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March 2019 • Vol.10 No.2

Colorectal Cancer Growing concern among young Americans

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CONTENTS »» MARCH 2019

6 The Pediatrician’s Office: A Good Place to Start Heart disease begins early in life

8 Heart Disease: An Uphill Climb 14 Colorectal Cancer

Growing concern among young Americans

22 Health news and notes 26 Small Guys Finish Last Small practices lag behind big ones under MIPS

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3

TRENDS

The Pediatrician’s Office: A Good Place to Start Heart disease begins early in life Gerald Berenson, M.D., professor of cardiology at LSU

mark research because it established a

Health New Orleans School of Medicine, passed away in No-

link between diet, exercise, and genet-

vember. He was 96. Berenson is best known for the Bogalusa

ics and the development of coronary

Heart Study, a multi-decade study of the development of heart

heart disease.”

disease, diabetes and metabolic syndrome.

4

In fact, Berenson believed that school-

A primary finding of the Bogalusa Heart Study, which began

children should be routinely tested for

in 1972, is that the major causes of adult heart diseases begin in

blood pressure, cholesterol and body

childhood – including atherosclerosis, coronary artery disease,

mass. “This internationally acclaimed

hypertension, type 2 diabetes and obesity.

research project is the foundation for

“The impact of the Bogalusa Heart Study cannot be over-

diet and lifestyle interventions that are

stated,” noted Dr. Frank Smart, LSU Health New Orleans chief

commonly employed today,” Smart was

of cardiology, in the LSU Health obituary. “The study was land-

quoted as saying.

March 2019 | The Journal of Healthcare Contracting

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TRENDS

The pediatrician

“The doctor has to make time to talk

One of the greatest risk factors for heart disease among children

to the child and the parents,” he says.

today is obesity, notes Christopher Snyder, M.D., FAAP, Univer-

Obesity is usually a family affair; that is

sity Hospitals, Cleveland, and chair of the American Academy of

to say, pediatricians seldom see an obese

Pediatrics Section on Cardiology and Cardiac Surgery.

child with two parents of healthy weight.

“Obesity is dangerous, it limits kids’ lives, and it’s a public health issue which we have to recognize,” he says.

“You can’t just walk into the exam room, tell the child and his parents that he’s

Obesity is more common among adolescents today than in

obese, and then leave. You have to help

years past, says Snyder. And even though overweight or obesity

them set goals and continue working to-

may not be the reason a child visits the pediatrician, “it’s what

ward them.”

we see. If we want to move the needle and help people live longer, we have to attack it.”

Again, that is often more easily said than done, he says. Some families can’t

“Pediatricians have to make the time to talk to families about how obesity can affect life expectancy, high blood pressure and diabetes.”

– Christopher Snyder, M.D., FAAP, University Hospitals, Cleveland, and chair of the American Academy of Pediatrics Section on Cardiology and Cardiac Surgery Gerald S Berenson, MD, Photo Courtesy of LSU Health

That’s a tall order, given popular culture, which still prizes tasty but unhealthy food, as well as today’s more sedentary lifestyles.

In 2011, the American Academy of Pediatrics endorsed guidelines by the National Heart, Lung and Blood Institute

opt for cheaper junk food instead. Some live in unsafe neighborhoods, where kids are unable to play outside with friends.

(NHLBI), part of the National Institutes of Health, which recom-

“Obesity is an epidemic,” says Snyder.

mended universal cholesterol screening at ages 9-11 and 17-21

“We cannot ignore it, even though it can

years, and selective cholesterol screening in children ages 2-21

be really difficult.

years with risk factors.

6

afford the price of healthy food, and so

“Pediatricians have to make the time

But long-term change calls for: 1) willingness on the part of

to talk to families about how obesity

the child and his/her parents to adopt a healthy lifestyle, and 2)

can affect life expectancy, high blood

help from professionals, such as dieticians and fitness experts,

pressure and diabetes. If we don’t do it,

says Snyder.

who will?”

March 2019 | The Journal of Healthcare Contracting

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PATIENT CARE

ENVIRONMENT OF CARE

INTERVENTIONAL CARE

TRENDS

Heart Disease: An Uphill Climb 8

Despite decades-long improvement, heart disease and stroke remain leading causes of morbidity, mortality, and healthcare costs in the United States.

