News & Updates

The CMS issued a “request for information” Wednesday from providers and patient advocacy groups on new ideas to bring to the Center for Medicare and Medicaid Innovation responsible for creating new payment models.

The notice came after CMS Administrator Seema Verma wrote in a Wall Street Journal op-ed Tuesday evening that the Innovation Center’s old policies led to consolidation that has been widely blamed for growing overall healthcare costs. She also said the policies burdened providers.

“Providers need the freedom to design and offer new approaches to delivering care. Our goal is to increase flexibility by providing more waivers from current requirements,” she wrote.

The CMS is asking for feedback on ways to promote competition in the market; enhance provider choice; encourage patient feedback and improve price transparency.

Verma’s op-ed and the CMS’ request for information likely eases concerns from some in the industry that the new administration was taking a step away from value-based care, said Gail Wilensky, who led CMS during the George H. Bush’s tenure and is now a senior fellow at not-for-profit Project HOPE.

The decision by the CMS this summer to make some previously mandatory bundled payments for replacing knees and hips, voluntary, likely spurred some of that concern. The agency also eliminated the expansion of bundled payments for heart attacks, bypass surgery, hip and femur fractures, and cardiac rehabilitation.

“Seema Verma has made it clear she recognizes the importance of moving away from a fee-for-service model to more value-based care,” Wilensky said.

The CMS notice did say it will focus on voluntary models instead of mandatory ones. Ways to “reduce burdensome requirements and unnecessary regulations” for physicians will be a focus too, the agency said.

HHS Secretary Tom Price, a former surgeon and member of Congress who is now Verma’s boss, has long criticized the mandatory nature of some of the payment models that came out of the Innovation Center.

“I think this (voluntary models) will be a welcome change for providers,” said Clay Richards, CEO of naviHealth, a healthcare consultant company part of Cardinal Health. “You’re letting the market work through what the innovation looks like with providers. Most people would find that as a positive.”

But other policy experts argue that without mandatory requirements providers might not have an incentive to choose alternative models and stick with more lucrative fee-for-service reimbursement.

David Muhlestein, chief research officer at Leavitt Partners, said making models voluntary when they are still experiments should not concern providers since they will always be interested in trying new ways to deliver care. But he said its concerning that the CMS has made no comment about how it will act if models are shown to be successful. The CMS will likely need to make successful models mandatory at some point in order to ensure widespread adoption, he said.

“There will be providers who are worried about new models and want to continue with fee-for-service,” Muhlestein said. Because of this, the CMS will likely have to make successful models mandatory.

A recent JAMA Internal Medicine study found that value-based payment models like accountable care organizations and bundled payment models netted $32 million in savings in 2015 among nearly 3,000 hospitals.

The CMS also said it’s looking for ways to promote price and quality transparency for consumers. The agency said it may release cost data and quality metrics publicly to encourage patients to shop for their care. One suggestion the CMS gave was to encourage beneficiaries to participate in arrangements that would allow them to reap savings if they shop for care and choose the lower-cost option.

Muhlestein said if the CMS makes an effort to promote price shopping among Medicare and Medicaid beneficiaries, it will motivate providers to think more critically about their prices compared to their competitors.

“When you get the consumers engaged on prices, you expand what providers are competing for, and today they don’t compete on price,” he said.

Suggestions on ways to reform Medicaid delivery and payment also were mentioned in the CMS request. The experiments from the Innovation Center have often focused on Medicare. Muhlestein said that was inevitable given Verma’s history drafting conservative state Medicaid programs with cost sharing and work requirements.

“We spend a lot of money as a country on the Medicaid program, and there is room for improvement,” Muhlestein said. “Administrator Verma is a great person to work on that because that is where she cut her teeth.”

The emphasis on stakeholders input is also unique, Wilensky said. Providers have notoriously complained that the Obama administration didn’t illicit enough provider insight on innovations.

“Whether or not there will be a lot of responses and how interesting they will be is another matter,” she added.

In a statement, the American Hospital Association said the group, “will continue to work with Secretary Price, Administrator Verma, and others at HHS to give hospitals the opportunities, flexibility, and predictability they need to improve care coordination and efficiency and deliver better value for their patients and communities.”

The CMS is looking for ideas through Nov. 20.

