Taking on Diabetes

Posted on May 8, 2012 by Patrick Dunn

An estimated 23.6 million Americans have diabetes and another 5.7 million Americans are unaware that they have this chronic, progressive and ultimately life threatening condition. Another 57 million Americans have pre-diabetes, with an elevated fasting blood glucose level (100 – 125 mg/dl), which left untreated is likely to lead to diabetes. There is ample evidence that lifestyle factors, such as obesity, unhealthy eating habits, physical inactivity and smoking are associated with an increased risk of diabetes. Responses from the Consumer Awareness Survey indicate that this population generally understands the key risk factors for diabetes, yet only 60% are aware that there are things they can do to prevent diabetes. Even worse, the majority do not view themselves as at risk for diabetes.

Less than 50% of consumers are aware of community resources where they can find information on diabetes. Selection and determination of high quality health care providers is largely subjective or related to customer service rather than quality indicators. Also, a large number of patients do not persist in asking questions of their physicians even though answering questions and discussing treatment options were ranked by survey respondents as the highest indicators of quality.

While the majority of patients with diabetes are aware of the tests that need to be ordered, including hbA1C, LDL, foot exam and eye exam, the 2006 data aggregation suggests that many of these patients still do not complete these tests.

Calls to action for consumers

To improve the quality of diabetes care in our community, or any community, it is imperative that consumers and patients take better care of themselves. This involves getting more physical activity, improving eating habits, achieving a desirable weight and avoiding smoking. The Diabetes Prevention Program has demonstrated that lifestyle modification can prevent the onset of diabetes by 58%. All consumers should know their numbers (body mass index, blood pressure, cholesterol and fasting glucose). Consumers with pre diabetes or the metabolic syndrome should work with their physician on getting their numbers to goal.

People who have been diagnosed with diabetes should insist on quality by asking questions, determining if all appropriate tests and procedures have been completed, and discuss treatment options with their physician.

There are many community and employer based wellness and disease management programs available to consumers. A good place to start is with Human Resources Department, the health plan or the local chapter of the American Diabetes Association. Consumers should be aware of the resources available. Consumers must participate in diabetes educational programs, even if all or part of the expense is not covered by their insurance.

Physicians

Systemic Issues for physicians

Physicians are confounded by a system that provides inadequate reimbursement for the treatment of diabetes. Physicians are reimbursed based on the number of patient encounters (office visits and procedures) and are graded for efficiency (utilization). Proper care for a patient with diabetes requires more time than can be allocated in a traditional office visit. To provide appropriate care physicians must spent more time with the patient than they are allowed to bill for, hire additional staff, such as certified diabetes educators, or both. This results in an unsustainable business model for most physicians. The result is that there is little incentive on the part of the physician to follow evidence based guidelines or to achieve the NCQA’s Diabetes Physician Recognition Program (DPRP) certification.

Providing diabetes education requires a knowledgeable staff with specialized training, including certified diabetes educators, registered dietitians and registered nurses. These professionals generally have more time for patient consultation and focus more on goal planning and compliance. It also requires facilities that can accommodate group educational sessions and the ability to provide long term follow up and support.

Treatment of chronic disease, including diabetes requires physicians to manage their population of patients, rather that focusing on one patient at a time, every 15 minutes. Effective care requires nutrition consultations and group education, which may or may not be covered by insurance.

Calls to action for physicians

Physicians must take a proactive and population based approach to the treatment of their patients. This approach includes identifying patients that may be at risk for diabetes, such as those with impaired fasting glucose (pre diabetes) and the metabolic syndrome. It involves a much greater investment in, and use of electronic medical records so that patients not at goal (for example, HbA1C > 7) or out of compliance (no hbA1C or LDL test in chart) can easily be identified for additional follow up by physicians or office staff. The resulting additional office visits and improved compliance with evidence based guidelines will result in a positive return on the investment made.

Physicians that treat patients with diabetes must either provide adequate diabetes education or refer patients to programs that do. Adequate diabetes education programs are those that have staff with specialized training in diabetes, including certified diabetes educators, registered dietitians and registered nurses, and facilities that can accommodate group classes that include family members.

Ultimately, the best strategy for physicians is to provide the highest quality medicine possible, resulting in greater perceived value by the other stakeholders. While there is little doubt that physicians want to provide high quality medical care, the data suggests that there are many patients that are not receiving the minimum in acceptable quality. Achieving NCQA DPRP certification is a good way for physicians to ensure that they are providing high quality diabetes care.

