JHC March 2022

March 2022 • Vol.13 • No.2

Collaboration for the Win Yankee Alliance President and CEO Larry Kaufman believes there’s more value for healthcare stakeholders in working together than remaining insular.

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CONTENTS »» MARCH 2022

2 CMS projecting over 11 million will be served

by Shared Savings Program ACOs 4 A Long-Term Care Crisis?

Long-term care has faced staffing challenges for years, and the pandemic has only made it worse.

8 Collaboration for the Win Yankee Alliance President and CEO Larry Kaufman believes there’s more value for healthcare stakeholders in working together than remaining insular.

14 Atrium Health’s MED-1 mobile hospital marks milestone 16 Which States Have the Best Telehealth Practices?

A new report rates every state’s telehealth policy for patient access and ease of providing virtual care.

26 Telemedicine: What’s Ahead in 2022?

How will it affect procedures performed and products used by clinicians?

The Journal of Healthcare Contracting is published bi-monthly

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The Journal of Healthcare Contracting | March 2022

1

TRENDS

CMS projecting over 11 million will be served by Shared Savings Program ACOs The Centers for Medicare & Medicaid Services (CMS) released data recently on Accountable Care Organizations (ACOs), with CMS projecting that over 11 million people with Medicare will be served by Shared Savings Program ACOs in 2022.

The Medicare Shared Savings Program is Medicare’s national ACO program.

“With one in every five health care

a new agreement period starting January

that join together voluntarily to provide

dollars paid by Medicare, we can strength-

1, 2022. This brings the total number of

coordinated, high-quality care and ensure

en and transform our health care system,”

ACOs in the Shared Savings Program

that people with Medicare receive the

said CMS Administrator Chiquita Brooks-

to 483 in 2022. As of January 1, 2022,

right care at the right time, while avoiding

LaSure. “Accountable Care Organizations

over 11 million people with Medicare

unnecessary duplication of services and

present an invaluable opportunity to move

receive care from a health care provider

preventing medical errors. When an ACO

Medicare toward person-centered care.”

in a Shared Savings Program ACO, up

succeeds both in delivering high-quality

CMS is announcing that 66 new

324,000 (3%) from the previous year.

care and spending health care dollars

ACOs joined the program and 140 exist-

ACOs are groups of doctors, hos-

ing ACOs renewed their participation for

pitals, and other health care providers

more wisely, the ACO may be eligible to share in the savings it achieves for the Medicare program. In certain instances, an ACO may owe a portion of losses if it increases costs or does not meet certain

Shared Savings Program Fast Facts – As of Januar y 1, 2022

quality metrics.

Medicare Shared Savings Program ACO Assigned Beneficiar y Population by County

“Over the last decade, Medicare has promoted participation in value-based care to reward better care, smarter spending, and improved outcomes,” said Meena Seshamani, MD, PhD, CMS Deputy Administrator and Director of the Center for Medicare. “CMS’ commitment to value-based care has never been stronger. As we continue working toward our goal of increasing the number of people in a care relationship with accountability for quality and total cost of care, we celebrate this increase in ACO participation, and know we have more work to do.”

2

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March 2022 | The Journal of Healthcare Contracting

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TRENDS

BY PETE MERCER

A Long-Term Care Crisis?

Long-term care has faced staffing challenges for years, and the pandemic has only made it worse.

In the last couple of years, we have seen the coronavirus pandemic stretch

of assisted living providers have said that

and exhaust the healthcare industry past any semblance of what it used to look like. The

their workforce situation has gotten worse

ramifications of the current state of the healthcare system will likely be felt for many

in recent months, while 58% of nursing

years to come, especially in the long-term care sector. Long-term care is currently going

homes are even limiting new admissions.

through what experts are calling a dangerous staffing crisis that could put the future of

This is not only an unsustainable situation

this sector of the healthcare industry in jeopardy.

for these long-term facilities, but it’s also dangerous and detrimental to a vulnerable part of the population that depends on

The American Health Care Associa-

other health care sector, with an employ-

tion and National Center for Assisted

ment level drop by 14% (about 221,000

Living (AHCA/NCAL) represents over

jobs) since the start of the pandemic.

14,000 nursing homes and assisted living

this industry.

In a media release, Mark Parkinson, president and CEO of AHCA/NCAL,

Staffing levels in other healthcare

said, “As many caregivers are getting

communities across the country that

sectors have fluctuated in the past couple

burned out by the pandemic, workers

provide care to approximately 5 million

of years, but nursing homes and assisted

are leaving the field for jobs in other

people each year. The AHCA/NCAL

living facilities are still experiencing

healthcare settings or other industries

recently released a report showing that

substantial job losses. According to a

altogether. Chronic Medicaid under-

long-term facilities are suffering from

study conducted by the AHCA/NCAL

funding, combined with the billions

the worst labor crisis and job loss of any

in 2021, 86% of nursing homes and 77%

of dollars providers have spent to fight

4

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TRENDS

the pandemic, have left long-term care

any sort of competitive edge they would

options available. This also perpetuates

providers struggling to compete for

need to hire new people. Crawford said

the vicious cycle with COVID surges.

qualified staff.

they “cannot compete with other health-

It’s also important to remember that this

care settings, like hospitals, that can offer

isn’t a problem that’s going to resolve itself.

better pay and benefits.”

