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U.S. needs to raise investment, shift medical research priorities

U.S. needs to raise investment, shift medical research priorities | Healthcare and Technology news |

The U.S. is losing its lead in global medical research, and many of the projects that do get funded overlook common diseases that afflict millions of people, according to a new analysis.

Experts point to falling public and private spending on the kind of basic research that leads to new discoveries, and a lack of innovation in delivering healthcare, in a paper in the Journal of the American Medical Association that’s part of a series on the future of medicine,

"With respect to U.S. public financing there has not been the political will to make biomedical research a priority in the same way that it was in the 1970s with the war on cancer or in the 1980s with the war on AIDS," said lead study author Dr. Hamilton Moses, of the Alerion Institute and Alerion Advisors LLC in North Garden, Virginia.

At the same time, private U.S. companies have concentrated investment in advanced clinical trials rather than on the basic research that’s needed to tackle some of the chronic conditions like diabetes that afflict the greatest number of people, Moses told Reuters Health in an interview.

Overall U.S. investment in biomedical and health services research grew just 0.8 percent a year from 2004 to 2012, down from a 6-percent annual growth rate between 1994 and 2004, Moses and his colleagues found.

Government funding in the U.S. fell to 49 percent of the world's public research investment by 2011, down from 57 percent in 2004.

U.S. industry, which accounted for nearly half of corporate investment worldwide in 2004, slipped to 41 percent of private funding in 2011.

Asia, aided largely by China, tripled investment to $9.7 billion in 2012 from $2.6 billion in 2004.

In the U.S., public funding concentrated on cancer and rare diseases, with less than half of government investment targeting 27 common diseases – including chronic obstructive lung disease, injuries, stroke, dementia and pneumonia - that account for 84 percent of deaths in the U.S. and significant disability.

Cancer alone accounted for 16 percent of total funding from the National Institutes of Health and was the target of one in four medicines in clinical trials, the study found.

"With cardiovascular disease, the number one killer, some of the large pharmaceutical companies have really pulled back in this area," said Dr. Kenneth Kaitin, director of the Tufts Center for the Study of Drug Development in Boston, Massachusetts.

"The industry has changed over the last few years and there has been tremendous pressure to reduce research and development costs that has resulted in a tremendous shift away from high-volume, low-cost medicines toward seeking a billion- dollar drug that treats a very, very small population," said Kaitin, who wasn't involved in the study.

Health services research, which looks at issues around access to care as well as quality and costs, has accounted for less than 0.33 percent of national health expenditures between 2003 and 2011, the study found.

Private insurers ranked last (0.04 percent of revenue) and health systems 19th (0.1 percent of revenue) among 22 industries in their investment in innovation in this area, the authors note.

"This is concerning in terms of trying to tackle improved quality of care and improved access to care, and in terms of bending the cost curve," said Glen Giovannetti, a global life sciences expert at Ernst & Young in Boston.

"There's lots and lots of research done on drug development and much less done on whether one course of treatment is better than another," said Giovannetti, who wasn't involved in the study.

With respect to both biotech and health services research, there is an acute need to increase research investment and to create more reliable funding mechanisms, said Dr. Victor Dzau, president of the Institute of Medicine, a division of the U.S. National Academies of Science.

Dzau, who co-wrote an editorial accompanying the study in JAMA, said the danger of disparate, unreliable funding streams is that it forces scientists to work in fits and starts, often abandoning promising basic research.

"If you think about all of the major advances in health care services, biomedical research, and diagnostics, there is no question that it's based on innovation and relied at the start on basic research," Dzau told Reuters Health.

"When we decided to put a man on the moon that was an aspirational goal, and we as a nation should be able to recognize that this is now an important moment in medical research," Dzau said. "We aren't saying give money for money's sake. We are saying set priorities, and give researchers at least five years of stable funding to pursue specific goals."