To be effective in managing their population of patients, the physician must invest in systems to identify at risk for diabetes and patients that are out of compliance. While an electronic medical record is the most efficient way to monitor patients, less expensive resources are also available. The Texas Diabetes Council has developed algorithms and tracking tools, which can be found online at http://www.dshs.state.tx.us/diabetes.

Health Plans

Systemic Issues for health plans

Managing diabetes risk (screening, pre-diabetes prevention and diabetes management) was proven to be both clinically beneficial and cost effective in the Diabetes Primary Prevention Trial, conducted in 1993 under the direction of the National Institutes of Health. However, effective diabetes risk management is confounded by a health system that emphasizes treatment over prevention, has a bias toward expensive procedures, offers few incentives to treat the entire disease and offers virtually no incentive to prevent the condition in the first place. In many cases diabetes related care, including dietary counseling and certified diabetes educators is not reimbursed.

Medical inflation has returned and employers are demanding that health care systems continue to reduce costs. The Employer Survey indicates that the Health Plans are not only a payer of health care services, but also are a provider of wellness and disease management services. Of the employers that offer disease management programs, 68% offer them through their health plans.

Effectiveness of disease management programs is constrained by low levels of participation on the part of employers, low levels of adherence to lifestyle and medical management by consumers and inconsistent adherence to evidence based guidelines by physicians.

Calls to action for health plans

Health plans must evaluate reimbursement procedures to make sure they are setting up incentives for the desired behavior in consumers, employers and physicians. They should implement physician reimbursement procedures which reward quality care. The Plans should encourage, not only compliance with evidence based guidelines, but achievement of better outcomes, such as reduced morbidity and mortality, and lower cost.

Health Plans should hold physicians accountable for following evidence based guidelines. In addition to HbA1C, LDL test, eye exams and nephropathy, health plans should also monitor compliance to hypertension guidelines, influenza vaccine and smoking cessation strategies for patients with diabetes. Health Plans should train physicians and their staff on proper coding of claims to ensure they receive the reimbursement they are entitled to, and should reimburse for the cost of obtaining NCQA DPRP certification or provide resources to help to perform the reviews necessary to obtain certification.

Health Plans must provide tools to consumers, employers and physicians that make it easier to manage diabetes. Health plans must make diabetes prevention programs easily accessible and affordable. Age, culture, and socio-economic status must be taken into consideration by the Health Plans when designing these programs. Programs that have Spanish translations and are multimedia (video, audio and print) should be encouraged.

Employers

Systemic Issues for employers

The cost of healthcare and especially diabetes related care continues to rise to the point where it is jeopardizing the financial viability of many employers. Today, businesses in the US spend the equivalent of one-half to two-thirds of their after tax profits on healthcare.

Most DFWBGH Corporate Members appear to recognize the connection between healthy employees and a healthy bottom line and are investing in worksite health management programs such as Health Risk Assessments and Disease Management. In spite of their willingness to invest in worksite health management programs, the Employer Survey indicated that only a few of the respondents reported that their health management programs were “very successful” in helping employees with diabetes manage their condition.

The majority of survey respondents cover key diabetes health care services, including lipid panel, A1C test, foot exams and retinal eye exams, which are considered quality of care indicators by national accrediting organizations. Nutritional counseling, weight management and the use of certified diabetes educators, however, are covered 50% of the time or less.

Many companies provide either an incentive (66%) or penalty (6%) to encourage participation in the health risk assessment; however the presence of incentives or penalties alone did not guarantee a high rate of participation. The type and level of an incentive or penalty probably impacts its effectiveness.

Calls to action for employers

To derive the most value from worksite disease management programs for both the employer and employees, it is important for employees with diabetes to have access to appropriate clinical tests and treatments that help the physician and patient manage the condition. The finding that most DFWBGH Corporate Members cover key diabetes services suggests good alignment of health plan coverage with disease management programs and thus eliminates what could be a huge barrier to patient compliance among DFWBGH’s employee population.