There will always be an elderly population

Parkinson said, “We desperately need the help of policymakers to attract and retain more caregivers so that our nation’s

This isn’t a new issue. Long-term

that will need to be cared for, whether there

most vulnerable have access to the long-

care has faced staffing challenges for

are places to provide that care or not. “If

term care they need.”

years, and the pandemic has only made

policymakers do not act, the consequences

it worse. Crawford said, “Workforce

will be devastating and could result in nurs-

recruitment and retention has been an

ing home closures, which will ultimately

Why workers are leaving

ongoing challenge prior to the pandemic,

affect access to care that our nation’s seniors

To put it simply, long-term care providers

and we have been calling for help for

need and deserve,” Crawford said.

are exhausted. As we have seen over the

years. Now, the pandemic has exacer-

last two years, when a workforce is un-

bated our workforce challenges, and we

derstaffed, it creates a trickle-down effect

are in a full-blown crisis.”

The path forward For long-term care providers to begin

throughout the whole industry. Long-

the road to recovery, Crawford said they

term care facilities have trouble with staffing workers, which creates an unnecessary

The effects on the residents

would need immediate assistance from

strain on those who are working, which

When healthcare workers suffer, the

federal and state public health officials

further perpetuates this cyclical nightmare

patients suffer. Without a stable option

to support the frontlines and prioritize

of exhaustion that so many are experienc-

in place, residents and families are often

resources for long-term care providers.

ing right now.

left to find care alternatives that are less

Crawford also argued for a long-term solution to “help recruit and retain the next generation of caregivers and to prepare

“ We desperately need the help of policymakers to attract and retain more caregivers so that our nation’s most vulnerable have access to the long-term care they need.”

for a growing elderly population.”

“Policy makers must act and support the multi-tiered workforce proposals we have put forth in our reform agenda, the Care for Our Seniors Act,” Crawford said. “These proposals include assistance programs for caregivers like affordable housing and childcare, tax credits, loan

than optimal. Losing these workers is a

forgiveness, and incentives for higher

Public Affairs for the American Health

dangerous prospect for the residents and

learning institutions to train the next

Care Association, said, “This pandemic has

patients of long-term care providers.

generation of healthcare heroes.”

Cristina Crawford, Senior Manager,

taken an enormous toll on our staff and

“The workforce crisis threatens access

State and federal policy makers also

residents. Not only have many experienced

to care for vulnerable seniors,” Crawford

need to do things like fully fund Medicaid,

tremendous losses, but it has also been

said. “More than half of nursing homes

which would allow long-term care provid-

exhausting – physically and emotionally –

are limiting new admissions because of

ers to invest in their workforce and have

battling this virus day in and day out.”

staffing shortages.” Not only are the

a competitive hiring edge. “The strategies

families put in a difficult position regard-

laid out in the Care for Our Seniors Act

left and right. Additionally, Crawford

ing the safety and care of their loved

offer a comprehensive approach to recruit

described long-term care providers as

ones, but hospitals are unable to discharge

more health care heroes to help solve this

“chronically underfunded,” which limits

patients if there are no long-term care

workforce crisis,” Crawford said.

Essential workers are dropping

6

March 2022 | The Journal of Healthcare Contracting

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March 2022 | The Journal of Healthcare Contracting

Collaboration for the Win Yankee Alliance President and CEO Larry Kaufman believes there’s more value for healthcare stakeholders in working together than remaining insular.

BY DANIEL BEAIRD

Larry Kaufman has been president and CEO of Andover, Massachusetts-based Yankee Alliance, a national GPO and certified sponsor of Premier, Inc., for a little over a year, taking the helm last February, after former president and CEO Cathy Spinney retired. He has a demonstrated history of creating patient-focused cultures for serving health systems, most recently as president and CEO of Trivergent Health Alliance MSO in Maryland and 35 years with HCA Healthcare and HealthTrust, the HCA-initiated national GPO. After more than 20 years running hospitals at the C-suite level for HCA, Kaufman moved into the CEO role for the eastern U.S. for HealthTrust and his responsibilities expanded to non-HCA facilities.

“That gave me exposure to a lot of organizations from Miami to Maine that had their unique challenges,” he said. “And states in between like Georgia that suffered from a large number of critical access facilities closing over the last several years and that was pre-COVID. Just challenges upon challenges, and then COVID hit.”

Trivergent gave him the opportunity to work with a group of hospitals in Maryland to centralize some of their enterprises like supply chain, pharmacy, and laboratory operations. “The idea being that we are better together. That gets more important over time,” Kaufman said. “It was doubly important in Maryland because Maryland is the only state in the U.S. that has a capitated approach to healthcare. That kind of population health focus drew me there.”

