MDAdvisor Fall 2016 by MDAdvantage Insurance Company of New Jersey

HARNESSING HEALTH INFORMATION TECHNOLOGY TO IMPROVE CARE

Commissioner Cathleen D. Bennett

ABDOMINAL PAIN AND IMAGING STUDIES IN THE EMERGENCY DEPARTMENT: STANDARD OF CARE OR STANDARD OF FEAR?

Joseph C. Hummel, DO, & John Zen Jackson, Esq. Kirsten Tandberg, PA-C

IMPROVING PATIENT SAFETY: PRACTICES TO PREVENT POLYPHARMACY IN THE ELDERLY

Jean Anderson Eloy, MD, Michael J. Sylvester & Soly Baredes, MD

ANALYSIS OF THE IMPACT OF “NEVER EVENTS” IN NEW JERSEY

CME

VOLUME 9 • ISSUE 4 • FALL 2016

PRESCRIBING TO BEST PRACTICES FOR PATIENT SAFETY AND QUALITY CARE

MDADVISOR: A JOURNAL FOR THE HEALTHCARE COMMUNITY.

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Join us for a unique, firsthand glimpse inside the courtroom as we present our annual mock trial. Friday, March 17, 2017 The Crowne Plaza, Plainsboro Twp, NJ Register online at www.MDAdvantageonline.com or call us at 888-355-5551.

Scan the QR code to view a short video clip from the 2016 MDAdvantage Mock Trial.

TE N A OST C . A

his of t s i s ene ving he g t Im pro T rs . e erro por issu e c i r t ” s s y st t o it t lea Safe lished iagn a d t e , n c t alth pub atie por rien r “P dicine e re ill expe e he v u h i t t o – e w to ga is o r of M rding ople cant ne e e Adv t p o D u i t c t s if c ostic of M e Insti agn 5. A that mo to sign i e 1 d u 0 e h s g 2 t s d ucin it becam all i ber ikely an lea hen l d F m e w s r i e e , th and rs c ago n Sept , and it ively journal e to i fety erro . fect ear e f a r y e m e s e e a r h o s r t a t c n a c s e n o f me e of Wel atie ely o . Th cost tegies f th C tings o l a u l l e p s c o a a s s i i e m g e i c t s H ant stra ovin ocu ll se eir lifet d finan t h e m osis in the the port mpr n’t f ut a i s n h a m o : s t i a l c n h ing u s a s t i g n c e g i s o c s a h i u i w t e a r g D er istr hro rro hat to d ude in imp logy larg ist t ed t tic e are cal d began cl z a i i t l n f g no i a a o pers i a g n o s o re th to rd ol ech le t a e s h d c f c e o a e d W t t y o u B n , ps rial wan care one use ans. llary iss e te mes e Edito eric alth are, t we just on o o e c r a m c h f o h t A t c ou all n th ics he are lity o icians, ear s re to all of t fordabi Whe the top e cl rors y a r c h m e a p y f tic lit nd ng ,a to bec is nos qua rs, a deri care oke quickly o p t re th erro hat diag ivery of o consi s s o l s e t p i e l x w c s e rt ers, As s ac e de hout al clea fully e of mak ch a els. g th o t y i t u n d c i i s r w l r som o , e u o t y m s d t n m p r n e s safe ironme ement r fro in o and ent v hea proache ices rs tors o a u o l t v pati care en b u eir red reg eim e ap is. lth er r of th ly hono novativ ans, i l d l as hea i c i a v r in la em ily b de pro u a g d u c l a n i d i d t c c an par s, a e us o in pics on a o ar rney eded t We are ety e to f h s o a t e w s t h s a nt ne er nt ic. we top lead ct patie used o as an d n a e i that c t a c o e si not imp lly f tifac phy ifica s to w it c mul ersey’s e e e c i i p v t s J rac we ture e is New r own p y fu issu lity, l n a l a u a i F e q to m tinuing in th hile our ty and off k on e c f i W k to c sa e ics, t d h r n t a top tie rw as a o e f t s p u k e of th t b loo isor poin . We hts into Adv s d D n n o e at M ti g u re w th ersa ew insi t v e u i n f v co n of ro m ring ints ng f i o r p a to b e e hav to h ho and w . ors eard auth o be h dt nee

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Opioid Epidemic Costs the United States $78.5 Billion Annually Researchers at the United States Centers for Disease Control and Prevention (CDC) recently analyzed the financial toll of opioid abuse, including its impact on direct healthcare costs, lost productivity and costs to the criminal justice system. The study showed that opioid abuse costs the United States economy approximately $78.5 billion a year, and more than 40 Americans die each day from overdoses involving prescription opioids. The study findings were published in the October issue of the journal Medical Care.

A Journal for the Healthcare Community

49 States Have Reduced Avoidable Hospital Readmissions According to new data released by the Centers for Medicare and Medicaid Services (CMS), 49 states in the United States have reduced avoidable hospital readmission rates since 2010. (The sole exception was Vermont, where rates remained virtually unchanged.) These improvements follow the implementation of various CMS programs and initiatives to improve the quality of care, chief among them the Hospital Readmissions Reduction Program. Of the states where readmissions fell, 43 saw decreases of more than five percent, and 11 states saw rates fall by more than 10 percent, including New Jersey, which experienced a 13.3 percent reduction. The United States Faces a Shortage of Maternal Healthcare Professionals Faced with a shortage of OB/GYNs and nurse midwives, several states are considering proposals that advocates say would improve healthcare for women. The American Congress of Obstetricians and Gynecologists (ACOG) estimates the United States will have between 6,000 and 8,800 fewer OB/GYNs than needed by 2020 and a shortage of possibly 22,000 by 2050. ACOG is pushing measures in the U.S. Congress that would provide financial incentives to encourage medical school graduates to go into the field.

NEWS & ACKNOWLEDGEMENTS

WHAT’S HAPPENING IN HEALTHCARE?

PUBLISHER PATRICIA A. COSTANTE, FACHE Chairman & CEO MDAdvantage Insurance Company PUBLISHING & BUSINESS STAFF CATHERINE E. WILLIAMS Senior Vice President MDAdvantage Insurance Company JANET S. PURO Vice President MDAdvantage Insurance Company THERESA FOY DIGERONIMO Copy Editor MORBELLI RUSSO & PARTNERS ADVERTISING INC. EDITORIAL BOARD PAUL J. HIRSCH, MD, Editor-in-Chief HON. PAUL W. ARMSTRONG, JSC (Ret.) STEVE ADUBATO, PHD PETE CAMMARANO DONALD M. CHERVENAK, MD STUART D. COOK, MD VINCENT A. DEBARI, PHD JEREMY S. HIRSCH, MPAP WILLIAM G. HYNCIK, ATC JOHN ZEN JACKSON, ESQ. ALAN J. LIPPMAN, MD JUDITH M. PERSICHILLI, RN, BSN, MA EMERGING MEDICAL LEADERS ADVISORY COMMITTEE NATALYA ANDRIYANYCHEVA RYAN MILLER RONAK MISTRY RACHEL MORALES FAN, MD

RICHARD STEINWANDTNER MELISSA VILLARS, MD NICOLE VIOLA

PUBLISHED BY MDADVANTAGE INSURANCE COMPANY 100 Franklin Corner Road, Lawrenceville, NJ 08648-2104 www.MDAdvantageonline.com Phone: 888-355-5551 • Editor@MDAdvisorNJ.com INDEXED IN THE NATIONAL LIBRARY OF MEDICINE’S MEDLINE® DATABASE.

Material published in MDAdvisor represents only the opinions of the authors and does not reflect those of the editors, MDAdvantage Holdings, Inc., MDAdvantage Insurance Company and any affiliated companies (all as “MDAdvantage®”), their directors, officers or employees or the institutions with which the author is affiliated. Furthermore, no express or implied warranty or any representation of suitability of this published material is made by the editors, MDAdvantage®, their directors, officers or employees or institutions affiliated with the authors. The appearance of advertising in MDAdvisor is not a guarantee or endorsement of the product or service of the advertiser by MDAdvantage®. If MDAdvantage® ever endorses a product or program, that will be expressly noted. Letters to the editor are subject to editing and abridgment. MDAdvisor (ISSN: 1947-3613 (print); ISSN: 1937-0660 (online)) is published by MDAdvantage Insurance Company. Printed in the USA. Subscription price: $48 per year; $14 single copy. Copyright © 2016 by MDAdvantage®. POSTMASTER: Send address changes to MDAdvantage, 100 Franklin Corner Road, Lawrenceville, NJ 08648-2104. For advertising opportunities, please contact MDAdvantage at 888-355-5551.

MDADVISOR | FALL 2016

LETTER FROM MDADVANTAGE® CHAIRMAN & CEO PATRICIA A. COSTANTE

ABDOMINAL PAIN AND IMAGING STUDIES IN THE EMERGENCY DEPARTMENT: STANDARD OF CARE OR STANDARD OF FEAR? | By Joseph C. Hummel, DO, & John Zen Jackson, Esq.

CME

FALL 2016 – CONTENTS

ANALYSIS OF THE IMPACT OF “NEVER EVENTS” IN NEW JERSEY | By Jean Anderson Eloy, MD, Michael J. Sylvester & Soly Baredes, MD

PAYMENT REFORM COMES TO NEW JERSEY | By Joel C. Cantor, ScD, & Margaret Koller, MS

HARNESSING HEALTH INFORMATION TECHNOLOGY TO IMPROVE CARE | By Commissioner Cathleen D. Bennett

POINT OF VIEW: “AFFORDABLE HEALTHCARE” IS NOT AFFORDABLE | By Donald M. Chervenak, MD

HOW ONE ANESTHESIA GROUP HANDLES GROWTH AND FACILITY DIVERSIFICATION WHILE MAINTAINING PATIENT SAFETY AND SATISFACTION | By Jill Young, DO

THE RIVERSIDE MEDICAL GROUP: OFFERING A MODEL OF HEALTHCARE’S FUTURE | Interviewed by Janet S. Puro, MPH, MBA, & Lee Ann Trulio, RN

IMPROVING PATIENT SAFETY: PRACTICES TO PREVENT POLYPHARMACY IN THE ELDERLY | By Kirsten Tandberg, PA-C

MDADVISOR

ABDOMINAL PAIN AND IMAGING STUDIES IN THE EMERGENCY DEPARTMENT:

STANDARD OF CARE OR STANDARD OF ? By Joseph C. Hummel, DO, & John Zen Jackson, Esq.

MDADVISOR | FALL 2016

“Complaints related to abdominal pain represent almost 10 percent of all visits to the ED.” In the 2015 report Improving Diagnosis in Health Care, the Institute of Medicine (IOM) reviewed varying and, at times, conflicting definitions of “diagnostic error.” The IOM then formulated a two-part, patient-centered definition: Diagnostic error is “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.”1 The IOM formulation regarding whether a failure to diagnose or a misdiagnosis in itself presents a liability situation is unclear. New Jersey, like other states, recognizes that an incorrect diagnosis is not necessarily a matter of fault or negligence–the determining factor is whether standard medical practice allowed for some latitude in the diagnostic process and whether the steps taken to obtain a diagnosis were consistent with standard medical practice.2 In any event, although there is some discussion of “unavoidable” and “no-fault” categories of diagnostic error, the IOM noted that reviews of closed malpractice claims demonstrated that diagnostic errors were the leading type of paid malpractice claims and were responsible for the highest proportion of total payments.3 Moreover, more than half of the diagnoses associated with malpractice claims were for “commonly encountered diseases” such as appendicitis.4 The American College of Emergency Physicians (ACEP) has stated that “[t]he diagnosis of appendicitis can be challenging even in the most experienced of clinical hands.”5 Appendicitis is one among various possible

diagnoses for a patient presenting with abdominal pain. Such patients trigger medical liability concerns and the potential for the practice of defensive medicine, which the IOM identified as another factor to be addressed in connection with diagnostic errors. The IOM described defensive medicine as occurring “when doctors order tests, procedures, or visits, or avoid high-risk patients or procedures, primarily (but not necessarily solely) to reduce their exposure to 6 malpractice liability.” The IOM aptly noted that the practice of defensive medicine is a barrier to high-quality care because it can lead clinicians to order more diagnostic tests than necessary, thus creating the potential for patient harm. This potential exists from the risk of the diagnostic test itself, as well as from the resulting cascade of diagnostic and treatment decisions that stem from the test results. And, of course, defensive medicine has known impact on the overall cost of care. Patients presenting to the emergency department (ED) with abdominal pain are an illustrative matrix of the competing factors surrounding diagnostic error and defensive medicine and the difficulty of finding a solution to these problems.

10%

DIAGNOSING ABDOMINAL PAIN Complaints related to abdominal pain represent almost 10 percent of all visits to the ED.7 The most common discharge diagnosis is “Abdominal Pain NOS.” Although abdominal pain is frequently nonemergent and self-limited, it can also present medical and surgical emergencies. There is a wide and broad differential for a patient with

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abdominal pain as illustrated in Figure 1. History and physical examination remain the foundation for reaching an appropriate diagnosis and disposition. The classic textbook presentation of appendicitis begins with a vague crampy periumbilical pain, which gradually moves to the right lower quadrant. The pain is frequently associated with nausea and/or vomiting and anorexia and eventually rebound tenderness. A low-grade fever may or may not be present. Although this is the classic textbook presentation, unfortunately, many patients do not read the book. Nonetheless, as Sir Zachary Cope once said: “Appendicitis should never be lower than 8 second on any list of potential causes of abdominal pain.” Numerous factors can help focus the history and examination, such as the patient’s age, gender and

comorbidities. Other heuristics, such as the Alvarado score, have been advanced in an effort to assist with 9 clinical decision making. The Alvarado score has been used to improve diagnostic acumen. This score is fairly predictable in ruling out appendicitis using a cutoff score of five with a sensitivity of 99 percent but with a lower specificity; however, the score overpredicts the probability of appendicitis in women and is reportedly inconsistent 10 in children. The Alvarado score seems to be of more benefit in determining which patients need diagnostic imaging. Low scores, such as three, could be sent home after initial observation, scores five to seven require further testing and scores above seven should have surgical evaluation without further testing or delay.