Employers can drive engagement and empowerment of employees in decisions about their health with better access and benefit design. Earlier identification and appropriate medical care can benefit employee and employer in terms of health and economics. Economic benefits of healthier employees include lower health care costs, as well as higher productivity and lower absenteeism. Offering and encouraging the use of health risk assessments can help in early identification of employees at greater risk for type 2 Diabetes and encourage them to make lifestyle changes now to delay or prevent the onset of diabetes. Employers should design value based benefits that provide incentives and encourage employees to engage in a healthy lifestyle and to obtain necessary medical treatment. These plans should offer wellness programs and educational opportunities to inform employees about their benefits, lifestyle issues, etc. Senior management needs to get behind an emphasis on health and personal responsibility for health. Employers should engage programs that reward high quality, such as pay for performance.

Employers should engineer health and wellness into the workplace just like they do with safety and infection control. This means healthier food in the cafeteria, access to exercise facilities or walking areas, etc. They should also make it a part of their corporate culture. Company sponsored events and activity can emphasize health and wellness, but also send a signal that employees are valued, and enhances the overall work environment.

In addition to wellness and disease management services provided by the Health Plans, other community based services are available through worksite diabetes prevention and disease management programs, such as the American Diabetes Association’s “Winning at Work” program, or the National Diabetes Education Program. Also the marketplace offers a broad array of commercially available programs to educate employees and encourage healthier lifestyles and better health care consumerism.

Heal HER Heart: Healthy, Energized and Revitalized

Posted on May 3, 2012 by Patrick Dunn

According to the American Heart Association, from 1980 to 2000 the mortality rates from heart disease were declining in men but increasing in women (Roger, 2012). While the mortality rates in women are now on a downward trend, more women still die of heart disease than men and the gap is much wider when looking a race and ethnic status (Christian, 2007). Mosca (2010) assessed the awareness of heart disease risk and barriers to health in women and found that awareness of cardiovascular disease as the leading cause of death in women is suboptimal. Only 53% of women were aware that heart disease is the leading cause of death in women. While 1 in 8 women die of breast cancer, 1 in 2 die from cardiovascular disease. Mosca (2010) also found that women are less likely to call 9-1-1 if they thought they were having a heart attack and perceive that therapies to reduce their risk of a heart attack are unproven.

Heart disease is generally thought to be a man’s disease. Nearly all of the research and virtually all of the recommendations are based on and specific to men. Heal Her Heart is a comprehensive heart disease prevention program specifically for women.

Women have higher HDL and less belly fat which reduces their risk of heart disease. Estrogen has a protective quality and so risk increases after menopause. Symptoms of a heart attack present differently, causing many, including healthcare professionals to dismiss them as “stress” or “hormonal”. Diagnostic tests, especially stress tests are less accurate. Finally, women are more family focused.

The goal of Heal Her Heart is to:
1. Increase awareness of heart disease as the leading cause of death in women to 75%(Knowing Her Heart),
2. Detect metabolic syndrome and heart disease in women prior to the onset of clinical events, such as myocardial infarction or stroke (Checking Her Heart),
3. Prevent cardiovascular events and improve compliance and risk factors, including lipids, blood pressure, obesity and impaired glucose metabolism in high risk women by increasing the number of women at evidence based treatment goals and by reducing the Framingham risk by 50% (Healing Her Heart),
4. Improve lifestyle habits, such as smoking, overeating and sedentary lifestyle in women (Living with Her Heart), by 50%.

In the United States, almost 500,000 women die of heart disease each year, which approximates 1 death every minute. Heart disease is the single leading cause of death for women in the United States. Whereas heart disease deaths in US men have steadily declined since 1980, the number of cardiovascular deaths in women remains unchanged or is increasing. Furthermore, since 1984, the number of cardiovascular deaths for females has exceeded those for males. Heart disease is often fatal, and because nearly two thirds of women who die suddenly have no previously recognized symptoms, it is essential to prevent CHD.

Recent data have demonstrated the important sex-based differences in heart disease including: risk factor stratification, clinical presentation, diagnostic strategies, response to therapies, and adverse outcomes. Yet, few women appreciate that CHD is a major female-specific health problem. Interestingly, it has been reported that 1 in 30 deaths in women is due to breast cancer, while 1 in 2.5 deaths is due to cardiovascular disease. Still, many women perceive breast cancer as their major health concern. This disparity between fact and perception highlights the need to increase women’s awareness about their vulnerability to CHD.

But why this gender gap? Women present to emergency rooms or chest pain centers 1-2 hours later than men. Do multiple roles a woman takes delay care of because of her responsibilities to others? Do women delay care because they perceive that heart disease is something that happens to one’s father, brother, or spouse?

