User login
Interdisciplinary care reduces deep dyspareunia in endometriosis
VANCOUVER – Interdisciplinary care for women with deep dyspareunia led to a reduction in severe cases, but had no effect on superficial dyspareunia, a study showed.
The findings were measured after 1 year in a treatment program that included laparoscopic surgery, hormonal suppression, biofeedback, pelvic floor physiotherapy, cognitive-behavioral therapy, and mindfulness-based therapy.
About half of women with endometriosis experience deep dyspareunia, which can have a strong, negative impact on quality of life and relationships, Paul Yong, MD, PhD, reported at the World Congress on Endometriosis. For women who do not respond to surgical or medical interventions, interdisciplinary approaches that address the biopsychosocial aspect of pain in endometriosis could be of benefit, he said.
He said the researchers didn’t expect the superficial dyspareunia to respond to the treatments, since it is likely tied to nerve issues. But as a secondary measure, superficial dyspareunia acted as a sort of built-in control to show that the interventions were not having a broad placebo or nonspecific effect on pain.
The study included 296 women who came to the BC Women’s Hospital Centre for Pelvic Pain and Endometriosis with complaints of deep dyspareunia between December 2013 and December 2014. In total, 58% had a confirmed diagnosis of endometriosis, 24% had suspected endometriosis, and 18% had no endometriosis. More than half of the women had irritable bowel syndrome, 42% had painful bladder syndrome, and 30% had pelvic floor dysfunction.
About 55% of patients underwent surgery, while 13% were on hormonal treatment at both baseline and 1 year, 11% were on a pain adjuvant, 30% were on opioids, and 17% were enrolled in a pain program.
At baseline, half of the women reported severe symptoms of deep dyspareunia, but that percentage dropped to 30.4% at 1 year. Moderate cases increased from 17.7% at baseline to 25.0% at 1 year, and mild cases increased from 27.3% to 44.6% (P less than .0001).
A secondary analysis of patients with superficial dyspareunia showed no statistically significant changes in category frequencies. Severe cases represented 22.4% of the population at baseline and 20.2% at 1 year, and similarities were also seen in proportions of moderate (20.2% vs. 19.8%) and mild cases (57.4% vs. 60.1%, P = .65).
“This really suggests that the treatment program has some specificity for deep dyspareunia,” Dr. Yong said.
Depressive symptoms at baseline, as assessed by the Patient Health Questionnaire–9 scale, predicted deep dyspareunia at 1 year (odds ratio, 1.07; 95% confidence interval, 1.03-1.11).
The efficacy against deep dyspareunia is encouraging, but superficial dyspareunia is also a key concern.
“The study suggests that the typical treatments for endometriosis may not impact at all this really prevalent issue of superficial pain, so there’s more for us to do there because that can be a cause of long-term suffering and decreased quality of life,” said Lori Brotto, PhD, director of the sexual health laboratory at the University of British Columbia, who moderated the session during which the research was presented.
Dr. Yong called for more research, specifically a trial targeting treatment of depressive symptoms to determine any effect on endometriosis-related sexual pain or function.
“I think there needs to be more work in the role of depression – not only screening for depression in women with endometriosis, but trying to understand what role it plays in endometriosis symptoms,” Dr. Yong said.
The study was funded by the Canadian Institutes of Health Research. Dr. Yong and Dr. Brotto reported having no relevant financial disclosures.
VANCOUVER – Interdisciplinary care for women with deep dyspareunia led to a reduction in severe cases, but had no effect on superficial dyspareunia, a study showed.
The findings were measured after 1 year in a treatment program that included laparoscopic surgery, hormonal suppression, biofeedback, pelvic floor physiotherapy, cognitive-behavioral therapy, and mindfulness-based therapy.
About half of women with endometriosis experience deep dyspareunia, which can have a strong, negative impact on quality of life and relationships, Paul Yong, MD, PhD, reported at the World Congress on Endometriosis. For women who do not respond to surgical or medical interventions, interdisciplinary approaches that address the biopsychosocial aspect of pain in endometriosis could be of benefit, he said.
He said the researchers didn’t expect the superficial dyspareunia to respond to the treatments, since it is likely tied to nerve issues. But as a secondary measure, superficial dyspareunia acted as a sort of built-in control to show that the interventions were not having a broad placebo or nonspecific effect on pain.
The study included 296 women who came to the BC Women’s Hospital Centre for Pelvic Pain and Endometriosis with complaints of deep dyspareunia between December 2013 and December 2014. In total, 58% had a confirmed diagnosis of endometriosis, 24% had suspected endometriosis, and 18% had no endometriosis. More than half of the women had irritable bowel syndrome, 42% had painful bladder syndrome, and 30% had pelvic floor dysfunction.
About 55% of patients underwent surgery, while 13% were on hormonal treatment at both baseline and 1 year, 11% were on a pain adjuvant, 30% were on opioids, and 17% were enrolled in a pain program.
At baseline, half of the women reported severe symptoms of deep dyspareunia, but that percentage dropped to 30.4% at 1 year. Moderate cases increased from 17.7% at baseline to 25.0% at 1 year, and mild cases increased from 27.3% to 44.6% (P less than .0001).
A secondary analysis of patients with superficial dyspareunia showed no statistically significant changes in category frequencies. Severe cases represented 22.4% of the population at baseline and 20.2% at 1 year, and similarities were also seen in proportions of moderate (20.2% vs. 19.8%) and mild cases (57.4% vs. 60.1%, P = .65).
“This really suggests that the treatment program has some specificity for deep dyspareunia,” Dr. Yong said.
Depressive symptoms at baseline, as assessed by the Patient Health Questionnaire–9 scale, predicted deep dyspareunia at 1 year (odds ratio, 1.07; 95% confidence interval, 1.03-1.11).
The efficacy against deep dyspareunia is encouraging, but superficial dyspareunia is also a key concern.
“The study suggests that the typical treatments for endometriosis may not impact at all this really prevalent issue of superficial pain, so there’s more for us to do there because that can be a cause of long-term suffering and decreased quality of life,” said Lori Brotto, PhD, director of the sexual health laboratory at the University of British Columbia, who moderated the session during which the research was presented.
Dr. Yong called for more research, specifically a trial targeting treatment of depressive symptoms to determine any effect on endometriosis-related sexual pain or function.
“I think there needs to be more work in the role of depression – not only screening for depression in women with endometriosis, but trying to understand what role it plays in endometriosis symptoms,” Dr. Yong said.
The study was funded by the Canadian Institutes of Health Research. Dr. Yong and Dr. Brotto reported having no relevant financial disclosures.
VANCOUVER – Interdisciplinary care for women with deep dyspareunia led to a reduction in severe cases, but had no effect on superficial dyspareunia, a study showed.
The findings were measured after 1 year in a treatment program that included laparoscopic surgery, hormonal suppression, biofeedback, pelvic floor physiotherapy, cognitive-behavioral therapy, and mindfulness-based therapy.
About half of women with endometriosis experience deep dyspareunia, which can have a strong, negative impact on quality of life and relationships, Paul Yong, MD, PhD, reported at the World Congress on Endometriosis. For women who do not respond to surgical or medical interventions, interdisciplinary approaches that address the biopsychosocial aspect of pain in endometriosis could be of benefit, he said.
He said the researchers didn’t expect the superficial dyspareunia to respond to the treatments, since it is likely tied to nerve issues. But as a secondary measure, superficial dyspareunia acted as a sort of built-in control to show that the interventions were not having a broad placebo or nonspecific effect on pain.
The study included 296 women who came to the BC Women’s Hospital Centre for Pelvic Pain and Endometriosis with complaints of deep dyspareunia between December 2013 and December 2014. In total, 58% had a confirmed diagnosis of endometriosis, 24% had suspected endometriosis, and 18% had no endometriosis. More than half of the women had irritable bowel syndrome, 42% had painful bladder syndrome, and 30% had pelvic floor dysfunction.
About 55% of patients underwent surgery, while 13% were on hormonal treatment at both baseline and 1 year, 11% were on a pain adjuvant, 30% were on opioids, and 17% were enrolled in a pain program.
At baseline, half of the women reported severe symptoms of deep dyspareunia, but that percentage dropped to 30.4% at 1 year. Moderate cases increased from 17.7% at baseline to 25.0% at 1 year, and mild cases increased from 27.3% to 44.6% (P less than .0001).
A secondary analysis of patients with superficial dyspareunia showed no statistically significant changes in category frequencies. Severe cases represented 22.4% of the population at baseline and 20.2% at 1 year, and similarities were also seen in proportions of moderate (20.2% vs. 19.8%) and mild cases (57.4% vs. 60.1%, P = .65).
“This really suggests that the treatment program has some specificity for deep dyspareunia,” Dr. Yong said.
Depressive symptoms at baseline, as assessed by the Patient Health Questionnaire–9 scale, predicted deep dyspareunia at 1 year (odds ratio, 1.07; 95% confidence interval, 1.03-1.11).
The efficacy against deep dyspareunia is encouraging, but superficial dyspareunia is also a key concern.
“The study suggests that the typical treatments for endometriosis may not impact at all this really prevalent issue of superficial pain, so there’s more for us to do there because that can be a cause of long-term suffering and decreased quality of life,” said Lori Brotto, PhD, director of the sexual health laboratory at the University of British Columbia, who moderated the session during which the research was presented.
Dr. Yong called for more research, specifically a trial targeting treatment of depressive symptoms to determine any effect on endometriosis-related sexual pain or function.
“I think there needs to be more work in the role of depression – not only screening for depression in women with endometriosis, but trying to understand what role it plays in endometriosis symptoms,” Dr. Yong said.
The study was funded by the Canadian Institutes of Health Research. Dr. Yong and Dr. Brotto reported having no relevant financial disclosures.
AT WCE 2017
Key clinical point:
Major finding: Severe cases of deep dyspareunia dropped from 50.0% to 30.4% at 1 year.
Data source: A retrospective analysis of 296 patients at a single center.
Disclosures: The study was funded by the Canadian Institutes of Health Research. Dr. Yong and Dr. Brotto reported having no relevant financial disclosures.
Mole count predicted melanoma death, especially among men
PORTLAND, ORE. – Among white men, the presence of at least one cutaneous nevus measuring 3 mm or more significantly predicted death from melanoma, in an adjusted analysis of a large prospective cohort study.
Mole count also predicted melanoma death among white women, but the association reached statistical significance only when women had at least three cutaneous nevi measuring 3 mm or more, Eunyoung Cho, ScD, said at the annual meeting of the Society for Investigative Dermatology. The reasons why these associations varied by sex is unclear, although previous studies have documented higher rates of melanoma death among men than among women, and even male physicians tend to seek health care less frequently than their female counterparts, Dr. Cho said in her poster presentation.