... Figure 1

DIFFERENTIAL DIAGNOSIS CONSIDERATIONS FOR PATIENTS PRESENTING WITH LOCALIZED ABDOMINAL PAIN (List not inclusive of every possible diagnosis)

Right Upper Quadrant Cecal volvulus Cholecystitis Diverticulitis Gastritis Hepatitis Inflammatory bowel disease Pancreatitis Peptic ulcer disease Pneumonia Pulmonary embolism Retrocecal appendicitis

Midepigastrium Appendicitis Aortic aneurysm Cholecystitis Colitis Enteritis Gastritis Gastroenteritis Inflammatory bowel disease Pancreatitis Peptic ulcer

Left Upper Quadrant Colitis Diverticulitis Gastritis Hepatitis Inflammatory bowel disease Pancreatitis Peptic ulcer disease Pulmonary embolism Pyelonephritis Sigmoid volvulus Splenic enlargement

Right Lower Quadrant Appendicitis Aortic aneurysm Cholecystitis Diverticulitis Ectopic pregnancy Hernia Inflammatory bowel disease Nephrolithiasis Ovarian cyst Testicular torsion

Umbilical Appendicitis Aortic aneurysm Bowel obstruction Cystitis/UTI Diverticulitis Ectopic pregnancy Hernia Pyelonephritis

Left Lower Quadrant Appendicitis Aortic aneurysm Diverticulitis Ectopic pregnancy Hernia Inflammatory bowel disease Pyelonephritis Sigmoid volvulus Testicular torsion

MDADVISOR | FALL 2016

Many practitioners frequently use abdominal imaging, especially computerized tomography (CT), to narrow the differential and isolate the source of the patient’s abdominal pain. Although the technology is said to improve diagnostic accuracy for acute appendicitis, some commentators have perceived an overreliance on imaging studies in this regard and questioned the appropriateness of these modalities, especially in the absence of surgical evaluation.11 Surgeons are often the driving force in declining to do consults until the CT study is in hand. Traditionally, physicians were taught to be clinicians–listening to our patients, looking at them and touching them in order to make a clinical diagnosis and treat them appropriately. Unfortunately, today, physicians have become more like technicians, depending on laboratory and radiographic tests to make the diagnosis. This becomes more evident in the diagnosis of the acute abdomen. In the past, physicians would evaluate a patient, get a complete blood count (CBC) and then call the surgeon to see the patient for the acute abdomen. In today’s environment, the question usually asked by the surgeon in response to a call from the ED is: “What does the CT show?” What happened to coming and seeing the patient? The radiology perspective often is that the reason we do so many CTs is because we are afraid to make a mistake and miss the diagnosis, we’re worried about too many normal appendices, and last, we’re afraid of the lawyers. CHALLENGES TO THE USE OF CT IN THE EVALUATION AND MANAGEMENT OF ABDOMINAL PAIN The use of abdominal CT in connection with the evaluation of children and young adults has come under particularly critical evaluation because the long-term effects of ionizing radiation are being debated. The trend of increased use of CT scanning with its attendant radiation exposure, especially in young patients who are likely to have multiple studies over a lifetime, has presented

concerns for the long-term potential for radiation-induced malignancies and fatalities in the population.12 After abdominal CT scanning, the concern is for leukemia and myelodysplasia, as well as other soft tissue cancers.13 The radiation dose for one abdominal CT scan has been estimated to be equivalent to the exposure to 100 to 250 chest radiographs. However, awareness of an increased cancer risk from the use of CT in patients with abdominal and flank pain is not widespread.14 The 2010 ACEP Clinical Policy regarding suspected appendicitis provided only a Level C recommendation that given the concern about exposing children to ionizing radiation, ultrasound should be considered the initial imaging modality. When the diagnosis remains uncertain after ultrasound, ACEP-supported CT may be performed. Children ideally should have an ultrasound first, which “is better at positively identifying appendicitis than excluding it with a negative or equivocal result.”15 However, the use of ultrasound is operator and reviewer dependent and is best performed by an experienced technician or in a children’s facility. In cases in which there is an equivocal diagnosis, “CT is the most accurate study for evaluating patients.”16 The IOM also included overutilization of medical imaging techniques as a matter of special concern and noted that efforts were under way to reduce radiation exposure, especially in children.17 Today’s modern CT scanners have dose-reduction software built into them, driven by patient weight and body mass index, as well as reconstructive software that further decreases ionizing radiation. Tracking a patient’s radiation dose is an additional concern. Software is built into modern CT scanners to track dosing utilized by radiology technicians for quality purposes.18 Defending a failure to diagnose appendicitis with no order for a CT scan presents a number of difficulties in the courtroom. The decision to not obtain a CT study because of the risk of cumulative radiation exposure is intellectually valid as an exercise of medical judgment but lacks persuasive power in front of a jury. The doctrine of informed

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“potential risk of a radiation-induced cancer years in the future [VS.] the reality of a ruptured appendix” consent, which may be invoked in the face of a medical judgment defense based on a choice of alternative 19 approaches, has been held inapplicable to the choice of diagnostic tests.20 Because the benefits and risks of the radiation dose from CT are rarely a matter of discussion between the physician and the patient or family, the assertion of an exercise of judgment in this regard at the time of trial can seem like a fabricated justification. Unless such consideration is part of the contemporaneous charting, it is not likely to be believed. Moreover, there are the drawbacks of a defense based primarily on statistics and the remoteness of the cancer risk. Most patients and jurors (as well as many physicians) do not 21 have any real facility with statistics. Determining the legal culpability of a diagnostic decision based on the potential risk of a radiation-induced cancer years in the future weighed against the reality of a ruptured appendix from a diagnostic error is heavily influenced by hindsight. SUGGESTED SOLUTIONS FROM THE IOM In Improving Diagnosis in Medicine, the IOM presents a number of options for dealing with the problems of diagnostic error in the context of the legal system. They include communication and resolution programs, administrative health courts and safe harbors for adherence to evidence-based clinical practice guidelines. We will comment only on the use of clinical practice guidelines (CPGs). They have been discussed by academic legal writers for quite some time.22 As summarized by the IOM: Safe harbors for following evidence-based clinical guidelines have the potential to raise the quality of health care by creating an incentive–liability protection–for clinicians to follow evidence-based clinical practice guidelines. Safe harbors can create an affirmative defense for health care professionals who adhered to accepted and applicable clinical practice guidelines. Input to the committee suggested that safe harbors, unlike other approaches to improving the medical liability environment, offer direct opportunities to improve diagnosis. ...While other approaches to improving medical liability focus on improving learning through improved disclosure, safe harbors focus on aligning clinical care with best practices.23 While these comments present protection of physicians and advancement of quality care and patient safety, there are a number of barriers at the substantive and procedural

MDADVISOR | FALL 2016

implementation levels. The IOM acknowledged the challenge as far as the inadequacy of the evidence base supporting CPGs and the difficulty in determining the applicability of the guidelines to individual patients with varying circumstances. The IOM referred to the work of the Agency for Healthcare Quality and Research (AHQR) in funding pilot programs. The mission of AHQR is to produce evidence to make healthcare safer, of higher quality and more accessible, equitable and affordable. AHQR works within the U.S. Department of Health and Human Services and other partners to make sure that the evidence is understood and used. AHQR has indicated a number of sources available online to help physicians better understand CPGs for evaluating and managing suspected appendicitis. One such document is the ACEP Clinical Policy from 24 2010, and another is from the American College of Radiology, offering criteria for appropriate imaging studies in patients with right lower quadrant pain and/or suspected appendicitis.25 Noting that studies typically focus on test accuracy and not on the impact of a test on patient outcomes, the IOM commented that the available scientific evidence made it difficult to provide guidance to clinicians. Diagnostic testing guidelines frequently formed a minority of the recommendations in CPGs and often had lower levels of evidence supporting them than treatmentrelated CPGs. The IOM concluded: “The adoption of available clinical practice guideline recommendations into practice remains suboptimal due to concerns about the trustworthiness of the guidelines as well as the existence of varying and conflicting guidelines.”26 Moreover, clinicians have been resistant to the use of practice guidelines in other settings, such as in insurance reimbursement and managed care, as well as when they conflict with hospital requirements.27 In addition, use of safe harbors based on adherence to CPGs requires either judicial or legislative endorsement of the use of such guidelines in malpractice litigation. However, a recent obstacle to the use of CPGs in a legal context can be found in the policy reflected in the 2015 amendment of the Affordable Care Act that repealed the sustainable growth rate formula used to calculate Medicare payments. The Medicare Access and CHIP Reauthorization Act of 2015 contained a provision that stated: “The development, recognition, or implementation

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“the surgeon should not fear having too many negative appendices”

of any guideline or other standard under any Federal health care provision shall not be construed to establish the standard of care or duty of care owed by a health care provider to a patient in any medical malpractice or medical product liability 28 action or claim.” This law defines “Federal health care provision” to mean the Affordable Care Act or any provision of Medicare or Medicaid. Although the impetus of the legislation was to prevent plaintiffs from taking advantage of CPGs to make malpractice cases, it also undermines the concept of a safe harbor affirmative defense based on compliance with an applicable CPG. If the CPG cannot be used to establish a standard of care alleged to have been breached, it is difficult to articulate how compliance with a CPG presumably demonstrates adherence to a standard of care that cannot be established through use of the CPG. The 2015 federal legislation does not preempt and, therefore, preclude any state or common law governing medical professional or medical product liability actions. Any impact in New Jersey is uncertain as there is limited discussion in the case law regarding use of CPGs in the formulation and presentation of expert opinion at trial. One of the factors that will need to be addressed in this setting is the use of CPGs to identify the applicable standard of care and a physician’s deviation from that standard to establish the basic elements of the malpractice claim. The utilization of CPGs as standard of care evidence or a safe harbor involves a determination of which CPG applies, when and under what circumstances the CPG applies and who makes that determination. In most contested cases, this will be a dispute between expert witnesses that may be left to the jury to decide but with seemingly more objective evidence than the naked opinion of the testifying expert witness. However, that seems a minor change from the present litigation system. CONCLUSIONS There is broad-based agreement that healthcare costs too much in the United States. At least in part, the problem results from physicians’ fears of lawsuits for failure to do everything possible for patients, which leads to overutilization of resources by routinely ordering advanced imaging or other tests. Since being introduced in the 1970s, the use of

MDADVISOR | FALL 2016

advanced imaging has increased exponentially as the technology has allowed for better visualization of the anatomy and identification of pathophysiological processes. However, as the use of imaging has increased, the costs of imaging have also increased. It is time to acknowledge that reliable, evidence-based clinical guidelines, identifying low-value utilization and providing “authoritative” standards of good care before an incident giving rise to litigation can contribute to cost containment, quality of care and patient safety. The solution to defensive medicine need not and should not result in immunizing physicians and has nothing to do with caps limiting damage awards. Instead, legislation affirming that adherence to reliable guidelines constitutes a “safe harbor” against liability would remove the motivation for defensiveness. The feasibility of this concept, however, remains challenging because of the difficulties of creating enough reliable guidelines and keeping them up to date. In addition, when the "safe harbor" is adequately defined it presents the potential of being not only a shield but a sword giving rise to liability because of the failure to adhere to the guidelines. Despite the challenges, as in the example of appendicitis diagnosis, patients can be evaluated and, if felt to be of low potential for appendicitis, discharged to home and reevaluated later. Those felt to be clinically positive for appendicitis should be evaluated by a surgeon, without the costs or effects of radiation, and the surgeon should not fear having too many negative appendices or being sued for it. It should not be some fantasy that physicians can become clinicians again–that they can utilize diagnostic modalities when needed to help with a difficult diagnosis but without the fear of being sued for honest errors when appropriate standards of care have been met. Joseph C. Hummel, DO, is Medical Director of Emergency Medical Services at Virtua Health. John Zen Jackson, Esq., is a partner at McElroy, Deutsch, Mulvaney & Carpenter, LLP and is certified by the Supreme Court of New Jersey as a civil trial attorney. 1

National Academies of Sciences, Engineering, and Medicine. (2015). Improving diagnosis in health care (p. 85). Washington, DC: The National Academies Press (emphasis in original).

Schueler v. Strelinger, 43 N.J. 330, 344-45 (1964); Aiello v. Muhlenberg Regional Medical Center, 159 N.J. 618, 628629 (1999); Model Civil Jury Charge 5.50G.

National Academies of Sciences, Engineering, and Medicine. (2015). 107–108.

National Academies of Sciences, Engineering, and Medicine. (2015). 108. Howell, J. M., Eddy, O. L., Lukens, T. W., Thiessen, M. E. W., Weingart, S. D., & Decker, W. W. (2010). Clinical policy: Critical issues in the evaluation and management of emergency department patients with suspected appendicitis. Annals of Emergency Medicine, 55(1), 72. [Available at http://www.annemergmed.com/article/S01960644(09)01644-8/fulltext]

R., Quazi, R. R., Voci, S., Veazie, P., & Block, R. (2012). Physicians’ and midlevel providers’ awareness of lifetime radiation–attributable cancer risk associated with commonly performed CT studies: Relationship to practice behavior. American Journal of Roentgenology, 199(6), 1328–1336. 15

Howell, J. M., et al. (2010). 78.

Rosen, M. P., Ding, A., Blake, M. A., Baker, M. E., Cash, B. D., Fidler, J. L., … Coley, B. D. (2011). ACR Appropriateness Criteria® right lower quadrant pain--suspected appendicitis. Journal of the American College of Radiology, 8(11), 750. [Available at http://doseoptimization.jacr.org/ Content/PDF/Rosen-ACR-Ped.pdf ]

National Academies of Sciences, Engineering, and Medicine. (2015). 93.

National Academies of Sciences, Engineering, and Medicine. (2015). 315.

Smith-Bindman, R. (2010). Is computed tomography safe? New England Journal of Medicine, 363, 1–4.

