September 1, 2016

Freestanding emergency rooms are expanding fast in North Texas. You can hardly drive down any major street in Dallas without seeing one. But are they good for patients?

Park Cities, Allen and Plano are the newest locations for these slick and efficient facilities that claim the capabilities and services of full-service emergency rooms, guaranteeing treatment without the wait of a hospital-based emergency room. In a sense, patients receive the convenience of an urgent care center, but they anticipate receiving the same quality of a hospital emergency service.

Unfortunately, urgent care is not the same as emergency care, and freestanding emergency rooms simply cannot provide the same level of emergency treatment as hospitals. Urgent care centers, or walk-in clinics, are usually open outside of regular business hours, including evenings and weekends. They are ideal for treating minor injuries, such as sprains, or illnesses like fever or sore throat. Emergency rooms — open 24/7 — are the best place for treating severe or life-threatening conditions. True ERs can handle trauma, X-rays and surgical procedures and have access to specialists.

The freestanding emergency room concept is not new. According to health care management consultant Cherilyn G. Murer, the facilities were established in the early 1970s to expand services to underserved and critical-access areas that cannot support the economic obligations of a dedicated hospital. The increased demand for emergency care has prompted the growth of these types of emergency rooms, as hospitals cut back on emergency departments.

It is expensive to sustain a full-service hospital with surgical suites and sophisticated imaging capabilities. It is even more difficult in smaller, rural communities.

In response, freestanding emergency rooms provide immediate care, with less urgent patients treated and discharged, and more complicated cases transferred immediately to affiliated hospitals with more robust facilities. It seems like a perfect solution to provide appropriate and quality care throughout the region.

Unfortunately, innovative medical entrepreneurs recognize an opportunity to label urgent care services as emergency room care and are able to charge accordingly. A typical urgent care visit may cost $50. But re-label it as an emergency room visit, and your average charge inflates to more than $300. Not a bad pricing strategy.

Freestanding emergency room advocates claim that consumers resent long waits in hospital emergency rooms and prefer a more convenient, efficient solution. While this may be true in some cases, we should also recognize that hospital-based emergency rooms are staffed with trained technicians and clinicians prepared to respond to the most critically ill. A burst appendix, full cardiac arrest or a severe stroke all require immediate surgical or diagnostic intervention.

A fully staffed surgical suite is available 24/7. The cardiac catheterization department times “door-to-needle” care, and the MRI is always available along with technicians for immediate treatment. Suffering a stroke? Clinicians are standing by to administer clot-busting medicines or initiate other protocols for emergent care. These are just a few examples of the preparation and readiness that a hospital-based emergency room provides. And consumers expect this level of care.

What they don’t realize is that a freestanding emergency room is ill-equipped to treat these types of illnesses. Instead, the patient will be diagnosed and then transferred to a hospital-based emergency room for treatment. This wastes critical time to treatment and generates additional expenses for the second emergency room care.

But perhaps even less consumer friendly are the exorbitant charges incurred by the growing number of patients at freestanding emergency rooms. The arriving patient might pay a minimal co-pay or even a no-pay; however, consumers complain about charges after they leave. They are often bombarded with uncovered charges due to insurance plan design or high-end deductibles.

Freestanding emergency rooms are an example of health care entrepreneurs responding to consumer demands with good intentions to benefit economic interests. However, in many cases, these facilities stray far from the original intent to provide care in underserved areas and may even cost patients precious time for treatment in hospitals.

Britt Berrett is director of the undergraduate program in Healthcare Management in the Naveen Jindal School of Management at UT Dallas. Email: britt.berrett@utdallas.edu

Original article can be accessed here.