Robert Coward, a long-time company executive picked in December to lead the integration of Envision’s physician-staffing business with merger-partner Amsurg’s staffing division, is leaving to pursue other opportunities.

Envision had not signaled specific problems with the business during several recent earnings calls and analyst conference presentations, said Richard Close, analyst with Cannacord Genuity.

Additionally, Envision did not affirm earnings guidance that was lowered after the first quarter in the face of softening of hospital volumes, Close said.

That only adds to investor uncertainty about what might be behind Coward’s departure, he said.

“Bottom line, we view the news as concerning,” said Mizuho Securities analyst Ann Hynes in a note to investors Tuesday.

Envision’s shares were down about 9% at 3 p.m. Eastern time Tuesday after announcing Monday the departure of Coward and retirement of Chief Financial Officer Claire Gulmi.

An Envision spokesman did not return requests for comment.

But Envision’s statement released Monday said Coward’s decision was “not the result of a disagreement with the company on any matter relating to the Company’s operation, policies or practices.”

Coward will remain on board for two months to help with the transition.

At a Baird healthcare conference this month, Envision CEO Chris Holden said the integration between merger partners Envision and Amsurg is proceeding on schedule.

Envision merged with Nashville-based Amsurg in December to create the nation’s largest physician-staffing company with annual revenue of about $8.5 billion.

Since then, Envision has agreed to divest its ambulance business to a subsidiary of KKR to focus on its physician-staffing and its other major business line, ambulatory surgery centers.

Holden reiterated to Baird analysts that he believed physician staffing revenue would grow organically by 3% to 5% annually, with new contracts chipping in 1% to 3% of that growth.

Envision contracts with hospitals to provide physician staffing in emergency rooms and provide hospitalists, anesthesiologists and radiologists to hospitals and post-acute facilities.

Holden told Baird that Envision generates about 3.5% of its revenue in Houston, where hospitals were affected by Hurricane Harvey. About 30% of the company’s revenue is in Florida, which was awaiting the arrival of Hurricane Irma as Holden spoke at the conference.

Holden said Envision, like the entire industry, has seen some softening in emergency room visits over the past few quarters. But he said it was too early to say whether that’s a long-term trend or something cyclical.

Close said declining healthcare stock prices overall show investors are responding to that trend.

Add to that the revived efforts to replace Obamacare, and Envision’s management changes are magnified, Close said.

He added that new blood could build a strong bench at Envision. But the uncertainty generally is not good for investors looking for signs of future growth.

“Is it foreshadowing something?” Close asked.

The green light bulb glows over Kari Dawson’s desk, signaling she’s ready to take a call.

Dawson is a new addition to the Las Vegas Fire Department communications center, but her role is different from the rest of the call-takers whose voices fill the room.

“Las Vegas Fire and Rescue, this is Kari, I’m a registered nurse,” she says into her headset, pausing to listen to the man on the other end of the line. “I’m going to ask you some questions to make sure we get you the right kind of help.”

Dawson is one of eight registered nurses staffing the new nurse call line in Las Vegas, where some of the less severe medical calls are being sent. The pilot program kicked off last month.

A software program walks the nurse on duty through a protocol with a caller, prompting new questions based on the sick or injured person’s answers.

Dawson’s other two computer screens show the status of all the active 911 calls at the center, and the ride-sharing service Lyft’s website.

In cases in which patients need medical care but not necessarily an ambulance, the nurses can order a 21st-century alternative — a Lyft to pick the patients up and take them to a hospital or an urgent care facility.

Many of the people whose calls are sent to the nurse call line don’t have a primary care physician and might not be aware of the other options available in less acute medical situations, aside from taking an ambulance to the hospital, Dawson said.

The program means ambulances can be used less in cases where they’re not needed, Las Vegas Fire Department Assistant Fire Chief Sarah McCrea said.

Over-the-phone treatment
The nurse will urge the patient to seek care immediately, in four hours, 12 hours, one to three days or at home.

“We use our knowledge of how to treat these things in the ER,” said Dawson, who also works as a pediatric emergency room nurse at Sunrise Hospital and Medical Center. “I can’t see what it looks like. If you walk into the ER, I can tell that’s definitely broken, it looks broken, it’s not broken. You have to rely on what they’re telling you.”

Hoping for a year
One nurse is on duty from 9 a.m. to 6 p.m. daily. The number of calls sent to the nurse line vary, but Dawson estimates they get an average of five or six a day.