Gray-Eurom, K., & Deitte, L. (2007). Imaging in the adult patient with nontraumatic abdominal pain. Emergency Medicine Practice, 9(2), 1–31.

See generally, Lomurro, J. H., Riveles, G. L., & Brown, A. S. (2017). New Jersey medical malpractice law. (7th ed.; p. 30). Newark, NJ: New Jersey Law Journal.

See generally, Silen, W. (2010). Cope’s early diagnosis of the acute abdomen (22nd ed.). New York: Oxford University Press.

Eagle v. Newman, 325 N.J. Super. 467 (App. Div. 1999); Farina v. Kraus, 333 N.J. Super. 163 (App. Div. 2000); Linquito v. Siegel, 370 N.J. Super. (App. Div. 2004).

See, e.g., Alvarado, A. (1986). A practical score for the early diagnosis of acute appendicitis. Annals of Emergency Medicine, 15(5), 587–564.

Gigerenzer, G., Gaissmaier, W., Kurz-Milcke, E., Schwartz, L. M., & Woloshin, S. (2007). Helping doctors and patients make sense of health statistics. Psychological Science in the Public Interest, 8(2), 53–96.

See, e.g., Brennan, T. A. (1991). Practice guidelines and malpractice litigation: Collision or cohesion? Journal of Health Politics, Policy & Law, 16, 67–85; Havighurst, C. G. (1991). Practice guidelines as legal standards governing physician liability. Law & Contemporary Problems, 54(2), 87–117.

National Academies of Sciences, Engineering, and Medicine. (2015). 321.

Howell, J. M., et al. (2010). 71–116.

Smith, M. P., Katz, D. S., Lalani, T., Carucci, L. R., Cash, B. D., Kim, D. H., . . . Rosen, M. P. (2015). ACR Appropriateness Criteria® right lower quadrant pain--suspected appendicitis. Ultrasound Quarterly, 31(2), 85–91.

National Academies of Sciences, Engineering, and Medicine. (2015). 68.

National Academies of Sciences, Engineering, and Medicine. (2015). 322.

PL 114-110, Section 106(d) codified as 42 U.S.C. 18122.

Ohle, R., O’Reilly, F., O’Brien, K. K., Fahey, T., & Dimitrov, B. D. (2011). The Alvarado score for predicting acute appendicitis: A systematic review. BMC Medicine, 9, 139. [Available at http://bmcmedicine.biomedcentral.com/articles/10.1186/1741 -7015-9-139] See, e.g., Lee, S. L., Walsh, A. J., & Ho, H. S. (2001). Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis. Archives of Surgery, 136, 556–562. Brenner, D. J., & Hall, E. J. (2007). Computed tomography: An increasing source of radiation exposure. New England Journal of Medicine, 357, 2277–2284. Mathews, J. D., Forsythe, A. V., Brady, Z., Butler, M. W., Goergen, S. K., Byrnes, G. B., … Darby, S. C. (2013). Cancer risk in 680000 people exposed to computed tomography scans in childhood or adolescence: Data linkage study of 11 million Australians. BMJ, 346, 12360. [Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC3660619] Lee, C. I., Haims, A. H., Monico, E. P., Brink, J. A., & Forman, H. P. (2004). Diagnostic CT scans: Assessment of patient, physician, and radiologist awareness of radiation dose and possible risks. Radiology, 231, 393–398; Puri, S., Hu,

MDADVISOR

In order to obtain AMA PRA Category 1 credit™, participants are required to: 1) Review the CME information along with the learning objectives at the beginning of the CME article. Determine if these objectives match your individual learning needs. If so, read the article carefully. 2) The post-test questions have been designed to provide a useful link between the CME article and your everyday practice. Read each question, choose the correct answer and record your answers on the registration form. 3) Complete the evaluation portion of the Registration and Evaluation Form. Forms and tests cannot be processed if the evaluation section is incomplete. 4) Send the Registration and Evaluation Form to: MDAdvisor CME Dept c/o MDAdvantage Insurance Company 100 Franklin Corner Rd Lawrenceville, NJ 08648 Or Fax to: 978-367-8545 5) Retain a copy of your test answers. Your answer sheet will be graded, and if a passing score of 70% or more is achieved, a CME certificate awarding AMA PRA Category 1 Credit™ and the test answer key will be mailed to you within 4 weeks. Individuals who fail to attain a passing score will be notified and offered the opportunity to reread the article and take the test again. 6) Mail the Registration and Evaluation Form on or before the deadline, which is November 1, 2017. Forms received after that date will not be processed. Authors: Jean Anderson Eloy, MD, Michael J. Sylvester and Soly Baredes, MD, of Rutgers New Jersey Medical School, Newark, NJ Joint Providership Accreditation: This activity has been planned and implemented in accordance with the Accreditation Requirements and Policies of the Medical Society of The State of New York (MSSNY) through the joint providership of Kern Augustine, P.C. and MDAdvantage Insurance Company. KA is accredited by The Medical Society of the State of New York (MSSNY) to provide continuing medical education for physicians. Kern Augustine, P.C. designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Disclosure: Kern Augustine, P.C. relies upon planners, moderators, reviewers, authors and faculty participants in its CME activities to provide educational information that is objective and free of bias. In this spirit and in accordance with MSSNY and ACCME guidelines, all planners, moderators, reviewers, authors and faculty participants must disclose relevant financial relationships with commercial interests whose products, devices or services may be discussed in the CME content or may be perceived as a real or apparent conflict of interest. Any discussion of investigational or unlabeled use of a product will be identified.

Analysis of the Impact of

in New Jersey

The planners, moderators, reviewers, authors and faculty participants do not have any financial arrangements or affiliations with any commercial entities whose products, research or services may be discussed in these materials. No commercial funding has been accepted for the activity.

MDADVISOR | FALL 2016

CME

The term “never event” was introduced in 2001 by the National Quality Forum to refer to adverse events that are clinically devastating and largely preventable, such as 1 wrong-site surgery. In 2008, the Center for Medicare and Medicaid Services (CMS) implemented a no pay for errors list.1 This list was composed of hospital-acquired conditions (HACs) that “(1) are high cost, or high in volume, or both, (2) result in cases being assigned to a diagnosis-related group that has higher payment when present as a secondary diagnosis, and (3) could reasonably have been prevented 2 through the use of evidence-based guidelines.” The HACs that comprise this list, many associated with specific procedures, are deemed harmful and preventable and thus do not qualify for financial compensation. The full list currently includes3: Foreign objects retained after surgery Air embolism Blood incompatibility Pressure ulcer stages III and IV Falls and trauma resulting in fracture, dislocation, intracranial injury, crushing injury, burn or other injuries Catheter-associated urinary tract infection (UTI) Vascular catheter-associated infection Manifestations of poor glycemic control Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG) Surgical site infection following certain orthopedic procedures Surgical site infection following bariatric surgery for obesity Surgical site infection following cardiac implantable electronic device (CIED) Deep vein thrombosis and pulmonary embolism following certain orthopedic procedures Iatrogenic pneumothorax with venous catheterization

LEARNING OBJECTIVES:

At the conclusion of this activity, participants will be able to: Discuss the impact of “never 1 events” on patients/families and hospital systems.

List the risk factors associated with increased incidence of “never events.”

Identify possible interventions to help decrease the frequency of “never events.”

By Jean Anderson Eloy, MD, Michael J. Sylvester & Soly Baredes, MD

Starting in 2009, Medicare began withholding additional payments for hospitalizations associated with these events.4 Fighting back, many hospital leaders have argued that this list represents adverse events that are not wholly

CME

MDADVISOR

Table 1. 2008–2011 NIS: NJ Data Number of Cases of “Never Event”

Total Number of Cases

Percent

926,880

0.00

Air Embolism

≤10*

926,880

0.00

Blood Incompatibility

≤10*

926,880

0.00

Catheter-associated UTI

1,280

926,880

0.14

Vascular Catheter-associated Infection

1,997

926,880

0.22

Manifestations of Poor Glycemic Control

5,142

926,880

0.55

Pressure Ulcer Stages III and IV

6,067

926,880

0.65

Iatrogenic Pneumothorax with Venous Catheterization

293

48,405^

0.61

Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG)

≤10*

4,026^

0.02

5,685^

0.79

Surgical Site Infection Following Bariatric Surgery for Obesity

≤10*

2,805^

0.18

Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED)

189

8,973^

2.11

Deep Vein Thrombosis and Pulmonary Embolism Following Certain Orthopedic Procedures

276

18,565^

1.49

14,963

926,880

1.61

Hospital-acquired Condition Foreign Object Retained After Surgery

Surgical Site Infection Following Certain Orthopedic Procedures

Any “Never Event” (Of All Hospitalizations)

*Cells with values ≤10 are not reported per the NIS data use agreement.

^Total count reflects the number of cases of specified procedure. Adapted from Healthcare Cost and Utilization Project, June 2016. Copyright 2016 by Agency for Healthcare Research and Quality, Rockville, MD.

preventable.5 Additionally, some have suggested potential unwanted consequences, such as a disincentive for hospitals to treat the sickest patients who are probably more likely to experience these, not always preventable, complications.6 THE BURDEN OF “NEVER EVENTS” Mehtsun and colleagues utilized data from the National Practitioner Data Bank to study the impact of “never events” from 1990 to 2010.7 Over this 20-year period, they

MDADVISOR | FALL 2016

identified 9,744 paid malpractice settlements and judgments for surgical “never events.” These “never events” resulted in a total of $1.3 billion in medical malpractice payments. In addition to the financial burden, “never events” were also associated with a 6.6 percent rate of mortality, a 32.9 percent permanent injury rate and a 59.2 percent temporary injury rate.7 Regardless of the opinion one has about the CMS list of adverse events that are not reimbursable, it is difficult

CME

to deny the burden that these events place on the healthcare system and on the individual patients and families who experience them. Thus, analysis of these events and efforts aimed at minimizing them is warranted. “NEVER EVENTS” IN NEW JERSEY In 2004, New Jersey became one of the first three states to enact legislation requiring hospitals to report 8 “never events.” A recent survey by The Leapfrog Group (a nonprofit aimed at improving healthcare safety) suggested that New Jersey hospitals are among the leaders in having adequate “never event” policies. More than 90 percent of hospitals in the state had policies for “never events” that met The Leapfrog Group’s standards.9 Still, “never events” occur in New Jersey, and the morbidity and mortality they cause in patients is undeniable. In 2012 alone, the New Jersey Department of Health reported that there were 238 total events of iatrogenic pneumothorax statewide. NATIONWIDE INPATIENT SAMPLE ANALYSIS OF IMPACT OF “NEVER EVENTS” IN NEW JERSEY In the present analysis, the 2008–2011 Nationwide Inpatient Sample (NIS) was utilized to explore the impact of “never events” in the state of New Jersey. The NIS is the largest all-payer inpatient database in the United States and is part of the Healthcare Cost and Utilization Project (HCUP), sponsored by the Agency for Healthcare Research and Quality. The database represents a sample of approximately 20 percent of all U.S. discharges, with data on more than 8 million discharges per year.10 As illustrated in Table 1, in total we identified 926,880 inpatient hospitalizations in the 2008–2011 NIS. Of these, 14,963 (1.61 percent) cases were associated with a “never event.” To derive variables for “never events,” we used CMS 2013–2015 definitions, which use International Classification of Diseases, 9th Revision codes.3 Trauma/falls are unable to be identified because the NIS does not specify whether a specific code is a complication of the hospitalization or whether the patient presented with the diagnosis. On average, “never events” were associated with a more than doubling of the total length of hospital stay (10.0 days versus 4.7 days; p < 0.001) and hospital charges ($102,137 versus $46,822; p < 0.001). Regarding

payment method, “never event” patients were more likely to pay with Medicare and less likely to pay with private insurance. Demographic differences between patients in New Jersey who experienced “never events” and those who did not are striking. Regarding race, blacks who were hospitalized were more likely to experience a “never event” compared to other races. Specifically, blacks made up a higher proportion of patients experiencing “never events.” In the group of patients experiencing a “never event” in this analysis, 26.7 percent were black, while in the group of patients not experiencing a “never event," only 15.9 percent were black (p < 0.001). All other races (white, Hispanic, Asian/Pacific Islander and other) showed lower proportions. On average, patients experiencing “never events” were older (61 years versus 51 years; p < 0.001) and presented with more comorbidities, supporting the notion that older and sicker patients are more likely to experience “never events.” To analyze the impact of comorbidities on the frequency of “never events,” a multivariate logistic regression analysis was performed. Correcting for the impact of age, gender and race, the two comorbidities that were associated with the highest odds of “never events” were paralysis (4.673 times greater odds; p < 0.001) and fluid and electrolyte disorders (3.038 times greater odds; p < 0.001). In-hospital mortality was greater among patients experiencing a “never event” (7.2 percent versus 2.0 percent; p < 0.001). RECENT LITERATURE ON POSSIBLE INTERVENTIONS TO DECREASE FREQUENCY OF “NEVER EVENTS” Attenello and colleagues analyzed the 2002 through 2010 NIS data and found that weekend admission was associated 12 with an increased likelihood of hospital-acquired conditions. They suggested that education about this effect, proper weekend staffing and implementation of specific protocols may decrease this association. Wen and colleagues analyzed the 2008 through 2011 NIS data and found that hospital admissions in July were associated with an increase in hospital-acquired conditions.13 They suggested that hospitals adopt guidelines dedicated to decreasing the frequency of hospital-acquired conditions, specifically during this high-risk month.

