6 March 2012

Midwest Edition
Calendar
April 25
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Progress Made On Pre-Term Births

Some Hospitals Are Reporting Dramatic Reductions
Michael Leonardi was working on a masters degree in patient safety when he recognized the increasing number of early elective deliveries being performed at his hospital group, OSF Saint Francis Medical Center in Peoria, Ill. The rate of these deliveries throughout the system ranged from 9% to 42%. Leonardi, the head of the maternal fetal diagnostic center, asked to take the issue on as a project and has since created a system-wide collaborative with rules regarding elective early-term deliveries. About a year ago, they started creating a program that empowers nurses, educates patients, tracks the deliveries by provider and enforces strict rules regarding when the deliveries can be performed. Rates at most of the OSF hospitals over the past year have dropped, some by more than half. Leonardi took the project upon himself, but hes not the only one aware that choosing to induce deliveries has become the norm in hospitals across the country. The Leapfrog Group released a report last month highlighting early elective delivery rates at 757 hospitals. The numbers showed the prevalence is decreasing the average went from 17% in 2010 to 14% in 2011. Sixty-ve percent of the providers that took the survey improved their performance over the year. But the numbers vary widely. Leapfrogs target rate is 5% of a hospitals total deliveries; reporting organizations ranged from just less than that to more than 40 percent. The lowest rate by state is Ohio, which came in at 7.6 percent. A large number of hospitals declined to provide the information. We see signicant progress in the rates; hospitals are less likely to permit these deliveries to take place, said Leah Binder, Leapfrogs CEO. It was extremely good news and there is lots more work to do. For about 30 years, the American College of Obstetricians and Gynecologists has recommended against delivering before the end of the 39th week unless the health of the mother or baby is compromised. Legitimate health reasons to deliver early include preeclampsia, a ruptured membrane or a baby with birth defects. Leonardi said there are also gray areas to be considered. At a tertiary provider like OSF, doctors sometimes have to decide if its best to schedule a delivery for a high-risk patient living 100 miles away or take their chances. Babies born between 37 and 39 weeks have increased risk of ending up in the neonatal intensive care unit, having a prolonged hospital stays or ending up on a ventilator.
Continued on Next Page

April 27-28
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June 11-13
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WEBINAR
E-Mail info@payersandproviders.com with the details of your event, or call (877) 248-2360, ext. 3. It will be published in the Calendar section, space permitting.

Thursday, March 29, 2012

Noon CDT

REDUCING READMISSIONS: COLLATERAL EFFECTS

Please join Warren Hosseinion, M.D., chief executive officer, Apollo Management Executive Director, Association for Community Health Improvement, and Daniel Cusator, M.D., vice president of The Camden Group, to discuss the upcoming changes on avoiding preventable readmissions and their financial impact on hospitals, physicians and patients.

http://www.healthwebsummit.com/pp032912.htm

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Payers & Providers

Top Placement... Bottomless Potential

NEWS
Charity
(Continued from Page One)

Page 2

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In Brief
UnitedHealthcare Moves Toward ValueBased Model
Like other payers, the gargantuan UnitedHealthcare is beginning the transition away from fee-for-service and toward a new compensation framework for healthcare delivery. In a recent memo to providers, the Minnetonka, Minn.-based company said it will move toward something called value-based contracting. The shift toward increased collaboration, outcome-based payment and new benet design is driving innovation in how we pay for healthcare, the company said in a notice to self-funded customers. UnitedHealth will begin an aggressive transformation of its provider network this year, with a signicant ramp-up of alternative payment models during the next three years. It expects 1% to 2% of commercial members to participate in the value-based initiative this year, reaching 50% to 70% by 2015. Uniteds move comes a few weeks after Indianapolis-based WellPoint Inc., the parent company of for-prot Blue Cross and Blue Shield plans in 14 states, announced it would devise a new compensation program for primary-care ofces, rewarding them for higher quality and coordination of care, and diminishing the incentives to run up the bill in the standard fee-for-service manner (Payers & Providers, Jan. 31). The Centers for Medicare and Medicaid Services are also introducing a variety of new payment methodologies to reward physicians and hospitals for more intensive collaboration and fewer readmissions. United said it would establish a limited set of quality metrics that would connect physicians compensation to their daily performance. To earn incentive

Early induction also comes with a much greater risk of having a c-section. But there seems to be a disconnect between what doctors know and what they do. Leonardi calls the issue a normalization of deviance. Most physicians dont do enough deliveries to see the harm that they cause, Leonardi said. Unless they do an awful lot of deliveries, they say a baby was just sick and stayed a few days longer in the hospital and then goes home and it is no big deal. Scheduling an early delivery that is not necessary may be more convenient for a patient who has family in town to help after the delivery. It helps a hospital plan stafng. Doctors dont like having a reputation of missing deliveries. And Leonardi said the payment system is weighted so that a doctor gets paid more for being present at delivery than for providing prenatal care. But the attention brought to the subject is forcing hospitals to understand the potential hazards of delivery early without medical cause. And to nd ways to arrest the practice. Research has shown that the best way to end early elective deliveries is by using a

