Entries in Cost & Utilization (50)


Midwest Business Group on Health’s Quest to Reduce Elective Preterm Deliveries

By Clive Riddle, March 2, 2012

Last week,  Larry S. Boress, President & CEO of the Midwest Business Group on Health was one of three featured speakers in the HealthcareWebSummit event: Managing an Increasing Trend of Elective Preterm Deliveries.

MBGH has taken a keen interest in facilitating a reduction in elective preterm deliveries, and Larry shared why purchasers have gotten involved, and what they are doing about it.

Larry’s opening arguments were:

  • Maternity care is the number one reason for hospitalization among employee populations
  • The highest cost for maternity care is when underdeveloped infants are treated in the neonatal intensive care units of hospitals
  • Preterm infants are less likely to survive to their first birthday than infants delivered at full term
  • Those preterm babies who do survive are more likely to suffer long-term costly disabilities than infants born at term

He shared 2009 Data compiled by Thomson Reuters for the March of Dimes, which compared average expenditures for newborn care yielding $4,551 for uncomplicated cases vs. $49,033  for premature/ low birth weight cases.

So what exactly is an early elective delivery. Larry offered these characteristics:

  • The newborns delivered with a gestational age between the 37th and 39thcompleted week, that were delivered electively
  • Early elective deliveries are performed on women of all backgrounds and incomes.
  • These are distinct from early deliveries performed due to clinically-appropriate reasons to avoid health problems facing the mother or the infant

And what is the scope of early elective deliveries? We learned that the national average is up to a rate of 17% of deliveries, while the Leapfrog group has set a current target at 12%. Minnesota, South Carolina, Indiana and Arizona all have rates above 25%. Virginia, Florida, and New York exceed 20%. While 53% of hospitals are at or below the Leapfrog target of 12%, 33% of hospitals have rates of 20% or higher (6% of hospitals have rates of 45% or higher.)

What are the motivations to have an elective preterm delivery, despite the dangers and costs? Larry cites these delivering physician convenience factors: (A) Guarantee attendance at birth;  (B) Avoid potential scheduling conflicts; (C)  Reduce being woken at night; and (D) the NICU can handle it. Furthermore, Larry offered these motivations for the mothers:

  • Prior bad pregnancy
  • Desire to deliver on special date or holiday
  • Special circumstances
  • Cultural factors
  • Ability to  plan in advance for birth
  •  Convenience
  • Ability to be delivered by her doctor
  • Maternal intolerance to late pregnancy
  • Excess edema, backache, indigestion, insomnia

But there are serious quality implications of non-medically indicated early deliveries beyond cost that Larry cited:

  • Increased NICU admissions (and separation from mother)
  • Increased respiratory illness
  • Increased jaundice and readmissions
  • Increased suspected or proven sepsis
  • Increased newborn feeding problems and other transition issues
  • Under developed brain and lungs
  • Potential development of cerebral palsy

The good news is this is now a national quality measure for the National Quality Forum (NQF); Leapfrog Group; The Joint Commission; and AMA Physician Performance Consortium Measure.

Larry closed by noting that in the twelve months since MBGH made its initial Call to Action to reduce elective preterm deliveries, over 70% of hospitals reduced their early elective delivery rates below previous levels, and many have set 5% as their goal.


Thought Leaders Thoughts on Readmissions

By Clive Riddle, January 20, 2012

Health Policy Publishing LLC this week launched its inaugural issue of Readmissions News, which is targeted at stakeholders interested in the management of hospital readmissions. One of the features of the new monthly newsletters is a Thought Leaders corner, and in this issue, experts were asked "Do you feel significant potential savings and improvements from further reductions in hospital readmissions can be achieved through the current set of public and private initiatives, or are expectations too high?"

Here are excerpts of what they had to say in response:

Randall Krakauer, MD, FACP, FACR; Aetna’s National Medical Director, Consumer Segment said in part “….The potential for impact has been demonstrated with several different programs under different conditions.  However, there is still a significant opportunity to broaden these efforts and create additional improvements in quality and savings.  Aetna has partnered with Dr. Mary Naylor at the University of Pennsylvania School of Nursing in developing and implementing a transitional care model that has resulted in improved quality and reduced costs for our Medicare Advantage members.  The demonstrated potential creates an imperative that public and private organizations work together to continue to expand these initiatives.  We should expect these types of programs to be as much a part of health care delivery as any other public health measure with demonstrated and accepted value.”

 Jeff Lemieux, AHIP’s Senior Vice President, Research, gave a response that included:  “The 20 percent reduction in readmission rates proposed in the Partnership for Patients Initiative sets an initial target for all stakeholders.  However, preliminary studies of variation in readmission rates across regions and plan types – and the measured success of certain transitional care programs – suggest that larger reductions may be possible.  We should aim for across-the-board improvements in all hospitals and for all patients, whether coverage is through public programs or employer sponsored insurance.  We should track progress on readmissions in the context of overall hospitalization rates….”