Maryland operates the nation’s only all-payer hospital rate regulation system. Under a 36-year-old Medicare waiver that exempts Maryland from the Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS) and allows the state to set rates for these services, all third parties paid the same rate. CMS and Maryland partnered to modernize the state’s unique all-payer rate-setting system for hospital services that aimed to improve patients’ health and reduce costs, and updated the waiver to allow Maryland to adopt new policies that reduced per capita hospital expenditures and improved health outcomes.

9

COLLABORATION FOR THE WIN

“Finally, Yankee Alliance was an opportunity to work with an organization established a long time ago with the idea of working together,” Kaufman said.

“Yankee has done well since its beginnings in 1984 given how many changes have affected the healthcare industry.”

“Yankee’s members are always looking to take it to the next level to drive out unnecessary cost. I like being around people who are inspired to do better and are open-minded to work with organizations that could be identified as competitors,” he said. “There’s more value in working

Larry Kaufman, FACHE, joined Yankee Alliance as its president and CEO on Feb. 1, 2021. He most recently served as president and CEO of Trivergent Health Alliance MSO in Maryland and has held various hospital administration and GPO leadership positions. He has more than 35 years of experience in labor and non-labor cost reduction, physician and clinical integration, and the development of strategic initiatives – both operational and clinical – to reduce variation, cost and improve quality.

Yankee Alliance has grown to more than 18,000 members in all classes of trades across all 50 states. It is a member-driven national healthcare GPO with a two-fold mission: to collaborate with members to reduce supply and operating expenses through aggregation of data, purchasing, ideas and knowledge, and to excel in strategic innovations that continually assist members in reducing their cost while recognizing their individual needs.

together than being insular.”

Kaufman classifies group purchasing as a service industry serving a service industry. “My previous employer HCA

membership. We’re flexible to whatever is

to what’s happening within our member-

had – at any given time – north of 250

slamming our facilities that week.”

ship and using that data to tell us what we

hospitals, but they still needed all the

Yankee Alliance is a certified sponsor

need to be contracting for and not.”

friends they could get. Hospitals will con-

of Premier, Inc., and its group purchasing

tinue to look to each other to improve.

program combines the Yankee Alli-

assistance in clinical areas with a large focus

CEOs are looking for real ways to work

ance portfolio of contracts with those

on value analysis. “Our job there is to see

together like they never have before, not

negotiated by Premier. Yankee Alliance’s

where our members are relative to the best

just sharing information over a cup of

contract managers assist with implemen-

demonstrated practices in the value analysis

coffee but structuring components of

tation, troubleshooting problems with

process,” Kaufman said. “We use evidence-

operations,” he said.

suppliers or contract service issues and

based practices to help them move from

answering questions.

where they are to where they’d like to be.”

That’s where GPOs like Yankee

Yankee Alliance also offers support and

Alliance come in. They have a tremendous

“From the start, we’ve focused on

amount of information but they’re not the

contracting, whether it’s commodities or

sharing information is all the same. Yan-

source of it. “We’re kind of like a good

other supplies that a hospital uses, we

kee Alliance runs comparative analytics to

point guard in basketball. We get the ball,

look at what our members are purchasing

show its members where they stand rela-

and we pass it,” Kaufman said. “We’re

and identify opportunities for aggrega-

tive to each other. That creates interest,

making sure we’re plugged into the indus-

tion to increase our negotiating strength,”

positive peer pressure and motivation to

try and connected with our members.”

Kaufman said.

members to do better.

Whether it’s access to PPE, a value

Yankee Alliance’s contract portfolio in-

Kaufman says the common theme of

“It’s all about operational excellence,”

analysis function or contracting, Yankee

cludes 2,641 Premier contracts, 456 Yankee

Kaufman concluded. “You never know

Alliance provides the environment for its

Alliance aggregated Premier contracts and

where a solution is going to come from.

membership to interface with each other

191 Yankee Alliance specific contracts.

This industry is always changing, and

for solutions. “Everything we do is in a

“We create our own contracts for

hospitals will collaborate in ways they

glass house with the lights turned on,”

what our members are buying that aren’t

haven’t before to benefit from speed

Kaufman explained. “Everything we’re

Premier contracts,” Kaufman added.

to learning, strength in numbers and

tackling should be something that has

“Things like purchased services and other

functioning more effectively to drive

been a problem or an opportunity for our

areas. It’s a matter of us paying attention

out unnecessary variations.”

10

March 2022 | The Journal of Healthcare Contracting

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COLLABORATION FOR THE WIN

Labor shortages, technology, critical supplies and sourcing Labor Shortages Hospitals are being forced to shelve services because of staffing shortages. Boston’s Tufts Medical Center announced recently it is closing its Boston children’s hospital, known as the Floating Hospital for Children (due to its founding as a ship in the 1800s to bring sick children into the Boston Harbor for fresh air and medical treatment).