There’s $300,000 in the Las Vegas Fire Department’s regular budget to operate the pilot program, including training and pay for the nurses, who work one day a week, McCrea said.

The program is expected to run for about a year, or until that money dries up. During that time, department officials will evaluate data to determine whether it’s meeting the goals — curbing unnecessary ambulance dispatches and hospital trips, McCrea said.

It would take Las Vegas City Council approval to make the program and its staffing permanent.

The communications center is increasingly busy, taking roughly 600,000 calls per year. About 400,000 of those are medical calls, characterized in declining order of severity as echo, delta, charlie, bravo, alpha and omega. The alphas and omegas are the calls that can be transferred to the nurse call line, McCrea said.

Certain thresholds are in place: Callers complaining of chest pain won’t be sent to the nurse call line. Callers with minor injuries might not be sent over if they have potentially more serious risk factors. And if the caller insists on an ambulance or is uncomfortable with a Lyft, the nurse on duty won’t try to deter them from an ambulance, Dawson said.

The nurses take calls only within the city of Las Vegas jurisdiction now. But because the program is new, some of the kinks are still being worked out. A Clark County call slips through to Dawson’s line. In the meantime, an ambulance was dispatched to the man.

“This is a labor of love right now,” McCrea said.

Checking in with callers
The nurses make follow-up calls the next day for anyone they don’t send an ambulance to. During a follow-up call on Tuesday, Dawson asked the patient if he had gotten any medical attention the day before, after he called 911.
He hadn’t yet, but said he planned to later that day. Dawson put another alert in the system, so the nurse working the next day would call to see if he sought medical care.

The software program also creates patient records, so if someone calls a second time, their medical information and last call record can be accessed.

The Regional Emergency Medical Services Authority in Washoe County allows residents to call its nurse health line directly. Las Vegas Fire Department Chief Willie McDonald envisions giving Las Vegas residents a direct line they can call to speak to a nurse in the future, if the call line here becomes permanent, he said.

“I think it’s a really innovative service, that’s also a better use of resources,” McDonald said.

Mount Sinai Health System’s St. Luke’s Hospital has been looking for a way to decrease readmissions among its recently discharged heart failure Medicaid patients.

The hospital’s 30-day readmission rate of 20% to 25% among such patients was comparable to national statistics within national averages. But a growing Medicaid patient population in New York’s Harlem neighborhood coupled with a systemwide push to incorporate more population health strategies within its clinical settings led to a search for a better way to help heart failure patients manage their conditions outside of the hospital.

“It was a good and important time to make sure that we were integrating some of these social need interventions as well as connection to the community in really trying to address root causes,” said Dr. Theresa Soriano, senior vice president of care transitions and population health at St. Luke’s.

That was the impetus behind St. Luke’s pilot program launched in July aimed at reducing hospital readmissions among Medicaid beneficiaries with congestive heart failure by educating patients how to better self-manage their conditions at home.

The program will provide individualized health coaching to 100 Medicaid beneficiaries in three adjacent city neighborhoods: Harlem, the Upper West Side and Washington Heights. Community health workers trained by nurse specialists on St. Luke’s cardiac-care team will provide individualized coaching to patients on the health issues and warning signs related to heart failure, such as the importance of checking weight and limiting fluid intake.

The one-year initiative is a collaborative effort between Mount Sinai and City Health Works, a Harlem-based not-for-profit organization started in 2012 that trains community members to be health coaches. Coaches meet patients at their homes or within the community and work with clinicians on care plans. CHW currently works with about 400 patients, with coaches also serving as a bridge between healthcare professionals and the community by communicating with clinicians about any social factors they find that may be hindering a patient’s progress toward achieving their health goals.

City Health Works founder and Executive Director Manmeet Kaur said the collaboration with St. Luke’s came about as a result of CHW’s past success working with outpatient providers on improving their patients’ management of conditions like diabetes, hypertension and asthma. According to CHW, health coaches were responsible for helping to identify a medical issue unknown to a provider in half of patients they served.

She said the hospital will evaluate the program over the next six months to measure primary and secondary outcomes. Mount Sinai hopes to expand the service across the entire system based on the results. Kaur said plans were already underway to scale up CHW to offer its services to providers in areas of Brooklyn and the Bronx.