Fort Wayne, IN – At the 2016 Emergency Response Conference on August 26, 2016, Fort Wayne’s 911 and non-emergency ambulance service provider, Three Rivers Ambulance Authority (“TRAA”) was selected as the State’s 2016 recipient of the “ALS Provider of the Year”. The annual recipient of this award is chosen by committee members of the Indiana Association of Cities and Towns and is given to the ambulance provider that most exemplifies the highest standards in areas such as professional accreditations received, involvement in community-wide public education programs as well as other areas of community involvement. TRAA was one of eight finalists for this prestigious award. Additionally, TRAA dispatcher Rita Hughes was awarded the 2016 “Dispatcher of the Year” awarding, recognizing her for her excellence in the performance of her duties. “We are extremely honored to receive this award” said Gary Booher, Executive Director of TRAA, “It’s the recognition of the dedication that all of our staff has to serving our community with the highest quality of care possible each and every day.”

For more coverage, access the TRAA website here.

August 29th, 2016

A Facebook post, a shared photo, a video on Periscope: What do all of these things have in common? The first answer is that EMTs and paramedics have lost their jobs over such things. The second is that the ripple effect of these events places an unexpected spotlight on agencies where an EMS chief faces the inevitable media question: “What can you do to reassure the public this is an isolated incident?”

When you receive this question from the press, you better hope you have enough goodwill on your side to help make your case. You may love to hate them, but the media can be your friend if you play nicely. So what does that mean?

“We have to realize we must interface with the media,” says Matt Zavadsky, MS-HSA, EMT, public affairs director at MedStar Mobile Healthcare in Ft. Worth, TX. “We cannot pretend they do not exist, or that if we mind our own business we’ll never have to deal with them. Further, to be the kind of responsible community partner we want to be, we often need to educate the community through the media on important issues and happenings.”

Key to this interface is providing story leads to help a reporter fill those slow news days. “Media ride-alongs are great opportunities,” says Zavadsky. “Create a culture within your agency that embraces and enhances media interactions. It’s also a good idea to regularly remind your team members that your ‘brand’ is one of your most important assets and everything they do has an impact on that brand.”

“EMS providers are so busy doing the work every day that they have limited time to focus on building positive community relations. The presenters for this session will provide numerous easy-to-implement strategies that will make it easy to promote the positive!” notes Zavadsky.

The workshop will cover how to:

• Interpret how national and local issues may impact your agency;
• Stay informed about issues impacting EMS and healthcare;
• Create newsworthy stories for positive press coverage;
• Develop key message points that are honest but minimize potential negative perceptions;
• Build effective relationships with local stakeholders, including the media;
• Conduct an interview with helpful and hostile reporters;
• Create a social media presence that promotes both your agency and public health issues to your community.

Additional faculty includes Rob Luckritz, Esq., EMS director for Jersey City Medical Center; Carissa Caramanis O’Brien, EMT-B, president of Red Box Communications; and Rob Lawrence, MCMI, is chief operating officer of the Richmond (VA) Ambulance Authority.

Allison Braxton-Baehr a FOX 8 News Orleans reporter, will make a special guest appearance to share her top advice on working with the media.

Continue this discussion with Matt and the Team at EMS World Expo, where they will cohost a half-day workshop, “PR Boot Camp: An Exercise in Positive Press,” on October 4.

Register at EMSWorldExpo.com. E-mail your media success stories to editor@emsworld.com.

Original article written by Nancy Perry, and can be accessed here.

August 19th, 2016

As more hospitals and healthcare facilities move away from a fee-for-service model, they may find it difficult to apply alternative payment models to the emergency department, frequently a safety net for patients who may be uninsured or unable to pay for care.

The ED also presents challenges because emergency care isn’t set up to follow patients after discharge, which makes it difficult for organizations to obtain a full grasp on care costs, according to new study published in the American Journal of Managed Care. Furthermore, ER doctors may order a large number of tests to rule out life-threatening conditions for patients, so payment reform may lead to misdiagnoses as care patterns change, study authors note.

Despite the unique challenges the ED presents to payment reform, the report’s authors examine how payment models under the Department of Health and Human Services’ four-category framework could work.