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Hospitals want Congress to keep ICD-10 on track

Hospitals want Congress to keep ICD-10 on track | Healthcare and Technology news |

Any attempts to delay, again, ICD-10 compliance would be a waste of time and money, and should be opposed, eight healthcare organizations--including the American Hospital Association and the Premier healthcare alliance--stressed to members of Congress in a recent letter.

ICD-9 is "outdated" the organizations said, and ICD-10 would enable providers to keep up with medical advances.

"The [most recent] delay added billions of dollars in extra costs," the organizations said. "Many of our members had to quickly reconfigure systems and processes that were prepared to use ICD-10 back to ICD-9. Newly trained coders who graduated from ICD-10 focused programs were unprepared for use of the older code set and needed to be retrained back to using ICD-9. ... This results in a doubling of costs that are not productive."

An ICD-10 delay was not included in the proposed "Consolidated and Further Continuing Appropriations Act, 2015" to fund the government, which is also being referred to as the "cromnibus" bill. The proposal is expected to be voted on by Congress later today.

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Are U.S. Hospitals Delivering a Better Patient Experience? | CustomerThink

Are U.S. Hospitals Delivering a Better Patient Experience? | CustomerThink | Healthcare and Technology news |

The Centers for Medicare & Medicaid Services (CMS) use patient feedback about their care as part of their reimbursement plan for acute care hospitalsUnder the Hospital Value-Based Purchasing ProgramCMS makes value-based incentive payments to acute care hospitals, based either on how well the hospitals perform on certain quality measures or how much the hospitals’ performance improves on certain quality measures from their performance during a baseline period. This program began in FY 2013 for discharges occurring on or after October 1, 2012.

A standard patient satisfaction survey, known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), is the source of the patient feedback for the reimbursement program. I have previously used these publicly available HCAHPS data to understand the state of affairs for US hospitals in 2011 (see Big Data Provides Big Insights for U.S. Hospitals). Now that the Value-Based Purchasing program has been in effect since October 2012, I wanted to revisit the HCAHPS patient survey data to determine if US hospitals have improved. First, let’s review the HCAHPS survey.

The HCAHPS Survey

The survey asks a random sample of recently discharged patients about important aspects of their hospital experience. The data set includes patient survey results for US hospitals on ten measures of patients’ perspectives of care. The 10 measures are:

  1. Nurses communicate well
  2. Doctors communicate well
  3. Received help as soon as they wanted (Responsive)
  4. Pain well controlled
  5. Staff explain medicines before giving to patients
  6. Room and bathroom are clean
  7. Area around room is quiet at night
  8. Given information about what to do during recovery at home
  9. Overall hospital rating
  10. Recommend hospital to friends and family (Recommend)

For questions 1 through 7, respondents were asked to provide frequency ratings about the occurrence of each attribute (Never, Sometimes, Usually, Always). For question 8, respondents were provided a Y/N option. For question 9, respondents were asked to provide an overall rating of the hospital on a scale from 0 (Worst hospital possible) to 10 (Best hospital possible). For question 10, respondents were asked to provide their likelihood of recommending the hospital (Definitely no, Probably no, Probably yes, Definitely yes).

The Metrics

The HCAHPS data sets report metrics for each hospital as percentages of responses. Because the data sets have already been somewhat aggregated (e.g., percentages reported for group of response options), I was unable to calculate average scores for each hospital. Instead, I used top box scores as the metric of patient experience. I found that top box scores are highly correlated with average scores across groups of companies, suggesting that these two metrics tell us the same thing about the companies (in our case, hospitals).

Top box scores for the respective rating scales are defined as: 1) Percent of patients who reported “Always”; 2) Percent of patients who reported “Yes”; 3) Percent of patients who gave a rating of 9 or 10; 4) Percent of patients who said “Definitely yes.”

Top box scores provide an easy-to-understand way of communicating the survey results for different types of scales. Even though there are four different rating scales for the survey questions, using a top box reporting method puts all metrics on the same numeric scale. Across all 10 metrics, hospital scores can range from 0 (bad) to 100 (good).