Kaur said CHW has to date been largely funded with philanthropic support as the organization developed its care model, but she said the organization is prepared to make the transition of scaling up to take on contracts for its service.

She saw CHW as an ideal service for those healthcare providers that have already transitioned a significant share of their patients covered in risk-based contracts.

“We’re now at the stage where we’re operationally preparing for that type of scale-up in other states in addition to growing in New York,” Kaur said.

Within 10 minutes of receiving a 911 call that a 61-year-old man had passed out, a paramedic and a doctor pulled up outside J.K. Lewis Senior Center in a red SUV.

The health care duo checked the patient’s heart rate, blood pressure and temperature.

Last year, the man would have been taken by ambulance to the ER to receive treatment for his dehydration.

Memphis Fire is one of several agencies across the country that is rethinking 911 services for non-emergency calls like this and at the same time addressing health care needs of patients they are called to assist.

The city has the largest 911 EMS/ambulance service in the state. Last year, the fire department had 130,000 EMS calls and of that number 25,000, or about 1 in 5 were categorized as non-emergency.

“That doesn’t mean they are not urgent to the people who are calling, it means that 22 percent were non-life threatening. So we recognized those kinds of calls were tying up our resources, so we wanted to make sure we have the right resource available at the right time,” said Memphis Fire Department Director Gina Sweat.

In April, the fire department launched the “Right Response” a pilot program that pairs a doctor and a paramedic for non-emergency calls.

“We recognized that with our EMS system the call volume continued to increase year after year and city budgets don’t always increase in line with that need, so we recognized that if this continued it would be a point to where we wouldn’t be able to provide efficient service,” Sweat said.

‘The Right Response’
Memphis paramedic/firefighter Rebecca Luckey drives the rapid response SUV on a recent Tuesday morning as Dr. John David Williamson with Resurrection Health navigates through the 911 calls on a laptop.

Since 8 a.m., the two have been on three house calls. Sending an ambulance to those calls instead would have cost the patient $850 to go to the ER for non-life threatening illnesses.

After treating the patients, the two provide them with information about a primary care doctor if they need one, and most do. They also secure them a ride to a doctor’s office.

Since the “Right Response” program launched five months ago, the doctors and paramedics have responded to more than 600 calls. The pilot program costs roughly the price of two firefighter/paramedic salaries -which is about $55,000.

The fire department has partnered with Resurrection Health who provides doctors to ride with the paramedics on the calls. The Plough Foundation provided grants that bought the two SUV’s that are used on house calls.

Other health care organizations have provided staffing or funding for the initiative including the Assisi Foundation, Saint Francis Hospital, Baptist Memorial Healthcare, Regional One Health, Christ Community Healthcare, Methodist Le Bonheur Healthcare and Innovate Memphis.

“Right Response” is a pilot project now, but fire officials hope to make it permanent.

‘Can I speak with the nurse?’
This month, another phase of the project will launch and will have a nurse working at the 911 dispatch center to talk with residents and assess their health care needs.

“We realize those residents are calling us because they don’t know where else to turn,” said Sweat. “If it is not an emergency, residents can speak directly with the nurse.”

The community paramedicine or telemedicine concept is gaining momentum across the country, said Matt Zavadsky, president-elect of the National EMT Association.

Zavadsky said their data shows that 210 EMS systems in the United States have programs operating as “mobile integrated health” and they coordinate house calls and telemedicine through 911 systems, fire departments and local health departments.

Zavadsky, who is the chief strategic integration officer for MedStar Mobile Healthcare in Fort Worth, Texas said their mobile integrated health project started in 2009. It includes a nurse in the 911 center and an 11-person team of paramedics and a nurse case manager who manage the high utilizer group or HUGS – patients who frequently call 911 for non-emergencies.

“We have seen, with the high utilizer program, there is about a 55 percent reduction in 911 and emergency department use with the patients who enrolled in the program,” Zavadsky said. “With our nurse in our communication center, about 33 percent of the calls go to the nurse. They don’t even get an ambulance response because people will say “can I speak with the nurse?”

He added that the programs are helping patients avoid costly and time-consuming trips to the emergency room and helping improve their health care needs.