In the Nurses’ Health Study, white women with at least three moles measuring at least 3 mm in diameter were at significantly increased risk of dying of melanoma, compared with those with no moles that size (hazard ratio, 2.5; 95% confidence interval, 1.5-4.1), even after the investigators controlled for many other potential confounders, including sunburn history, skin reaction to sun during childhood, tanning ability, family history of melanoma, personal history of nonmelanoma skin cancer, age, activity level, smoking, body mass index, alcohol intake, and hair color. Women with one or two moles also showed a trend toward increased risk of melanoma death (HR, 1.4), but the 95% confidence interval for the hazard ratio did not reach statistical significance (0.9-2.3).
The investigators estimated that among white women, each additional mole measuring 3 mm or more conferred about a 12% increase in the melanoma death rate, even after confounders were controlled for.
In the Health Professionals Follow-Up Study, men with one or two moles of at least 3 mm had about twice the melanoma death rate as men without moles of this size (HR, 2.0; 95% CI, 1.3-3.3), even after investigators controlled for potential confounders. The risk of melanoma death was even greater among men with at least three moles (HR, 4.0; 95% CI, 2.5-6.2), and the difference in rates was statistically significant (P less than .0001). After confounders were accounted for, each additional mole measuring at least 3 mm conferred a 20% increase in the rate of melanoma death.
A different picture emerged after narrowing the adjusted analyses to include only people diagnosed with melanoma: In this group, mole count did not predict melanoma death among women, but continued to do so among men with melanoma who had at least three moles at baseline (HR, 1.8; 95% CI, 1.1-3.0), Dr. Cho reported. Among men, higher mole count also predicted melanoma of at least 1-mm Breslow thickness, an important prognostic factor, she added. Hazard ratios for these “thicker melanomas” were 1.9 (95% CI, 1.1-3.3) among men with one or two moles, and 2.5 (95% CI, 1.5-4.4) among men with three or more moles. Among women with melanoma, mole count did not predict Breslow thickness.
The extent to which sex affected trends in this analysis highlights the need for more studies of sex and other phenotypic risk factors for melanoma death, Dr. Cho concluded. She presented on behalf of lead author Wen-Qing Li, PhD, also of Brown University.
The National Institutes of Health and the Dermatology Foundation provided funding. Dr. Cho and Dr. Li had no relevant financial disclosures.
PORTLAND, ORE. – Among white men, the presence of at least one cutaneous nevus measuring 3 mm or more significantly predicted death from melanoma, in an adjusted analysis of a large prospective cohort study.
Mole count also predicted melanoma death among white women, but the association reached statistical significance only when women had at least three cutaneous nevi measuring 3 mm or more, Eunyoung Cho, ScD, said at the annual meeting of the Society for Investigative Dermatology. The reasons why these associations varied by sex is unclear, although previous studies have documented higher rates of melanoma death among men than among women, and even male physicians tend to seek health care less frequently than their female counterparts, Dr. Cho said in her poster presentation.
In the Nurses’ Health Study, white women with at least three moles measuring at least 3 mm in diameter were at significantly increased risk of dying of melanoma, compared with those with no moles that size (hazard ratio, 2.5; 95% confidence interval, 1.5-4.1), even after the investigators controlled for many other potential confounders, including sunburn history, skin reaction to sun during childhood, tanning ability, family history of melanoma, personal history of nonmelanoma skin cancer, age, activity level, smoking, body mass index, alcohol intake, and hair color. Women with one or two moles also showed a trend toward increased risk of melanoma death (HR, 1.4), but the 95% confidence interval for the hazard ratio did not reach statistical significance (0.9-2.3).
The investigators estimated that among white women, each additional mole measuring 3 mm or more conferred about a 12% increase in the melanoma death rate, even after confounders were controlled for.
In the Health Professionals Follow-Up Study, men with one or two moles of at least 3 mm had about twice the melanoma death rate as men without moles of this size (HR, 2.0; 95% CI, 1.3-3.3), even after investigators controlled for potential confounders. The risk of melanoma death was even greater among men with at least three moles (HR, 4.0; 95% CI, 2.5-6.2), and the difference in rates was statistically significant (P less than .0001). After confounders were accounted for, each additional mole measuring at least 3 mm conferred a 20% increase in the rate of melanoma death.
A different picture emerged after narrowing the adjusted analyses to include only people diagnosed with melanoma: In this group, mole count did not predict melanoma death among women, but continued to do so among men with melanoma who had at least three moles at baseline (HR, 1.8; 95% CI, 1.1-3.0), Dr. Cho reported. Among men, higher mole count also predicted melanoma of at least 1-mm Breslow thickness, an important prognostic factor, she added. Hazard ratios for these “thicker melanomas” were 1.9 (95% CI, 1.1-3.3) among men with one or two moles, and 2.5 (95% CI, 1.5-4.4) among men with three or more moles. Among women with melanoma, mole count did not predict Breslow thickness.
The extent to which sex affected trends in this analysis highlights the need for more studies of sex and other phenotypic risk factors for melanoma death, Dr. Cho concluded. She presented on behalf of lead author Wen-Qing Li, PhD, also of Brown University.
The National Institutes of Health and the Dermatology Foundation provided funding. Dr. Cho and Dr. Li had no relevant financial disclosures.
PORTLAND, ORE. – Among white men, the presence of at least one cutaneous nevus measuring 3 mm or more significantly predicted death from melanoma, in an adjusted analysis of a large prospective cohort study.
Mole count also predicted melanoma death among white women, but the association reached statistical significance only when women had at least three cutaneous nevi measuring 3 mm or more, Eunyoung Cho, ScD, said at the annual meeting of the Society for Investigative Dermatology. The reasons why these associations varied by sex is unclear, although previous studies have documented higher rates of melanoma death among men than among women, and even male physicians tend to seek health care less frequently than their female counterparts, Dr. Cho said in her poster presentation.
In the Nurses’ Health Study, white women with at least three moles measuring at least 3 mm in diameter were at significantly increased risk of dying of melanoma, compared with those with no moles that size (hazard ratio, 2.5; 95% confidence interval, 1.5-4.1), even after the investigators controlled for many other potential confounders, including sunburn history, skin reaction to sun during childhood, tanning ability, family history of melanoma, personal history of nonmelanoma skin cancer, age, activity level, smoking, body mass index, alcohol intake, and hair color. Women with one or two moles also showed a trend toward increased risk of melanoma death (HR, 1.4), but the 95% confidence interval for the hazard ratio did not reach statistical significance (0.9-2.3).
The investigators estimated that among white women, each additional mole measuring 3 mm or more conferred about a 12% increase in the melanoma death rate, even after confounders were controlled for.
In the Health Professionals Follow-Up Study, men with one or two moles of at least 3 mm had about twice the melanoma death rate as men without moles of this size (HR, 2.0; 95% CI, 1.3-3.3), even after investigators controlled for potential confounders. The risk of melanoma death was even greater among men with at least three moles (HR, 4.0; 95% CI, 2.5-6.2), and the difference in rates was statistically significant (P less than .0001). After confounders were accounted for, each additional mole measuring at least 3 mm conferred a 20% increase in the rate of melanoma death.
A different picture emerged after narrowing the adjusted analyses to include only people diagnosed with melanoma: In this group, mole count did not predict melanoma death among women, but continued to do so among men with melanoma who had at least three moles at baseline (HR, 1.8; 95% CI, 1.1-3.0), Dr. Cho reported. Among men, higher mole count also predicted melanoma of at least 1-mm Breslow thickness, an important prognostic factor, she added. Hazard ratios for these “thicker melanomas” were 1.9 (95% CI, 1.1-3.3) among men with one or two moles, and 2.5 (95% CI, 1.5-4.4) among men with three or more moles. Among women with melanoma, mole count did not predict Breslow thickness.
The extent to which sex affected trends in this analysis highlights the need for more studies of sex and other phenotypic risk factors for melanoma death, Dr. Cho concluded. She presented on behalf of lead author Wen-Qing Li, PhD, also of Brown University.
The National Institutes of Health and the Dermatology Foundation provided funding. Dr. Cho and Dr. Li had no relevant financial disclosures.
AT SID 2017
Key clinical point: Mole count was an independent risk factor for melanoma death among men and, to a lesser extent, among women.
Major finding: Adjusted hazard ratios were 2.0 among white men with one or two moles at least 3 mm in diameter and 4.0 among those with at least three moles, but among white women, the association was not significant unless they had at least three moles (HR, 2.5).
Data source: Adjusted analyses of 77,288 white women from the Nurses’ Health Study and 32,455 white men from the Health Professionals Follow-Up Study for 1986 through 2012.
Disclosures: The National Institutes of Health and the Dermatology Foundation provided funding for the study. Dr. Cho and Dr. Li had no relevant financial disclosures.
Trump administration loosens up HealthCare.gov
Patients buying health insurance through an Affordable Care Act health insurance exchange will no longer have to complete the transaction via HealthCare.gov.
The move is intended to help bring stability to the health insurance market, Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said in a statement.
“It is common sense to make it as simple and easy as possible for consumers to shop for and access health coverage,” she said. “It is time to get the federal government out of the way and give patients the best tools to make their own health care decision.”
The change will take effect with the open enrollment period for the 2018 coverage year.
Since the beginning of the health insurance exchanges, patients were required to complete their coverage applications via HealthCare.gov. Feedback from users indicated that “the process was confusing and made it harder to complete the application,” Ms. Verma said in a statement.
The move comes as the Republican-led Congress and the Trump Administration seek to repeal and replace the ACA. This move would deemphasize the government’s role in providing coverage as consumers could potentially avoid contact with HealthCare.gov altogether if they are using a third party to purchase coverage.
Patients buying health insurance through an Affordable Care Act health insurance exchange will no longer have to complete the transaction via HealthCare.gov.
The move is intended to help bring stability to the health insurance market, Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said in a statement.
“It is common sense to make it as simple and easy as possible for consumers to shop for and access health coverage,” she said. “It is time to get the federal government out of the way and give patients the best tools to make their own health care decision.”
The change will take effect with the open enrollment period for the 2018 coverage year.
Since the beginning of the health insurance exchanges, patients were required to complete their coverage applications via HealthCare.gov. Feedback from users indicated that “the process was confusing and made it harder to complete the application,” Ms. Verma said in a statement.
The move comes as the Republican-led Congress and the Trump Administration seek to repeal and replace the ACA. This move would deemphasize the government’s role in providing coverage as consumers could potentially avoid contact with HealthCare.gov altogether if they are using a third party to purchase coverage.
Patients buying health insurance through an Affordable Care Act health insurance exchange will no longer have to complete the transaction via HealthCare.gov.
The move is intended to help bring stability to the health insurance market, Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said in a statement.
“It is common sense to make it as simple and easy as possible for consumers to shop for and access health coverage,” she said. “It is time to get the federal government out of the way and give patients the best tools to make their own health care decision.”