I examined PX ratings of acute care hospitals across two time periods. The two time periods were 2011 (Q3 2010 through Q2 2011) and 2013 (Q4 2012 through Q3 2013). The data from the 2013 time-frame are the latest publicly available patient survey data as of this writing.


Hospital reimbursements are based, in part, on their patient satisfaction ratings. Consequently, hospital executives are focusing their efforts at improving the patient experience.

Comparing HCAHPS patient survey results from 2011 to 2013, it appears that hospitals have improved how they deliver patient care. Patient loyalty and PX metrics show significant improvements from 2011 to 2013.

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How hospitals are tackling costs in 2015

How hospitals are tackling costs in 2015 | Healthcare and Technology news |

It's no secret that Americans pay a pretty penny for their healthcare – the highest in the developed world, in fact. What's more, by many reports, they're not even getting the quality outcomes to match that hefty price tag.

As providers face pressure to reduce costs on the front end – for their patients – they're also feeling the pinch on the back end: their bottom lines. For hospitals and health systems, especially, 2015 is a landmark year for everything related to costs.

In 2013, national health expenditures approached $3 trillion, representing $9,255 per person and accounting for a whopping 17.44 percent of the gross domestic product. In the wake of the Affordable Care Act, the industry now more than ever is facing pressure to be accountable and value based. That's often a struggle for many.

So as the industry works to comply with myriad regulatory changes that have been implemented, what’s top of mind this year for the healthcare finance folks?
For Karen Mihalik, executive director of revenue cycle managementat the Cleveland Clinic, there are several things that come to mind.
For one? This year, risk-based contracting is going to be tough, said Mihalik, who works with an RCM team comprising 1,700 FTEs. Also, ACOs and handling bundled paymentswill pose big challenges.
"This year is different in that we really need to make sure that we align again with the clinical component, and that we're building the right business model and administrative model to manage that risk-based population," she said.
One risk-based model, the Medicare ACO, has been a serious challenge for many provider groups. The federal government's Pioneer ACOprogram, for instance, which originally started with 32 participants has whittled down to 19 organizations as of September 2014. 
For the folks at the Denver-based Physician Health Partners, one of the groups that dropped out of the Pioneer model back in 2013, the benchmark setting process within the Pioneer model needed some serious re-working.
We can't take that much risk when the game keeps changing a little bit," Kenneth Nielsen, president and CEO of Physician Health Partners, told Healthcare IT News back in 2013, especially when these adjustments aren’t geographically based. "The Denver market, where our benchmark was $8,000 per beneficiary, per year is a lot different than an East Coast market where their benchmark was twice that."
For PHP, it wasn't all bad news, however. It was able to decrease its readmissions and hospitalizations rates and met all the quality metrics. But, financially, it wasn’t viable. It reported shared losses for fiscal year one, which was anticipated, Nielsen said, but another two years before reaping the supposed financial benefits? It proved just too risky. "We just weren't able to take enough time to take the risk over three years at this point," Nielsen added. Right now, he said, "We're between bleeding edge and cutting edge."
Cleveland Clinic passed on the Medicare ACOs in the first round, with its CEO Toby Cosgrove saying the organization was "disappointed" with the Centers for Medicare and MedicaidServices ACO proposal, claiming they requirements weren’t outcomes based and had other reporting requirements that were burdensome to healthcare organizations. 
Another item on the to-do list this year, aside from risk-based contracts? Payers have some work to do with the insurance verification process.
Specifically, Cleveland Clinicneeds to be able to identify patients enrolled in an ACA-related plan and gather crucial information related to their coverage, said Mihalik. Having the ability to know who these specific patients are and how they are doing in digesting this "new world" is essential, she added. 
For year two, Cleveland Clinic is really focused on making sure payers are able to specifically identify those patients as being in an ACA-related plan and subsequently providing that data to the clinic as part of the registration verification process. 
"We want to be able to take a look at that population, and we really can't effectively do that right now because the payers haven't built the right models," said Mihalik, "so the system changes really aren't needed on our side; they're needed on the payer side."
Mihalik isn't alone. In fact, 62 percent of MGMAmembers said they had moderate or extreme difficulty with identifying patients with ACA coverage, according to a 2014 MGMA survey. "We are going to have to hire additional staff just to manage the insurance verification process," one MGMA practice manager reported in the survey. 
As far as the IT goes, the payers are the ones with the work to do, Mihalik added. 