This gap may also extend to healthcare providers. Only 38% of women discuss heart health with their healthcare provider. The one year death rate for men following a heart attack is 25% and for women it is 38%. Only part of this gap can be explained by age. Finally, recommended treatments for heart disease, such as aspirin, referrals to cardiac rehabilitation programs and use of cholesterol lowering medications are less likely to be used in women.

So what can you do?

Seek medical advice for warning signs, act promptly when acute symptoms, seek information related to your risk level and make appropriate modifications in lifestyle to reduce risk.

Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden, WB, Bravata DM, Dai S, Ford ES, Fox CS, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Kissela BM, Kittner SJ, Lackland DT, Lichtman, JH, Lisabeth LD, Makuc DM, Marcus GM, Marelli A, Matchar DB, Moy CS, Mozaffarian D, Mussolino ME, Nichol G, Paynter NP, Soliman EZ, Sorlie PD, Sotoodehnia N, Turan TN, Virani SS, Wong ND, Woo D, Turner MB; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:e2–e220.

Christian, A.H., Rosamond, W., Berra, K., Taubert, K., Mills, T., Burdick, K.A., Simpson, S.l. (2007). Nine-year trends and racial and ethnic disparities in women’s awareness of heart disease and stroke: An American Heart Association National study. Journal of Women’s Health. 16:68-81.

Mosca, L., Mochari-Greenberger,H., Dolor, R.J., Newby, L.K., Robb, K.J. (2010). Twelve-Year Follow-Up of American Women’s Awareness of Cardiovascular Disease Risk and Barriers to Heart Health. Circ Cardiovasc Qual Outcomes.;3:120-127

Re-engineering Cardiac Rehabilitation to “Get with the Guidelines”

Posted on April 24, 2012 by Patrick Dunn

Preventive Cardiology remains an enormously under-utilized service. There is now an abundance of evidence from clinical trials and from our own programs that cardiovascular disease management is successful at modifying risk factors, reducing recurrent cardiovascular events and controlling cost. The ACC, however, has identified a lack of patient access to appropriate programs, insufficient motivation on the part of the physician and patient non-compliance with medical and lifestyle management as reasons for the lack of growth and profitability of Preventive Cardiology. Recently, the American Heart Association has developed Get with the Guidelines, to improve compliance with AHA/ACC guidelines for cardiovascular management.

There are examples of Cardiac Rehabilitation/Cardiovascular Disease Management programs that have been both clinically and financially successful. The keys to success of these programs included:
 Assessing the prevention related needs of all inpatients and matching of those needs with outpatient services
 Increasing the capacity and operational efficiency of outpatient programs to accommodate new growth
 Provide comprehensive menu of services that provide a seamless transition from programs billed to insurance and self pay programs.

Phase 1: Needs Assessment/Resource matching
Cardiac Rehabilitation is a fundamental part of a cardiology service line. Inpatient services are an important aspect of the care for patients who have undergone cardiovascular surgery, angioplasty or stent, for patients who have survived a myocardial infarction or who suffer from angina pectoris, congestive heart failure, arrhythmias or valvular heart disease. They can also be the way to accomplish necessary reporting functions, such as the AHA Get with the Guidelines. Successful implementation into an inpatient cardiac rehabilitation program using the Get with the Guidelines format can improve the care to the patient by improving compliance to treatment, reducing morbidity and mortality and increasing general health perception and satisfaction. Inpatient cardiac rehabilitation is also the first step in the long term recovery of the patient and the initiation of a secondary prevention program.

The Cardiac Rehabilitation staff will assess the needs of the patients in the Hospital and match those needs with available resources available to the patients. An inpatient cardiovascular disease management plan will be developed for each patient. This plan will be interactive with the patient, nurse and physician and will use the motivational interviewing style. This care plan will include an exercise therapy/activity plan, risk assessment and needs analysis, education plan and discharge planning. The Cardiac Rehabilitation staff will review the charts of all cardiovascular inpatients as well as those with cardiovascular risk factors, including obesity, hypertension and diabetes. The Cardiac Rehabilitation staff will consult with each patient’s primary care nurse, and physician when appropriate, on the exercise therapy/activity and education plans. The Cardiac Rehabilitation staff member will document the risk assessment and needs analysis in the patients chart. The Cardiac Rehabilitation staff will also interact with the patients daily as appropriate providing education, assessment and support. The Cardiac Rehabilitation staff will discuss patient’s risk/needs assessment with the physician. If outpatient services are indicated, such as Phase II Cardiac Rehabilitation, the Cardiac Rehabilitation staff will coordinate the follow-up care.