The change will take effect with the open enrollment period for the 2018 coverage year.
Since the beginning of the health insurance exchanges, patients were required to complete their coverage applications via HealthCare.gov. Feedback from users indicated that “the process was confusing and made it harder to complete the application,” Ms. Verma said in a statement.
The move comes as the Republican-led Congress and the Trump Administration seek to repeal and replace the ACA. This move would deemphasize the government’s role in providing coverage as consumers could potentially avoid contact with HealthCare.gov altogether if they are using a third party to purchase coverage.
More telemedicine shifts to system-wide models
As telemedicine gains momentum, more health providers are moving from stand-alone programs to system-wide approaches.
In a survey of 436 U.S. health care executives, physicians, nurses, hospitals, and other health professionals, 25% of respondents with a telemedicine program began with a departmental approach but are now shifting to an enterprise system, 39% had an established enterprise system, and 36% remain with a departmental basis.
The survey of health care professionals’ priorities, objectives, challenges, and telemedicine models of care was conducted between December 2016 and January 2017 for REACH Health, a telemedicine software company.
Fifty-one percent of respondents reported that telemedicine is a top priority or high priority, a decrease from last year’s survey in which 66% of respondents said so. This shift could be linked to a continuing evolution and maturation of telemedicine as more programs move from ad-hoc project status to mainstream service, according to the report.
The telemedicine features most valuable to health providers were clinical documentation, the ability to send documentation to/from the electronic medical record, and the ability to analyze consult data. For the second year, health providers rated their top three telemedicine objectives as: improving patient outcomes, improving patient convenience, and increasing patient engagement.
Overall, health providers responded that the possible repeal and replacement of the Affordable Care Act would be positive for telemedicine. Forty-one percent of respondents said that patient adoption and the use of telemedicine would increase with ACA repeal/replace and 40% of health providers said that internal adoption and use of telemedicine would rise with replacement of the health law.
Just under half (47%) said they were uncertain how health care law changes would impact telemedicine parity laws, and 45% were unsure how repeal and replace would affect Medicare and Medicaid reimbursement for telemedicine services.
[email protected]
On Twitter @legal_med
As telemedicine gains momentum, more health providers are moving from stand-alone programs to system-wide approaches.
In a survey of 436 U.S. health care executives, physicians, nurses, hospitals, and other health professionals, 25% of respondents with a telemedicine program began with a departmental approach but are now shifting to an enterprise system, 39% had an established enterprise system, and 36% remain with a departmental basis.
The survey of health care professionals’ priorities, objectives, challenges, and telemedicine models of care was conducted between December 2016 and January 2017 for REACH Health, a telemedicine software company.
Fifty-one percent of respondents reported that telemedicine is a top priority or high priority, a decrease from last year’s survey in which 66% of respondents said so. This shift could be linked to a continuing evolution and maturation of telemedicine as more programs move from ad-hoc project status to mainstream service, according to the report.
The telemedicine features most valuable to health providers were clinical documentation, the ability to send documentation to/from the electronic medical record, and the ability to analyze consult data. For the second year, health providers rated their top three telemedicine objectives as: improving patient outcomes, improving patient convenience, and increasing patient engagement.
Overall, health providers responded that the possible repeal and replacement of the Affordable Care Act would be positive for telemedicine. Forty-one percent of respondents said that patient adoption and the use of telemedicine would increase with ACA repeal/replace and 40% of health providers said that internal adoption and use of telemedicine would rise with replacement of the health law.
Just under half (47%) said they were uncertain how health care law changes would impact telemedicine parity laws, and 45% were unsure how repeal and replace would affect Medicare and Medicaid reimbursement for telemedicine services.
[email protected]
On Twitter @legal_med
As telemedicine gains momentum, more health providers are moving from stand-alone programs to system-wide approaches.
In a survey of 436 U.S. health care executives, physicians, nurses, hospitals, and other health professionals, 25% of respondents with a telemedicine program began with a departmental approach but are now shifting to an enterprise system, 39% had an established enterprise system, and 36% remain with a departmental basis.
The survey of health care professionals’ priorities, objectives, challenges, and telemedicine models of care was conducted between December 2016 and January 2017 for REACH Health, a telemedicine software company.
Fifty-one percent of respondents reported that telemedicine is a top priority or high priority, a decrease from last year’s survey in which 66% of respondents said so. This shift could be linked to a continuing evolution and maturation of telemedicine as more programs move from ad-hoc project status to mainstream service, according to the report.
The telemedicine features most valuable to health providers were clinical documentation, the ability to send documentation to/from the electronic medical record, and the ability to analyze consult data. For the second year, health providers rated their top three telemedicine objectives as: improving patient outcomes, improving patient convenience, and increasing patient engagement.
Overall, health providers responded that the possible repeal and replacement of the Affordable Care Act would be positive for telemedicine. Forty-one percent of respondents said that patient adoption and the use of telemedicine would increase with ACA repeal/replace and 40% of health providers said that internal adoption and use of telemedicine would rise with replacement of the health law.
Just under half (47%) said they were uncertain how health care law changes would impact telemedicine parity laws, and 45% were unsure how repeal and replace would affect Medicare and Medicaid reimbursement for telemedicine services.
[email protected]
On Twitter @legal_med
Teletriage cut dermatology wait times ninefold for patients at a free clinic
PORTLAND – For uninsured patients with limited health care access, a teledermatology triage protocol cut average appointment wait times by ninefold, and usually provided adequate dermatologic care without the need for in-person follow-up, Peter B. Chansky reported at the annual meeting of the Society for Investigative Dermatology.
“In our study, teledermatology was sufficient to triage 70% of cases, which significantly reduced time to evaluation, increased the availability of in-person appointments, and provided a new chance for volunteer dermatologists to serve disadvantaged populations that do not have access to specialty providers,” Mr. Chansky, a medical student at the University of Pennsylvania, Philadelphia, said during an oral presentation of his poster.
Puentes de Salud is a nonprofit, multidisciplinary health care clinic that serves uninsured Latino immigrants in southern Philadelphia, explained Mr. Chansky, who conducted the study under the mentorship of Jules B. Lipoff, MD, of the department of dermatology, at the University of Pennsylvania. Volunteer dermatologists hold a clinic at Puentes de Salud once per month, but patients’ need substantially outpaces supply, which has fueled long wait times and delays in care.
To test an alternative, the volunteer dermatologists created a “teletriage” system for primary care providers to turn to first, before attempting to schedule in-person dermatology appointments at Puentes de Salud. The results were striking: Teledermatology cut average wait times by a factor of 9.3, and patients who typically had gone months with unevaluated skin lesions waited an average of 1.4 days (standard deviation, 3.1 days) for a teledermatology consult, instead of 13.4 days (SD, 1.9 days) for an in-person appointment (P less than .0001).
Just as notably, teledermatologists changed or expanded on 70% of primary care providers’ diagnoses and altered their treatment plans 95% of the time. “Teledermatology also reclaimed 18% of monthly in-person clinic appointments for patients who needed face-to-face consultation,” Mr. Chansky said. “Access to dermatologic care is especially limited among uninsured patients, and using teledermatology to triage patients in a volunteer free clinic has never been evaluated,” he noted.
The analysis included 60 teletriage referrals from nurses and physicians over 2.5 years. Patients were usually male, averaged 32 years in age, and reported an average symptom duration of 15 months. Most lesions had not previously been treated. Cases were usually inflammatory in nature (45%), while 18% were neoplastic, 17% were infectious, and 8% were pigmented lesions. Lesions were usually located on visible areas of skin, including the face, hands, and arms.
This protocol relied on volunteer dermatologists, but teletriage repeatedly has been shown to provide effective dermatologic care in a variety of health care settings, Mr. Chansky noted. “Teledermatology is an accurate, cost-effective, and efficient tool for improving access to dermatologic care,” he added.
Mr. Chansky did not acknowledge external funding sources and had no conflicts of interest.
PORTLAND – For uninsured patients with limited health care access, a teledermatology triage protocol cut average appointment wait times by ninefold, and usually provided adequate dermatologic care without the need for in-person follow-up, Peter B. Chansky reported at the annual meeting of the Society for Investigative Dermatology.
“In our study, teledermatology was sufficient to triage 70% of cases, which significantly reduced time to evaluation, increased the availability of in-person appointments, and provided a new chance for volunteer dermatologists to serve disadvantaged populations that do not have access to specialty providers,” Mr. Chansky, a medical student at the University of Pennsylvania, Philadelphia, said during an oral presentation of his poster.
Puentes de Salud is a nonprofit, multidisciplinary health care clinic that serves uninsured Latino immigrants in southern Philadelphia, explained Mr. Chansky, who conducted the study under the mentorship of Jules B. Lipoff, MD, of the department of dermatology, at the University of Pennsylvania. Volunteer dermatologists hold a clinic at Puentes de Salud once per month, but patients’ need substantially outpaces supply, which has fueled long wait times and delays in care.
To test an alternative, the volunteer dermatologists created a “teletriage” system for primary care providers to turn to first, before attempting to schedule in-person dermatology appointments at Puentes de Salud. The results were striking: Teledermatology cut average wait times by a factor of 9.3, and patients who typically had gone months with unevaluated skin lesions waited an average of 1.4 days (standard deviation, 3.1 days) for a teledermatology consult, instead of 13.4 days (SD, 1.9 days) for an in-person appointment (P less than .0001).
Just as notably, teledermatologists changed or expanded on 70% of primary care providers’ diagnoses and altered their treatment plans 95% of the time. “Teledermatology also reclaimed 18% of monthly in-person clinic appointments for patients who needed face-to-face consultation,” Mr. Chansky said. “Access to dermatologic care is especially limited among uninsured patients, and using teledermatology to triage patients in a volunteer free clinic has never been evaluated,” he noted.
The analysis included 60 teletriage referrals from nurses and physicians over 2.5 years. Patients were usually male, averaged 32 years in age, and reported an average symptom duration of 15 months. Most lesions had not previously been treated. Cases were usually inflammatory in nature (45%), while 18% were neoplastic, 17% were infectious, and 8% were pigmented lesions. Lesions were usually located on visible areas of skin, including the face, hands, and arms.
This protocol relied on volunteer dermatologists, but teletriage repeatedly has been shown to provide effective dermatologic care in a variety of health care settings, Mr. Chansky noted. “Teledermatology is an accurate, cost-effective, and efficient tool for improving access to dermatologic care,” he added.
Mr. Chansky did not acknowledge external funding sources and had no conflicts of interest.
PORTLAND – For uninsured patients with limited health care access, a teledermatology triage protocol cut average appointment wait times by ninefold, and usually provided adequate dermatologic care without the need for in-person follow-up, Peter B. Chansky reported at the annual meeting of the Society for Investigative Dermatology.
