Population Health: Cockroaches, Health Behaviors, and Social Determinants

By Nalini K Pande, JD

I was at a conference a year ago on dual eligibles when I heard that a health plan was going to focus on pest control to help its patients. What? A health plan was going to hire exterminators for its patients? Then, I realized just how brilliant this idea was.  Cockroaches present numerous health issues, including triggering asthma attacks.  If you want to stop expensive Emergency Room (ER) asthma visits, then attacking the root cause of the problem would be a good start.  In essence, treating the asthma attack in the ER would be only one piece of the puzzle.  Focusing on how to make sure you don’t send your patient home to a cockroach infested housing complex would make much more sense.   Had the health plan stumbled upon something innovative, cutting edge and timely? Yes!  In fact, it did so by adopting a population health focus.  

What is Population Health?

Population health can be defined as  “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”  Population health shifts our concept of health away from individual, clinical health, and instead complements public health by emphasizing a more community health focus.  David Kindig’s County Health Rankings Model (below) provides a nice overview of key factors to consider beyond clinical care.  In fact, we see that health behaviors, social and economic factors and physical environment are even more critical to health outcomes.  Thus, if you want to improve the health of vulnerable, sick and poor populations, perhaps moving outside the clinical walls of the doctor’s office might be the best place to start.

County Health Rankings Model

Aligning Forces For Quality and Population Health

Aligning Forces for Quality (AF4Q) is the Robert Wood Johnson Foundation’s “signature effort to lift the overall quality of health care in targeted communities, reduce racial and ethnic disparities and provide models for national reform.”   These targeted communities, known as Alliances, have played a unique role in improving the population health of their communities. Alliances, as neutral conveners, have, among other things, created strong partnerships to improve Health Behaviors and address Social Determinants. 

Health Behaviors: Providers and health plans need to focus on activities that help identify and assist patients in managing their own care and modifying their health behaviors.  Their ability to proactively reach out to patients who need preventive and chronic care and help them access care management will require them to transform their systems for communicating with patients.  AF4Q Alliances have stepped up to help:

• • Puget Sound  Health Alliance conducted an outreach campaign to engage consumers in their health care.  Own Your Health is a campaign to empower consumers to become active participants in their own health and health care. 
•  
• • P2 Collaborative of Western New York worked with New York eHealth Collaborative (NYeC) to gather consumer input for the design of a patient portal to help New York state residents better manage their health and health care.
•  
• • Let’s CHANGE (Commit to Healthy Activity and Nutrition Goals Every day) is a partnership with the Healthy Memphis Common Table and the Shelby County Health Department to fight childhood and family obesity.  It includes 37 organizations spanning a broad spectrum of businesses, community-based organizations, and government.

Social Determinants: “Bridging the gap” between health care and population health stakeholders, includes a recognition of the importance of social determinants of health ranging from poverty, to education, to housing.     P2 Collaborative of Western New York is working with the Mayor’s Task Group for Creating a Healthier Niagara Falls on an empowerment approach for Niagara Falls. 

Can hospitals, health plans and other providers “go it alone” to address every category of Kindig’s model?  Perhaps the more important question to ask is: “Why would they?”  By partnering with community groups such as RWJ’s AF4Q Alliances, as well as public health entities, health systems can finally treat the whole individual and truly impact health outcomes. 


Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, population health, and emerging payment models including accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.
Follow @nalinipande

Last Chance to Save $600 to Medicare Congress 2015 is Friday!

Be prepared for the toughest operational and finance environment in Medicare!

Attend the Medicare Congress, Feb 3-5 in New Orleans to:

• Increase reimbursement with stronger Star Ratings
• Drive enrollment and retention through customer centric approach
• Ensure CMS compliance and prepare for audits
• Improve quality of care with higher performing networks
• Expand your network by meeting the needs of dual eligibles

Join us in February at the only event that gives you the freshest, newest, and adrenaline-charged content as we power through the next 50 years of Medicare! Download the brochure for full details.

Don't miss out on maximum savings for IIR' s Medicare Congress. You have until this Friday, December 12th, to save $600! Be sure to use the code: XP2007BLOG | Register here.

PLUS! Dual Forum and Stars University are back by popular demand. Click here to learn more.

$840 Million opportunity for AAAs to help primary care offices improve care quality

Via Care at Hand

The Centers for Medicare and Medicaid Innovation (CMMI) recently announced the Transforming Clinical Practice Initiative (TCPI), a new $840 million effort over the 4 years to support 150,000 clinicians in sharing, adapting and further developing comprehensive quality improvement strategies.

Although the funding will go predominantly to physician groups in the outpatient setting, part of the grant consideration will be based on the physician group applicants’ ability to partner with community organizations.

The funding will depend on achieving certain quality measures, many of which are best achieved through partnering with community-based organizations. Unfortunately, there is no reference to area agencies on aging (AAAs) specifically. However, if AAA leadership can quickly curate ROI calculators for AAAs to appeal to the grant applicants, there is a good chance AAAs can see revenue through this grant mechanism similar to their success with a similar funding mechanism in Massachusetts.

While this funding does not explicitly cater to AAAs like other CMMI initiatives such as the Community Based Care Transitions Program (CCTP), the TCPI may be a productive way for AAAs to diversify their revenue streams over the next four years.

Care at Hand is a 2014 FDA/CMS Summit for Payers event supporter. The FDA/CMS Summit for Payers is taking place next week, December 11-12 in Washington DC and it is not too late to register. Save $100 when you register with the code XP1917BLOG – Register now!

The Medicare Trajectory: Take the Healthcare Quiz

By Nalini K Pande, JD

Want to reduce the nation’s spending on healthcare?  How about your own healthcare spending? This quiz could help do just that.  “How” you ask?  It’s quite simple.  When we think about Medicare spending, we don’t often think about kids, young adults or even adults under 65.  But, we should.  The major driver of Medicare costs is spending on chronic disease.  How do we reduce this spending?  We get people like you and me to take care of their health, focus on prevention, and become an active player in the health system before we become Medicare-eligible.  In doing so, you could end up saving money.  And, we also engage those already on Medicare to better manage their care.  Certainly, this is easier said than done.  

