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Managed Care

Editors Desk

Frank Diamond

Managing Editor

There’s a gap in the proverbial health care safety net that’s big enough for a whale to swim through.

People who are incarcerated, on probation, or on parole — what a recent study calls the “justice-involved population” — make up 22% of the 13 million newly eligible people.

“The justice-involved population has a higher disease burden than the general population, yet as many as 90% of justice-involved people lack health insurance at the time of their release from incarceration,” says the study, published in Health Affairs. “This disparity between disease burden and access can drive up the cost of health care, result in worse outcomes, and cause patients to seek care later than appropriate and in care settings that are often isolated and lack care coordination.”

The study — “Integrating Correctional and Community Health Care for Formerly Incarcerated People Who are Eligible for Medicaid” — points out that jails, unlike prisons, house inmates for a year or less. There is constant turnover.

“Jails admitted an estimated 11.8 million people in the 12 months preceding June 30, 2011, the period for which the most recent data are available,” the study states.

Of particular concern are rates of substance abuse and HIV infection. Because this population has high rates of poverty and unemployment, it’s not easy to blend in again.

“Seeking health care after release from jail is often a low priority, although there is evidence that treating medical and behavioral health conditions improves the probability of successful reintegration into the community.”

The study cites programs that reduced recidivism while addressing health care needs. But it says that access to Medicaid alone is not enough, and that “clinically and socially effective engagement in care can be achieved through robust collaboration between criminal justice personnel and community health providers.”

Sometimes, it’s just a matter of pushing the bureaucracy.

“Many people who leave the criminal justice system — and their new, community-based health care providers — must wait for weeks, if not months, for accurate copies of their medical records.”

Frank Diamond

Managing Editor

Remember when many predicted that accountable care organizations (ACOs) will save health care? A study by the Health Research and Educational Trust (HRET) states that “ACOs are entities willing to be held accountable for the costs and quality of care for a defined population of patients. When the ACA [Affordable Care Act] became law, such would-be organizations were likened by some observers to unicorns — they exist in our imagination, but no one has actually seen one.” (Certainly not Regina Herzlinger, PhD, as we reported here.)

Harsh, perhaps, but a recent study by the Centers for Disease Control and Prevention searched in vain for the cost savings in Medicare ACO pilots. The HRET says that “only 25% of physician practices have joined or formed ACOs, and another 15% plan to do so.”

Still, the trust looks on the bright side. “These findings clearly suggest that not only do unicorns exist but a significant number of physician practices find them attractive and they are propagating across the country.”

But are they propagating fast enough? Health care doesn’t need one unicorn; it needs a herd of them.

“Physician practices that are currently participating in ACOs appear to be relatively large, or to be members of an IPA or PHO, are less likely to be hospital-owned and are more likely to use more care management processes than nonparticipating partners,” states the study, “Physician Practice Participation in Accountable Care Organizations: The Emergence of the Unicorn.”

Practices that are already ACOs performed better in 25 measures of care management, patient engagement, and quality. That participating practices are large did not come as a surprise — smaller practices might lack the heft to do all of these things well.

The study states that 48% of practices have five or fewer doctors; and many others have fewer than 20. “The extent to which these practices can develop affiliations, alliances, or other forms of partnership to give them the size and infrastructure to participate in assuming risk for defined populations is a major question,” the study states.

Major indeed.

Frank Diamond is managing editor of Managed Care.

Frank Diamond

Managing Editor

Health reform means that much of what health insurance plans did is being taken on by providers. An obvious example is the Choosing Wisely campaign, an effort by physician professional organizations to cut down on overtreatment and overtesting.

The Affordable Care Act shifts a lot of the responsibility and financial risk onto providers, and some doctor groups are rising to the challenge, says John Cuddeback, MD, PhD, chief medical informatics officer for the American Medical Group Association. The AMGA represents a variety of physician group types. More than 130,000 physicians practice in AMGA member organizations, providing health care services for 120 million patients, approximately one in three Americans.

Cuddeback cites the Holston Medical Group (HMG), of Kingsport, Tenn., which has about 150 primary care physicians, specialists, and mid-level providers. In about 2.5 years, HMG reduced hospital admissions per month by 20% for Medicare fee-for-service patients and by 28% for Medicare Advantage and commercial patients. It’s saving about $23 per member, per month overall.