“Nationally, these programs are taking off primarily because of the economic incentives today for hospitals. Third-party payer insurance companies are really focusing on value,” Zavadsky said. “I will be the first to tell you, I have been in EMS for 37 years and there is more value in navigating someone through the health care system than just simply schlepping every person that calls 911 to the emergency room.”

Though many emergency rooms are overcrowded and some patients may not have urgent needs, just a fraction of visits are truly “avoidable,” according to a new study.

Researchers examined data from the National Hospital Ambulatory Medical Care Survey from 2005 to 2011 that included more than 115,000 records representing 424 million emergency department visits, and found that only 3.3% were avoidable. The study team defined avoidable visits as those that did not require diagnostic tests, screenings, procedures or medications.

A number of these avoidable visits were for concerns that the ER is not equipped to treat, like dental or mental health issues, according to the study. Of the avoidable visits, 6.8% were for alcohol- or mood-related disorders, like depression or anxiety, while 3.9% were for dental conditions.

The findings, published in the International Journal for Quality in Health Care, challenge the commonly held belief that many people visit the ER needlessly, said Rebecca Parker, M.D., president of the American College of Emergency Physicians, in an announcement.

“Despite a relentless campaign by the insurance industry to mislead policymakers and the public into believing that many ER visits are avoidable, the facts say otherwise,” Parker said. “Most patients who are in the emergency department belong there and insurers should cover those visits. The myths about ‘unnecessary’ ER visits are just that—myths.”

The ER has been a frequent target for initiatives seeking to reduce overuse and the costs associated with emergency care. However, the researchers said that their findings point more toward the value in programs to improve patient access to services like mental health and dental care.

The study found that 10.4% of visits from patients with alcohol-related disorders and 16.9% of visits from patients with mood disorders were avoidable, suggesting that policymakers could do more to increase access to the services that would keep those patients out of the ER.

“Our findings serve as a start to addressing gaps in the U.S. healthcare system, rather than penalizing patients for lack of access, and may be a better step to decreasing ‘avoidable’ ED visits,” the authors wrote.

Overcrowded emergency rooms are common in hospitals across the country. But several key strategies unite the facilities that are most effectively tackling this problem, according to a new study.

Researchers stratified hospitals into three groups based on data from the Centers for Medicare & Medicaid Services: highest-performing, high-performing and low-performing, according to the Annals of Emergency Medicine study.

They chose a representative sample of 12 hospitals, four from each group, and interviewed 60 leaders across those hospitals to determine what was working to reduce overcrowding.

Four strategies, which could be replicated in other hospitals, were identified:

• Executive buy-in: Leaders in the highest-performing hospitals had identified overcrowding as a key problem for them to solve, setting goals and providing the resources to accomplish them.
• Responses coordinated across the hospital: Hospitals in the low-performance group often operated in silos, while the highest-performing deployed strategies that required coordination between departments.
• Use of data: High-performing hospitals gathered and leveraged data to adjust ER operations in real time and to provide feedback to key staff members. Predictive analytics allowed ER staff to map needs and estimate patient flow.
• Accountability: The highest-performing hospitals addressed issues immediately and held staff members accountable.

Benjamin Sun, M.D., a professor of emergency medicine at Oregon Health & Science University and the study’s senior author, said in an announcement that overcrowded ERs can be dangerous for patients, so finding a solution to the issue is crucial.

“Emergency department crowding can be dangerous for patients,” he said. “We know, for example, that emergency department crowding can lead to delays in pain medications for patients with broken bones, as well as delays in antibiotics for patients with pneumonia. We know the risk of death is higher when the emergency department is more crowded than when it’s less crowded.”

Hospitals have deployed a number of programs aimed at reducing overcrowding in the emergency department. Baptist Health South Florida, for instance, introduced “tele-triage” to address patients with minor injuries or other common, but not urgent, maladies.

Others have hired “bed czars” to monitor flow in the ED or have launched fast-track programs to speed up treatment for patients with minor needs.

Nothing seemed to help the patient — and hospice staff didn’t know why.

They sent home more painkillers for weeks. But the elderly woman, who had severe dementia and incurable breast cancer, kept calling out in pain.

The answer came when the woman’s daughter, who was taking care of her at home, showed up in the emergency room with a life-threatening overdose of morphine and oxycodone. It turned out she was high on her mother’s medications, stolen from the hospice-issued stash.