The goal of this will be to:
 Identify patients who are appropriate for outpatient Cardiac Rehabilitation, Pulmonary Rehabilitation and PAD Rehabilitation;
 Identify patients who are appropriate for other disease management services provided by the Hospital, including the Lipid Clinic, CHF Clinic, Diabetes Center, etc; and
 Identify patients who are appropriate for wellness and prevention services, such as smoking cessation, weight management, stress management, etc.
Staff Training
In order to provide the most informed, educated, sophisticated and caring environment for patient recovery, the nursing care giver staff must be informed regarding a variety of areas of cardiology, physiology, exercise physiology, risk stratification and psychology. This has great relevance in the area of successful beginning and early implementation of motivating patients to alter harmful risk factors/behaviors. A curriculum of information will be developed including educational materials, evaluations and competencies to insure that all care givers are educated. Cardiac Rehabilitation will work with the Hospital staff development educators. Areas of emphasis will be in cardiac rehabilitation, bio-psychosocial risk factor assessment and intervention and motivational interviewing.

Phase II: Increasing volume/improving efficiency

Phase II Cardiac Rehabilitation is capital and labor intensive. Once the capital (space, telemetry monitors and exercise equipment) has been purchased and the staff have been hired, the marginal cost of increasing volume is very small. For example, adding one additional patient to a session is typically 3 electrodes and one sheet of paper. Examples A and B each achieved approximately a 3-fold increase in volume. Example C is an example of the impact of a 2-fold and 3-fold increase in volume on unit cost and profitability. A 3-fold increase in volume decreases the average cost per session from $32 to $11 and makes the margin a positive number. This, of course, is assuming that the program is not already at capacity, requiring additional equipment, space and staff. Most programs, however, are far from capacity.

Increasing capacity
Most Phase II sessions are conducted one at a time including a 15 minute preparation phase (history, vitals, hooking up telemetry), a 45 minute exercise phase, and a 15 minute cool down phase. Phase II sessions, therefore, are usually scheduled at 75 minute intervals. The 30 minutes of exercise down time from the cool down period of the previous class and the preparation phase of the next class can be reduced if they are conducted concurrently, outside of the exercise area. As patients are cooled down and taken off of the telemetry monitor, the next arriving patient can be started. New, high risk and/or difficult patients can actually be scheduled in that 30 minute window. This system works best with 3 staff, 2 conducting the exercise sessions and 1 coordinating the prep/cool down and conducting education.
Phase III: Multi faceted and Comprehensive

Needs assessment and resource matching will result in an increased number of Phase III/prevention related participants. This increased growth will come from a larger number of Phase II participants as well as a larger number of non Phase II participants (those with coronary artery disease or equivalent and congestive heart failure). It is essential that programs be designed to appeal to both groups. While the content is very similar, the packaging of the program needs to be more comprehensive and focus on cardiovascular wellness vs. cardiovascular disease. Consideration should be given to changing the name of the program to reflect an all encompassing cardiovascular disease management program. Examples A and B developed completely new names (Personal Wellness and PHD) that were open to everyone. These programs were used as a hub that utilized the resources of other prevention related programs. It is much easier to market these programs than individual wellness programs, such as weight management, stress management and smoking cessation. Content from these programs can also be used as an educational format for disease management programs, such as Phase III, CHF Support, Diabetes Self Management, PAD Rehab, Pulmonary Rehab, Cancer Rehab, chronic pain, etc. Newer cardiovascular wellness programs, such as the Game of Health have been modeled after these experiences. Finally, a new, cutting edge cardiovascular wellness program, such as the Game of Health can be used in employee wellness and marketed to corporate wellness and occupational health clients as well as the general community, resulting in even greater revenue for the program.