CME

MDADVISOR

CONCLUSION “Never events” in New Jersey are associated with increased hospital charges, morbidity and mortality, making it imperative to address this healthcare issue. Black race, older age and increased comorbidities all appear to be particularly associated with higher rates of “never events.” The Leapfrog Group has developed a policy that involves five key best practice steps to be taken by a hospital should a “never event” occur. These standards include apologizing to the patient/family, reporting the event to an outside agency within 10 days of becoming aware of the event, performing a root-cause analysis, waiving costs directly related to the “never event” and making a copy of the policy available to the parties involved 9 upon request. Efforts such as these taken to minimize the frequency of “never events,” are prudent and ethical and should be a focus of healthcare providers and hospital administrators. Jean Anderson Eloy, MD, FACS, is Professor and Vice Chair, Department of Otolaryngology–Head and Neck Surgery; Director, Rhinology and Sinus Surgery; Director, Otolaryngology Research; Co-Director, Endoscopic Skull Base Surgery Program; Professor, Department of Neurological Surgery; and Professor, Department of Ophthalmology and Visual Science, Neurological Institute of New Jersey, at Rutgers New Jersey Medical School in Newark, New Jersey. Michael J. Sylvester is a fourth-year medical student at Rutgers New Jersey Medical School. Soly Baredes, MD, FACS, is Professor and Chair, Department of Otolaryngology – Head and Neck Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School. 1

Austin, J. M., & Pronovost, P. J. (2015). “Never events” and the quest to reduce preventable harm. Joint Commission Journal on Quality and Patient Safety, 41, 279–288.

Centers for Medicare and Medicaid Services. (n.d.). Hospitalacquired conditions: Statute/regulations program instructions. www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalAcqCond/Statute_Regulations_Program_Ins tructions.html.

www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Downloads/FY_2013_Final_HACsCodeList.pdf. 4

Wachter, R. M., Foster, N. E., & Dudley, R. A. (2008). Medicare’s decision to withhold payment for hospital errors: The devil is in the details. Joint Commission Journal on Quality and Patient Safety, 34, 116–123.

Milstein, A. (2009). Ending extra payment for “never events”: Stronger incentives for patients’ safety. New England Journal of Medicine, 360, 2388–2390.

Pronovost, P. J., Goeschel, C. A., & Wachter, R. M. (2008). The wisdom and justice of not paying for “preventable complications.” Journal of the American Medical Association, 299, 2197–2199.

Mehtsun, W. T., Ibrahim, A. M., Diener-West, M., Pronovost, P. J., & Makary, M. A. (2013). Surgical never events in the United States. Surgery, 153, 465–472.

Kizer, K. W., & Stegun, M. B. (2005). Serious reportable adverse events in health care. In K. Henriksen, J. B. Battles, E. S. Marks, & D. I. Lewin (Eds.), Advances in patient safety: From research to implementation (Vol. 4). Rockville, MD: Agency for Healthcare Research and Quality.

The Leapfrog Group. (2016). Never events: Data by hospital on nationally standardized metrics. www.leapfroggroup.org/sites/default/files/Files/Castlight-Leapfrog_Never _Events_Final.pdf.

Healthcare Cost and Utilization Project. (2016, February). Rockville, MD: Agency for Healthcare Research and Quality. [Available at www.hcup-us.ahrq.gov/nisoverview.jsp]

Healthcare Cost and Utilization Project. (2016, February). Nationwide data use agreement. www.hcupus.ahrq.gov/team/NationwideDUA.jsp.

Attenello, F. J., Wen, T., Cen, S. Y., Ng, A., Kim-Tenser, M., Sanossian, N., . . . Mack, W. J. (2015). Incidence of “never events” among weekend admissions versus weekday admissions to US hospitals: National analysis. BMJ, 350, h1460.

Wen, T., Attenello, F. J., Wu, B., Ng, A., Cen, S. Y., & Mack, W. J. (2015). The July effect: An analysis of never events in the nationwide inpatient sample. Journal of Hospital Medicine, 10, 432–438.

Center for Medicare and Medicaid Services. (n.d.). FY 2013, FY 2014, FY 2015 final HAC List.

MDADVISOR | FALL 2016

CME

Analysis of the Impact of “NEVER EVENTS” in New Jersey CME EXAMINATION (Deadline November 1, 2017)

✁

The term “never event” was introduced by CMS in 2001. a) True b) False

Which of these is not on the no pay for errors list? a) Pressure ulcer stage 1 b) Air embolism c) Retained foreign object d) Catheter-associated urinary tract infection e) All of the above are on the list

Patients who experience “never events” tend to be younger. a) True b) False

Weekday admissions are associated with an increased likelihood of hospital-acquired conditions. a) True b) False

On average, “never events” have been associated with a more than doubling of total length of stay and hospital charges. a) True b) False

Which of the following two comorbidities have been found to be associated with the highest odds of “never events”? a) Paralysis and diabetes b) Paralysis and fluid/electrolyte disorders c) Fluid/electrolyte disorders and diabetes d) Paralysis and chronic kidney disease e) None of the above

CME

The month of September has been identified as a high-risk month for hospital-acquired conditions. a) True b) False

Patients who experience “never events” are more likely to pay with Medicare than with private insurance. a) True b) False

Which of the following is not a best practice recommended by The Leapfrog Group, should a “never event” occur? a) Provide a copy of the organization’s “never event” policy to involved parties upon request b) Apologize to the patient and/or the patient’s family c) Waive the hospital costs directly related to the “never event” d) Provide the patient a copy of the root-cause analysis e) Report the event to an outside agency

10 Hispanics who were hospitalized have been shown to be more likely to experience a “never event” compared to other races. a) True b) False

MDADVISOR

Analysis of the Impact of “NEVER EVENTS” in New Jersey REGISTRATION AND EVALUATION FORM

(Must be completed in order for your CME Quiz to be scored – Deadline for Response: November 1, 2017)

REGISTRATION FORM First Name

Middle Initial

Last Name

City

State

ZIP

Phone

E-mail Address

Specialty

Degree

Address

ANSWER SHEET Circle the correct answer. 1) T F

2) A B C D E

3) T F

4) T F

5) T F

6) A B C D E

7) T F

8) T F

9) A B C D E

10) T F

Number of hours spent on this activity _______ (reading article and completing quiz) I attest that I have read the article “Analysis of the Impact of ‘Never Events’ in New Jersey” and am claiming 1.0 AMA PRA Category 1 Credit.™ Signature EVALUATION 1. 2. 3. 4.

The The The The

Date Completed by

content of the article was: authors’ writing style was: graphics included in the article were: stated objectives of this program were:

❑

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Non-Physician

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Was this article free of commercial bias? Yes _________ No _________ If not, why not __________________________________________________________________________ Please share your name and contact information so that we may investigate further. Participant Name __________________________________ Telephone/E-mail: _____________________ 5. Will the knowledge learned today affect your practice? Very Much____ Moderately____ Minimally____ None____

7. Did this CME activity change what you know about: • The impact of “never events” on patients/families and hospital systems. Yes ❑ No ❑ • The risk factors associated with increased incidence of “never events.” Yes ❑ No ❑ • The possible interventions that can be used to help decrease the frequency of “never events.”

✁

6. Based on your participation in the CME activity, will you change the way you practice medicine? __Yes Describe ___________________________________________________________________________________ __No Why not ___________________________________________________________________________________ __N/A Were you the wrong audience for this activity? _________________________________________________

Yes ❑ No ❑

8. Based on your participation today, what barriers to the implementation of the strategies or skills taught today have you identified?

Suggested topics for future programs:_________________________________________________________________________________

MDADVISOR | FALL 2016

CME

PAYMENT REFORM COMES TO NEW JERSEY

By Joel C. Cantor, ScD, & Margaret Koller, MS One of the ambitious goals of the Patient Protection and Affordable Care Act (ACA) is to improve the quality and efficiency of healthcare.1 President Obama’s signature health reform legislation created the Innovation Center within the Centers for Medicare and Medicaid Services (CMS) to develop and test strategies to improve quality and reduce healthcare costs. The health reform law established a series of new initiatives, operated by CMS, including the Medicare Shared Savings Program, bundled payments strategies and the Hospital Readmission Reduction Program. Taken together, these initiatives, and other efforts, constitute the core of the movement toward value-based purchasing (VBP), in which payments are tied to quality performance and outcomes rather than simply to the volume of care delivered. Since enactment of the ACA, the federal government has sought to accelerate the shift to VBP. Writing in the New England Journal of Medicine, Sylvia Burwell, Secretary of the U.S. Department of Health and Human Services, announced ambitious new goals for Medicare.2 Within a year, 85 percent of Medicare fee-for-service (FFS) payments will be linked to quality, including 30 percent of payments shifted from FFS to alternative, value-based payment approaches. By 2018, half of all Medicare payments would be in alternative models, including accountable care organizations (ACOs) and bundled payment arrangements. By replacing the failed “sustainable growth rate” in the Medicare physician payment system, Congress endorsed the leap toward VBP in the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.3 MACRA will shift Medicare FFS physician payments to alternative

OVER QUANTITY payment models (ACOs, bundled payments and the like) or to a new merit-based incentive payment system (MIPS). The MIPS will implement strong payment incentives based on attainment of a series of benchmarks related to quality of care, resource use, practice improvement and meaningful use of electronic health records. In short, traditional Medicare FFS is going to be a thing of the past. While the federal government has used the Medicare program, the country’s single largest healthcare payer, as the driver of payment reform, it has also advanced its reform goals through Medicaid and the private sector. Numerous pilot programs, operated through the CMS Innovation Center, involve VBP in Medicaid and private payers. CMS has also used other policy levers, such as Medicaid Section 1115 demonstration waivers, to advance VBP goals. Prominent among them is the Delivery System Reform Incentive Payment (DSRIP) programs, which tie pools of Medicaid hospital payments to population health improvement goals. It seems reasonable to assume that linking payment to outcomes and cost-effectiveness will lead to higher-value healthcare than traditional FFS, which rewards simply doing more, no matter the outcome of the care delivered. But evidence of the impact of VBP strategies is only now beginning to emerge. Many strategies, including the Medicare Shared Savings Program, led to the establishment of accountable care organizations across the country, well ahead of evidence about their impact. As we wait for stronger evidence, VBP strategies are not without their

MDADVISOR

ACRONYM DIRECTORY ACA

Patient Protection and Affordable Care Act

CMS

Centers for Medicare and Medicaid Services

CPCi

CMS Innovation Center’s Comprehensive Primary Care Initiative

DSRIP

Delivery System Reform Incentive Payment

emergency department

FFS

fee-for-service

MACRA

Medicare Access and CHIP Reauthorization Act

MIPS

Merit-Based Incentive Payment System

OB/GYN Obstetrics and Gynecology PCMH

patient-centered medical home

PCPs

primary care physicians

VBP

value-based purchasing

critics. Some have argued that redesigning the FFS payment system–for example, by reducing fees for “overvalued” interventions and increasing fees for “undervalued” cognitively intensive care–can be a more effective way of containing costs and improving value than using complex systems of shared savings and bundled payments.4,5 However, VBP has considerable momentum and is likely here to stay. In fact, VBP strategies are being widely adopted among private healthcare payers as well.6 VBP IN NEW JERSEY Alternative payment systems have a large footprint in New Jersey. Twenty-nine Medicare Shared Savings Program ACOs are authorized to operate in the state, including 13 operating exclusively here,7 and New Jersey providers have participated in numerous other VBP and related models.8 The CMS Innovation Center’s Comprehensive Primary Care Initiative (CPCi, now sometimes called “CPC Classic”) is a good example of VBP in New Jersey. Since 2012, New Jersey has been one of seven regions engaged in CPCi, a multipayer VBP model focused on patient-centered, primary care transformation, using population-based care management fees with shared savings opportunities.9 At the start of the project, more than 70 practices engaged with four payers and a host of stakeholders to advance the goals of patient-centered care, using data to inform

MDADVISOR | FALL 2016

transformation efforts. Results to date have been modest but promising; recent data shared by the federal government showed that from July 2013 to December 2015, New Jersey had the lowest rate of emergency department (ED) visits among the seven regions, with an eight percent 10 decrease in total ED use. New Jersey was also recently named as one of the 14 regions participating in “CPC+,” the successor initiative that expands the opportunity for practice participation by designing two provider tracks with incremental care delivery requirements. CPC is by no means the only VBP initiative involving private insurers and provider organizations. As elsewhere, the private sector in New Jersey is embracing VBP. The state’s largest private payer, Horizon Blue Cross Blue Shield, for example, sponsors patient-centered medical home ACOs and episode-of-care models (akin to bundled 11 payments). It is also noteworthy that the Department of Family Medicine and Community Health at New Jersey’s Robert Wood Johnson Medical School is one of the nation’s leading research groups studying and refining patient-centered models of care.12 Although the full extent of VBP penetration in physician practice in the state is hard to quantify, a recent survey of primary care practices conducted by our group, the Rutgers Center for State Health Policy, sheds some important light.13 Table 1 shows that about two in five primary care physicians (PCPs) in the state are affiliated with one or more ACO, including the Medicare Shared Savings Program and commercial contracts, or both. More than one in 10 PCPs have the highest level of patient-centered medical home (PCMH) recognition with another 16 percent certified at lower levels. PCMH status is often a prerequisite for engagement in VBP incentive programs and involves adoption of high-functioning electronic health records and active engagement in strategies to advance care management of patients with complex, chronic conditions. Still, despite fairly high levels of ACO and PCMH penetration, only about one in four PCPs reports receiving more than five percent of practice revenue in performance-based payments. WHAT THE FUTURE HOLDS The need to address high healthcare costs is clear. As a share of gross domestic product, the United States spends nearly 50 percent more than the next developed nation (France); yet by most metrics our outcomes are no

TABLE 1. NEW JERSEY PRIMARY CARE PHYSICIAN ENGAGEMENT IN ALTERNATIVE PAYMENT MODELS, 2015 SPECIALTY N

Full sample

Family medicine

Internal medicine

OB/GYN

Pediatrics

Medicare and Commercial

13.5%

19.0%

16.8%

12.5%

3.9%

Medicare only

117

16.8%

17.9%

24.8%

19.3%

2.8%

Commercial only

10.6%

5.4%

7.3%

15.9%

17.9%

Neither

412

59.1%

57.7%

51.1%

52.3%

75.4%

ACO PARTICIPATION

PATIENT CENTERED MEDICAL HOME RECOGNITION LEVEL Level 3

13.0%

15.4%

12.2%

0.0%

17.3%

Level 1 or 2

16.0%

24.4%

13.6%

12.1%

12.7%

None

421

71.0%

60.3%

74.2%

87.9%

70.0%

SHARE OF REVENUE FROM PERFORMANCE-BASED PAYMENTS 5% or more

148

21.2%

26.2%

25.1%

6.8%

17.9%

Under 5%

184

26.4%

19.6%

31.6%

26.1%

25.1%

None or Unknown

366

52.4%

54.2%

43.3%

67.0%

57.0%

Note: Data based on author analysis of “New Jersey Primary Care Practice Survey: Methodology report and data memo,” by Abt SRBI, Inc. Health Research Division, 2015.