One year ago, the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services launched Million HeartsŽ 2022, a national initiative to prevent a million heart attacks, strokes, and other acute cardiovascular events during 2017–2021.

March 2019 | The Journal of Healthcare Contracting

A predecessor program – Million Hearts® – aimed to prevent 1 million heart attacks and strokes in the United States over the course of five years, 2012 to 2016. During the first two years of that initiative, about 115,000 cardiovascular events were prevented, relative to the expected number of events. And although final numbers had not been reported at press time, Million Hearts estimates that up to half a million events may have been prevented from 2012 through 2016.

The economic toll of CVD is high. More than $316 billion each year in the United States, with CVD treatment accounting for about one of every seven dollars spent on healthcare in this country.

Million Hearts 2022 focuses on a small set of priorities selected for their impact on heart disease, stroke, and related conditions: • 20 percent reduction in sodium intake • 20 percent reduction in tobacco use • 20 percent reduction in physical inactivity • 80 percent performance on the ABCS Clinical Quality Measures (i.e., (i.e., Aspirin when appropriate, Blood pressure control, Cholesterol management, and Smoking cessation).

• 70 percent participation in cardiac rehab among eligible patients.

Every 40 seconds, an adult dies from a heart attack, stroke, or other adverse outcome of cardiovascular disease (CVD), reports the CDC. These deaths account for about one third of all deaths in the United States, or more than 800,000 deaths each year.

About one in five of these deaths is a person younger than 65.

Heart disease and stroke can also lead to other serious illnesses,

Special attention needed Addressing heart disease is important for all Americans, but four groups require special attention, as heart disease and stroke events among them are increasing: • Blacks/African-Americans with hypertension.

• 35-to-64-year-olds.

• People who have had a heart attack or stroke.

• People with mental and/or substance use disorders.

In 2016, hospitalization and mortality rates were highest among men (989.6 and 172.3 per 100,000, respectively) and non-Hispanic blacks (211.6 per 100,000, mortality only), and they increased with age, reports the Centers for Disease Control and Prevention. Among adults aged 18-64 years, 805,000 hospitalizations and 75,245 deaths occurred. Without preventive intervention, it is possible that 16.3 million events and $173.7 billion in hospitalization costs could occur from 2017-2021.

Source: Centers for Disease Control and Prevention, https:// www.cdc.gov/mmwr/volumes/67/ wr/mm6735a3.htm?s_ cid=mm6735a3_w

disabilities, and lower quality of life.

The Journal of Healthcare Contracting | March 2019

9

TRENDS

Heart disease: Where you live matters Aspirin use, blood pressure and cholesterol control, cardiac rehab and heart-healthy behaviors are effective healthcare strategies to combat heart disease. Nevertheless, adherence is inconsistent throughout the country, resulting in geographic variation in cardiovascular disease (CVD) outcomes, reports the Centers for Disease Control and Prevention.

In 2016, state-level mortality was higher in the southeastern United States, which aligns with the findings from previous studies. Rates for emergency-department visits and hospitalizations

were higher in the Southeast and elsewhere, including many Midwestern states.

State-level variation in 2016 occurred in heart-disease-related rates of: • Emergency department visits (a low of 56 per 100,000 in Connecticut, to 275 per 100,000 in Kentucky).

• Hospitalizations (from 484 per 100,000 in Wyoming, to 1,670 per 100,000 in Washington, D.C.) • Mortality (from 111 per 100,000 in Vermont, to 267 per 100,000 in Mississippi).

Each state would need to realize an approximate 6 percent decrease in its expected event totals during 2017–2021 to collectively prevent 1 million events at the national level. For that to occur, the participants in Million Hearts® 2022 believe an 80 percent or greater performance on the ABCS (i.e., aspirin use, blood pressure control, cholesterol control and cessation of smoking) and at least a 20 percent reduction in physical inactivity, tobacco use, and sodium consumption are necessary.

