Tuesday
Aug252015

The Role of Master Data Management in Health Care

By Claire Thayer, August 25, 2015

Health Market Science tells us that Master Data Management (MDM) in health care encompasses everything from patient data to provider data detailing the treatments, procedures, modalities, products and processes which govern and describe patient interactions and outcomes. A recent KPMG survey finds that a slight 10% of health care organizations are effectively using advanced data collection and analytic tools in this regard.  MCOL’s recent infoGraphoid outlined summary findings from the KPMG survey, along with core customer entity types, key barriers to properly implementing data and analytic tools and primary main drivers to MDM:

MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more here.

Thursday
Aug202015

Seven Things to Know About Medicaid Going Forward

By Clive Riddle, August 20, 2015

  1. The most current CMS report indicates total Medicaid and CHIP enrollment of 71,637,638; with 509,082 additional people were enrolled during the past 30 days in the most recent reporting month (May 2015.)
  2. Total Medicaid spending will be close to $500 billion going into 2016.
  3. Since initial Marketplace open enrollment period began in October 2013, more than 12.8 million additional individuals are enrolled in Medicaid and CHIP as of May 2015, more than a 22 percent increase (Among states participating in Medicaid expansion, enrollment rose by 29.2 percent, while non participating states reported an increase of approximately 9.5 percent.)
  4. Regarding where states stand on medicaid expansion decisions, 20 states are not expanding Medicaid; 25 states (count includes the District of Columbia) are expanding Medicaid ; 5 states are expanding Medicaid, but using an alternative to traditional expansion; and 1 state is expanding Medicaid; pending federal waiver approval.
  5. According to the Center for Health Care Strategies, nine states have an active Medicaid ACO program (Oregon, Utah, Colorado, Minnesota, Iowa, Illinois, New Jersey, Vermont, and Maine) and ten states are pursuing Medicaid ACOs (Washington, Michigan, Alabama, North Carolina, Virginia, Maryland, New York, Massachusetts, Connecticut, and Rhode Island.)
  6. The GAO recently listed four key issues facing the Medicaid program, in their brief MEDICAID: Key Issues Facing the Program, including (A) access to care; (B) transparency and oversight (lack of complete and reliable data on states' spending, and need for improved HHS management of state demonstrations; (C) program integrity (the program's size and diversity make it vulnerable to improper payments). ; and (D) federal financing approach (automatic federal assistance during economic downturns and more equitable federal allocations of Medicaid funds to states.)
  7. Medicaid Managed Care now involves 39 states that contract with comprehensive MCOs for Medicaid, with around 74 percent of beneficiaries receiving care through these plans. CMS recently issued the first major proposed rule addressed Medicaid Managed Care since 2002, which addresses issues including Network Adequacy; Medical Loss Ratio; Actuarially Sound Capitation Rates; Quality of Care Standards; Appeals and Grievances ; Beneficiary Enrollment Protections; Utilization Management; Managed Long-Term Services and Supports; State Monitoring Standards; and Information Standards.
Friday
Aug142015

Examining ACO Makeup Evolution During Past Three Years

By Clive Riddle, August 14, 2015

Compiling Accountable Care Directory Data, we can look at how the makeup of ACOs around the country has evolved from since 2012. MCOL’s HealthQuest Publishers just released version 2 of its 2015 Accountable Care Directory, and has published updated directory twice a year since mid 2012. We’ve compiled data from the directories to provide a look at ACO composition over time.

A few challenges present themselves in considering the data – the biggest one involving commercial ACO reporting. Given there is no uniform standard, or reporting requirement for what constitutes an commercial ACO, there is certainly a disparity as to the national number of commercial ACO arrangements that are reported by various organizations. But at least in looking at the same company’s reporting on commercial arrangements over time, there is at least a relative measure.

Another issue is that the number of Medicare ACOs will be very close, but not exactly match CMS reporting year by year, due to the timing of reporting specific contract cancellations and CMS counting multiple contracts for a few organizations.