Holston Medical Group Hospital Admits Since 2011

Part of this was achieved by creating an ambulatory intensive care option – a place to keep patients for a few hours who are too ill to be managed in a physician’s office, but who don’t require inpatient hospital care. “They get them stabilized, even let them go home to sleep in their own bed – hospitals can be disorienting, especially for elderly patients, not to mention the risk of infection – and come back tomorrow for more treatment,” says Cuddeback. “The overall cost is much less, and the outcomes are better.”

For commercial contracts, HMG is 3.2% better than market in quality performance, 8.1% better than market in total medical cost. This is a good example of how compensation models are changing, says Cuddeback.

Frank Diamond is managing editor of Managed Care.

Peter Wehrwein


So last week it was all doom and gloom about Pioneer ACOs.

The buzz in health care wonkdom was all about 9 of the 32 organizations defecting from a program supposedly designed for the best and brightest of American health care organizations — with maybe more to follow. Accepting downside risk was just too perilous. Lags in getting data from Centers for Medicare & Medicaid Services (CMS) were undermining cost and quality control efforts. And the contradiction of being responsible (aka accountable) for the costs of Medicare enrollees but having no direct control over where they receive care — a central feature of the ACO model — was simply untenable.

But this morning CMS attempted to change the doleful Pioneer ACO tune with a long-awaited announcement of cost and quality results from 2012, the first year the Pioneer ACOs were in operation.

The government agency spin was unabashedly upbeat: The announcement characterized the results as “positive and promising”

The Wall Street Journal, which got the scoop on the results, was more measured (no surprise there). The headline on this morning’s front-pager is “Mixed Results in Health Pilot Plans.” But story creates a favorable impression with sunny quotes from executives whose Pioneer ACOs had good rookie years and will get back shared savings.

“We did great,” the Journal quotes Gary Gottlieb, president and chief executive of Partners Healthcare in Boston, as saying. “We saved about $14.4 million for Medicare and will get back a little over $7 million.”

Here are a few highlights from today’s CMS announcement:

  • Thirteen of the 32 Pioneer ACOs reduced costs enough to generate savings large enough to split with CMS. The total savings tallied up to $87.6 million. The Journal reported that an additional five Pioneer ACO generated savings but apparently not enough to meet the threshold required for a split with CMS.
  • Two of the 32 had shared losses, totaling $4 million. The Journal identified Atrius Health, a not-for-profit group in Massachusetts, as one of them.
  • All 32 Pioneer ACOs earned the incentive payments available for reporting quality measures.
  • Beneficiaries in 25 of the 32 Pioneer ACOs had lower risk-adjusted hospital readmission rates than regular Medicare fee-for-service beneficiaries.
  • Rates for blood pressure and LDL cholesterol checks of adults with diabetes were higher among the Pioneer ACO beneficiaries than they were for a comparison group of adult diabetics in managed care plans.
  • Seven of the 32 Pioneer ACOs that didn’t generate savings have told CMS they want to leave the Pioneer program for the less-demanding Medicare Shared Savings Program. Two want out of the ACO program altogether, although CMS is not saying which two. Here is a list of the nine ACOs leaving the Pioneer program:
    • Healthcare Partners of California ACO LLC; Los Angeles and Orange Counties, CA
    • Healthcare Partners of Nevada ACO LLC; Clark and Nye Counties, NV
    • JSA Care Partners LLC; Orlando, Tampa Bay, and surrounding areas in South Florida
    • Physician Health Partners LLC; Denver, CO
    • Plus (North Texas Specialty Physicians and Texas Health Resources; Tarrant, Johnson, and Park Counties, North Texas
    • Presbyterian Healthcare Services; Central New Mexico
    • Primecare Medical Network; Riverside and San Bernardino Counties, Southern California
    • Seton Health Alliance; Central Texas
    • University of Michigan; Southeastern Michigan
Frank Diamond

Managing Editor

Everybody else always knew that they weren’t really invincible, and now they seem to be grasping that fact as well. More than 70% of people 30 and younger say that having health insurance is very important to them, according to a poll by the Kaiser Family Foundation (http://tinyurl.com/insured-youth). These have historically been called the “young invincibles” because of their belief that chances are slim that they’ll suffer serious illness or injury and that, therefore, they don’t need to buy insurance.