Example A

This is an example of a Hospital-based Cardiac Rehabilitation program that transformed itself from a traditional program to a Comprehensive Cardiac Rehab Program. The setting was a 320 bed Hospital with a full service Cardiology program. Significant program growth was achieved by: (1) increasing the presence and role of Cardiac Rehab in the Hospital; (2) expanding the role of the Medical Director; and (3) creating new, cutting edge prevention programs that were marketed to the Cardiac Rehab patients as well as the community. Phase II volume increased from an average of 22 patients to an average of 75 patients. Phase III participation increased from 133 to over 1,200. In addition to program growth, this program also demonstrated significant improvement in hospital utilization and a reduction in cost.

Example B

This is an example of a private Preventive Cardiology program that was not affiliated with a hospital or cardiology group. This program’s core business, therefore, was Cardiac Rehabilitation, Lipid Clinic and Cardiovascular Wellness. This program contracted with a local hospital to provide inpatient cardiac rehabilitation. The outpatient Cardiac Rehab facility was located outside of the Hospital. Even with rent, physician compensation and overhead included, this program was able to achieve a positive cash flow.

Practical Approaches in the Design and Implementation of an Advanced Cardiovascular Prevention Program that emphasized, not ignores Cardiac Rehabilitation

Posted on April 16, 2012 by Patrick Dunn

Over the past 30 years the US healthcare system has made tremendous breakthroughs in both the treatment and delivery of healthcare services. Cardiology has witnessed the development of new diagnostic procedures, such as echocardiography, nuclear imaging and ultrafast CT scanning and new surgical procedures. Modern laboratory tests have also emerged including LDL and HDL phenotyping, lipoprotein (a) and homocysteine level detection as well as determination of C-reactive protein levels. Moreover, over the past two decades interventional cardiology has also evolved in areas such as percutaneous coronary angioplasty, carotid atherectomy and arterial stenting. Over such period time, advanced medications such as tissue plasminogen activator (tPa), HMG Co-A reductase inhibitors (statins) and anti-platelet drugs have been developed and are now routinely used.

The delivery of healthcare has also seen many changes, such as patient focused care, chest pain and fast track ERs, physician extenders, and managed care. Unfortunately, the science and delivery of cardiac rehabilitation has changed very little over the last quarter of a century. Cardiac rehabilitation remains an enormously under utilized service. Lack of patient access to appropriate facilities, insufficient motivation on the part of the physician to refer patients routinely to cardiac rehabilitation and patient non-compliance with medical and lifestyle management that continue to constrain the growth of cardiac rehabilitation.

Most cardiac rehabilitation programs today have maintained a strategic focus on improving the patient’s functional capacity through exercise programming while additionally providing in-valuable education for patients and family members. However, there is an emerging trend in today’s modern U.S. health care system to position preventive cardiology as a medical subspecialty by including cardiac rehabilitation, lipid management, congestive heart failure and coumadin checks as a service line. This new approach changes both the science and delivery of preventive cardiology making it a more relevant part of a full service cardiology program.

Components of a modern cardiovascular prevention program:
1. Cardiac Rehabilitation
2. Heart Failure Clinic
3. Lipid Clinic
4. Metabolic/Diabetes Center

Preventing heart failure readmissions by taking a population approach

Posted on April 10, 2012 by Patrick Dunn

The key to preventing readmissions taking a population approach. Many initiatives designed to reduce readmissions are destined to fail because they are using the same model that got us into this mess in the first place. Healthcare providers are significantly outnumbered. There simply is not enough capacity in the system to get every patient seen in a timely manner.

The process should begin by providing discharge instructions that promote health literacy. This means providing a tiered approach that is action oriented and provides the patient with parameters. For example, we tell patients to weigh themselves every day, but do we give them actionable parameters, such as “if you gain 3 pounds in 3 days, call me.”

We also need to leverage each healthcare provider through the use of technology. While there is no argument that direct contact is always to best, we cannot send a nurse home with every patients. How many patients can one nurse call in a day, 10-15? That same nurse can monitor 200-300 patients telephonically, and then interact with the 10-15 that need the most attention. This requires learning how to manage 200-300 patients at a time, rather than focusing on a smaller number. These skills should focus on education, motivation, and coaching.

Preventing readmissions

Posted on April 3, 2012 by Patrick Dunn

Core Measures

Posted on April 3, 2012 by Patrick Dunn

With the Affordable Care Act and Value Based Purchasing, Core Measures are more important than ever. Currently, 70% of the Value Based Purchasing score is based on Core Measures.