But with that said, here’s a snapshot of Accountable Organizations, past and present:

ACOs by top 25 States:

State

Mid
2012

Jan
2013

Mid
2013

Jan
2014

Mid
2014

Jan
2015

Mid
2015

CA

23

34

42

49

51

57

54

FL

17

33

35

46

47

48

48

TX

16

22

25

38

39

41

41

NY

17

19

21

25

25

31

31

NJ

8

14

15

23

23

26

26

IL

3

7

7

11

14

22

22

MA

11

18

18

19

20

22

22

NC

6

9

9

14

17

20

20

GA

10

12

12

16

17

17

17

MD

7

9

10

14

14

18

17

VA

4

6

7

15

16

17

17

MI

5

7

7

13

13

16

16

OH

7

12

12

14

14

16

16

IN

4

7

7

10

10

15

15

TN

7

10

11

13

14

16

15

AZ

5

9

9

12

13

15

14

PA

2

5

6

10

10

15

14

CO

3

7

8

10

10

11

10

CT

2

6

6

7

7

11

10

ME

8

9

10

10

10

10

10

MO

2

5

5

8

8

10

10

KY

5

6

6

6

7

9

9

WI

5

8

8

9

9

10

9

AR

1

1

3

4

4

8

8

MN

5

6

6

8

8

8

8

Others

24

40

41

61

63

74

73

Grand Total

207

321

346

465

483

563

552

ACOs by Medicare vs, Commercial Contracts:

Type

Mid
2012

Mid
2013

Mid
2014

Mid
2015

Medicare Only

126

209

307

346

Commercial Only

59

96

118

130

Both

22

41

59

77

Grand Total

207

346

484

553

Mid 2015 ACO Attributed Patients Per ACO

Patients

Medicare

Commercial

< 10 K

28.8%

38.5%

10K - 24K

42.4%

28.6%

25K - 49K

18.8%

16.5%

50k - 99K

5.9%

9.9%

100K +

4.1%

6.6%

Avg/ACO

33,262

61,209

% Reporting #

40.2%

44.0%

The average attributed patients combined for Commercial and ACO in Mid 2015 was 32,566, compared to 29,584 in Mid 2012.

Mid 2015 ACO Physicians Per ACO

Physicians

Percent

<50

10.5%

50-99

10.8%

100-249

21.7%

250-499

20.4%

500-999

19.2%

1000+

17.3%

Avg

509

% Reporting #

58.4%

The average number of physicians per ACO historically has been:

 

Mid

2012

Mid

2013

Mid

2014

Mid

2015

Physicians

620

613

567

509

Friday
Aug072015

Pharmaceutical Industry in Transition

By Clive Riddle, August 7, 2015

KPMG has just conducted a survey of pharmaceutical and medical device companies, finding “their biggest commercial challenges coming from payers, surpassing hurdles posed by regulators, declining access to healthcare providers, and the move toward specialty drugs.”

Based on these findings, KPMG’s Bill Shew, Alison Little and Peter Gilmore have released a twelve-page report:  Change in pharma? Not optional; 10 Integrated imperatives for pharmaceutical commercial transformation.  Page two contains just these 35 words, in large font – which sums up the situation for pharma: “The pharmaceutical industry is caught between a blockbuster-driven past and a future  comprising precision medicine, curative therapies, and payment for outcomes. The years of consistent  double-digit growth and unconstrained pricing power are fading into memory.”

Author Alison Little tells us "life sciences companies face increasingly high demands from payers to prove the value of their products in terms of improved patient outcomes and lower costs. This requires not only clinical and analytical rigor, but increased focus on account management and strategy. This is a significant part of the commercial model for the pharma, biotech and medical device sectors, which need to evolve to compete in the future.  These are dramatic changes in bringing drugs to market and are far removed from the blockbuster model of marketing drugs with large direct-to-consumer advertising budgets and extensive physician detailing. Newer brand name drugs are treating much more complex medical conditions and have more stringent handling and administration requirements than those a decade ago. Pharmaceutical and biotechnology companies need to consider 'beyond the pill' services to help with patient engagement and helping them adhere to treatment."

