Comprehsensive Care for Joint Replacement - The Final Rule

CMS just published the final rule in their bundled payment initiative for hip and knee replacements. They are now calling it CJR (instead of CCJR). The final rule follows the earlier proposed rule pretty strongly, with a few changes noted below:

• The program now begins April 1, 2016, giving hospitals three more months to prepare for this new payment methodology.  
• The list of MSAs which will be required to participate has changed, with 8 areas dropped from the list.
• Hip Fractures will get their own pricing, associated with DRG 470, since the cost for these non-elective procedures tends to be greater than the elective ones.
• Quality links to payment changed (and became more complicated)
• Stop-loss (and stop-gain) provisions limit the financial impact of the rule as follows:
• Year 1: (really 9 months)  No loss; 5% gain
• Year 2: 5% loss; 5% gain
• Year 3: 10% loss; 10% gain
• Year 4/5: 20% loss; 20% gain

There is concern in the press that making this program mandatory is a sea change from CMS. It shouldn't come as a surprise; the program has been promising to move large percentages of care away from the fee for service model over the next few years. A frequent, expensive operations such as a Lower Extremity Joint Replacement (LEJR) seems like a good place for them to begin in a big way.

If hospitals do the right thing with their surgeons and especially with their post-acute providers, this program could prove to actually achieve the Triple Aim:

• Improve the patient experience of care (including quality and satisfaction);
• Improve the health of populations
• Reduce the per capita cost of health care

Hospice care and curative care together MCCM

CMS will start a 5 year program called Medicare Care Choices Model or MCCM at 141 hospice agencies in 2016.

CMS originally anticipated selecting 30 Medicare-certified hospices for the project but given the overwhelming interest from the U.S. hospice community, the list of MCCM demonstration sites grew to the current 141.

One of the biggest problems with hospice is that people will not avail themselves of the service because they are not ready to give up hope for a cure. The average length of stay in a hospice remains shorter than it should be, to the detriment of hospice care recipients.

From the agencies point of view, the most intense patient needs are at the beginning of service and the end of life. If these two come very close together, the agency doesn't have the time to establish the rapport that becomes so crucial for the family as the end nears. CMS is also looking to address this with a U shaped payment model.

Hospice remains the highest quality and lowest cost way to approach end-of-live issues. Any program that increases hospice usage and length of stay is a step in the right direction.

Bundled payments for joint replacements

CMS is proposing to pay health systems a fixed amount for all care related to knee and hip replacements.

From the proposal:

The hospital where the hip or knee replacement takes place would be held accountable for the quality and costs of care for the entire episode of care - from the time of the surgery through 90 days after discharge.
As a result, hospitals would have an incentive to work with physicians, home health agencies, and nursing facilities to make sure beneficiaries get the coordinated care they need, with the goal of reducing avoidable hospitalizations and complications.
(Italics mine)

In 2013, Medicare spent more than 7 Billion dollars in hospital costs alone related to these procedures.  Clearly, they recognize the savings that occur if the three sectors of health care, Hospitals, Physicians, and Healthcare at Home all work together.

I have long advocated better coordination between Healthcare at Home and the other sectors.  In 75 different geographic regions, that coordination is going to be crucial to the financial well being of the health systems.

Healthcare at Home - the undervalued sector of healthcare

Homecare, Hospice and Tele-Monitoring have been deeply undervalued in our modern medical system. So much so that there isn't even a good name to use when talking about them.  "Post-acute care" is not right - there is so much that can and should be done before (or instead of) a hospital stay. There is some movement lately toward the term "Healthcare at Home".  Seems like an apt description.  The twitter hashtag #healthcareathome shows it as the name of a home care company in India, which may limit its use in the US.  But I'm going to follow the lead of NAHC, as eloquently described in a recent Home Care Technology Report.

Although I have long advocated that home care and hospice need to be part of strategic thinking, health enterprises still not embracing these care delivery systems.  Why is that?