William J DeMarco, MA, CMC, President & CEO, Pendulum Healthcare Development Corporation, included in his response:  “…Hospitals that dropped their home health agencies need to rethink how they can realign the existing home health system or expand their own to take the pressure off of doctors by having these agencies step in with skilled nursing and custodial care.  This may include cross training people to come to the aid of those with chronic conditions early instead of having these patients filling the ER.  Several HMOs and some hospitals are building ‘navigator’ programs to attract and train people who are not professional RNs or LPNs but can be trained to watch for signs of a chronic care patient losing their way on the path to improved health status….”

Brian Jack MD, Professor and Vice Chair, Department of Family Medicine, Boston University School of Medicine / Boston Medical Center;  concluded his remarks with:  “….A variety of implementation demonstrations for hospital based transition programs such as RED, BOOST, STARR, and H2H are gaining momentum and allowing researchers to study what works and what does not.  Across the country there is now a long list ‘early adopter’ hospitals that have demonstrated remarkable reductions in readmission rates.  All this effort is forcing hospitals and communities to work together as partners, a necessary ingredient for successful ACOs.  However, safe readmission reduction can only happen if hospitals have well developed community-based partners, particularly primary care partners, willing and able to care for patients in the community.  We need to ensure that this primary care safety net is available for patients.”

Alexander Domaszewicz, Principal, Mercer, concluded  “…. real, sustainable improvements that don't require constant oversight, monitoring, and effort will likely take a shift in marketplace practices driven by payment practices. HHS not paying for readmissions caused by ‘never events’ and guarantees like Geisinger's pledge to not charge for readmissions after heart surgery within ninety days are key examples of how to get every facility and practitioner keenly focused on eliminating readmissions.”

Benjamin Isgur, Director, PricewaterhouseCoopers LLP's Health Research Institute, continued his discussion, asking  “….How responsible should hospitals be when community doctors or patients fail to follow discharge instructions?  Can hospitals realistically cut readmissions when so much is out of their control?  However, it is possible to reduce preventable readmissions if hospitals address three major issues: discharge planning, length of stay, and closer alignment to physicians.  All of these issues relate to focusing on the total health of a patient instead of performing a procedure. ….”

Peter Kongstvedt, MD, FACP, Principal, P.R. Kongstvedt Co., LLC , opened his reply with “We’re going to see modest improvements at best until we address the lack of coordination and follow up in both the transition from inpatient to outpatient and coordinated outpatient management of patients with multiple chronic diseases. Many of the approaches to managing patients with multiple complex diseases are able to demonstrate improvements in quality, but few demonstrate improvements in overall costs.  The exception is nurse-led teams involving multiple clinical disciplines and access to physician support…..”

Finally, Martin S. Kohn, MD, MS, FACEP, FACPE, Chief Medical Scientist, Care Delivery Systems

IBM Research;   concluded his remarks by saying  “….Many organizations have substantially reduced re-admissions using current technology. The greater challenge will be reducing all admissions, over longer periods for more patients.  A patient will not view a re-admission on the 31st day differently from an admission on the 29th day.   Keeping more patients safely out of the hospital will require enhanced population and predictive analytics to personalize the prevention programs to make them economically efficient with improved outcomes.”

A complimentary copy of the inaugural issue of Readmissions News can be obtained by visiting http://www.readmissionsnews.com/sample_issue.php


Health Net Said: ACEP Said – A Dustup Over Emergency Room Use

By Clive Riddle, September 9, 2011

Yesterday Health Net released what they thought was a benign media statement on Emergency Room use, entitled “Know When the ER is the Right Choice for Care.” The health plan opened by stating “with flu season waiting in the wings, emergency rooms nationwide will likely soon be crowded with those who’ve been bit by the annual bug and who are mistakenly seeking treatment in the ER instead of in their primary care physician’s office or in an urgent care setting. In advance of these yearly throngs, Health Net, Inc. (NYSE:HNT) is working to increase awareness regarding when it’s appropriate to visit an emergency room.”

Jonathan Scheff, MD, Health Net’s Chief Medical Officer tells us “while emergency rooms play a vital role in our communities by providing lifesaving services, many ER visits are unnecessary” and goes on to say   “because the most serious cases are treated first in emergency rooms, those with non-emergency needs can expect extended waits.”

This wouldn’t seem like controversial stuff to most, but Health Net then goes on to state “the American College of Emergency Physicians (ACEP) points out that it’s in everyone’s best interest to reserve emergency rooms for those who are seriously ill or injured” and cites the ACEP’s list of warning signs for adults and for children a medical emergency that should demand immediate attention.