Source: Centers for Disease Control and Prevention, https://www.cdc.gov/mmwr/volumes/67/wr/ mm6735a3.htm?s_cid=mm6735a3_w

The economic toll of CVD is high. More than $316 billion each

The CDC reports that acute myocar-

year in the United States, with CVD treatment accounting for about

dial infarctions and strokes accounted

one of every seven dollars spent on healthcare in this country.

for approximately half (47 percent) of

And while cardiovascular deaths have been declining for the

hospitalizations (rates = 204.5 and 199.1

past 40 years, the reduction in these deaths has slowed since

per 100,000, respectively) and approxi-

2011, indicating the need for focused, sustained action by pub-

mately two thirds (61 percent) of deaths

lic and private partners to improve our nation’s cardiovascular

(42.2 and 53.7 per 100,000, respectively).

health, says the CDC. Managing blood pressure and cholesterol

Other cardiovascular events, which in-

levels is more important than ever. Cardiac rehabilitation pro-

clude those related to heart failure, con-

grams, increased physical activity and healthy eating habits are

tributed to 46 percent of hospitalizations

other priorities.

and 38 percent of deaths (rates = 394.6 and 59.8 per 100,000, respectively).

In 2016, heart disease caused:

10

• 2.2 million hospitalizations (850.9 per 100,000 population).

Editor’s note: Refer your clinical cus-

• $32.7 billion in costs.

tomers to the Million Hearts website at

• 415,480 deaths (157.4 per 100,000).

www.millionhearts.hhs.gov March 2019 | The Journal of Healthcare Contracting

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TRENDS

The cost of heart disease, 2016

By gender

Hospitalization/mortality rates

Hospitalization cost ($)

Men (total)

1.18 million

$18.6 billion

Women (total)

1.06 million

$14.1 billion

Men by age

Hospitalization/mortality rates

Hospitalization cost ($)

18-44 years

73,000

$1.3 billion

45-64 years

426,000

$7.4 billion

65-74 years

286,100

$4.8 billion

75 years and over

395,000

$5.1 billion

Women by age

Hospitalization/mortality rates

Hospitalization cost ($)

18-44 years

46,900

$0.8 billion

45-64 years

258,700

$4.1 billion

65-74 years

231,100

$3.3 billion

75 years and over

520,500

$5.9 billion

Race/ethnicity

Hospitalization/mortality rates

Hospitalization cost ($)

White, non-Hispanic

320,200

NA

Black, non-Hispanic

52,200

NA

Hispanic

25,400

NA

Other, non-Hispanic

12,600

NA

Asian/Pacific Islander

10,600

NA

Alaskan native

2,000

NA

Sources: Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS); National Center for Health Statistics’ National Vital Statistics System Mortality Data. (https://www.cdc.gov/mmwr/volumes/67/wr/mm6735a3.htm?s_cid=mm6735a3_w)

12

March 2019 | The Journal of Healthcare Contracting

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March 2019 | The Journal of Healthcare Contracting

Colorectal Cancer Growing concern among young Americans

Rates of colorectal cancer are rising for the under-50 crowd, but declining for those over 50 to 55. Those findings, reported by the American Cancer Society in its May 2018 Colorectal Cancer Screening Guideline, caused ACS to recommend that average-risk adults aged 45 years and older undergo regular screening with either a high-sensitivity stool-based test (e.g., iFOBT) or a structural – visual – exam, based on personal preferences and test availability. As a part of the screening process, all positive results on non-colonoscopy screening tests should be followed up with timely colonoscopy, according to ACS. True, the Society calls its most recent guideline a “qualified recommendation,” whereas its prior recommendation for regular screening in adults aged 50 years and older remains a “strong recommendation.” Nevertheless, ACS issued its recommendation based on a systematic evidence review of colorectal cancer screening literature and modeling analyses.

Not every professional group is completely on-

“ Young onset rates of colorectal cancer are absolutely rising, and we as clinicians need to be cognizant of that when we see our young patients in the office who present with digestive complaints of concern.”

board with the ACS recommendation. The U.S.