In addition to using the existing fee-for-service model, they suggest that organizations could:

Connect the fee-for-service model to quality benchmarks. In this model, according to the study, EDs would still operate under a fee-for-service system, but they could earn additional payments by achieving certain goals, like improving patient satisfaction or better care coordination. Being paid directly for coordination of care can lead to better outcomes and lower costs, according to the study.

Build a new payment model based on fee-for-service. One way this could work is for providers to establish frequent use programs, which cut costs by personalizing plans for patients with more complex medical, psychological and social needs. EDs could also offer bundled payments for more episodic conditions, which may reduce both costs and unnecessary readmissions, according to the study.

Create a population-based payment system. Under this model, ED providers would be paid a fixed sum based on local population, previous emergency care use or projected costs across a certain window of time. Basing payments around population gives incentives to providers to address inefficient care and to prevent unneeded ER visits for acute care.

Here’s the link to the AJMC Study:

http://www.ajmc.com/journals/issue/2016/2016-vol22-n8/aligning-payment-reform-and-delivery-innovation-in-emergency-care

Original article written by Paige Minemyer, and can be accessed here.

AIMHI Commentary: Interesting reading – while these concepts are used to apply to EDs, they certainly could apply to other safety net healthcare providers such as EMS.

MedStar paramedic Jason Hernandez is profiled in the national news magazine, The Atlantic.

The Atlantic, based in Washington, D.C., is a literary and cultural commentary magazine, with a national reputation as a high-quality monthly publication. The magazine focuses on foreign affairs, politics, and the economy, as well as cultural trends aimed at a target audience of serious national readers and thought leaders. The magazine is subscribed to by over 400,000 readers and publishes ten times a year.

MedStar was asked to provide a paramedic for this profile by the National Association of EMTs, after they were contacted by The Atlantic for an EMS professional they could profile in their publication.

Congratulations, Jason!

Click on the link below to view the on-line version of the story:

http://www.theatlantic.com/business/archive/2016/08/paramedic/497300/

CBS-11 Traffic Reporter Chelsey Davis kicked off her new segment “Chelsey’s Hero’s” with a profile of MedStar Emergency Vehicle Technician Josh Enlow!!

Click here to view the news story…

A little lengthy, but valuable insight to the reasons some healthcare systems have been able to successful become integrated care networks…  Love the Dell analogy!

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8 Ways to Chart A Savvy Course to Integrated Care

Dan Beckham looks at eight health systems that have followed consistent strategies particularly well to create value

August 15, 2016

Dan Beckham

http://www.hhnmag.com/articles/7531-charting-a-path-to-integrated-care

Strategic decisions have positioned some health systems particularly well in the past and promise to do so in the future.

Respected industry leaders helped me identify eight of them: Advocate Health Care (Illinois), Banner Health (Arizona), Baylor Scott & White Health (Texas), the Cleveland Clinic (Ohio), Geisinger Health System (Pennsylvania), Intermountain Healthcare (Utah), the Mayo Clinic (Minnesota) and Sentara Healthcare (Virginia).

In studying them anew, I have relied on personal interviews as well as an extensive review of existing literature and data. And I drew on my own experiences working with a number of health systems to develop their strategic plans over the past 30 years. My key areas of study have included reputation, geographic influence, strategic coherence over time and demonstrated performance, particularly as it has related to quality.

Pursuing integration

For at least three decades, these eight health systems have shared a single value proposition — the delivery of integrated care.

Integration is the antidote to fragmentation. And fragmentation remains the greatest threat to value in health care. Autopsy just about any medical accident, misdiagnosis, failure to provide timely care, disaffected patient or unsustainable cost, and you’ll find fragmentation as a cause.

For these eight organizations, integration has been about creating a connected and coordinated system that delivers care distinguished by markedly enhanced value, including quality, safety, accessibility, satisfaction and affordability. (For an in-depth overview of each organization’s strategic commitments, visit www.hcstrategyinnovation.com.)

