Today THCB is spotlighting Lumeris which creates a platform to help set-up and develop health plans and manage care delivery for patients. Working with its associated medical group Essence, Lumeris has been creating actionable steps to reduce Medical Cost Rates (MCRs) and is now taking that process to other health systems that want to set up Medicare Advantage plans. Lumeris is working with 12 health systems and is growing rapidly. Recently, Lumeris partnered with Cerner to bring their product to market.
Matthew Holt interviewed Matt Cox, Chief Marketing Officer at Lumeris to find out the details.
In my mid-twenties, I was twice prescribed the common antihistamine
Benadryl for allergies. However, my body’s reaction to the drug was anything
but common. Instead of my hives fading, they erupted all over my body and my
arms filled with extra fluid until they were almost twice normal size. I subsequently
described my experience to a new allergist, who dismissed it as “coincidence.”
When I later became a nurse, I learned that seemingly “harmless” medications often cause harm, and older adults are particularly vulnerable. Every year, Americans over age 65 have preventable “adverse drug events” (ADEs) that lead to 280,000 hospital stays and nearly 5 million outpatient visits. The Lown Institute in Boston draws attention to this underrecognized problem in their recent report, Medication Overload: America’s Other Drug Problem. Policymakers, patients, and health professionals must act, because over the next decade, medication overload is predicted to cause 4.6 million hospitalizations of older Americans and 150,000 premature deaths.
Nearly half of all older adults take at least five
prescription drugs, a 300 percent increase from 25 years ago. The
more drugs we take, the likelier it is that one of them, or some combination,
will cause serious harm. When you add in non-prescription medications,
including over-the-counter drugs like ibuprofen and Tylenol, as well as
vitamins and herbal supplements, the potential for harm only goes up.
I’ve seen this in my
work. It is not unusual for elderly, very ill patients on hospice to have
prescriptions for 20 to 30 drugs. Several of their medications may treat the
same problem, amplifying any serious side effects. Blood pressure medications provide
a good example. As older patients become more debilitated, lose weight, and are
taxed by other health issues, the effect of these medications can intensify,
severely lowering blood pressure, and causing the patients to fall. Indeed, if
I am following up with a hospice patient who has fallen, the first thing I
check is their prescription medications for hypertension.
By SAMYUKTA MULLANGI MD, MBA, DANIEL W. BERLAND MD, and SUSAN DORR GOOLD MD, MHSA, MA
Jenny, a woman in her twenties with morbid obesity (not her real name), had already been through multiple visits with specialists, primary care physicians (PCPs), and the emergency department (ED) for unexplained abdominal pain. A plethora of tests could not explain her suffering. Monthly visits with a consistent primary care physician also had little impact on her ED visits or her pain. Some clinicians had broached the diagnosis of functional abdominal pain related to her central adiposity, and recommended weight loss. This suggestion inevitably led her to become defensive and angry.
our standard screen for safety at home had been completed long ago, I wanted to
probe further, knowing that many patients with obesity, chronic pain and other
chronic conditions have suffered an adverse childhood – or adulthood –
experience (ACE). Yet, I hesitated. Would a busy primary care setting offer enough
latitude for me to ask about a history of trauma when it can occur in so many
forms, in so many ways and at different times of life? Furthermore, suppose she
did report a history of trauma or adverse experience. What then? Would I be
able to help her?
I began: “Jenny, many patients with symptoms like yours have been abused,
either emotionally, physically, or sexually, or neglected in their past.
Sometimes they have suffered loss of a loved one, or experienced or witnessed
violence. Has anything like this ever happened to you?”
yielded our first breakthrough. Yes, she had experienced neglect, with parents
who were separated for much of her childhood, and then later divorced. She had
seen her father physically abuse her mother. With little parental oversight,
she had engaged in drug and alcohol use throughout her teenage years. But, she
wanted to be sure we understood that this was all behind her. She had gotten an
education, was in a committed relationship, and had a stable job as a teacher.
That part of her life was thankfully now closed.