Why is America so alienated from their own health care? Could it be that the health system has become so complex that you would have to be a health care expert to figure out what’s going on?  And, who has the time?  This holiday season as you dine with your loved ones and catch up on some good books, you might consider sharing this fun Healthcare Quiz.  This “take” on the 12 days of Christmas will teach you everything you need to know - well, at least 12 important health topics. 

Quiz Directions: Read the Healthcare Quiz and see how many of these terms you know.  Use the red short answer key to see what these terms mean.  You get 1 point for each numbered phrase/term you know for a total of 12 points. Want to earn extra points?  Then, read the “Detailed Answers” section below to learn why these 12 issues are critical to the health policy landscape and earn extra points.

Detailed Answers
(Give yourself an extra point for every detailed answer you know)

12 States Expanding: The Supreme Court has indicated that states can determine whether they will expand Medicaid to cover some of the uninsured under the Affordable Care Act.  Thus far, 28 states and DC have expanded Medicaid.  You get a bonus point if you know whether your state has expanded.  Click the link to see if you are right.

11 Measures Measuring: Health quality measurement is critical to improving the quality of health care services and identifying areas in need of improvement. Measures also inform consumers.  Check out the following consumer health quality sites: for hospitals (Hospital Compare), health plans (HEDIS), and doctors (HealthGrades), as well as an overview of all consumer sites.  Measures can be controversial given operational challenges, and concerns that incorrect inferences have been made from measures. All of this leads many to question how useful some measures are for determining true health quality. Now that I have you completely confused, let’s move on to the Exchanges.

10 Exchanges enrolling:  Also known as Health Insurance Marketplaces, the Exchanges are where both individuals and small businesses can go to shop for health insurance coverage.  Federal subsidies (premium tax credits) are available to consumers if they meet certain incomes requirements. Some states established their own Exchanges. Other states relied on the federal government to do so.  Open enrollment for 2015 coverage started Nov 15 2014 and ends Feb 15, 2015.

9 Duals pending: Dual eligibles are given this name because they are covered under both the Medicare and Medicaid programs.  They are generally the sickest and most costly beneficiaries of the Medicare and Medicaid programs.  Currently, 9 states are in the process of implementing a capitated (managed care) model with goals of improving quality and cutting costs for duals.  What’s pending is the evaluation.  It has yet to be seen how successful these initiatives will be.  Additional states are implementing other models as well.  What’s important is that HHS is focusing on ways to address this vulnerable and high-cost population that maintains strong quality standards while also reducing costs. 

8 Curves a bending: Bending the cost curve in the policy arena really means reducing costs over time.  If someone is acting like a know-it-all about some policy, just throw out the phrase, “but will it bend the cost curve?” and watch them quickly back away.  You get a bonus point if you use this phrase at work or with friends today.

7 COBRAs extending: The Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions require group health plans to continue your employer health coverage (18 months) if you have a qualifying event such as being laid off.  However, you will now pay 100% of the premium costs (not just a portion).  If you’re feeling really adventurous, you can also investigate whether the Exchanges give a better deal given their subsidies or check out your local health plan’s website (except in DC and VT) and shop around accordingly.

6 Health apps trending: Health apps are specialized programs/software often used on mobile devices that focus on health, nutrition or exercise programs.  What’s exciting is that a new app focusing on managing chronic conditions is out.  No longer do the healthy get to have all the apps.  Venture capitalists have been challenged to do more in the chronic condition app arena and it will be interesting to see this field develop further.  You get a bonus point if you have a health app on your mobile device and you use it.

5 Bundled payments!!! Bundled payments is a new payment model that transforms multiple claims into a single payment for one “episode” of care based on predetermined lump sum amount. Why is this important?  This new payment model may lead to higher quality and more coordinated care at a lower cost.  It essentially incentivizes providers to coordinate care and prevent costly and avoidable hospital readmissions. The jury is out as to whether this model will be a strong cost-saver. What is most critical is the cost transparency that the new reform represents.

4 EHRs: Electronic Health Records (EHRs) are seen as the wave of the future (and are currently being used in some health systems). EHRs allow doctors and hospitals to access your medical history, lab tests, allergies, immunizations, and radiology images all in one digital format.  EHRs improve quality, efficiency and care coordination across your care while reducing waste such as duplicative tests.  However, adoption has been slow, and transitioning from paper to digital has been challenging. Further, not everyone believes it is improving efficiency given additional burdens and high costs.  Addressing privacy and security issues are critical for successful implementation.  You get a bonus point if you already have access to your health records online (and another bonus point if you actually use it!)

3 Co-pays: A copay is a fixed amount that you pay when you visit the doctor’s office or when you buy prescription drugs. Why is it important?  As you probably have seen recently, your premium (how much you pay monthly for your health insurance), co-insurance (a percentage you pay of your medical bill) and your deductible (how much you must pay before your insurance will kick in) has been increasing over the years.  How can you effectively select a plan that will best meet your budgetary needs?  Hint: The lowest premium plans aren’t always the best.  They can have high deductibles and out-of-pocket maximums that might make a different plan a more financially appropriate choice.

2 ACOs:  An Accountable Care Organization (ACO) is a group of coordinated providers (doctors, hospitals) in which provider reimbursements are linked to improving quality and reducing costs for a  population of patients. Doctors get more money if their patients stay healthy and if they save money.  (This is unlike previous systems, where doctors are incentivized to reduce costs without always focusing on improving quality). ACOs are seen as cutting edge.  Whether they are the “next big thing” has yet to be seen.  Pioneer ACOs have seen some real success.

