Community Health Program: 3 Steps To Doubling Your Business In 2015
Community health program http://communitywellnessday.com/google-hangout-special.html In this video Community Health Program expert Dr. Randi Ross. This week Dr. Ross interviews, Dr. Ray Omid, ...
By: Dr Randi Ross
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Community Health Program: 3 Steps To Doubling Your Business In 2015 - Video
A MacArthur genius grant winner is now formally studying how hot-spotting method cuts expensive emergency room visits and delivers better care
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Even the most trivial of emergency-room trips can quickly add up. Going in for an upper respiratory infection averages more than $1,000. A urinary tract infection can set patients back thousands of dollars. But before Obamacare came on the scene, New Jersey physician Jeffrey Brenner was already working on innovative ways to slash health-care costs. He scoured health-care billing data at local hospitals and discovered that a small number of super utilizers clustered in certain geographic areas were responsible for the bulk of health-care costs in Camden, N.J. He brought together a team of social workers and medical professionals, who made regular house calls to those patients, accompanied them to doctors appointments and conducted long interviews with them to obtain health historiesall to help the city cut medical costs and provide better care to these neediest patients. That was some six years ago. His work, called health-care hot spotting, helped net him a MacArthur genius award in 2013. Now he works full-time on this issue and oversees a team of about 20 nurses, social workers, community health-care workers, Americorps volunteers and a psychologist who attack this problem around Camden. More than 50 similar operations have popped up around the country, and Brenner assists half of them. The latest such health hot spotting project Brenner works with is Sutter Health, a huge system consisting of some 30 hospitals in northern California. Brenner, the executive director of the nonprofit Camden Coalition of Healthcare Providers, spoke with Scientific American about how to predict who will cost the health-care system the most, his plans for his genius prize winnings, and his latest efforts to study health hot spotting with a randomized controlled trial. [An edited transcript of the conversation follows]: What made you think to start mapping out super utilizers of health care? I was a frontline family doctor in Camden, N.J., for 12 years. I accepted Medicaid patients and found that they had the most complex health problems to tease apart. In a typical primary-care model, we dont serve those patients very well. It was a big, audacious, hairy problem where the tools we have been given are inadequate to solve it. How can communities identify these complex, chronic patientsthese so-called super utilizers that cost hospitals the mostwhile respecting patient privacy? Wouldnt tapping such billing data run up against HIPAA protections? It turns out that HIPAA allows you to work with large data sets for billing purposes, if you are improving quality or if its a valid research project. In our case, we originally got approval because it was a large research project. But we also have a business agreement as part of the health information exchange. That exchange under HIPAA says you are allowed to have data sharing agreements as long as patients are given forms to explain what their data is being used for. Not many patients opt out. Your early hot-spotting efforts saved community hospitals millions of dollars, Ive read. How much did you actually save? We have no idea. Statistically, savings are actually really hard to calculate. I have not talked about dollar figures in the last few years because the only way we will know savings for sure is by doing a randomized controlled trial. Thats what we are doing now. We certainly believe our interventions save money. Why is it hard to determine the savings? There is a patient in Trenton, N.J., who went 450 times to the local hospitals in a single year. She was chronically homeless and alcoholic, and she had a lot of physical and sexual abuse in her history. Through a collaboration with the local hospitals and social agencies, she was able to get into a special housing unit and worked with a multidisciplinary team like ours that got her down to 18 visits a year. We have a policy premised on why the intervention would make a difference, but it turns out that if you took 200 overutilizers like her and watch them over a year, they drop in utilization some 20 percent to 30 percenteven if you do nothingbecause statistically, when you are dealing with outliers, outlier data tends to regress toward the mean. These people are quite sick, and its hard to get to the hospital 450 times each year. Our randomized controlled trial will get us some real answers. Why are you doing a randomized controlled trial now? There is a lot of research on pills and devices, but there has been very little high-quality research on how to deliver better care at lower cost. If you look at our funding for our nonprofit, there are about 28 sources of funding cobbled together to keep our team in the field and to keep the structure in place so we can do this randomized controlled trial. Thats why its taken so long to launch a trial. Weve now partnered with the Abdul Latif Jameel Poverty Action Lab, which does randomized trials around the world on social interventions. The lead is up at the Massachusetts Institute of Technology , and its the researcher that did the well-known Oregon health research that randomized people into access to Medicaid. Theyve been helping us set this up. You were awarded a MacArthur genius grant in 2013. What did you do with the $625,000? Its an interesting grant. Its not a grant to the Camden Coalition of Healthcare Providers organization. It