The Daily Briefing

News for Health Care Executives

10 ways to expand primary care access

November 2, 2011

Primary care growth is now a top strategic priority for many hospitals and health systems. As increased physician employment tightens referral networks throughout the care continuum, organizations are racing to capture downstream volumes starting from the system’s front door: the primary care office.

Population shifts and payment reform will further heighten the focus on primary care. Emerging payment models, including readmissions penalties, episodic bundled payments, and shared savings programs, require effective ambulatory patient management for hospitals to succeed under new incentives.

However, many hospitals and health systems are poorly positioned to capture primary care share. Capacity is already backlogged—nationwide, primary care appointment wait times average 20 days—and the primary care physician (PCP) shortage shows no signs of abating. Meanwhile, demand for services is anticipated to grow by 15% across the coming decade.

To expand access to primary care services amid this capacity crunch, leading health systems are employing a two-pronged approach:

Elevating practice productivity

With the PCP shortage expected to hit 65,000 by 2025, few health systems should expect simply to hire or align their way to sufficient primary care access. Asking physicians to work longer hours is also likely unviable: 53% of PCPs already report feeling significant time pressure during patient visits, and a growing number of younger physicians are prioritizing work-life balance. Providers and health systems will instead need to evaluate new care delivery models and strategies such as:

  • Migrating primary care practices toward ideal practice size;
  • Strengthening care teams through more effective use of midlevel providers, clinical assistants, and even front-office staff;
  • Implementing group visits for targeted populations;
  • Deploying system resources to support practice efficiency improvements; and
  • Redesigning facilities for next-generation care processes.

Planning the coordinated network

Even when operating efficiently, primary care practices alone will not be able to meet expected demand. Health systems are currently exploring how to offload some care to alternative sites by positioning additional access points to supplement capacity and increase market share. These strategies include:

  • Engaging stakeholders in identifying ideal care locations;
  • Co-locating practices with urgent care centers and other ambulatory services;
  • Offloading care to integrated convenient care clinics;
  • Increasing worksite clinic presence; and
  • Offering e-visits based on payer and market receptivity.

Register now

Marketing and Planning Leadership Council members may explore these and other strategies for driving volume growth, responding to new payment models, and building patient loyalty by registering for a series of webconferences across November and December. Not a member? Visit our website to learn more.

Understanding medical mindsets

How two Harvard docs make the 'best medical choices'

November 2, 2011

In a Time interview last week, Harvard University physicians Jerome Groopman and Pamela Hartzband outlined "medical mindsets" that determine physicians' and patients' treatment approaches.  

The married couple recently published Your Medical Mind: How to Decide What Is Right for You, a book outlining how personal values and history influence medical decision making. In the book, Groopman and Hartzband explain how understanding one's medical mindset can lead to making smart decisions, Time reports.

Types of medical mindsets

Groopman and Hartzband separate medical mindsets into a handful of distinct categories.

First, they say each physician is either a minimalist or a maximalist. Minimalists generally opt to do the least possible to treat a medical problem, while maximalists will attempt to "be ahead of the curve" and do anything possible to address the problem.

Second, each physician tends to be a believer or a doubter. Believers tend to think medicine will provide a good solution for any given health problem, while doubters are more concerned with possible side effects or unintended consequences.

How backgrounds influence medical mindsets

According to Groopman and Hartzband, each person's medical mindset is determined by lifestyle, personal history, and values. For example, Groopman was raised in a household that respected physicians and dismissed natural healing and folklore. After his father died from a myocardial infarction, he turned to medicine as a way to save lives. As a result, he considers himself a believer and maximalist.

Meanwhile, Hartzband's mother was "an artist and freethinker" who was quick to dismiss experts and physicians. At 80 years old, both of Hartzband's parents are in excellent health. "If you believe you have generally good health, you don't want to do anything that might make matters worse," Hartzband says. According to her, these experiences caused her to become a doubter and minimalist.

