Industry Outlook | Winter 2015 Edition by Premier, Inc.

LETTER 01

EXECUTIVE LETTER

The care conductor Mike Alkire, chief operating officer, Premier, Inc.

FEATURES | EMBRACING CHANGE

04 THE EVOLUTION OF PRIMARY CARE

PERSPECTIVES 26 Embracing change: Delivery models, admission types, payment partnerships and more

10 RISING LABOR COSTS AND THE WORKFORCE SHORTAGE

16 PHYSICIAN SHORTAGES AND THE INCENTIVES INTENDED TO STOP THEM

19 EXAMINING PRIMARY AND PATIENT-CENTERED CARE

TRENDS 34 ICD-10 integration in the ambulatory care setting 36 Managing supply costs in the physician office 38 When enough really is enough: Antibiotic overuse 42 Success Story: DebMed

34 36

OUTLOOK LEADERSHIP

MANAGING DIRECTOR Kayla Sutton

EDITORIAL STAFF

E XECUTIVE SPONSORS Mike Alkire, chief operating officer Durral Gilbert, president, supply chain services Amy Denny, vice president, strategy, supply chain services A special thanks to Lauren Hannan, Tina Harlan, Bill Lammers, Steve Robinson, Brent Wiseman and Laura Yandell for their contributions to this edition of the Industry Outlook.

DESIGN AND PRODUCTION Chris Cardelli, director, creative services Sung Ginader, project manager, creative services Dave Dixon, senior graphics designer, creative services EDITORIAL SUPPORT Amanda Forster, vice president, public relations Morgan Bridges-Guthrie, manager, public relations Bryan Alsop, senior manager, corporate communications

About the cover The U.S. healthcare system is a complex environment for many patients to navigate alone. Primary care physicians have often served a major role in managing the patient experience by coordinating a patient’s care across disparate practitioners. Further, in these times of change, improving care coordination among disparate providers and stakeholders is considered by many an essential part of the ongoing goal to increase the quality and decrease the cost of healthcare. The cover of this edition emphasizes the many moving parts of care coordination that are necessary to create a seamless care experience.

About the publication This edition marks the second annual

als and how gaps can be filled, as well as

Industry Outlook, part of Premier’s Outlook

implementation of programs that enhance

series. Unlike the other publications in

the patient-centeredness of healthcare.

the series, the Industry Outlook highlights one specific macro-level trend impacting

A key aspect of the long-term strategy for

healthcare and examines that trend across

the Outlook series is collaboration among

the supply chain.

internal and external subject matter experts to build consensus across diverse

This second edition, which illustrates the

points of view. The publication harnesses

reinvigorated focus on primary care as a

the expertise of our network of health-

means to coordinate care and drive popu-

care leaders to illuminate best practices

lation health efforts, offers strategic insight

and strategies that can drive performance

on how the trend is shaping stakeholders’

improvement. Our goal is providing our

decisions across the industry. Through

members and other healthcare organiza-

subject matter expertise and interviews

tions with valuable, timely information

with key healthcare executives, this edition

and business intelligence derived from the

demonstrates how various factors impact

industry’s most progressive participants.

the availability of primary care profession-

We welcome your comments and questions. For additional information, please email economicoutlook@premierinc.com. premierinc.com/economicoutlook

EX E C U TI V E LE TTER

The conductor of care

Like a conductor, part of the PCP’s role is ensuring their patients receive the right care at the right time and in the right setting. This includes preventative or well care that can keep a patient from using the healthcare system at all. Saint Vincent Health System’s (Erie, PA) employed physician group embarked on the PCMH journey in 2006, in an effort to better care for patients. According to Dr. Sam Reynolds, chief

MEMBERS OF THE PREMIER ALLIANCE, A beautiful, harmonic symphony requires talented musicians, but its conductor ensures that each piece is playing at the appropriate time. A gifted conductor, an important role that all famous orchestras share, seamlessly leads musicians to perform with coordination, skill and vision.

medical officer for the group, “There were elements in the PCMH model that focused on the needs of the patient, as well as the concerns of the provider and payer. It’s really a marriage of the fundamental principles of primary care.” Among other PCMH care management initiatives, Saint Vincent’s physician group has a health coach in each practice to help patients better understand their disease, and reach out to those overdue for care or with chronic diseases that need ongoing management.

Acting as guides for musicians, conductors cue when to play, set the tempo and help to unify the performance. They shape the way an audience experiences the music. In healthcare, the primary care physician (PCP) serves as a conductor, helping to coordinate a patient’s care experience. New care delivery models, such as accountable care organizations (ACOs), bundled payment and patient-centered medical homes, incent providers to become more accountable for the costs, quality and outcomes of care. Greater care coordination is a natural byproduct of these efforts, and a key to ongoing success. Creating harmonious transitions of care can help increase the likelihood of shared savings payments among providers participating in the various new care delivery models. But to do it successfully, all the complex pieces and parts need to be pulled together by an expert who can help patients navigate to get the care they need. OUTLOOK

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EX E C U TI V E LE TTER

The conductor of care

“It’s not possible for one physician to manage all of the needs

Like all markets, shortages drive higher wages, forcing health

of a patient, so team-based care models are really intrinsic to

systems to spend more on employing medical professionals

the next wave of population health management. They allow for

in competitive markets. Add to that the increase in demand as

increased attention to the patient, more contact, and greater

many health systems adopt ACO or patient-centered models of

coordination,” Reynolds said.

care, and Houston, we have a problem.

The PCMH model can decrease the administrative burden for

Health systems and non-acute facilities across the country

physicians, as Saint Vincent’s employed physician groups have

are feeling the pinch of decreasing reimbursement, required

seen, but the benefits of the model don’t stop there. Successes

investments in health information technology, and the cost

include “higher patient satisfaction scores, great tools for patients

of building an infrastructure to better control or reduce costs

to improve self care, low staff turnover and great outcomes.”

while providing excellent quality care. These unprecedented labor costs again cut into the bottom line.

Results from the first year of CMS’ Medicare Shared Savings Program (MSSP) suggest that outcomes improvements from

The ACA aimed to bolster the primary care workforce through

new care delivery models are widespread. MSSP participants

a variety of incentives like scholarships and Medicare pay

demonstrated improvement in 30 of 33 quality measures,

increases, but doesn’t reach the mark to addressing the short-

and higher average performance rates on 17 of 22 measures

term need. Greater efficiencies within the workforce, and the

compared to other Medicare fee-for-service providers.

use of physician extenders like physicians’ assistants and nurse

practitioners will have to fill the gap. New care delivery models center around the PCP, so having enough practitioners to fill and support these roles is important.

Care coordination is essential to reducing costs and improving

However, more than two-thirds of C-suite respondents to

outcomes, as well as helping patients access and navigate the

our semiannual Economic Outlook survey are currently

healthcare system in an appropriate manner.

experiencing a shortage of primary care doctors. Along with demand for PCPs to helm new care delivery models, the aging

An orchestra can’t perform to its best ability without a

population and millions of newly insured consumers across the

conductor to coordinate the different groups of musicians and

country means this demand is surging. Dr. Ted Epperly, former

make sure the whole team is utilized to their best abilities, and

board chair and president of the American Academy of Family

the same is true of our healthcare conductors.

Physicians (AAFP) and current president and chief executive officer of The Family Medicine Residency of Idaho is concerned. “This inequity in the increased number of people covered

– MIKE ALKIRE Chief operating officer

/ Premier, Inc.

without growth in the PCP workforce will, in the short run, lead to frustration for patients trying to find a PCP, and possibly, a return to overuse of emergency departments,” said Epperly. REFERENCES 1. Centers for Medicaid and Medicare Services, “Medicare ACOs continue to succeed in improving care, lowering cost growth,” fact sheet, November 10, 2014, http://www.cms.gov/ Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-11-10.html.

Features

The evolution of primary care, 4 Rising labor costs and the workforce shortage, 10 Physician shortages and the incentives intended to stop them, 16 Examining primary and patient-centered care, 19

FEATURES

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Kayla Sutton, MPH Managing director, Outlook, and senior manager, supply chain strategy / Premier, Inc.

Ms. Sutton is a healthcare supply chain strategist who researches, writes and speaks about trends in the healthcare system. As the managing director of the Outlook, Sutton leads strategy and execution of Premier’s quarterly thought leadership publications: Industry Outlook, Quality Outlook and its semiannual flagship publication, Economic Outlook. She also holds responsibilities within the supply chain strategy team. Previously, Ms. Sutton served as research manager for the Center for Healthcare

reating a foundation for population health management is integral in today’s environment, where managing health outside of the healthcare system is becoming as important to cost and outcomes as managing health within it.

“Primary care is the foundation for population health management,” says Sam

Reynolds, MD, medical director of population health at Saint Vincent Healthcare Partners, a hospital-owned ACO that is part of Saint Vincent Health System (Erie, PA). “Without a strong primary care base,” Dr. Reynolds continues, “it’s nearly impossible to integrate primary care and specialty physicians, track patient utilization across the system, and improve transitions within the health system or from the hospital to home, all of which are instrumental to good population health.” But simply put, primary care, for a variety of reasons – several of which we

Supply Chain Research, the non-profit arm

discuss in this edition – has struggled to keep up with a demand that is far

of the Healthcare Distribution Management

outpacing the country’s ability to incentivize and build this workforce.

Association, where she authored several

In fact, in 1961, half of all physicians in the U.S. were general practitioners.

benchmarking studies on the specialty

That number now sits at 39 percent.1 Evidence shows that access to a

pharmaceutical industry, track and trace,

primary care physician drives preventative care, a key component in

and other supply chain issues. Prior to her work in supply chain research, Sutton coordinated clinical research programs in cancer, stroke and communicable disease care at Georgetown University Medical Center and Wake Forest University School of Medicine.

reducing overuse of emergency departments and associated costs.2 Still, a reported 75 percent of Americans have difficulty getting an appointment with a primary care physician. 3 Clearly the demand for physicians is significant, but a quick fix to match supply has not materialized, even though enrollment in primary care residency programs is up, and incentives such as the Health Resources and Services Administration loans for primary care medical education are growing.

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Although it will take time to bolster

have an improved ability to keep

initiatives are actually focusing more

the workforce, team-based care models,

patients within their systems and

on home health and telemedicine,

which are becoming more popular in the

monitor the care they receive.

which increase access to appropriate

drive to reduce costs while improving

caregivers when needed. According to

New models create new opportunities

C-suite respondents to the semiannual

and strengthen care coordination with population health initiatives.