Tufts plans to continue operating its pediatric primary care services and neonatal intensive care unit, but the closure announcement has caused concern among Massachusetts’ pediatrician offices. Representatives for Tufts Medical Center have stated that the children’s hospital has been in question for a while and the hospital faces high demand for beds as more adult patients require specialized care.

“Right now, people are looking at two things,” Kaufman said. “They’re looking at the pain they’re feeling – there are nursing units closing across the U.S., among other negative things. Then, they’re looking at the future and how to get out of these predicaments.”

12

Kaufman says there’s nobody rushing to the forefront with the solution, but that it will be a combination of many different things.

“First, it’s about creating environments in which the staff wants to be there, in spite of having gone through a pandemic,” Kaufman said. “You want to make sure the world you’re putting your employees in is as good as it can possibly be, so when they’re thinking about ‘do I stay or do I go,’ they stay. You also have to make sure you’re using those employees as efficiently as possible.”

“And finally, hospitals and health systems are trying to reinvigorate some things they’ve been doing for years and looking at the work that needs to be done in higher education and teaching institutions to produce more labor,” Kaufman said.

After the pandemic, Kaufman says the challenge of attracting more labor lies in the perception of what the healthcare industry is about. “We need a serious makeover on the value and quality of life you can have by working in a hospital,” Kaufman said.

“Working in healthcare used to be seen as an awesome thing to do. But the question today is do people want to do something they feel like puts them in harm’s way? We have to work on that.”

Technology Technology is advancing in every way in the healthcare and supply chain industries.

“It’s going to advance with or without us,” Kaufman said. “We don’t have a choice of taking advantage of AI (artificial intelligence) or machine learning. There are applications in every area, certainly within supply chain.”

“Healthcare is going to follow every other industry.

We won’t turn into the auto industry with robots running assembly lines, but we’ll have robots functioning in hospitals in one form or another – whether it’s in the pharmacy, roaming the halls or cleaning the patient rooms with a UV scan. It’s going to continue to be a disruptor,” Kaufman said.

Critical Supplies and Sourcing “Our members have critical supplies now that they

wouldn’t have been carrying two or three years ago,” Kaufman said. “Everything was just-in-time back then and now with all of this inventory sitting around, there has to be an efficient way of keeping it.”

“It’s similar to looking at hospitals on the Gulf Coast. I spent most of my career in Florida being ready for the next hurricane. There was always a part of the warehouse that was just hurricane supplies – everything from water to plywood to cots. Now, we have hurricanes hitting everywhere and supply chain issues still going on,” Kaufman said.

Yankee Alliance works in coordination with Premier on sourcing. “We support onshore and near shore manufacturing as much as we can, and diversifying sourcing so it’s not all coming from China,” Kaufman said. “We’re also advocates for the industry, making sure our members and ourselves are speaking to Congressional representatives on the importance of developing a database to know where critical supplies are.”

March 2022 | The Journal of Healthcare Contracting

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NEWS

Atrium Health’s MED-1 mobile hospital marks milestone

Atrium Health and its Mobile Medicine recognized a historic milestone for Atrium Health MED-1, the health system’s state-of-the-art emergency department on wheels. The mobile hospital marked 365-days of being deployed to Atrium Health Pineville on Saturday, January 22, the longest self-deployment in MED-1 history.

able to deploy and do so quickly, gives me

pain, lacerations and minor sprains.

pacity challenges for hospitals across the

a sense of pride that we were able to help

Although patients suspected of having

nation, Atrium Health deployed MED-

come together and use our resources to

COVID-19 are not treated in the mobile

1to help treat less critical patients, provid-

better serve our community,” said Alicia

hospital, the additional 14 beds have been

ing added bed space at its Pineville hos-

Campbell, facility executive at Atrium

especially helpful during busy times, such

pital. Located in South Mecklenburg

Health Pineville. “The value of having a

as while the Delta and Omicron vari-

County and given its proximity to the

mini-hospital come set up, and do it so

ants have driven patient census numbers to

South Carolina border, Atrium Health

quickly, it’s difficult to put into words and

capacity. The additional emergency room

Pineville provides convenient access

is nothing less than impressive.”

space allows continued treatment of other,

As COVID-19 surges have created ca-

to high-quality care to patients throughout the region, according to a release.

“Knowing we have a resource like Atrium Health MED-1 in our system, that was

14

Atrium Health MED-1 has been stationed near the emergency department

non-critical patients while the emergency department handles the COVID surge.

to help treat a number of illnesses, including but not limited to rashes, ear

Read more here.

March 2022 | The Journal of Healthcare Contracting

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TRENDS

BY PETE MERCER

Which States Have the Best Telehealth Practices?

A new report rates every state’s telehealth policy for patient access and ease of providing virtual care.

After public health emergencies started to end and executive orders were withdrawn, much of the flexibility that users enjoyed for months disappeared almost immediately. Even the new laws passed by certain states only made incremental changes without a sort “best practices” roadmap.

