Harmful medication errors, or preventable adverse drug events (ADEs), are prominent quality and cost issues in healthcare. Injectable medications are important therapeutic agents, but they are associated with a greater potential for serious harm than oral medications. The economic burden of preventable ADEs associated with inpatient injectable medications and the associated medical professional liability (MPL) costs had not been previously described in the literature.
This study finds that the healthcare and MPL costs associated with preventable ADEs are substantial. The authors estimate that inpatient preventable ADEs associated with injectable medications increase annual U.S. payor costs by $2.7 billion up to $5.1 billion, while MPL costs associated with injectable medications total $300 million to $610 million annually.
Consumer operated and oriented plans (CO-OPs) share many similar values with the community health centers (CHCs) that are supported by the Health Resources and Services Administration (HRSA). Both are nonprofit with consumer-majority governing boards, and the population that currently obtains care through CHCs will likely account for many of the members that CO-OPs enroll. This edition of Milliman’s CO-OP Point of View newsletter discusses how CO-OPs and CHCs are currently in alignment and may be poised for mutual success. Click here to view the newsletter.
As reported in Modern Healthcare, the Centers for Medicare and Medicaid Services (CMS) has provided nearly $4.5 billion in electronic health records (EHR) incentive payments. About $2.4 billion of that is under Medicare, which started EHR incentives in May 2011. The rest is under Medicaid, which began EHR incentives in January 2011. Hospitals have received the bulk of the total in both programs, about $3.1 billion. The program has more than 225,000 active accounts. The EHR incentive program is part of the American Recovery and Reinvestment Act of 2009, which authorized $19 billion for the EHR incentive program.
Community-based data pooling initiatives in Minnesota, Massachusetts, Oregon, Washington, and Wisconsin (commonly known as Chartered Value Exchanges or CVEs) have already shown that, at least using administrative data, it is possible to bring stakeholders to the table, get appropriate infrastructure in place, and begin using community health data to improve quality and transparency. These organizations may serve as models or building blocks for more meaningful use of EHR data nationally.
With accountable care organizations (ACOs) soon to serve more than a million Medicare patients, it is clear that this model of care delivery is receiving an unprecedented test of its viability, and, if it works as intended, may reshape how healthcare is paid for on a larger scale. Cigna alone plans to have more than a million people enrolled in ACOs by 2014, and says it believes that ACOs are going to be important regardless of the Supreme Court’s ruling on the Patient Protection and Affordable Care Act (PPACA).
With so much focus on the topic, it’s worth taking a look back at some of the research and analysis on ACOs published by Milliman on the topic over the past couple of years.
First, for a good summary of ACOs—what they are and how they work—start with this overview video featuring a number of Milliman experts.
For many observers, the key question about ACOs is whether they represent a financially viable model compared to fee-for-service. Effective financial management will be key to success. Milliman has produced a number of relevant papers:
“ACO Gain/Loss Sharing” proposes a framework for allocating savings within an ACO that emphasizes rewards for an ACO’s component entities based on their relative contributions to the organization’s total shared savings and quality performance. Such a framework is required when applying as a Medicare ACO, but the Centers for Medicare and Medicaid Services (CMS) has not provided a detailed procedure for creating one. This paper tries to help fill that gap.
With all the attention on Medicare ACOs, it’s easy to forget that they exist in the private market, as well. For more on such entities, look at “ACOs Beyond Medicare,” which describes the potential advantages for providers who partner with a private insurer rather than with CMS. A 2011 Managed Healthcare Executive roundtable featuring Milliman consultant Rob Parke also discussed ACOs in the private market.
A number of other papers have also been published discussing various aspects of ACOs such as:
Accountable care organizations (ACOs) are an operational and reimbursement healthcare model that is intended to help achieve the dual goals of managing healthcare costs while improving quality of care. Evidence-based guidelines for care management hold great potential for helping ACOs meet these goals in several ways, such as by promoting best practices, by assisting with payment allocation among providers of care, and by facilitating communications among providers and between providers and patients. This paper presents clinical referral guidelines as an example of how evidence-based guidelines can affect and enhance the accountable care concept.