Though they play an instrumental role

two area of resource dedication for

in new care delivery models, primary

population health includes home

Not just house calls

care physicians aren’t the whole story.

health (17 percent) and telemedicine

Physicians began as community-

According to the Institute of Medicine,

or virtual care (11 percent).

based providers who made house calls.

primary care physicians who care for

Especially in small communities,

Medicare recipients are linked to an

which use the primary care physician as

the local physician was the only

average 229 other physicians each

a care coordination hub, enhance access

healthcare option. As medical care

year in the care of their patients.5

and strengthen relationships among

outcomes, can limit physician burdens

developed, the concept of this isolated

Since care coordination is an essential

Economic Outlook survey, a top-

Patient-centered medical homes,

patients and personal care teams.7

clinician model became outdated.4

part of the primary care role, Medicare

Research by The Commonwealth

Not only was the demand for care too

now gives a 10 percent bonus to primary

Fund and the Lewin Group suggests

great for single clinicians to manage,

care physicians who accept Medicare

that national adoption of the patient-

the burgeoning wealth of medical

patients. New care delivery models,

centered medical home model could

information made it impossible for a

such as accountable care organizations

result in a $175 billion reduction in

sole practitioner to know everything

and patient-centered medical homes,

healthcare spending by 2020.8

necessary to provide optimal care.

also represent promising opportunities,

As more care moved to hospitals and other healthcare facilities, access

The combination of population health

because they emphasize patient care and

management practices and a renewed

connectivity among diverse caregivers.

emphasis on primary care requires investments in additional human and

to various specialty physicians grew.

Accountable care organizations

Tracking patient care became more

use scale to ensure that patients have

technological resources, as well as

difficult, especially given the lack

local access to all the physicians and

related infrastructure improvements.

of technology to connect disparate

clinicians they need to see. And while

Even so, early pilots and programs have

physicians. That challenge continues

patient care has moved away from

demonstrated the benefits of augmented

in our healthcare system today as

last century’s house calls, emerging

care coordination efforts that drive

the aging U.S. population swells and

population health management

higher quality and better outcomes.

more people who previously could not afford healthcare take advantage of the expansion of public and private insurance marketplaces. While perhaps not as rapidly as desired, change is underway. With the adoption of EHR systems, implementation of advanced data analytics, and the growth of accountable care models, healthcare providers

REFERENCES 1. American Academy of Family Physicians, Family Physician Workforce Reform: Recommendations of the AAFP, 2014, http://www.aafp.org/about/policies/all/workforce-reform.html. 2. Karen Davis, Melinda Adams, and Kristof Stremikis, “How the Affordable Care Act Will Strengthen the Nation’s Primary Care Foundation,” J Gen Intern Med 26, no. 10 (Oct 2011): 1201–1203, doi:10.1007/s11606-011-1720-y, http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3181291/ (published online Apr 27, 2011). 3. Ibid. 4. Pamela Mitchell, Matthew Wynia, Robyn Golden, Bob McNellis, Sally Okun, C. Edwin Webb, Valerie Rohrbach, and Isabelle Von Kohorn, “Core Principles & Values of Effective Team-Based Health Care,” Discussion Paper, Institute of Medicine, Washington, DC, October 2012, www.iom.edu/Global/Perspectives/2012/TeamBasedCare.aspx. 5. Ibid. 6. “How the Affordable Care Act Will Strengthen the Nation’s Primary Care Foundation,” http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3181291/. 7. Ibid. 8. Ibid.

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The ACA includes a number of important provisions that strengthen and incentivize primary care services as part of the effort to reduce healthcare costs and improve quality. These include the following:

PHS Act Sec. 2719A

Sec. 1302

Patient protections (as modified by Sec. 10101), which requires a

Essential health benefits requirements (as modified by Sec. 10104),

choice of healthcare professionals, coverage of emergency services, and

which requires a catastrophic plan.

access to pediatric, obstetrical, and gynecological care. Sec. 1202 of HCERA Sec. 1301

Payments to primary care physicians, which requires states to pay

Defines a qualified health plan (QHP) as one that has in effect a

physicians for primary care services furnished in 2013 and 2014 at a rate

certification (which may include a seal or other indication of approval)

that is no less than 100 percent of the Medicare payment rate (limited

meeting the Act’s certification criteria issued or recognized by each

to physicians with a primary specialty designation of family, general

exchange through which such plan is offered. It must also provide the

internal, or pediatric medicine).

essential health benefits package described below, as well as care from a health insurance issuer that: • Is licensed and in good standing in each state in which the issuer offers coverage; • Agrees to offer at least one QHP in the silver level and at least one plan in the gold level in each exchange; and • Agrees to charge the same premium rate for each QHP without regard

Sec. 3022 Medicare shared savings program (as modified by Sec. 10307), which permits providers meeting certain criteria to be recognized as accountable care organizations (ACOs), beginning January 1, 2012, and to qualify for a new shared savings program (provided they meet certain quality thresholds). It also expands the ACO definition to include

to whether the plan is offered through an exchange, directly from the

specified groups of providers and suppliers that have an established

issuer, or through an agent.

mechanism for shared governance, including partnerships or joint venture arrangements among hospitals, ACO professionals, and hospitals employing ACO professionals.

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Sec. 3024

Sec. 5101

Independence at home demonstration program, which authorizes a

National Health Care Workforce Commission (as modified by Sec.

Medicare demonstration program to test the provision of physician

10501), which gives initial priority to areas such as:

and nurse practitioner-directed home-based primary care to certain

• Workforce planning that maximizes the skill sets of health

beneficiaries and coordinate healthcare across all treatment settings, beginning no later than January 1, 2012. Eligible beneficiaries are those having two or more chronic illnesses, a nonelective hospital admission within the past 12 months, previous acute or subacute rehabilitation services, and two or more functional dependencies. Participating

professionals across disciplines; • Workforce demands for the enhanced information technology workplace; • Alignment of Medicare and Medicaid graduate medical education policies with national workforce goals;

practices must furnish services to at least 200 Medicare beneficiaries

• Elimination of barriers to entering and staying in primary care;

and must use electronic health information systems, remote monitoring,

• Education and training capacity to meet projected demands for

and mobile diagnostic technology. They may also have savings in

professionals in nursing; oral, allied, and public health; and

excess of 5 percent.

emergency medicine; and • The geographic distribution of providers compared to state and

Sec. 3208

regional needs.

Making senior housing facility demonstration permanent, which permits Medicare Advantage plans that meet specific criteria to limit their service areas to a senior housing facility within a geographic area. Sec. 3502

Sec. 5201 Federally supported student loan funds. Sec. 5208

Establishing community health teams to support the patient-centered

Nurse-managed health clinics, which establishes a new mandatory

medical home (as modified by Section 10321), which mandates a

grant program to pay for the cost of operation of nurse-managed health

new grant or contract program to establish health teams that support

clinics (NMHCs).

primary care practices, including obstetrics and gynecology, to help them coordinate and manage care, including coordination of the

Sec. 5301

appropriate use of complementary and alternative services to those who

Training in family medicine, general internal medicine, general

request them and 24-hour care management/support during transitions

pediatrics, and physician assistantship, which authorizes:

in care settings.

• Five-year grants or contracts with capable entities to plan, develop, and operate training programs in primary care; • Financial assistance to trainees and faculty; • Enhanced faculty development in primary care and physician assistant programs; and • Development and operation of a demonstration program that may include training relevant to patient-centered medical homes.

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Sec. 5303

Sec. 5503

Training in general, pediatric, and public health dentistry, which

Distribution of additional residency positions, which reduces the

authorizes five-year awards (grants or contracts) to capable entities

authorized residency level if a hospitalâ&#x20AC;&#x2122;s actual residency level for any

to develop and support dental training programs, including pediatric

of the three most recent reporting periods is less than its authorized

programs.

level. (Authorizes an increase in a hospitalâ&#x20AC;&#x2122;s residency level, but the total of increases granted may not exceed the total decreases in

Sec. 5316

residencies.) A qualifying hospital must ensure that the number of

Demonstration grants for family nurse practitioner training

primary care residencies during the five-year period beginning on the

programs (added by Sec. 10501), which requires establishment of a

date of the increase is not less than the average over the preceding

demonstration program for family nurse practitioners to employ and

three years and that at least 75 percent of the new residency slots are

provide one-year training of nurse practitioners who have graduated

in primary care or general surgery.

from a nurse practitioner program for careers as primary care providers in federally qualified health centers and nurse-managed health clinics.

Sec. 5508 Increasing teaching capacity, which authorizes award grants to teaching

Sec. 5405

health centers to support new or expanded primary care residency

Primary care extension program, which mandates the establishment

programs. Eligible health centers are community-based ambulatory

of a primary care extension program to educate and provide technical

patient care centers that operate a primary care residency program.

assistance to primary care providers about preventive medicine, health promotion, chronic disease management, mental and behavioral health, and evidence-based and evidence-informed therapies and techniques.

Sec. 5604 Co-locating primary and specialty care in community-based mental health settings, which mandates award grants and cooperative

Sec. 5501

agreements to eligible entities to establish demonstration projects for

Expanding access to primary care and general surgery services (as

providing coordinated and integrated services to special populations

modified by Sec. 10501), which mandates a 10 percent Medicare bonus

through the co-location of primary and specialty care in community-

payment for primary care services (office and other outpatient visits,

based mental and behavioral health settings.

nursing facility visits, domiciliary and rest home visits, and home visits) furnished by primary care physicians (family, internal, geriatric, or pediatric medicine), nurse practitioners, clinical nurse specialists, and physician assistants, if at least 60 percent of their Medicareallowed charges in a prior period were for primary care services.

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abor is now the top driver

In short supply

(21 percent). Roughly the same number

of healthcare costs,

Another major factor impacting

reported a shortage of nurses.

overtaking the ACA and

labor costs is the ongoing shortage of

other legislation, according

Shortages also varied by size of

medical professionals. While many

facility, and less significantly, by

to C-suite health system executives who

health systems have experienced

geographic region. While the lack of

responded to our fall 2014 Economic

a shortage of nurses, primary care

primary care physicians was relatively

Outlook survey. As healthcare systems

doctors, and specialty physicians

equal across large, midsized, and small

face mounting financial pressures

for several years, new care delivery

facilities – between 71 and 77 percent –

and the need to reduce costs while

models have increased the demand for

smaller sites reported a more significant

maintaining quality continues, labor

other medical professionals as well.

shortage than larger ones (see Figure 2).

