13 March 2012

Midwest Edition
Calendar
April 25
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Veterans Struggling With Addiction

VA, Other Providers Confront Issues With Opiates
Veterans from Iraq and Afghanistan with mental health disorders are more likely to use, and possibly abuse, prescription opiates than those without mental illness, according to an article in the most recent edition of the Journal of the American Medical Association. As a result, providers in the Midwest sometimes struggle to confront the issue. The study looked at more than 140,000 veterans in the VA Health Care system with pain diagnoses that were not cancer related between autumn 2005 and the end of 2010. A total of 11% were prescribed opioids for 20 or more consecutive days. Researchers found that patients with mental health disorders, particularly post-traumatic stress disorder, were the most likely to receive opioid prescriptions. The individuals who were most likely to be prescribed opiates (33.5%) were veterans who had comorbid PTSD and drug use disorders. These results are not surprising to me, said Sujatha Ramakrishna, M.D., a psychiatrist in private practice outside of Chicago. Someone with a mental health disorder is more likely to have an addiction because there is a mind/body connection. Pain medication relieves pain, but also has a psychological affect, she said. It can relieve the feelings of stress that come along with anxiety, depression and, particularly, PTSD. If you take Demerol and it makes you calmer, you will make that connection and want to take more and more, Ramarkrishna said. People develop a tolerance to it and have to increase it and that is how addiction is created. This addictive trend was borne out in the study. Veterans with post-traumatic stress disorder were more likely to have high-risk behaviors like receiving greater doses of opioids, getting two or more at the same time, taking hypnotics concurrently and obtaining early rells. PTSD, especially for soldiers, stems from some sort of physical trauma being hit by a bomb or jumping out of a plane, said E. Cameron Ritchie, M.D., a retired Army colonel now working as chief clinical ofcer of the District of Columbia's Department of Mental Health She said the issue of pain and addiction was brought to the attention of the Army some time ago, eliciting the creation of a Pain Management Task Force. The group completed a report in May 2010 providing 109 recommendations to standardize Armyprovided pain care.
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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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Top Placement... Bottomless Potential

NEWS
Vets
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Page 2

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In Brief
Cap On Insurance Benefits Lifted For Millions Of Americans
The U.S. Department of Health and Human Services has estimated that 105 million Americans no longer have lifetime limits on their health insurance because of prohibitions on spending limits in the Affordable Care Act. According to HHS, approximately 95 million of these people had employer-sponsored plans; the rest had private insurance. Individuals on the private market were more likely to have benet limits, with 89 percent having some sort on their plans in 2009, according to statistics from the Kaiser Family Foundation. The mandate to get rid of lifetime limits has impacted approximately 28 million children, with the remainder of the 105 million split almost equally between adult men and women. Midwestern states with the largest number of individuals whose plans have changed include Illinois, with 4.6 million; Ohio, 4.1 million; Michigan, 3.5 million; and Indiana with 2.2 million.

These suggestions included creating a culture of pain awareness through education and intervention, encourage and support research in pain management and build a suite of best practices for acute and chronic pain care. Ritchie said the task force recommended using alternative methods of treating pain like acupuncture or NSAIDs. This is a viable option, but one that is not always easy to provide. Take acupuncture, which we know has good data in treating pain and is helpful with PTSD, she said. The challenge is there are not enough people in the military system, or anywhere, to provide enough treatments. Also, we dont have a rigorous database to support complementary medicine. By contrast, opioids appear to work more effectively and quickly. Therapies such yoga take time and willingness on the part of a patient and physician, according to Ritchie. For acute pain, things like opioids are very appropriate, she said. For more chronic pain, thats where we need to start looking at alternatives. About half of all veterans go to the VA for care. That means the other half use civilian providers, making this an issue for everyone. But if the extensive medical record system at the VA cant curtail the issue, it will be that much more difcult elsewhere.

Catherine Johnson, a pharmacist at the William S. Middleton Veterans Memorial Hospital in Madison, Wis., said she is alerted if she tries to ll a prescription early. It is easier in the VA because we have access to the data, she said. It would be more difcult to coordinate in private institutions. If there was movement in the private sector for high alerts, it would help reduce abuse. Providers can be proactive in stopping the issue as well. Patients looking to abuse medication typically have tells if a physician knows what to look for, Ramakrishna said. She recommended watching for patients who frequently make excuses (like losing medication, or saying they didnt get the right number from the pharmacist) for getting rells early. Another indication is someone who frequently asks for increased doses. The best way to know if someone might have an issue is to screen them well before writing a prescription. Ask questions like how frequently they drink alcohol, if they have tried illegal drugs (if they say no, they are probably lying, Ramakrishna said). If there is any question, alternative medications or treatments are best. A careful history is very important in terms of weeding out who might have a problem and who wont, Ramakrishna said.