And it would seem Health Net might not have consulted and collaborated with the ACEP on their release.

ACEP fired back a media release the same day:  “ACEP Takes Issue with Statements Made Today by Insurance Giant Health Net, Inc. Regarding Emergency Visits.”  Dr. Sandra Schneider, President of ACEP tells us “the nation’s emergency physicians take issue with the efforts of health insurance companies to prevent emergency visits. It may save some money for them, but it’s bad for patient health and potentially life threatening. It also violates the spirit of the prudent lawperson law, which requires insurance plans to pay for emergency care based on whether an average person would believe they have the symptoms of a medical emergency.  In addition, emergency care represents less than 2 percent of the nation’s health care dollar, so preventing emergency visits will never put a significant dent in the nation’s soaring health care costs.”

The two organizations have different takes on using National Center for Health Statistics data. Health Net states  “according to the National Center for Health Statistics, of the more than 300,000 Americans who are treated in our nation’s ERs each day, the majority don’t require emergency care.”  ACEP cites “less than 8 percent of emergency visits are classified as nonurgent by the National Center for Health Statistics, which also says “nonurgent” does not mean unnecessary. Nonurgent visits can include broken bones and kidney infections that require treatment within two to 24 hours.”

Doctor Schneider closes with “these health plan tactics are dangerous because it puts people in situations of having to self-diagnose their medical conditions — out of fear the plans won’t pay, for example, when their chest pain turns out to be heart burn. Health plans send messages to their beneficiaries not to make any “unnecessary” emergency visits. But it’s not that simple — I’ve seen people with mild symptoms turn out to have life-threatening emergencies. ….This is a very simple message we want to share with all Americans — if you think you’re having a medical emergency, go to an ER immediately. Leave the diagnosis to the experts: emergency physicians.’”

Health Net, in its defense, closes with the tip: “for more information about when emergency care is needed, as well as about injury prevention, visit http://www.emergencycareforyou.org .” This web site, by the way, is operated by the ACEP Foundation.


Big Bump in Emergency Department Use of CT Scans

By Clive Riddle, August 11, 2011

Keith Kocher, M.D., M.P.H., a clinical lecturer in U-M Department of Emergency Medicine, was lead author for a 14 page paper just published in the August issue of Annals of Emergency Medicine:  “National Trends in Use of Computed Tomography in the Emergency Department” [doi:10.1016/j.annemergmed.2011.05.020]. They examined national data for CT Scan use in EDs from 1996 to 2007, using CDC’s National Hospital Ambulatory Medical Care Survey, that involved 1.29 billion weighted records of emergency visits , 97.1 million of which included patients who received a CT scan.

Kocher’s team found that the “rate of CT use grew 11 times faster than the rate of ED visits during the study period. The study also showed that the use of CT scans was less common early in the study period, but rose significantly over time. Just 3.2 percent of emergency patients received CT scans in 1996, while 13.9 percent of emergency patients seen in 2007 received them.”

Doctor Kocher tells us "this means that by 2007, 1 in 7 ED patients got a CT scan. It also means that about 25 percent of all the CT scans done in the United States are performed in the ED. There are risks to overuse of CT scans, because each scan involves radiation -- so if they’re done for marginal reasons you have to question why. For example, patients who complained of flank pain [pain in the side] had an almost 1 in 2 chance of getting a CT scan by the end of the study period. Usually most physicians are doing that to look for a kidney stone, but it’s not clear if it’s necessary to use a CT scan for that purpose. I think a lot of the increase is related to changes in how doctors practice medicine and the availability of CT scanners. They provide lots of information quickly and so doctors and patients see CTs as a means of arriving at diagnoses efficiently and conveniently. Couple that with the fact that CT scanners are commonly housed in or near the ED itself, and the barriers to getting the test done are lower than in the past."

On the other hand, they note that “patients who received a CT scan in the beginning of the study had a 25 percent chance of being admitted to the hospital directly from the ED, while by 2007, this rate had been cut in half…[and that] this difference suggests that CT use may also prevent ICU admissions, perhaps shifting these hospitalizations toward a non-ICU bed. In general, however, the effect of CT use in the ED and hospitalization or transfer appeared to diminish after 2003 when the adjusted rate flattened and stabilized between 10.8% and 12.8% despite a continuing increase in overall CT use.”

They also note that “for all of the 20 most common reasons patients came to the ER for treatment, the study found that CT use increased during the study period. However, CT use was particularly high for the following complaints” [% of visits with CT scans indicated] impairments of nerve, spinal cord or brain function (50.7%); flank pain (43.3%); convulsions (38.9%); vertigo, dizziness or light-headedness (36.3%); headache (32.5%); abdominal pain (31.7%); and general weakness (25.6%).


Health Insurance is Good For You (?)

Kim Bellard, July 11, 2011

Finally, a study that indicates health insurance is good for you! 

