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

Your Complimentary Webinar: Patient-Centered Care

According to predictions earlier this year, 2013 was going to be the year of patient centricity, with payers and providers taking a more holistic approach to care management. Although we have seen changes over the past year, many stakeholders are just beginning to implement more patient-centric programming. 

Innovators such as Dr. Jeffrey Epstein, a Medicare Congress 2014 speaker, are making bold strides to make sure that the patient-centric vision comes to fruition sooner as rather than later. 

In our upcoming webinar, in a preview of his session at Medicare Congress 2014, Dr. Epstein will outline how those changes are being made on a provider level and how you can implement them. 

This webinar will cover: 

• How to design a primary care office in an accountable care delivery system 

• The role of the Specialist 

• How to educate and engage patients in self-care and self-management 

• The triple aim: higher quality care, lower cost care and optimized value. 

• Why systems of the future should be patient-centered and primary care centric. 

About our speaker: 

Dr. Jeffrey Epstein is an experienced healthcare professional focused on developing systems of accountable care. Successful in clinical practice, administration, general management and business development, Dr. Epstein serves as the President and CEO of The Epstein Group, as well as, the President of the National Association of Physician Advisors (NAPA). 

Epstein's past roles include medical director of Stamford Hospital, medical director of Morristown Medical Center, medical director of Epstein Internal Medicine, associate medical director of Independence Blue Cross/AmeriHealth-NJ, physician advisor at Executive Health Resources, and Chief Medical Officer of Conversion Technology International, Inc. Dr. Epstein completed his residency in Internal Medicine at Mercy Hospital and Medical Center in San Diego, CA. 

Space is limited, reserve your seat today! 

Cheers, 

The Medicare Congress Team 

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P.S. As a reader of this blog, you’ll receive 15% off of the standard rate when you use priority code XP1907BLOG to register for the 2014 Medicare Congress. To learn more about our program, download our agenda.

Understanding Accountable Care Organizations (ACO)

Our guest blogger,  Tammy Mahan has worked in the healthcare field for over 20 years. In her free time, she shares her knowledge by writing articles for Healthline.com. 

The Accountable Care Organizations is primarily about doctors and healthcare facilities and their Medicare patients. It is part of the Health Care Reform and it encompasses two things:

“The healthcare reform law established the Medicare Shared Savings Program for ACOs as a key way to accomplish its two core objectives: (1) reduce healthcare costs, while (2) preserving and improving quality. Like most new legislative ideas, the ACO regs raise lots of questions.”

How Does this Affect Medicare Patients?

First, it is important to know that out of all the government funded healthcare programs, doctors, hospitals, nursing homes, and any other health care related person and facility receive the highest payment from the government for Medicare patients.

Medicare patients have to be notified if they are enrolled in an ACO and they have the right to refuse to participate in the program as well as having their medical information shared among the members in the ACO.

The goal for a Medicaid recipient in an ACO is to be provided with the best health care by their primary doctor and specialists. The ACO believes that by having the Medicaid patient in an Accountable Care Organization it will reduce the number of unnecessary tests, repeated tests and procedures, and provide better overall quality of care for the patient. It also ensures that the patients are seen in a timely manner on an inpatient and outpatient basis. It is also said to cut back on hospital admissions which of course saves thousands of dollars in patient care and prevents the patient from getting sicker in the hospital setting.

How ACO’s affects Doctors and Healthcare

Facilities Doctors and healthcare facilities must enroll in the program and agree to be a member for at least three years. In addition to caring for 5000 Medicaid patients during that time, the doctor of health care facility must agree to have no less than 75% of the ACO’s governing body.

In the event of a financial loss, the members must be willing to repay shared losses and is willing to agree to “substantial monitoring and reporting requirements, including public reporting of quality data to ensure transparency.”

Ideal Candidates for an ACO

● Doctors who work with several other doctors under one roof or are connected as one entity but spread out across rural and urban areas.
● Networks of doctors that practice different types of medicine but are all connected through a network.
● Hospitals that have doctors on staff
● Partnerships between doctors and hospitals
● Partnership between staff doctors and nursing homes Who is Not Eligible to participate in an ACO
● Nursing homes who do not staff doctors (but have one or two who come in and over-see all of the patients’ healthcare needs)
● Children’s Hospitals (most are non-profit)
● Psychiatric hospitals (Generally only have a few staff doctors and most patients are covered by Medicare or private insurance)
● Federally funded hospitals (Veterans)
● Long-term Care hospitals (usually patients are hospice and treatment is limited to comfort care)

Although this article briefly scratched the surface of Accountable Care Organizations, I hope it provided enough information so you have a better understanding of what an ACO is all about.

Want to learn more about ACOs? Join us February 10-12 in New Orleans, LA for IIR's 2014 Medicare Congress. For more information visit our website.

MDRP 2012 Session Spotlight:Impact of Healthcare Reform and the Changing Healthcare Delivery System

The Healthcare Industry is always changing. Today, with the advent of Health Insurance Exchanges and Accountable Care Organizations, Americans have more options than they’ve had before in choosing how to receive care. While MDRP provides the most up to date information on how federal and state authorities are implementing public sector reimbursement programs, understanding the healthcare sector on a broader level is also a necessity. For that reason, MDRP will present the session, “Impact of Healthcare Reform and the Changing Healthcare Delivery System: Accountable Care and Patient Centered Medicine.” In this session, Steve Phillips, Senior Director for Health Policy at Johnson & Johnson will delve into how cost savings for insurance companies will not compromise patient care, and how patients will continue to have access to the care and providers most appropriate for their needs.

The Medicaid Drug Rebate Program Summit will take place September 10-12, 2012 in Chicago, IL.  For more information on the event, download the brochure.  If you'd like to join us, as a reader of this blog register to join us and mention code XP1715BLOG to save 25% off the standard rate!

Featured session: Impact of Healthcare Reform and the Changing Healthcare Delivery System:

Accountable Care Organizations and Patient Centered Medicine

Featured Speaker: Steve Phillips, Director, Health Policy, JOHNSON & JOHNSON

About the session: When matched with appropriate financial incentives and quality metrics, ACOs can encourage treatment options that are best tailored (based on available evidence) to meet individual patients’ needs; rather than choices that are driven by payers’ coverage and reimbursement policies. The challenge is to identify and implement the appropriate incentives and measures.

• • The goal of cost savings must be balanced with ensuring that quality patient care is not compromised
• • Ensuring patients have access to the care and providers most appropriate for their needs, inside and outside the ACO
• • Access to innovative treatments