1. Traditional payment for these services has been different than hospitals and physicians are used to.Home care is paid a fixed amount per 60 days of care delivery, regardless of number of visits.
   Hospice is paid a per diem rate, with four different rates based on patient acuity.Essentially, Healthcare at Home has been out of the fee for service business for over a decade!
2. Healthcare at home revenue is small percentage of the system budget
   Just as football and basketball tend to occupy most of an athletic director's energies, Cardiac and Orthopedic surgery departments tend to occupy most of a system CFO's energies.  Time follows money.
3. Clinicians and patients are not in the same building as administration
   Even the most enthusiastic "management by walking around" won't get to the strip mall down the street where the home care agency is, and the patients are spread all over the county.
4. Care delivery is not curative
   Hospice care by definition is not curative (even though there are pilot programs coming up that will allow curative care concurrent with hospice), and home care is mainly teaching patients and caregivers.  The benefits of healthcare at home are in improved quality of life, and allowing patients to remain where they want to be, not in recoveries.  It's not glamorous, but it is good care.

So given all of that, why should Healthcare at Home be part of a health enterprise's strategy?

1. Payment systems are changing
   Healthcare at Home has not been fee for service for a long time.  These services already know how to deliver quality care at the lowest possible cost.
2. Revenue will no longer be attributable to specific functions
   Under value based pricing, entities are paid for quality care delivery and outcomes, not services performed.  Home Care and Hospice can improve care delivery and outcomes, and at less cost than other care delivery mechanisms.
3. Location is less important
   The rise of remote visits, the vast expansion of satellite facilities, and even health kiosks are all signs that the most efficient care delivery does not happen in the largest, nicest building on a health care campus.
4. Outcomes are not always about cures
   The savings from hospice are extremely well documented, as is the amount of money spent in the late stages of care, frequently with no good effect.  Patients consistently say they want to stay at home, even as their health may be fading.

CMS has at least two proposals moving things in this direction:

• CMS is proposing bundling payment for joint replacement care.  My thoughts.
• CMS will let 141 hospice agencies care for patients while they continue to receive curative care.  My thoughts.

Both of these proposals show the largest payer in healthcare is also beginning to recognize this sector as undervalued.

Being Mortal

I just finished reading Being Mortal: Medicine and What Matters in the End, by Atul Gawande, MD.  I wish my father were alive to have read this book; he would have thoroughly appreciated the themes it covers.  As a small town private practice family physician, he lived them.

In Being Mortal, Dr. Gawande works through what happens at the end of our lives, and how we should best respond to it.  It's a question that is not discussed as much as it should be, and he makes several excellent points.

Death is a very different experience in the era of modern medicine than it used to be.  Society has gotten good at preventing many of the things (medical or social) that used to kill people when they were younger, which means we are much more likely to endure the decline which becomes inevitable as our bodies age.  But we as a society are not really ready to cope with that.  Medicine's desire to address discreet problems does not address the systemic issues that become the real issue for people as they age.

In a Norman Rockwell America, the elderly remain in the home with one of their children.  But in the end, that proves not to be a practical solution.  Because children have long since moved out of the parent's home, it's not remaining, but moving into their children's house.  And as the care needs escalate, those needs inevitably become more than a child/caregiver can provide.

Dr. Gawande discusses what assisted living started as, a place that can care for the infirm without institutionalizing them.  Much of the discussion in the book is around what is wrong in most nursing home care and end-of-life medicine - that there is no interest in individual desires, just efficient care-giving.

The solution, both in housing and in medicine, are in more a whole-person approach.  Real assisted living, palliative care, and hospice all work to use that approach.  The key factor is a willingness to discuss what is important to the person as they age and lose some of their capabilities.  The author cites a 2010 study by Mass General Hospital offered that palliative care in addition to treatment to ½ their patients with Stage 4 lung cancer.  “The result: those who saw a palliative care specialist stopped chemotherapy sooner, entered hospice care earlier, experienced less suffering at the end of their lives—and they lived 25% longer.  In other words, our decision making in medicine has failed so spectacularly that we have reached the point of actively inflicting harm on patients rather than confronting the subject of mortality.  If end-of-life discussions were an experimental drug, the FDA would approve it.”