The Patient Protection and Affordable Care Act of 2010 mandates the implementation of an inpatient hospital value-based purchasing Program, a pay-for-performance program that will link Medicare payment to quality performance for acute care hospitals paid under the Inpatient Prospective Payment System.

The Medicare Hospital VBP final rule was published in the May 6 Federal Register. This final rule will implement the first year of the VBP Program mandated by the PPACA, effective beginning Oct. 1, 2012; federal fiscal year 2013. The rule also puts in place a number of policies of the FFY 2014 VBP Program. The final rule draws heavily from CMS’ 2007 Report to Congress: Plan to Implement a Medicare Hospital VBP Program, and does not deviate significantly from CMS’ proposed rule, published in January.

Using a subset of the quality data reported under the Hospital Inpatient Quality Reporting Program, grouped into quality domains, hospitals will earn points towards an overall VBP score. The scoring methodology will provide points for hospitals that achieve high quality standards as well as points for improvement in those quality measures. An overall VBP score will be calculated for each hospital; those scores will then serve as the basis for determining hospitals’ VBP incentive payments.

As required by the PPACA, a pool of funds, to be redistributed to hospitals based on their VBP scores, will be funded through an across-the-board reduction to Medicare IPPS payments. The reduction is scheduled to be 1.0 percent in FFY 2013, increasing by 0.25 percent each year until the reduction reaches 2.0 percent for FFY 2017 and subsequent years.

The Hospital VBP Program applies to all “subsection (d)” inpatient hospitals – all hospitals paid under the IPPS. Critical Access Hospitals and small hospitals with insufficient numbers of measures and/or cases are excluded from the program. The program does not apply to psychiatric, rehabilitation, long-term care, children’s and cancer hospitals, and hospitals in Puerto Rico.

Introducing the other members of the family

Posted on March 24, 2012 by Patrick Dunn

Your Heart Score now has some new family members that I would like to introduce to you. Knowing Your Heart (http://www.knowingyourheart.com) is a new site dedicated to heart health literacy. Knowing Your Diabetes (http://www.knowingyourdiabetes.com) is a companion site to Knowing Your Heart and is dedicated to diabetes literacy. TWC Alumni (http://www.twcalumni.com) is dedicated to the art of coaching (baseball). A new family member is also on the way called the ‘VERBS’. More to come on the VERBS later.

Outpatient monitoring of chronic diseases: Who should we monitor…. and why!

Posted on March 11, 2012 by Patrick Dunn

Most industries in the United States have the ability to pick and choose who their customers are. A retail store may have a sale on one item and take other items… the ones that are not selling, off of the shelf. A manufacturing company may stop producing a product if the costs are higher than the expected revenue, or they might raise the price.

A full service, community based hospital must provide for the healthcare needs of its community. Most hospitals have service lines that they specialize in, such as cardiology, orthopedics, labor and delivery. In fact, most hospitals only make a profit on a few services, such as interventional cardiovascular procedures (coronary artery bypass surgery and percutaneus coronary intervention, or stents) and orthopedic surgery. But they also, however, have thousands of patients with chonic conditions, such as heart failure, diabetes, hypertension and asthma walking into their emergency departments. Very few, if any, hospitals are able to make a profit on these patients.

Heart Failure is the second most common admitting diagnosis for Medicare Beneficiaries. The average US Hospital loses approximately $1,368 on each heart failure admission and the average length of stay is 5.1 days.

But what does the average mean? It means that 50% of the values are lower than the average and 50% of the scores are higher than the average. While some hospitals may be doing well compared to the average, all hospitals have patients that are in high risk groups and are well above the average.

Proper identification and effective management of the patients that may end up to the right of the curve is not only good for the patient, and good for society, but will also help flush excess cost out of the system.

Who should be monitored?

Clinical indications for monitoring heart failures based on the Crusade Study and studies conducted with Healthcall patients.

Class III/IV or Stage C/D
Prior myocardial infarction or coronary intervention (PCI, CABG, ICD)
Systolic blood pressure < 115 mmHg
BNP > 650
Ejection fraction < 30%

Coding and utilization indications for monitoring heart failure pateints:

2 or more hospitalizations for heart failure in 12 months
Diagnosis of diabetes (ICD 250)
Diagnosis of Hypertension (ICD 401-405)
Diagnosis of coronary artery disease (ICD 410-414)

Any Why?