was granted to me individually. I had a private Medicaid practice in Camden, and my payment rates kept getting cut. I actually went out of business. By the time I closed my office, I was getting $19 a visit because of cuts happening at the state level that were trickling down through the Medicaid HMOs. The MacArthur grant is not one lump payment. Its broke out over five years and about half of it is paid out in taxes. It comes as quarterly payment, and the first few years will go to paying off the debts from my practice. How does that experience affect your current efforts with hot spotting? Primary care is dying while hospitals are expanding, which underscores why reforms are needed. You get what you pay for. If you underspend on primary care, then you wont get enough of it. We need to move some of that money spent in hospitals back to primary care providers and save the health-care system costs. What does your randomized controlled trial look like? It will have a total of 800 patients. Four hundred patients will receive our intervention, and 400 will be controls receiving normal routine care where they are discharged from the hospital and make their own appointments. We recruit patients into the trial from four hospitals in New Jersey where we have set up real-time data systems that allow us to know when these patients have been admitted: two admissions in six months signals to us that a patient may be the worst of the worst and that she or he is likely a $20,000 patient. We then explain our project to the patients and ask them to consent to participate. If they consent, we leave the room, hit the random button on our computer and the patient is randomized into intervention or control. We need to do that 800 times. We then follow them in our data system. At the end of the study, we will also look through Medicaid records to make sure we catch if they received care elsewhere. When do you expect all the data to be in? Weve been collecting good data now for six months. We have 80 patients in each arm of the study now, and so if we can ramp up and accelerate enrollment, then well probably have data next December. What do patients receiving the intervention get? For 90 days we go to patients appointments with them, make home visits, and if they are homeless, we help them get housing. We also help them apply for other social services. Its a multidisciplinary approach with social workers, community health-care workers and nurses, and we are also inside local primary health-care offices for training. What happens after the 90 days of intervention? We try to graduate them and plug them into a stable, well-run system of care. Sometimes, since many primary care providers have closed, we have trouble finding a practice that accepts Medicaid patients. We have been using some of our funds to augment Medicaid payments to primary care providers. We pay them $150 if they get one of these patients in for a visit five to seven days after when they were in the hospital. And we pay the patient with a $20 gift card and a cab voucher to go see the doctor. We have found in our data that the first week to two weeks after hospitalization is a critical time, and if we can engage them quickly, it makes a world of difference. And for those medical practices, its a lot of money. Were giving out a couple thousand dollars to practices that are struggling. Do you think this model of hot spotting is a good fit in both rural and urban areas? Yes. We have worked with groups in Eureka, Calif., which is incredibly isolated, and found the same patterns hold up. We have also worked with a group in rural Maine, another in rural Michigan and also in rural Pennsylvania. What were finding over and over with our partners across the country is that the number-one determinant of being a high utilizer of health care is the amount of adverse childhood experiences you had, like physical and sexual abuse. There is interesting literature to back that up. In short, those traumatic experiences in early childhood lead to lifelong health costs and can help predict health-care utilization rates. Is it early life trauma specifically, or might other factors be at work there, such as socioeconomic status, economic and health access issues or childhood stability? In a lot of studies we say that some bad outcome is due to socioeconomic status, but there has been very little work to look at the causality. There are higher levels of early life trauma in underserved communities; therefore, the true variable is probably the early life trauma and probably trauma and early life conditions. The social determinants of health and all the underlying pieces of it have not been fully explored, and we dont understand the ethnography of it all. Has the Affordable Care Act (Obamacare) impacted your work? The law sent a huge market signal out to the health-care industry that the game needs to change and become more efficient and accountable. Under the Affordable Care Act, there was also a $10 billion fund put together to support innovation over a decade. The Centers for Medicare and Medicaid Services have been putting grants out. We got a $2.7 million three-year innovation grant that is helping to pay for the research team in the field. Its one of our 28 sources of funding. Your approach has been likened to a weather map for health. Is that an appropriate analogy? Hot spotting is not just making maps. Its the strategic use of data to find outliers and to improve their care. Mapping is one example of how you segment data. There are other strategies you can use as well, like hospital claims data. A lot of our work has been simplified down to terms like hot spotting and super utilizers, but its a multidimensional intervention. We are trying to get the cost curve to drop by focusing on the poorest patients. We are using data in real time to target outliers who are the canary in the coal mine to understand how the system is failing.