“In our study, teledermatology was sufficient to triage 70% of cases, which significantly reduced time to evaluation, increased the availability of in-person appointments, and provided a new chance for volunteer dermatologists to serve disadvantaged populations that do not have access to specialty providers,” Mr. Chansky, a medical student at the University of Pennsylvania, Philadelphia, said during an oral presentation of his poster.
Puentes de Salud is a nonprofit, multidisciplinary health care clinic that serves uninsured Latino immigrants in southern Philadelphia, explained Mr. Chansky, who conducted the study under the mentorship of Jules B. Lipoff, MD, of the department of dermatology, at the University of Pennsylvania. Volunteer dermatologists hold a clinic at Puentes de Salud once per month, but patients’ need substantially outpaces supply, which has fueled long wait times and delays in care.
To test an alternative, the volunteer dermatologists created a “teletriage” system for primary care providers to turn to first, before attempting to schedule in-person dermatology appointments at Puentes de Salud. The results were striking: Teledermatology cut average wait times by a factor of 9.3, and patients who typically had gone months with unevaluated skin lesions waited an average of 1.4 days (standard deviation, 3.1 days) for a teledermatology consult, instead of 13.4 days (SD, 1.9 days) for an in-person appointment (P less than .0001).
Just as notably, teledermatologists changed or expanded on 70% of primary care providers’ diagnoses and altered their treatment plans 95% of the time. “Teledermatology also reclaimed 18% of monthly in-person clinic appointments for patients who needed face-to-face consultation,” Mr. Chansky said. “Access to dermatologic care is especially limited among uninsured patients, and using teledermatology to triage patients in a volunteer free clinic has never been evaluated,” he noted.
The analysis included 60 teletriage referrals from nurses and physicians over 2.5 years. Patients were usually male, averaged 32 years in age, and reported an average symptom duration of 15 months. Most lesions had not previously been treated. Cases were usually inflammatory in nature (45%), while 18% were neoplastic, 17% were infectious, and 8% were pigmented lesions. Lesions were usually located on visible areas of skin, including the face, hands, and arms.
This protocol relied on volunteer dermatologists, but teletriage repeatedly has been shown to provide effective dermatologic care in a variety of health care settings, Mr. Chansky noted. “Teledermatology is an accurate, cost-effective, and efficient tool for improving access to dermatologic care,” he added.
Mr. Chansky did not acknowledge external funding sources and had no conflicts of interest.
AT SID 2017
Key clinical point: For uninsured patients with limited health care access, teledermatology triage protocol can significantly cut appointment wait times and usually obviates the need for in-person follow-up.
Major finding: Teledermatology triage cut average appointment wait times by a factor of 9.3, and 70% of patients did not need additional in-person care.
Data source: An analysis of 60 referrals to teletriage over 2.5 years, among patients seen at a free clinic in Philadelphia.
Disclosures: Mr. Chansky did not acknowledge external funding sources, and had no conflicts of interest.
6MWTs improved following online pulmonary rehab
WASHINGTON – An online pulmonary rehabilitation program for patients with chronic obstructive pulmonary disease (COPD) was not inferior to an in-person program, according to study findings presented at an international conference of the American Thoracic Society, Tuesday.
In a walking test conducted after all patients completed a 7-week program, participants in the online program, on average, increased their 6MWT (6-minute walking test) score by 23.8 m (P = .098) from baseline; this amount of improvement is much greater than the noninferiority threshold for this study. COPD assessment, hospital anxiety, respiratory function, and modified medical research council dyspnea scores of patients who participated in the online program were also not inferior to the scores of patients who participated in the in-person program.
If found to be a viable option, online options for COPD patients could be useful for treatment in those who would otherwise not have access to in-person rehabilitation sessions, said Tom Wilkinson, MD, PhD, of the University of Southhampton (England), in his presentation.
“The challenges for patients with COPD are quite real; there are factors which are limiting the access of treatments ... in the way of geography of where our patients live,” said Dr. Wilkinson. “[Also] some patients may be housebound or have social anxiety but would benefit from using programs more regularly.”
The study’s 90 participants were assigned to participate either in an online program designed as an in-home guide for pulmonary rehabilitation or in pulmonary rehabilitation sessions at a local facility, after a baseline 6-minute walking test, according to Dr. Wilkinson.
The average age of patients participating in the face-to-face program was 71 years, while the average age for the online group was 69 years. Both groups were predominantly male and former smokers.
Investigators designed the online program to mimic face-to-face sessions by integrating advice on exercises, and information about a patient’s condition, into the program. While the online program included five sessions per week of either exercise or education, the program for patients in the control group involved two facility sessions per week.
Dr. Wilkinson said the online form of rehabilitation used in this study would not only benefit patients, but would help hospitals financially.
An online application could be a helpful supplement for facilities that do not have the resources to hire additional workers or do not have the proper facility to conduct these sessions, he added.
Attendees expressed concern that the learning curve of an online platform could make participating in the program difficult for COPD patients.
Dr. Wilkinson said he and his team had taken that potential learning curve into account when designing the program, by including digital literacy programs and a service hotline.
This study was funded by a grant awarded through the U.K. small business research initiative. The investigators reported no relevant financial disclosures.
[email protected]
On Twitter @eaztweets
WASHINGTON – An online pulmonary rehabilitation program for patients with chronic obstructive pulmonary disease (COPD) was not inferior to an in-person program, according to study findings presented at an international conference of the American Thoracic Society, Tuesday.
In a walking test conducted after all patients completed a 7-week program, participants in the online program, on average, increased their 6MWT (6-minute walking test) score by 23.8 m (P = .098) from baseline; this amount of improvement is much greater than the noninferiority threshold for this study. COPD assessment, hospital anxiety, respiratory function, and modified medical research council dyspnea scores of patients who participated in the online program were also not inferior to the scores of patients who participated in the in-person program.
If found to be a viable option, online options for COPD patients could be useful for treatment in those who would otherwise not have access to in-person rehabilitation sessions, said Tom Wilkinson, MD, PhD, of the University of Southhampton (England), in his presentation.
“The challenges for patients with COPD are quite real; there are factors which are limiting the access of treatments ... in the way of geography of where our patients live,” said Dr. Wilkinson. “[Also] some patients may be housebound or have social anxiety but would benefit from using programs more regularly.”
The study’s 90 participants were assigned to participate either in an online program designed as an in-home guide for pulmonary rehabilitation or in pulmonary rehabilitation sessions at a local facility, after a baseline 6-minute walking test, according to Dr. Wilkinson.
The average age of patients participating in the face-to-face program was 71 years, while the average age for the online group was 69 years. Both groups were predominantly male and former smokers.
Investigators designed the online program to mimic face-to-face sessions by integrating advice on exercises, and information about a patient’s condition, into the program. While the online program included five sessions per week of either exercise or education, the program for patients in the control group involved two facility sessions per week.
Dr. Wilkinson said the online form of rehabilitation used in this study would not only benefit patients, but would help hospitals financially.
An online application could be a helpful supplement for facilities that do not have the resources to hire additional workers or do not have the proper facility to conduct these sessions, he added.
Attendees expressed concern that the learning curve of an online platform could make participating in the program difficult for COPD patients.
Dr. Wilkinson said he and his team had taken that potential learning curve into account when designing the program, by including digital literacy programs and a service hotline.
This study was funded by a grant awarded through the U.K. small business research initiative. The investigators reported no relevant financial disclosures.
[email protected]
On Twitter @eaztweets
WASHINGTON – An online pulmonary rehabilitation program for patients with chronic obstructive pulmonary disease (COPD) was not inferior to an in-person program, according to study findings presented at an international conference of the American Thoracic Society, Tuesday.
In a walking test conducted after all patients completed a 7-week program, participants in the online program, on average, increased their 6MWT (6-minute walking test) score by 23.8 m (P = .098) from baseline; this amount of improvement is much greater than the noninferiority threshold for this study. COPD assessment, hospital anxiety, respiratory function, and modified medical research council dyspnea scores of patients who participated in the online program were also not inferior to the scores of patients who participated in the in-person program.
If found to be a viable option, online options for COPD patients could be useful for treatment in those who would otherwise not have access to in-person rehabilitation sessions, said Tom Wilkinson, MD, PhD, of the University of Southhampton (England), in his presentation.
“The challenges for patients with COPD are quite real; there are factors which are limiting the access of treatments ... in the way of geography of where our patients live,” said Dr. Wilkinson. “[Also] some patients may be housebound or have social anxiety but would benefit from using programs more regularly.”
The study’s 90 participants were assigned to participate either in an online program designed as an in-home guide for pulmonary rehabilitation or in pulmonary rehabilitation sessions at a local facility, after a baseline 6-minute walking test, according to Dr. Wilkinson.
The average age of patients participating in the face-to-face program was 71 years, while the average age for the online group was 69 years. Both groups were predominantly male and former smokers.
Investigators designed the online program to mimic face-to-face sessions by integrating advice on exercises, and information about a patient’s condition, into the program. While the online program included five sessions per week of either exercise or education, the program for patients in the control group involved two facility sessions per week.
Dr. Wilkinson said the online form of rehabilitation used in this study would not only benefit patients, but would help hospitals financially.
An online application could be a helpful supplement for facilities that do not have the resources to hire additional workers or do not have the proper facility to conduct these sessions, he added.
Attendees expressed concern that the learning curve of an online platform could make participating in the program difficult for COPD patients.
Dr. Wilkinson said he and his team had taken that potential learning curve into account when designing the program, by including digital literacy programs and a service hotline.
This study was funded by a grant awarded through the U.K. small business research initiative. The investigators reported no relevant financial disclosures.
[email protected]
On Twitter @eaztweets
Key clinical point:
Major finding: The 6-minute walking test scores for patients participating in an online pulmonary rehabilitation program improved by 23.8 m, on average (P = .098).
Data source: A single-blind, randomized controlled trial of 90 patients conducted through the Portsmouth Hospital.
Disclosures: This study was funded by a grant awarded through the U.K. small business research initiative. Investigators reported no relevant financial disclosures.
Inpatient prenatal yoga found feasible for high-risk women
AT ACOG 2017
SAN DIEGO – Inpatient prenatal yoga is a feasible and acceptable intervention for high-risk women admitted to the hospital, results from a single-center study suggested.
“We know that outside of obstetrics, yoga is beneficial to stress relief, musculoskeletal pain, and sleep quality,” Veronica Demtchouk, MD, said in an interview at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “Inpatient high-risk obstetrics patients have very limited physical activity that they feel is safe to do.”
In an effort to investigate the feasibility of establishing an inpatient prenatal yoga program, the researchers recruited 40 women with anticipated admission to the antepartum service for at least 72 hours and who received medical clearance from their primary obstetrician. One of the medical center’s nurse practitioners, who is also a certified yoga instructor, taught a 30-minute prenatal yoga session once a week in a waiting room.