A Closer Look At The Safety Net

Report Makes Post-ACA Recommendations
A report released last week by the Commonwealth Fund Commission on a High Performance Health System offers recommendations to sustain and support safety net hospitals facing changes under health reform. Deborah Bachrach and colleagues at Manatt Health Solutions created the report with the anticipation that low Medicaid payments, an inux of Medicaid patients and a reduction in disproportionate share funding under the Affordable Care Act may bring challenges to the already-strapped institutions. Medicaid is currently the largest payer at safety net hospitals, according to the report. In 2014, the number of Medicaid patients will increase an estimated 17 million of those currently uninsured will become Medicaid recipients. The report, Toward a High Performance Health Care System for Vulnerable Populations: Funding for Safety Net Hospitals, offers ways to reward performance at and target public dollars toward safety net hospitals. One of the commissions recommendations is to increase Medicaid rates to safety net hospitals that meet quality targets and deliver accessible, reasonably priced care. While targeting enhanced Medicaid payments to hospitals based on their safety net status is far from ideal, the report said, they do contend that tying payments to performance and improvement targets, would offer a means to address quality and access concerns at a time when state Medicaid rates are otherwise low and state resources limited.

Minneapolis Named Nations Healthiest City

The metropolitan area surrounding Minneapolis ecently ranked as the healthiest in the nation on Forbes magazines annual ranking of fit cities. The rankings are based on the American College of Sports Medicines Fitness Index. The report grades 50 metro areas across the country and creates a composite score based on factors including preventive health behaviors, prevalence of chronic diseases,

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HHS Issues Transparency Regulations

Insurers Have to be More Open to Consumers
The U.S. Department of Health and Human Services last month released rules regarding transparency for health insurers. The mandates are for insurance plans not grandfathered under the Affordable Care Act; they are meant to provide clarity regarding benets for enrollees and applicants. Implementation of some of these provisions is taking place currently and others will be phased in over time. Following is an outline of the provisions: Uniform summary of coverage When health plans are renewed this coming fall, insurers will have to provide applicants and enrollees a uniform summary of benets and coverage. This will provide information about coverage, limits, exclusions and cost-sharing. This rule is in part meant to help consumers evaluate plans to be provided in the insurance exchanges in 2014. Transparency in coverage disclosures Plans will also be required to disclose other pertinent information on plans including: claim reimbursement reliability, adequacy of provider networks, enrollment data, number of claims denied and information on costsharing and payments to out-of-network providers. Quality reporting for private health insurance This Secretary of HHS must create reporting requirements for group and individual health plans dealing with covered benets, reimbursement to improve outcomes and implementing wellness activities. The government is hoping that providing this level of transparency will increase competition among insurers in the exchanges and help individuals compare plans. Healthcare.gov was launched in July 2010 by HHS to help individuals and small businesses nd affordable health insurance. The site provides information about private policies in ones insurance market, PreExisting Condition Health Insurance program, state high-risk pools, Medicaid and the Childrens Health Insurance Program. Healthcare.gov will offer standard premium information for plans, rejection rates and surcharges based on underwriting and cost sharing. It will soon provide the number of policies that are rescinded, percentage of denied claims and appeals on denied claims.

In Brief
access to care, policies supporting physical activity and crime levels. Minneapolis ranked first because of its benefits like low poverty and unemployment levels, low prevalence of chronic conditions like cardiovascular disease, asthma and diabetes. They also have abundant parkland and playgrounds, farmers markets and public transportation. The residents tend to be physically active, have lower smoking rates and are apt to bike or walk to work. Other Midwestern metro areas ranking in the top 50 include: Denver at 5, Cincinnati, 14; Milwaukee, 21; Kansas City, Kan., 22; St. Louis, 26; Chicago, 28; and Indianapolis, 45.

Worth Named Payers & Providers Editor

Veteran journalist Tammy Worth has been named editor of the Midwest edition of Payers & Providers. Worth, who is based in Kansas City, replaces Duncan Moore. Her work has appeared in The Economist, the Los Angeles Times, WebMD, Health.com, Todays Hospitalist and the Kansas City Business Journal. Worths work has received honors from the Suburban Newspapers of America and the Kansas Press Association. In 2008, she was named a fellow of the Association of Health Care Journalists. Worth earned a masters degree in journalism from Northeastern University and a bachelors degree in English from the University of Missouri at Kansas City. Tammys deep experience in covering healthcare business issues will make her an invaluable asset to Payers & Providers, particularly as we move forward with a publication and website redesign and expand the webinar offerings to our Midwest readership, said Publisher Ron Shinkman.