Telehealth was a dynamic solution during an unprecedented time, which makes all of the new challenges with utilizing more frustrating and confusing than before. A new report from Reason Foundation, Cicero Institute and Pioneer Institute rates every state’s telehealth policy for patient access and ease of providing virtual care. With this in-depth report on the current state of the telehealth landscape throughout the country, this may provide some relief for healthcare providers and patients alike.

In a media release regarding the report, Josh Archambault, senior fellow with Cicero Institute and Pioneer Institute and co-author of the report, wrote, “While they cannot and should not replace all in-person medical appointDespite the challenges that COVID-19 has created for the entire world in the

ments, virtual visits can save patients

past two years, it has also presented a unique opportunity for people that still needed

time and help them avoid germ-filled

access to healthcare. Millions of people in the U.S. tried telehealth for the first time

waiting rooms. Providers can also

because of the pandemic, made easier by changes federal officials made to the Medicare

take some pressure off overburdened

program as well as governors waving certain barriers to advance health access with flex-

systems as they can see patients from

ible provider licensure for new uses of telehealth.

an office or home.”

16

March 2022 | The Journal of Healthcare Contracting

Best practices for telehealth

services, since research has shown

states don’t allow providers to cross over

This report laid out certain best practices

mixed outcomes for certain services

states lines. Arizona, Florida, and Indiana

for what telehealth should and shouldn’t

over telehealth, can lead to wasteful

are the only three states that allow all pro-

do, giving policymakers a better picture

spending. A mandate also inhibits

viders to easily practice telehealth across

of a successful telehealth program. These

innovation in care delivery.

state lines. The other forty-seven states

best practices included the following:

ʯ Do support modality

have arbitrary barriers that limit patient’s

ʯ Do support provider access

access to specialists and available appointments based purely on residency.

neutral options

to telehealth

Allowing different avenues of access

Patient accessibility is crucial to the

for users is a critical component of a

success of a telehealth program, but

restrictive telehealth policies, as both don’t

successful telehealth policy. Not only

it’s just as important to improve pro-

require an in-person visit, are modality

does it further help to establish trust

vider access. Including providers that

neutral, and allow for providers to cross

in a patient-provider relationship, it

possess a license or registration in

state lines, even if Utah is less lenient with

gives the patient the agency to decide

good standing will help with the con-

the out-of-state policies.

what works best for them.

tinuation of care, as well as increase access in rural communities.

Arizona and Utah both have the least

As it stands with this report, Tennessee has the most restrictive telehealth

ʯ Don’t arbitrarily limit provider tools Part of the challenge of providing telehealth opportunities is the inherent limitations that come with providing a diagnosis and treatment over a virtual channel. Any further unnecessary limitations of provider tools only exacerbate

Arizona, Florida, and Indiana are the only three states that allow all providers to easily practice telehealth across state lines. The other fortyseven states have arbitrary barriers that limit patient’s access to specialists and available appointments based purely on residency.

the existing challenges of telehealth, while creating new ones altogether.

ʯ Don't mandate payment ʯ Do support access to care

policy. While most states have removed

rates in law

the requirement that a patient must see a

The greatest opportunity with tele-

A payment mandate will actively

provider in-person before using telehealth

health is increased access to those

work against any improvement in

services, Tennessee is the only state that

who are either unable to go to an

accessibility. Enforcing a payment

still requires an initial in-person visit.

in-person appointment or looking for

parity mandate that requires telehealth

a convenient and easy way to schedule

visits to cost as much as an in-person

in-person visit before certain services can

a doctor’s appointment. Either way, it’s

visit will hurt vulnerable patients and

be provided. The report says, “Alaska

important for all kinds of providers

small businesses that are trying to

regulations limit a physician’s provision of

to utilize telehealth to allow for more

provide a virtual care option.

services based ‘solely on a patient- supplied

Alaska and West Virginia require an

team-based care, while prohibiting facil-

history received by telephone facsimile or

ity fees from being charged for services

electronic format.’” For the state of

Which states have better telehealth policies?

Virginia, the report says, “the statewide

Overall, most of the United States does

remote patient monitoring and store-

for everything

not require an in-person visit to a physi-

and-forward. However, there are separate

Passing insurance coverage parity

cian's office and there aren’t many barriers

definitions for teledentistry and store-

mandates that require paying for all

to the preferred modality for access. Most

and-forward technologies for dentists.”

that can be delivered from anywhere.

ʯ Don't mandate coverage

The Journal of Healthcare Contracting | March 2022

telehealth plan definition does mention

17

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March 2022 | The Journal of Healthcare Contracting

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TRENDS

BY MARK THILL

Telemedicine: What’s Ahead in 2022?

How will it affect procedures performed and products used by clinicians?

Telemedicine soared in 2020 due to the pandemic. Usage has plateaued since

Video or audio telemedicine can

then, but it’s a safe bet it’s not going away. And with it comes questions. What role will it

offer access to a clinician for patients

play in urgent care and chronic care management? Will it lead to fewer in-person visits,

who lack transportation or who can’t

or more? Will it change the type – and number – of procedures performed in the clinic?

take time off from work, according to

How about the type – and volume – of medical supplies, devices and equipment used there?

researchers from Kaiser Permanente Division of Research, Oakland, California.