“It was a large enough space; we moved away the furniture and did the yoga sessions there,” Dr. Demtchouk said.
Study participants completed a questionnaire after each yoga session and at hospital discharge, while 14 nurses completed questionnaires regarding patient care and patient satisfaction. Of the 40 patients, 16 completed one or more yoga sessions; 24 did not participate because of scheduling conflicts with ultrasound or fetal testing, change in clinical status, lack of interest on the day of the session, and delivery or discharge prior to the yoga session.
Of the 16 study participants, 8 reported a decreased level of stress, 4 reported better sleep, 4 reported applying the yoga techniques outside of class, and 3 reported decreased pain/discomfort.
“Not a single woman complained or was displeased with the yoga sessions,” Dr. Demtchouk said. “The biggest challenge was the timing of the yoga session. It was just once a week, which limited the number of women who could attend.”
Of the 14 nurses who completed questionnaires, all viewed yoga as beneficial to their patients, none found it disruptive to providing patient care, and all indicated they would recommend an inpatient prenatal yoga program to other hospitals with an antepartum service.
“I think having several sessions throughout the week is essential for having adequate patient participation,” Dr. Demtchouk added. “It’s essential to have the nurses on board with it.”
She reported having no relevant financial disclosures.
AT ACOG 2017
SAN DIEGO – Inpatient prenatal yoga is a feasible and acceptable intervention for high-risk women admitted to the hospital, results from a single-center study suggested.
“We know that outside of obstetrics, yoga is beneficial to stress relief, musculoskeletal pain, and sleep quality,” Veronica Demtchouk, MD, said in an interview at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “Inpatient high-risk obstetrics patients have very limited physical activity that they feel is safe to do.”
In an effort to investigate the feasibility of establishing an inpatient prenatal yoga program, the researchers recruited 40 women with anticipated admission to the antepartum service for at least 72 hours and who received medical clearance from their primary obstetrician. One of the medical center’s nurse practitioners, who is also a certified yoga instructor, taught a 30-minute prenatal yoga session once a week in a waiting room.
“It was a large enough space; we moved away the furniture and did the yoga sessions there,” Dr. Demtchouk said.
Study participants completed a questionnaire after each yoga session and at hospital discharge, while 14 nurses completed questionnaires regarding patient care and patient satisfaction. Of the 40 patients, 16 completed one or more yoga sessions; 24 did not participate because of scheduling conflicts with ultrasound or fetal testing, change in clinical status, lack of interest on the day of the session, and delivery or discharge prior to the yoga session.
Of the 16 study participants, 8 reported a decreased level of stress, 4 reported better sleep, 4 reported applying the yoga techniques outside of class, and 3 reported decreased pain/discomfort.
“Not a single woman complained or was displeased with the yoga sessions,” Dr. Demtchouk said. “The biggest challenge was the timing of the yoga session. It was just once a week, which limited the number of women who could attend.”
Of the 14 nurses who completed questionnaires, all viewed yoga as beneficial to their patients, none found it disruptive to providing patient care, and all indicated they would recommend an inpatient prenatal yoga program to other hospitals with an antepartum service.
“I think having several sessions throughout the week is essential for having adequate patient participation,” Dr. Demtchouk added. “It’s essential to have the nurses on board with it.”
She reported having no relevant financial disclosures.
AT ACOG 2017
SAN DIEGO – Inpatient prenatal yoga is a feasible and acceptable intervention for high-risk women admitted to the hospital, results from a single-center study suggested.
“We know that outside of obstetrics, yoga is beneficial to stress relief, musculoskeletal pain, and sleep quality,” Veronica Demtchouk, MD, said in an interview at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. “Inpatient high-risk obstetrics patients have very limited physical activity that they feel is safe to do.”
In an effort to investigate the feasibility of establishing an inpatient prenatal yoga program, the researchers recruited 40 women with anticipated admission to the antepartum service for at least 72 hours and who received medical clearance from their primary obstetrician. One of the medical center’s nurse practitioners, who is also a certified yoga instructor, taught a 30-minute prenatal yoga session once a week in a waiting room.
“It was a large enough space; we moved away the furniture and did the yoga sessions there,” Dr. Demtchouk said.
Study participants completed a questionnaire after each yoga session and at hospital discharge, while 14 nurses completed questionnaires regarding patient care and patient satisfaction. Of the 40 patients, 16 completed one or more yoga sessions; 24 did not participate because of scheduling conflicts with ultrasound or fetal testing, change in clinical status, lack of interest on the day of the session, and delivery or discharge prior to the yoga session.
Of the 16 study participants, 8 reported a decreased level of stress, 4 reported better sleep, 4 reported applying the yoga techniques outside of class, and 3 reported decreased pain/discomfort.
“Not a single woman complained or was displeased with the yoga sessions,” Dr. Demtchouk said. “The biggest challenge was the timing of the yoga session. It was just once a week, which limited the number of women who could attend.”
Of the 14 nurses who completed questionnaires, all viewed yoga as beneficial to their patients, none found it disruptive to providing patient care, and all indicated they would recommend an inpatient prenatal yoga program to other hospitals with an antepartum service.
“I think having several sessions throughout the week is essential for having adequate patient participation,” Dr. Demtchouk added. “It’s essential to have the nurses on board with it.”
She reported having no relevant financial disclosures.
Key clinical point:
Major finding: Of the 16 study participants, 8 reported a decreased level of stress, 4 reported better sleep, 4 reported applying the yoga techniques outside of class, and 3 reported decreased pain/discomfort.
Data source: A feasibility study of 16 hospitalized high-risk pregnant women.
Disclosures: Dr. Demtchouk reported having no relevant financial disclosures.
AAP advises against giving fruit juice to children under 1 year
according to a 2017 policy statement by the American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition and the Committee on Nutrition.
In addition, no more than 4 ounces of fruit juice per day should be given to toddlers aged 1-3 years, and no more than 4-6 ounces to children aged 4-6 years. For children aged 7-18 years, fruit juice intake should be limited to 8 ounces (Pediatrics. 2017 Jun;139[6]:e20170967).
In fact, the AAP recommends that human milk be the only nutrient for infants up to 6 months of age, or a prepared infant formula for mothers who cannot breastfeed or choose not to breastfeed their infants. In a study of 168 children aged either 2 years or 5 years, consumption of 12 fluid ounces or more per day of fruit juice was associated with short stature and with obesity (Pediatrics. 1997 Jan;99[1]:15-22).
If toddlers are given fruit juice, it should be in a cup rather that a bottle, sippy cup, or box of juice that they can carry around for long periods. Also, infants and toddlers should not be put to bed with a bottle of fruit juice, according to the statement. Prolonged exposure of the teeth to the sugars in juice can result in dental caries.
Fruit juice is sometime erroneously used instead of oral electrolyte solutions to rehydrate infants and young children with gastroenteritis or diarrhea, but the high carbohydrate content of fruit juice “may exceed the intestine’s ability to absorb carbohydrate, resulting in carbohydrate malabsorption. Carbohydrate malabsorption causes osmotic diarrhea, increasing the severity of the diarrhea already present,” according to the statement. Also, if fruit juice is used to replace fluid losses in infants, it may cause hyponatremia.
There are several medical conditions in which it is prudent to determine how much fruit juice is being consumed:
- Overnutrition or undernutrition.
- Chronic diarrhea, excessive flatulence, abdominal pain, and bloating.
- Dental caries.
- Poor or excessive weight gain.
Fruit juice is viewed by parents as nutritious, but toddlers and young children should be encouraged to eat whole fruit instead.
“We know that excessive fruit juice can lead to excessive weight gain and tooth decay,” coauthor Steven A. Abrams, MD, of the University of Texas, Austin, said in a press release. “Pediatricians have a lot of information to share with families on how to provide the proper balance of fresh fruit within their child’s diet.”
The authors said they had no relevant financial conflicts.
The AAP’s new policy statement regarding limiting juice consumption has potential to make a big difference in the prevention of two largely preventable diseases – obesity and dental caries. Recognizing that obesity and dental caries are silent epidemics in the United States, and that overconsumption of sugar is a common risk factor for both of these diseases, the AAP’s new policy statement is overdue. Fruit juice has as much sugar as soda drinks, yet parents feel it is a healthy drink alternative because juice comes from fruit. Parents often introduce juice to their children at a very young age and serve them more juice than is needed. Also, young children commonly consume juice in a sippy cup or bottle, which can lead to dental decay, because the frequent sipping of the juice fuels the acid-producing bacteria that contribute to enamel erosion.
As pediatricians, my colleagues and I are challenged to help children maintain a healthy weight and healthy mouths, and we have long battled the early introduction and overconsumption of juice. Medical and dental health care professionals, along with public health programs, can rally around this new policy statement.
Patricia Braun, MD, is a professor of pediatrics at the University of Colorado, Denver, and a practicing pediatrician at Denver Health. She had no conflicts of interest.
The AAP’s new policy statement regarding limiting juice consumption has potential to make a big difference in the prevention of two largely preventable diseases – obesity and dental caries. Recognizing that obesity and dental caries are silent epidemics in the United States, and that overconsumption of sugar is a common risk factor for both of these diseases, the AAP’s new policy statement is overdue. Fruit juice has as much sugar as soda drinks, yet parents feel it is a healthy drink alternative because juice comes from fruit. Parents often introduce juice to their children at a very young age and serve them more juice than is needed. Also, young children commonly consume juice in a sippy cup or bottle, which can lead to dental decay, because the frequent sipping of the juice fuels the acid-producing bacteria that contribute to enamel erosion.
As pediatricians, my colleagues and I are challenged to help children maintain a healthy weight and healthy mouths, and we have long battled the early introduction and overconsumption of juice. Medical and dental health care professionals, along with public health programs, can rally around this new policy statement.
Patricia Braun, MD, is a professor of pediatrics at the University of Colorado, Denver, and a practicing pediatrician at Denver Health. She had no conflicts of interest.
The AAP’s new policy statement regarding limiting juice consumption has potential to make a big difference in the prevention of two largely preventable diseases – obesity and dental caries. Recognizing that obesity and dental caries are silent epidemics in the United States, and that overconsumption of sugar is a common risk factor for both of these diseases, the AAP’s new policy statement is overdue. Fruit juice has as much sugar as soda drinks, yet parents feel it is a healthy drink alternative because juice comes from fruit. Parents often introduce juice to their children at a very young age and serve them more juice than is needed. Also, young children commonly consume juice in a sippy cup or bottle, which can lead to dental decay, because the frequent sipping of the juice fuels the acid-producing bacteria that contribute to enamel erosion.
As pediatricians, my colleagues and I are challenged to help children maintain a healthy weight and healthy mouths, and we have long battled the early introduction and overconsumption of juice. Medical and dental health care professionals, along with public health programs, can rally around this new policy statement.