Approximately two-thirds (68

Regionally, the Northeast/Mid-Atlantic

expense is a growing concern.

percent) of C-suite respondents said

showed higher levels of primary care

because of the desire to align physicians

their systems have a shortage of

shortages than the rest of the country.

with ACA mandates. As hospitals

primary care physicians, a role that

create or join ACOs, begin population

is very important to ACOs, patient-

shortages drive costs up. When health

health management partnerships or

centered medical homes, and many

systems hire physicians or nurses in a

initiatives, and more closely tie quality

population health initiatives. While

tight market, salaries and compensation

to cost, the alignment of physicians

primary care has the largest shortage,

packages are higher than they might be

with organizational goals is crucial.

other areas are also affected: 44 percent

otherwise. As Mike Alkire, Premier’s

Labor costs have risen in part

Just as they do in other sectors, these

of respondents reported a shortage of

chief operating officer, recently told

contracted to provide care at certain

specialty physicians and 18 percent had

Fortune magazine, “There’s pressure

hospitals and health systems, leaving

a shortage of nurses (see Figure 1).

on a market that has a small supply, and

Historically, physicians have been

hospital officials with no way to ensure

More than half of those responding

that patients receive care at specific

(58 percent) had at least one shortage.

facilities. Now that it’s vital to track

Urban facilities were more likely

it’s having financial implications.”1 According to the Association of American Medical Colleges, there

treatment and see that patients receive

to have a shortage of primary care

will be a shortage of approximately

the right care in the right place at

physicians than rural areas (70 percent

91,000 physicians by 2020.2 Dr.

the right time, many hospitals are

compared to 43 percent). However,

Ted Epperly, president and CEO of

employing more, and sometimes all,

rural respondents were more than

The Family Medicine Residency of

of their own physicians. And they’re

twice as likely (50 percent) to have

Idaho, who is featured elsewhere in

using physician pay as a way to align

a shortage of specialty physicians

this issue, estimates that nearly 50

actions with health system priorities.

compared to their urban counterparts

percent of all graduating medical

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Fig.1

Shortage of medical professionals (C-suite only) 70%

60%

50%

40%

30%

20%

10%

0% Primary care physicians

Specialty physicians

Nurses Source: Premier online survey for Economic Outlook fall 2014 publication

students need to move into primary

well change in the future, and in the

care if we are to support the

meantime, certain ACA initiatives

Administration reports that there

infrastructure and coordination

are helping to incentivize medical

will be a 30 percent and 58 percent

necessary for population health.

students to go into primary care by

increase in nurse practitioners and

Primary care physicians, as Dr.

While the Health Resources Services

offering scholarships and some student

physician assistants, respectively,

Epperly notes, are the quarterbacks

debt forgiveness. As a result, family

by 2020,4 the nursing shortage in

of healthcare, since in a coordinated

medicine residency rates were up 39

general offers an opportunity for

care model, they manage how a

percent in 2013, compared to 2012.

creative problem solving. As Alkire

patient interacts with the system

As the demand for primary care

said in his recent Fortune interview,

overall. As more health systems

physicians grows, many industry

“Organizations need to figure out how

move to these types of care delivery

experts are encouraging a more

other clinicians step up to fill the gaps

models, demand will increase even

appropriate skill mix within primary

so doctors can be more efficient.”5

though the supply cannot keep up.

care through the use of other medical

By 2025, some predict the nursing

“extenders,” such as nurse practitioners

shortage will reach 260,000, a number

care because of higher pay. At the

and physician assistants. These

twice as large as any U.S. nursing

same time, primary care physicians

medical professionals can take on

shortage since the 1960s.6 Incentives

are being asked to assume additional

some of the traditional primary

similar to those offered to primary

care coordination duties even though

care duties and free physicians to

care physicians may be necessary to

they are not currently reimbursed by

manage more complex issues.

expand the nurse workforce to the

Many residents favor specialty

payers for those services. That may

size needed in the next decade.

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Fig.2

Shortages of medical professionals by facility size

80%

Primary care physicians Specialty physicians

70%

Nurses 60% 50% 40% 30% 20% 10% 0% Large

Midsized

Small

Non-acute

Source: Premier online survey for Economic Outlook fall 2014 publication

Finding the right fit

Eliminating these shortages will

These shortages of medical

take time and require targeted

professionals make it all the more

incentives, as well as infrastructure

important for hospitals to use available

changes that allow physicians,

information to drive better resource

nurses, and extenders to perform the

use. In the spring 2014 Economic

roles for which they are trained.

Outlook, Premier identified an average waste-reduction savings opportunity of $1.8 million in skill mix alone. This means that through the effective use of data, health systems can determine where they have less-than-optimal staffing levels and skill sets. That knowledge can help management reorganize functional areas to drive savings and keep physicians focused on critical patient care.

REFERENCES 1. Laura Lorenzetti, “It’s not Obamacare that really has hospital execs worried,” Fortune, November 14, 2014, http://fortune.com/2014/11/14/its-not-obamacare-that-really-has-hospital-execs-worried/. 2. Ibid. 3. Modern Medicine, “Interest in primary care up, but shortage still looms,” May 10, 2013, Medical Economics Weekly, http://medicaleconomics.modernmedicine.com/medical-economics/content/modernmedicine/ modern-medicine-feature-articles/interest-primary-care-shor?page=full. 4. Ibid. 5. Ibid. 6. American Association of Colleges of Nurses, “Nursing Shortage,” fact sheet, April 24, 2014, http://www.aacn.nche.edu/ media-relations/fact-sheets/nursing-shortage.

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from the blog:

ACTION FOR BETTER HEALTHCARE

Physician extenders = key to profitability Bill Lammers national director, labor management / Premier, Inc.

s enrollment in

Now, providers will receive a lump

To me, physician extenders

Obamacare continues,

sum to manage a patient population,

physicians throughout

and this lump sum is much less than

the country are

what they’ve been paid in the past

term, “physician extenders” include

to see and treat the same patients.

physician assistants (PAs) and nurse

preparing to deal with an influx of

sound like the better option. In case you aren’t familiar with this

newly insured patients, as well as

So how do you remain profitable?

practitioners (NPs) who function

the increased financial demands

Profitable physician practices

under the supervision of a physician,

this will place on their practices.

will have two options to succeed

and may diagnose, order tests, develop

with this new model:

treatment plans and write prescriptions.

However, two key factors stand in the way.

1. Physician shortage The American Association of Medical

1. See more patients in the same

Physician extenders often offer

amount of time and try not

financial profitability for the practice as

to sacrifice quality, or

well as efficiency, improved quality of

2. Employ physician extenders

Colleges (AAMC) estimates that the

who can help see more patients

U.S. will face a physician shortage of

at a lower cost than MDs while

over 90,000 physicians by 2020 – a

maintaining quality care.

care, enhanced flexibility for physicians and greater patient satisfaction.

figure that’s expected to reach over 130,000 by 2025.1 This shortage is

Projected supply and demand, physicians, 2008-2020

propelling physician extenders into

(all specialties)

an increasingly important role in primary care as more healthcare

900,000

providers employ them to fill the gap.

2. Reimbursement

800,000

Until now, third-party reimbursement has allowed physician practices to

DEMAND

profit by using doctors as primary 700,000

caregivers. Because of the current fee-

the office visit, each procedure done and the supplies used. And insurance pays for some (or all) of these charges.

SUPPLY

2020

agreement, each patient is charged for

2015

for-service and fee-for-procedure payer 2010

Source: Association of American Medical Colleges

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Reduced salary expenses The base physician salary is more than double that of physician extenders. If you can hire a PA, you’ll get similar expertise for a fraction of the cost. This is one of the biggest benefits for physician practices. Just think... you can get another

Physician extenders often offer financial profitability for the practice as well as efficiency, improved quality of care, enhanced flexibility for physicians and greater patient satisfaction.

person to help you practice and do almost the same things, and not have to pay what you would for a physician. Higher patient volumes Physician extenders help alleviate some of the routine work for physicians to help maximize office hours and treat more patients. A study published in Health Affairs found that patients are still likely to see a doctor, but if they know they have to wait for the doctor, they’re happy to see a PA or NP instead. And with the influx of patients, 2

extra hours in the week to research, concentrate on difficult cases or take much-needed time away from the office. Physician extenders can lighten your workload considerably, giving you more time to do what you need to do. Greater patient satisfaction As we continue to shift toward a patientcentric model of care, satisfaction ratings are becoming increasingly

everyone’s expertise and help is needed.

important. Popular consumer-facing

Improved quality of care

let patients rate their experience,

By hiring a physician extender, you can expand your medical staff, ensuring patients receive medical care faster, get all their questions answered and are better satisfied with their healthcare team as a whole. Because of the volume of patients, physicians often can’t provide the level and depth of patient care that is necessary. Physician extenders improve the quality of care

websites like Healthgrades and Vitals which can affect a practice’s retention rate and ability to add new patients. Studies have consistently shown that PAs provide high-quality care with outcomes similar to physician-provided care. 3 Research also shows that patients are just as satisfied with medical care

Putting it all together State and regional practice guidelines will soon be established to put best practice standards in place. Currently, physician practices are averaging around 1:2 MDs to PAs. Going forward, these same practices will need to look at moving to around 1:6 or even 1:8 MDs to PAs to remain profitable. While these guidelines are still being established, it’s become more important to have the proper tools in place to run a profitable physician practice. With proper business intelligence tools, you’ll gain competitive peer information that can be used to establish practice-level targets, organizational charts and skill mix assessment. And the use of internal productivity tools can ensure operations are managed within budget.

provided by PAs as with that provided by doctors and do not distinguish between types of care providers.

provided to patients because of the extra time they can spend with them. More flexibility What can be better than having an extra pair of medically trained eyes and hands assisting you? Imagine having

REFERENCES 1. Association of American Medical Colleges, “GME funding: How to fix the doctor shortage,” www.aamc.org/advocacy/campaigns_ and_coalitions/fixdocshortage/. 2. Michael J. Dill, Stacie Pankow, Clese Erikson and Scott Shipman, “Survey shows consumers open to a greater role for physician assistants and nurse practitioners,” Health Affairs, June 2013, http://content.healthaffairs.org/content/32/6/1135.abstract. 3. American Nurses Association, “Advanced practice nursing: A new age in health care,” 2011, http://www.nursingworld.org/ FunctionalMenuCategories/MediaResources/MediaBackgrounders/APRN-A-New-Age-in-Health-Care.pdf.

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FACE TIME WITH

Ted Epperly I

President and CEO, The Family Medicine Residency of Idaho

Physician shortages and the incentives intended to stop them Ted Epperly, MD, FAAFP, is the president and CEO of The Family Medicine Residency of Idaho and the former board chair and president of the American Academy of Family Physicians (AAFP).

Two-thirds of Premierâ&#x20AC;&#x2122;s member health systems are experiencing a shortage of primary care physicians (PCPs). How, if at all, has the growth of ACA initiatives been impacted by this shortage? The shortage of PCPs is a major issue. For the healthcare system to work best, it needs a robust, vibrant, and healthy primary care component. As more people gain coverage through the exchanges and Medicaid expansion (both ACA initiatives), they must have access to quality PCPs. This inequity in the increased number of people covered without growth in the PCP workforce will, in the short run, lead to frustration for patients trying to find a PCP, and possibly, a return to overuse of emergency departments.

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At the same time, these shortages will drive the expansion

This last point is why the payment methodology needs to

of PCP training, as well as an increase in physician assistant

change. Fee-for-service per individual patient is a different

(PA) and nurse practitioner (NP) programs. These will

model than capitated per member per month (PMPM)

produce more medical professionals who can join primary

payments used in population health. Both need to occur in

care physicians in the patient-centered medical home

what many term a “blended payment model,” accompanied

(PCMH) model.

by incentives for quality outcomes and some degree of shared

Other ACA initiatives, such as National Health Service Corps

savings with insurers to lower healthcare spending.