ICD-10 confusion not helping

Hospitals and health systems are businesses. Sure, their purpose is to provide patients with quality care at lower costs, but at the end of the day if they're not financially viable and their bottom lines are consistently in the red, there's a big problem.
For Arnette Marbella, director of HIM and CDM revenue cycle at Tufts Medical Center, it's the ICD-10limbo that's concerning from a financial perspective. There's talk that ICD-10 will be delayed yet again, pushing its go-live data of October 2015, even further down the road. The revenue implications in that is that most hospitals have already started at least a year or a year and a half ago on preparing for the transition," said Marbella. 
This preparation, of course, means systems are tested, making sure that the systems are upgraded to be able to accept the news codes, physicians are trained on documenting. That part – clinical documentation is integral, she added. If you think about it, she said, the industry is going from some 14,000 diagnosis codes to nearly 70,000 codes, so "there's no one-to-one match for the codes."
Ultimately, clinical documentation translates to "we have to be more specific on the codes that we assign, and that in turn translates to the reimbursement that we get or the bill that we submit to the payers and they reimburse and then we get," she said. A loss of revenue due to coding errors or administrative/procedural issues is a "concern in every hospital," Marbella added. 
Mihalik has her own concerns about ICD-10. 
It impacts really nearly every system," she said. "Most of our systems work off of diagnosis data, so the work we're doing around remediation and cross walks and testing is significant but very, very necessary," she added. The other area we're really focused on has to do with our coding and clinical documentation so that we are prepared now as we can be prior to go-live in making sure that we have quality training and audits going on to help make sure that we're there to the level that we need to be."
Investments in technology that they’re leveraging with computer assisted coding is also key, she said. 
With all of these items on providers to-do lists, it's difficult to focus on much else. But there is more, said Mihalik. Patients and their engagement are absolutely key. Our focus is really on what's still to come," she said, "because there are significant changes still in front of us related to primarily patient engagement so our world is really focused on first and foremost patients and being able to provide them timely and integrated information."

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Diffusing Angry Patients: It's as Simple as ABCD | Physicians Practice

Diffusing Angry Patients: It's as Simple as ABCD | Physicians Practice | Healthcare and Technology news |
Unsurprisingly, people are more stressed than ever before. According to a recent poll by NPR, the Robert Wood Johnson Foundation, and the Harvard School of Public Health, nearly half of 2,500 adults surveyed admitted to a major stressful event within the last year. More than a quarter tied their specific stressor to a health-related problem.

And when that outside stress becomes too much for patients (see sidebar below), physicians may witness more angry or violent behavior in the exam room.

Acknowledge the anger

Emergency rooms are notorious for running high on emotional energy, simply due to the nature of the operation. So it can be difficult to pinpoint what is triggering a patient's outbursts.

Aaron Braun, medical director of PhysiciansER Mission Bend, a freestanding emergency room located in the Houston area, tries to find the path of least resistance. "If the patient is angry, is there some quick fix? If the answer is simple," said Braun, "I would capitulate and get them what they would like within reasonable bounds."

That may mean providing a snack or meal to a hungry patient, or if the anger is stemming from a personality conflict with staff, reassigning nurses or caretakers as needed. Regardless, the focus should be on listening and acknowledging the patient's anger, even if you can't solve the immediate problem at hand.

"Frequently, there are no simple solutions, especially if the patient is psychotic," said Braun. "And the best way to [approach] them is to talk to them in a calm and gentle manner."