Empowering patients to make personal medical decisions

Discussing treatment options in terms of medical mindsets can help empower patients to make smart medical choices, according to Groopman and Hartzband. Experts often disagree on treatment options because of differing medical mindsets, and patients should understand how those mindsets could influence their decisions, the pair says (Szalavitz, Time, 10/28).

CMS revises physician pay cut down to 27.4%

Agency also releases final 2012 OPPS, ASC rules

November 2, 2011

CMS on Tuesday issued final rules for hospital and physician payments in calendar year (CY) 2012, outlining a 27.4% cut in physician reimbursement and finalizing new quality metrics.

Final 2012 physician fee schedule

Current law requires Medicare to reduce physician payments under the controversial sustainable growth rate (SGR) formula, and CMS originally proposed a 29.5% cut in physician reimbursement beginning in 2012. However, the physician payment final rule calls for a payment cut of 27.4%, because Medicare cost growth was lower than expected.

The still-steep payment cut—and resulting backlash—has renewed HHS officials' calls for Congress to pass a permanent fix to the SGR formula. Calling U.S. physicians "the backbone of our health care system," HHS Secretary Kathleen Sebelius said that the Obama administration is "100% committed to fixing the flawed Medicare payment system and protecting Medicare beneficiaries' access to doctors."

In addition, the agency finalized cost and quality measures that will help establish a new value-based modifier to adjust payments for physicians who provide higher quality, more efficient care. The rule also finalized CY 2013 as the initial performance year for CY 2015 payment adjustments.

Additional changes announced on Tuesday include:

  • Slight payment increases for annual Medicare beneficiary wellness visits;
  • Amended values for 300 "misvalued" physician fee schedule services codes;
  • Changes to how CMS adjusts Medicare payments based on local practice costs; 
  • A reduction—in some cases, up to 50%—for some imaging payments for repeated scans within the same visit; and
  • An expanded list of telehealth services covered by Medicare.

The rule is scheduled to be published in the Federal Register on Nov. 28, and CMS will accept comments until Jan. 3, 2012.  The agency says it will respond to comments in the CY 2013 rules.

Outpatient, ASC final rule

CMS on Tuesday also issued a final rule for outpatient services and ambulatory surgical centers (ASCs) that would begin on Jan. 1, 2012. Specifically, the agency will increase hospital outpatient rates by 1.9% and raise ambulatory surgical center payments by 1.6%.

The rule added a clinical process of care measure to the Hospital Value-Based Purchasing Program that aims to protect patients against catheter-associated infections. In addition, the rule institutes performance periods, standards, and a weighting scheme for the FY 2014 program.

The rule also expands reporting measures for Hospital Outpatient Quality Reporting Program and for the first time establishes a quality reporting program for ambulatory surgical centers, which includes four outcomes measures and one surgical infection measure.

The rule is scheduled to be published in the Federal Register on Nov. 30, and CMS will accept comments until Jan. 3, 2012. The agency says it will respond to comments in the CY 2013 rules (CMS release [1], 11/1; HHS release, 11/1; Daly, Modern Healthcare, 11/1 [subscription required]; Robeznieks, Modern Healthcare, 11/1 [subscription required]; CMS release [2], 11/1).

Hospital smoking bans could put patients at risk

Study finds patients, staff continue to smoke despite policies

November 2, 2011

Hospitals' anti-tobacco policies may have a surprising side effect: they can inadvertently put patient safety at risk, Canadian researchers assert in a new Canadian Medical Association Journal study.

Many hospitals in the United States and Canada have enacted bans on smoking, both indoors and outdoors on hospital campuses. Some health care organizations also are rejecting job applicants for smoking, citing their institutional missions to encourage healthier lifestyles.

For the study, researchers from the University of Manitoba, University of Alberta, and the Winnipeg Regional Health Authority analyzed data for 82 patients and 81 health care professionals at two large acute-care hospitals in Canada. They found "ample" evidence that both groups continue to smoke on hospital grounds regardless of the policies. The results also showed that hospitals' efforts to enforce bans  were minimal, and cleaning crews picked up between five and 10 pounds of cigarette butts on some days.