better (and by some measures, worse).14 And New Jersey has challenges even greater than the national average, ranking 36th in “avoidable hospital use and cost of care” in the most recent Commonwealth Fund State Health System scorecard.15 The ACA has greatly increased health insurance coverage in New Jersey, with more than 450,000 new, low-income Medicaid beneficiaries and about 150,000 people gaining private insurance (many with government subsidies). The large number of newly enfranchised will only increase the imperative for higher-value care. Large numbers of new Medicaid beneficiaries were likely uninsured for years, and many have poorly controlled chronic illnesses, behavioral health conditions and challenging social circumstances. Among those buying private insurance through the ACA marketplace, affordability is a huge challenge, even with federal subsidies. Consequently, health plans will be pressing providers to reduce costs and improve value. Government programs and private, value-based initiatives are accelerating. To be ready, medical practices will have to achieve “meaningful use” of electronic health

records and adopt assertive care management strategies. Physicians will have to “think outside the visit” by employing care managers, engaging in more patient education, adopting electronic disease registries and reminder systems and more. Whether value-based payment systems are ready for prime time, the clock is now ticking. Joel C. Cantor, ScD, is a Distinguished Professor of Public Policy at Rutgers University and Director of the Rutgers Center for State Health Policy. Margaret Koller, MS, is the Executive Director of Rutgers Center for State Health Policy. 1

Patient Protection and Affordable Care Act (PPACA), Pub. L. No. 111-148, 124 Stat 119 (March 23, 2010), Title III.

Burwell, S. M. (2015, March 5). Setting value-based payment goals: HHS efforts to improve U.S. health care. New England Journal of Medicine, 372(10), 897–899.

P.L. 114–10, 2015.

Feldman, R. (2015, August). The economics of provider payment reform: Are accountable care organizations the answer? Journal of Health Politics, Policy and Law, 40(4), 745–760.

MDADVISOR

Berenson, R. A., & Goodson, J. D. (2016, April 7). Finding value in unexpected places: Fixing the Medicare physician fee schedule. New England Journal of Medicine, 374(14), 1306â&#x20AC;&#x201C;1309.

Horizon Blue Cross Blue Shield of New Jersey. (n.d.). Patient-centered programs. www.horizonblue.com/providers/productsprograms/patient-centered-programs.

20 health systems, insurers agree to make 75% of contracts value-based. (2015, January 29). Advisory Board. www.advisory.com/daily-briefing/2015/01/29/20-healthsystems-insurers-agree.

Ferrante, J. M., Balasubramanian, B. A., Hudson, S. V., & Crabtree, B. F. (2010, March-April). Principles of the patient-centered medical home and preventive services delivery. Annals of Family Medicine, 8(2), 108â&#x20AC;&#x201C;116.

Centers for Medicare and Medicaid Services. (2016, February 25). ACOs in your state. www.cms.gov/medicare/medicarefee-for-service-payment/sharedsavingsprogram/acos-in-yourstate.html.

Abt SRBI, Health Research Division. (2015). New Jersey Primary Care Practice Survey: Methodology report and data memo. www.cshp.rutgers.edu/Downloads/10990.pdf.

Squires, D., & Anderson, C. (2015). U.S. health care from a global perspective: Spending, use of services, prices, and health in 13 countries (Publication No. 1819). New York: Commonwealth Fund. [Available at www.commonwealthfund.org/~/media/files/publications/issuebrief/2015/oct/1819_squires_us_hlt_care_global_perspectiv e_oecd_intl_brief_v3.pdf]

McCarthy, D., Radley, D. C., & Hayes, S. L. (2015). Aiming higher: Results from a scorecard on state health system performance. New York: Commonwealth Fund. [Available at www.commonwealthfund.org/~/media/files/publications/fu nd-report/2015/dec/2015_scorecard_v5.pdf]

Note: For a searchable list, see Centers for Medicare and Medicaid Services. (n.d.). Where innovation is happening. www.innovation.cms.gov/initiatives/map/index.html#model.

Centers for Medicare and Medicaid Services. (2016, July 27). Comprehensive Primary Care initiative. www.innovation.cms.gov/initiatives/Comprehensive-PrimaryCare-Initiative/.

TMF Health Quality Institute. (2016). Comprehensive primary care regional synthesis report (5th release). Washington, DC: Centers for Medicare and Medicaid Services.

MDADVISOR | FALL 2016

Harnessing Health Information Technology to Improve

Care

By Commissioner Cathleen D. Bennett Department of Health, are improving the NJHIN’s ability to identify the right patients when connecting providers so they are receiving accurate information.

Health information technology holds great promise to make healthcare more efficient, to improve the quality of care and to reduce medical errors. Electronic health records give healthcare providers the ability to track patients’ medications and test results, fill in the gaps in patients’ health histories and avoid ordering unnecessary procedures. Technology can ensure that life-saving patient information will be there when patients are brought into the emergency department or are treated by a new provider or specialist. However, to reap the benefits of these advances, it is critical that providers are receiving the right information about the right patient to make informed decisions about treatment. Unfortunately, matching patients to facilitate the exchange of health information is difficult due to variations in how patient information is stored in different health provider and insurer systems. NEW JERSEY HEALTH INFORMATION NETWORK The New Jersey Department of Health is working with the New Jersey Institute of Technology’s New Jersey Innovation Institute to pilot the New Jersey Health Information Network (NJHIN). This network will connect regional health information organizations and exchanges that are currently exchanging data among local healthcare providers, including hospitals, doctor’s offices, federally qualified health centers and laboratories. The NJHIN will allow healthcare providers across the state to have electronic access to patient information, such as medical histories, medication allergies and lab test results at the point of care. The NJHIN also is the primary vehicle for New Jersey to eventually exchange health information nationally with the eHealth Exchange, the largest health information exchange infrastructure in the United States. Working with New Jersey Innovation Institute, we, at the

COMMON KEY SERVICE AND MASTER PERSON INDEX The Department is working to increase the reliability of the NJHIN to bring the correct patient information to providers using the statewide Common Key Service (CKS) and the Master Person Index (MPI). The Common Key Service provides a consistent and reliable way to match patients across multiple organizations, applications and services. This matching capability allows for patient safety and high data integrity when information is shared. The CKS links information for individuals or organizations by using best practices for matching criteria to ensure that identifiers and attributes accurately link to 1 the correct data. The MPI offers the provider a complete view of a patient’s medical and treatment history. It has the ability to uniquely identify patients across systems and provide a list of all treating facilities at which a patient has received care.2 If the patient is found in the MPI, then the CKS creates a Common Key for the patient and cross-references it with the State’s MPI to ensure accurate mapping across systems. If a person is not found in the MPI, then the CKS assigns a Common Key and passes it to the State’s MPI, which creates or modifies a record for that patient. If a potential match or possible duplicate is identified in the State’s MPI, the requestor receives a list of possible matches and is prompted to review the records in detail to identify the correct patient and/or to identify errors that caused the duplication in the MPI. The requestor then sends a message that informs the MPI which of the duplicates is the right person. If the MPI is the source of the duplicate data, the MPI staff will review the data and correct duplicates and errors. This process helps ensure that personal records are kept up to date, thus improving the integrity of the Common Key Service and making the Master Patient Index and the CKS more robust.1 The secure and accurate matching of patient information makes it possible for healthcare

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providers to share electronic health records among different facilities and providers, even when they use dissimilar electronic health records systems. NEW JERSEY IMMUNIZATION INFORMATION SYSTEM The New Jersey Department of Health is piloting the use of the Master Patient Index and the Common Key through the Departmentâ&#x20AC;&#x2122;s New Jersey Immunization Information System known as the NJIIS, a free, confidential, population-based online system used to collect and consolidate vaccination data for all New Jersey residents. This system consolidates immunization information from all providers into one record to provide an accurate immunization assessment and eliminates the use of manual vaccine administration logs. The NJIIS is a very large system, which includes more than 19,000 active users, such as physicians, nurses, pharmacists and local health departments, and more than 3.7 million patients. More than 52 million doses of vaccine are logged in the system. Given the number of providers, patients and doses, the Department recognized the need to focus on ensuring accuracy of this information. When providers query patient data through the NJIIS, it is important that the data are correct to avoid duplications of vaccination, improve management of vaccine inventory and reduce paperwork and staff time spent obtaining records. Additionally, an accurate immunization information system can help the Department better assess the vaccination status of our population, which helps identify pockets of

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needâ&#x20AC;&#x201C;and it also would be a helpful tool in the event of a preventable disease outbreak, such as a novel flu. EXPANDING THE USE OF HEALTH INFORMATION TECHNOLOGY Our immunization registry is one small piece of patient care. The Department recognizes that patients are often seen by many providers, and this adds complexity to coordination of care. With a growing aging population with a variety of chronic illnesses, this complexity is sure to grow. Recognizing that health information technology provides an opportunity to better manage care, improve the quality of care and reduce medical errors, New Jersey is working to expand its use. Using tools like the Common Key Service and the Master Patient Index, we can make the information shared even more valuable to providers. The Department is committed to enhancing the way patient data are shared electronically to help physicians better manage patient care and improve outcomes for their patients. Cathleen D. Bennett is the Commissioner of the New Jersey Department of Health. 1

Michigan Health Information Network. (2014, November 11). Use case summary. https://mihin.org/wpcontent/uploads/2013/07/MiHIN-UCS-Common-Key-Servicev8-11-11-14.pdf.

Veterans Health Administration. (2008, June). Master Patient Index. www.ehealth.va.gov/EHEALTH/docs/080630_Dqtrifoldbrchre_WebV.pdf.

POINT OF VIEW:

Affordable “Healthcare Is Not Affordable By Donald M. Chervenak, MD

ffordable healthcare is a desirable, laudable and attainable goal. However, as we, as a nation, and, in particular as a medical community, seek to reach this goal, it is imperative that we first stop to define what we mean by “affordable” and by “healthcare.” In far too many cases, our understanding of these words does not match the present state of “affordable healthcare” touted by the government and in the media. The Affordable Care Act (ACA), enacted in March 2010, requires most U.S. citizens to have health insurance. The ACA has created state-funded American health benefit exchanges through which individuals can purchase coverage, with premium and cost-sharing credits available to individuals/ families with incomes between 133 and 400 percent of the federal poverty level ($20,160 for a family of three in 2016). In addition, this Act required businesses with 100 or more employees to provide business-sponsored health insurance by 2014; by 2016, businesses with 50 to 99 employees have to comply with ACA guidelines. With these directives now in place, taking a closer look at the ACA and the policies of the Centers for Medicare and Medicaid Services begs the following questions: Does affordable mean that a person can obtain healthcare and still afford the basic necessities of life? Does healthcare mean bare bones medical therapy or the full spectrum of medical services? A look at some statistics will help us answer these questions. ACCOMPLISHMENTS IN PURSUIT OF AFFORDABLE HEALTHCARE According to the U.S. Department of Health and Human Services, the provisions of the Affordable Care

Act have resulted in an estimated 20 million people gaining health insurance coverage between the passage of the law in 2010 and early 2016–an historic reduction in the number 1 of uninsureds. This statistic includes: • 17.7 million nonelderly adults (ages 18 to 64) who gained health insurance coverage from the start of open enrollment in October 2013 through early 2016 • 2.3 million young adults (ages 19 to 25) who gained health insurance coverage between the enactment of the Affordable Care Act in 2010 and the start of the initial open enrollment period in October 2013 due to the ACA provision allowing young adults to remain on a parent’s plan until age 26 • In total, 6.1 million uninsured young adults ages 19 to 25 have gained health insurance coverage because of the Affordable Care Act. This is especially important because young adults were particularly likely to be uninsured before the law went into effect. FAILURES IN PURSUIT OF AFFORDABLE HEALTHCARE As encouraging as these numbers appear, they do not tell the whole story. Although health insurance is more readily available and obtained since the passage of the ACA, frequently, it is not usable due to cost. The high deductibles and other forms of cost-sharing are placing a great financial burden on individuals and families who have low or moderate incomes. In New Jersey, cumulative data on the number of individuals who have selected or have been automatically reenrolled in a 2016 marketplace medical plan indicated that 90 percent of ACA enrollees chose bronze- or silver-level policies (see Table 1). The average range of monthly premiums

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in New Jersey for a bronze policy is approximately $400 to $700, and $500 to $800 for a silver policy. With a bronze policy, the health plan pays 60 percent, on average; for a silver policy, the health plan pays 70 percent. As shown in Tables 2 and 3, what may be affordable coverage for a 27 year old, whose average premiums range from $285 for a bronze policy to $398 for a gold policy in New Jersey quickly escalates to a range of $485 to $677 for the same coverage for a 50 year old. Of course, that does not consider the additional out-of-pocket expenses, such as significant deductibles and copays. In New Jersey, the deductible is $1,500 for an individual and $2,500 for a family. Given the economic disadvantage of those who purchase bronze and silver coverage and looking at the copays and deductibles for medical care and medicine, the question must be asked: Is this affordable? Most of the patients I speak with are unable to obtain subsidies and, therefore, choose policies based on the lowest premiums. Little consideration is given to the cost of deductibles–which ultimately become entirely unaffordable. In June 2015, The Fiscal Times reported that high2 deductible plans were forcing people to delay treatment. A 2014 study conducted by The Commonwealth Fund showed that 23 percent of Americans (31 million) could afford the monthly premiums only on policies with high out-of-pocket costs.3 A New York Times report found that 46 percent of respondents describe basic medical care as a hardship,4 and a 2015 Gallup poll found that slightly fewer than one in three Americans (31 percent) said that they, or a family member, had put off medical treatment within the past year because of the cost. This is essentially unchanged from the 33 percent who said this in 2014, and the figure has remained steady for the past decade.5 The financial hardships remain even for the 169 million Americans whose primary source of health insurance is employer-based–and perhaps even more so than those who receive coverage through the ACA plans. A large management services organization (MSO) in New Jersey, with which I am affiliated, compiled a list of the best 20 percent of family plans available in the state, and even these plans had an expensive $2,300 per month fee with a $3,000/$6,000 deductible. The fact that even the most affordable health plans available are barely affordable for working families is a big problem.