Scholarships intended to train and place more PCPs, will also help. The creation of additional community health centers, where many Medicaid patients see PCPs, will be important for the overall primary care infrastructure, as well.

Our rural members indicate they have a higher rate of physician shortages (PCP and specialty physicians) than members in non-rural areas. You’ve previously addressed the issue of education reform as a possible influencer for encouraging physicians to practice in underserved areas. Do you think reform of the medical education system is necessary to provide physicians with the skills required to manage population health in these areas?

Our members are engaging in partnerships and dedicating resources to population health in a variety of ways. What role do you think PCPs have in population health management? What should those in primary care be doing to transition to a well-care service model? Must the PCP mindset change regarding how care is provided? PCPs are the quarterbacks of the system. They are intrinsically involved in integrating patient care within the entire system. But now PCPs must develop registries to manage the health of their patient populations. The good thing is that FM providers and other PCPs are already geared to think about managing and coordinating

Health policy can help medical students identify family

patient health. Appropriate and robust technology must be

medicine (FM) or other primary care careers as a way to be

in place to create and support these registries. And payment

part of the solution for our current healthcare problems.

systems must exist that compensate physicians for providing

However, traditional payment systems discourage

this service. The system has to value PCPs for their skills.

physicians from pursuing primary care. Estimates show that approximately 50 percent of physicians need to enter primary care if we are to have a truly connected and coordinated healthcare system. Paying PCPs appropriately to manage the Institute of Healthcare Improvement’s Triple Aim is the biggest factor in encouraging this percentage of physicians to move into primary care. Further, medical education reform valuing comprehensive,

You authored a book called “Fractured” in 2012, in which you discuss the gaps and disparities in the U.S. healthcare system. How has the ACA addressed these? What additional policies or changes will be necessary in the future to further bridge the gap? The ACA did several major things to help close gaps and disparities in the U.S. healthcare system. It:

broad-scope FM education and training specifically around

• Provided options that allowed more people to be insured;

the PCMH will be important if we’re to leverage the value

• Improved a wildly out-of-control health insurance system;

of integrated teams of physicians, nurses, PAs, NPs, and

• Started to focus the nation on quality and preventative care;

others working together to provide quality medical care to

• Created mechanisms to control costs; and

individuals and communities. The future of healthcare will

• Began to address healthcare delivery and the inequities

require building integrated practices that enhance patient and

in the physician workforce, especially in the area of

population health.

primary care.

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If the system provides as many people as possible with coverage and a standard source of care, then healthcare disparities and gaps will start to disappear.

The next step is to continue to balance the system by building out the delivery side to provide quality primary care, so that everyone in the nation has the opportunity for adequate access. If the system provides as many people as possible with coverage and a standard source of care (FM/PC/PCMH), then healthcare disparities and gaps will start to disappear.

What groups do you expect will resist the switch to new delivery models (PCMHs, ACOs, teambased care, etc.)? What might be the drawbacks or challenges in implementing these models? The ACA has not done enough to implement new care

Since the implementation of the ACA, millions of Americans who were previously uninsured now have coverage. This was one of the major goals of the ACA, but there are concerns about whether or not the newly insured have enough information to use their coverage to its full potential. How can we educate the public about how to navigate this changing healthcare landscape? What can we do to prevent patients from making the same choices they have historically made? Who is responsible for making this happen? For all of this to work cohesively, we need incentives for –

delivery models such as PCMH and Accountable Care

and innovation from – all healthcare stakeholders. We also

Organizations (ACOs). There have been efforts around value-

need engaged, educated, and informed patients who have skin

based purchasing and shared savings programs, but much

in the game. There should be ongoing education for the public

more needs to be done to incentivize individual practices and

that explains how best to use the system, focuses on wellness

healthcare systems to make these transitions. When CMS

and prevention, and encourages engagement in shared

decides how it will pay for Medicare and Medicaid services,

decision making about the right care at the right time and in

private insurers will likely follow its lead.

the right location.

Sub-specialist physicians and some hospitals have been

Today, technology allows patients to interact virtually with

profitable in the fee-for-service environment, and they are

their physicians and medical staff. This can help keep patients

likely to maintain these models until additional incentives

healthy and engaged. Maximum functionality and ease of

are offered. Insurance companies actually stand to gain

use will be integral to managing population health. Federal

significantly from new care delivery and payment models, so

and state governments, along with insurance companies,

I am surprised not to see more progressive action from them.

employers, physician practices, and dedicated patient

I think they are being cautious in rapidly changing times. It’s not

education software companies can play a big part of making

easy to change people or systems, but that is exactly what needs

many of these things happen.

to happen if we want to provide better care for our patients.

In short, if we want to change the healthcare system, we must change its delivery model, and just as importantly, the payment model that supports it. These two models must align and be synergistic to sustain the changes needed.

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Marci Nielsen, PhD, MPH Chief executive officer / Patient-Centered Primary Care Collaborative

Marci Nielsen, PhD, MPH, joined the PatientCentered Primary Care Collaborative (PCPCC) as chief executive officer in 2012. Previously, Dr. Nielsen served as Vice Chancellor for Public Affairs and Associate Professor at the University of Kansas School of Medicine’s Department of Health Policy and Management. She was appointed by then-Governor Kathleen Sebelius as first Board Chair and Executive Director of the Kansas Health Policy Authority (KHPA), including the State Children’s Health Insurance Program, the State Employee Health Plan, health information technology and health policy. She is director of the American Board of Family Medicine and the Center for Health Policy Development/National Academy for State Health Policy. She is also a former Board member of the Health Care Foundation of Greater Kansas City, TransforMED LLC, and the Mid-America Coalition on Health Care. She was a committee member for the Institute of Medicine’s Leading Health Indicators for Healthy People 2020 and Living Well with Chronic Illness: A Call for Public Health Action. Dr. Nielsen has an MPH from the George Washington University and a PhD from the Johns Hopkins School of Public Health.

EXAMINING PRIMARY AND PATIENT-CENTERED CARE

he United States spent roughly $2.9 trillion on healthcare in 20131 (nearly 18 percent of its gross domestic product2) while continuing to rank among the worst nations in terms of quality and outcomes. With those results, it’s no wonder the transformation

of primary care and the revival of the patient-centered medical home concept have emerged front and center in many public policy discussions. But how can healthcare leaders develop a culture that values information sharing and care coordination when recent statistics show that just 17 to 20 percent of primary care physicians are routinely notified of hospital discharges?3 Many providers are looking for guidance from provisions in the Affordable Care Act (ACA) that are designed to strengthen and improve primary care services and resurrect the foundational elements of the patient-centered medical home (PCMH).

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A patient-centered medical home, as defined by the Agency for Healthcare Research and Quality, identifies five core attributes:

The PCMH evolution The concept of the PCMH was first introduced in 1967 by the American Academy of Pediatrics to improve the care of children with complex needs.

Person-centered: A partnership among clinicians, patients, and families ensures that decisions respect patients’ wants, needs, and preferences, and that patients have the knowledge and support they need to make decisions and participate in their own care. Comprehensive: A team of care providers or clinicians is accountable for a patient’s physical and behavioral healthcare needs, including prevention and wellness, mental and behavioral health, and acute/chronic care. Accessible: Patients are able to access services with shorter wait times, after-hours care, and 24/7 electronic or telephone support. They are able to communicate with providers through email, patient portals, or other health IT tools. Coordinated: Care is organized across all elements of the broader healthcare system, including specialty care, hospitals, home health, community services, and support systems. A system-wide commitment to quality and safety: Clinicians and staff enhance quality improvement using information technology and other tools to ensure patients and families can make informed decisions.

It has since become a widely accepted approach to primary care among clinicians, health plans, employers, policymakers, and many consumer groups. The approach describes an expert and evidence-supported set of expectations regarding how primary care should be organized and delivered for patients and their families – to include coordinating care with the rest of the healthcare delivery system. In 2007, the momentum behind the PCMH received a boost when the major primary care physician associations developed and endorsed the Joint Principles of the Patient-Centered Medical Home and ultimately formed the Patient-Centered Primary Care Collaborative (PCPCC). A precise definition of the medical home continues to evolve, but consensus is emerging on key principles. The PCPCC actively promotes the broad definition of the medical home used by the Agency for Healthcare Research and Quality (AHRQ), which identifies five core attributes: person-centered, comprehensive, accessible, coordinated, and with a system-wide commitment to quality and safety (see sidebar, this page).

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Identifying PCMH building blocks

access to care, coordination of care,

This strategy still relies on FFS at

Assistance is available from many

and a template of the future.

its core, with the same issues around

outside organizations that offer

fragmentation and incentives to

technical support and individualized

The PCMH and payment reform

provide too much care. Despite this,

coaching to help primary care

The PCMH model continues to

the care management fee helps to

practices meet the demanding

demonstrate its ability to lower costs

reimburse for services that often go

leadership, cultural, financial, and

by reducing services that are often

unreimbursed today. Examples include:

organizational changes needed for

unnecessary – a glaring example

• Paying for essential care team

true practice transformation.

being emergency department use

members who coordinate care

The Commonwealth Fund

when treatment could have been

and consult with and educate

has developed and tested a set of

offered in a primary care setting.

patients and families;

comprehensive, free online tools

No payment system is perfect, but

for safety net providers to assist

modernizing today’s physician payment

them in their PCMH journey. In

system and investing in primary

• The exchange of health information

addition, some of the best research to

care is crucial for improvement.

across the medical neighborhood;

• Proactive population health management processes;

date on PCMH management comes

One of the most important goals in

from the University of California at

the future is understanding the impact

San Francisco’s (UCSF) Center for

of aligning new payment methods

Excellence in Primary Care (CEPC) and

with the PCMH and Accountable

measures to track outcomes

researchers engaged by the American

Care Organization (ACO) models and

and success.

Board of Internal Medicine (ABIM).

the subsequent impact on outcomes.

Other payment reforms, such as

They describe major characteristics

Fee-for-service (FFS) for many

shared savings models, bundled

of PCMHs or “high-performing

healthcare services will ultimately be

payment methodologies, and partial

primary care” and suggest 10 essential

phased out, because it rewards volume

or full capitation, promote alignment

building blocks (see page 23).5

and prioritizes sick care rather than

among and across health providers.

preventative care. The current FFS

Each has its benefits and challenges,

four fundamental characteristics

incentives are unbalanced and are a

but they collectively hold great

that develop and sustain on-going

driving force behind the perpetually

potential and are being tested in

transformation. They include engaged

lopsided design of our healthcare

both the private and public sectors.

leadership, data-driven improvement,

system, failing to reward clinical

empanelment, and team-based care.

quality or outcomes, especially

payment incentives that reward

Researchers also suggest that the next

among primary care clinicians.

practices for providing coordinated

These building blocks begin with

building blocks logically flow from

However, payment reform is

• 24/7 access and alternatives to traditional face-to-face visits; and • The use of quality improvement

The on-going challenge is to create

team-based care without onerous

the initial investment and encompass

complex. Most PCMHs still include

administrative burdens, which remains

patient-team partnerships, population

a FFS component with an added care

an issue with several of the innovative

management, and continuity of

management fee or per member per

payment models. However, without

care. Finally, PCMHs are ultimately

month (PMPM) increase that varies

sustainable reimbursement, it will

encouraged to focus on prompt

in amount from one payer to another.

be increasingly difficult to encourage OUTLOOK

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broader adoption of the PCMH or to tackle the next phase of its evolution.