“Still, it is unclear whether telemedicine

“We don’t pretend to read all the tea

head of the health system’s telemedicine

visits adequately address the patient’s

leaves; but we believe the right ecosystem

and digital health initiatives. “That means

clinical concern, are more likely to

is a hybrid model,” that is, a combination

providing the level of care that is appro-

require subsequent follow-up outpatient

of face-to-face and virtual visits, says

priate every time and providing patients

care, or are more likely to be followed

David Houghton, M.D., MPH, chief of

with accessible and available technology

by a serious health event that requires an

the Division of Movement Disorders

that complements the important patient-

emergency department visit or hospital

at Ochsner Health in New Orleans and

provider relationship.”

stay,” they wrote.

26

March 2022 | The Journal of Healthcare Contracting

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TRENDS

Legislative and regulatory boost

McKinsey & Company released a report

from May to June 2021. By comparison,

Regulatory and legislative adjustments

showing that telehealth utilization had

telehealth utilization rose 2% nationally

in response to the pandemic boosted

stabilized at levels 38X higher than before

the previous month, following decreases

telemedicine in early 2020. The Centers

the pandemic.

each month from February to April.

emergency waiver authorities to expand

American Medical Association 2020 survey data

Other changes from May to June 2021

access to telehealth services, including

demonstrates a dramatic upswing in the

involved the top five telehealth diagnoses:

waiving geographic restrictions and al-

use of telehealth between 2018 and 2020:

for Medicare & Medicaid Services used

lowing beneficiaries to receive telehealth in their homes. Additionally, the HHS Office for Civil Rights relaxed enforcement of Health Insurance Portability

ʯ In 2020, 79% of physicians worked in a practice that used telehealth compared to only 25.1% in 2018.

ʯ The percentage of physicians who

ʯ Joint/soft tissue diseases and issues rose from No. 4 to No. 3.

ʯ Acute respiratory diseases and infections rose nationally from No. 3 in May to No. 2 in June.

and Accountability Act (HIPAA) privacy

used telehealth to manage patients

ʯ Urinary tract infections appeared

requirements for videoconferencing.

with chronic disease or to diagnose

in fifth place among telehealth diagnoses in the South in June 2021.

This was the first time since the start

‘ For telehealth to remain a successful option for physicians and patients, it is imperative that a telehealth visit be reimbursed at parity and in the same manner as an in-office visit.’

of the pandemic in March 2020 that this diagnosis appeared on any regional or national list, although it had been common on the lists prior to the pandemic.

ʯ Mental health conditions remained in the No. 1 spot among telehealth diagnoses.

Physicians enrolled in the Medi-

or treat patients also increased

care program licensed in any state were

(9.9% to 59.2% and 15.6% to

granted the authority to provide telehealth

58%, respectively).

services to people anywhere in the U.S.

An uptake among clinicians

ʯ Twenty percent of physicians said

“Clearly telehealth has been embraced by

if the state allows it. The waivers also

their practice used remote patient

physicians of many specialties and their

allowed physicians to practice from home.

monitoring, up from 10.4% in 2018.

patients,” says Christopher Garofalo,

What’s more, CMS’ Interim Final Rule

ʯ Sixty-seven percent of physicians

M.D., owner of Family Medicine Associ-

allowed for payment for audio-only evalu-

worked in a practice that used phone

ates in South Attleboro, Massachusetts,

ation and management (E&M) services.

call visits with patients in 2020.

and chair of the Massachusetts Medical

ʯ Fifty percent of physicians were

Society Committee on Sustainability of

In November 2021, CMS announced it would continue to reimburse providers

in a practice that used telehealth

Private Practice. “We saw a large increase

for extended Medicare telehealth services

to provide care to patients with

in the use of telehealth visits in our

through Dec. 31, 2023.

acute disease and 34.3% to provide

private family medicine practice, using

preventative care.

the visits for both acute and follow-up

These regulatory changes brought about desired results. The Department of Health and Human Services reported that

care.” (In March 2020, the MassachuAll that said, a plateauing of usage has

setts Medical Society co-founded The

The share of Medicare visits conducted

occurred. In September 2021, FAIR Health

Telehealth Initiative, designed to support

through telehealth in 2020 increased

reported that telehealth utilization, mea-

physicians implementing telehealth.

63-fold, from approximately 840,000 in

sured as a percentage of all medical claim

Other co-founders were the American

2019 to 52.7 million. And in July 2021,

lines, fell from 5% to 4.5% nationally

Medical Association, Florida Medical

28

March 2022 | The Journal of Healthcare Contracting

SUBSCRIBE TO JHC FOR YEAR-ROUND COVERAGE JHC PUBLISHES YEAR-ROUND 6 PRINTED • 6 DIGITAL To ensure you are receiving every issue please email Anna McCormick at amccormick@sharemovingmedia.com or visit our website at www.jhconline.com

TRENDS

Association, Texas Medical Association and the Physicians Foundation.)