As odd as it may sound, Braun relies on food to help these situations. "I always try to get the angry patient to eat something, because it gets their mind off of what is bothering them and a full stomach tends to make for a sleepy (more docile) patient."

Be benevolent

Marc Leavey, board-certified in internal medicine and a primary-care specialist at Maryland-based Lutherville Personal Physicians, says he's seen finances become a catalyst for this type of erratic behavior too.

Is Your Patient Prone to Greater Stress?

NPR's recent study shed light on specific groups who were more likely to experience periods of great stress. Note that personal health concerns ranked among the top three groups.

• Poor health condition: 60 percent
• Disabled: 45 percent
• Chronic illness: 36 percent
• Income less than $20,000: 36 percent
• Experiences dangerous work situations: 36 percent
• Single parent: 35 percent
• Parent of a teen: 35 percent

Given the drastic changes to healthcare recently, and the misinformation that has inevitably followed, patients are rightfully concerned about being able to afford ongoing treatments. "It doesn't seem to matter if you say to the patient, 'Don't worry about [the cost] or we will deal with it [later],' they begin getting a little bit testy," said Leavey.

Remembering that these patients are most likely scared to lose their coverage or medical access can help lead physicians to a solution. "Being creative and trying to come up with a solution that meets the patient's needs while still maintaining good medical care [is ideal]," said Leavey.

And ensuring patients know about options like alternative treatments and medications can go a long way in negating their anger, especially when their concerns are based on personal finances. If a patient is most upset because they can't afford the medicine as prescribed, simply offering a generic medication — at a fraction of the cost — can resolve the entire dilemma.

Curtail confrontation

Confrontation may seem inevitable in these instances, but ideally, it should be avoided at all costs.

"If you do confront [the patient], all you are going to do is make them [more] angry," said Leavey. He recalls a patient who jumped over the front check-in desk during a fit of rage. Knowing he wasn't angry at the front-desk employee, but was instead, angry in general, helped staff understand how to approach the patient.

"It sounds trite, but you have to understand where they're coming from," said Leavey. "You have to be aware of your voice and body language and avoid doing things that are obviously antagonistic."

Although it goes against human instinct, physicians will have greater success at diffusing a scenario if they remain calm and monitor their language, while avoiding raised voices or body language like crossed arms.

Don't forget to document

As in every other patient-physician exchange, documentation is key. Physicians will want to include the details of angry and violent outbursts in the patient's chart. This not only serves to forewarn other healthcare professionals who encounter the patient, but also may identify an ongoing decrease in mental health status that warrants further intervention.

Ideally, physicians would be able to diffuse every angry patient, while also determining the core of their angst. But Braun reminds us that's just not feasible. "Negotiation is an art that is learned simply by experience. Some are better at it than others," he said. "The bottom line is that the safety of the staff, other patients, and the patient must be of first priority and not every situation will allow a physician the luxury of being able to tease out the root of the patient's abnormal behavior."
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Draft Medicare ACO rules would allow more time with less risk - Modern Healthcare

Draft Medicare ACO rules would allow more time with less risk - Modern Healthcare | Healthcare and Technology news |

The CMS is planning major changes to the financial incentives for Medicare accountable care organizations in a revamp aimed at preventing hospitals and medical groups from dropping out of the initiative.

A proposed rule issued late Monday (PDF)would alter the structure of the Medicare Shared Savings Program, an attempt launched in 2012 under the Patient Protection and Affordable Care Act to reduce U.S. health spending with new incentives that seek to improve the quality and efficiency of healthcare.

Those incentives have been a battleground between policymakers and the healthcare industry since the program's start. Policymakers have sought more substantial incentives—penalties as well as rewards—as a means to hasten changes to the way healthcare is delivered. Hospital officials and physicians have called for less financial risk so they can build the infrastructure and expertise they need to succeed.

The rules adopted in 2011 require accountable care organizations to face penalties after the first three years unless they volunteer to assume downside financial risk earlier in exchange for bigger bonuses if they do well.