MDADVISOR | FALL 2016

According to a 2015 survey utilizing the Commonwealth Fund Health Care Affordability Index (a comprehensive measure of consumer healthcare costs), one quarter of privately insured working-age adults had high healthcare cost burdens relative to their incomes, and this figure 6 was unchanged from 2014. When looking specifically at adults with low incomes, more than half had high cost burdens. The report also noted that health plan deductibles and copayments had negative effects on many people’s willingness to get needed healthcare or to fill prescriptions. An employer plan must cover 60 percent of total allowed costs to meet the minimum value requirement and provide other benefits. Under the ACA’s own definition, premiums surpassing 9.5 percent of income are not considered “affordable.”7 There are several problems with this definition–the first being that few Americans would consider spending 9.5 percent of their income on healthcare as affordable. Beyond that, the ACA definition does not consider deductibles along with premiums in that 9.5 percent limit. When the deductibles are also considered, 37 percent of private sector employees who are heads of families will face the prospect of unaffordable healthcare by 2020. By 2025, it has been estimated that the majority of private sector employees will fall into the unaffordable category, as 53 percent will surpass the 9.5 percent threshold in premiums and deductibles.8 However, instead of supporting employer-based plans, public policy is pushing employer plans in the opposite direction. Although the ACA’s Cadillac tax was initially sold as a plan to hit only the highest value health plans, it is increasingly hitting plans held by middle-income earners. According to a recent Towers Watson survey, 62 percent of employers are already finding that the Cadillac tax is impacting their healthcare strategy, and this will only continue as time goes on. In 2031, even an average-cost family health plan will likely cross the Cadillac tax threshold, which seems to indicate that employer-sponsored plans may not be affordable at all in the future.8 It does not appear that the situation will improve any time soon. Several well-known insurance providers have had dramatic losses with the ACA.9 UnitedHealth Group (parent company of UnitedHealthcare), Humana, Aetna and several Blue Cross Blue Shield insurers all reported

sizable losses in 2015. UnitedHealthcare is pulling out of the ACA marketplace in New Jersey after this year, and Aetna has canceled plans to enter.10 It is fair to expect that cost increases will occur in 2017 and beyond. Affordability of healthcare is also a serious concern for our Medicare patients, as many are also impacted by rising premiums, deductibles and copays. The costs of prescription drugs, even with Medicare Part D, are frequently burdensome to the elderly population. In fact, some common medications have become prohibitive in cost. The cost of one of two available estrogen vaginal medications is now quoted at $407.99 at a local pharmacy. I was greatly disturbed to find a similar medication purchased in Israel with no insurance and a U.S. prescription to be less than $10. Denavir cream, which comes in an even smaller delivery device, was quoted at $944.99. Zovirax cream, in the “large tube,” was quoted at $811.99. Even the generic for Ambien (which is on most formularies) requires hours of office precertification, which if not performed reflects an exorbitant cost to the patient when the cost with no insurance is $51. BACK-TO-BASICS SOLUTIONS It is clear is that the escalating costs of healthcare are not being addressed in any effective way. Issues like tort reform and a lack of transparency in pharmaceutical and insurance charges are not encompassed in current ACA plans in a meaningful way. Instead of an analysis of cost drivers, the focus is put on healthcare gains and increasing computerization. The real problem is that the areas of greatest cost are protected by special interests. Instead of an emphasis on decreasing physician reimbursements because of the small percentage of physicians who are excessive, reform efforts should circumvent lobbyists who are protecting their segment of cost drivers. Attention should be focused on where lobbying money is going and who is being protected. Aetna and Anthem have spent more than $21 million combined on state and federal lobbying 11 concerning mergers. This is just the tip of the self-interest iceberg that is destined to sink affordable healthcare if the stronghold of special interests is not broken. Additionally, the out-of-control compensation to for-profit insurance company CEOs and pharmaceutical

companies must be addressed. Executives at healthcare companies in the United States had the highest median CEO pay of any industry in 2014, according to an analysis by 12 Equilar/Associated Press. Of particular note is the CEO of UnitedHealth Group, who took home more than $66 million in 2014. These oversized paychecks, not just for CEOs but also for other managers in the healthcare industry, are helping to drive up the costs of healthcare. Quoting Ethan Rome, Executive Director of Health Care for America Now: “It is unconscionable that insurance companies are jacking up premiums and giving their CEOs multimillion-dollar pay packages when families are 13 struggling to make ends meet.” In contrast, Britain, Spain, Portugal, France, Australia, New Zealand, Israel and Canada receive accolades for their cost-efficient healthcare systems. All have limitations on tort, and insurance company CEOs have nowhere near the obscene salaries offered in the United States. This past summer’s biggest corporate scandal–the life-threatening price gouging committed by the drugmaker Mylan–has shoved the issue of management compensation onto the front pages. Mylan sells a medical device that injects an antidote to deadly allergic reactions. Mylan bought this medical technology in 2007. At the time, the injector and medicine sold for approximately $100–and the Mylan CEO was taking home $2.5 million a year. Mylan’s executives doubled the price of their EpiPen product and then more than doubled it again–to $608 for a two-dose package. In the process, Mylan CEO Heather Bresch watched her compensation soar. The New York Times has Bresch on its list of top-paid CEOs for 2015 across all industries; she earned $18.2 million in 2015 and $24.3 million in 2014.14 We need to go back to basics, and we need to refocus our attention on caring for our patients and making sure no one falls through the cracks. Why are the hardships facing healthcare consumers overlooked in healthcare reform? Why is this tolerated? We in the healthcare community should all be alarmed by this information and should proactively become involved in the public and legislative domains to bring truly affordable healthcare to the American public. These words of the late Elie Wiesel seem stingingly pertinent today: “There may be times when we are powerless to prevent injustice, but there must never be a time when we fail to protest.”15

MDADVISOR

Table 1.

Marketplace Enrollment by Metal Level, March 31, 2016 Location

Marketplace Type

Bronze Plan

Silver Plan

Gold Plan

22%

70%

11,081,330

United States

Platinum Catastrophic Total Plan Plan Enrollment

State-based

27%

32%

20%

16%

17,666

Partnership

22%

62%

13%

25,379

State-based

23%

67%

135,208

Federally-facilitated

15%

75%

249,395

State-based

25%

41%

16%

18%

224,014

Federally-facilitated

15%

73%

11%

412,347

Federally-facilitated

22%

70%

378,838

Partnership

19%

70%

11%

N/A

33,235

Note. Data represent a point-in-time estimate of Marketplace enrollment on March 31, 2016. Enrollment data in this table include individuals who have enrolled in a Marketplace plan, have paid their first month’s premium (“effectuated” enrollment) and who have an active policy. Adapted from “March 32, 2016 Effectuated Enrollment Snapshot,” by Centers for Medicaid and Medicare Services. June 30, 2016. Copyright 2016 by CMS.

Table 2.

Average Premiums and Individual Deductibles for a 27 Year Old, ACA Marketplace Plans 2016 Location

Bronze Premiums Deductible

Silver Premiums Deductible

Gold Premiums Deductible

$146

$5,293

$203

$1,886

$270

$708

$239

$6,536

$305

$3,325

$363

$1,342

$184

$5,809

$238

$2,780

$295

$949

$285

$2,619

$311

$2,004

$398

$1,135

$403

$4,423

$479

$2,388

$561

$834

$195

$6,069

$240

$2,537

$295

$1,204

$223

$5,534

$264

$2,969

$335

$1,182

$247

$5,344

$305

$3,035

$368

$965

Table 3.

Average Premiums and Individual Deductibles for a 50 Year Old, ACA Marketplace Plans 2016 Location

Bronze Premiums Deductible

Silver Premiums Deductible

Gold Premiums Deductible

$286

$5,293

$400

$1,886

$530

$708

$407

$6,536

$521

$3,325

$618

$1,342

$313

$5,796

$405

$2,780

$574

$1,000

$485

$2,619

$529

$2,004

$677

$1,135

$403

$4,423

$479

$2,388

$562

$834

$333

$6,069

$409

$2,537

$504

$1,204

$381

$5,534

$451

$2,969

$571

$1,182

$421

$5,344

$520

$3,035

$627

$965

MDADVISOR | FALL 2016

Donald M. Chervenak, MD, FACOG, is an obstetrician/gynecologist at Florham Park OB/GYN in Florham Park, New Jersey. 1

Herman, B. (2016, May 14). Aetna, Anthem face shareholder rebuke over political spending. Modern Healthcare. www.modernhealthcare.com/article/20160514/MAGAZINE/305149966.

Equilar/Associated Press. (2016, May 25). S&P 500 CEO pay study 2016. www.equilar.com/reports/37-associated-presspay-study-2016.html.

Healthcare for America Now. (2011, August 9). CEOs from 10 health insurers took nearly $1 billion in compensation. www.healthcarefor americanow.org/2011/08/09/ceos-from10-health-insurers-took-nearly-1-billion-in-compensation.

Russell, K., & Williams, J. (2016, May 27). Meet the highest-paid C.E.O.s in 2015. The New York Times. www.nytimes.com/interactive/2016/05/29/business/howmuch-ceos-made-last-year.html?_r=0.

Nobel Media. (2014). Elie Wiesel – Nobel lecture: Hope, despair and memory. www.nobelprize.org/nobel_prizes/peace/laureates/1986/wiesel-lecture.html.

Uberoi, N., Finegold, K., & Gee, E. (2016, March 3). Health insurance coverage and the Affordable Care Act, 2010 – 2016. ASPE Issue Brief. https://aspe.hhs.gov/sites /default/ files/pdf/187551/ACA2010-2016.pdf. Ehley, B. (2015, June 10). Obamacare gap traps millions with coverage who can’t afford care. The Fiscal Times. www.thefiscaltimes.com/2015/06/10/Obamacare-GapTraps-Millions-Coverage-Who-Can-t-Afford-Care. Collins, S. R., Rasmussen, P. W., Beutel, S., & Doty, M. M. (2015, May 20). The problem of underinsurance and how rising deductibles will make it worse: Findings from the Commonwealth Fund Biennial Health Insurance Survey. The Commonwealth Fund. www.commonwealthfund.org/publications/issue-briefs/2015/may/problemof-underinsurance.

Rosenthal, E. (2014, December 18). How the high cost of medical care is affecting Americans. The New York Times. www.nytimes.com/interactive/2014/12/18/health/cost-ofhealth-care-poll.html.

Dugan, A. (2015, November 30). Cost still delays healthcare for about one in three in U.S. Gallup. www.gallup.com/poll/ 187190/cost-delays-healthcare-one-three.aspx.

impact state market. NJBIZ. www.njbiz.com/article/20160822/NJBIZ01/160819790/jersey-insurers-stickingwith-aca-the-exit-of-national-firms-wont-impact-state-market.

Collins, S. R., Gunja, M., Doty, M. M., & Beutel, S. (2015, November). How high is America’s health care cost burden? Findings from the Commonwealth Fund Health Care Affordability Tracking Survey, July – August 2015. The Commonwealth Fund. www.commonwealthfund.org/publications/issue-briefs/2015/nov/how-high-health-care-burden.

77 Fed. Reg. 30377.

Troy, T. D., & Wilson, D. M. (2015). Hitting the wall: When health care costs are no longer manageable. American Health Policy Institute. www.americanhealthpolicy.org/content/documents/resources/hitting_the_wall_2015_final.pdf.

Japsen, B. (2016, February 7). Insurer Obamacare losses reach billions of dollars after two years. Forbes. www.forbes.com/sites/brucejapsen/2016/02/07/insurerobamacare-losses-reach-billions-of-dollars-after-twoyears/#6542ca257f0a.

Khemlani, A. (2016, August 22). Jersey insurers sticking with ACA: The exit of national firms won’t

It is clear is that the escalating costs of healthcare are not being addressed in any effective way. Issues like tort reform and a lack of transparency in pharmaceutical and insurance charges are not encompassed in current ACA plans in a meaningful way.