Granted, the study looked at Medicaid, for a low-income population, in a specific state, but in a time when health insurers are commonly castigated as villains, perhaps they can take some comfort in the findings.  Or perhaps not.

A brief recap of the study.  In 2008 Oregon realized it had funds to expand their Medicaid rolls (having substantially dropped them several years earlier).  They knew demand would exceed the number of slots available, so they set up a lottery that allowed potentially eligible consumers to enter; almost 80,000 did.  Researchers realized they finally had a classic study design – populations randomly selected into those who got health insurance and those who remained uninsured.  This appears to be the first such ever done when it comes to health insurance. 

The results from the first year indicate that those with health insurance did appear to benefit.  I won’t recap all the results, but some examples include that the newly insured saw doctors 35% more often, went to the hospital 30% more often, got mammograms 60% more often, and were 25 percentage points more likely to say their health was good or excellent.

Not surprisingly, they also cost 25% more.

The increased utilization may be partly an artifact of the so-called “woodwork” effect, i.e., people tend to use benefits more when they first get them (or, conversely, are about to lose them).  The researchers are continuing to mine the data, looking in particular at longer term impacts on health results.  Those extra doctor or hospital visits may or may not actually be improving health; several of my previous blogs (e.g., here) have discussed some of the overuse and errors that appear to be prevalent in the health care system. 

Earlier studies have tried to quantify the impact of health insurance, or lack thereof, have on health outcomes, such as those by the IOM or Mathematica.  Numbers like 44,000 deaths annually attributable to lack of health insurance have been claimed.  It’s not even only a matter of the uninsured not receiving services; even when they obtain services they may have worse outcomes.  Another recently released study indicates that payor status impacts mortality and morbidity for patients undergoing cardiac value operations, with privately insured patients faring better than either the uninsured or those with Medicaid.  So, any way you cut it, having insurance seems like a good thing. 

Clive Riddle recently posted a blog that reminded us how disproportionate health expenditures are distributed, with 5% of the population accounting for about half of the spending.  The fifty percent of the population with the lowest spending accounted for only 3% of all spending.  And that, for insurance purposes, is good.  Historically, and still true in other sectors, insurance is supposed to protect against unpredictable and catastrophic losses.  Anyone can get hit by lightening, catch a rare virus, or develop cancer.  Protection for the high expenses caused by relatively rare events that are outside of the individual’s control is what insurance does best. 

Insurance doesn’t work well at all when the insureds either already are incurring expenses or know they soon will be; for example, persons with chronic conditions.  People in this situation are basically depending on the other insured people to subsidize their expenses.  The data that Clive cited in his blog also noted the persistence of high spending for persons with chronic conditions; high spenders are no longer primarily one-time catastrophic cases, but more often now involve ongoing situations.  At some point, low cost people may balk at continuing to subsidize higher cost persons who have ongoing expenses; many would argue that this is exactly what is happening already in the individual market.

Don’t get me wrong; I am all in favor of reducing financial barriers to care for low-income people.  I’m all in favor of ensuring that health expenses don’t bankrupt families.  Medicaid has many, many flaws, but in any health care system we’re likely to get there will need to be some kind of special consideration for populations on whom financial burdens of health care fall hardest.  Where I start to scratch my head is how far those special considerations need to apply.

A common perception seems to be that without essentially full or low cost coverage for services, people will not get them.  The antipathy towards high deductible or consumer-directed health plans reflect this, with critics fearful that consumers will not behave responsibly when they are accountable for the initial deductible of a few thousand dollars.  PPACA similarly added requirements for coverage without cost-sharing of various preventive services, on the premise that consumers are too irresponsible to obtain services if they bear any financial burden when obtaining them.

A little Insurance 101 might be helpful.  If 100 people are covered, and one of them is likely to incur a $100 charge, then charging an annual premium of $1 per person (plus an add-on for administrative overhead) suffices.  However, if every person was going to get, say, an annual preventive visit that cost $70, then each person will have to pay a $70 annual premium (plus the add-on for administrative overhead) to pay for that visit.   There is no insurance, simply dollar trading with a mark-up. 

For skeptics who say people are irresponsible and won’t obtain appropriate services if there is cost-sharing for them, then I would argue (and have, here) that we have a far bigger problem.  Rather than waiving any financial involvement from patients, we’d be better off figuring out how to motivate patients to take better care of themselves and how to motivate physicians to ensure their patients are doing so. 

I.e., it’s not the coverage; it’s the behavior.  Coverage is necessary but not sufficient.  Sadly, we’ve built our delivery system and much of our health behavior around what insurance pays for rather than around makes the most sense from a health outcomes standpoint.  Or perhaps we’ve built our coverage around what is easy to pay for rather than what we should pay for.   Either way, it’s a problem.

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