We are reminded that medicine and institutions are designed to promote safety and longer life.  But the sick and the aged have priorities beyond merely being safe and living longer.  I am a staunch advocate of hospice, mostly because it provides care that is sensitive to those real priorities.

Dr. Gawande concludes by saying that:

"Our job in medicine is not to ensure health and survival, it is to enable well-being."

He's right, and hospice and palliative care are the services that currently address that.  We need a medical system where ALL care providers are focused on enabling well-being, and not simply addressing whatever immediate medical need there is.

Read the book.  Engage in discussions with those you love about their end-of-life desires. You will be happy you did.

Tele-monitoring for Chronic Diseases - The Numbers

Finally, a study summarizing all the other studies done over the last several years.

The evidence is overwhelming.  Using technology in the home of patients with chronic diseases reduces hospitalizations, emergency room visits and overall cost.

This overview analysis focused on studies that deployed some telehealth mechanism (tele-monitoring-monitoring in patient's homes, video-conferencing, nurse telephone interventions) for patients with a chronic disease, specifically,  congestive heart failure (CHF), stroke, and chronic obstructive pulmonary disease (COPD).

As an aside, it is interesting to note that as early as 1879, there is anecdotal evidence of diagnosis over the telephone.  A physician listened to the cough of a child who was thought to have the croup, and determined that the child did not.  The concept of medicine being delivered without a doctor present has been around longer than we might have imagined.

The studies included in this analysis took place from 2000 to early 2014.  After examining hundreds of reports, this analysis found 19 CHF studies, 21 stroke studies, and 17 COPD studies that met their criterion for size and completeness.  There were some experiments in video medicine, telephone check-ins, and tele-monitoring.  The consistent conclusion is that doing something while the patient is not actively in the medical system improves outcomes and saves money.

As the authors say:
The preponderance of evidence from studies using rigorous research methods points to beneficial results from telemonitoring in its various manifestations, albeit with a few exceptions. Generally, the benefits include reductions in use of service: hospital admissions/readmissions, length of hospital stay, and emergency department visits typically declined. It is important that there often were reductions in mortality. Few studies reported neutral or mixed findings.

It's past time where we should be debating this.  It's time to implement telehealth at every health system that is interested in better outcomes at lower cost.

Thanks to the folks at Advanced Telehealth Solutions for bringing this study to my attention in their blog.

Home Care

I’ve already written about hospice and tele-monitoring.  Home care is the obvious third leg of the non-acute care stool.  For patients that are at home, and can’t get anywhere else, providing care to them in their home is significantly more attractive to them and to whoever has to pay the total bill than having them go without care, get worse, and finally need a visit to the emergency room.

Medicare alone spent 78 Billion Dollars on home care in 2012.  It’s a big business.  But is certainly is not being used to the fullest.  It is interesting to note that although there is a lot of discussion these days about our payment systems evolving from fee-for-service to some sort of Outcomes Based Reimbursement, home care under medicare has been operating that way since 2001.  The system is called PPS (prospective payment system) and basically gives home care agencies a flat amount for a 60 day episode of care.  The amount of that payment is determined by the answers to an assessment (OASIS) designed to determine how difficult that patient will be to care for.

Home care has made this system work for them for over a decade now.  Providing good care to people in their homes has avoided some hospitalizations, and has allowed some patient to stay in their home, rather than have to move to a facility.

Traditionally, health care systems have not put much emphasis on home care.  Even hospitals that own home care agencies frequently don’t have a good handle on how that business works.  In the past, with separate payments, hospital visits avoided by home care did not necessarily benefit the bottom line.  Going forward, they will.  That means large health care organizations that don't own or affiliate closely with a home care agency will have higher costs.

Like so much of what needs to happen in health care, the need to use home care more is just plain old common sense.  Let's hope health entities begin to catch on to that.