MDADVISOR

How One Anesthesia Group Handles

Growth and Facility Diversification While Maintaining

Patient Safety and Satisfaction By Jill Young, DO Significant research has focused, over time, on tracking and reducing anesthesia-related patient mortality and morbidity. Happily, the overall risk of anesthesia-related mortality and morbidity has declined exponentially from approximately 1 death in 1,000 anesthetics in the 1940s to 1 death in 1,000,000 anesthetics in 2005.1, 2 Simultaneously, we have seen broad demographic shifts in the healthcare landscape in the United States. The population aged 65 to 74 is growing at a rate double that of the population under age 64, and the rate of growth in the population over age 74 is growing three times as fast.3 With aging comes inevitable decline in organ function and a rise in comorbid conditions.4 Improving anesthesia safety, while broadening the physical scope of a medical practice in the context of an aging and sicker population, has required anesthesiologists

MDADVISOR | FALL 2016

to develop protocols that include patient care and contactâ&#x20AC;&#x201C;not simply at the time of surgery but also before, during and well after the procedure. This is especially important today given that anesthesia services are provided not only in traditional hospitals but also in a variety of settings. In fact, most surgery today is done in ambulatory surgery centers (ASCs).5 Understandably, the concept of a perioperative specialist can be overwhelming to anesthesia groups that have spent years practicing only point-of-service care. However, anesthesia care today must be delivered on a continuum. A successful perioperative program requires that every aspect of anesthesia care is reevaluated and refined over time. At Morris Anesthesia Group, we practice safe anesthesia in diverse settings despite wide

variability in ancillary staff experience and training, in equipment availability and in site-specific protocols. Underlying everything is a very basic principle: Consistent practice, driven by ongoing assimilation of evidence-based care, results in best patient outcomes. In this article, we outline the protocols and practices necessary to reach a high level of safety and patient satisfaction in anesthesia care. THE NATION’S FIRST ANESTHESIA-LED EOC Measuring quality of healthcare has never been simple, but recent rising healthcare costs have made quality assessment paramount. The episode of care (EOC) model, first described in 1985 by Hornbook and Hurtado and refined by the Centers for Medicare and Medicaid Services over the following decades, has come into widespread use as a method to obtain a high level of quality 6 care at a lower cost. A surgical EOC covers the entire perioperative period, and thus, the success of the EOC depends on all the various healthcare providers involved during that period. A successful EOC also requires efficient use of facilities and material resources. An EOC is thus a logical framework in which to evaluate quality of care.7 Morris Anesthesia Group has developed the first anesthesia-led EOC in the country for patients undergoing total knee or total hip replacement. We developed and honed our program in the hospital setting, and it incorporates the safest, most efficient processes. Our experience in developing our EOC program demonstrates the need for thorough preoperative protocols, patient follow-up protocols and training programs for staff. Recently, our group became the new anesthesia providers at an existing hospital that has a large volume of orthopedic cases. We were able to introduce our EOC protocol to this hospital for knee and hip surgeries. The development and introduction of our protocol at this hospital demonstrates how best practices may translate between facilities. INTRODUCING REGIONAL ANESTHESIA We were aware that this hospital did not routinely use regional anesthesia (the injection of local anesthetic into

the space surrounding the perineurial sheaths of nerves) for postoperative pain control for patients receiving orthopedic surgery–although its benefits over general anesthesia include improved patient satisfaction, decreased postoperative cognitive impairment, fewer immunosuppressive effects 8 and decreased postoperative nausea and vomiting. All of these advantages facilitate faster patient recovery and discharge. Months before our group gave a single anesthetic at the hospital, we began meeting and speaking regularly with the hospital’s surgeons. Our goal was to evaluate the needs of the surgeons, ancillary staff and patients at this particular hospital. We explained that our experience showed that a well-planned regional anesthesia program could substantially increase patient satisfaction while decreasing length of stay and improving the quality of patient outcomes. We met with the perioperative nursing staff, and we walked the patient floors and spoke with patients. We found surgeons, staff and patients amenable to a regional anesthesia program. Developing our program required months of advanced preparation. We studied patient flow through the perioperative environment, from preadmission testing (PAT) to admission on the day of surgery to the operating room to recovery and through discharge to home or rehabilitation. We learned which vendors the hospital used, and we worked with them to provide the necessary equipment by day one of our hospital contract. We met with the pharmacy, orthopedic rehabilitation specialists and physical therapists, familiarizing them with the expectations and precautions for patients receiving regional anesthesia. In any setting, we require our patients to be medically optimized before surgery. To ensure this, we worked with the operating room (OR) schedulers in the surgeons’ offices and learned their procedures for scheduling a patient for surgery. We found that their lead time was generally several weeks before the procedure. This allowed for PATs to be done well in advance. Using the most current guidelines from the American Society of Anesthesiologists, we suggested requirements for preadmission testing and arranged to have results forwarded immediately to the hospital for review by an anesthesiologist.

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With the regional anesthesia model well understood, we were ready to accept patients using this protocol. PREOPERATIVE PREPARATION FOR PATIENTS AND PHYSICIANS At the hospital, we review incoming PAT results for future patients on a daily basis. Any abnormality is flagged immediately, and, if necessary, the patient is required to visit the primary physician or a specialist before surgery. By the day of surgery, our protocols ensure that patients arrive in an optimal state of health. However, the day of surgery is not the first direct contact our anesthesiologist has with the patient. To prepare patients for the unfamiliar experience of regional anesthesia, each patient receives a preoperative phone call from his or her anesthesiologist the evening before surgery. During this call, we address the benefits and risks of regional anesthesia. This includes a full discussion of the available alternatives. We discuss the specific steps of the regional anesthesia procedure, and we prepare our patients for the expected temporary numbness and weakness associated with a nerve block. Upon admission on the day of surgery, our patients are brought to the preoperative holding room. A patient who chooses regional anesthesia is taken directly to our Block Room, where we have all the necessary equipment to perform regional anesthesia and to deal with its potential complications. Included among this equipment is an ultrasound machine. In the last two decades, ultrasound guidance has been shown to improve nerve localization, with benefits in rapid 9 onset time and quality of analgesia and safety. Technological advances have made portable ultrasound equipment affordable and practical for hospitals and ASCs. However, because this technology is so new, many practicing anesthesiologists were not introduced to it during their training but instead are taught techniques informally by their colleagues or via short weekend educational courses. With such new and rapidly evolving technology, it is unsurprising that there is a general lack of standardization among practitioners. Our group has made efforts to bring each practitioner’s ultrasound regional anesthesia practice up to the level of the most current, best-supported standards. The first step was the introduction of a preprocedure form. This form provides prompts to ensure that all relevant patient history

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and physical exam findings are documented before the nerve block. We use the same form at all of our practice locations, including hospitals and ASCs. Each practitioner quickly becomes familiar with the form’s requirements, and variance in documentation quality is eliminated. After minimizing poor documentation, we can focus on the anesthesiologist’s ability to skillfully and safely provide superior regional anesthesia. We recently became the first anesthesia group in the country to obtain American Institute in Ultrasound in Medicine (AIUM) certification in ultrasound-guided regional anesthesia. This accreditation required extensive data collection from each anesthesiologist demonstrating experience, training and compliance with AIUM practice standards. Multiple case studies for each practitioner are also required to demonstrate technical proficiency and safe outcomes. THE PREOPERATIVE HUDDLE In the hospital setting, a day’s actual surgical schedule may be only vaguely similar to the planned schedule. Emergency cases take priority over scheduled cases. A canceled case may create an empty time slot, and so, a case may be moved from another OR in the interest of efficiency. An anesthesiologist is typically assigned to a particular OR rather than to a patient. Therefore, the anesthesiologist who has prepared for one patient’s case may find him- or herself giving anesthesia to another patient instead. Our anesthesia group, therefore, holds a preoperative huddle the evening before every scheduled day of surgery. During this conference call, the anesthesiologists present their scheduled cases for the following day, including the patients’ pertinent medical histories. All anesthesia staff learn about every patient in every OR. We also benefit from our staff’s institutional knowledge, as we share specific suggestions regarding patient management. On the following day, if a patient’s surgery is moved to another OR, that anesthesiologist has been briefed on the plan of care and is aware of that patient’s medical history. Delays are avoided while efficiency and safety are optimized. To further ensure that our staff practices consistent and safe regional anesthesia techniques, we hold quarterly hands-on, weekend workshops. We work with manufacturers to make available a variety of ultrasound machines and demonstration models. Led by our colleagues who are

fellowship-trained in regional anesthesia, each of us has the opportunity to observe optimal technique and to practice it in a stress-free environment. Our high-quality patient outcomes reflect the time and effort our group has expended. POSTOPERATIVE CARE Quality assurance applies continuously to every patient. Thus, every one of our patients who receives regional anesthesia receives a postoperative visit (for inpatients) or phone call (for outpatients) the following day. Our follow-up evaluates our patients for complications, provides reassurance and assesses the quality of their anesthesia. The modern medical environment favors early patient discharge, and so we often send patients

home with continuous nerve block catheters in place. Remote management of these patients demands close and frequent communication. These patients receive daily followup calls for as long as their nerve catheters are in place. We have informally noted excellent patient satisfaction. It is clear that our protocol contributes to our high-quality outcomes. Recently, we have been able to gather formal data supporting this. DATA COLLECTION The EOC model facilitates data collection. A large national insurance company recently shared with us its most recent data on patient satisfaction with our groupâ&#x20AC;&#x2122;s total joint replacement EOC. These data are presented in Table 1.

TABLE 1. MORRIS ANESTHESIA GROUP EPISODE OF CARE PATIENT SATISFACTION FOR 2015

Satisfaction With Experience

EOC 2015

Practice Totals 20151

Practice Results: Mid Year 2015

Practice Results: Year End 2015

Overall Experience

100%

Professionalism of Anesthesiologist

100%

Communication/ Easy to Understand

100%

Level of Pain/ Discomfort

95%

86%

100%

Adequate Time to Ask Questions

100%

Adequate Information Provided

100%

Likelihood to Recommend Your Anesthesiologist

100%

#EOC Eligible Patients

#EOC Complete Surveys

#Practice Eligible Patients

#Practice Complete Surveys

Total Eligible Patients & Completed Surveys

Note: Data provided to author by Horizon Blue Cross Blue Shield of New Jersey with permission to copy.

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REDUCING COST The EOC concept was developed to help reduce healthcare costs and improve patient safety. One component of reducing costs is decreasing patient length of stay, and our EOC provides several solutions. Postoperative nausea and vomiting (PONV) is one of the most common causes of delayed discharge in ambulatory surgery, and the use of perioperative narcotics is considered a risk factor 10 for PONV. Because it reduces or eliminates the need for narcotics, regional anesthesia is recommended by consensus, evidence-based guidelines as a preventative measure for PONV.10 Additionally, it may even be possible to avoid a costly hospital visit altogether by having surgery in an ASC that applies our EOC protocols as follows. LATERAL TRANSFER TO VARIOUS SURGICAL SETTINGS The lessons learned in developing our EOC protocols are applicable to anesthesia care in all settings–not simply total joint replacements in hospitals. Developing our EOC forced us to consider every step of a patient’s journey through the perioperative process. We now have the data to prove how effective our refinements have been. Not every component of our EOC applies to every surgical patient, but every patient undergoing outpatient surgery in an ASC benefits from one or more of the procedures proven to work in our EOC. As we have outlined, we use a rigorous process of preoperative patient contact, patient preparation, intraoperative care and postoperative follow-up. In the ASC environment, our standards remain just as rigorous. The nature of surgery performed at ASCs and patient scheduling factors may demand a more compact timeline for our processes, but this does not mean shortcuts may be taken. For example, PAT requirements in an ASC must meet the standards we have developed for hospitals. The scheduling timeline for procedures in an ASC is often compressed when compared to a hospital. In an ASC, PATs are usually performed closer to the date of surgery. We must, therefore, review incoming results more frequently–even multiple times per day–to ensure that every test is still reviewed and every required test is performed before surgery. PAT protocols remain unchanged regardless of surgical setting, and so does our standard of advance review. Our EOC has helped to create a core group of regional

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anesthesia experts. These anesthesiologists frequently work in ASCs, and their proficiency with regional anesthesia translates to this setting. Patients and the facility itself benefit from quicker discharge to home, increased patient satisfaction and cost savings. Our efforts in developing a hospital-based EOC benefit our ASC patients and our ASC partners. IN CONCLUSION Our anesthesia group has found that hospitals provide an ideal environment for developing anesthesia protocols for varying episodes of care. The redundant safety systems in hospitals allow for protocols to be perfected with minimal risk. Once developed, these protocols may be laterally transferred into ASCs or office-based settings, with small modifications. In the course of this work, we have learned the following lessons that may benefit all practices: • Education and assessment must be provided to practitioners and ancillary staff to achieve standardization of practice and best outcomes. • Collection and review of data must be ongoing. Conclusions must be quickly assimilated into practice. • Consistent data should be collected on all patients. For example, we have standardized forms that we use for preassessment of all patients undergoing regional anesthesia, in all settings. • Lateral translation of all of the above may occur, from hospitals to ASCs to offices. However, modification may be required to account for shorter PAT windows, lack of additional personnel or lack of certain equipment. Though our rigorous protocols and continuous refinement of procedures in the delivery of anesthesia have produced outstanding patient satisfaction, we remain on a never-ending path of improving patient care. Our experience has shown that striving to provide context-aware, data-driven anesthesia care is the modern evolution of the “art of anesthesia.” Jill Young, DO, is Chairman/CEO, Morris Anesthesia Group in Parsippany, New Jersey. 1

Beecher, H. K., & Todd, D. P. (1954). A study of deaths associated with anesthesia and surgery: Based on a study

of 599,548 anesthetics in ten institutions, 1948-1952, inclusive. Annals of Surgery, 140, 2–34. 2

National Quality Forum. (2010). Measuring framework: Evaluating efficiency across patient-focused episodes of care. www.qualityforum.org/Publications/2010/01/Measurement_ Framework__Evaluating_Efficiency_Across_Patient-Focused_ Episodes _of_Care.aspx.

Morgan, G. E., Mikhail, M. S., & Murray, M. J. (2006). Clinical anesthesiology. New York: Lange Medical Books/McGraw-Hill.

Neal, J. M., Brull, R., Chan, V. W., Grant, S. A., Horn, J. L., Liu, S. S., . . . Tsui, B. C. (2010, March/April). The ASRA evidence-based medicine assessment of regional anesthesia and pain medicine: Executive summary. Regional Anesthesia & Pain Medicine, 35(2), S1–S9.

Gan, T. J., Diemunsch, P., Habib, A. S., Kovac, A., Kranke, P., Meyer, T. A., . . . Tramer, M. R. (2003, June). Consensus guidelines for managing postoperative nausea and vomiting. Anesthesia & Analgesia, 97(1), 62–71.

Li, G., Warner, M., Lang, B. H., Huang, L., & Sun, L. S. (2009, April). Epidemiology of anesthesia-related mortality in the United States, 1999-2005. Anesthesiology, 110(4), 759–765. Valvona, J., & Sloan, F. (1985). Rising rates of surgery among the elderly. Health Affairs, 4(3), 108–119.