– Sophie M. Balzora, MD, FACG

Multi-Society Task Force (MSTF) on Colorectal Cancer – which represents the American Gastroenterological Association, American College of Gastroenterology, and the American Society for Gastroenterological Endoscopy – is standing by its 2017 recommendations, The Journal of Healthcare Contracting | March 2019

15

COLORECTAL CANCER

which call for screening for colorectal cancer be-

diet, including high consumption of alcohol and

ginning at age 50 years in average-risk people, ex-

red and processed meat and low consumption of

cept in African-Americans, in whom some evidence

fruits/vegetables, dietary fiber, and dietary calci-

supports screening at 45 years. Nevertheless, MSTF

um; and physical inactivity, says ACS. The risk for

recognizes that earlier screening may improve ear-

developing colorectal cancer is associated with

ly detection and prevention of colorectal cancer.

several identified hereditary conditions, includ-

At the very least, the Task Force acknowledges that

ing family history; medical conditions, including

the ACS recommendation will stimulate discussion

chronic inflammatory bowel disease and type 2

and further research on the risks and benefits of

diabetes; and a history of abdominal or pelvic ra-

earlier screening.

diation for a previous cancer.

Among adults younger than 55 years, the incidence of colorec-

By the Numbers

tal cancer increased 51 percent from 1994 to 2014, and mortality increased 11 percent from 2005

Colorectal cancer (CRC) is the fourth most commonly diagnosed cancer among adults in the United States, reports the ACS. Over 140,000 Americans were expected to be diagnosed with it in 2018. It is the second leading cause of cancer death, leading to over 50,000 deaths annually.

to 2015.

“Young onset rates of colorectal cancer are absolutely rising, and we as clinicians need to be cognizant of that when we see our young patients in the office who present with digestive complaints of concern,” says Sophie M. Balzora, MD, FACG, who

16

is chair of the American College

Onset among the young

of Gastroenterology’s Public Relations Committee

Colorectal cancer (CRC) is the fourth most com-

and of the NYU School of Medicine. It is not clear

monly diagnosed cancer among adults in the Unit-

why colorectal cancer is increasing in this popula-

ed States, reports the ACS. Over 140,000 Americans

tion, she adds.

were expected to be diagnosed with it in 2018. It is

While Balzora could not comment on ACG’s

the second leading cause of cancer death, leading to

behalf on the American Cancer Society’s newest

over 50,000 deaths annually. The highest incidence

recommendations, “what I can say is that the rec-

and mortality rates are among African-Americans,

ognized increased rate of rectal cancer in those

American Indians, and Alaska Natives.

under age 50 has sounded an alarm, and height-

Risk factors associated with a Western life-

ens the importance of informing patients in this

style that have been shown to increase CRC risk

age group to not ignore their digestive symptoms

include: cigarette smoking; excess body weight;

and to seek the care of their physician sooner, March 2019 | The Journal of Healthcare Contracting

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COLORECTAL CANCER

rather than dismissing symp-

American Cancer Society Guideline for CRC Screening, 2018

toms. This is something we have

The American Cancer Society recommends that adults aged 45 years and older with an average risk of colorectal cancer (CRC) undergo regular screening with either a high-sensitivity stoolbased test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on non-colonoscopy screening tests should be followed up with timely colonoscopy.

The recommendation to begin screening at age 45 years is a qualified recommendation.

The recommendation for regular screening in adults aged 50 years and older is a strong recommendation.

The ACS recommends that average-risk adults in good health with a life expectancy of greater than 10 years continue CRC screening through the age of 75 years (qualified recommendation).

The ACS recommends that clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history (qualified recommendation).

The ACS recommends that clinicians discourage individuals over age 85 years from continuing CRC screening (qualified recommendation).

The good news

Options for CRC screening Stool-based tests: • Fecal immunochemical test every year.

• High-sensitivity, guaiac-based fecal occult blood test every year.

• Multitarget stool DNA test every 3 years.

increased screening, with im-

always stressed, but this message is more important now than ever.”

If there is good news to report, it is this: Colorectal cancer incidence and mortality among adults aged 55 years and older have shown a decline for several decades, which accelerated around 2000, particularly among adults aged 65 years and older, according to ACS. Although changes in exposure to risk factors account for an estimated one-half of the reduction in incidence and one-third of the reduction in mortality before 2000, subsequent accelerated declines in incidence and mortality since 2000 are largely attributable to proved treatment also contributing to mortality reduction.

“Screening saves lives, and this group [those aged 55 and over]

Structural examinations • Colonoscopy every 10 years.

• CT colonography every 5 years.

• Flexible sigmoidoscopy every 5 years.

has been heavily targeted, which is fantastic to see,” says Balzora.

