Wednesday, April 16, 2014

HDI Podcast Series with Steward Health Care Network

Healthcare Data Insights Podcast Series
 Below is a teaser from our podcast series. Thank you to our participants...

John Donlan, Chief Operating Officer
Dominique Morgan-Solomon, Vice President, Population Health
Steward Health Care Network

What are some of the challenges you faced when implementing data-driven strategies and how did you overcome them?

Dominique: We are a very heterogeneous network, we have over 2700 providers. With that we are on over – I want to say at least 30, but there are more than that – EMRs. They all look different and the data coming out of them is different. So, our challenge over the last two years has been about how do we integrate or aggregate the data that’s coming out of those EHRs such that we can use it and use it in a much more real-time fashion because that’s really what’s meaningful. That’s one of the larger challenges.

We also have the challenge of while we sit on the Network – and I’m glad that John described the larger system – we are part of a larger hospital-based system and so how do we integrate information that is coming out of those EMRs, along with the information that is coming from the ambulatory-based provider’s EMRs to be able to get to the clinical data that is necessary for us to be able to identify the population. As well as from a performance perspective, be able to articulate who are the people who fall into various populations, like our diabetic and our heart failure patients. A lot of that information is defined based off of clinical measures and not claims-based measures. So, getting access to that data is one of the larger challenges that we face.

One other challenge that is tied into that is getting information in a real-time manner. One of the interesting challenges of being part of a pioneering ACO is that the population turns over on an annual basis. While we retain a significant proportion of the population year-over-year, when January 1st comes along, we have either an influx of new patients or potentially an out flux of old patients based off the methodology that CMI uses to do attribution. Because of that, in order for us to effectively impact that population in a real-time manner, we have to be able to pull data out of systems and use real-time information so that we can quickly stratify, identify and engage that population within a less than 12 month period in order to make an impact in that performance year. So, timeliness of data, I would say, is a huge challenge in the integration of the heterogeneous system that we have within our Network are two of the biggest challenges that we’ve had with data.

Now, how do we go about overcoming them? We’ve engaged some partners who have helped other organizations resolve this problem and who have some background and experience in being able to access various EMR data sets and integrate and aggregate that data. Certainly, it’s a challenge that I wouldn’t say today that we’ve overcome it, but we have a plan to overcome it and we’re moving forward on it. But, I would also say the other quick and dirty, so to speak, are boots-on-the ground way of overcoming, which is what I said before which is we have to spend a lot more time engaging providers and members themselves to get to some of the information that is more actionable in a real-time basis.

As John mentioned, we have a very robust governance structure, but underlying that governance structure is an operational structure where we have field operations teams that are aligned to a local chapter and aligned to our local provider groups so that they can be much more in the practices and much more engaged with the providers so that they can glean a lot of that information, like Mrs. Jones who has financial issues and that’s why she’s not filling her medications, which won’t be apparent in an EMR or we don’t have access to that information in the EMR quickly.

So, we’ve chosen in the interim – as well as really trying to leverage the medical home kind of model – we leverage our field operations team being much more embedded in our local chapters. The folks who make up those teams are both clinical, as well as operational in nature. So, our performance improvement advisors are really working on workflow enhancement and work hand-in-hand with a nurse care manager and social workers and pharmacists who are also working with the providers to best identify and manage the populations for which they serve.

To hear more from Steward Health Care Network, join us June 23rd through 25th in Chicago for IIR’s Healthcare Data Insights Conference.

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Friday, April 11, 2014

Download Gorman Health Group’s expert summary of the 2015 Final Rate Announcement from CMS

John Gorman predicted that -- if the rate announcement was enacted as outlined in the draft call letter -- it would be "just about a worst-case scenario for flabby, distracted, uncommitted health plans in Medicare."  John declared "there is no question that the 2015 call letter is an evolutionary event and some inferior species will be eliminated."

Now that the Final Rate Announcement has been released we can finally get some concrete answers. Gorman Health Group's renowned financial and policy experts Bill MacBain and Jean LeMasurier are teaming up to provide a detailed analysis and summary of the final regulation.

While Jean and Bill are finalizing the Summary of the Final Call Letter, you can request a copy and we will notify you as soon as it is ready.  But while you wait, enjoy access to some additional resources.  Request a copy of the Summary here.

As an added bonus, Bill and Jean will also be hosting a complimentary webinar today from 2:00PM – 3:30PM to offer insight on the Final Rate Announcement from CMS. You will walk away from this session with critical to-do items and issues to tackle in order to ensure your success in 2015 and beyond. Register now. 


Reminder – Don’t miss IIR’s Healthcare Data Insights taking place June 23-25 in Chicago. Register by Friday 4/25 to save $400 on the standard conference rate.  For more information, click here.