And a PCP in a Pear Tree! No, this is not the drug, PCP, but rather what we call in the health field, a Primary Care Provider.  Why is your PCP important?  Having a PCP leads to better health outcomes and reduced costs (through lower hospitalizations), including improved prevention and better coordination of care for those with chronic diseases. You get a bonus point if you have a PCP. 


What’s your Number? How many did you get right? 
• You get 1 point for each numbered phrase/term you knew based on the red answer key for a total of 12 points
• You get an extra point for every detailed answer you knew based on the detailed answers section above for a total of 12 additional points.  
• You get additional bonus points as indicated above for a total of 6 bonus points.

28+: Congratulations! You are a Health Guru. We need more experts like you!

21-27: Great job! You are a Health Professor.  Everyone in the office comes to you for help with their health questions.  Keep up the great work!

11-20: Nice work!  You are a Health Enthusiast. You are on your way to becoming an active player in the health system.  Keep learning and sharing what you know with others!

1-10: Hang in there!  You are a Health Rookie. Healthcare is a very complex topic. It's hard to understand health reform, health delivery system changes and payment reform when the existing system is so confusing. Keep learning!



Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, and emerging payment models including accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  She previously taught a graduate health quality course at Georgetown University as an Adjunct Professor.  Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.
Follow @nalinipande

Cyber Monday starts early! See details how you can save 30% on upcoming events!

To get a head start on the holiday season, as a blog reader, we’re giving you an extended chance to take advantage of our Cyber Monday sale. Register for any of the following IIR events and receive 30% off the standard rates. Mention code CYBER2014 when registering for each or any of the following:

IIR’s 12th Annual Medicare Congress 
February 3-5, 2015 in New Orleans, LA.  
Survive the toughest rate environment to date with lessons from top-notch healthcare executives.
Visit the event website.
Register here.
 
IIR’s FDA/CMS Summit for Payers 
December 11-12, 2014 in Washington, D.C.
Drive collaboration and innovation to succeed in a patient-centric environment.
Visit the event website.
Register here.

Have any questions? Email Jennifer Pereira.

*This promotion is only valid Wednesday, Nov. 26th 2014 until Monday, December 1st  2014. Offer cannot be applied retroactively to confirmed paying registrants and cannot be combined with any other discounts or promotions. All registrants and guests are subject to IIR approval.

Health Care Insights | Weekly Round Up

Health Care Insights brings you your weekly healthcare round up*. Below you will find relevant articles on key industry topics that we thought our readers would benefit from - enjoy.

Top Stories:
 
Healthcare's Big Data Opportunity
Global healthcare is at a pivotal moment in its history, on a par with Alexander Fleming’s discovery of penicillin and Louis Pasteur’s groundbreaking work with sterilization. As the quantity of data we generate rapidly expands and we continue to develop the computational power to store it, health authorities will be able to gather more information about their patients in a single year than has been open to them in all history.

Wearable Technology And Digital Healthcare Strategies Should Shift Focus To Chronic Medical Illness

As we marvel at the gadgets that companies such as Nike, Fitbit, Jawbone and Apple have recently produced and brought to market–gadgets that can record our heart rate, calories expended, and steps taken—one can only think of how this technology could likely be used on a greater scale to help those who truly need it the most: people with chronic medical illnesses such as emphysema, diabetes, or congestive heart failure.

 FDA approves Purdue's painkiller that can reduce abuse
The U.S. Food and Drug Administration has approved a long-acting narcotic painkiller with abuse-resistant properties made by Purdue Pharma L.P., the agency said on Thursday. The FDA approved the once-daily drug, Hysingla ER, with the expectation that it will reduce, though not necessarily prevent, abuse through snorting or injecting.

CMS Names Niall Brennan as Nation's First Chief Data Officer  
(Niall Brennan will be speaking at the FDA/CMS Summit for Payers)

On Wednesday, CMS announced Niall Brennan will become the agency's first chief data officer and will be responsible for overseeing efforts to improve data collection and transparency and leading the department's new Office of Enterprise Data and Analytics

Have a great weekend!


*Health Care Insights has no affiliation with any of the above publications. These articles are aggregated by our team based upon our audience's areas of interest.

Turn Population Health Data into Meaningful Disease Management Strategies

Via Health IT Analytics, a FDA/CMS Summit for Payers event supporter. View the complete article here.

How can providers turn population health data into meaningful chronic disease management?

When you hear the words “population health management” chronic disease care almost immediately comes to mind, diseases such as; diabetes, asthma, hypertension, and COPD. They sap billions of dollars from the healthcare system every year, and represent an enormous challenge for providers.  From medication adherence apps to appointment reminders sent through the EHR, providers have a range of tools at their disposal to track, corral, and encourage patients to manage their own care.

How can providers leverage these technologies while employing effective management strategies that provide patient-centered, population-minded care?

Which patient engagement, adherence strategies will work?

A provider can implement all the health IT in the world, but effective chronic disease management will still rely almost entirely on the patient’s willingness to engage with their care strategies, take their medications, and show up at their appointments.  Devising patient engagement strategies that produce measurable results requires an intimate knowledge of the targeted patient population, an understanding of what drives non-adherent behaviors, and a familiarity with technologies that truly appeal to patients.

For example, the patient population that is covered by Medicaid may face much different socioeconomic challenges than a privately insured community that receives support via their employers.

Dr. Margie Rowland, Chief Medical Officer of CareOregon said, "Many of our members are very poor and have literacy issues" She added, “It’s not just about taking the right pills or coming back for appointments, but it’s making sure people actually understand their illness and understand what questions to ask, or getting help with transportation to their provider - it’s not just health literacy.  It’s literacy in general.”

Different communities require differ services. For instance a non-english speaking population may require a translation service, while a rural population could require telehealth services to eliminate long drives.

Healthcare providers should be sure to assess their patient population before committing to any engagement strategy. The pairing of data with community feedback will provide a base for future efforts.