“At the start of the pandemic we used telehealth to provide some Medicare Annual Wellness Visits, as the physical

‘ I know the work done by the digital medicine team has taken care of the patient’s most pressing conditions, so I can focus on the immediate reason for the visit.’

exam is quite limited, and even for some annual checkups for adults and wellchild checks,” says Garofalo. In 2021 the

in the pandemic, as most elective proce-

help inform us if there a lot of clutter or

number of telehealth visits decreased to

dures were on hold. Certain subspecial-

poor lighting that may increase their fall

around 10% to 15% of all visits and were

ists, such as GI and neurology, had more

risk. We can take a virtual look into their

conducted only for acute and follow-up

telehealth visits than more “hands-on”

kitchen cabinets and refrigerator to help

care. Even so, he predicts that telehealth

specialists, such as those in dermatology

assess dietary habits.”

visits “will be overall higher than prior to

and orthopedics.

the pandemic, but not as high as we saw

“One of the great advantages of telehealth is that it often brings us directly

Impact on in-office visits

into the home environment of the patient

Ochsner Health’s Houghton has found

health among his primary care colleagues

and their family,” says Garofalo. “We can

that telehealth – including remote moni-

than among subspecialists. “That’s to be

ask them to get their medicine bottles and

toring – has improved the quality of

expected, as primary care has a smaller

look at them, rather than relying on hand-

in-person primary care visits. “I know

number of visits that are procedures,” he

written notes. We can ask them to move

the work done by the digital medicine

says. Even so, he saw office notes from

the phone or the laptop camera to give us

team has taken care of the patient’s

most of his subspecialists, especially, early

a view of their environment, which can

most pressing conditions, so I can focus

early on in the pandemic.”

Garofalo saw a greater uptake of tele-

on the immediate reason for the visit, whether it’s back pain, an orthopedic issue or a behavioral health issue. I can

Telemedicine by specialty American Medical Association survey data demonstrates a dramatic upswing

in the use of telehealth between 2018 and 2020. The practice-level use of videoconference and phone visits was over 75% in cardiology, endocrinology/ diabetes, gastroenterology, nephrology, and neurology. In addition, the AMA survey data showed: ʯ Hematologists/oncologists had a high rate of videoconference visits (88.5%) but were less likely than other medical specialties to report the use of visits by phone (68%). ʯ Endocrinologists/diabetes physicians were the most likely to report use of telehealth to diagnose or treat patients (71.9%), manage patients with chronic disease (92.1%) and provide preventative care (52.6%). ʯ More than half of gastroenterologists, nephrologists, and neurologists said their practices used telehealth to provide acute care. ʯ Thirty-three percent of medical specialists said their practices used remote patient monitoring. This was driven by high rates of use among cardiologists (63.3%) and endocrinologists/diabetes physicians (41.6%).

focus on the patient-doctor relationship, because I know that the other work is being done continually.” And it’s being done better, he adds. “Because of digital medicine, we don’t just work with a handful of blood glucose readings; now we have dozens. We have 30 or 40 times the amount of data and we can manage the patient not only reactively, but proactively.”

Telemedicine may lead to fewer diagnostic procedures in the office.

Kaiser Permanente researchers reported in November 2021 that laboratory tests or imaging were ordered in 59.3% of office visits, compared with 29.2% of video visits and 27.3% of telephone visits.

Medication was prescribed more often in the clinic – 60% of visits compared with

30

March 2022 | The Journal of Healthcare Contracting

Definition of terms The word “telemedicine” means different things to different people, but the Centers for Medicare & Medicaid Services refers to three main types of telemedicine services: ʯ Telehealth visits. Routine office visits provided via video (requires synchronous, real-time audio and/or video communication) with new or established patients. ʯ Virtual check-ins. Short patient-initiated communications with a healthcare practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed. ʯ E-visits. Non-face-to-face patient-initiated communications with a healthcare practitioner through an online patient portal.

38.6% by video and 34.7% by telephone.

The differences could be due to patients choosing to see their doctor in person when the severity of their medical com-

‘ One of the great advantages of telehealth is that it often brings us directly into the home environment of the patient and their family.’

plaints was higher, they said.