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Positive action on multiple fronts and the recovering economy are helping to reduce the growth in health-care costs to historically moderate levels. But there is no comprehensive national approach to controlling health-care costs. Further, there islittle coordination of the disparate efforts across the country, and we cant say for sure what is working and what is not.
The Centers for Medicare and Medicaid Services (CMS)reportreleased Wednesday showed that health-care spending per person grew 2.9% in 2013, in line with the modest rates of spending growth seen in recent years. As the chart above shows, per capita health-care spending is growing unusually slowly by historical standards, but it is projected to pick up again as the economy improves, as more people are covered under the Affordable Care Act, and as the population ages.
By 2020 growth in per capita health spending is projected to be almost twice the current rate. But that is still much slower than in many years past. If we were to shave one percentage point off the annual rate of increase in health spending, more than $2 trillion would be saved over the next 10 years. Similarly, cutting half a percentage point off projected increases would make a substantial difference.
Most current efforts to reduce costs and improve quality focus on reforming the delivery of medical care. The primary objective is to reduce unnecessary hospital stays and overuse of tests and procedures. The ACA is accelerating the pace of delivery reform and changing payment incentives primarily through pilot projects implemented by a new Innovation Center in the CMS. Pilot projects are testing shared savings with Accountable Care Organizations, bundled payments (rather than fee for service) for some illnesses, and coordinated care for people with multiple health needs who are eligible for both Medicare and Medicaid. The CMS pilots are to be independently evaluated, and the results will be closely watched.
These efforts at delivery reform have promise, but they are scattered across the country and highly variable. They do not represent a comprehensive approach to health-care costs.
The focus on delivery also does not address a major factor influencing demand for health services: health insurance. The country has been so focused on the Affordable Care Act, and many in health care have been so focused on reforming delivery and payment, that a veritable sea change in the nature of insurance has unfolded without much scrutiny or debate. Changes in insurance, especially changes in cost sharing such as the growth in high-deductible insurance plans, can strongly influence the demand for health services. The average deductible in an employer health plan is about $1,200; it is $1,800 for smaller employers, more than $2,000 for high-deductible plans with savings accounts, and more than $2,500 for the most commonly selected silver plan in the ACA insurance exchanges.
The price of health services is also unaddressed by delivery reform. While health prices have been rising fairly slowly in recent years, the price of health care, including what Americans pay for procedures and drugs and what we pay doctors, is what most distinguishes the cost of our system from those of other developed nations. There is growing interest in price transparency to help consumers shop for less expensive care, but far less attention is paid to reducing the actual prices we pay for health services.
One reason we lack a comprehensive approach to health costs is that it is not really anyones job in our fragmented health system. Health-care institutions are changing how they deliver care in ways that make sense for them, keeping an eye on market leaders and competitors. Insurers have increased cost sharing to dampen demand and keep their premiums lower. The public is alarmed by the high prices people pay for health carebut cant do much about it. CMS oversees Medicare and Medicaid, but no government agency is responsible for developing a health-cost strategy or a comprehensive approach to dealing with delivery, demand, price, and other cost drivers. Such an approach would almost certainly represent a far greater role for government than would be palatable today. Our fragmented approach to controlling health costs may be enough while health spending is rising at historically moderate rates, but as the rate of increase picks up again pressure will rise do more, and for a more organized and comprehensive approach.
Drew Altman is president and chief executive officer of theKaiser Family Foundation. He is on Twitter:@drewaltman.
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NEW YORK (CNNMoney)
Actually, national health spending grew 3.6% in 2013, the lowest annual increase since 1960, when the Centers for Medicare and Medicaid Services began tracking the statistic, officials said Wednesday.