While this may be actuarially true for the group, the individual exceptions are one of the reasons for skyrocketing costs, as we at Managed Care have pointed out over the years (http://tinyurl.com/invincible-coverage). The foundation decided to zero in on this demographic because the success of the Affordable Care Act may very well depend on it. The healthy younger people will need to join the insurance pool to cover the costs for the rest of us.

“While young adults are sometimes described as viewing themselves as ‘young invincibles,’ the poll findings indicate that many young adults worry about affording medical bills, particularly catastrophic ones,” the report states. “Among those ages 30 and younger, roughly two thirds say they are worried about ‘not being able to pay medical bills in the event of a serious illness or accident,’ while over four in ten say they worry about affording medical bills ‘for routine health care services.’”

The concern over catastrophic illness is the main driver for all demographic groups, according to the report. Three quarters say that protection against such events is the reason they want coverage, while 23% say it’s to pay for things like check-ups and prescriptions.

Frank Diamond is managing editor of Managed Care.

Frank Diamond

Managing Editor

Forget about patients not refilling their prescriptions. Many don’t fill them the first time, according to a study in the Canadian journal Plos One (http://tinyurl.com/non-adherence-study).

New prescriptions were given to 232 patients from April to August 2010 at St. Michael’s Hospital in Toronto. Twenty-eight percent exhibited primary non-adherence at 7 days after discharge; 24 percent at 30 days. Perhaps more surprising is that patients discharged to home had a better adherence rate (26 percent) than those discharged to a nursing home (43 percent). There were no significant demographic differences between the adherent and non-adherent groups. Participants were all 66 or older; the average age was 78.

“In some instances, nursing homes may not have robust systems in place to ensure that the discharge prescription is rapidly approved by the nursing home physician and then sent to a pharmacy,” the study states.

The analysis looked at adherence to antibiotics and medications for coronary artery disease, heart failure, stroke, diabetes, COPD, and osteoporosis.

“Primary medication non-adherence occurred despite the significant life event of a hospital admission and the interdisciplinary nature of the general internal medicine service at a teaching hospital,” the study states. “Our study demonstrates that primary non-adherence is not limited to the primary care setting and emphasizes that hospital discharge is an important time to be aware of the potential for primary medication non-adherence.”

We at Managed Care have reported on both medication non-adherence (http://tinyurl.com/Diamond-adherence) and the possible pitfalls in transitions of care (http://tinyurl.com/Diamond-transitions), keeping in mind the link between the two — which this study reinforces.

Frank Diamond

Managing Editor

The appropriate cliché at the appropriate moment can have an impact. For instance, hearing “the right hand doesn’t know what the left hand is doing” in a hospital might be enough to spin you right back out the revolving door. You know the horror stories. Wrong limb amputated. Forgotten utensils cozying up to innards for the long haul. Those are the sensational examples, but care coordination — or lack of it — was and remains a vexing problem. This story by Kaiser Health News describes it as health care’s “dirty little secret” but it’s something we’ve been reporting on for a long time.

Another phrase that goes way back: physician buy-in. Well, turns out that physicians may buy into care coordination in a big way. About 20 percent of physician practices now employ care coordinators, according to the 2013 Staff Salary Survey by Physicians Practice magazine, a practice management publication for doctors.

Editorial Director Bob Keaveney says that the time was right to include care coordinators in the publication’s survey. “Health care is changing,” says Keaveney. “We are theoretically doing away with the volume-based system of reimbursing providers and transforming into a value-based system that will pay for outcomes and quality of care. Outpatient medical practices typically have five or fewer physicians, and traditionally have not tried to perform complex, holistic case-management that might track patients on everything from their diet to their mental health status.

“That’s why we didn’t have it in the survey before. But in this era of accountable care, practices are realizing that outcome-based population-management is how they will increasingly be paid, and that will require coordination. So we thought it was time to ask whether practices are hiring care coordinators. Still, I was surprised to see that 20 percent have already done so.”