Patricia Braun, MD, is a professor of pediatrics at the University of Colorado, Denver, and a practicing pediatrician at Denver Health. She had no conflicts of interest.
according to a 2017 policy statement by the American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition and the Committee on Nutrition.
In addition, no more than 4 ounces of fruit juice per day should be given to toddlers aged 1-3 years, and no more than 4-6 ounces to children aged 4-6 years. For children aged 7-18 years, fruit juice intake should be limited to 8 ounces (Pediatrics. 2017 Jun;139[6]:e20170967).
In fact, the AAP recommends that human milk be the only nutrient for infants up to 6 months of age, or a prepared infant formula for mothers who cannot breastfeed or choose not to breastfeed their infants. In a study of 168 children aged either 2 years or 5 years, consumption of 12 fluid ounces or more per day of fruit juice was associated with short stature and with obesity (Pediatrics. 1997 Jan;99[1]:15-22).
If toddlers are given fruit juice, it should be in a cup rather that a bottle, sippy cup, or box of juice that they can carry around for long periods. Also, infants and toddlers should not be put to bed with a bottle of fruit juice, according to the statement. Prolonged exposure of the teeth to the sugars in juice can result in dental caries.
Fruit juice is sometime erroneously used instead of oral electrolyte solutions to rehydrate infants and young children with gastroenteritis or diarrhea, but the high carbohydrate content of fruit juice “may exceed the intestine’s ability to absorb carbohydrate, resulting in carbohydrate malabsorption. Carbohydrate malabsorption causes osmotic diarrhea, increasing the severity of the diarrhea already present,” according to the statement. Also, if fruit juice is used to replace fluid losses in infants, it may cause hyponatremia.
There are several medical conditions in which it is prudent to determine how much fruit juice is being consumed:
- Overnutrition or undernutrition.
- Chronic diarrhea, excessive flatulence, abdominal pain, and bloating.
- Dental caries.
- Poor or excessive weight gain.
Fruit juice is viewed by parents as nutritious, but toddlers and young children should be encouraged to eat whole fruit instead.
“We know that excessive fruit juice can lead to excessive weight gain and tooth decay,” coauthor Steven A. Abrams, MD, of the University of Texas, Austin, said in a press release. “Pediatricians have a lot of information to share with families on how to provide the proper balance of fresh fruit within their child’s diet.”
The authors said they had no relevant financial conflicts.
according to a 2017 policy statement by the American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition and the Committee on Nutrition.
In addition, no more than 4 ounces of fruit juice per day should be given to toddlers aged 1-3 years, and no more than 4-6 ounces to children aged 4-6 years. For children aged 7-18 years, fruit juice intake should be limited to 8 ounces (Pediatrics. 2017 Jun;139[6]:e20170967).
In fact, the AAP recommends that human milk be the only nutrient for infants up to 6 months of age, or a prepared infant formula for mothers who cannot breastfeed or choose not to breastfeed their infants. In a study of 168 children aged either 2 years or 5 years, consumption of 12 fluid ounces or more per day of fruit juice was associated with short stature and with obesity (Pediatrics. 1997 Jan;99[1]:15-22).
If toddlers are given fruit juice, it should be in a cup rather that a bottle, sippy cup, or box of juice that they can carry around for long periods. Also, infants and toddlers should not be put to bed with a bottle of fruit juice, according to the statement. Prolonged exposure of the teeth to the sugars in juice can result in dental caries.
Fruit juice is sometime erroneously used instead of oral electrolyte solutions to rehydrate infants and young children with gastroenteritis or diarrhea, but the high carbohydrate content of fruit juice “may exceed the intestine’s ability to absorb carbohydrate, resulting in carbohydrate malabsorption. Carbohydrate malabsorption causes osmotic diarrhea, increasing the severity of the diarrhea already present,” according to the statement. Also, if fruit juice is used to replace fluid losses in infants, it may cause hyponatremia.
There are several medical conditions in which it is prudent to determine how much fruit juice is being consumed:
- Overnutrition or undernutrition.
- Chronic diarrhea, excessive flatulence, abdominal pain, and bloating.
- Dental caries.
- Poor or excessive weight gain.
Fruit juice is viewed by parents as nutritious, but toddlers and young children should be encouraged to eat whole fruit instead.
“We know that excessive fruit juice can lead to excessive weight gain and tooth decay,” coauthor Steven A. Abrams, MD, of the University of Texas, Austin, said in a press release. “Pediatricians have a lot of information to share with families on how to provide the proper balance of fresh fruit within their child’s diet.”
The authors said they had no relevant financial conflicts.
Making sense of MACRA: MIPS and Advanced APMs
Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.
Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.1,2
This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.2
The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.1
Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.
Some health policy experts, like Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute, say MACRA could actually drive more hospitalists into employment to avoid the costs associated with complying with the law.
Regardless, there is much about MACRA that hospitalists should familiarize themselves with this year. The CMS has announced 2018 will also be a transition year and, as such, additional rules are forthcoming.
Here is what to know for now:
MIPS
All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.3 There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.4
Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.
The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.5 Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.
The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.
“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”
For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.4
“We’re working to ensure the program is structured so that providers can confidently report on just the measures applicable to them, even if it’s fewer than six,” he said. To ensure physicians are not penalized or disadvantaged for being unable to report the required number of measures, Dr. Greeno said CMS is working to develop a validation test, though it has not yet released details.
The measures most applicable to hospitalists include two related to heart failure (ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction [LVSD] and beta-blocker for LVSD), one stroke measure (DC on antithrombotic therapy), advance care planning, prevention of catheter-related bloodstream infection (central venous catheter insertion protocol), documentation of current medications and appropriate treatment of methicillin-resistant Staphylococcus aureus bacteremia.
However, Dr. Afsarmanesh expects hospitalists will shine in the improvement activities category. “It’s part of our DNA,” she said. “Improvement activities... have become part of the core responsibilities for many of us within hospitalist groups, hospitals, and health systems.”
In 2017, CMS requires providers to report four improvement activities, which include: implementation of antibiotic stewardship programs, connecting patients to community chronic-disease management programs, and integrating pharmacists into a patient care team. Dr. Afsarmanesh suggests hospitalists visit SHM’s Quality and Innovation guide for ideas, implementation toolkits, and more.
In the cost category, “for the most part, hospitalists aren’t acquainted with cost and there is not a lot of cost transparency around what we do... In general, medical care needs to be discussed between physicians and patients so they can weigh the cost-benefit,” she said, which includes not just dollars and cents, but the impact associated with procedures, like radiation exposure from a CT scan.
However, Dr. Afsarmanesh acknowledges this is challenging, given the overall lack of cost transparency in the American health care system. “It is disjointed and we don’t have any other system where the professionals who do the work are so far-removed from the actual cost,” she said. “The good thing is, I think we are heading toward an era of more cost-conscious practice.”
In addition, hospitalists are poised to help with overall cost-reduction in the hospital. “I could imagine something relevant around readmissions and total cost,” said Dr. Patel. “But risk-adjustment is key.”
This category will increase to 30% of a provider’s or group’s overall score by payment year 2021, CMS says. It will be determined using claims data to calculate per capita costs for all attributed beneficiaries and a Medicare Spending per Beneficiary measure. The CMS also says it is finalizing 10 episode-based measures determined to be reliable and that will be made available to providers in feedback reports starting in 2018.4
Clinicians may report MIPS data as individual providers (a single National Provider Identifier tied to a single Tax Identification Number) by sending data for each category through electronic health records, registries, or qualified clinical data registries. Quality data may be reported through Medicare claims.
Hospitalists who report through a group will receive a single payment adjustment based on the group’s performance, using group-level data for each category. Groups can submit using the same mechanisms as individual providers, or through a CMS web interface (though groups must register by June 30, 2017).5
The SHM has also asked CMS to consider allowing employed hospitalists to align with and report with their facilities, though Dr. Greeno says this should be voluntary since not every hospitalist may be interested in reporting through their hospital. Dr. Greeno says CMS is “very interested and receptive” to how it could be done.
“We are trying to create the incentive for everybody to provide care at lower costs,” Dr. Greeno said. “There are two goals: Create alignment, and decrease the reporting burden on hospitalist groups.”
Additionally, CMS recognizes the potential burden MIPS imposes on small practices and is working to allow individuals and groups of 10 or fewer clinicians to combine to create virtual groups. This option is not available in 2017.4
The CMS has also authorized $100 million, dispersed over 5 years, for certain organizations to provide technical assistance to MIPS providers with fewer than 15 clinicians, in rural areas and those in health professional shortage areas.4
According to Modern Healthcare, projections by CMS, released last May, show that 87% of solo practitioners and 70% of physician groups with two to nine providers will see their reimbursement rates fall in 2019. Meanwhile, 55% of groups with 25 to 99 providers and 81% of those with 100 or more clinicians will see an increase in reimbursement.7
“I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right,” Dr. Greeno said. “If I was just a really small group with very little overhead, no infrastructure to support, I’d consider taking the penalty and just living with it because I don’t have many costs and just pay my own salary. But it’s still a hard road.”
Dr. Afsarmanesh says SHM continues to look across the board and advocate for all its members.
In 2019, physicians reporting under MIPS will see up to a 4% increase and as low as a 4% decrease in reimbursement. This rises to plus-or-minus 5% in 2020, 7% in 2021 and 9% thereafter.2
Dr. Patel and many others say it appears to be the intention of CMS to move providers toward alternative payment models. A January 2015 news release from the U.S. Department of Health and Human Services announced a goal of tying 50% of Medicare payments to Accountable Care Organizations (ACO) by the end of 2018 (it’s worth noting this was pre-MACRA, and not all ACOs qualify as Advanced APMs).8
“The awkwardness and clunkiness of MIPS needs to be addressed in order to make it successful because many people will be in MIPS,” Dr. Patel said. “I think it’s the intention to move people into Advanced APMs, but how long it takes to get to that point – 3-5 years, it could be 10 – physicians have to thrive in MIPS in order to live.”
One of the most important things, she and Dr. Berenson said, is adequately capturing the quality and scope of the care physicians provide.
“I know hospitalists complain how little their care is reflected in HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) and the quality measures they have now, and readmission rates don’t reflect what doctors do inside the hospital. My colleagues are telling me they want something better,” Dr. Patel said.
Advanced APMs
Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.9 They are paid based on the parameters of their particular model.
Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.
In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)5
The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.4
At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.
Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.
Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.
“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.
For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.
The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.
“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”
The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.
“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”
Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.
For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”
References
1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.
2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.
3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.
4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.
5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.
6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.
7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.
8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.
9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.
Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.
Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.1,2
This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.2
The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.1
Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.
Some health policy experts, like Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute, say MACRA could actually drive more hospitalists into employment to avoid the costs associated with complying with the law.