While many Hospitals are focused on improving core measures for heart failure as an indicator of quality, most are resigned to the fact that they will lose money treating these patients. HF disease management is a solution on both ends of the curve that could actually make the treatment of heart failure profitable.

1. Left side of the curve: By reducing the number of readmissions, the number of un-reimbursed care will decrease. HF disease management has demonstrated a 72% reduction in readmission rates. If the number of uncompensated cases was reduced by 72%, the average reimbursement would increase to $5,734, compared to an average cost of $2,685 (average cost went down because many of the outliers were in the uncompensated care group).

2. Right side of the curve: By reducing the number of outliers, which are patients that have a cost of > $7,000, the average cost will significantly decrease. By monitoring these patients on a daily basis and optimizing therapy, interventions will occur sooner resulting is a decrease in the acuity of the patient.

If the outliers were reduced, the average cost would drop to drop to $4,582 with reimbursement of $5,019. If both sides of the curve are impacted, the average revenue could be $5,734 with an average cost of $4,582, resulting in a profit of $1,152, rather than a loss of between $545 and $1,368.

References

Gambetta M, Dunn P, Nelson D, Herron B, Arena R. Impact of a Heart Failure Disease Management Program on Hospitalization. Heart Failure Society ofAmerica,Seattle,WA, Journal of Chronic Heart Failure, 2006.

Gambetta M, Dunn P, Nelson D, Herron B, Arena R. Impact of the Implementation of Telemanagement on a Disease Management Program in an Elderly. Press: Progress in Cardiovascular Nursing Prog Cardiovasc Nurs. 2007;22:196–200.

Patrick Dunn, Miguel Gambetta, Dawn Nelson, Bobbi Herron, Community Health Care System,MunsterandHobartIndiana. Ross Arena,VirginiaCommonwealthUniversity,Richmond,VA

Reduction of B-Type Natriuretic Peptide using Telemanagement in Patients with Heart Failure. Heart Failure Society ofAmerica,WashingtonDC, Journal of Chronic Heart Failure, 2007.

Dunn P, Gambetta M, Nelson D, Herron B, Arena R. Relationship between Brain Natriuretic Peptide and Heart Failure Symptoms. Heart Failure Society ofAmerica,Seattle,WA, Journal of Chronic Heart Failure, 2006.

Dunn P, Gambetta M, Nelson D, Herron B, Arena R. Change in Brain Natriuretic Peptide Predicts Risk for Hospitalization in Patients with Heart Failure. Heart Failure Society ofAmerica,Seattle,WA, Journal of Chronic Heart Failure, 2006.

Broken In Plain Sight

Posted on February 26, 2012 by Patrick Dunn

In Broken In Plain Sight by Bridgette L. Collins, the author describes her new book as ‘a creative self-help book that includes imagined dialogue and events based on what she has experienced, witnessed, heard, or read about.’ But what exactly does that mean? It means the author has used healthy living tips (mind, body, and soul) as a base from which to create a fictional, highly imaginative, and exciting story of healing and healthy living through truth, healing, and love. The novel-like feel works marvelously to illustrate the underlying reasons for unhealthy lifestyle habits and offers practical and innovative solutions for living healthier.

Bridgette’s candid descriptions of how a family is destroyed by years of poverty causing a spiral of hurt, neglect, incest, physical abuse, and betrayal will have readers clinching their seats. This tear dropper begins when fitness coach, Trevor MacElroy reluctantly has dinner with his Uncle Bert, a successful and influential businessman and state representative in Texas. His uncle wants to discuss his regret over the family’s self-destruction and he solicits Trevor’s help to turn around their lives. Trevor utilizes his life coaching experience to push his cousins into a self-developing and healing program educating readers on the importance of overcoming years of hurt mind, body, and spirit.

Throughout the book, Bridgette charts an unspoken perspective, and an all-too-common trajectory from unhealthy lifestyles, casting crucial light on why individuals have difficulty implementing and sustaining healthy lifestyle habits. The author has obviously done an exceptional amount of research. Her style is detailed and meticulous. This might sound slow-going, but it isn’t. Once she has set the scene in the early chapters, there’s no stopping it.

It comes as no surprise to learn that Bridgette Collins is a fitness coach and inspirational speaker. Her experience in the area of health and fitness shines through her new book, lending genuineness and interest.

Bridgette’s new book is available at http://www.Amazon.com, http://www.BN.com, and everywhere books are sold. And ebooks like Kindle and Nook too!