hard stop, Binder said. Such a policy that hospitals employ forbidding deliveries prior to 39 weeks unless a physician receives medical approval. It works, she said. Where we see hospitals do that, we see rates dip to 5% or less. Ken Nunes, M.D., executive medical director of The Womens Care Center at the University of Chicago Medical Center, said his groups rates were hovering around 15% before they implemented a hard stop on the practice in April 2010. The hospital created a written policy dening things like how to properly date a pregnancy, the process for scheduling a delivery and educated staff on the issue. An early delivery must meet certain criteria or get approval from a medical director. After the changes were implemented, the rates dropped to 4 percent. OSF has also implemented a hard stop, which Leonardi said has reduced the number of doctors who ever ask to perform early elective deliveries. Just because that process is there and doctors know they cant get around it, and they dont ask us, he said.

For Diabetes, Meds May Be Cheaper

Making Lifestyle Changes Actually Costs More
Lifestyle intervention may be more successful at staving off Type II diabetes than metformin, but medication has been found to be more cost effective. This was the conclusion of a study by Bill Herman, MD, of the University of Michigan in Ann Arbor. Herman and colleagues performed a follow-up analysis of the universitys Diabetes Prevention Program and presented the information at this years conference for the American Diabetes Association. A 10-year follow up of participants found that the development of Type II diabetes was reduced by 58% with lifestyle intervention and 31% with metformin. Lifestyle changes also showed a much greater quality of life improvement than did the medication. But these interventions dont come without a price. Over a decade, lifestyle intervention cost $4,500 per patient, treatment with metformin cost $2,600. When cost reductions and expenses were totaled, the lifestyle changes cost about $1,500, while metformin saved $30 per person over 10 years. The data came from the DPP, which included more than 3,000 overweight or obese individuals with impaired glucose tolerance. Patients were split into three groups, one taking a placebo, the second taking metformin, and the third receiving education on diet, exercise and behavioral modication. Cost is an important factor when considering the impact of diabetes. Almost 26 million people in the United States have diabetes, diagnosed or undiagnosed, 95 percent of whom have Type II. Diabetes has been linked with blindness, heart disease, stroke, high blood pressure, blindness and is the leading cause of kidney failure in the United States. According to the American Diabetes Association, $1 in every $10 health dollars spent in the United States goes toward diabetes care.

Continued on Page 3

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Payers & Providers

Longer ALOS!*

NEWS

Page 3

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Split On Contraception Coverage

Americans Are Evenly Divided on Touchy Issue
Americans are divided in support of an issue that has been framed as a standoff between womens rights and religious freedom. The debate is focused on the Obama administrations decision to require all employers including religious institutions to provide contraception to female employees for no cost. According to a Gallup poll from midFebruary, 48 percent of individuals say they sympathize more with religious leaders on the topic; 45 percent with the administration. A survey by the Kaiser Family Foundation performed in February found that 63 percent support the new requirement. As part of the Affordable Care Act, insurance companies will be required to provide preventive services including immunizations, screening for high blood pressure and cholesterol, and smoking cessation. This past August, the administration adopted guidelines from the Institute of Medicine specic to womens health. Insurers will be required to provide services such as well-women visits, HPV testing, domestic violence screening and the controversial issue: contraception. Though this is already law in 28 states, it has created a divisive, national debate on the issue. The administration is placing impetus on insurers to reach out to women at organizations like religious-afliated hospitals and charities to provide and pay for the services. Support for the measure is somewhat equal among women and men. Lines are being drawn, however, along religious afliation, age and political party. Both Catholics and Protestants side more than half with the position of religious leaders, according to the Gallup poll. Only 39 percent of Catholics and 42 percent of Protestants agree with the law. Sixty-eight percent of nonreligious individuals agree with the law. The Kaiser survey found that eight in 10 Democrats, four in 10 Republicans and 6 in 10 independents support the coverage. The poll also found that half of younger Republicans those ages 18 to 49 are in support of the issue, in contrast to 33 percent of Republicans over the age of 50.

In Brief
payments, physicians must achieve both quality and efciency targets, United said in its presentation to selffunded clients. The cost and efciency measures could include risk-adjusted total cost of care, rates of readmissions, inpatient admissions per 1,000 members, inpatient days per 1,000 members, rates of emergency room utilization, as well as rates of laboratory services and ambulatory surgery utilization. United expects the return-oninvestment in this program to exceed 2-to-1, because only a portion of the savings will be shared with providers. United, the largest insurer by some measures, has about 34 million covered lives. United would also compensate physicians practices that turned themselves into patient-centered medical homes, which integrate and coordinate patients care. The company expects to announce in July where it will launch initial programs. Clients will be invited to opt-in but will not be required to participate. As programs deploy and providers change behavior, savings will ow through the claims experience in real time, United said, so that clients realize savings as they are incurred. DUNCAN MOORE