Strengthening primary care and advancing population health The ACA launched a significant

by Medicare – it will be critical that Congress take action on the SGR repeal. Still, after more than 30 years of

PCMHs at the state level

number of initiatives that have proven

academic study, research findings

The role of states in advancing these

to be advantageous to primary care.

demonstrate that countries and health

collaborative models is increasingly

Primary care providers are embracing

systems that invest heavily in primary

important. Quite simply, states

and leading many of the innovative

care have better population health

have been leading the PCMH effort

programs included in the ACA through

outcomes at lower total cost.11,12 The

for years. State Medicaid programs

the CMS Innovation Center. The

future of family medicine is bright,

have been experimenting with

PCPCC’s 2014 annual report highlights

because policymakers are realizing

the PCMH and other advanced

recently published clinical, quality,

that investing in primary care – and

primary care models, as have various

and financial outcomes of PCMH

certainly family medicine – can both

state employee health plans.

initiatives from across the United

improve health and lower costs.

Because states are uniquely

States. In the public sector, millions

Primary care and the PCMH are at

positioned with economies of scale and

of beneficiaries are receiving patient-

the nexus of healthcare delivery and

the ability to convene stakeholders

centered primary care through 25

community and public health. This

without the fear of anti-trust violations,6

state Medicaid programs, the Federal

fact is especially true for high-risk or

they have been leading the effort

Employee Health Benefits program,

complex patients, such as those with

around all-payer or multi-payer

Medicare, the U.S. military, and the

chronic diseases, mental and behavioral

initiatives that include Medicaid,

Veterans Administration. In addition,

health issues, and other special

Medicare, health plans, employers,

millions more patients are attributed to

needs. Environmental factors such as

labor unions, and other purchasers.

the thousands of medical home private

socioeconomic status, employment,

The potential of multi-payer initiatives

practices, community health centers,

access to healthy foods, transportation,

is particularly promising as various

and hospital ambulatory care networks.

and physical surroundings are

payers in a given community or region

Unfortunately, primary care

important predictors of health. For

have the unique ability to incentivize

continues to be undervalued in the

low-income individuals and families,

the transformation of primary care

overall health system (representing

limited access to care coordination

practices, using the same set of payment

only 4 to 7 percent of overall healthcare

and health literacy can make attaining

methods and quality metrics. These

spend8,9,10). For the PCMH model

good health more challenging.

multi-payer initiatives convince

to be sustainable in the long term,

healthcare providers that the daunting

initiatives funded in the ACA must

PCMH include collaborating with

task of redesigning their clinical

be implemented on a larger scale

various medical neighbors to encourage

practice is worth the time, effort, and

and require continued investment.

the flow of information across and

investment because a majority of their

Because the ACA did not include a

among clinicians and patients.

payer-mix supports the redesign.

repeal of the Medicare Sustainable

These neighbors include specialists,

Growth Rate (SGR) – the flawed

hospitals, home health, long-term

physician reimbursement formula used

care, and other clinical providers.

The goals of a high-functioning

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Research from the University of California at San Franciscoâ&#x20AC;&#x2122;s Center for Excellence in Primary Care and researchers engaged by the American Board of Internal Medicine describe major characteristics of PCMHs or â&#x20AC;&#x153;high-performing primary careâ&#x20AC;? and suggest 10 essential building blocks.

Engaged leadership, specifically, leaders within the practice engaging and motivating teams toward a common vision.

Empanelment, which links each patient to a specific clinician or team.

Data-driven improvement with data systems that track clinical and operational metrics shared with the entire staff and used for quality improvement.

4 5

Team-based care, using a team of health professionals to enhance capacity and pairing a single physician and a medical assistant or nurse with a patient and family/caregiver.

Population management, which includes panel management that involves a staff member (usually a medical assistant, licensed practical nurse/ licensed vocational nurse, or registered nurse) periodically checking a registry to identify patients overdue for routine services, as well as health coaching, which provides individualized self-management support for patients with chronic conditions.

Patient-team partnerships that support evidence-based medicine and shared decision making, which encourages patients to become more interested in their health and involved in quality improvement efforts.

Continuity of care, supporting the ongoing relationship between the patient and the care team, which is created by the empanelment process.

Prompt access to care, such as evening and weekend hours, email access, group visits, etc., achieved by having proper panel sizes and using teambased care that promotes the balance of capacity and demand.

Coordination of care, assisting patients and their families in navigating the medical neighborhood, including specialty, hospital, and other care transitions.

A template of the future, specifically, a daily schedule that banishes the 15-minute clinician visit and substitutes more extensive visits, phone calls, group discussions, and consultations with team members (RNs, pharmacists, behaviorists, health coaches, and others). The template of the future limits the number of patients a physician sees each day to 15, drastically lower than the current fee-for-service (FFS) model of 25. This reduction allows clinicians more time with patients, enhancing communication and care coordination. It also establishes a new role for the clinician as the clinical leader and team mentor.

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In addition, non-clinical partners like

dynamics head on by identifying

That said, one of the greatest strengths,

community centers, faith-based

competencies and training goals

and yet an ongoing challenge, is that the

organizations, schools, employers,

for team-based care. To emphasize

PCMH is not a one-size-fits-all model.

public health agencies, YMCAs, and

the importance of interprofessional

The lack of clear rules for implementation

nutrition providers for home-bound

teams, the PCPCC recently released

means that the model looks different

seniors are also part of the equation.

a publication that highlights how

in different practice settings. Although

Together these organizations can

seven programs from around the

this variation makes clean analytic

actively promote care coordination,

country train a variety of healthcare

comparisons difficult, the flexibility

fitness, healthy behaviors,

professionals to work together in

of the model yields something more

proper nutrition, and better

patient-centered medical homes.

valuable: the freedom for primary

environments and workplaces. In order to successfully implement

The PCMH is an innovation that

care practices to implement the core

requires additional refinement and

principles in a way that is consistent

PCMH interventions and care for

further evaluation. The conceptual

with their culture and the needs of

populations, a paradigm shift toward

framework makes intuitive sense in that

their patients and their families.

a strong culture of information

a well-functioning primary care delivery

sharing and care coordination across

system should be more person-centered,

large systems of care is required.

comprehensive, accessible, coordinated,

This is no small endeavor. Although

and committed to quality and safety.

the PCPCC believes that primary care transformation is the key to well-functioning ACOs, all players

REFERENCES

in the system must be in alignment

1. Centers for Medicare & Medicaid Services. (2014). NHE Projections 2013 – 2023 – Tables. Retrieved from http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/ NationalHealthAccountsProjected.html. 2. The World Bank. (2014). Health expenditure, total (% of GDP). Retrieved from http://data.worldbank.org/indicator/ SH.XPD.TOTL.ZS. 3. Kripalani, S. LeFevre, F., Phillips, C.O., Williams, M.V., Basaviah, P., & Baker, D.W. (2007). Deficits in community and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA, 297(8), 831-841. 4. Sugarman, J.R., Phillips, K.E., Wagner, E.H., Coleman, K., Abrams, M.K. (2014). The Safety Net Medical Home Initiative. Medical Care, (52)11. 5. Rachel Willard, M.P.H., and Tom Bodenheimer, M.D., “Profiles In Primary Care: Patient-Centered Medical Homes and the 10 Building Blocks of High-Performing Primary Care,” Primary Care Insight, http://primarycareprogress.org/insight/4/profiles. 6. Wirth, B., & Takach, M. (2013). Issue brief: state strategies to avoid antitrust concerns in multipayer medical home initiatives. Retrieved from http://www.nashp.org/sites/default/files/1694_Wirth_state_strategies_avoid_antitrust_ib.pdf. 7. Nielsen, M., Olayiwola, J.N., Grundy, P., & Grumbach, K. (2014). The patient-centered medical home’s impact on cost & quality: an annual update of the evidence, 2012-2013. Retrieved from http://www.pcpcc.org/resource/medical-homes-impact-cost-quality. 8. Goroll, A.H., Berenson, R.A., Schoenbaum, S.C., & Gardner, L.B. (2007). Fundamental reform of payment for adult primary care: comprehensive payment for comprehensive care. Journal of General Internal Medicine, 22(3), 410–415. doi: 10.1007/ s11606-006-0083-2. 9. Phillips, R. L., Jr., & Bazemore, A.W. (2010). Primary care and why it matters for U.S. health system reform. Health Affairs, 29(5), 806-10. doi: 10.1377/hlthaff.2010.0020. 10. Health Care Cost Institute. (2014). 2013 Health care cost and utilization report appendix, table A1: expenditures per capita by service category and region (2011-2013). Retrieved from http://www.healthcostinstitute.org/files/2013%20HCCUR%2010-28-14.pdf. 11. Starfield, B. Shi, L., & Macinko, J. (2005). Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly, 83(3), 457–502. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1468-0009.2005.00409.x/full. 12. Friedberg, M.W., Hussey, P.S., & Schneider, E.C. (2010). Primary care: a critical review of the evidence on quality and costs of health care. Health Affairs, 29(5), 766-772. doi: 10.1377/hlthaff.2010.0025.

around the patient to achieve better population health. Adequate resources and interoperable technology are also necessary to accomplish this goal. Experience shows that healthcare professionals partner better with others on collaborative, interprofessional teams when they understand and appreciate their challenges, roles, and how they come together in a PCMH. Groups like the Interprofessional Education Collaborative, including physician, dental, nursing, pharmacy, and other healthcare representatives, are tackling PCMH practice

Perspectives

Embracing change: Delivery models, admission types, payment partnerships and more, 26

PERS PECTIVES

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ore than one-third

higher average performance rates on

of C-suite executives

17 of 22 measures reported by other

respondents, a number that

responding to the

Medicare fee-for-service providers.1

remains fairly static from 2012,

semiannual Economic

In their second year, Pioneer ACOs

Approximately one-fifth of

do not plan to become part of an

Outlook survey said their facilities are

saw improvement in 28 of 33 quality

ACO primarily because of:

part of an accountable care organization

areas and average increases of 14.8

• Their size (41 percent);

(ACO), and another 29 percent plan to

percent across all quality measures.

• Patient population or

join or create one by the end of 2016.