Meanwhile, patients and hospital staff identified potential patient safety incidences related to leaving the hospital to smoke, including staff being unaware of patients' whereabouts, patients getting locked out of entrances, and weather-induced equipment malfunctions.

According to the study authors, instead of focusing on enforcing anti-tobacco policies, hospitals should address smoking on hospital grounds as a treatment issue. They note that patients may be under stress and need support from health care providers to manage tobacco withdrawal symptoms during their hospital stay (Kirkey, Postmedia News/Vancouver Sun, 11/1; Paul, Winnipeg Free Press, 11/1; CMAJ release, 10/31).

Survey: 10% of hospitals ready for Stage 1 of meaningful use

Survey: 53% of hospitals unlikely to meet Stage 1 of meaningful use soon

November 2, 2011

About 10% of U.S. hospitals are ready to meet all 14 core measures for Stage 1 of the meaningful use program, according to a report by HIMSS Analytics, the research arm of the Healthcare Information and Management Systems Society (HIMSS).

For the report, HIMSS Analytics surveyed 778 hospitals between Feb. 1 and Sept. 30. It found that 31% of hospitals "should be prepared to meet Stage 1 of meaningful use shortly." Such hospitals are ready to meet at least 10 of the 14 core measures for Stage 1.

The report also found that about 53% of hospitals are classified as being unlikely to meet Stage 1 soon, having met nine or fewer core criteria. Moreover, about 6% of hospitals are not ready to meet any core measures.

John Hoyt, executive vice president of organizational services at HIMSS, says, "We see hospitals working across the country to meet Stage 1 of meaningful use, and we are pleased at the progress they are making, even though it varies." He notes that all facilities must stay focused on implementing privacy and security measures as they strive to achieve meaningful use (Japsen, "Prescriptions," New York Times, 11/1; Goedert, Health Data Management, 11/1; Merrill, Healthcare IT News, 11/1).


Highmark, West Penn approve deal for new integrated system

Insurer-hospital deal may set quality, cost model

November 2, 2011

Pittsburgh-based insurer Highmark and West Penn Allegheny Health System on Tuesday approved a definitive agreement to form an integrated health system, Modern Healthcare reports. 

Although some health plans have purchased clinics, and many hospitals have payment models that mimic insurance plans, insurers typically have avoided purchasing hospitals because they are large investments that pose operating challenges. However, with health spending on the rise, insurers and providers are weighing alternative cost-cutting strategies.

Highmark in June announced plans to acquire the struggling five-hospital health system and immediately provided a $50 million grant. The agreement reached this week will create a new not-for-profit named Highmark that includes two subsidiaries: a not-for-profit health plan and a not-for-profit provider organization, which will include West Penn Allegheny. The deal ultimately will be worth roughly $475 million, including $75 million to fund scholarships for students attending West Penn-affiliated medical schools.

According to West Penn Allegheny Chair Jack Isherwood, the agreement "will create a highly efficient and lower-cost health care system, expand access to additional clinical services for patients, and enhance medical education and training for physicians and other health care professionals."

The two organizations this week plan to file their agreement with the Pennsylvania Insurance Department. The department, the state attorney general, and the Internal Revenue Service then will review the deal. If approved, the new system intends to reopen Western Pennsylvania Hospital's ED next year, after it was shuttered in January in an effort to downsize operations (West Penn Allegheny release, 11/1; Evans, Modern Healthcare, 11/1 [subscription required]; Mamula, Pittsburgh Business Times, 11/1).

The obstacles to reform repeal

If elected, GOP candidates could struggle to fulfill health law pledges

November 2, 2011

Every GOP presidential candidate has pledged to repeal the federal health reform law, but myriad practical and political obstacles could stymie their plans, the Wall Street Journal reports.

As public support for the health law wanes, Republican presidential candidates have launched into a "lively debate" about how they would repeal it. For example, former Massachusetts Gov. Mitt Romney says he would sign an executive order on his first day in office that would allow states to opt out of the law. On his second day, he would repeal the law through budget reconciliation in the Senate, which requires only 51 votes. Meanwhile, Texas Gov. Rick Perry says he would repeal as much of the law as he could through executive order while leading Congress to fully peel back its provisions.