“The ‘Katie Couric Effect’ was a true phenomenon that increased

Source: Colorectal cancer screening for average-risk adults:

colorectal cancer screening rates

2018 guideline update from the American Cancer Society, CA: A Cancer Journal for Clinicians, https://onlinelibrary.wiley.com/doi/ full/10.3322/caac.21457#caac21457-tbl-0001

tremendously,” she says, referring to the efforts of the journalist and author. “Having her colonoscopy nationally broadcast on

18

March 2019 | The Journal of Healthcare Contracting

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COLORECTAL CANCER

live television in March 2000 was an innovative

U.S. Multisociety Task Force on Colorectal Cancer: Statement regarding new recommendations

and extremely successful method of driving home the importance of colorectal cancer screening.

“As gastroenterologists, we strive to prevent colorectal cancer over detecting it, which is why we feel colonoscopy is the best test, as it can

The MSTF has previously recommended that colorectal cancer screening for average-risk persons (persons who do not have a family history of colorectal cancer in a first-degree relative) begin at age 45 years in African Americans and age 50 in other groups. The MSTF has reviewed the recent recommendation from the American Cancer Society (ACS) to lower the age to begin screening from 50 to 45 years in all Americans. This change was a qualified recommendation based largely on a modeling study utilizing updated data on the incidence of colorectal cancer in younger people.

Evidence from screening studies to support lowering the screening age is very limited at this time. Based on the modeling study used to support the ACS recommendation, the MSTF recognizes that lowering the screening age to 45 may improve early detection and prevention of CRC. The MSTF expects the new ACS recommendation to stimulate investigation that will clarify the benefits and risks of earlier screening.

As the MSTF has previously noted and discussed, rates of colorectal cancer are increasing in Americans down to age 20 years. Beginning screening at 45 years addresses only part of the increasing risk of colorectal cancer in young persons. For all persons under 50 years, it remains critical to promptly assess symptoms consistent with colorectal cancer. In particular, rectal bleeding and unexplained iron deficiency anemia have substantial predictive value for colorectal cancer and should be thoroughly evaluated.

truly prevent colorectal cancer, as well as detect

Source: U.S. Multisociety Task Force on Colorectal

Recommendations for Physicians and Patients

Cancer, June 14, 2018, https://www.gastro.org/ press-release/statement-from-the-u-s-multisocietytask-force-on-colorectal-cancer

From the U.S. Multi-Society Task Force on

it,” says Balzora.

Stool-based, noninvasive testing – such as iFOBT, or FIT – does not prevent colorectal cancer, because its primary goal is to detect colorectal cancer, and not precancerous polyps, she says.

“But ultimately, the best test is the one that gets done (properly)!”

FIT testing is an excellent noninvasive alternative to colonoscopy, assuming that patients follow through by getting a colonoscopy should the FIT test return positive, says Balzora. “FIT has a significant advantage over FOBT testing, as it is specific to lower intestinal bleeding, and is a better, more accurate test overall compared with FOBT testing.”

Resources: American Cancer Society Colorectal Cancer Screening Guideline (2018), https://www.cancer.org/health-careprofessionals/american-cancer-societyprevention-early-detection-guidelines/ colorectal-cancer-screening-guidelines.html Colorectal Cancer Screening:

Colorectal Cancer, July 2017, Gastroenterology (https://www.gastrojournal.org/article/S00165085(17)35599-3/fulltext)

20

March 2019 | The Journal of Healthcare Contracting

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HEALTH NEWS

Health news and notes Get happy

said Petra Hanson, MBChB, MRCP, AFHEA,

Being active can help you improve your health and feel better,

a clinical research fellow at Clinical Sci-

says the Department of Health and Human Services. It can low-

ences Research Laboratories, University

er your blood pressure and reduce your risk of chronic diseases,

Hospitals Coventry and Warwickshire, U.K.

like type 2 diabetes and certain cancers. Physical activity can

“Mindfulness taught in such a setting can

also boost your mood and help sharpen your focus. In its new

also improve patients’ confidence and

Physical Activity Guidelines for Americans, HHS says that adults

ability to manage weight in the long term.

need at least 150 minutes of moderate-intensity physical activ-

It is a very scalable intervention that can

ity per week. You can start with just 5 minutes at a time. Swim,

be applied to everyone.”

garden, walk the dog, dance, or bike your way to feeling better.