Mean quality scores for the group grew

location (23 percent);

by 72 percent in 2012 to 85 percent

• Investment or cost (9 percent);

percent) of respondents had already

in 2013. These figures reiterate that

• Lack of perceived value

established an ACO. That number

many organizations were able to

has increased to 34 percent of C-suite

produce substantial savings while

respondents in the fall 2014 survey.

also improving quality outcomes.

In 2012, less than one-quarter (23

While creation of ACOs was slower than

Sam Reynolds, MD, medical director

(9 percent); and • Risk (5 percent). Due to patient population and location, as well as the ability to

some respondents predicted in 2012,

of population health for Saint Vincent

scale, ACO participation among rural

there is great potential for growth of

Healthcare Partners, a hospital-owned

respondents is significantly lower than

ACOs in the foreseeable future with

ACO, part of the Saint Vincent Health

that among respondents from non-rural

43 percent of C-suite respondents

System (Erie, PA) and a member of the

areas (see Figure 2). Almost half (44

indicating they currently have plans to

Allegheny Health Network, credits the

percent) of C-suite respondents from

join or create an ACO (see Figure 1).

ACO for helping the system enhance

non-rural facilities are currently part

resource sharing and partnerships

of an ACO, compared to 18 percent

been created since the Affordable

with other providers to impact

of respondents from rural facilities.

Care Act (ACA) was passed, and CMS

population health in the region.

While respondents from both rural

More than 360 Medicare ACOs have

has recently reported cost savings

“We have a panel of care managers

and non-rural facilities report similar

and quality improvement among that

who reach out to higher-risk patients

levels of intent to create or join an ACO

group. Combined, the Pioneer ACO

across the community, as well

in the near future, one-third of rural

Model and Medicare Shared Savings

as a diabetes outreach program,

respondents do not have any plans to

Program (MSSP) reduced total annual

including nurses and educators who

be part of an ACO compared to only

Medicare costs by $417 million.

work with patients to manage their

10 percent of non-rural respondents.

MSSP participants earned more

disease. These are resources we’re

Patient population and location

than $315 million in shared savings

using to work collaboratively with

are important factors in determining

payments in the program’s first year and

patients to improve outcomes and

the potential risks and/or benefits

demonstrated improvement in 30 of 33

reduce costs,” says Dr. Reynolds.

associated with an ACO. After careful

quality measures. They also achieved

consideration, members of the Western

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PERSPECTIVES

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Fig.1

ACO participation (C-suite only) Fall 2014 Spring 2014

Currently part of an ACO

Fall 2013 Spring 2013 Fall 2012

Plans to create or join an ACO by 2016

Plans to create or join an ACO after 2016

No foreseeable plans to join or create an ACO

10%

20%

30%

40%

50%

60%

Source: Premier online survey for fall 2014 Economic Outlook publication

Fig.2

ACO participation by rural or non-rural location (C-suite only) Rural Non-rural

Currently part of an ACO

Plans to create or join an ACO by 2016

Plans to create or join an ACO after 2016

No foreseeable plans to join or create an ACO

10%

20%

30%

40%

50%

Source: Premier online survey for fall 2014 Economic Outlook publication

PERS PECTIVES

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Healthcare Alliance (WHA), rural

patients, receive capitated monthly

hospitals in Colorado that combine

payments to provide comprehensive

Better care coordination drives outpatient volume

resources to improve regional

care to Medicaid recipients.

Improving care coordination is

Similarly, in Colorado, when a

considered by many an essential part of

model and opted for a community

Governor-sponsored task force was

providing accountable care and meeting

care organization (CCO), another

created to develop strategies for

the goals of the ACA, so that patients

approach to accountable care.

controlling the costs of expanding

receive the right care at the right time

Medicare eligibility, the WHA saw the

in the right setting. Outpatient care

president of the WHA, explains, “All

writing on the wall and started working

requires lower overhead (labor and

of our members are typically smaller

together to prepare for that potential

equipment), which reduces healthcare

facilities in rural areas, and they don’t

eventuality. The group applied for and

expense overall. On the flip side, costs

have the same resources that larger or

received a three-year Health Resources

have gone up for many outpatient

urban facilities have at their disposal.

and Services Administration rural

procedures, due to the emphasis on

Medicare ACOs require 5,000 covered

health grant that will get the CCO

delivering the most appropriate care in

lives, and the majority of our members

program up and running. The financing

the proper setting and CMS’ inpatient/

don’t have those numbers within

will largely be used to hire staff and

outpatient reimbursement redefinitions.

their communities. The risk of losing

implement and share IT resources, since

money in this model was much greater

technology is such a major expense.

healthcare, decided against the ACO

As Scot Mitchell, senior vice

than the potential to gain money.”

The WHA’s first area of focus for

The majority of C-suite survey respondents (73 percent) predicted an increase in outpatient admissions

population health is its own hospital

in the next 12 months, compared to

for its membership, the WHA did

employees. “In the next six to 12

19 percent anticipating an increase in

see value in developing the ability to

months, we’re going to roll out a care

inpatients. These forecasts were largely

manage the care of its populations in a

management program to our hospitals

affected by hospital size (see Figure 3).

different manner. “WHA’s main focus

with self-funded insurance for their

is providing collaborative approaches

staff members. Hospital employees tend

hospitals (57 percent) reported

to dealing with the issues our hospitals

to be high utilizers of hospital services,

decreases in inpatient admissions

are facing. The CCO is a way we can help

so this is a good way to start reducing

compared to midsized (43 percent)

our hospitals get some experience in

expenses and improving the health of

and small (50 percent). The opposite

managing population health without

our own employees,” says Mitchell.

is true for outpatients – 87 percent of

Despite the limitations of an ACO

having to invest all of the resources

“We’re also in discussions with

More respondents from large

respondents from large hospitals cited

different payers in Colorado, as well as

an increase in outpatients compared

with other rural networks in California

to 65 percent from midsized hospitals

as an example for the WHA. Per a state

and Illinois that are trying to do CCOs

and 75 percent from small hospitals.

Medicaid mandate, Oregon payers no

or similar models with their patient

longer pay providers directly for their

populations. These partnerships are a

services. Instead, they pay the CCOs,

great way to share resources and build

Population health efforts support new care delivery models

and the CCOs then manage payment

a larger population health footprint.”

Healthcare executives are focusing

individually,” Mitchell continues. The state of Oregon ultimately served

to providers. The CCOs, covering more

on an array of broad-based health

than 90 percent of state Medicaid

initiatives to bolster connectivity, care

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PERSPECTIVES

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Fig.3

Admissions forecasts by hospital size (C-suite only)

Increase Large

No change

INPATIENT

Decrease Midsized

Small

Large OUTPATIENT

Midsized

Small

10%

20%

30%

40%

50%

60%

70%

80%

90%

Source: Premier online survey for fall 2014 Economic Outlook publication

coordination and patient outcomes.

“It’s not possible for one physician

and really developed a sense of unity

There are a number of activities that

to manage all of the needs of a patient,

around certain standards. A clinical

directly address improving population

so team-based care models are really

design team instituted several PCMH

health, including patient-centered

intrinsic to the next wave of population

tenets, such as appropriate testing

medical homes (PCMH), which had the

health management. They allow for

and follow-up processes, through

most dedicated resources (25 percent)

increased attention to the patient, more

our workflow development so there

in our last survey (see Figure 4).

contact and greater coordination.”

were collaborative expectations.”

Saint Vincent Health System’s

In 2006, when 16 individual primary

The movement toward PCMH

employed physician group embarked

care practices in the network were

began with one physician practice

on the PCMH journey in 2006, in

transitioning from paper charts to a

receiving recognition from the National

an effort to better care for patients.

common EHR platform, Dr. Reynolds

Committee for Quality Assurance

According to Dr. Sam Reynolds, chief

saw the move toward technological

(NCQA) and grew exponentially

medical officer for the group, “There

standardization as an opportunity to

from there. “We worked with that

were elements in the PCMH model that

standardize care delivery processes.

physician as a coach to set up his

“Moving to the EHR system gave

practice with PCMH principles,

focused on the needs of the patient, as well as the concerns of the provider

us a platform to bring the different

starting from the ground up. In 2012,

and payer. It’s really a marriage of the

teams together, and through that

we started discussions with payers

fundamental principles of primary care.

process, we established workflows

about financial recognition for the

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Fig.4

Top area of resource dedication for population health (C-suite only)

Patient-centered medical homes Partnering with payers Patient risk stratification Virtual care/telemedicine Transitional and/or end-of-life care Community engagement programs Home health Lifestyle/wellness coaching Integrated clinical, supply chain and financial data Patient registry 0%

10%

15%

20%

25%

30%

Source: Premier online survey for fall 2014 Economic Outlook publication

NCQA designation, and last year,

now with an activated team-based

one of our major payers agreed to

approach, he is home for dinner.”

Saint Vincent Healthcare Partners’ care management program, Compass

pay additional money per visit for all

Dedicating resources to the PCMH

Care, which integrates behavioral

patients who were coded to our level-

effort was integral to Saint Vincent’s

healthcare into primary care, has

three NCQA designated medical home.”

adoption of the model. Dr. Reynolds

seen improved outcomes since

and his population health team serve as

implementation. Patients enrolled in

to team collaboration but physician

transformation consultants, or medical

Compass Care receive care from a multi-

engagement is critical to true

home coaches, to assist practices

disciplinary team of care managers, a

transformation. “At first, stressed

through the transformation process.

psychiatrist, and an internal medicine

out physicians had a difficult time

As part of a team-based model,

consultant who meet weekly to review

Success of the model is largely due

embracing that the intangibles of the

physicians are not the only stakeholders

cases and offer recommendations. Care

model – less administrative burden,

improving population health. Saint

managers work as liaisons with patients

the sense of accomplishment for better

Vincent’s is also moving toward

and primary care providers to establish

patient management – were possible,”

employing a health coach in each PCMH

and implement care treatment plans.

Dr. Reynolds remembers. “But now

to help patients better understand their

With over 500 patients enrolled,

they all know what is in it for them.

diseases and to reach out to those who

Compass Care has seen a 65 percent

One physician was staying until 9 p.m.

are overdue for care or with chronic

improvement in depression scores (55

each day completing documentation;

diseases that may be unmanaged.

percent of patients have gone from

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PERSPECTIVES

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“depressed” to “non-depressed” on

(79 percent), with 43 percent of rural

the standardized PHQ9 tool). That’s

respondents reporting no involvement.

respondents’ participation in:

significant, since patients with a

The same disparity exists with size/type

• Bundled payments (41 percent);

chronic disease and depression cost

– 88 percent of large hospitals have at

• Care management fees (35 percent);

65 percent more to care for than those

least one payer partnership, compared

• Capitation (35 percent); and

who are not depressed. The hospital

to 68 percent of midsized, 65 percent

• Shared savings with downside

has also seen improvements in blood

of small, and 54 percent of non-acute.

pressure and diabetic control rates of 55 and 14 percent, respectively. “Our ACO success stories are

Regionally, the Southeast is least

Our survey also revealed

risk (22 percent). The numbers may change, but

likely to have a payer partnership,

the picture remains the same. U.S.

with only 51 percent of respondents

healthcare is no longer the static, set-in-

numerous,” says Dr. Reynolds. “They

having at least one. That compares

its-ways system of the past. The C-suite

include higher patient satisfaction

to more than 70 percent in other

executives who responded to our last

scores; great tools for patients to

sections of the country.