CEO Turnover Continuing To Rise

Healthcare Chiefs Struggling With Burnout
The healthcare industry has struggled with high turnover rates of CEOs for some time. According to number released last month by the outplacement rm Challenger, Gray & Christmas, Inc., the landscape is not improving. The report, 2012 Begins With CEO Turnover Surge, found there were 25 CEOs who left their posts in healthcare in January the highest of any industry. Although one month might not suggest a pattern, but the industry had the highest in 2011 on the whole, with 187 leaving their jobs. There may be some positive impacts of CEO turnover like improved nancial performance, hospital culture and employee morale. But a 2006 study on the topic found that CEOs who had left hospitals perceived that a lot of areas suffered after the loss. These included: medical staff relations, construction progress, physician recruitment, community outreach and strategic planning and development. The report, created for the American College of Healthcare Executives, also found there was often a high rate of turnover with other executive personnel like chief medical ofcers and COOs shortly after the departure of a CEO. Thomas C. Dolan, president of and CEO of ACHE, wrote in a 2011 issue of Trustee magazine, that the median tenure of hospital CEOs is four years. The mean for community hospitals in 2011 was 6.2 years. Fifty-eight percent who are now working have been there for fewer than ve years. Reasons cited for CEOs leaving their positions, according to the ACHE report, include moving to a better position, hospital instability, conict with board and medical staff and inadequate salary.

CMS Uses Texting To Promote CHIP Enrollment

The Centers for Medicare and Medicaid Services is partnering with Text4Baby to encourage enrollment in Medicaid and the Childrens Health Insurance Program. It also provides free messages on health issues like the signicance of prenatal visits and importance of health coverage to pregnant women and young mothers. A handful of states are promoting the program with efforts including automatic signup for those applying for Medicaid and CHIP online.

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Payers & Providers

OPINION

Page 4

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Having The HENS Rule The Henhouse

Hospital Engagement Networks Can Cut Errors, Deaths
The Medicare program is betting on a new plans to eliminate 1.6 million preventable course of action to curb what one medical hospital readmissions. journal has dubbed an "epidemic" of Still, there remains the question of whether uncontrolled patient harm. the program's goals should be even more The effort is pegged to the success of a little- sweeping. And one might wonder why the chance known entity called a "hospital engagement to not harm patients is not reason enough for network" (HEN). In December, the government hospitals to change without being paid by the selected 26 HENs and charged them with government. preventing more than 60,000 deaths and 1.8 For context, it helps to understand that the million injuries from so-called "hospitalmost widely quoted estimate of preventable acquired conditions" over the next three years. patient harm 44,000 to 98,000 deaths and one That would be the equivalent of eliminating all million injuries annually was probably low. That deaths from HIV/AIDS or homicide over the estimate caused an uproar in a 1999 Institute of same period. Medicine report. Today, it seems Despite those big numbers, conservative. The IOM total was and an initial price tag of $218 based on studies conducted in million, it's unclear whether the hospitals in the mid-1980s. HENs are adequately ambitious Recent research by the HHS or still only pecking away at the Ofce of the Inspector General patient safety problem. While this and others has found a much is by far the most comprehensive higher rate of harm. A Medicare public or private patient safety patient today has a one-in-seven effort ever attempted in this chance of suffering harm in the country, it still aims to eliminate hospital. less than half the documented, Moreover, nearly 9 out of 10 preventable patient harm. incidents are never reported, the In December, the OIG concluded, even By government chose a mix of including incidents that led to Michael Millenson patient deaths. That lack of national and local groups -primarily health systems and progress testies to very modest hospital organizations -- to run individual pressure to show results. HENs. Each HEN is charged with spreading Enter the HENs, prodded by a stick. safety-improvement innovations that have been In 2008, Medicare began denying payments to proven to work in leading hospitals to others hospitals for eight complications of treatment, the through intensive training programs and program's rst major use of negative incentives. technical assistance. Although the program The number of conditions has since lasts three years, initial HEN contracts are for increased, along with efforts to pressure hospitals two years, with an "option year" dependent through public quality report cards. Meanwhile, upon performance. the 2010 health reform law includes nancial This bottom-line accountability is what sets penalties that go into effect later this year to the HENs apart from past voluntary efforts. discourage preventable readmissions. Program co-directors Paul McGann, M.D. and Put differently, hospitals now have a Dennis Wagner give weekly briengs to Health signicant nancial as well as ethical incentive to and Human Services Secretary Kathleen participate in a hospital engagement network. Sebelius. "This is a full-court press unlike anything I've seen in my 10 years in Michael Millenson is president of Health government," McGann said. Quality Advisors LLC in Highland Park, Ill. He is Although the HENs' total cost is slated to a member of the Payers & Providers editorial rise to $500 million by its third year, that's still board. A version of this op-ed first appeared in chicken feed compared to what the Kaiser Health News (www.khn.org). government says will be savings of up to $35 billion from safer care, including up to $10 Op-ed submissions of up to 600 words are billion in savings for Medicare. In addition to welcomed. Please e-mail proposals to preventing injuries and deaths, the program editor@payersandproviders.com

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Payers & Providers

MARKETPLACE/EMPLOYMENT

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