We’re betting that medical directors are pleasantly surprised as well. 

Frank Diamond is managing editor of Managed Care.

Frank Diamond

Managing Editor

Many economists wonder if health insurance exchanges will actually perform one of their primary functions when they open in October — increasing the competition among health insurers offering products to millions of new beneficiaries. This according to Stateline, a wire service for the Pew Charitable Trusts (http://tinyurl.com/Pew-exchanges).

States in which multiple insurers already compete are likely to see a continuation. States where one plan dominates — and Stateline lists 10 of them — won’t see any difference, according to economists. Of course, there’s always the possibility that insurers, attracted by a burgeoning market, will take the leap, but “Insurance companies have been mostly silent about their plans, with some citing uncertainty about federal and state rules as a reason for holding back,” according to Stateline.

Insurance companies might not be the only ones not to show for the party. The educated consumer, that much-talked-about but seldom-sighted person of interest, might also hold out. The Kaiser Family Foundation finds that a majority of Americans don’t know what exchanges are (http://tinyurl.com/exchanges-survey). 

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The study was done in March, so hope, if you wish, that a lot of education has gone on in the intervening months. But education is one thing; learning’s another. The Affordable Care Act did foresee the possibility that the uninsured might need some help getting coverage for the first time. So the ACA includes “navigators,” who will help people choose the coverage they need. But will there be enough of them?

California, for instance, wants 21,000 navigators. All of this adds to the costs which adds to the headaches which adds up, some would say, to a fine mess. And the starting pistol has not even been fired. 

Frank Diamond is managing editor of Managed Care.

Frank Diamond

Managing Editor

Sisyphus had to roll that boulder up the hill as punishment for deceit. Telling the truth has its own rewards, thankfully, because sometimes that too can seem a Sisyphean enterprise. Yet another warning that antibiotics are being overprescribed, this time in a letter in the April 11 issue of the New England Journal of Medicine (http://tinyurl.com/antibiotic-prescribing). The authors note that over 50 percent of antibiotics are distributed unnecessarily and find — surprise! — wide variation in prescribing patterns based on provider specialty, patient age, and location.

“Prescribing rates were higher among persons younger than 10 years of age and persons 65 years of age or older,” write authors Lauri A. Hicks, DO, and Thomas H. Taylor, Jr., MS. They examined 2010 data in the IMS Health Xponent database and found that 258 million courses of antibiotics were prescribed. Prescribing rates were highest in the South. The most frequently prescribed antibiotic agent was azithromycin.

Here’s some context: Almost 90 percent of Americans know that antibiotics can treat bacterial infections, but a third also believe that they can fight viral infections as well, according to a poll by the Centers for Disease Control and Prevention last year. More context? How about the soaring growth of antibiotic-resistant superbugs? Keep pushing that rock.  

Frank Diamond

Managing Editor

Clinician executives at health insurance plans can stop worrying about whether consumers are savvy enough to navigate the changing landscape of coverage and start worrying about how small businesses will fare under the Affordable Care Act. (Well, keep worrying about both because both will continue to be problems.)

Let’s just look at small businesses for now. Expect a learning curve, to say the least, according to a study by EHealth, the parent company of eHealthInsurance, a private health insurance exchange. (See:"Small Employer Health Insurance Survey" )

Only about 18 percent of the 259 small businesses that buy insurance through eHealthInsurance.com can confidently explain what a health insurance exchange is, while 62 percent say they don’t understand the concept at all. Another 20 percent have “only a vague understanding of the role that exchanges are expected to play.”

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Government run exchanges will be launched in October.  Not far away.

Fifty-six percent of businesses with fewer than 50 employees think that they need to provide coverage to workers or be fined, but the fine applies only to businesses with more than 50 people working at least 30 hours a week.

“I think chaos is not too strong of a word to describe what’s going on in this market,” Robert Hurley, EHealth’s senior vice president for sales and operations, tells Bloomberg Businessweek, a publication that minces no words in its headline: “Small Employers Are Clueless About Obamacare.”

For health plans, it might be a matter of “So little time; so much education that needs to be done.” Or is that the government’s job? What do you think?

Frank Diamond is Managing Editor of Managed Care