Legislative limitations
However, various legislative limitations could make enacting any of the candidates' proposals difficult, according to the Journal.

Without a 60-seat majority in the Senate, Republicans could be unable to force a vote on repeal legislation. The Senate's budget reconciliation process is the only way to circumvent the 60-vote requirement, but it only can be used to tackle issues directly related to the budget. According to the Journal, leaving the defunded law on the books would allow Democrats to provide funding for it in the future.

Should Republicans attempt to defund the law though reconciliation, Senate rules would require them to find additional savings to offset the cost of repealing or defunding the law, which the Congressional Budget Office says will reduce the federal deficit.

Meanwhile, early waivers would have little impact on the law's implementation because they are not effective until 2017, Bloomberg Businessweek reports, noting that any effort to move up the effective date likely would fail in a Democratic-controlled Senate.

Patients' political pull
The Journal also notes that Republicans would struggle to avoid cutting popular provisions of the law, such as those prohibiting insurers from denying coverage to people with preexisting conditions.

Because many of the provisions are linked with others, it likely would be difficult to repeal unpopular provisions without repealing or weakening popular ones, the Journal reports (Radnofsky, Journal, 10/29; Armstrong/Jensen, Bloomberg Businessweek, 10/27).


How well do you know hospitals?

Try your luck at 'Jeopardy!'

November 2, 2011

Dan Diamond, Managing Editor

Health care wonks who watch "Jeopardy!": This was your week to amaze friends and family. As devoted fans already know, Monday's episode of the long-running TV quiz show devoted an entire category to hospital trivia.

It wasn't the first time that health care's been in Jeopardy!, so to speak. The show regularly quizzes contestants on medical maladies or famous physicians, although hospital-focused trivia only crops up every few years. Meanwhile, IBM's Watson supercomputer starred on the TV quiz show earlier this year, before going to work with WellPoint. A number of human health care professionals, like Anne Arundel Medical Center's Dr. Jay Rhee, also have competed for Jeopardy! fortune and fame.

How well do you know U.S. hospitals? Try your luck at answering Monday's trivia below.

Just remember to phrase your answer in the form of a question—and no phone-a-friend allowed either. Monday's Jeopardy! contestants swept this category; we think regular readers of the Briefing will ace this quiz, too.

Monday's Jeopardy questions

  • $200: This Rochester, Minn. clinic is around 15 million square feet, about three times the size of the Mall of America.
  • $400: Sylvia Plath worked as a secretary at this hospital, MGH for short.
  • $600: Now closed, the Washington, D.C., hospital named for him opened in 1909 and in World War I, went from 80 beds to 2,500 in months. (A Daily Double)
  • $800: This city's Johns Hopkins Hospital opened on May 7, 1889; today, it's part of a $5 billion medical system.
  • $1,000: Known for its mental health facilities, this New York City hospital was founded in 1736, four years after George Washington's birth.

Answers follow below, but before that, here's some filler text to cushion any spoilers.

First, the information in this post is courtesy of the wonderful J! Archive, a fan-created database of 28 years' worth of Jeopardy! questions and answers. Second, for those looking to scratch their trivia itch, here are links to three other episodes that featured a category devoted to hospitals, whether real or fictional:

(Answers: $200: Mayo Clinic. $400: Massachusetts General Hospital. $600: Walter Reed. $800: Baltimore. $1,000: Bellevue Hospital.)

Executives on the move

This week’s industry transitions

November 2, 2011

Each week, the Daily Briefing highlights executive transitions among the nation's hospitals and health systems. Are you moving to a new institution? Please e-mail to let us know.

  • Harold Siglar named CEO at Southwest Surgical Hospital (Hurst, Texas)
  • Robert Friedberg named COO at Delnor Community Hospital (Geneva, Ill.)
  • Mary Ann Conroy named CEO at Terre Haute Regional Hospital (Terre Haute, Ind.)
  • Alice Taylor named CEO at Imperial Point Medical Center (Fort Lauderdale, Fla.)
  • Albert Wiss named CFO at Share Medical Center (Alva, Okla.)
  • Todd Forkel named Regional President and CEO at Avera St. Luke's (Aberdeen, S.D.)
  • Dennis Joseph Eith named CFO at Danville Regional Medical Center (Danville, Va.)