Economic Outlook survey confirmed

improve self care, like patient-

The most common types of payer

friendly disease management

relationships are upside-only shared

sense of urgency to demands facing the

reporting; happy physicians because

savings, such as track one of the

industry from legislative mandates,

of lifestyle improvements and reduced

Medicare Shared Savings Program.

quality expectations, financial

administrative burdens; low staff

Of those respondents with at least

pressures, and most importantly,

turnover; and great outcomes from

one payer partnership, 67 percent

the needs of their patients.

programs like Compass Care.”

were participating in an upside-

Payer partnerships (18 percent),

that point. They’re responding with a

only shared savings program.

patient-risk stratification (14 percent), virtual care/telemedicine (10 percent), and transitional or end-oflife care (10 percent) complete the top five areas where executives are dedicating the most resources for population health (see Figure 4). Payer partnerships, a chief part of the ACO model, help to align provider payments with quality outcomes. The majority of C-suite respondents (60 percent) said their systems are engaged in at least one payer partnership for population health. Of those, two-thirds have up to three payer partnerships, while the others have more than three. These partnerships were more likely to be found among urban respondents

REFERENCES 1. Centers for Medicaid and Medicare Services, “Medicare ACOs continue to succeed in improving care, lowering cost growth,” fact sheet, November 10, 2014, http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/ 2014-Fact-sheets-items/2014-11-10.html. 2. Ibid.

Trends

ICD-10 integration in the ambulatory care setting, 34 Managing supply costs in the physician office, 36 When enough really is enough: Antibiotic overuse, 38 Success Story: DebMed, 42

Steven Robinson, vice president, engagement and delivery Premier Performance Partners

earning a new language

the Centers for Medicare & Medicaid

to documentation. How do we help

can be a challenge, since

Services (CMS). “For patients under

physicians and other healthcare

it’s basically a complex

the care of multiple providers, ICD-10

providers learn a new coding language?

system of small details

can help promote care coordination.”

Facilities are approaching the issue

that can seem overwhelming at first. And ICD-10 is no different. ICD-10 is a new language for

Documentation (both inpatient and outpatient) is meant to reflect the care provided to a patient. Until October

in different ways. They include: • Requiring employed physicians to take part in ICD-10

healthcare, and documentation accuracy

1, 2014, there was a wide variance in

is dependent upon understanding it.

application of coding conventions, with

In a final rule issued July 31, 2014,

two differing diagnostic and procedure

proof of ICD-10 training as part

HHS formally set an October 1, 2015

rules/guidelines in place. With the

of their credentialing process;

compliance date for conversion to

adoption of ICD-10, coding for all

ICD-10 diagnostic and procedure codes.

inpatient and outpatient diagnoses will

with overviews of ICD-10

use a single code set. Rule applications

training by specialty; and

“ICD-10 codes will provide better support for patient care and improve

will be the same for both care venues

disease management, quality

for the first time in U.S. history.

measurement and analytics,” said Marilyn Tavenner, administrator of

Many in the industry have concerns about ICD-10, specifically with regard

Web-based training; • Asking physicians to submit

• Providing physician trainers

• Preparing documentation tip cards for each specialty. While these methods are a great start in helping physicians understand

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the foundations of documentation specificity, many physicians feel the

Fig.1

Inpatient and outpatient ICD-10 facilitation comparison

administrative burden negatively affects their ability to take care of patients. In reality, the change can be helpful by summarizing critical, need-to-know information into a “provider brief.”

Function

Inpatient ICD-10 facilitation

Outpatient ICD-10 facilitation

Provider education

Supported by hospital.

Supported by provider or billing management company.

Provider concurrent support (support team at the time of services)

Clinical documentation specialists; coding professionals; physician advocates; education/ training by consulting staff.

Coding/billing company; practice managers; physician motivation; ICD-10 hotline.

Physician needs

Support team of advanced practitioners; clinical documentation specialists; coding professionals.

Trained and proficient office coding staff; documentation specialists to concurrently review documentation the day of encounter and prompt to correct gaps.

How we educate users about the new code set in practice settings may differ primarily based on patient flow. Figure 1 indicates some of the similarities and differences in inpatient and outpatient ICD-10 facilitation. Merging the types of patients (by principal diagnosis) with relevant documentation specifics customized to the provider offers “need-to-know” priorities. This same information can be incorporated into delivery formats.

Premier Provider Briefs identify top diagnoses per provider with ICD-9/ ICD-10 documentation requirements and alternate diagnoses as applicable, and includes clinical parameters for diagnostics. Identifies quality measures associated with same top-volume diagnoses.

Outpatient focus on ICD-10 is equally important. Supporting the health of the physician practice and patient acuity in the outpatient area will also support the welfare of the medical staff who practice in the hospitals. Complete documentation is important to reflect: • Severity of patient illness; • Alignment of resources consumed for the care delivered; • Quality of care provided; and • Accurate profiles for analytic and comparative metrics. Even though the transition to ICD-10 has its challenges, it also brings the benefits of consistent coding and documentation language across historically disparate areas of care. As we move to greater standardization in supplies, procedures, and outcome guidelines, it’s fitting that we also standardize the language we use.

Audits/metric tools

Quarterly spot checks on provider gaps/education/ retraining; ongoing training; educate on audit findings.

Provider Briefs are applicable in the outpatient setting since they are focused on diagnostics.

Quarterly units initially with ongoing training for providers/support team.

WILL YOU BE READY FOR ICD-10 ON OCTOBER 1, 2015? Take the pledge at https://premierinc.com/icd-10-pledge/ OUTLOOK

QTR 1.15

or many physician offices, especially those that do not have access to a larger health system’s supply

chain, managing operating expenses can be a challenge. While large systems are able to leverage their scale to purchase supplies and services, single practices or groups of physician offices are often unable to purchase products in bulk to minimize commodity costs. “Non-acute providers, such as skilled nursing facilities, ambulatory care centers and primary care providers, are facing many of the same cost pressures as hospitals, but are at times overshadowed by their acute care brethren,” says Rob Falk, senior director of continuum of care at Premier. The pressures are indeed significant. A 2013 HealthLeaders’ survey of 300 physicians showed them to be very concerned about: • Having a stable income (62 percent); • Declining reimbursements (55 percent); and • Escalating practice expenses (43 percent).1

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Medical-Surgical, which ensures the

and ensuring the office receives the

reason to be worried. Managing

Those physicians have every

best pricing through McKesson and the

correct pricing. Many GPOs offer

operating expenses – medical supplies,

GPO portfolio, as well as assistance with

procure-to-pay solutions that extend

pharmaceuticals (including vaccines),

contract utilization, standardization

to non-acute facilities, which allow

office products, purchased services, and

and inventory management.

providers to order and manage all

related items – can make the difference

But supplies are not the only

of their supply purchases online.

between just getting by and thriving

opportunity. GPO contracts typically

financially. That’s particularly true

span outside of the medical-surgical

of financial pressures to focus on

today as provider reimbursements

space, and include pharmaceuticals, IT,

hospitals, healthcare facilities across

are decreasing, and the industry is

foodservice, housekeeping products,

the continuum need to reduce costs to

facing additional challenges dictated

furniture, facilities maintenance and

be viable. Access to an alliance such

by legislation, new care delivery

more. “These non-medical products and

as Premier can also introduce doctors

models and payments tied to outcomes.

services can account for over half of a

and their staffs to goods, services,

In short, the better managed the

non-acute provider’s spend,” Falk notes.

and innovations they might not be

physician office operating expenses, the more profitable the practice.

While it’s typical for the discussion

Again supported by McKesson,

aware of (and would probably have no

the pharmacy portfolio includes a

idea they could afford). As physicians

Many single and smaller practices

comprehensive list of pharmaceuticals

increasingly find themselves at the heart

have discovered that a GPO affiliation

including branded drugs, generics and

of patient care coordination and new

can relieve some of these financial

vaccines. It also includes office products

ways of delivering care, turning to an

pressures. Premier, for example, offers

and equipment, such as uniforms,

outside source for help with everyday

Continuum of Care,™ ProviderSelect:

computer supplies, exam room furniture

expense management simply makes

MD,™ and other programs that

and practice administration contracts

good business sense. At the same time,

are designed to lower both clinical

for express shipping, insurance

it frees clinicians to do what they do

and non-clinical expenses.

services and background checks.

best: care for their patient populations.

While discussion of the impact of

Keeping track of orders and expenses,

the ACA typically focuses on what

especially across disparate physicians’

happens within the four walls of a

offices in a multi-group practice, is

hospital, new care delivery models

important to standardizing purchases

A special thanks to Brent Wiseman and Rob Falk for their contributions to this article.

and payment incentives emphasize the need to contain costs across the continuum. ProviderSelect: MD is a group purchasing program specifically built to serve physicians’ offices as they work to reduce clinical and non-clinical spend, facilitate contract optimization and improve administrative functions. Using its contract portfolio, independent and multi-group physician practices have been able to save, on average, 15 percent in supply expense. Premier’s program is anchored by a distribution agreement with McKesson

REFERENCE 1. Michael Zeis,” How the Dynamics of Physician Alignment Are Changing,” HealthLeaders, September 13, 2013, http://www.healthleadersmedia.com/content/FIN-296271/How-the-Dynamics-of-Physician-Alignment-Are-Changing.