The Naples News takes a local look at a national trend: The move toward accountable care organizations (ACOs). Here’s an excerpt:
The American Hospital Association sent a nine-page letter Nov. 17 to the federal Center for Medicare and Medicaid Services, which outlines the need for flexibility in how ACOs are structured, starting slowly and focusing on a small set of quality measurements initially and addressing how seasonal residents will be treated, among other issues.
The reimbursement piece of an ACO is the hard part, [Dr. Allen] Weiss [president and chief executive officer of the NCH Healthcare System in Collier County] said. For certain, all the ACO partners would have to agree to share clinical information about patients and use a care approach that’s proven effective, what’s called evidence-based medicine, he said.
Patients also would have their role of taking part in prevention and wellness programs, he said. They would be assigned to someone as a mid-level professional as a caregiver.
“Eighty percent of what a primary-care doctor does can be done by a mid-level provider and 64 percent of what patients go to the doctor for can be done over the phone, when a mid-level provider knows the patient,” Weiss said…
A leading national health-care group, Milliman, determined that 25 percent of total health-care spending in 2008, or about $600 billion, was wasted, Weiss said.
“Milliman defines waste or inefficiency in the health-care system as treatment that is unnecessary, redundant, or ineffective and is contrary to, or not demonstrably associated with health-care quality and outcomes,” he said. “What are they (the federal government) going to use for money? The 25 percent waste is what we are really going after.”
With increased scrutiny by CMS contractors of hospital admission and treatment documentation, scientifically based medical guidelines can be a valuable tool for supporting the physician decision-making process and providing evidence of appropriate care. Whether in reviewing retroactive cases or current billings, contractors will be looking at physician documentation in making their determinations. Supporting records from auxiliary caregivers will count for very little if the physician has not made the right decision and properly recorded it.
As an example, a physician admitted a patient for heart failure, noting respiratory compromise, abnormal renal function ( BUN 27 and creatine 2.0), and a blood oxygen saturation level of 96 percent with the patient on low-flow oxygen at 2L/min. The Milliman Care Guidelines® indications for admission for heart failure include documenting worsening renal function and a blood oxygen saturation level below 90. In this instance, the case manager using the Care Guidelines would provide the physician with the following prompts: “Please document the patient’s renal function prior to admission” and “Please indicate in your notes the patient’s O2 saturation on room air.” With these prompts, the physician taking care of this patient could have chosen to admit the patient for observation and then determine if the patient meets the criteria for admission for heart failure.
Well-researched medical guidelines can help hospitals improve and demonstrate best practices in the face of CMS scrutiny. They can be used to:
Provide supporting evidence in case of appeal
Help determine appropriateness for admission
Prompt physicians to provide documentation to the clinical record
The United States spends upwards of $600 billion each year on wasteful healthcare, and as the biggest hospital payor in the country, the federal government has an interest in minimizing this waste. For almost 20 years, the Centers for Medicare & Medicaid Services (CMS) has been developing various auditing capabilities. When the recovery audit contractor program was made permanent in August 2009, it became just the latest example of the War on Waste that has been mustering for many years and has now reached maturity. What can physician executives do to arm themselves for the War on Waste? Scientifically based guidelines and documentation of best practices will play an important role and can help ensure more efficient and quality care even as the War on Waste challenges the way hospitals provide care.
[P]hysician societies, business groups, health insurers and consumer groups have called for more research on the effectiveness of different treatments. The results of that research should help doctors develop better guidelines – and better care for patients.
Despite the contention that it will lead to “one-size-fits all” care, comparative effectiveness research is a step removed from the guidelines themselves. The contention also ignores how guidelines are designed to be used.
“It’s a mistake to think of guidelines in black and white,” said Helen Blumen, a physician and managing editor of Milliman Care Guidelines LLC, which develops guidelines.
The words to live by, she said, are “most of the time.”
The science for developing guidelines is relatively new, and guidelines are far from perfect. The thousands that exist vary in quality and at times conflict. And a treatment that works equally well for all patients is rare.
But guidelines stillcan reduce the unnecessary variation in how doctors practice medicine and encourage them to follow what are considered best practices.
“The job of guidelines is to make it easy for physicians to do the right thing and hard to do the wrong thing,” Blumen said.