_____________________________________________

At FDA/CMS Summit for Payers, Michael Willis, PhD, Vice President & Business Information Officer at Kaiser Permanente will discuss how information technology shows tremendous potential in helping reduce disparities by improving access and information flow as well as communication between providers and patients. Session information below:

Health Disparities Using Technology to Bridge the Divide

Health disparities continues to be a major issue for our country. As our country’s diversity has grown we have also seen a parallel increase in health disparities. This presentation will focus on the challenges associated with health disparities and how Information Technology can be used as a catalyst for collaboration and education to measurably improve the lives of individuals and their families.


Register for FDA/CMS Summit for Payers now and take $100 off the current rate when you use the code XP1917BLOG.


Register Here!

Dual Eligibles and HIT: Managing Not Just Measuring

By Nalini K Pande, JD

Why is HIT Important to Duals?

There’s an old saying in the health care quality world: “We cannot improve what we don’t measure.”   And, of course, the follow-up to that is: “how can we measure without good data?” Health Information Technology (HIT) is at the heart of one the most exciting aspects of health reform.  HIT systems are designed to collect and display data related to the delivery and care of patients.  

Dual eligibles are covered under both the Medicare and Medicaid programs and are generally the sickest and most costly beneficiaries of the Medicare and Medicaid programs.  Given this, it is essential that HIT systems, including Electronic Health Records (EHRs),  are designed to supply actionable data for the measurement of dual eligibles and ultimately, to improve the care of this unique population and reduce costs.

Where Are We Now?

The future of the nation’s health measurement and  HIT agenda is at a cross-roads.  We are still in the process of changing old systems to move us into the health electronic age.  We are also in the process of developing and endorsing measures specific to the duals population.  As we do so, there are several key issues that we must focus on to improve the care of the dual eligibles population.  One issue that stands out above the rest is how to better manage this unique population, not just measure them.  It is not enough to just collect the data.   Rather, it is what we do with this data and the measurement findings that will ultimately lead to improvements in health outcomes and care delivery for dual eligibles. HIT can capture data that is critical in improving care coordination, care transitions and disease management for dual eligibles.  We must use this information to analyze clinical trends and better engage dual eligibles as well as help providers in clinical decision support.

It’s no surprise that in the world of health apps and iphones, we turn to HIT to revolutionize our health care systems and improve outcomes.  However, HIT alone is not the Holy Grail we seek.   Rather, HIT is only a tool to get us the data we need to measure and improve our patient outcomes, our clinical care, and our delivery systems.  The story cannot end with more measures and data.  Otherwise, we will simply collect a lot of good information without much action.  We must re-tool our delivery systems and health care culture so we can act on the data we capture such as changing patient care plans and engaging patients differently.  Essentially, we must focus on moving from health measurement to health management and outcome improvement.   This will take a stronger focus on analyzing the data, and measurement findings, using predictive modeling, and taking a more proactive rather than reactive approach.  Many Accountable Care Organizations and other health entities have embraced this new approach but it is far from the norm.  Can we afford to shift from measurement to management?  Many fear the cost of HIT alone is too great.   However, with duals costing Medicare and Medicaid $250 billion, can we really afford not to?



Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, and emerging payment models including health information technology, accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.

Follow @nalinipande

Health Care Insights | Weekly Round Up

Health Care Insights brings you your weekly healthcare round up. Below you will find relevant articles on key industry topics that we thought our readers would benefit from - enjoy.

Top Stories:

CMS Says Some Providers are Obstructing Dual-Eligible Demonstration
The CMS official in charge of coordinating care for Americans covered by both Medicare and Medicaid says some healthcare providers are illegitimately trying to dissuade dual-eligible beneficiaries from participating in a managed-care initiative designed to test ways to reduce costs and improve quality. She said her agency has increased its surveillance of these providers, though she did not identify any by name.

Plans Say Duals Bring Down Star Ratings, Beneficiary Advocates Not Convinced
(Subscription Required)
As CMS looks at possible changes to the Medicare Advantage star ratings program, health plans say that poorer beneficiaries are causing lower-than-appropriate star ratings for some MA plans, though the Medicare Rights Center says that current data do not show that beneficiaries' low income is the root cause of lower quality care for those beneficiaries.

Work Group Submits Comments to CMS on Sovaldi, Breakthrough Therapy Designation Medications
The Medicaid Work Group sent a comment letter to the Centers for Medicare and Medicaid Services on the introduction of Sovaldi and other new  Breakthrough Therapy Designation medications and their potential impact on Medicaid costs.

Vitamin B Doesn't Reduce Cognitive Risk in Healthy Elderly
Lowering plasma homocysteine levels with oral vitamin B12 and folic acid does not appear to be an effective strategy for reducing memory loss and Alzheimer's risk, according to findings from a randomized, clinical trial of elderly people in the Netherlands with elevated homocysteine.

Joint Commission Report: U.S. hospitals are getting better, but there is still room for improvement
If the Joint Commission‘s assessment of a hospital is any indication – and by just about all accounts, it’s the indication – hospitals across the U.S. are improving, with more than 1,200 having achieved “top performer” status. A total of 1,224 made that cut, an increase of 11 percent from last year. The top performers represent nearly 37 percent of more than 3,300 Joint Commission-accredited hospitals that contributed data, according to its annual report.



Have a great weekend!

Register for the FDA/CMS Summit for Payers by Friday 11/14 to Save $300!

Attend the FDA/CMS Summit for Payers to initiate the collaboration, with top government and key regulatory bodies working closely with healthcare leadership to join forces and build an open culture of harmonization to provide efficient and affordable healthcare to all patients.


This meeting stemmed from the infamous Solvaldi case, as the FDA approved the specialty drug to go to market but with it being so expensive, it caused major problems for the CMS and health plans. No longer can regulatory bodies work in silos, it's time for collaboration!

But hurry—time is running out! Register by this Friday 11/14 and save up to $300 off the two-day rate. Or, if budgets and time are tight, choose the one-day option and attend for only $895. Be sure to use the code XP1917BLOG to save.

