Overutilization of ERs May Not be as Great as Perceived

Far fewer hospital emergency room visits are for medical problems better addressed in other settings, according to a new study.

In a review of six years worth of data encompassing 424 million ER visits, researchers found that only 3.3 percent of those visits were truly “avoidable,” with the avoidable visits mostly involving problems ERs are not equipped to address, such as dental and mental health issues.

This finding flies in the face of the conventional wisdom that people turn too quickly to hospital ERs for routine medical problems or use ERs because they lack access to more appropriate care.

Learn more about the study and its findings in this Fierce Healthcare article or go here for a link to the study “Avoidable emergency department visits: a starting point,” which was published in the International Journal for Quality in Health Care.


Defining “Success” in Addressing Social Determinants of Health

With a growing number of programs designed to address the social determinants of individuals’ health care challenges, the question arises as to how to define “success” in those approaches.

A recent article on the Health Affairs Blog addresses this question by illustrating the many variables that go into determining what constitutes “success” and suggesting that success be viewed from a number of perspectives, including:

  • success for entire communities
  • success from the perspective of individual patients
  • success based on the effectiveness of addressing specific social needs (such as housing, transportation, or food security)

The article also describes the different ways that success can be defined and measured.

This is an especially important matter for urban safety-net hospitals because so many of these new programs will be launched in the generally low-income communities they serve.

Learn more by reading the article “Defining Success In Resolving Health-Related Social Needs,” which can be found here.

MedPAC Meets

Last week the Medicare Payment Advisory Commission met in Washington, D.C.

During two days of meetings, MedPAC commissioners addressed the following issues:

  • accountable care organizations
  • Part B drug payment policies
  • behavioral health care
  • health care reform quality measures
  • measures of hospital use for long stay nursing facility residents
  • biosimilars in Medicare Part D

To see issue briefs on these subjects and the presentations offered during the meetings, go here, to MedPAC’s web site.

CMS Posts Tentative List of Essential Community Providers

The Centers for Medicare & Medicaid Services has posted on its web site a draft list of essential community providers for 2018.

iStock_000001497717XSmallTo qualify as essential community providers, organizations must serve predominantly low-income, medically underserved patients.  Qualified health plans must contract with at least 30 percent of the essential community providers in their markets and must offer contracts in good faith to at least one such provider in each of six categories, including federally qualified health centers, hospitals, and family planning providers.

Providers that believe they have mistakenly been excluded from the list may petition for inclusion.

Find the draft list here.


CMS Urges Improvements in Care for Physically, Mentally Disabled

New guidance issued by the Centers for Medicaid Services outlines how states can make better use of home care in serving physically and mentally disabled Medicaid beneficiaries.

Those steps include establishing open registries of home care workers; establishing qualifications for such workers; and paying wages that will help foster continuity of care for the clients of those home care workers.

In making these recommendations, CMS seeks to make greater use of managed long-term services and supports and home- and community-based services when serving individuals who might otherwise need costly nursing home care.

Learn more about CMS’s recommendations and why it made them in this informational bulletin from CMS to state Medicaid directors.

A Closer Look at Social Determinants of Health

The National Association of Urban Hospitals often points to the socio-economic status of the patients its members serve as constituting one of the greatest challenges private safety-net hospitals face. That challenge typically takes two major forms: how to serve such patients more effectively and how to encourage public officials to shape government (Medicare and Medicaid) reimbursement policies that reflect this distinct challenge and treat such caregivers fairly.

Now, the National Academy of Medicine has taken a closer look at the social determinants that play such a major role in community health and in the health of the residents of the communities private safety-net hospitals serve.

-academy-of-medicine-274x168In its new report An Environmental Scan of Recent Initiatives Incorporating Social Determinants in Public Health, NAM reviews such initiatives in six categories:

  1. community-generated initiatives to foster community health
  2. data and metrics initiatives to support measurement of community health
  3. tool kits to promote multi-sector efforts to promote health
  4. campaigns intended to inspire broad multi-sector approaches to health
  5. federal initiatives promoting a broad vision for fostering community
  6. philanthropic initiatives supporting and motivating multi-sector collaboration to improve health

Find the report here.


HHS Issues Report on Changes in Care in Urban, Rural Areas

ASPEsealThe U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Planning and Evaluation has issued a new report titled Impact of the Affordable Care Act Coverage Expansion on Rural and Urban Populations.

The report looks at changes in coverage rates and access to care and how these populations have used federal tax credits to obtain health insurance.

Find the report here.

Background Information on Payment Methodologies and Benefit Design

The Urban Institute has issued two new papers with background information on health care payment methodologies and the design of health care benefits packages.

The first paper, Payment Methods: How They Work, describes nine payment methodologies:

  • fee schedules
  • primary care capitation
  • per diem payments to hospitals for inpatient visits
  • DRG-based payments to hospitals for inpatient visits
  • global budgeting for hospitals
  • bundled payments
  • global capitation for organizations
  • shared savings
  • pay for performance

The second paper, Benefit Designs: How They Work, explains seven different types of benefit designs:

  • value-based design
  • high-deductible health plans
  • tiered networks
  • narrow networks
  • reference pricing
  • centers of excellence
  • benefit design for alternative sites of care

urban institute 2A third paper, Matching Payment Methods with Benefit Designs to Support Delivery Reforms, describes how to match benefit designs with payment methods.

Go here to find Payment Methods: How They Work.

Go here to find Benefit Designs: How They Work.

And go here to find Matching Payment Methods with Benefit Designs to Support Delivery Reforms.

Do Medicare Patient Satisfaction Surveys Foster Opioid Abuse?

A coalition of physicians and medical providers has questioned whether Medicare’s patient satisfaction surveys indirectly encourage physicians to prescribe opioids to help their patients with pain problems.

The New York Times reports that coalition participants

…filed a petition Wednesday with the federal agency that administers Medicare and Medicaid, the government health programs for the elderly, disabled and poor. The letter asks that officials eliminate certain pain-related questions from patient-satisfaction questionnaires, such as: “During this hospital stay, how often was your pain well controlled?”

The groups argue that such questions inadvertently encourage aggressive use of painkillers to maintain high patient-satisfaction metrics.

“Aggressive management of pain should not be equated with quality health care as it can result in unhelpful and unsafe treatment,” states the petition, which calls on the government to release a proposal for a new questionnaire within 90 days.

Last week a bipartisan group of senators introduced legislation that would eliminate the connection between pain survey questions and the payment rates hospitals receive from Medicare.

Prescription Medication Spilling From an Open Medicine BottleThe subject was among a number of issues providers raised addressing ways that some formal practices may indirectly encourage opioid use and abuse.

NAUH has long expressed concern about the Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) survey Medicare uses to evaluate the performance of hospitals.

To learn more about how providers are urging lawmakers to fight opioid abuse, see this New York Times article.

Do Return ER Visits Yield Better Outcomes?

Patients who visit hospital emergency rooms for care, return home, and then return to the ER within 30 days have better outcomes than those who are admitted to the hospital from the ER.

And their care costs less as well.

jama1This according to a new study published in the Journal of the American Medical Association.

What does this mean?

According to the study’s abstract,

These findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit.

To learn more about the study and its surprising findings, see this Fierce Healthcare article or go here for a link to the JAMA article “In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department.”