Daily roundup: Nov. 2, 2011

Bite-sized hospital and health industry news

November 2, 2011

  • Illinois: Chicago Mayor Rahm Emanuel (D) has proposed eliminating free water and sewer services for some of the city's not-for-profit hospitals, Crain's Chicago Business reports. A recent report from the city's inspector general found that Chicago hospitals save tens of thousands of dollars through free or reduced water fees. According to Emanuel, the city could save $9.3 million next year by reducing not-for-profit fee waivers for water and sewer service, as well as building permits and city licenses. The proposal would provide a 20% discount to hospitals that handle a disproportionately high volume of Medicare or Medicaid patients. A Metropolitan Chicago Health Council spokesperson says 30 not-for-profit hospitals could face higher fees if the proposal becomes law (Maidenberg, Crain's Chicago Business, 10/14).
  • Massachusetts: One percent—or about $93 million—of the $9.6 billion the state spent on Medicaid this past fiscal year went to undocumented immigrants, according to a state report. The state provided emergency, prenatal, and postpartum care for immigrants who could not document their status, but about 94% of Medicaid funds were spent on state residents. Five percent of state Medicaid spending went to qualified immigrants or legal immigrants who are not yet qualified (AP/Boston Globe, 10/31).
  • New Hampshire and Vermont: Dartmouth-Hitchcock Health in New Hampshire and Southwestern Vermont Health Care (SVHC) in Bennington, Vt., have signed an agreement to create a physician group that will serve southwestern Vermont, the AP/Boston Globe reports.  Under the agreement, SVHC's 60 physicians will be employed by Dartmouth-Hitchcock. SVHC CEO Thomas Dee says the deal will improve the organizations' ability to recruit staff and enhance patient services (AP/Globe, 10/28).
  • Washington: Seattle Children's Hospital on Monday announced a $50 million gift from an undisclosed source to the Seattle Children's Research Institute, the Seattle Post-Intelligencer reports. The donation—which is the largest in the organization's history—will be used to improve infrastructure, scientist recruitment, and early-stage treatment of childhood diseases. The hospital also announced a second donation of $15 million, which will go to Children's Bellevue Urgent Care Clinic, to advanced nurse training, and to Children's Bellevue Clinic and Surgery Center (Sunde, Post-Intelligencer, 10/31).

How will you manage your Pioneer patient population?

November 2, 2011

Some health systems chose to apply for CMS’ Pioneer ACO Program, while others will choose to contract with private payers. Regardless of the model, in order to continue to deliver higher quality care, hospitals still face the challenge of cost containment and chronic condition management across populations.

Join us on Nov. 9 to hear how organizations are optimizing their network performance by drawing on Milliman’s 60 years of actuarial experience and the Advisory Board’s provider-centric analytics and ongoing implementation and process consulting. More.

HHS releases Healthy People 2020 Leading Health Indicators

HHS on Monday announced the Leading Health Indicators for the Healthy People 2020 campaign, National Journal reports.

The list of metrics to track public health goals is updated once per decade. Oral health, social determinants—such as education, income, and race—and maternal, infant, and child health were added to the nine existing categories of Leading Health Indicators. Meanwhile, metrics to track abstinence among young people, which was included in the 10 indicators for 2010, was dropped from the list for 2020.

The list of indicators for 2020 also includes:

  • Access;
  • Clinical preventive services;
  • Environmental quality;
  • Injury and violence;
  • Mental health;
  • Nutrition;
  • Physical activity and obesity;
  • Reproductive and sexual health; and
  • Substance use disorders and tobacco.

HHS Assistant Secretary Howard Koh said the list reflects "a new dimension right now in public health ... a paradigm shift with respect to social determinants" (Quinton, National Journal, 10/31 [subscription required]).