Strengthening your muscles is important too. At least two days

Housework for brainiacs

each week, do some push-ups or lift weights. Children ages

Now there’s no excuse for not doing more

three to five should be physically active for at least three hours

housework. Even simple housework,

throughout the day. Kids six through 17 need at least one hour

like cooking and cleaning, may make a

per day. All of your physical activity adds up. Moving more often

difference in brain health, according to

throughout the day can help you get enough activity.

researchers at Rush University Medical Center in Chicago. In the last years of re-

22

Pay attention

search before death, each participant in

Adults with obesity who attended group sessions teaching mind-

the Rush study wore an activity monitor

fulness-based eating techniques lost an average of 2.85 kg more

called an accelerometer, similar to a Fitbit,

than similar adults who attended group classes without mindful

which measured physical activity around

eating strategies, according to findings published in The Journal

the clock – everything from small move-

of Clinical Endocrinology & Metabolism and reported by Helio.

ments, such as walking around the house,

com. “Our study has shown that mindfulness techniques can

to more vigorous movements, like exer-

improve eating behavior and facilitate weight loss in patients

cise routines. Researchers collected and

with obesity attending specialist weight management service,”

evaluated 10 days of movement data for March 2019 | The Journal of Healthcare Contracting

Better, faster.

It’s what we want for patients.

What about your clinicians?

Connecting vital signs monitors to the EMR has been shown to: Y

Reduce errors caused by manual processes1

Y

Save clinicians time by removing manual documentation steps2

Y

Increase clinical time spent on value-added care3

40

1

Reduction in minutes of vital signs data latency in the EMR after connecting vital signs4

Welch Allyn partners with leading EMRs to send data from the Connex® family of vital signs devices directly to the patient’s record. Our goal is simple: help your clinicians work better, faster so they can focus on getting patients better, faster.

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1 CIN: Computers, Informatics, Nursing: Eliminating Errors in Vital Signs Documentation, FIELER, VICKIE K. PhD, RN, AOCN; JAGLOWSKI, THOMAS BSN, RN; RICHARDS, KAREN DNP, RN, NE-BC, 2013. The paper vital signs recording had an error rate of 18.75%.

2 JHIM FALL 2010 Volume 24:Number 4, Vital Time Savings: Evaluating the Use of an Automated Vital Signs Documentation System on a Medical/Surgical Unit 3 Going One Step Further at Scott & White Medical Center—Temple: Eliminating manual vital signs documentation to prioritize value-added care. 2017 Welch Allyn. www.welchallyn.com 4 CareAware® VitalsLink: Eliminating Data Latency & Manual Documentation at Naples Hospital. Prepared by Cerner, 2013. © 2017 Welch Allyn

MC14605

HEALTH NEWS

each participant and calculated an average daily activity score.

less. The report from a panel of nutrition,

The findings showed that higher levels of daily movement were

agriculture and environmental experts

linked to better thinking and memory skills, as measured by the

recommends a plant-based diet, and en-

yearly cognitive tests. And when researchers analyzed brain tis-

courages whole grains, beans, fruits and

sue under a microscope, this finding turned out to be the case

most vegetables. Added sugars should

even for individuals with at least three signs of Alzheimer’s dis-

be limited, as should refined grains, such

ease, such as amyloid plaques and neurofibrillary tangles. Even

as white rice, and starches, like potatoes

though these individuals might have been diagnosed with Al-

and cassava. It says red meat consump-

zheimer’s, 30 percent of them had “normal” cognition at death.

tion on average needs to be slashed by

What to do about vaping?

Health authorities agree: Teen vaping is an epidemic that affects

half globally, though reductions would need to be more dramatic in richer countries like the United States.

some 3.6 million underage users of Juul and other e-cigarettes, reto help teenagers who may be addicted to nicotine. E-cigarettes