Zevesi, Z. G. (2006). Geriatric disorders. In R. L. Hines & K. E. Marschall (Eds.), Stoelting’s anesthesia and co-existing disease (5th ed.; pp. 630–650). Philadelphia, PA: Churchill Livingstone.

Fleisher, L. A., Pasternak, L. R., & Lyles, A. (2007). A novel index of elevated risk in inpatient hospital admission immediately following outpatient surgery. Archives of Surgery, 142(3), 263–268.

Hornbook, M. C., & Hurtado, A. V. (1985, Fall). Health care episodes: Definition, measurement, and use. Medical Care Review, 42(2), 163–218.

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Interviewed by Janet S. Puro, MPH, MBA, & Lee Ann Trulio, RN iverside Pediatric Group was started in Jersey City by pediatrician Dr. Azzam Baker almost four decades ago. Today, the renamed Riverside Medical Group (RMG) has emerged as one of the fastest-growing and largest, private, primary care-based, multispecialty organizations in the New York City Metro area. Along the way, RMG has also become a strong example of what the thought leaders are saying will be the future of healthcare: a financially strong facility offering full access to a variety of quality doctors under one roof. The following interview with Omar Baker, MD, Chief Quality & Safety Officer/Director, Performance Improvement and Principal and Zeyad Baker, MD, a Principal at RMG, with input from Iyad Baker, MD, RMG’s Chief Medical Officer/Principal and Director of the Family Practice Residency Program at Palisades Medical Center, explores how a small medical practice successfully transitioned into a complete medical home. MDAdvisor: How did RMG successfully manage such a complete transformation from Riverside Pediatric Group to Riverside Medical Group? >Dr. Zeyad Baker: RMG had to find a way to decrease the incredible growth in healthcare spending that threatens to devastate the economy. The method used to do this sounds simple, and it’s one that you’ve heard many times, but it is one that we take quite seriously: focused emphasis on quality, access and cost. MDAdvisor: We know that RMG has facilities in Bergen, Hudson and Essex counties, with a team of 115 providers

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(all board certified) who are firmly rooted in a primary care base. These numbers give us a basic understanding of the scope of your resources, but what has RMG done to foster exceptional quality care for patients? >Dr. Zeyad Baker: RMG holds quarterly meetings where all the providers review cases in an academic setting and invite nationally regarded speakers across medical disciplines to educate RMG providers on the future trends in healthcare. RMG also runs internal audits on a quarterly basis to assure that it ranks in the top percentile in all measured quality metrics, such as vaccination rates and lead screenings in the pediatric population and diabetes HgBA1c monitoring and stringent blood pressure control in its adult population. >Dr. Iyad Baker: Additionally, RMG is unique as a private medical organization in that it mandates that its physicians hold teaching roles. RMG physicians are required to teach medical students and residents attending medical schools in the region. Whereas many physicians are not keen on teaching or maintaining an academic culture once they’ve gone into private practice, we actually insist on it at Riverside. We firmly believe that by requiring that our providers teach students and residents in our offices, they are never too far from academia, and this serves to keep them abreast of the most current medical advances. This can only translate into better care for our patients. MDAdvisor: These quality-care initiatives focus on the physicians in your system. Have you made any changes in your approaches to patient care?

>Dr. Omar Baker: Riverside Medical Group is an outcomesbased organization. We emphasize evidence-based best practices. Our providers are held to the highest standards and are extremely engaged and immersed in the care they deliver. We understand that we must have complete physician and patient engagement in order to achieve the iron triangle of healthcare (highest quality, most access and lowest cost). Our outpatient care and inpatient care teams communicate daily to provide the best care, without duplication of services. Riverside’s Hospitalist program and transitional care team allow us to have stellar scores for hospital length of stay, readmission rates, medication compliance and immediate outpatient follow-up upon discharge. We understand that a team-based approach allows for the very best care of our patients. MDAdvisor: What has been the result of this emphasis on quality care? >Dr. Zeyad Baker: Because of this focused emphasis on quality, RMG has received the highest national certification for quality out of Washington, DC’s National Committee for Quality Assurance (NCQA) with Level III certification. The efforts to intentionally pursue an exceptional level of quality certainly can pay off for any health organization moved to emulate these practices. MDAdvisor: Earlier, you mentioned a focus, not only on quality but also on access and cost. Can you describe how you have been able to address these two important healthcare issues? >Dr. Zeyad Baker: At RMG, we’ve built an integrated delivery system that views access, quality and cost as intertwined factors to be tackled all at once. Practicing medicine the way it should be practiced turns out to also be a winning business model. I think it’s crazy that I can go to Dunkin’ Donuts at midnight and get a cup of coffee, but apart from RMG, I can’t take my grandmother to see her doctor if she has chest pain at 8:00 p.m. RMG rejects the notion that patients have to choose between

the convenience of the emergency department or urgent care and quality or familiarity at the site where their regular doctor practices. It seems clear that the biggest cost our healthcare system endures occurs when access is limited. Consider patients with heart failure or chronic obstructive pulmonary disorder (COPD) who run out of their medications or start to have an exacerbation but cannot be seen by a physician that same day. Instead, too often, the patient calls on Friday, can’t get an appointment until next week, is in respiratory distress by Sunday, has to use the emergency department and is now admitted for 10 days. This now costs all of us $15,000. Had that patient had access to his physician on Friday afternoon, not only would the patient not have had to suffer through poor-quality medicine–but our system would have saved a lot of money. That is just a small, everyday example of how access, quality and cost are really elements of the same problem, not three different problems. That patient will always be seen at RMG on that Friday. That is the culture we have. Anytime I hear so-called experts speak about the future of healthcare and how we have to improve quality and access and decrease cost, it makes me laugh. The truth is, any real consideration of these serious problems that mar our healthcare system and really endanger our patients shows that these are not mutually exclusive elements. To

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think of them and then address them as separate matters is the reason why we’re not really getting anywhere listening to these “experts.” MDAdvisor: Can you describe the structure of your model? >Dr. Zeyad Baker: Each site offers three offices within each footprint: one-third devoted to pediatrics, one-third devoted to adult primary care and one-third devoted to subspecialists. Each location has specialists who do sessions in a given location, i.e., otolaryngology (ENT) Monday morning, podiatry Monday afternoon, psychiatry Tuesday morning, etc. This kind of scheduling assures the highest form of convenience for the patients given that the entire family can receive its primary and preventative care at one site with the convenience of extended hours of access. This model also allows for true clinical integration, with all players involved in the patient’s care–the primary care provider and the specialist–using the same electronic health records, within the same medical practice, with the same culture and standards of care. Certainly, this translates into high-quality and improved access with resulting decreased cost. By offering these market differentiators (long hours of access, superior quality and complete medical care under one roof), RMG has been able to attract many new patients and grew at a rate of almost 40 percent a year over the past three years. MDAdvisor: Do you regularly monitor and/or measure patient outcomes, and if so, how? >Dr. Omar Baker: As part of RMG’s population health initiatives, we provide customized and high-quality care to our patients. We do this by monitoring our patient quality metrics for each patient for preventative actions and chronic condition monitoring. We track all emergency room visits, all inpatient admissions, all surgical procedures and all discharges; in essence, any intervention on a Riverside patient we need to know about in as close to real time as possible. Chronic conditions that we monitor include diabetes, depression, heart disease and hypertension. For our pediatric patients, we track routine vaccinations, as well as patients who may be overdue for pediatric screenings, including screening for development issues, tuberculosis, lead and anemia. Additionally, as an active participant in

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the Hackensack Alliance ACO, Riverside regularly collects data and measures performance on a list of clinical quality measures. We have a population health team composed of clinicians/RNs, MBAs, MPHs and social workers solely devoted to data gathering and data analytics and taking actionable change utilizing this information to improve upon our healthcare delivery initiatives and pathways to obtain the best medical outcomes with the highest patient satisfaction scores. We also provide psycho-social support to our elderly and disabled patients via home health and emphasize the importance of communication and education with our sickest patients. Our data-driven team hopes to predict who will be the overutilizers of healthcare in future years so that we can take proactive measures now that will reduce costs in the long run while improving overall health. MDAdvisor: How do you provide feedback to the healthcare providers in your practice on their performance/quality of care? >Dr. Zeyad Baker: Riverside has appointed a Clinical Medical Director for each medical division (Pediatrics, Internal Medicine, Otolaryngology, Podiatry, Physical Therapy, Behavioral Health, Gastroenterology, Cardiology and Pulmonology). The Clinical Medical Director is a board-certified physician responsible for quality improvement initiatives and the development of patient safety policies to ensure high-quality care. Riverside’s Clinical Medical Director meets one-on-one with each provider to discuss performance on a quarterly basis. The following performance metrics are shared with each provider on a quarterly basis: level of visits, patient visits per hour, specialty referrals, common procedures, clinical quality metrics, open encounters and patient satisfaction scores. In addition, policy reminders and best practices are shared with all providers and managers through quarterly meetings, monthly briefs from the Clinical Medical Director, ondemand training/work labs and biweekly conference calls. MDAdvisor: It is understandable that at a time when so many physicians are thinking of leaving the profession and almost all are complaining about declining reimbursements and climbing expenses, many wonder how this growth rate is possible. How do you explain the success you have had with your practice?

>Dr. Zeyad Baker: RMG has bucked the trend with its very aggressive expansion strategy. Our approach has always been to remain financially viable by real growth. In fact, doing more procedures to a patient than absolutely necessary isn’t real growth–even if more revenue is created. Real growth involves performing fewer procedures but caring for a larger population. All said, by 2017, RMG will have approximately 100 or so offices with about 250 providers serving the northern two-thirds of New Jersey, caring for approximately 350,000 lives. By “caring for,” we mean taking responsibility for where they receive all aspects of their care–outpatient, inpatient, etc.–and assuring that whether it’s within RMG’s walls or outside them, the patient gets the absolute best care at the right time–day or night, seven days a week. >Dr. Iyad Baker: I believe that this is New Jersey’s practice model of the future–a medical home concept that can be emulated, duplicated and successfully

implemented by other healthcare organizations throughout the state who desire growth through the clinical integration of quality, access and cost. >Dr. Omar Baker: We begin by training and recruiting the very best medical providers. Our providers, along with our staff of 650+, are all aligned with the Riverside culture of putting the patient first in all aspects, including quality care, access and accountability. Riverside’s emphasis on our patients and our staff to create one large family in the community has allowed us to become one of the leaders in outpatient care. Well-trained teams provide the high-quality care that leads to healthy patients. Rather than react to the future of healthcare, we hope to help continue to create it. Janet S. Puro is Vice President, Business Development and Corporate Communications, and Lee Ann Trulio, RN, is Assistant Vice President, Risk Management, at MDAdvantage Insurance Company.

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Improving Patient Safety:

Practices to Prevent Polypharmacy in the Elderly By Kirsten Tandberg, PA-C We’ve all seen elderly patients in our practices who take a variety of medications with multiple doses per day. According to the American Society on Aging, people over the age of 65 are taking one-third of all medications prescribed in the United States and consuming 40 percent of 1 all over-the-counter medications, despite accounting for only 13 percent of the population. Often, a patient is unclear about what malady the medications treat, which healthcare provider prescribed them and the names and/or doses of the medications. This scenario presents a puzzle for the immediate provider to figure out the pieces of the patient’s medication regimen and subjects a highly-sensitive patient population to the dangers of polypharmacy. Polypharmacy is defined as the use of high numbers of medications to treat one or more conditions or for the treatment of side effects caused by another medication. The use of multiple medications by the elderly contributes to increased morbidity and mortality linked to medication errors, side effects, drug interactions and increased risk for falls. Each year, 175,000 adults age 65 and older are seen in an emergency room in the United States due to adverse drug reactions.1 When physicians and their clinical support staff regularly and consistently practice polypharmacy prevention, hospitalizations, medication errors, negative side effects, drug interactions, falls and even death can be reduced, if not avoided. Through my experiences as a practicing physician assistant, as well as my participation in clinical rotations and learning opportunities from senior medical providers, I have identified five key practices for preventing polypharmacy in my elderly patients. These practices can and should be applied routinely to all areas of medical practice and patient care: • Always review patient medication regimens at every visit. Do not assume that the patient is on the same medications and doses since his or her last visit. Most likely, the patient has visited a cardiologist, nephrologist, endocrinologist or other medical practitioner since that last visit, and most likely, a medication was discontinued or changed, or another medication was prescribed. • Remind patients to bring an updated list of their medications to each visit, or, better yet, ask them to bring all their labeled medication containers to be reviewed. Expecting a patient to remember each medication and its dosage is a prelude to a polypharmacy disaster, especially when medication regimens can consist of more than 20 pills in a pill box.

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• Teach the patient or caregiver how to properly fill pill boxes at the beginning of each week. The most helpful pill boxes divide medication dosing into morning, noon, evening and bedtime compartments. This prevents patients from receiving multiple doses of the same medication or from missing doses, and it eliminates the daunting task of opening and closing pill containers many times a day–a task that can be difficult and frustrating for patients with arthritis. • Encourage patients to use one pharmacy to fill all of their prescriptions. This allows patient medications to be up to date and allows one pharmacist the ability to track a patient’s medications, interactions and doses. • At each patient encounter, evaluate the necessity of each prescribed medication. If, for example, a medication has been prescribed to treat a side effect caused by an initial medication, evaluate whether it is best to change the first medication in an attempt to eliminate the side effect or to continue with the additional pill burden. Following these practices is instrumental to the care and safety of our elderly patients. Not only can they improve the level of risk associated with polypharmacy, they can lessen the financial burdens of patients continuing on extensive medication regimens that might not be entirely necessary or affordable. Kirsten Tandberg, PA-C, is a family medicine physician assistant practicing at Summit Medical Group in Nutley, New Jersey, and a 2013 Edward J. Ill Excellence in Medicine Scholarship Recipient. 1

American Society on Aging. (2016, January 12). Why polypharmacy in older adults is such a big deal: And what can be done to prevent it. www.asaging.org/blog/why polypharmacy-older-adults-such-big-deal-and-what-canbe-done-prevent-it.