Spending slowed for private health insurance, Medicare, hospitals, physicians and clinical services and out-of-pocket spending by consumers. However, it accelerated for Medicaid and for prescription drugs, according to the report, published online by the journal Health Affairs.
Premiums for private health insurance grew 2.8% last year, compared to a 4% increase in 2012. Low overall enrollment growth, greater usage of high deductible plans and other benefit design changes and the health law's medical loss ratio and rate review provisions contributed to the decline, the Centers found.
Nearly 190 million people -- or 60% of the population -- were covered by private health insurance in 2013. Enrollment increased 0.7% last year, the third straight annual increase.
Consumer out-of-pocket spending -- including co-payments and deductibles or payments for services not covered by a consumer's health insurance -- grew 3.2% in 2013, down from the 3.6% growth in both 2011 and 2012.
Spending for physician and clinical services grew 3.8% last year, a slowdown from 2012 when spending grew 4.5%. Expenditures for hospital care increased 4.3%, slower than the 5.7% rate of growth in 2012.
Drug costs, however, rose at a faster rate than the previous year. Total spending growth for retail prescription drugs increased 2.5% last year, compared to 0.5% in 2012. Drug spending growth increased in 2013 for several reasons, among them higher prices for brand-name and specialty drugs.
Overall, health care spending has grown at historically low rates for the past five years, which is consistent with declines generally seen during economic downturns, such as the Great Recession that crippled the U.S. economy at the end of 2007. Looking ahead, "the key question is whether health spending growth will accelerate once economic conditions improve significantly; historical evidence suggest that it will," noted the authors, who are from the Centers' Office of the Actuary.
They also pointed out, however, that in the near term, the health sector will "undergo major changes that will have a substantial impact" on consumers, providers, insurers and sponsors of health care. These are the result of the health law's creation of online exchanges, its expansion of Medicaid, and restraints the law made to the Medicare program, the analysts found.
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NEW YORK (CNNMoney)
Actually, national health spending grew 3.6% in 2013, the lowest annual increase since 1960, when the Centers for Medicare and Medicaid Services began tracking the statistic, officials said Wednesday.
Spending slowed for private health insurance, Medicare, hospitals, physicians and clinical services and out-of-pocket spending by consumers. However, it accelerated for Medicaid and for prescription drugs, according to the report, published online by the journal Health Affairs.
Premiums for private health insurance grew 2.8% last year, compared to a 4% increase in 2012. Low overall enrollment growth, greater usage of high deductible plans and other benefit design changes and the health law's medical loss ratio and rate review provisions contributed to the decline, the Centers found.
Nearly 190 million people -- or 60% of the population -- were covered by private health insurance in 2013. Enrollment increased 0.7% last year, the third straight annual increase.
Consumer out-of-pocket spending -- including co-payments and deductibles or payments for services not covered by a consumer's health insurance -- grew 3.2% in 2013, down from the 3.6% growth in both 2011 and 2012.
Spending for physician and clinical services grew 3.8% last year, a slowdown from 2012 when spending grew 4.5%. Expenditures for hospital care increased 4.3%, slower than the 5.7% rate of growth in 2012.
Drug costs, however, rose at a faster rate than the previous year. Total spending growth for retail prescription drugs increased 2.5% last year, compared to 0.5% in 2012. Drug spending growth increased in 2013 for several reasons, among them higher prices for brand-name and specialty drugs.
Overall, health care spending has grown at historically low rates for the past five years, which is consistent with declines generally seen during economic downturns, such as the Great Recession that crippled the U.S. economy at the end of 2007. Looking ahead, "the key question is whether health spending growth will accelerate once economic conditions improve significantly; historical evidence suggest that it will," noted the authors, who are from the Centers' Office of the Actuary.
They also pointed out, however, that in the near term, the health sector will "undergo major changes that will have a substantial impact" on consumers, providers, insurers and sponsors of health care. These are the result of the health law's creation of online exchanges, its expansion of Medicaid, and restraints the law made to the Medicare program, the analysts found.
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If you're new to the job market or looking for a change of employment, you might want to consider getting into the health care sector.