In this episode of Radiology Firing Line Podcast, I speak with Bishal Gyawali MD, PhD. Dr. Gyawali obtained his medical degree from Kathmandu. He received a scholarship to pursue a PhD in Japan. Dr. Gyawali’s work focuses on getting cheap and effective treatment to under developed parts of the world. Dr. Gyawali is an advocate for evidence-based medicine. He has published extensively in many high impact journals. He coined the term “cancer groundshot.” He was a research fellow at PORTAL. He is currently a scientist at the Queen’s University Cancer Research Institute in Kingston, Ontario.
At its April 4, 2019 meeting, the staff of the Medicare Payment Advisory Commission (MedPAC) asked the commission to discuss a very strange proposal: Doctors who treat patients enrolled in Medicare’s traditional fee-for-service (FFS) program must join an “accountable care organization” (ACO) or give up their FFS Medicare practice. (The staff may have meant to give hospitals the same Hobbesian choice, but that is not clear from the transcript of the meeting.)
Here is how MedPAC staffer Eric Rollins laid out the proposal:
“Medicare would require all fee-for-service providers to participate in ACOs. The traditional fee-for-service program would no longer be an option. Providers would have to join ACOs to receive fee-for-service payments. Medicare would assign all beneficiaries to ACOs and would continue to pay claims for ACOs using standard fee-for-service rates. Beneficiaries could still enroll in MA [Medicare Advantage] plans. (p. 12 of the transcript)”
first question that should have occurred to the commissioners was, Are ACOs
making any money? If they aren’t, there’s no point in discussing a policy that
assumes ACOs will flourish across the country.
only two of the 17 commissioners bothered to raise that issue. They asserted
that Medicare ACOs are saving little or no money. Those two commissioners – Paul
Ginsburg and commission Vice Chairman Jon Christianson – did not mince words.
Ginsburg said ACO savings were “slight” and called the proposal to push doctors
into ACOs “hollow” and premature. (pp. 62-63) Christianson was even more
critical. He said the proposal was “really audacious,” and that no “strong
evidence” existed to support the claim that ACOs “can reduce costs for the
Medicare program or improve quality.” (pp. 73-74) Ginsburg and Christianson are
correct – ACOs are not cutting Medicare’s costs when Medicare’s “shared
savings” payments to ACOs are taken into account, and what little evidence we
have on ACO overhead indicates CMS’s small shared savings payments are nowhere
near enough to cover that overhead.
A friend of mine told me the other day, “We’ve seen our insured patient population go from 15% to 70% in the few years since Obamacare.” As a primary care physician in the Midwest, he’s worked for years in an inner-city clinic that serves a poor community, many of whom also suffer from mental illness. Before the Affordable Care Act (ACA), the clinic constantly struggled to stay afloat financially. Too often patients would be sent to an emergency room because the clinic couldn’t afford to provide some of the simplest medical tests, like an x-ray. Now, with most of his patients insured through the Medicaid expansion program, the clinic has beefed up its staffing and ancillary services, allowing them to provide better preventive care, and in turn, reduce costly ER visits.
From the time Medicaid was established in 1965 as the country’s first federally-funded health insurance plan for low-income individuals, state governments have only been required to cover the poorest of their citizens. Before the ACA, some 47 million Americans were uninsured because their incomes exceeded state-determined benchmarks for Medicaid eligibility and they earned far too little to buy insurance through the private marketplace.
The ACA reduced the number of uninsured Americans by mandating that states increase their income requirement for Medicaid to 138% of the federal poverty line (about $1,330 per month for a single individual), and promising that the federal government would cover the cost to do so. However, in a 2012 decision, the Supreme Court left it to the states to decide if they wanted to increase their Medicaid eligibility. If they agreed to adopt Medicaid expansion, the federal government offered to cover 100% of the increased cost in 2014 and 90% by 2021.
The 2016 21st Century CURES Act is the law. It is built around two phrases: “information blocking” and “without special effort” that give the administration tremendous power to regulate anti-competitive behavior in the health information sector. The resulting draft regulation, February’s Notice of Proposed Rulemaking (NPRM) is a breakthrough attempt to bend the healthcare cost curve through patient empowerment and competition. It could be the last best chance to avoid a $6 Trillion, 20% of GDP future without introducing strict price controls.
