vaping? Health authorities agree: Teen vaping is an epidemic that affects
half globally, though reductions would need to be more dramatic in richer countries like the United States.
some 3.6 million underage users of Juul and other e-cigarettes, reto help teenagers who may be addicted to nicotine. E-cigarettes
Older adults: Mind your protein
heat a liquid solution that usually contains nicotine into an inhal-
Older adults need to eat more protein-
able vapor. Federal law prohibits sales to those under 18, though
rich foods when losing weight, dealing
many high schoolers report getting them from older students or
with a chronic or acute illness, or facing
online. In recent months, government officials have rolled out
a hospitalization, according to a grow-
a series of proposals aimed at keeping the products away from
ing consensus among scientists, reports
youngsters, including tightening sales in convenience stores and
Kaiser Health News. During these stress-
online. In November, vaping giant Juul voluntarily shut down its
ful periods, aging bodies process pro-
Facebook and Instagram accounts and pulled several flavors out
tein less efficiently and need more of it
of retail stores. But there’s been little discussion of how to treat
to maintain muscle mass and strength,
nicotine addiction in children as young as 11 years old. Physicians
bone health and other essential physi-
who treat young people now face a series of dilemmas: The anti-
ological functions. Even healthy seniors
smoking therapies on the market – such as nicotine patches and
need more protein than when they were
gums – are not approved for children, due to lack of testing or in-
younger to help preserve muscle mass,
effective results. And young people view the habit as far less risky
experts suggest. Yet up to one-third
than smoking, which poses another hurdle to quitting.
of older adults don’t eat an adequate
ports the New York Times. But no one seems to know the best way
Unhappy meal
24
amount due to reduced appetite, dental issues, impaired taste, swallowing
A hamburger a week, but no more – that’s about as much red
problems and limited financial resources.
meat people should eat to do what’s best for their health and
Combined with a tendency to become
the planet, according to a report by EAT, a Stockholm-based
more sedentary, this puts them at risk
nonprofit, and published in the medical journal Lancet, reports
of deteriorating muscles, compromised
the New York Times. Eggs should be limited to fewer than about
mobility, slower recovery from bouts of
four a week, and dairy foods should be about a serving a day, or
illness and the loss of independence. March 2019 | The Journal of Healthcare Contracting
TRENDS
Small Guys Finish Last Small practices lag behind big ones under MIPS
26
Small and rural medical practices didn’t fare nearly as
Nearly one in every five small practices
well as their bigger, non-rural counterparts in the first year (2017)
(19 percent) in MIPS received negative pay-
of the Quality Payment Program of the Centers for Medicare and
ment adjustments compared to 5 percent
Medicaid Services, researchers reported in Health Affairs.
of program participants overall. This could
Many large practices qualified as exceptional performers
have occurred for a number of reasons, in-
(mean and median CPS – composite performance score – of
cluding limited ability to shoulder program
74.37 and 90.29, respectively), while most small practices did
reporting burden or a combined effect of
not (mean and median CPS of 43.46 and 37.67, respectively). On
inadequate risk adjustment in MIPS and
average, rural practices performed worse than large practices
high clinical or social complexity at smaller
(median CPS of 75.29 versus 90.29, respectively).
practices, according to the researchers. March 2019 | The Journal of Healthcare Contracting
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TRENDS
Small practices
19%
Rural practices
6% 1%
National
5% 2%
0%
8%
30%
44%
28%
65%
22%
10%
20%
71%
30%
40%
50%
60%
70%
80%
90%
100%
Negative (0 pts) Neutral (3 pts) Positive only (>3.01-69.99 pts) Positive with additiontial adjustment for exceptional performance (>=70-100 pts) Source: Health Affairs Further research should examine why smaller practices ap-
• Improvement activities (15
pear to be at a systematic disadvantage, and policymakers
percent of final score), a category
should consider measures to avoid unfairly penalizing these
that gauges participation in activi-
practices in MIPS, they concluded.
ties that improve clinical practice,
Implemented through the Medicare Access and CHIP Reau-
such as expanding practice access,
thorization Act of 2015 (MACRA), QPP is a value-based payment
improving care coordination and
program with two participation options: the MIPS track and the
promoting patient safety.
Alternative Payment Model (APM) track. •C ost (10 percent of final score). This For MIPS, physicians earn a payment adjustment based on evi-
category – new in 2018 – measures
dence that they provided high-quality, efficient care supported
resources that clinicians use to care for
by technology. To do so, they must submit information in the
patients, and the Medicare payments
following categories: • Quality (50 percent of final score), which measures health
for care (items and services) given to a beneficiary during an episode of care.
care processes, outcomes, and patient care experiences. Note because the “cost” category was • Promoting interoperability requirements (25 percent of final score), which promotes patient engagement
new in 2018, it was not considered in the 2017 performance data.
and electronic exchange of information using certified electronic health record technology. 28
Source: Health Affairs, Jan. 18, 2019 March 2019 | The Journal of Healthcare Contracting
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