Their report cites challenges for the industry including a paltry one percent annual growth rate for top 25 life sciences companies in 2014, down from double digits five years ago; and that seventy percent of recent brand launches underperformed analyst forecasts.

Without further adieu, here’s The ten “Imperatives for Commercial Transformation” they elaborate on, in their report:

  1. Use commercial tactics, not clinical data, to differentiate new products
  2. Elevate pricing and contracting within the organization
  3. Take a more holistic approach to stakeholder mapping and prioritization
  4. Base sales models on a collaborative approach to improving outcomes
  5. Play a larger role in the industry transformation from “volume to value”
  6. Support providers in improving quality and patient satisfaction
  7. Leverage data and analytics to enhance commercial strategies
  8. Allocate commercial resources optimally across markets and brands
  9. Evolve performance metrics and incentives to reflect new realities
  10. Drive the transformation agenda throughout the enterprise\

The author’s sum up where the industry needs go from here:  “Pharmaceutical companies need to transform their commercial models so that they can continue to thrive. In our evolving healthcare ecosystem, power centers are shifting, quantifiable outcomes are expected, and companies must demonstrate value for every healthcare dollar spent. We are approaching a tipping point when pharmaceutical companies, no matter the size or therapeutic focus, will no longer be able to view commercial transformation as an aspiration. Instead, they will need to recognize that it is a critical imperative.”

Friday
Jul312015

The Most Difficult Part Of The Patient-Centered Medical Home 

By Clive Riddle, July 31st, 2015

The medical home transformation for primary care, incorporating a team approach, technology, elements of care coordination and much more, has been a significant driver of change and innovation this decade. In the about to be released August issue of Medical Home News, the Thought Leaders Corner asks the question:  What was the most difficult part of the patient-centered medical home transformation that you experienced or observed? Here’s what the panel shared in their responses:

Sam JW Romeo, MD, MBA, of Tower Health & Wellness Center in Turlock, CA says  “having surveyed many organizations nationally for accreditation as a Medical Home, including the USAF primary care centers, the two hurdles (difficult parts of the PCMH) that are most prominent are: (1) payer emphasis on case management, and (2) cultural transformation needs within the medical profession. With regards to the case management emphasis, the payers want to save money first and foremost (‘quarterly reports’) more than provide care for patients.  They create the economic incentives and support structures to minimize, for example, hospitalization and ER use and, if per chance, they transform the provider to be more patient centric vs disease centric, whoopee!!  This transformation, however, is not often seen. With regard to the cultural change requirements, there is the ‘upstream’ challenge of providers being trained in medical schools and residencies to care for diseases in patients and not patients with or without disease.  The PCMH transformation requires providing patients with prevention (beyond immunizations and screening and the typical PQRS measures), wellness and lifestyle support, along with the care of disease.  The PCMH care model includes coordinating all of a patient’s care needs.  These needs include caring for the whole patient, i.e., body, mind and spirit, and this is not often in evidence.”

Joseph E. Scherger, MD, MPH, Vice President, Primary Care at Eisenhower Medical Center  and the Marie E. Pinizzotto, MD Chair of Academic Affairs at the Annenberg Center for Health Sciences in Rancho Mirage, CA states  “the most difficult part of adopting a PCMH model is changing how physicians and other providers work.  Implementing a care coordinator is not hard.  Having an advanced IT system is part of modern medicine.  But getting providers off the treadmill of many brief visits and spending time in longer visits with complex patients and doing population care coordination is a difficult paradigm shift.”

R. Scott Hammond, MD, FAAFP, Family Practice, Westminster Medical Clinic and Clinical Professor, University of Colorado School of Medicine, in Westminster, CO shares that  “Westminster Medical Clinic was early to the PCMH movement, being recognized in 2009.  Our biggest challenge was trying to understand exactly what we needed to do to satisfy NCQA standards.  At that time, there were few tracks to follow. I do not believe that is an issue now, as NCQA has improved and clarified their implementation guide. In retrospect, the most difficult part of transformation was sharing our vision of the PCMH with our entire staff and changing the culture of our practice to meet the patient-centered principles of the PCMH.  Only then were we able to operate as a collaborative team. This was also the most rewarding part of the journey.”