Older adults: Mind your protein

heat a liquid solution that usually contains nicotine into an inhal-

Older adults need to eat more protein-

able vapor. Federal law prohibits sales to those under 18, though

rich foods when losing weight, dealing

many high schoolers report getting them from older students or

with a chronic or acute illness, or facing

online. In recent months, government officials have rolled out

a hospitalization, according to a grow-

a series of proposals aimed at keeping the products away from

ing consensus among scientists, reports

youngsters, including tightening sales in convenience stores and

Kaiser Health News. During these stress-

online. In November, vaping giant Juul voluntarily shut down its

ful periods, aging bodies process pro-

Facebook and Instagram accounts and pulled several flavors out

tein less efficiently and need more of it

of retail stores. But there’s been little discussion of how to treat

to maintain muscle mass and strength,

nicotine addiction in children as young as 11 years old. Physicians

bone health and other essential physi-

who treat young people now face a series of dilemmas: The anti-

ological functions. Even healthy seniors

smoking therapies on the market – such as nicotine patches and

need more protein than when they were

gums – are not approved for children, due to lack of testing or in-

younger to help preserve muscle mass,

effective results. And young people view the habit as far less risky

experts suggest. Yet up to one-third

than smoking, which poses another hurdle to quitting.

of older adults don’t eat an adequate

ports the New York Times. But no one seems to know the best way

Unhappy meal

24

amount due to reduced appetite, dental issues, impaired taste, swallowing

A hamburger a week, but no more – that’s about as much red

problems and limited financial resources.

meat people should eat to do what’s best for their health and

Combined with a tendency to become

the planet, according to a report by EAT, a Stockholm-based

more sedentary, this puts them at risk

nonprofit, and published in the medical journal Lancet, reports

of deteriorating muscles, compromised

the New York Times. Eggs should be limited to fewer than about

mobility, slower recovery from bouts of

four a week, and dairy foods should be about a serving a day, or

illness and the loss of independence.

March 2019 | The Journal of Healthcare Contracting

TRENDS

Small Guys Finish Last Small practices lag behind big ones under MIPS

26

Small and rural medical practices didn’t fare nearly as

Nearly one in every five small practices

well as their bigger, non-rural counterparts in the first year (2017)

(19 percent) in MIPS received negative pay-

of the Quality Payment Program of the Centers for Medicare and

ment adjustments compared to 5 percent

Medicaid Services, researchers reported in Health Affairs.

of program participants overall. This could

Many large practices qualified as exceptional performers

have occurred for a number of reasons, in-

(mean and median CPS – composite performance score – of

cluding limited ability to shoulder program

74.37 and 90.29, respectively), while most small practices did

reporting burden or a combined effect of

not (mean and median CPS of 43.46 and 37.67, respectively). On

inadequate risk adjustment in MIPS and

average, rural practices performed worse than large practices

high clinical or social complexity at smaller

(median CPS of 75.29 versus 90.29, respectively).

practices, according to the researchers.

March 2019 | The Journal of Healthcare Contracting

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TRENDS

Small practices

19%

Rural practices

6% 1%

National

5% 2%

0%

8%

30%

44%

28%

65%

22%

10%

20%

71%

30%

40%

50%

60%

70%

80%

90%

100%

Negative (0 pts) Neutral (3 pts) Positive only (>3.01-69.99 pts) Positive with additiontial adjustment for exceptional performance (>=70-100 pts) Source: Health Affairs Further research should examine why smaller practices ap-

• Improvement activities (15

pear to be at a systematic disadvantage, and policymakers

percent of final score), a category

should consider measures to avoid unfairly penalizing these

that gauges participation in activi-

practices in MIPS, they concluded.

ties that improve clinical practice,

Implemented through the Medicare Access and CHIP Reau-

such as expanding practice access,

thorization Act of 2015 (MACRA), QPP is a value-based payment

improving care coordination and

program with two participation options: the MIPS track and the

promoting patient safety.

Alternative Payment Model (APM) track.

•C ost (10 percent of final score). This For MIPS, physicians earn a payment adjustment based on evi-

category – new in 2018 – measures

dence that they provided high-quality, efficient care supported

resources that clinicians use to care for

by technology. To do so, they must submit information in the

patients, and the Medicare payments

following categories: • Quality (50 percent of final score), which measures health

for care (items and services) given to a beneficiary during an episode of care.

care processes, outcomes, and patient care experiences.

Note because the “cost” category was • Promoting interoperability requirements (25 percent of final score), which promotes patient engagement

new in 2018, it was not considered in the 2017 performance data.

and electronic exchange of information using certified electronic health record technology.

28

Source: Health Affairs, Jan. 18, 2019 March 2019 | The Journal of Healthcare Contracting

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