By JOSEPH ANTOS and YEVGENIY FEYMAN

New York has an opportunity to make real improvements to its Medicaid program; but it is leaving out key health care providers which might be best positioned to cut costs and improve value.

The state has undertaken a $6.4 billion dollar initiative, the Delivery System Reform Incentive Payment (DSRIP) program, to reduce avoidable hospital use by 25 percent over the next 5 years. DSRIP is testing ways to do everything from cutting unnecessary emergency room visits to reducing transmission of HIV/AIDS.

This could lead to healthier, more productive lives for New York’s 6 million Medicaid beneficiaries and could generate positive spillover effects for all New Yorkers—if hospitals, physicians, and other providers adopt better ways to manage Medicaid patients, they are likely to use those improvements to assist all their patients.

A team approach, coupled with preventive health care to avoid hospitalization and appropriate follow-up care, is an important part of the strategy. Better coordination between community physicians and the hospital, and better information for patients, can save money and improve health outcomes.

The problem? New York’s DSRIP program is mainly confined to “safety net” providers,  including hospitals, academic medical centers, nursing homes, individual physicians, and others with a high volume of Medicaid or uninsured patients. The state limits the participation of physician groups known as Independent Provider Associations (IPAs) because they are not considered Medicaid providers.

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By JOEL KUPERSMITH, MD

As shown by breaches of personal information on innumerable individuals over the years, our approach to IT security falls short. Recent intrusions at Sony Pictures Entertainment and Anthem Health (80 million individuals) against a backdrop of substantial losses of personal health (PHI) and other IT information previously again brought this deficiency again to public attention. According to one estimate, almost 1 billion records were stolen via 1500 breaches in 2014, a 78% increase from the previous year and a clear indication of an increasing problem. Among personal information, health records are particular targets, bringing in $20 per record versus $1-$2 for a credit card and surveys consistently show considerable public concern about the privacy of PHI.

In a recent commentary, David Brailer proposed that raised security standards for health information be one of four principles underlying new privacy legislation. I strongly agree and would add a specific step to apply this principle – privacy accreditation for health data custodians.

Whether the information is stored for care, insurance or research, the public lacks understanding of the complexity of their stored PHI and the large number of individuals with access to or custodial responsibility for it. There is thus a wide gap and power differential between data providers and those who hold enormous amounts of sensitive health data. This circumstance creates a need for an empowered intermediary to act on the public’s behalf, i.e. an accreditation body.

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By ASHISH JHA, MD

A few months ago, the Centers for Medicare and Medicaid Services (CMS) put out its latest year of data on the Hospital Readmissions Reduction Program (HRRP). As a quick refresher – HRRP is the program within the Affordable Care Act (ACA) that penalizes hospitals for higher than expected readmission rates. We are now three years into the program and I thought a quick summary of where we are might be in order.

I was initially quite unenthusiastic about the HRRP (primarily feeling like we had bigger fish to fry), but over time, have come to appreciate that as a utilization measure, it has value. Anecdotally, HRRP has gotten some hospitals to think more creatively, focusing greater attention on the discharge process and ensuring that as patients transition out of the hospital, key elements of their care are managed effectively. These institutions are thinking more carefully about what happens to their patients after they leave the hospital. That is undoubtedly a good thing. Of course, there are countervailing anecdotes as well – about pressure to avoid admitting a patient who comes to the ER within 30 days of being discharged, or admitting them to “observation” status, which does not count as a readmission. All in all, a few years into the program, the evidence seems to be that the program is working – readmissions in the Medicare fee-for-service program are down about 1.1 percentage points nationally. To the extent that the drop comes from better care, we should be pleased.Continue reading…

By Tom Giulianni, MD

There is no doubt that the topic of patient engagement has taken center stage in healthcare. It was the hot topic at HIMSS 2015 where a major national study was unveiled, Three Perspectives of Patient Engagement. And that was just one of the many sessions, events, and booths focused on patient engagement at the event.

Thanks to Meaningful Use, a lot of the focus on patient engagement has been around patient portals. It makes sense since practices have to meet specific thresholds in both MU2 and MU3 for portal use. They certainly play a key role in providing patients with access to medical records, test results, and even tools like online scheduling and billpay. The benefits have not gone unnoticed by providers. Over 80% of doctors believe a patient portal helps with patient satisfaction and 71% believe it helps with patient/physicians communication. The benefits haven’t gone unnoticed by patients either. Two-thirds of patients say they would be more loyal to physicians who provides a portal through an EHR.

Despite the undeniable value of portals, they are just one component of true patient engagement. This was clear in the presentation about the new national study released at HIMSS. According to the presentation, the biggest problem in creating patient engagement isn’t providing access to health information. The problem is shifting the attitudes and expectations of both clinicians and patients.

Resolving this problem requires a major culture change in healthcare. Despite the fact that patients and providers say they want improved access, communication, and outcomes and that patient engagement may hold the key, change is slow.

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By NORTIN HADLER, MD

On Saturday, Dr. Hadler delivered the commencement address at the University of Michigan Medical School.  THCB is pleased to feature his remarks. 

Thank you, Class of 2015, for the privilege of sharing this special occasion with you, your families and the community that has come together to celebrate with you. This is a rare day of pure self-indulgence. Our professional life allows little room for self-indulgence and seldom applauds when one of us makes the room. For those of you who are drawn to a career anchored at the bedside, the trade-off is the quiet, internalized quest to become the best physician you can be. I have pursued this goal nearly all my life – literally, I have been working in hospitals since I was 12. If I had it to do over, I would pursue the same goal.

This goal demands expertise. Expertise requires intellect and discipline. I have a superabundance of both and so do you. Expertise is necessary but not sufficient.  More than expertise, one must understand myriad contexts in which illness plays out.

Medicine is not a science. Medicine is a philosophy informed by science.

I was a medical student when this dawned on me. Like you, I entered clinical rotations brimming with the pathophysiology of all those diseases that are poised to smite a mighty blow. Was I missing the forest for the biochemistry? Many of our patients are elderly patient and plagued by more than one serious disease. As we set to the task of confronting each in turn, it occurred to me that I might not care as much about what kills me as I care about when, and what the journey was like? Today, we have a good handle on that “when”. I can make a strong argument that if you manage to stay well to 85, you’re off warranty.

Notions of “fatal diseases” and of “saving a life” demand a temporal component.  Realize that in America, you can’t die without a diagnosis. In the mid-1980s, I started to sign the death certificates of frail elderly patients with “It was her time.” I would get a call from Raleigh; Doctor Hadler you can’t do that. I’d respond, “Which of the several diseases vying for the honor do you want me to list?” Whenever you hear of the epidemic of cancer or heart disease or stroke, ask the “When” question.

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