Regardless, there is much about MACRA that hospitalists should familiarize themselves with this year. The CMS has announced 2018 will also be a transition year and, as such, additional rules are forthcoming.
Here is what to know for now:
MIPS
All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.3 There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.4
Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.
The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.5 Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.
The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.
“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”
For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.4
“We’re working to ensure the program is structured so that providers can confidently report on just the measures applicable to them, even if it’s fewer than six,” he said. To ensure physicians are not penalized or disadvantaged for being unable to report the required number of measures, Dr. Greeno said CMS is working to develop a validation test, though it has not yet released details.
The measures most applicable to hospitalists include two related to heart failure (ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction [LVSD] and beta-blocker for LVSD), one stroke measure (DC on antithrombotic therapy), advance care planning, prevention of catheter-related bloodstream infection (central venous catheter insertion protocol), documentation of current medications and appropriate treatment of methicillin-resistant Staphylococcus aureus bacteremia.
However, Dr. Afsarmanesh expects hospitalists will shine in the improvement activities category. “It’s part of our DNA,” she said. “Improvement activities... have become part of the core responsibilities for many of us within hospitalist groups, hospitals, and health systems.”
In 2017, CMS requires providers to report four improvement activities, which include: implementation of antibiotic stewardship programs, connecting patients to community chronic-disease management programs, and integrating pharmacists into a patient care team. Dr. Afsarmanesh suggests hospitalists visit SHM’s Quality and Innovation guide for ideas, implementation toolkits, and more.
In the cost category, “for the most part, hospitalists aren’t acquainted with cost and there is not a lot of cost transparency around what we do... In general, medical care needs to be discussed between physicians and patients so they can weigh the cost-benefit,” she said, which includes not just dollars and cents, but the impact associated with procedures, like radiation exposure from a CT scan.
However, Dr. Afsarmanesh acknowledges this is challenging, given the overall lack of cost transparency in the American health care system. “It is disjointed and we don’t have any other system where the professionals who do the work are so far-removed from the actual cost,” she said. “The good thing is, I think we are heading toward an era of more cost-conscious practice.”
In addition, hospitalists are poised to help with overall cost-reduction in the hospital. “I could imagine something relevant around readmissions and total cost,” said Dr. Patel. “But risk-adjustment is key.”
This category will increase to 30% of a provider’s or group’s overall score by payment year 2021, CMS says. It will be determined using claims data to calculate per capita costs for all attributed beneficiaries and a Medicare Spending per Beneficiary measure. The CMS also says it is finalizing 10 episode-based measures determined to be reliable and that will be made available to providers in feedback reports starting in 2018.4
Clinicians may report MIPS data as individual providers (a single National Provider Identifier tied to a single Tax Identification Number) by sending data for each category through electronic health records, registries, or qualified clinical data registries. Quality data may be reported through Medicare claims.
Hospitalists who report through a group will receive a single payment adjustment based on the group’s performance, using group-level data for each category. Groups can submit using the same mechanisms as individual providers, or through a CMS web interface (though groups must register by June 30, 2017).5
The SHM has also asked CMS to consider allowing employed hospitalists to align with and report with their facilities, though Dr. Greeno says this should be voluntary since not every hospitalist may be interested in reporting through their hospital. Dr. Greeno says CMS is “very interested and receptive” to how it could be done.
“We are trying to create the incentive for everybody to provide care at lower costs,” Dr. Greeno said. “There are two goals: Create alignment, and decrease the reporting burden on hospitalist groups.”
Additionally, CMS recognizes the potential burden MIPS imposes on small practices and is working to allow individuals and groups of 10 or fewer clinicians to combine to create virtual groups. This option is not available in 2017.4
The CMS has also authorized $100 million, dispersed over 5 years, for certain organizations to provide technical assistance to MIPS providers with fewer than 15 clinicians, in rural areas and those in health professional shortage areas.4
According to Modern Healthcare, projections by CMS, released last May, show that 87% of solo practitioners and 70% of physician groups with two to nine providers will see their reimbursement rates fall in 2019. Meanwhile, 55% of groups with 25 to 99 providers and 81% of those with 100 or more clinicians will see an increase in reimbursement.7
“I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right,” Dr. Greeno said. “If I was just a really small group with very little overhead, no infrastructure to support, I’d consider taking the penalty and just living with it because I don’t have many costs and just pay my own salary. But it’s still a hard road.”
Dr. Afsarmanesh says SHM continues to look across the board and advocate for all its members.
In 2019, physicians reporting under MIPS will see up to a 4% increase and as low as a 4% decrease in reimbursement. This rises to plus-or-minus 5% in 2020, 7% in 2021 and 9% thereafter.2
Dr. Patel and many others say it appears to be the intention of CMS to move providers toward alternative payment models. A January 2015 news release from the U.S. Department of Health and Human Services announced a goal of tying 50% of Medicare payments to Accountable Care Organizations (ACO) by the end of 2018 (it’s worth noting this was pre-MACRA, and not all ACOs qualify as Advanced APMs).8
“The awkwardness and clunkiness of MIPS needs to be addressed in order to make it successful because many people will be in MIPS,” Dr. Patel said. “I think it’s the intention to move people into Advanced APMs, but how long it takes to get to that point – 3-5 years, it could be 10 – physicians have to thrive in MIPS in order to live.”
One of the most important things, she and Dr. Berenson said, is adequately capturing the quality and scope of the care physicians provide.
“I know hospitalists complain how little their care is reflected in HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) and the quality measures they have now, and readmission rates don’t reflect what doctors do inside the hospital. My colleagues are telling me they want something better,” Dr. Patel said.
Advanced APMs
Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.9 They are paid based on the parameters of their particular model.
Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.
In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)5
The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.4
At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.
Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.
Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.
“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.
For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.
The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.
“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”
The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.
“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”
Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.
For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”
References
1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.
2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.
3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.
4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.
5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.
6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.
7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.
8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.
9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.
Several months into 2017, physicians around the country are preparing for the first benchmark year of MACRA, the Medicare Access and CHIP Reauthorization Act. Passed in 2015, MACRA is the bipartisan health care law responsible for eliminating the Sustainable Growth Rate and it promises to continue to fundamentally alter the way providers are paid. This year determines reimbursement in 2019.
Under the law, physicians must report performance under one of two pathways: MIPS, the Merit-based Incentive Payment System, or participation in a qualified Advanced Alternative Payment Model, or Advanced APM. The first, MIPS, replaces the Physician Quality Reporting System, Meaningful Use and the Physician Value-Based Payment Modifier and is the track most providers can expect to follow, at least initially, because most will not meet the requirements for Advanced APMs.1,2
This is especially true for hospitalists, most of whom are not yet participating in qualifying alternative payment models.2
The MIPS track is budget neutral, which means for every physician or physician group that receives a boost in reimbursement, another will receive a cut. Others will receive a neutral adjustment. All physicians see an annual 0.5% increase in payment between 2016 and 2019 and MIPS clinicians receive a 0.25% annual boost starting in 2026. Providers participating in Advanced APMs will also receive an annual 5% payment bonus between 2019 and 2024, and a 0.75% annual increase in payments beginning in 2026.1
Both pathways are complex and will affect different clinicians in unique ways, particularly hospitalists.
Some health policy experts, like Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute, say MACRA could actually drive more hospitalists into employment to avoid the costs associated with complying with the law.
Regardless, there is much about MACRA that hospitalists should familiarize themselves with this year. The CMS has announced 2018 will also be a transition year and, as such, additional rules are forthcoming.
Here is what to know for now:
MIPS
All providers who receive Medicare Physician Fee Schedule payments and do not participate in an Advanced APM will fall into MIPS, and reporting applies to all patients, not just Medicare beneficiaries.3 There are, however, exemptions: providers in their first year of Medicare, those billing Medicare Part B less than $30,000 annually, and those who see 100 or fewer Medicare patients.4
Under MIPS, physicians are scored on a scale of 1 to 100 based on performance across four weighted categories: Quality (60%), Advancing Care Information (25%), Improvement Activities (15%), and Cost (not included for 2017). Hospitalists who provide 75% or more of their services in hospital inpatient or outpatient settings, or in the emergency department, are exempt from Advancing Care Information, which replaced meaningful use. As a result, the Quality category will make up 85% of the overall score in 2017.
The CMS also announced added flexibility for 2017 with regard to reporting under MIPS, intended to give providers who need it extra time to prepare.5 Physicians and physician groups can report for a full year, starting January 1, 2017, or report for just 90 days, to be eligible for a positive payment adjustment. To avoid a negative adjustment, they can simply submit more than one quality measure, improvement activity, or advancing care information measure (for those not exempt). Or, providers can choose to report nothing and incur a negative 4% payment.
The approach to MIPS in 2017 will vary widely among SHM members, said Joshua Boswell, SHM’s director of government relations.
“Some are looking to do just the bare minimum, not because of their lack of readiness, but for at least this year, to avoid the time, resources, and cost associated with reporting.” he said. “Other groups are considering jumping in with both feet and fully reporting, their thinking being that they can’t lose, and if there is money on the table for high performers, they might as well go for it.”
For 2017, providers who score 70 or more points are eligible for a performance bonus, drawn from a $500 million pool set aside by CMS. The minimum point threshold defined by CMS is three, which a clinician can earn by submitting just one of the six required quality measures.4
“We’re working to ensure the program is structured so that providers can confidently report on just the measures applicable to them, even if it’s fewer than six,” he said. To ensure physicians are not penalized or disadvantaged for being unable to report the required number of measures, Dr. Greeno said CMS is working to develop a validation test, though it has not yet released details.
The measures most applicable to hospitalists include two related to heart failure (ACE inhibitor/angiotensin receptor blocker for left ventricular systolic dysfunction [LVSD] and beta-blocker for LVSD), one stroke measure (DC on antithrombotic therapy), advance care planning, prevention of catheter-related bloodstream infection (central venous catheter insertion protocol), documentation of current medications and appropriate treatment of methicillin-resistant Staphylococcus aureus bacteremia.
However, Dr. Afsarmanesh expects hospitalists will shine in the improvement activities category. “It’s part of our DNA,” she said. “Improvement activities... have become part of the core responsibilities for many of us within hospitalist groups, hospitals, and health systems.”
In 2017, CMS requires providers to report four improvement activities, which include: implementation of antibiotic stewardship programs, connecting patients to community chronic-disease management programs, and integrating pharmacists into a patient care team. Dr. Afsarmanesh suggests hospitalists visit SHM’s Quality and Innovation guide for ideas, implementation toolkits, and more.
In the cost category, “for the most part, hospitalists aren’t acquainted with cost and there is not a lot of cost transparency around what we do... In general, medical care needs to be discussed between physicians and patients so they can weigh the cost-benefit,” she said, which includes not just dollars and cents, but the impact associated with procedures, like radiation exposure from a CT scan.
