Kaiser Health News

The federal government paid bonuses to 231 hospitals with subpar quality because their patients tend to be less expensive for Medicare, new research shows. The bonuses are small, generally a fraction of a percent of their Medicare payments. Nonetheless, rewarding hospitals of mediocre quality was hardly the stated goal when the Affordable Care Act created financial incentives to encourage better medical care from hospitals, doctors and other health care providers. A study published Monday in the journal Health Affairs looked at the more than $1 billion in payments made last year in the Hospital Value-Based Purchasing program, which raises or lowers Medicare payments to hospitals based on the government’s assessment of their quality. Medicare primarily uses death and infection rates and patient surveys to judge hospitals, but it also evaluates how much each hospitals’ patients cost, both in treatment and recovery. The 231 hospitals the study identified had below average scores on quality measures but were awarded the bonuses because caring for their patients during their stays and in the 30 days following their discharge cost Medicare less than what it cost at half of hospitals evaluated in the program. The Centers for Medicare & Medicaid Services, or CMS, began measuring cost in October 2014 to encourage hospitals to provide care in the most efficient way possible. In the period examined in the study — the federal fiscal year that ended in September 2015 — spending counted for 20 percent of a hospital’s score in determining whether a hospital would get a bonus, penalty or regular payment. Under this formula, hospitals with Medicare spending below the median hospital were able to qualify for bonuses even though their quality measures were below the median, the study found. Patients at those 231 hospitals cost Medicare on average nearly $16,000, about $2,300 less than the average spending for the patients at other hospitals that received bonuses, according to the study’s lead author, Anup Das, a medical and health policy student at the University of Michigan. The average bonus for those lower quality hospitals was an 0.18 percent increase in Medicare payments for each patient stay during that fiscal year. Most of the 1,700 hospitals that received a bonus that year had higher than average quality ratings, and their patients in some cases were more costly to Medicare. [See also: 15 quality chiefs at best hospitals.] “High-quality low-spending hospitals received the greatest financial benefit from the program,” the study said. “In this respect, CMS achieved its goal with the new spending measure. However, some low-quality hospitals received bonuses because of their low spending.” In a statement, CMS said it would consider revising the program for future years so that hospitals scoring below the national median for quality would not receive a bonus. The statement also noted that this year, three-fourths of hospitals’ scores were based on quality measures. “We believe that there needs to be a balanced consideration between quality and cost, which is reflected in our scoring methodology,” the statement said. The study found the lower-quality hospitals that received bonuses in the last fiscal year had higher death rates for heart attacks, heart failure and pneumonia than half of the nation’s other hospitals evaluated in the program. These hospitals were also less likely to follow recommended procedures for care, like choosing the right antibiotic for patients or performing an angioplasty on a heart attack patient within 90 minutes of their arrival at the hospital. [See also: 1,700 hospitals win Medicare quality bonuses, but will never collect.] The 231 lower-quality hospitals with bonuses also received less enthusiastic ratings from patients about how well doctors and nurses communicated, responded to issues and managed pain, the study found. The study did not name the 231 hospitals. “It’s a small decrease in quality, but the differences are significant,” Das said in an interview. Other new federal quality payment programs created by the health law, such as accountable care organizations, deny bonuses to doctors or hospitals with substandard quality of care, no matter how efficiently they operate. The study suggested the government add a similar limitation to the Value-Based Purchasing program. The study did not look at the current federal fiscal year, which runs through this September. This year, Medicare gave bonuses to 1,705 hospitals, averaging 0.51 percent, and reduced payments to 1,375 hospitals by an average of 0.34 percent, according to a Kaiser Health News analysis. Along with spending, Medicare’s other criteria are: death and infection rates; how faithfully a hospital followed basic clinical guidelines; and how patients rated their experiences in surveys. Spending counts for a fourth of each hospitals’ scores, more than last year, and is scheduled to continue to do so for the next two years. The study’s lead author, Das, said in the interview that a preliminary analysis found some lower-quality hospitals again received bonuses.  

The sheer number and variety of providers that patients see after leaving a hospital make medical mistakes and poor transitions in care all too common today. 

The nonprofit patient safety organization found that nearly  40 percent of potentially harmful drug orders weren’t flagged by existing software systems, including medication orders for the wrong condition or the wrong dose based on things like a patient’s size, other illnesses or likely drug interactions. 

EHR makers Epic and Cerner are building advanced directive features into their software to enable data sharing, an official said. Some lawmakers are looking to make directives portable while U.S. states are building databases to store them.  