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Thursday, April 3, 2014

Reminder - Complimentary Revenue Leakage Webinar | Register Now

Revenue Leakage:  Industry Definition, Insight and Best Practices to Mitigate Risk
Join us for a Webinar on April 14th—space is limited!
Reserve your Webinar seat here.
Mention Priority Code: XP1911WEB

Understand what ‘Revenue Leakage’ means to branded pharma, start-ups, generics, and biotechs with IIR’s 2nd Annual Gross-to-Net Accounting Forum’s discussion group chairs! 
• Collective Industry Definition
• Customer Segment and Channel impacts
• Financial Statement impacts (accruals, cash flow, forecasting)
• The industry risk between adjudication and audit —the need for continuous improvement.
• Industry best practices and next steps for mitigating risk and continuous improvement.   

Jennifer Sharpe, Revenue Analytics Gross-to-Net, daVIZta

From Big Pharma – Courtney Callihan, Finance Director, GlaxoSmithKline
From Small to Mid-Sized Pharma – Larry Breen, Director of Financial Planning and Analysis/Revenue Analytics, Sunovion Pharmaceuticals
From Generics – Roxana Santiago, Senior Finance Director, Gross to Net, Hospira Worldwide, Inc.

After registering you will receive a confirmation email containing information about joining the Webinar.

Keep the discussion going with our Chairs at IIR's 2nd Annual Gross-To-Net Accounting Forum

2014 Conference Highlights include:
• New tailored discussion groups to collaborate across Managed Markets, Commercial, Government Programs and Finance for Big, Small to Mid-Sized Pharma, and Generics
• First opportunity to get up close and personal with the AMP Final Rule at the pre-conference workshop
• Never-before-heard case studies on GTN automation and chargeback methodology, in addition to strategic forecasting panel discussions
• Quantifying approaches for the impact of Medicaid, 340B and Healthcare Reform

Register by 5/2 and save up to $400 off standard registration rates

If you have any questions about the agenda or event, please contact Ryan Geswell at or visit our webpage.

We look forward to seeing you June 17-18 in Philadelphia!

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Wednesday, April 2, 2014

Post-Hospital Syndrome: The Return to the Community After Hospitalization

Our guest blogger today is David Young, Ph.D., Vice President of the Center for Clinical Excellence at Seniorlink, the parent company of Caregiver Homes this year, Harlan Krumholz, MD, a cardiologist at the Yale New-Haven Hospital Center for Outcomes Research and Evaluation, published a provocative article in the New England Journal of Medicine titled "Post-Hospital Syndrome: An Acquired, Transient Condition of Generalized Risk". In the article, Dr. Krumholz reminds us that recently hospitalized patients are not only recovering from the illness or condition that prompted the hospitalization but are also experiencing a period of generalized risk for a range of adverse health events. He calls this an acquired "syndrome" that involves a temporary period of extreme vulnerability for other health problems.

Naturally, the post-hospital syndrome will vary from patient to patient based on a host of factors. However, care providers – notably those providing Home and Community-Based Services – should be on the lookout for changes in behavior that could include: heightened stress, sleep disturbance, medication changes, cognitive changes and deconditioning that can alter the ability to perform daily living activities. These changes often occur regardless of the original cause for hospitalization; it is a syndrome that can apply to all recent discharges in consumers – both young and old.

Home and community-based service providers, especially those assisting elders, should be comprehensively evaluating patients returning from the hospital for changes that might exacerbate the primary problem (that led to the hospitalization) as well as the syndrome of potential changes described by Krumholz. Details about the hospitalization should be gathered along with a comprehensive re-assessment of medical, functional and emotional status of the patient.

Critical-thinking questions should be asked. Here are some examples:

• Is the caregiver and family able to provide the post-hospital care needed?
• What is the potential caregiver strain (burden)?
• Does the caregiver need education about care requirements?
• Do caretakers have knowledge of the "red-flags" to look for so that decline can be identified early?

Dr. Krumholz suggests that community care providers use "risk-mitigation" strategies that go beyond the cause of the initial hospitalization to look at the potential for infection, medication adverse events, falling and confusion, just to name a few. He suggests that strategies aimed at reducing disruptions in sleep and pain be addressed. Good hydration and nutrition should be emphasized along with judicious, careful physical reactivation and re-introduction of leisure outlets.

Great care transition work in the community starts with great communication between all providers. When a consumer, especially an elder who needs help with several activities of daily living, returns from the hospital, a coordinated care team approach is advised; one that engages in a comprehensive assessment of patient requirements as well as the strengths and needs of the caregiver and family. By identifying areas of risk and then creating care plans that specifically address them in a person-centered manner, the risk of rehospitalization will be greatly reduced.

This is a "win" for all: the consumer is healthier and happier, caregivers feel more capable of providing the supports needed, and avoidable costs are eliminated.

To read more informative articles on person-first care planning, visit the Caregiver Homes blog here.