The industry appears to have scored a victory in the proposed rules, which acknowledge widespread concern among the participants and experts that some organizations may need more time before penalties take effect. The switch after three years “may be too steep” for organizations that lack experience and infrastructure to achieve quality and cost-saving targets and organizations may exit as a result. Even those that perform well but “not yet ready” to accept the risk of penalties may depart without another option, the agency said.

Medicare, under the revised structure, would no longer require organizations to face penalties after the third year, but they could forgo penalties only if they meet certain criteria. ACOs that fail to slow spending in their first two years would be excluded. All ACOs must assume the risk of penalties after six years if they want to remain in the program.

In order to make it more appealing for ACOs to jump into the riskier track, the CMS would reduce the potential bonuses after the third year in the safer track to 40% from 50%.

In another bid to make riskier contracts more attractive, the agency wants to add a new option, or a third track, that would include potential penalties and bonuses and would use new methods to identify which patients are included in the ACO. Organizations in this new track could keep up to 75% of what they save. They also would be responsible for up to 75% of their losses, but the amount could be reduced based on quality performance. The agency capped the bonuses at 20% of ACOs' benchmarks and losses at 15%.

Participants in the third track would also have a list of patients at the start of the year whose care and costs they must manage. Under the current rules, Medicare identifies beneficiaries as included in the ACO at the end of the year based on how much care they received from the providers in the network. ACOs have called on the CMS to identify the patients at the beginning of the year to allow more focused improvement efforts.

The CMS has rapidly expanded the Medicare Shared Savings Program over the past three years, and it is perhaps one of the most visible efforts under the law to tame the nation's healthcare bill. But many experts feared the widespread enthusiasm for the program would wane significantly if the CMS declined to modify the program to keep less experienced providers on board.

All but five of more than 300 ACOs in the program chose to forgo the penalty. That may have been wise, because their financial performance has been uneven. Only a quarter of ACOs launched in 2012 and 2013 have saved enough to earn bonuses.

Clif Gaus, chief executive officer of the National Association of ACOs, said he was “pleased and disappointed” by the proposed rule. He praised the proposal to give ACOs more time before they face penalties for financial performance, but he also said the decision to couple that with a smaller potential bonus was “counterproductive.”

Many ACOs need the additional time to prepare for the risk of potential penalties, he said. “Three years is not enough.”

Efforts to revamp the delivery of care will require more time as ACOs build new relationships, new infrastructure and learn and adapt early redesign efforts, he said. “It's probably a decade-long process to redesign all of the care processes that lead to both better care and more appropriate care,” based on experience of organizations such as Geisinger Health System or Intermountain Healthcare, he said. “There's a big learning curve for many ACOs,” he said. “They are almost new businesses starting from scratch.”

The association surveyed Medicare Shared Savings Program ACOs in October and found two-thirds were somewhat or highly unlikely to continue if they were required to accept penalties. About 20% of the MSSP ACOs responded. “There's too much risk for the amount of reward” under contracts with penalties and bonuses, he said.

Coastal Carolina Quality Care in New Bern, N.C., entered Medicare's accountable care program in 2012 and saw its expenditures increase a marginal 0.6% against projections during the first year.

“It's very unlikely that we would continue” without the continued option to forgo penalties, said Stephen Nuckolls, Coastal Carolina's CEO.

Dr. Farzad Mostashari, founder and chief executive of accountable care contractor Aledade, said the option to continue without penalties may benefit some smaller organizations in the program. “There are a lot of home grown ACOs,” said Mostashari, a former national coordinator for health information technology at HHS. “It takes them a long time to get going.”

Policymakers, however, likely also want to discourage organizations from abusing Medicare's shared savings program as a way to consolidate market clout with little interest in achieving the program's savings goals, he said. The proposed rule, however, may do little to discourage them from remaining in the program. The proposed criteria for ACOs to continue without penalties, Mostashari said, is “a pretty low bar."

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