Dr. Leslie Blackhall handled that case and two others at the University of Virginia’s palliative care clinic, and uncovered a wider problem: As more people die at home on hospice, some of the powerful, addictive drugs they are prescribed are ending up in the wrong hands.

Hospices have largely been exempt from the national crackdown on opioid prescriptions because dying people may need high doses of opioids. But as the nation’s opioid epidemic continues, some experts say hospices aren’t doing enough to identify families and staff who might be stealing pills. And now, amid urgent cries for action over rising overdose deaths, several states have passed laws giving hospice staff the power to destroy leftover pills after patients die.

Blackhall first sounded the alarm about drug diversion in 2013, when she found that most Virginia hospices she surveyed didn’t have mandatory training and policies on the misuse and theft of drugs. Her study spurred the Virginia Association for Hospices and Palliative Care to create new guidelines, and prompted national discussion.

Most hospice patients receive care in the place they call home. These settings can be hard to monitor, but a Kaiser Health News review of government inspection records sheds light on what can go wrong. According to these reports:

In Mobile, Ala., a hospice nurse found a man at home in tears, holding his abdomen, complaining of pain at the top of a 10-point scale. The patient was dying of cancer, and his neighbors were stealing his opioid painkillers, day after day.

In Monroe, Mich., parents kept “losing” medications for a child dying at home of brain cancer, including a bottle of the painkiller methadone.

In Clinton, Mo., a woman at home on hospice began vomiting from anxiety from a tense family conflict: Her son had to physically fight off her daughter, who was stealing her medications. Her son implored the hospice to move his mom to a nursing home to escape the situation.

In other cases, paid caregivers or hospice workers, who work largely unsupervised in the home, steal patients’ pills. In June, a former hospice nurse in Albuquerque, N.M., pleaded guilty to diverting oxycodone pills first by recommending prescriptions for hospice patients who didn’t need them and then intercepting the packages with the intention of selling the drugs herself.

Hospice, available to patients who are expected to die within six months, is seeing a dramatic rise in enrollment as more patients choose to focus on comfort, instead of a cure, at the end of life.

The fast-growing industry serves more than 1.6 million people a year. Most of hospice care is covered by Medicare, which pays for hospices to send nurses, aides, social workers and chaplains, as well as hospital beds, oxygen machines and medications to the home.

There’s no national data on how frequently these medications go missing. But “problems related to abuse of, diversion of or addiction to prescription medications are very common in the hospice population, as they are in other populations,” said Dr. Joe Rotella, chief medical officer of the American Academy of Hospice and Palliative Medicine, a professional association for hospice workers.

“It’s an everyday problem that hospice teams address,” Rotella said. In many cases, opioid painkillers or other controlled substances are the best treatment for these patients, he said. Hospice patients, about half of whom sign up within two weeks of death, often face significant pain, shortness of breath, broken bones, or aching joints from lying in bed, he said. “These are the sickest of the sick.”

Earlier this year in Missouri, government investigators installed a hidden camera in a 95-year-old hospice patient’s kitchen to investigate suspected theft. A personal care aide was charged with stealing the patient’s hydrocodone pills, opiate painkillers, and replacing them with acetaminophen, the active ingredient in Tylenol. Hospice nurses in Louisiana and Massachusetts also have been charged in recent years with stealing medication from patients’ homes.

But many suspected thefts don’t get caught on hidden cameras, or even reported.

In Oxnard, Calif., in 2015, a person claiming to be a hospice employee entered the homes of five patients and tried to steal their morphine, succeeding twice. The state cited the hospice for failing to report the incidents.

In Norwich, Vt., in 2013, a family looked for morphine to ease a dying patient’s shortness of breath. But the bottle was missing from the hospice-issued comfort care kit. The family suspected that an aide, who no longer worked in the home, had stolen the drug, but they had no proof. State inspectors cited the hospice, Bayada Home Health Care, for failing to investigate.

David Totaro, spokesman for Bayada Home Health Care, told KHN that situations like that are “very rare” at the hospice, which takes precautions, such as limiting medication supply, to prevent misuse.

There is no publicly available national data on the volume of opioids hospices prescribe. But OnePoint Patient Care, a national hospice-focused pharmacy, estimates that 25 to 30 percent of the medications it delivers to hospice patients are controlled substances, according to Erik Jung, a vice president of pharmacy operations.