Register Now! 

If you haven’t already done so, download the brochure to see the full speaking faculty, including some of the most influential people in health care.

See you this December!

Health Care Insights | Weekly Round Up

Health Care Insights brings you your weekly healthcare round up. Below you will find relevant articles on key industry topics that we thought our readers would benefit from - enjoy.

Top Stories:

A Post-Election Day Certainty: New Scrutiny for the Affordable Care Act
This week’s elections ensure a new round of political attacks on the Affordable Care Act, but they also create potential opportunities to repair provisions of the law that people on both sides of the partisan divide would like to fix.

Big data: Enabling the Future of Healthcare
Everyone’s talking about the importance of big data in healthcare. Yet, as the data piles up – most of it is isolated in different silos, and health systems are struggling to turn big data from a concept into a reality. Here’s how I see it having a substantial impact on the health of populations, today and in the future.

Electronic Medical Records, Built For Efficiency, Often Backfire
Electronic medical records were supposed to usher in the future of medicine. Prescriptions would be beamed to the pharmacy. A doctor could call up patients' medical histories anywhere, anytime. Nurses and doctors could easily find patients' old lab results or last X-rays to see what how they're doing. The computer system could warn doctors about dangerous drug combinations before it was too late.

Steward’s ACO focuses patient engagement efforts on 4 percent of covered lives
According to Girard, there are two fundamental processes in healthcare, information flows and people flows. The ideal, he said, is for both processes to be happening at the right time in the right place.

Coordinated care and patient engagement
The healthcare breakthrough of the 21st century may not come in the form of a miracle drug from the pharmaceutical industry. Rather, it's more likely to emerge from the ways caregivers interact and motivate patients.


Enjoy the weekend!

Five Steps to Get Started with Population Health Management

Via Health IT Analytics

Below is a snippet from an article by Health IT Analytics, an FDA/CMS Summit for Payers event supporter. To view the complete article, click here. 

Building a population health management program requires a strong vision and a data-driven strategy for providing high quality, coordinated care.

Population health management encompasses a wide and varied range of activities, including care coordination, chronic disease management, health information exchange, patient risk stratification, clinical analytics, community outreach, and internal quality improvement.  With so many different ways to approach what is basically a large-scale revolution in the way healthcare organizations views their role in patient care, it’s no wonder that many providers find it difficult to know where to begin.  What are some of the ways providers can start to build a population health management program that will produce better patient outcomes without breaking the bank?

1. 1. Clarifying goals and developing a roadmap
2. 2. Infrastructure investments and data analytics
3. 3. Engaging your staff members
4. 4. Engaging your patients
5. 5. Ensuring care coordination and follow-up

To learn more about each of the previously mentioned steps so providers can start to build a population health management program to produce better patient outcomes, visit Health IT Analytics where you can view the entire article.

Dual Eligibles and ACOs: A Blueprint for Success

By: Nalini K Pande, JD

Background:  Why Duals Need Stronger Focus and Attention

You may notice that when we talk about health reform, most health policy experts tend to bring the conversation back to the dual eligibles.  These beneficiaries are covered under both the Medicare and Medicaid programs and are generally sicker and costlier than Medicare and Medicaid beneficiaries as a whole.  Thus, it is no surprise that duals have been the focus of those trying to bend the cost curve.


ACOs May Be Uniquely Situated to Address Key Duals Issues

How do we improve the care of these beneficiaries while also working to reduce costs?  Accountable Care Organizations (ACOs) that take on dual eligibles, are uniquely positioned to provide effective solutions. An ACO is a group of coordinated providers in which provider reimbursements are linked to quality metrics and reductions in the total cost of care for an assigned population of patients. Given their emphasis on patient-centered, integrated care and coordinated Medicare and Medicaid benefits and funding streams, ACOs could facilitate greater quality improvements and reduce cost-shifting between programs as well as overall costs. Yet, the fundamental question still remains:  What is the blueprint for success?

Two core frameworks will need to be developed as part of a blueprint for success:
   • ROI Framework
   • Measurement Plan

Certainly additional key components will be necessary.  However, two critical components of the blueprint for ACO success are ROI (return-on-investment) and Measurement frameworks. First and foremost, a successful ROI framework is needed to ensure financial viability of the ACO structure: (e.g, hospitalization costs must be significantly reduced to pay for increased expenses in care coordination, care transitions, and care management). 

Second, a measurement framework will be needed to test improvements in quality.  Key measures should include patient-reported outcome measures, beneficiary experience, care coordination measures, utilization and cost measures, etc.

As part of this blueprint, the ACO must consider the barriers and challenges to changing the current system. How can the ACO overcome these barriers?  This will depend on whether the ACO can achieve a true culture change at three levels:

• • at the governing level with a stronger focus on clear and attainable management goals and benchmarks with diverse stakeholder input
• • at the clinical level with team-oriented care in order to improve care coordination and
• • at the community level with a focus on population health and collaboration with community organizations.

Can ACOs that take on duals bend the cost curve and improve quality? This has yet to be seen.  Setting ACOs up with a blueprint for success may be just what the doctor ordered.

Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, and emerging payment models including accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.

Follow @nalinipande

Health Care Insights | Weekly Round Up

Health Care Insights brings you your weekly healthcare round up. Below you will find relevant articles on key industry topics that we thought our readers would benefit from - enjoy.


Top Stories:

How The Upcoming Elections Might Shift The National Health Care Landscape
Here’s a solid prediction about next Tuesday’s elections: They’ll be crucial to the future of universal health care in America — or at least its near-term future.

Health Care Catches Data Fever
The United States is arguably in the midst of a health care crisis, but there is hope on the horizon and it involves learning how to make sense of big data. Over at Communications of the ACM, Oak Ridge National Laboratory (ORNL) shares how it is helping the health care industry benefit from patient data using the power of graph computing.