The Department of Health and Human Services (HHS) says the demand for primary health care services will continue to grow dramatically this decade and beyond. Part of that growth results from a U.S. population that's both aging and expanding. Another reason HHS cites is the estimated growth of health insurance coverage "under full implementation" of the Affordable Care Act, also known as Obamacare, which assumes all states will expand Medicaid.
The Bureau of Labor Statistics projects health care-related occupations and industries will add the most new jobs in the U.S. between 2012 and 2022.
"Job prospects across the entire health care sector are expected to grow through the next decade as more Americans gain access to health insurance and providers add staff to meet the demand," said Tony Lee, publisher at CareerCast, a job-search portal.
While many top health-care jobs require at least an associates or bachelor's degree, CareerCast says it's one sector where hiring remains above-average.
And a new CareerCast report, using data from its Jobs Rated report metrics, lists the top 10 health care jobs heading into the new year, including salary and the field's projected job growth over the next seven years. The firm considered a number of factors in its assessment, including pay, employment prospects, stress levels and environmental factors, with data drawn from federal and private sources:
Audiologist Average annual salary: $69,720 Projected job growth by 2022: 34 percent
Dental hygienist Average annual salary: $70,210 Projected job growth by 2022: 33 percent
Dietitian Average annual salary: $55,240 Projected job growth by 2022: 21 percent
Medical lab technician Average annual salary: $34,160 Projected job growth by 2022: 22 percent
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Washington County seeks tighter rules in contract bidding
Washington County is ratcheting down costs and imposing stricter rules on health care contracting at its jail, after a recent audit revealed staffing shortages from its medical contractor and a lack of oversight from the county.
A new Request for Proposal for jail health care services was issued Nov. 25 by the Washington County Administrators Office (CAO). Bids are due Jan. 16 for inmate care beginning July 1.
The current provider, Corizon Health Services, lost its contract two years early.
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GENEVA: Ebola-related deaths in west Africa will be higher than the number of people directly infected because of its disruption to already weak health care services, the World Health Organization warned Tuesday. The WHO is convening a meeting in Geneva next week with finance and health ministers from Liberia, Sierra Leone and Guinea, donors and NGOs, to develop practical actions on how to improve health care systems for the future. Ebola has strongly impacted the already weak health systems, and Ebola has probably killed more people than the 6,000 linked to the disease itself, said the WHOs coordinator of health systems, Gerard Schmets. He added: This is a real critical situation that these countries are facing. Vaccination programs and general health services have stopped altogether in the worst affected areas of the three countries, which have born the brunt of the outbreak, while pregnancy care has also been hit, he said. There was already a shortage of health workers Sierra Leone had only two doctors for every 100,000 people, or just about 120 doctors for six million people before the Ebola outbreak began. Since then, health workers have been disproportionately hit by the virus, with 333 dying across the three countries, out of 575 who were infected, the WHO says. Malaria remains a pressing problem, while people with chronic diseases have had to interrupt their treatment to move to other districts to continue their care, Schmets said. The gathering on Dec. 10-11 will include representatives of the African Development Bank, the World Bank, the Centers for Disease Control and groups working to combat Ebola on the ground in the affected countries. In the longer run we need to strengthen these health systems and to rebuild health systems that will be stronger, to be able to address future emergencies, Schmets said. Meanwhile, Doctors Without Borders warned Tuesday that the international response to Ebola is still too slow and piecemeal as officials said the disease is further crippling the economies of the three West African countries hardest hit. The vast majority of infections are in Guinea, Liberia and Sierra Leone, poor countries that have been left to handle the crisis without sufficient help, said the medical aid group. Foreign governments have focused primarily on financing or building Ebola case management structures, leaving staffing them up to national authorities, local health care staff and NGOs (non-government organizations) which do not have the expertise required to do so, said the group, which is a primary provider of treatment in the outbreak, said in a statement Tuesday. It reiterated its call for countries with biological-disaster response teams to deploy them. In addition to killing thousands, the Ebola outbreak, which was identified in March in Guinea, has shut hospitals, schools and markets, hampered cross-border trade and resulted in the suspension of many of the airline flights.
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