Jung said company drivers deliver medications in unmarked cars to prevent attempted robberies, which have happened on occasion.

Two recent studies suggest hospice doctors and social workers across the country are not prepared to screen patients and families for drug misuse, nor to address the theft of pain medication.

For family members struggling with addiction, bottles of pills lying around the house can be hard to resist. Sarah B., a 43-year-old construction worker in Vancouver, Wash., said when her father entered hospice care at his home in Oregon, she was addicted to opioids, stemming from a hydrocodone prescription for sciatica.

After he died, hundreds of pills were left on his bedside table. She took them all, enough Norco, oxycodone and morphine to last a month.

“I have some shame about it,” said Sarah, who declined to give her full last name because of the nature of her actions.

Sarah, who was one of her father’s primary caretakers, said the hospice “didn’t talk about addiction or ask if any one of us were addicts or any of that.”

“No one gave us instructions on how to dispose of all the medications that were left,” she added.

Medicare requires hospices to establish a safe way to administer drugs to each patient — by identifying a reliable caregiver, staff member or volunteer to manage the drugs or, if need be, relocating the patient. And it requires hospices to set policies, and talk to families, about how to safely manage and dispose of medications.

But there’s little oversight: Unlike nursing homes, hospices may go years without inspection, and even when they are cited for noncompliance, they rarely face any consequence except coming up with a plan to improve.

And in most states, hospices have little control over the pills after a patient dies. The U.S. Drug Enforcement Administration encourages hospice staff to help families destroy leftover medications, but forbids staff from destroying the meds themselves unless allowed by state law. Leftover pills belong to the family, which has no legal obligation to destroy them or give them up.

However, some states are taking action. In the past three years, Ohio, Delaware, New Jersey and South Carolina have passed laws giving hospice staff authority to destroy unused drugs after patients die. Similar bills moved forward in Illinois, Wisconsin and Georgia this year.

In Massachusetts, one of the states hit hardest by drug overdose deaths, VNA Care Hospice and Palliative Care advises families to empty leftover pills into kitty litter or coffee grounds before disposal — a common practice to prevent reuse, since flushing them down the toilet is now considered environmentally hazardous.

But families “don’t have to comply,” said VNA Care medical director Dr. Joel Bauman. “Our experience is maybe only half do. We don’t know what happens to these medications. And we have no right, really, to further inquire.”

Hospices across the country told KHN they take precautions, including counting pills when nurses visit the homes, limiting the volume of each drug delivery, giving families locked boxes for medication and giving patients random urine tests. They also said they prescribe medications that are harder to misuse, such as methadone.

Some, like VNA Care, have also started screening families of patients for history of drug addiction, and writing up agreements with families outlining the consequences if drugs go missing.

But “there’s so much moral distress” about punishing dying patients for family members’ actions, said Bauman. He said he tries to avoid doing that: “Why should we fire a patient for having inappropriate pill counts, when it may not be their fault in the first place?”

Though Blackhall helped spark a national discussion about hospice drug diversion, she said she’s also worried about restricting access to painkillers. Hospices must strike a balance, she said.

“It’s important to treat the horrible suffering that people have from cancer,” said Blackhall. But substance abuse is another form of suffering which is “horrible for anyone in the family or community that might end up getting those medications.”

KHN’s coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.

Health care is moving at the speed of light, and for many health system CEOs that requires a need for agility to tackle what’s now and what’s next. Deloitte recently surveyed 20 CEOs from large health systems across the country to uncover what’s top of mind and how they are moving forward in an uncertain – and sometimes challenging – market.

While none of the key themes emerging from our interviews around funding, value-based care, talent, and technology have really changed since we last spoke with health system CEOs in 2015, the urgency certainly has. Instead of talking about their 10-year plans like they did two years ago, these CEOs are now concerned with what’s happening now, and what might happen with Medicaid tomorrow. Many top concerns are compounded by uncertainty around the new administration, Congress, and the future direction of federal health care policy.

Top concerns among health system CEOs include:
• Preparing for potentially changing Medicaid reimbursement models and other policy issues
• Implementing population health and value-based care
• Maintaining or improving margins
• Recruiting and retaining top talent, including health care leaders
• Keeping up with evolving technology and cybersecurity risks
• Adapting to changing consumer demands and expectations

I’m not surprised health system CEOs are concerned about policy and federal funding. The debate around health care reform has dominated the news cycle since January. However, despite the uncertain outcome and impact of Congress’s health care reform efforts, there are, what I call, “no regrets” pursuits that health systems and hospitals can consider.