CFOs Feel Powerless When It Comes To Managing Healthcare Costs, Poll Finds
With U.S. enterprises spending more than $620 billion each year on healthcare costs, and nearly half of all Americans receiving their coverage through their employer, it’s no surprise that four out of five chief financial officers (CFOs) across all industries are feeling the pressure. In fact, nearly all CFOs (97%) believe that employers must “step-up” to the plate to help fix the broken healthcare system.

Omidria™ Granted Pass-Through Reimbursement Status from CMS
Omeros Corporation (NASDAQ: OMER) announced today that it has received transitional pass-through status for its lead product Omidria™ (phenylephrine and ketorolac injection) 1%/0.3% from the Center for Medicare & Medicaid Services (CMS), the federal agency that administers the Medicare program.

Health Groups Aim to Grow Pharmacists’ Care Delivery
Community Care of North Carolina (CCNC), GlaxoSmithKline (GSK), and the University of North Carolina (UNC) Eshelman School of Pharmacy have collaborated to generate new approaches to care delivery through pharmacists that will lower medical costs and improve health outcomes.

Have a great weekend!

The Medicare Congress Brochure is Now Available | Register Now to Save $600

The 12th Annual Medicare Congress was designed with you and your team in mind—covering Medicare and Dual Eligibles from A-Z. Make sure you join us this February 3-5 in New Orleans!


Let us help you navigate through the evolving landscape so you can increase reimbursement with stronger Star ratings, build relationships with provider networks to improve quality of care, meet the clinical needs of dual eligibles to attract and retain new members— and much more!

What’s new at Medicare Congress 2015:
• C-Level Sound Off
• Patient Advocacy Group Panel
• Think Tank Roundtable Luncheon
• Town Hall Round-up
• And more!

Download the 2015 Brochure Here.

Register now and SAVE $500 but use the code XP2007BLOG and take an extra $100 off – total savings of $600! Register here.

PLUS! Dual Forum and Stars University are back by popular demand. Click here to learn more.

Rising Drug Costs

Welcome to this FDA/CMS Summit for Payers podcast.

Below is a teaser from our podcast with Bill Winkenwerder, Former CEO, Highmark Inc.

Access the complete podcast and transcript here.

How should manufacturers determine drug prices and what consideration should there be?

Bill: Well, certainly manufacturers need to recover their costs – their investment in R&D – and it’s important that they make a profit. Nobody can be in business for any period of time without being able to make a profit. Now, more recently – especially with respect to certain manufacturers that have brought very expensive medications to the market – have been criticized and have been identified as charging too much. That’s the common perception, but I see the immediate evidence that the prices for these medications – given the relatively small population of people that would benefit from them – that there is a serious over-charging that’s going on. But, certainly we need to sit down and talk and determine if there is a better way to arrive at the price. What is a fair price? What is a good, market-based price? That’s what this Conference is about.


To see more from Dr. Winkenwerder, download the complete podcast here.

Download the updated event brochure here. 

Bill will be joining us at the FDA/CMS Summit for Payers in Washington D.C. for his closing keynote address "An Industry Perspective: Payment Policy for Clinically Valuable But Very Expensive Pharmaceuticals" on Friday December 12th.

Register now to save an extra $100 off the current rate with the code XP1917BLOG.

See you in Washington D.C.

Health Care Insights | Weekly Round Up

Health Care Insights brings you your weekly healthcare round up. Below you will find relevant articles on key industry topics that we thought our readers would benefit from - enjoy.


 Top Stories:

4 Principles Guiding Healthcare’s Age of Enlightenment
There are many emerging themes and movements driving healthcare innovation and evolution, which is comparable to the Age of Enlightenment with its new discoveries and ways of solving problems.

“There’s no mystery, no magic… you can access all patient data at the bedside“
 Katleen Smedts, Project Manager ICT at University Hospital Antwerp (UZA) and Bernard Algayres, GM Radiology IT EMEA, GE Healthcare, discuss how vendor neutral archiving can improve access to patient data, facilitate clinical collaboration and drive up quality of care.

Experts say Texas needs more than specialized centers to fight Ebola
Dr. Thomas Geisbert, a scientist at the University of Texas Medical Branch at Galveston, was at a conference in Germany in 2000 when he and a Canadian collaborator decided to work together on a vaccine against the deadly Ebola virus.

Avalere Analysis: Medicaid Managed Care Enrollment Set to Grow by 13.5 Million
A new analysis from Avalere Health projects that enrollment of Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries in managed care – i.e., state payment of private companies to provide benefits – will increase by 13.5 million individuals from 2013 to 2016.

CMS launches $840M effort to spur medical practice ‘transformation’
The effort, called the Transforming Clinical Practice Initiative, is a first-of-its kind effort from the public sector and large-scale investment dedicated solely to sharing information among physicians. CMS estimates that only about 185,000 of the country’s doctors take part in similar programs that strive to transform industry practices through the use of collaboration and technology.

Relaunched health IT company offers MDs chronic condition patient data between visits
A health IT company that previously provided migraine patient data to pharmaceutical companies, Ubiqi Health, has relaunched as Klio Health. The new business, which CEO Jacqueline Thong started earlier this year,  aggregates data from patients with chronic conditions with the goal of assessing effectiveness of treatment between visits through a portal.


Have a great weekend!

Center for Drug Evaluation and Research, New Drug Review: 2013 Update

FDA/CMS Summit 2014 speaker John K. Jenkins, M.D., Director, Office of New Drugs, Center for Drug Evaluation and Research, FDA.