Mary Takach, BSN, MPH, Senior Program Director, National Academy for State health Policy, in Washington, DC opines that “The biggest challenge is exercising patience in the PCMH model and not pulling the plug after the first year or even the second year if there is no return on investment.  This is difficult for policymakers on both the public and private side -- especially for those under pressure to deliver balanced budgets.  Waiting for practice transformation to take root and move the dial on desired outcomes requires firm resolve and belief that the current system is broken and that transforming primary care delivery is the right direction to go.”

Nancy Meisinger RN, MBA, PCMH CCE, Director Of Practice Transformation, Delaware Valley ACO in Radnor, PA feels that “the concept of population management and proactive outreach to patients vs. waiting till they come into the office for a visit is often a difficult concept for the offices to put into practice in a systematic way.  In order to be effective it involves consistently documenting preventative and chronic care services within the EHR and maximizing the use of the clinical decision support tools.  Training of staff and use of protocols so that the process is as systematic and accurate as possible can be a challenge no matter what size patient panel the office manages.”

Amy Mullins, MD, CPE, FAAFP., Medical Director, Quality Improvement, American Academy of Family Physicians in Leawood, KS tells us  “much like patients, patient-centered medical homes are all different and the process to become one presents different challenges to different practices.  However, looking from a broad national view, physician engagement has proven to be a challenge for many.  Physicians are smart, busy, and highly motivated individuals who want to do what is best for their patients and eliminate any unnecessary work. To increase their engagement you need to prove to them that PCMH transformation will not only benefit their practice, but will positively impact the health outcomes of their patients.  Once physicians are engaged, the challenge shifts to empowering care team members and integrating the patient in team-based care, which is integral to the patient-centered medical home.”

David Tayloe, MD, FAAAP, Goldsboro Pediatrics in Goldsboro, NC is of the opinion that “educating providers about community resources has been, and continues to be, the most difficult step in transition to the patient-centered medical home.  Many children are at-risk for poor outcomes because of social determinants of health (poverty, parenting, education, substance abuse, abuse/neglect, mental health issues of caretakers).  These children need support within the community from various agencies.  Primary care providers must identify these children and refer them to necessary support services.  Many primary care providers are not aware of the support structure available in their communities.”

Jaan E. Sidorov, MD, FACP, Chief Medical Officer, medSolis and Author, Disease Management Care Blog, in Harrisburg, PA  says “changing established workflows is often underestimated.  There's a tempo to patient ‘throughput’ and the diversion of patients into new pathways involving other clinicians requires new space, hand-offs, duties, policies, and templates.  Unless carefully planned, patients' additional waiting times in office can balloon or they'll be waiting at home for a call that is hours late.  Increasing ‘stops’ in an episode of care doesn't increase work linearly, it complicates it exponentially.” 

And finally, George Valko, MD, Gustave and Valla Amsterdam Professor of Family and Community Medicine and Vice-Chair for Clinical Programs and Quality, Department of Family and Community Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, and Medical Director, Jefferson Family Medicine Associates in Philadelphia, PA shares that “sfter deciding to pursue becoming a PCMH, I think the initial application for recognition and all that it entails, was the most difficult.  To me, it was a forest vs. trees analogy -- the whole process, using the NCQA in our case, is quite overwhelming. However, while sifting through the standards and elements, it became clear that we, and most others, were meeting many of the requirements already.  And, if we were not already meeting some requirements, many were activities we should have been doing in any case.  Now, ongoing improvements to become a true medical home, including changing the culture of a practice, doing outcomes measurements, and creating a medical neighborhood are and continue to be time consuming and costly.”

You can check out Medical Home News at www.MedicalHomeNews.com.