Caregiver Homes, the leader in Structured Family Caregiving, provides the training, support and financial assistance to keep around-the-clock caregiving in the home. Structured Family Caregiving (SFC) is a quality, 24/7 care alternative for consumers, caregivers, and the professionals who support them. The organization, a wholly owned subsidiary of Boston-based Seniorlink, Inc., is dedicated to helping elders with complex medical conditions and people with disabilities live with dignity and independence in their communities. Caregiver Homes employs highly-qualified professionals and specially-designed communication technology to empower family and community members to provide extremely effective, high-quality care at home while being paid for their commitment. The program was launched in 2005 and currently serves more than 2,000 consumers in Massachusetts, Rhode Island, Ohio, and Indiana, with plans to serve more states soon. For the professionals and families who collaborate with us, Caregiver Homes delivers safety, security, health, and well-being. Visit for more information. 

Monday, March 31, 2014

#GPSummit14: Day 3

Our live coverage from IIR's 6th Annual Government Programs Summit has been provided by Katie Lapins, Director, Huron Consulting Group and Lori Greene, Manager, Huron Consulting Group . 

It is the last day of IIR’s GP Summit with a focus on the 340B Program and it was well worth it to stick around.  Commander Krista Pedley, from the Office of Pharmacy Affairs (“OPA”), took us through the recent audits of Covered Entities (“CEs”).  Of significance is the number of CEs found to be requesting a Medicaid rebate for product purchased through the 340B program (“duplicate discounts”) and those diverting product purchased at the 340B discount for inpatient utilization (“diversion”).  Full audit results will soon be up on the OPA website along with the correction plans to be implemented by the CEs and CEs found to be violating terms of their agreements are required to submit their corrective action plan within 60 days of the findings or they face exclusion from the 340B program.

On the manufacturer side, the OPA is conducting its first manufacturer audit and is also developing documentation to assist manufacturers in their preparations for an OPA audit.  Manufacturers such as Daiichi Sankyo and Pfizer shared their experience in identifying duplicate payments and as Ed McAdam from Daiichi Sankyo stated, there is no silver bullet to fix this issue, but is a worthwhile investment for manufacturers to audit 340B transactions at least twice a year.  Not doing so means manufacturers could be “leaving money on the table.”  Identifying duplicate discounts and diversion may require a significant effort on behalf of the manufacturer, including the purchase of third party data in some instances, but the return on investment for many manufacturers has been worth it.

One other recent area getting additional attention is Gross-to-Net which was covered by Ankur Bansal from Alliance Life Science.   Bansal walked attendees through optimizing Gross-to-Net to help with accurately project Best Price the impacts of Medicaid liability.  With price increases, many manufacturers plot out the Best Price for three to five years and project sales by customer.  Pricing strategy teams that include marketing, contracting, brand management, and government pricing, can be important for manufacturers to fully understand the impact of price changes.  A price increase or decrease will usually have an impact on some, if not all, of the government price points, therefore, all price changes should include a comprehensive review, customer-by-customer and product-by-product, to understand the overall effect of the price change.  Ultimately, manufacturers want to find the “sweet spot” where revenues from both the commercial and government businesses are maximized.

As always, the IIR GP Summit was a success and we look forward to seeing you at MDRP in September and next year's GP Summit.

Friday, March 28, 2014

#GPSummit14: More from day 2

Our live coverage from IIR's 6th Annual Government Programs Summit has been provided by Katie Lapins, Director, Huron Consulting Group and Lori Greene, Manager, Huron Consulting Group . 

The theme around the afternoon sessions at this year’s GPSummit was documentation, documentation, documentation!!  The operational complexities when the Final Rule is published can be minimized tremendously if you have good documentation around your assumptions and processes.  One panel, led by Michael Panicaro from Revitas, focused on how manufacturers should be addressing their internal business objectives while developing an approach to identify the potential impacts of the Final Rule.  This session provided thoughtful insight as to how manufacturers should be preparing for the Final Rule and regardless of an organization’s size, how many products are currently marketed, or what is in the pipeline, every manufacturer will be affected.

Based on input from the conference attendees, most manufacturers have begun looking at what the Proposed Rule means to their organization, but few had gone as far as pulling data for modeling “what if” scenarios or advising other departments that could be impacted by the changes.  Most attendees expressed the opinion that CMS would issue the Final Rule by the end of May 2014, but a few others felt that it might be later in 2014.    As always there are going to be differences between what is in the Proposed Rule versus the Final Rule and interpretations and assumptions, especially before any additional guidance is issued, should always be documented.  Another point raised was that it is important that any assumptions or interpretations be consistent.  And of course, manufacturers should contact vendors to ensure that any system that provides data for the GP calculations, or performs the GP calculations, will be able to comply with the necessary changes and within the requisite time period. 

Food for thought…. One company in attendance has broken out the Proposed Rule into buckets.  For instance, with the possible expanded definition of “States” to include US Territories, which were previously excluded from the calculation of AMP and Best Price, the company located all of the data, entered it into their GP system, and analyzed the impact of the change to their numbers.  The biggest challenge for this company was locating where all of the data resided.

Tomorrow is another packed day focused on the 340B Program.  Of special note is the session with Commander Krista Pedley who oversees the Program.