 




Below you can access his presentation from last December at the FDA/CMS Summit. In his presentation, Dr. Jenkins addresses these key topics:

•    How is CDER doing with regard to meeting PDUFA goals?
•    What are the trends in new drug approvals?
          o    IND activity, NME submissions, and NME approvals
•    Implementation of PDUFA V/FDASIA
          o    “Program” for NME review
          o    Breakthrough Therapy Designation Program
•    Update on PMCs/PMRs


Dr. Jenkins also addresses the main themes in new drug review:

•    Continuing resolution – the new normal
•    PDUFA V; hold the additional resources
•    FDASIA implementation; what new resources?
•    The “Program” takes off
•    Breakthroughs breaking out
•    Sequestration bites
•    Shutdown shuffle
•    Patient-focused drug development refocused
•    “Slow down?” in NME approvals – not really
•    Despite challenges, new drug review program successes continue!

To access the complete presentation from Dr. Jenkins, click here.

Join us this December 11-12 in Washington D.C. to hear Dr. Jenkins address these challenges for the upcoming year. This is an event you do not want to miss. Register now and save $300 off the standard rate, just use the code XP1917BLOG at checkout. To register, click here.

mhpa2014, Medicaid Health Plans of America’s event for the Medicaid managed care industry

mhpa2014, the annual conference of Medicaid Health Plans of America and a must-attend for Medicaid MCOs, is on October 26-28 in Washington, DC.

mhpa2014’s sessions, expert insights, and networking receptions will provide health plan attendees all they need to succeed in the new age heralded by the ACA. 

Meet health plan executives, policy experts, state and federal Medicaid officials, and business leaders to discuss the latest in Medicaid managed care.

Speakers include CMS’s Barbara Edwards, CMO Dr. Steve Miller of Express Scripts, and John Lovelace, president of UPMC for You.

mhpa2014 also features Thomas Duncan, CEO of Trusted Health Plan, William S. George, CEO of Health Partners Plans, and Karen Clark, President, Horizon NJ Health, fielding questions from Forbes writer Bruce Japsen.

mhpa2014 will close with a discussion with Medicaid Directors from Kentucky, Louisiana, Tennessee, and Virginia.

For details, visit http://bit.ly/mhpa2014 
 
Questions? Contact Sarah Swango at 202-857-5772

What is the problem surrounding the emergence of new medications?

 

Welcome to the FDA/CMS Summit for Payers podcast series.

Below is a teaser from our recent podcast with Bill Winkenwerder, Former CEO, Highmark Inc. 

Access the complete podcast and transcript here.

Could you tell us a little bit about your background?

Bill: I trained as a Primary Care Physician and practiced for several years. I then became interested in the management of healthcare and population health. That led me to many years as a Medical Director and Chief Medical Officer and then as a Chief Operating Officer and then CEO. For several years I led the Military Health System – a very large job. I had the responsibility of caring for millions of American service members and their families. Most recently, I served as CEO of Highmark Health, which is a large, integrated healthcare delivery system.

Is there a problem with respect to the emergence of new medications that are truly effective for serious and life-threatening diseases, yet these medications are very expensive?

Bill: Yes, there is a problem. The problem is that the drugs are expensive. The problem is not that they are ineffective. In fact, that’s our challenge, that there are some really, truly, miraculous new medications that have come on the market and are going to be coming on the market in upcoming years. Targeted therapy – guided therapy – guided by pharmacokinetics and information that tells us exactly where to target the therapies. But, the problem is that these medications are expensive to develop. The pharmaceutical manufacturers have invested hundreds of millions – if not billions – of dollars into developing these medications and it’s important that they recover their costs.

So, it really does present a challenge for all of us – the pharmaceutical manufacturers, the providers, payers and government policy makers.

Download the complete podcast and transcript here.

Bill will be joining us at the FDA/CMS Summit for Payers in Washington D.C. for his closing keynote address "An Industry Perspective: Payment Policy for Clinically Valuable But Very Expensive Pharmaceuticals" on Friday December 12th. 

Register now to save an extra $100 off the current rate with the code XP1917BLOG.

See you in Washington D.C.

Celebrate Columbus Day! Register for FDA/CMS Summit for Payers by Monday & save $300!

Register for the following IIR event and receive $300 off*

Mention code COLUMBUSBLOG to save on the following:

Register here for IIR’s FDA/CMS Summit for Payers event taking place December 11-12, 2014 in Washington D.C., visit the website for full details.

Have any questions? Email Jennifer Pereira.

*This promotion is only valid October 10th-13th 2014. Offer cannot be applied retroactively to confirmed paying registrants and cannot be combined with any other discounts or promotions. All registrants and guests are subject to IIR approval.

How to Reduce Readmissions for At-Risk Medicare Patients Using Information Technology

Via AHRQ

Community-based health coaches and care coordinators reduce readmissions using information technology to identify and support at-risk Medicare patients after discharge.

Summary:
Supported by mobile technology, trained health coaches at Elder Services of Merrimack Valley (an Area Agency on Aging in Northeastern Massachusetts) visit recently discharged Medicare patients in their homes and monitor them via telephone to identify and address declines in health status that increase the risk of readmission. Administered in partnership with area hospitals, the 4-week program begins with an in hospital visit to determine the risk of readmission. Patients at medium or high risk for readmission receive an in-home visit within 48 hours of discharge and a weekly phone call for each of the next 3 weeks. During each encounter, the coach uses a tablet-based application that provides suggested questions written in lay language based on the patient’s diagnoses, treatment, and overall risk profile. If the answers indicate a decline in health status, the system sends a real-time alert to a nurse care coordinator, who subsequently uses a different component of the software to help the patient and coach address the issue within 24 hours, including arranging for any needed services. The use of health coaches supported by the tablet-based software significantly reduced readmissions among at-risk Medicare patients, as compared with use of health coaches without the software. This reduction generated substantial cost savings for partner hospitals and the health care system as a whole.

You can see the complete study and findings here.

Behavioral Economics: Consumer and Patient Engagement & New Models of Care

Extensive work in behavioral economics has demonstrated ways in which people are predictable irrational. This work is now being applied to better understand ways to increase healthier behaviors in a wide range of contexts ranging from health insurance benefit design, cafeteria food layout, smoking cessation, weight loss, medication adherence, and chronic disease management using wireless devices.