A healthcare startup made a wild pitch to Cara Waller, CEO of the Newport Orthopedic Institute in Newport Beach. The company said it could get patients more engaged by "automating" physician empathy. It "almost made me nauseous," she said. How can you automate something as deeply personal as empathy? But Waller needed help. Her physicians, who perform as many as 500 surgeries a year, manage large numbers of patients at various stages of treatment and recovery. They needed a better way to communicate with patients and track their progress. [Also: Patient-physician emails improve care quality] The California startup, HealthLoop, told Waller its messaging technology would improve their satisfaction and help keep them out of the hospital. High satisfaction scores and low readmission rates mean higher reimbursements from Medicare, so Waller was intrigued. So far, she's been surprised at patients' enthusiasm for the personalized -- but automated -- daily emails they receive from their doctor. "There's a limited number of resources in health care. If you do 500 joint replacements in a year, how do you follow up all of those patients every day?" Waller said. The technology "allows you to direct your energy to people who need the handholding." "Automating empathy" is a new healthcare buzzword for helping doctors stay in touch with patients before and after medical procedures -- cheaply and with minimal effort from already overextended physicians. It may sound like an oxymoron, but it's a powerful draw for hospitals and other health care providers scrambling to adjust to sweeping changes in how they're paid for the care they provide. Whether the emails actually trigger an empathetic connection or not, the idea of tailoring regular electronic communications to patients counts as an innovation in health care with potential to save money and improve quality. [Also: Healthcare security: Adapt or die] Startups like HealthLoop are promising that their technologies will help patients stick to their treatment and recovery regimens, avoid a repeat hospital stay, and be more satisfied with their care. Similar companies in the " patient engagement " industry include Wellframe, Curaspan, and Infield Health. HealthLoop's technology is being tested at reputable medical centers including the Cleveland Clinic, Kaiser Permanente-Southern California, the University of California, San Francisco, and the Newport Orthopedic Institute in Orange County, company officials said. Doctors can send daily emails with information timed to milestones in surgery prep and recovery and ask patients or caregivers for feedback on specific issues patients may face during recovery. The doctors may write their own email scripts, as Newport Orthopedics' physicians did, or use the company's suggested content. An online dashboard helps doctors and administrators keep track of which patients are doing well and who might need more follow-up care. Patients can also communicate with office staff about medications and office visits. Their responses to daily emails can trigger a call from the doctor's office. A patient might see this message: "How are you? Let me know so I can make sure you're okay. I have four questions for you today." Such a call may have been a lifesaver for David Larson, a Huntington Beach retiree. After Larson responded "yes" to an email that asked if he had calf pain after knee surgery, he got a call from his doctor's office telling him to come in immediately. An ultrasound confirmed he had a blood clot that could have landed him back in the hospital -- or threatened his life. With treatment, the blood clot dissolved and he resumed recovery. "There were times when it was like, 'Oh brother, they're contacting me again,' but none of this would have been caught if it wasn't for the email," said Larson, 66. "So it was more than worth it to me. Now I'm back to walking the dog, surfing, riding a bike." How to keep patients like Larson from hospital readmission because of avoidable complications after a hospital stay has long been one of health care's most vexing and expensive challenges. Almost one of every five Medicare patients discharged from a hospital -- approximately 2.6 million seniors -- must be readmitted within 30 days, at an annual cost of more than $26 billion, according to the Centers for Medicare and Medicaid Services. For decades, hospitals had no financial incentive to keep patients out of the hospital after they were discharged. But under the Affordable Care Act, financial penalties were established for hospitals with readmission rates higher than the national average for certain conditions. Also under the ACA, hospitals are financially rewarded for high scores on patient satisfaction scores and good performance on other quality measures set by CMS. Doctors' groups increasingly are affected financially by this sea change, either because they are part-owners in a hospital, as Newport Orthopedics is with Hoag Hospital in Newport Beach, or because they participate in other risk-sharing financial partnerships with hospitals. With that kind of money at stake, hospitals and other health care providers may be willing to pay for programs like HealthLoop, if the tryouts prove successful. And you could see your own relationship with your physician change as a result, whether you're on Medicare or not: HealthLoop is aimed at all patients, whatever the payment source. Some experts worry that health care providers will come to rely too heavily on electronic communication as a cheap substitute for the hard work of improving the doctor-patient relationship and the quality of care that patients get. "Automating personalized messages isn't a terrible thing; we all get some of that in our everyday lives," said Michael Millenson, a health industry consultant. "The real question is whether this kind of automated messaging is in conjunction with a cultural change in how doctors think about their patients or not." Health care providers have long experimented with ways to prevent complications that can land a patient back in the hospital, with varying success, said Kristin Carman, vice president of health policy research at the American Institutes for Research. Robo-calls reminding you to take your medicine, for example, don't seem to be very effective. And the new technologies don't always address demographic, cultural and language barriers that can prevent patients from communicating with their doctors. For now, HealthLoop is only available in English. Dr. Jordan Shlain, a San Francisco internist, said he founded HealthLoop because he wanted a simple way to keep track of his patients' progress after a hospital visit or procedure. "Every human has the same kind of trajectory of concerns and anxieties with regard to medical situations," Shlain said. [Like Healthcare IT News on Facebook] HealthLoop, based in Mountain View, offers "a digital extension of the doctor," he said. "You know your doctor can't email you every day; you know your doctor usually will not call you. Now you're in a world where your doctor says I'd like to use this system to stay in touch with you and guide you through your recovery." Dr. Thomas Vail, professor and chairman of the department of orthopedic surgery at the University of California-San Francisco would agree -- up to a point. With his UCSF colleagues, Vail is testing HealthLoop's system with his patients, and the university will be evaluating whether patients who use it have fewer adverse events than their peers. UCSF helped create some of the language for the automated emails and has a financial relationship with the company, said Dr. Aenor Sawyer, who directs UCSF's Skeletal Health Service and is a leader at the university's Center for Digital Health Innovation. While Vail thinks HealthLoop is potentially promising, he's cautious about its role in his practice. "I don't think it substitutes for face-to-face communication," Vail said, "but it does help us collectively to not overlook something that might be important." This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation. Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation. Twitter: @HealthITNews

Perched on an exam table at the doctor's office watching the clinician type details about their medical problems into their file, what patient hasn't wondered exactly what the doctor is writing? As many as 50 million patients may have a chance to find out in the next few years.

In its toughest crackdown yet on medical errors, the federal government is cutting payments to 721 hospitals for having high rates of infections and other patient injuries, records released Thursday show.

Jay Radcliffe breaks into medical devices for a living, testing for vulnerabilities as a security researcher. He's also a diabetic and gives himself insulin injections instead of relying on an automated insulin pump, which he says could be hacked.

Neglected to pick up your prescription? Now, there's a good chance your doctor will know and do something about it, thanks to a slew of new partnerships between CVS Health and various health systems.

When a car rolls off an assembly line, the automaker knows exactly what parts, labor and facilities cost. Not so in healthcare, and now some health executives are trying to change that.