These include:
• Integrating business vertically
• Triaging patients to direct them to the appropriate level of care
• Reducing cost and inefficiencies across the system

Vertical integration
As we know, health care is changing. For years, there has been little incentive for hospitals to direct patients to – or coordinate with – step-down or other less expensive settings of care. But now that is changing. Government payment models such as those promoted through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), along with commercial value-based reimbursement agreements, are helping push many hospitals to reconsider their relationships with other health care stakeholders.

Depending on a hospital’s patient population, it might make sense to vertically integrate with other health care partners. This could include payers, post-acute care facilities, and physician practices. If revenues aren’t going to increase, hospitals and health systems may need to think about new revenue streams. An integrated care delivery system can help coordinate care across the continuum and track patients more efficiently.

Triaging patients
Another strategy health system leaders could consider would be to implement stronger triaging systems that help direct patients to the most appropriate care setting. If a hospital or health system is vertically integrated, and owns or partners with urgent care clinics and/or physician practices, it can refer patients to those settings rather than providing care in the emergency department (ED), which can cost thousands of dollars per hour to operate. If an increasing number of uninsured patients come to the ED – and hospitals anticipate more uncompensated care – there is likely a financial incentive to actively direct some of these patients to a lower-cost and/or more appropriate care settings.

Reducing inefficiencies
Though many health systems have looked for efficiencies around the margins of providing care, they now likely need to find greater clinical efficiency. They might need to rethink how care is delivered and at what cost. Generally, reimbursement is not increasing in the government or commercial sectors. As many hospitals continue to take on more risk, it will likely be important to deliver care as efficiently and effectively as possible. Though many health system CEOs have found new revenue streams through the acquisition of physician practices and other hospitals, they might not yet understand how to operate as a system. Hospitals within a health system sometimes continue to operate independently of one another rather than tapping into their synergies.

Though the health care debate is ongoing, and the future of the Medicaid program is unclear, there are strategies that health system CEOs can pursue today. Regardless of what happens with Medicaid, government and commercial payers are likely not interested in paying hospitals more than they already do. Looking for ways to vertically integrate, triage patients, and reduce inefficiencies can help prepare hospitals for a value-based reimbursement system. Health system CEOs should consider how to deliver care to patients in the most cost-effective way possible. The organization leaders that figure this out first will be the ones shaping the future of health care, and those health system CEOs will sleep much more soundly.

The benefits coming from the CMS’ Hospital Readmissions Reduction Program have slowed enough that some industry experts and hospital leaders say it may be time to retire the program.

The program was mandated by the Affordable Care Act as part of a larger effort to curb health costs—readmissions make up about $41 billion in healthcare spending—and to motivate providers to improve outcomes.

By and large, the program seemed to work. The CMS’ spending on readmissions fell $9 billion by 2014 and readmission rates for Medicare beneficiaries suffering congestive heart failure averaged 22% from 2011 to 2014, down from 24.5% from 2005 to 2008, according to a Kaiser Family Foundation analysis of CMS data. But there has been a standstill on progress. From 2013 to mid-2016, readmissions have only dropped by 0.1% on average. Moreover, since the CMS began to dock U.S. hospitals for their readmission rates, a majority have consistently fallen victim to the penalty.

The minuscule movement now plaguing the program might mean it’s time for the CMS to move on, said Dr. Thomas Balcezak, chief medical officer of Yale New Haven (Conn.) Hospital, a safety-net academic medical center. The hospital received a 1.91% penalty this fiscal year and will be hit with a 1.7% penalty next year.

In 2013, the first year the reduction program issued penalties, 2,217 hospitals were hit with Medicare cuts. In its most recent round, the CMS expects 2,573 hospitals will get a penalty in the upcoming fiscal year. Each year, about 75% of the roughly 3,200 affected hospitals see up to 3% of their Medicare payments reduced because patients return 30 days after discharge. The CMS excludes psychiatric, critical-access and children’s hospitals as well as hospitals in Maryland because of its unique all-payer rate-setting system.

The CMS did not respond to requests for comment.