However, Dr. Afsarmanesh acknowledges this is challenging, given the overall lack of cost transparency in the American health care system. “It is disjointed and we don’t have any other system where the professionals who do the work are so far-removed from the actual cost,” she said. “The good thing is, I think we are heading toward an era of more cost-conscious practice.”
In addition, hospitalists are poised to help with overall cost-reduction in the hospital. “I could imagine something relevant around readmissions and total cost,” said Dr. Patel. “But risk-adjustment is key.”
This category will increase to 30% of a provider’s or group’s overall score by payment year 2021, CMS says. It will be determined using claims data to calculate per capita costs for all attributed beneficiaries and a Medicare Spending per Beneficiary measure. The CMS also says it is finalizing 10 episode-based measures determined to be reliable and that will be made available to providers in feedback reports starting in 2018.4
Clinicians may report MIPS data as individual providers (a single National Provider Identifier tied to a single Tax Identification Number) by sending data for each category through electronic health records, registries, or qualified clinical data registries. Quality data may be reported through Medicare claims.
Hospitalists who report through a group will receive a single payment adjustment based on the group’s performance, using group-level data for each category. Groups can submit using the same mechanisms as individual providers, or through a CMS web interface (though groups must register by June 30, 2017).5
The SHM has also asked CMS to consider allowing employed hospitalists to align with and report with their facilities, though Dr. Greeno says this should be voluntary since not every hospitalist may be interested in reporting through their hospital. Dr. Greeno says CMS is “very interested and receptive” to how it could be done.
“We are trying to create the incentive for everybody to provide care at lower costs,” Dr. Greeno said. “There are two goals: Create alignment, and decrease the reporting burden on hospitalist groups.”
Additionally, CMS recognizes the potential burden MIPS imposes on small practices and is working to allow individuals and groups of 10 or fewer clinicians to combine to create virtual groups. This option is not available in 2017.4
The CMS has also authorized $100 million, dispersed over 5 years, for certain organizations to provide technical assistance to MIPS providers with fewer than 15 clinicians, in rural areas and those in health professional shortage areas.4
According to Modern Healthcare, projections by CMS, released last May, show that 87% of solo practitioners and 70% of physician groups with two to nine providers will see their reimbursement rates fall in 2019. Meanwhile, 55% of groups with 25 to 99 providers and 81% of those with 100 or more clinicians will see an increase in reimbursement.7
“I think it’s going to be pretty tough unless you’re big enough to commit the resources you need to do it right,” Dr. Greeno said. “If I was just a really small group with very little overhead, no infrastructure to support, I’d consider taking the penalty and just living with it because I don’t have many costs and just pay my own salary. But it’s still a hard road.”
Dr. Afsarmanesh says SHM continues to look across the board and advocate for all its members.
In 2019, physicians reporting under MIPS will see up to a 4% increase and as low as a 4% decrease in reimbursement. This rises to plus-or-minus 5% in 2020, 7% in 2021 and 9% thereafter.2
Dr. Patel and many others say it appears to be the intention of CMS to move providers toward alternative payment models. A January 2015 news release from the U.S. Department of Health and Human Services announced a goal of tying 50% of Medicare payments to Accountable Care Organizations (ACO) by the end of 2018 (it’s worth noting this was pre-MACRA, and not all ACOs qualify as Advanced APMs).8
“The awkwardness and clunkiness of MIPS needs to be addressed in order to make it successful because many people will be in MIPS,” Dr. Patel said. “I think it’s the intention to move people into Advanced APMs, but how long it takes to get to that point – 3-5 years, it could be 10 – physicians have to thrive in MIPS in order to live.”
One of the most important things, she and Dr. Berenson said, is adequately capturing the quality and scope of the care physicians provide.
“I know hospitalists complain how little their care is reflected in HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) and the quality measures they have now, and readmission rates don’t reflect what doctors do inside the hospital. My colleagues are telling me they want something better,” Dr. Patel said.
Advanced APMs
Physicians who participate in Advanced APMs are exempt from MIPS. Advanced APMs must use Certified Electronic Health Record Technology (CEHRT) and take on a minimum amount of risk. For 2017 and 2018, providers must risk losing the lesser of 3% of their total Medicare expenditures or 8% of their revenue.9 They are paid based on the parameters of their particular model.
Additionally, for the 2019 payment year, 25% of a provider’s or group’s Medicare payments or 20% of their patients must be through the Advanced APM. This increases to 50% of payments and 35% of patients for 2021 and 2022, and in 2023, to 75% of payments and 50% of patients.
In 2017, APMs that meet the criteria for Advanced include: Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, Next Generation ACO Model, Shared Savings Program Tracks 2 and 3, Comprehensive Joint Replacement Payment Model Track 1, the Vermont Medicare ACO Initiative, and the Oncology Care Model. (APMs that do not qualify must report under MIPS.)5
The CMS also says that services provided at critical access hospitals, rural health clinics, and federally qualified health centers may qualify using patient counts, and medical home models and the Medicaid Medical Home Model may also be considered Advanced APMs using financial criteria.4
At this time, SHM is unable to quantify the number of hospitalists participating in Advanced APMs, and some, Dr. Greeno said, may not know whether they are part of an Advanced APM.
Currently, BPCI (Bundled Payments for Care Improvement) is the only alternative payment model in which hospitalists can directly take risk, Dr. Greeno says, but it does not yet qualify as an Advanced APM. However, that could change.
Prior to the passage of MACRA, Brandeis University worked with CMS to create the Episode Grouper for Medicare (EGM), software that converts claims data into episodes of care based on a patient’s condition or conditions or procedures. The American College of Surgeons (ACS) has since proposed an alternative payment model, called ACS-Brandeis, that would use the diagnostic grouper to take into account all of the work done by every provider on any episode admitted to the hospital and use algorithms to decide who affected a particular patient’s care.
“Anyone who takes care of the patient can take risk or gain share if the episode initiator allows them,” said Dr. Greeno.
For example, if a patient is admitted for surgery, but has an internist on their case because they have diabetes and heart failure, and they also have an anesthesiologist and an infectious disease specialist, everybody has an impact on their care and makes decisions about the resources used on the case. The risk associated with the case is effectively divided.
The ACS submitted the proposal to PTAC (the Physician-Focused Payment Model Technical Advisory Committee) in 2016 and SHM submitted a letter of support.
“In this model, everybody’s taking risk and everybody has the opportunity to gain share if the patient is managed well,” said Dr. Greeno. “It’s a very complicated, very complex model... Theoretically, everybody on that case should be optimally engaged – that’s the beauty of it – but we don’t know if it will work.”
The SHM got involved at the request of ACS, because it would not apply solely to surgical patients. Dr. Greeno says ACS asked SHM to look at common surgical diagnoses and review every medical scenario that could come to pass, from heart failure and pneumonia to infection.
“There’s bundles within bundles, medical bundles within surgical bundles,” he said. “It’s fascinating and it’s daunting but it is truly a big data approach to episodes of care. We’re thrilled to be invited and ACS was very enthusiastic about our involvement.”
Dr. Patel, who sits on PTAC, is heartened by the amount of physician-led innovation taking place. “Proposals are coming directly from doctors; they are telling us what they want,” she said.
For Dr. Greeno, this captures the intent of MACRA: “There is going to be a continual increase in the sophistication of models, and hopefully toward ones that are better and better and create the right incentives for everyone involved in the health care system.”
References
1. S. Findlay. Medicare’s new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed March 6, 2017.
2. The Society of Hospital Medicine. Medicare physician payments are changing. http://www.macraforhm.org/. Accessed March 6, 2017.
3. A. Maciejowski. MACRA: What’s really in the final rule. http://blog.ncqa.org/macra-whats-really-in-the-final-rule/. Blog post published November 15, 2016. Accessed March 6, 2017.
4. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program executive summary. https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf. Published Oct. 14, 2016. Accessed March 6, 2017.
5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Quality Payment Program: Modernizing Medicare to provide better care and smarter spending for a healthier America. https://qpp.cms.gov/. Accessed March 6, 2017.
6. D. Barkholz. Potential MACRA byproduct: physician consolidation. http://www.modernhealthcare.com/article/20160630/NEWS/160639995. Published June 30, 2016. Accessed March 6, 2017.
7. United States Department of Health and Human Services. Better, smarter, healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursement from volume to value. http://wayback.archive-it.org/3926/20170127185400/https://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html. Published January 26, 2015. Accessed March 6, 2017.
8. B. Wynne. MACRA Final Rule: CMS strikes a balance; will docs hang on? http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance-will-docs-hang-on/. Published October 17, 2016. Accessed March 6, 2017.
9. United States Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Documents for Public Comment: Physician-Focused Payment Model Technical Advisory Committee. Proposal for a Physician-Focused Payment Model: CAS-Brandeis Advanced Alternative Payment Model, American College of Surgeons. https://aspe.hhs.gov/system/files/pdf/253406/TheACSBrandeisAdvancedAPM-ACS.pdf. Published December 13, 2016. Accessed March 6, 2017.
VIDEO: Surgeon case volume linked to mitral valve repair outcomes
BOSTON – Individual surgeon case volume is a significant factor in degenerative mitral valve repair rates and overall patient survival, according to a study presented at the annual meeting of the American Association for Thoracic Surgery.
The analysis, which reviewed the outcomes of 38,128 adult patients, found that higher surgeon volume of mitral cases is associated with better degenerative mitral repair rates and higher survival. In this video, Ralph Damiano Jr., MD, of Washington University, St. Louis, discusses the threshold of mitral cases that led to better repair rates and how further cardiac surgical subspecialization could improve outcomes in patients with degenerative mitral disease.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
BOSTON – Individual surgeon case volume is a significant factor in degenerative mitral valve repair rates and overall patient survival, according to a study presented at the annual meeting of the American Association for Thoracic Surgery.
The analysis, which reviewed the outcomes of 38,128 adult patients, found that higher surgeon volume of mitral cases is associated with better degenerative mitral repair rates and higher survival. In this video, Ralph Damiano Jr., MD, of Washington University, St. Louis, discusses the threshold of mitral cases that led to better repair rates and how further cardiac surgical subspecialization could improve outcomes in patients with degenerative mitral disease.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
BOSTON – Individual surgeon case volume is a significant factor in degenerative mitral valve repair rates and overall patient survival, according to a study presented at the annual meeting of the American Association for Thoracic Surgery.
The analysis, which reviewed the outcomes of 38,128 adult patients, found that higher surgeon volume of mitral cases is associated with better degenerative mitral repair rates and higher survival. In this video, Ralph Damiano Jr., MD, of Washington University, St. Louis, discusses the threshold of mitral cases that led to better repair rates and how further cardiac surgical subspecialization could improve outcomes in patients with degenerative mitral disease.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @legal_med
AT THE AATS ANNUAL MEETING