This post highlights patient-directed access as the essential pro-competition aspect of the NPRM which allows the patient’s data to follow the patient to any service, any physician, any caregiver, anywhere in the country or in the world.
Today on Health in 2 Point 00, Jess and I are in New Orleans at the ATA Annual Conference. In this episode, Jess asks me about my takeaways from the conference, Cityblock’s $65 million raise, and Microsoft HealthVault shutting down. In terms of virtual care, it seems that there’s been low adoption of telehealth visits—but things are on the cusp, with lots of companies doing interesting things and with CMS expanding Medicare Advantage coverage of telehealth services. —Matthew Holt
The Robert Wood Johnson Foundation (RWJF) has partnered with Catalyst @ Health 2.0 to launch two innovation challenges on Social Determinants of Health (SDoH) and Home & Community Based Care. As a national leader in building a culture of health, RWJF is inspiring and identifying novel digital solutions to tackle health through an unconventional lens.
Health starts with where we live. As noted in Healthy People 2020 social determinants
of health are, “conditions in the environments in which people are born, live,
learn, work, play, worship, and age… [that] affect a wide range of health
functioning, and quality-of-life outcomes and risks.” For example, children who
live in an unsafe area cannot play outside making it more difficult for them to
have adequate exercise. Differences in SDoH heavily influences communities’
well-being and results in very different opportunities for people to be
Despite our knowledge on SDoH, the current healthcare system utilizes care models that often fail to take into account the social and economic landscape of communities– neglecting factors such as housing, education, food security, income, community resources, transportation and discrimination. Little progress has been made on incorporating SDoH into established health care frameworks. Healthcare providers and patients alike either have limited understanding of SDoH or have limited opportunities to utilize SDoH knowledge. RWJF established the “Social Determinants of Health Innovation Challenge” to find novel digital solutions that can help providers and/or patients connect to health services related to SDoH.
Home and community-based care is also important to enable Americans to live the healthiest lives possible. In-patient and long-term institutional care can be uncomfortable, costly, and inefficient. Digital health solutions in the home and community offer opportunities for care that better suit the patient and their loved ones. For example, innovations such as remote patient monitoring (RPM) have created new care models that allow the providers, caregivers, and patients to manage care where a person is most comfortable. RPM serves as a reminder that technologies in the home and community offer alternatives methods to engage the patient, increase access to care, and receive ongoing care. Therefore, RWJF is launching the “Home & Community-Based Care Challenge,” to encourage developers to create solutions that support the advancement of at-home or community-based health care.
The Office of the National Coordinator (ONC) and the Centers for Medicare and Medicaid (CMS) have proposed final rules on interoperability, data blocking and other activities as part of implementing the 21st Century Cures Act. In this series, we will explore ideas behind the rules, why they are necessary and the expected impact. Given that these are complex and controversial topics open to interpretation, we invite readers to respond with their own ideas, corrections and opinions.
When it comes to sharing health data, the intent of the 21st Century Cures Act is clear: patients and clinicians should have access to data without special effort or excessive cost. To make this a reality, the act addresses three major areas: technical architecture, data sets and behaviors. Part two of our series looked at how APIs address technical issues while part three covered the new data requirements. In this article, we delve into information blocking. A companion podcast interview with ONC expert Michael Lipinski provides an even deeper dive into this complex topic.
Blocking Comes in Many Forms
The Public Health Services Act (PHSA) broadly defines information blocking as a practice that is “likely to interfere with, prevent, or materially discourage access, exchange, or use of electronic health information.” The overarching assumption is information will be shared though the Act does authorize the Secretary to identify reasonable and necessary exceptions.
The proposed rules focus on “technical requirements as well as the actions and practices of health IT developers in implementing the certified API.” Information blocking can come in a variety of forms. It can be direct and obvious (“No you can’t have this data ever!”) or indirect and subtle (“Sure, you can have the data, but it will cost you $$$ and we won’t be able to get to your request for at least 12 months.”). The proposed rules are designed to address both. This passage illustrates some of the concerns:
“Health IT developers are in a
unique position to block the export and portability of data for use in
competing systems or applications, or to charge rents for access to the basic
technical information needed to facilitate the conversion or migration of data
for these purposes.”