MA Plans Can Reduce Readmissions

Study Concludes Double-Digit Reductions Possible
A study in the February issue of the American Journal of Managed Care found enrollees in Medicare Advantage plans had 13% to 20% lower hospital readmission rates within 30 days of discharge than those in traditional Medicare plans. Researchers compiled Medicare Advantage readmission rates between 2006 and 2008. They compared results with a study of Medicare fee-for-service rates from the same time period by Stephen Jencks and colleagues. Both studies looked at 30-day hospital readmission rates and adjusted results based on factors including demographics, geography, entitlement status and diagnosis. Over the three-year period, the unadjusted 30-day readmission rate for Medicare Advantage patients consistently hovered around 14.5 percent. Traditional Medicare rates were 19.6 percent. Looking outward to 60 and 90 days, the rates were also about 25 percent lower. Other studies have borne out these conclusions as well. A 2010 study from Americas Health Insurance plans four a 12 percent to 18 percent lower 30-day readmission rate for Medicare Advantage than traditional fee-for-service when comparing a handful of states data. To explain these differences, the study authors hypothesize that Medicare Advantage recipients may have healthier behaviors and stronger support networks because the plans build in incentives for these things. Medicare Advantage plans may be more likely to pay for things like transitional care, post hospitalization care coordination, pharmacy reconciliation efforts and disease-specic prevention programs. Affordable Care Act initiatives may reduce these numbers in the future.

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Payers & Providers

OPINION

Page 4

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Addressing The Chronic Care Crisis

Improving Outcomes Is Linked to Better Coordination
That healthcare consumes 17% of U.S. gross But the environment in which physicians domestic product is alarming, but the change practice also needs to change to support these in Americans' health status is equally care models. The Affordable Care Act provides staggering. The increasing prevalence of unique opportunities to organize the delivery chronic illness among Americans poses major system and build a strong primary care practice challenges to the medical profession and the infrastructure that will help improve care entire healthcare system. coordination. For example, the law established Nearly half of all Americans live with at the Primary Care Extension program, which will least one chronic condition. Care for these be administered by the Agency for Healthcare patients is complex. One study found that the Research and Quality to provide support to typical primary care doctor has the potential to primary care providers. interact with as many as 229 other doctors. A number of training demonstrations will The latest Commonwealth Fund invest in coordinated care teams that include International Survey examines care primary care physicians, midlevel providers such coordination, chronic care management, and as nurse practitioners, and community-based patient engagement among social services providers. Grants By "sicker" adults in 11 nations . In and contracts will support the U.S., 23% of respondents Anne-Marie J. Audet, medical homes through with chronic conditions saw four M.D. and Shreya community health teams, thereby or more doctors over the last increasing access to coordinated Patel year. Medication management for care. such patients is particularly complicated; 46% Given these opportunities, how will we know said they were taking four or more prescription whether we are successful? First, we need to set drugs on a regular basis. explicit short- and longer-term targets and Not surprisingly, the survey found problems monitor progress. Perhaps we can go from 58% of with care coordination. Patients said that they patients saying they are engaged in their care to often experienced problems obtaining medical 70% in 2013, and 90% by 2023. These measures records and test results, which increased with of coordination and engagement could certainly the number of doctors seen. be tracked as new models of care such as medical Coordination is a multifaceted activity that homes and accountable care organizations are requires effective participation among many implemented. different professionals and service The important lessons here are that we need a organizations. While there is strong evidence concerted effort and an overarching strategy to that a key to successful chronic care support the changes in the delivery system management is engaging patients in their care, required to achieve seamless care and the health only about half of those with chronic outcomes we seek. Tracking progress with conditions in the U.S. say that their regular comparative information and performance doctor always tells them about treatment benchmarking is essential. Attention needs to be options and involves them in decisions. given to strengthening primary care and to Physicians also still function as soloists: studies developing multidisciplinary teams that can have shown that only 35% said that improved oversee the care of people over time. We need to teamwork and communication are very ensure practices receive technical assistance to effective ways to improve quality of care. help them redesign the way they deliver care. The chronic care model has been developed and tested over the past 15 years. So the real Anne-Marie J. Audet, M.D., is vice president of challenge is not what to do, but how to do it. It health system quality and efficiency at The is a question of execution, and even more so of Commonwealth Fund. Shreya Patel is a scalability. Commonwealth Fund program associate. This Fortunately, medical education is adapting op-ed is adopted from a blog entry they coto the changing landscape. Increasingly young authored. doctors in training are exposed to teamwork both across medical specialties and across Op-ed submissions of up to 600 words are health professions, including nursing and welcomed. Please e-mail proposals to pharmacy. editor@payersandproviders.com

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