At the FDA/CMS Summit for Payers in Washington D.C. this December, Dr. Kevin Volpp, MD, PhD, Founding Director of the Center for Health Incentives and Behavioral Economics at the Leonard Davis Institute will briefly discuss some of the key principles of behavioral economics before talking about elements of choice architecture, incentive design, and 'automated hovering' that are being tested in field settings around the United States with the goal to increase consumer and patient engagement. In his sessions, you will:

- Understand how behavioral economics differs from traditional economics
- Learn ways to apply defaults and choice architecture to drive behavior change
- Understand the core concepts to optimize incentive design
- Be familiar with emerging trends of 'automated hovering'

Below you will find a video of a talk Dr. Volpp did in 2012 at Wharton on Behavioral Economics and Automated Hovering....

Make sure you join Dr. Volpp this December in Washington D.C. to hear what comes next. Download the updated FDA/CMS Summit for Payers agenda now to see who else will be speaking on the program.

And remember, blog readers receive a special $100 off the current rate when registering with the code XP1917BLOG - Register now! 

Apexus Wins HRSA Contract to Remain Prime Vendor of 340B Program

Texas-Based Company Will Continue to Assist Safety-Net Providers in Providing Care to More Patients

September 29, 2014

Apexus, LLC, the prime vendor for the 340B Drug Pricing Program, has announced that it has been selected by the Health Resources and Services Administration (HRSA) to continue serving in its role as the prime vendor through September 29, 2019. Apexus, which has held this position for the past 10 years, will continue to work with more than 25,000 safety-net provider locations, drug manufacturers, pharmacy wholesalers, and other stakeholders to negotiate discounts on pharmaceuticals and offer valued services, while supporting compliant operations and helping stakeholders to continue to deliver health care services to underserved populations.

“We are thrilled and proud for the opportunity to continue working with HRSA to strengthen this important program that helps so many families across the nation gain access to essential medications,” said Apexus President Chris Hatwig. “With our team’s unsurpassed knowledge of the 340B Program, our unique national distribution channels, and our highly regarded educational programs, we are able to deliver maximum value to 340B stakeholders through the promotion of program integrity, compliance, and optimization of the program.”

Beyond its contract work, Apexus is also the premier national resource for 340B educational programs, helping 340B stakeholders and healthcare policy experts receive and understand the latest information about the 340B program. Apexus Answers, its national call center, aligns with HRSA to provide up-to-date policy, compliance, registration, and recertification information.

The 340B Program was signed into law by President George H.W. Bush in 1992 with the purpose of requiring drug manufacturers to provide outpatient drugs to eligible hospitals, clinics, and other health care organizations at significantly reduced prices so these covered entities could stretch their resources and be able to provide medications and other services to underserved populations.

Apexus serves as the exclusive prime vendor for the 340B Program, managed by the Health Resources and Services Administration (HRSA). As the 340B prime vendor, Apexus works closely with HRSA’s Office of Pharmacy Affairs to enable approved entities to optimize the value of the 340B drug pricing by both reducing costs and supporting entities to establish compliant operations in the communities they serve. Apexus also operates Apexus Answers, the national call center available for all stakeholder questions, and manages in-depth 340B educational programs through 340B University™ to support stakeholder compliance and program integrity.

Based in Irving, Texas, Apexus currently serves more than 25,000 safety-net provider locations by delivering additional savings on pharmaceuticals through the 340B Prime Vendor Program (PVP).

 
Contact:
Lisa Sokol
(972) 910-6665

Specialty Drug Distributor 'Diplomat Pharmacy' Sets Terms for $200M IPO

Via NASDAQ

Operating as the fourth largest specialty pharmacy in the US – Diplomat Pharmacy has announced terms for its IPO on Monday. The company plans to offer 13.3 million shares at a price range of $14-$16.

Diplomat distributes drugs that require coordinated regimens by patients with complex chronic diseases. On top of distributing these drugs, they also provide support services to health systems related to the complexity of administering the treatments. The company has a national distribution network with one main facility and seven regional locations.

In terms of other specialty pharmacies, Diplomat hangs behind the likes of multinational pharmacies like Express Scripts, Walgreens, and CVS Caremark – but they are the largest independent specialty pharmacy in the US.

With a majority of specialty pharmacy revenue coming from government programs including Medicare and Medicaid, can the high cost of these specialty drugs be changed? For example, the high price and extraordinary demand for Gilead’s Sovaldi has prompted calls from insurers and other health care stakeholders for action on the specialty drug pricing model. What is the potential public policy response?

Join us at FDA/CMS Summit for Payers this December in Washington D.C. to learn the answers to these questions and many more. Hear from the FDA, CMS, Health Plans, and other industry game changers all under one roof, as they discussion the challenges facing payers and pharma. Download the updated agenda here and register with the code XP1917BLOG to save $100 off the current rate - $300 in total savings!

AHIP CEO Ignagni to headline FDA/CMS Summit for Payers

IIR is pleased to announce that Karen Ignagni, President and CEO of AHIP has been added to the speaking faculty at the upcoming FDA/CMS Summit for Payers. Ignagni, the voice of health insurance plans, will headline a keynote session on Pricing and Reimbursement - The Tipping Point in the Future of Healthcare. Recognized as one of the strongest and most effective lobbyists in Washington, Ignagni will provide compelling insights and a valuable perspective. Download the newly updated brochure here.

The Inaugural FDA/CMS Summit for Payers, scheduled for December 11-12 at the Fairmont Washington, will bring together the FDA, CMS and C-Level health plan and pharma executives to collaborate on important industry issues, including innovative technology, pricing and personalized medicine. Together we will tackle monumental issues facing the healthcare industry—such as the approval of the Hepatitis C drug, Sovaldi, as well as the impact of the ACA and the significant changes it has brought about to your daily operations.

Plus, if you register by this Friday September 26th you will save $500! Click here to reserve your seat and please mention the code XP1917BLOG for your special savings.