Regarding other diagnostic tools,

published in December 2021 showed

Both clinicians and patients in the

such as EKGs, stress tests or pulmonary

mixed feelings about telehealth visits on

survey noted technical challenges too,

function tests, “I haven’t seen these types

the part of older patients with chronic

such as spotty internet connectivity and

of diagnostics move out of the office

kidney disease as well as their care part-

application issues. However, all described

setting,” says Garofalo. “Some test results,

ners and clinicians. Patients reported con-

telehealth as more convenient, less

such as PFTs, are much improved by

cerns that their home diagnostic equip-

costly, and more efficient for patients

having office staff educate and coach the

ment was not as accurate as professional

than clinic visits. “Our findings … sug-

patient. I also am not sure that EKGs will

equipment at the clinician’s site, and they

gest that telehealth may best supplement

be replaced in the traditional sense. While

complained of a loss of social connection

rather than supplant in-person visits for

a single-lead EKG reading on a remote

with their clinician.

patients who are older and chronically

device can be helpful for very basic moni-

Meanwhile, clinicians in the survey

toring of certain conditions such as atrial

viewed telehealth as compromising qual-

fibrillation, patients with acute cardiopul-

ity care due to an inability to conduct

tations that hampered the use of

monary symptoms will still require a 12-

physical examinations and laboratory

telehealth was lack of reimbursement

lead EKG in the office to help triage and

tests, including inaccurate edema and

from payers, including Medicare and

determine best medical management.”

blood pressure measurement. They also

Medicaid, says Dr. Garofalo. “For

reported poorer telehealth experiences

telehealth to remain a successful op-

with older patients, those from low so-

tion for physicians and patients, it is

Kinks

cioeconomic status, patients with limited

imperative that a telehealth visit

Telemedicine is an evolving science, with

health literacy or a hearing impairment,

be reimbursed at parity and in the

kinks to straighten out. A survey-based study

and non-English-speaking patients.

same manner as an in-office visit.”

The Journal of Healthcare Contracting | March 2022

ill,” said the study’s authors.

One of the pre-pandemic limi-

31

TRENDS

When asked what impact virtual care might have on point-of-care testing, lab expert Jim Poggi of Tested Insights LLC says, “I think it depends on whether the physician practice is offering the virtual

Telemedicine’s digital cousin: Remote patient management

visit or whether the patient is using one of the many ‘pop-up’ online services. Will telehealth and virtual visits change where patients receive future care? Probably to some extent. They are a new gateway to healthcare, for sure. I have concerns about whether they impede progress on antibiotic stewardship and how broadly telehealth visits are used.”

More than 23,000 patients have volun-

In 2015, Ochsner Health in New Orleans launched the Hypertension Digital Medicine program, which provides digitally enabled chronic disease management to patients with hypertension. The voluntary program serves approximately 13,000 individuals across 10 states.

As explained in a 2021 American Medical Association report, “Moving

tarily opted to use Ochsner Health’s tele-

Beyond Dollars and Cents in Realizing

medicine and virtual medicine initiatives.

the Value of Virtual Care,” each program

Participation is voluntary on the part of physicians too. Rather than making them mandatory, Dr. Houghton and the Ochsner team intend to continue encouraging participation by presenting ongoing proof that the programs work. High HEDIS scores for telehealth visits are testament to their effectiveness and patients’ experience of care. “When physicians see this, they ask, ‘Why wouldn’t I want my HEDIS scores to be better?’”

Among Ochsner’s patients, satisfaction with telemedicine is high, as reflected in net promoter scores, which measure the loyalty of customers (patients) to an organization. “Some of the early euphoria around telemedicine has waned, as both patients and providers became more experienced and critical,” says Houghton.

“But our scores have remained high, even among our most vulnerable patients, including those who are economically disadvantaged and those with comorbidities. The fact that the programs offer a lot of touches has been the driver,” he says.

enrollee is assigned a care team (clinician, pharmacist and health coach) responsible for providing education, medication reconciliation and management, and lifestyle recommendations according to established hypertension treatment guidelines.

Custom visual tools developed within the electronic health record display the enrollee’s social needs, trending blood pressure over time, hypertension-related comorbidities, patient activation level, health literacy and relevant lab results. Program enrollees are asked to submit at least one blood pressure reading per week.

Care team members contact enrollees regularly by phone and review readings and treatment options for improving blood pressure control.

Enrollees are encouraged to work with the care team to co-create the treatment plan by choosing among various lifestyle and medication options. Each enrollee receives a monthly report on their progress and tips for achieving better blood pressure control. Information about the enrollee’s progress is also available to their primary care provider.

Ochsner reports the following statistics: ʯ Program enrollees achieved greater blood pressure control compared with a propensitymatched group that received usual care (79% versus 26%). ʯ Medication adherence improved 14% among patients in the Digital Medicine program and declined 2% among patients receiving usual care over the evaluation period of six months. ʯ Program enrollees had more frequent interactions with their care team and more blood pressure measurements recorded in the EHR compared with matched patients assigned to usual care.

Current enrollees submit, on average, 4.2 blood pressure readings per week. ʯ Ochsner reports that the program has enabled primary care clinicians to provide an elevated level of support to patients, which has enhanced clinician satisfaction. ʯ The program saves $77 per member per month compared with usual care. ʯ A recent evaluation found that primary care physicians experienced a 29% reduction in the number of in-clinic visits from participating patients.

Primary care clinicians reported the program helped reduce their workloads and enabled them to expand access to other patients.

“We will never have to make participation a requirement.”

32

March 2022 | The Journal of Healthcare Contracting

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