OUTLOOK

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Mike Alkire Chief operating officer / Premier, Inc.

ntibiotic-resistant

Antibiotics used to treat infections

combinations of antibiotics

bacteria, considered

can reduce mortality and save lives.

administered from 2008-2011, the

one of the world’s most

Administering a combination of

research showed that 78 percent of

urgent public health

antibiotics that fight different types of

hospitals had evidence of potentially

problems, infect more than two million

infections may lessen symptoms while

unnecessary combinations of

people in the U.S. and cause at least

waiting for the return of disease culture

antibiotics administered for two or

23,000 deaths each year. The Centers

results. A typical disease culture can

more days over the time period. Most

for Disease Control and Prevention

take up to two days – a long time for

(70 percent) were for three specific

(CDC) estimates that antibiotic

someone with painful or uncomfortable

IV drug combinations used to treat

resistance results in direct annual

symptoms – so physicians often

anaerobic infections. All of these drugs,

healthcare costs of $20 billion.

prescribe a combination of antibiotics

used individually, treat the same types

when a patient is first admitted and the

of bacteria. Thus, these instances are

type of infection is not yet known.

considered “never combinations,” as

In fact, the issue is so concerning that the Obama administration recently announced an executive order and

However, according to the CDC, up

national strategy to combat the growth

to half of patients treated in the U.S.

of bacteria resistant to antibiotics,

receive unnecessary or inappropriate

they have no added patient benefit than each antibiotic used alone. These combinations resulted in

the so-called “superbugs.” The

treatment. 3 This includes the use of

nearly $13 million in potentially

administration’s National Strategy to

multiple intravenous (IV) antibiotics

avoidable costs for IV antibiotics

Combat Antibiotic-Resistant Bacteria

to treat the same infection when either

for the 500 hospitals, excluding the

punctuates the need for a coordinated

one or none would be the best approach.

additional supply or labor expense

effort to slow or prevent the spread

New research conducted by the

in nursing or pharmacy or the costs

of resistant infections and improve

CDC and Premier, published in

associated with adverse drug events

national surveillance, notification, and

Infection Control and Hospital

and complications. Administering

diagnostics. It also points to a need

Epidemiology, affirms the need for

unnecessary combinations of

for greater antibiotic stewardship

targeted solutions to reduce overuse.4

antibiotics could account for more than

Using data from more than

$165 million in avoidable spending

these drugs and inadvertently

500 U.S. hospitals to identify 23

if the sample is representative and

contributing to their resistance.

potentially redundant or inappropriate

extended across all U.S. hospitals.

to ensure we’re not overprescribing

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QTR 1.15

TRENDS

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But as noted earlier, overuse of

other harm related to administration

of antimicrobial resistance. Medical

antibiotics isn’t just an issue of cost.

of that drug. Not giving a drug reduces

staff can flag “never combinations”

Unnecessary use of multiple antibiotics

risk of harm, saves time for nursing

or other potentially unnecessary

can also be harmful. Each antibiotic

and pharmacy staff and lowers costs.”

combinations within their clinical

has side effects and risks of adverse

Hospitals that leverage

drug events. The use of more than

antimicrobial stewardship

one antibiotic increases the risk of an

programs, a major part of the Obama

priority for many, including the

adverse event, and each combination

administration’s new strategy,

CDC, which has three “Get Smart”

may introduce risk for other

have consistently demonstrated

programs that provide resources for

complications, which further burden

decreases in antibiotic use with

patients, families, and providers. These

healthcare budgets. Inappropriate or

annual savings of up to $900,000.

programs are specifically designed to

overuse of antibiotics can also accelerate

The key to a comprehensive

surveillance solution to prevent overuse. Appropriate antibiotic use is a

educate key partners and the public

the growth of antibiotic-resistant

antimicrobial stewardship program

about the importance of appropriate

bacteria, especially among antibiotics

and to reducing unnecessary variation

antibiotic prescribing in doctors’

that are frequently prescribed to treat

in healthcare is data. Without

offices, healthcare facilities, veterinary

a wide range of infections. Research

patient, supply, and pharmacy data,

medicine and animal agriculture.

published in October 2014 in the

it would be difficult or impossible to

Journal of the American Medical

determine what care is redundant

providing medical care can result in

Association5 shows that, in a review

and what is worthwhile.

increased costs without improved

of more than 11,000 patients at 183

Data helps focus antimicrobial

The “more is better” approach to

quality. Given the pressures on the

hospitals, one in seven were prescribed

stewardship efforts by pointing

healthcare industry and our health as a

vancomycin, one of the antibiotics often

clinicians to inappropriate conditions

nation, it’s important we use the tools

associated with building resistance.

and antibiotics. Hospitals can use this

we have to determine when enough

information to target a limited number

is enough. By using data to identify,

a combination of coordinated

of antibiotic combinations, such as

target, and eliminate the areas in which

interventions to monitor and improve

those identified in the Premier/CDC

variation in care does not result in

the use of antibiotics, is an effective

research, to decrease unnecessary

better outcomes, we can ensure equally

way to reduce resistance, patient harm,

antibiotic use. Clinical surveillance

strong clinical and financial health

and unjustified variation in healthcare

systems that provide real-time

for patients and society as a whole.

costs. According to Leslie Schultz,

alerts are effective in helping health

director, Premier Safety Institute,

systems combat the growing threat

Antimicrobial stewardship,

A version of this article was originally printed in Infection Control Today’s December 2014 issue.

“Put simply, antibiotic stewardship is a concerted effort to ensure that every patient gets an antibiotic only when one is really needed and that we use the right antibiotic and the right dose only for as long as truly needed. “There are risks with all drugs, and especially with the use of IV drugs. So if we can reduce the number of IV drugs we give our patients, we reduce the chance of an adverse drug event or some

REFERENCES 1. The Centers for Disease Control and Prevention, “Antibiotic Resistant Threats in the United States, 2013,” CDC.gov, 2013, http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf#page=6. 2. Sabrina Tavernisesept, “Aims to Curb Peril of Antibiotic Resistance,” The New York Times, September 18, 2014, http://www.nytimes.com/2014/09/19/health/us-lays-out-strategy-to-combat-crisis-of-antibiotic-resistance.html?_r=1. 3. The Centers for Disease Control and Prevention, “Delivering safe care for patients: all healthcare providers play a role,” CDC.gov, November, 2014, http://www.cdc.gov/getsmart/week/downloads/gsw-factsheet-providers.pdf. 4. Leslie Schultz, et al, “Economic Impact of Redundant Antimicrobial Therapy in US Hospitals,” Infection Control and Hospital Epidemiology, Vol. 35, No. 10, October 2014, http://www.jstor.org/stable/10.1086/678066. 5. Michelle Fay Cortez, “Antibiotic Use for U.S. Hospital Patients Questioned,” Bloomberg Businessweek, October 07, 2014, http://www.businessweek.com/news/2014-10-07/antibiotic-use-for-u-dot-s-dot-hospital-patients-questioned.

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E S U E C R U O S RE IN THE Y C A M R A PH THE AVAILABILITY OF DATA to support pharmacy decision making extends beyond antibiotic overuse. Clinical surveillance and quality solutions allow pharmacists to compare outcomes of different drugs to one another before making decisions that have the potential to improve quality and lower costs. Paul Lewis, PharmD, BCPS, and an infectious disease clinical pharmacy specialist at Johnson City Medical Center (Johnson City, TN), the flagship hospital of Mountain States Health Alliance (MSHA), has seen first-hand the difference data can make. “The future of healthcare is doing more with less,” Lewis says. “We have limited resources, but we have to provide high-quality care, which means eliminating waste. It’s now everyone’s job within the organization to contain or remove costs. “Pharmaceuticals are such a significant area of cost for hospitals. Coupled with the unique position pharmacists have with visibility to the cost, quality, and outcomes of the products we dispense, it gives us an opportunity to be one of the biggest cost-containment departments in the organization.” Using Quality Advisor™, Lewis started doing queries on MSHA’s data to determine if pharmaceutical trends seen at other hospitals might also align for its patients. Starting with a query on proton pump inhibitors (PPIs), Lewis wanted

to know if C.difficile infections were higher among patients who were taking PPIs prior to or upon admission. Lewis’ analysis supported his suspicion. “Looking at two years of data from a very large patient population, we saw a six-fold increase in C.difficile among patients taking PPIs, compared to those who weren’t.” Based on this discovery, Lewis and his team are in the midst of educating physicians about the importance of critically evaluating whether their patients are at risk for stress ulcers during their hospitalization. If so, they are encouraged to try antacids or other options before prescribing PPIs. Using other queries, Lewis can make changes to the order sets if two similar drugs appear to have different outcomes. “We can place a pharmaceutical higher in our order set, mark it preferred, or remove it, depending on what we see in the data,” says Lewis. “It’s a wave of the future to find out the cost and lengthof-stay implications of the changes we make, or would like to make, in the pharmacy. We will be increasingly responsible for asking questions of current practices. Having access to my own system’s data in Quality Advisor helps me evaluate changes and confirm decisions.”

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SUCCESS STORY

DebMed system nearly doubles hand hygiene compliance at Riverside Medical Center

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iverside Medical Center, in Kankakee, IL, is renowned for its dedication to quality and safety for its patients.

“I believe the system really puts us into the next level.”

Among Riverside’s top quality and

safety priorities is hand hygiene. As Director of Quality Mary Schore notes, “Hand hygiene is one of the easiest

The team wanted to focus on the

Hygiene, or you’re not. So now we

unit level, providing data that would

have a true method of measuring and

prevent the spread of infection.”

help improve hand hygiene compliance

analyzing our own performance.”

The challenge: Gathering trusted data

learned about DebMed’s research-

system,” Schore says, “our

based monitoring solution and was

compliance was at 32 percent, and

impressed by a year-long study showing

now our hand hygiene compliance

the system produced results nearly

has risen to 62 percent.”

things we can do as hospital staff to

According to Nursing Director Shawnna Cunning, “For a long time we struggled with various methods of trying to analyze whether our staff members were compliant. Were they cleaning their hands frequently enough? Were our hospital-acquired infection rates low enough?” Riverside tried direct observation but ran up against what’s known as the “Hawthorne Effect.” “People would behave differently when you were observing them,” Cunning says, “and direct observation was very time consuming and tricky.”

The solution: Capturing every hand hygiene opportunity with DebMed GMS In choosing a reliable and effective technology, Vice President of Nursing Michael Mutterer says one requirement stood out: “We didn’t want staff to feel they were being punished, but rather that the system was truly for excellent patient care.”

for a group. Riverside leadership

identical to 24-hour video monitoring. Mutterer says that because the system

“Prior to using the monitoring

Mutterer says an important contributor to this improvement

monitors hand hygiene compliance

was the medical center’s support

based on the higher clinical standards

of the system at the administrative

used by the WHO and the CDC − and

level. “I believe that by engaging

not just simply washing before and

with the system and supporting it

after patient care − it raises the bar

from the top down, we’ve had better

for improving patient safety and

buy-in from the bedside nurse.”

reducing infections. “I believe the

He points out three advantages

system really puts us into the next

of the system, including:

level,” he says, “being able to teach and

• Patient quality and safety;

train our staff to look at opportunities

• Return on investment; and

beyond cleaning their hands as they

• A less-intrusive method for

enter and exit patient rooms.”

the organization to monitor hand hygiene compliance.

The results: Nearly doubling hand hygiene compliance

“I hear nurses encouraging families,

The monitoring system changed the

visitors, and even the physicians to be

quality culture at Riverside. “There

sure they clean their hands. We’re finally

were always a lot of excuses,” Cunning

aware of its importance and really

recalls. “With this, there are no

holding each other accountable now.”

“For the first time,” Cunning relates,

excuses; there are no debates; and there are no disputes. Either you’re cleaning your hands properly and using the Five Moments for Hand

THIS ARTICLE IS A PAID ADVERTISEMENT. This article was not written by Premier and is not an endorsement by Premier.

OUTLOOK

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