Each of these health systems has faced tough competitors. But the real competition has been between fragmentation and integration.

Fragmentation is well-entrenched, has strong champions, pushes back and evolves. It is a slippery foe. Strategy is about moving from a place in the present to a better place in the face of resistance and uncertainty. Fragmentation offers plenty of resistance and uncertainty.

Harvard Business School professor Clayton Christensen, author of The Innovator’s Dilemma, is well-known for his concept of disruptive competition. He applied his thinking to health care in a later book titled The Innovator’s Prescription.

Christensen uses a metaphor to describe fragmentation in health care and the proper role of size:

“If you take the cover off of your Dell computer, every component [is] made by a different company. … Intel can give you faster processors, Microsoft can give you Vista, Seagate more gigabytes on the drive. But none of them [has] the technical or commercial scope to wrap [its] arms around the whole system and rethink what it is.

“Most of America’s health care system is structured like a Dell computer. … But there are only a few institutions that have the scope to rethink it all … that can wrap [their] arms around all of the pieces of the system to just re‑architect it.”

These eight health systems, among others, have demonstrated the kind of scope Christensen describes:

1. Advocate Health Care: Advocate grew out of the merger of two health systems with flagship hospitals already recognized for quality and advanced capabilities. It was an early mover on physician employment and group practice formation, and it turned its physician-hospital organizations into a super-PHO, becoming the national benchmark for clinically integrated networks.
2. Banner Health: Built around a flagship hospital and a strong operating company model, Banner centralized leadership and governance, and standardized care and management processes. Banner grew aggressively through acquisitions and new hospital construction.
3. Baylor Scott & White Health: Two respected but distinctive organizations came together to form a delivery system serving a wide swath of north and central Texas (including Dallas and Temple). Scott & White brought its highly integrated multispecialty group practice model and its health plan to the merger, while Baylor brought a robust network of hospitals, surgery centers and entrepreneurial partnerships.
4. Cleveland Clinic: Few organizations have been as clinically innovative and tenacious as the Cleveland Clinic has been from its founding. Once focused intently on the heart, it has leveraged its worldwide reputation into other services and diseases. A pioneer in transparency related to demonstrated value and bundled contracts, Cleveland Clinic has combined one of America’s premier multispecialty group practices with community hospitals and independent physicians to produce a powerful economic engine.
5. Geisinger Health System: A large, sophisticated medical center in a small town serving a big chunk of rural Pennsylvania, Geisinger has focused on building deep intellectual capital related to care management. It is internationally recognized for innovating at the interface between health insurance, inpatient care, outpatient care and physician practice. Few organizations have positioned themselves as purposefully as Geisinger for the transition from volume- to value-based payment.
6. Intermountain Healthcare: The late W. Edwards Deming, a quality icon, was a central inspiration for Intermountain’s relentless battle to drive out variation. While many health systems treated total quality management and its variants as a passing fad, Intermountain dug in and made it a way of life. The presence of Intermountain contributes greatly to Utah’s position as one of America’s healthiest places to live.
7. Mayo Clinic: No organization has built as strong a brand for quality as Mayo. Its strength flows, to a great extent, from the team-based multispecialty group practice model that has been central to its operations since its founding, along with its unwavering focus on putting patient interests first. The “Mayo way” is well-engineered and nonnegotiable. No organization has deeper, better-connected data. Once satisfied to be insular, Mayo is stirring.
8. Sentara Healthcare: When other systems experimented with ownership of health plans, then exited in the face of losses, Sentara persevered. When physician employment became too big a financial burden for others, Sentara doubled down. Because it persisted when others folded, it was able to put more than two decades of experience into its intellectual bank vault. It learned to meld a managed care enterprise, a hospital enterprise and a physician enterprise into a formidable integrated delivery system.

Four paths

These eight health systems didn’t wait for health care reform to move them down the path toward integration and value. Indeed, their initiatives provided models that the Centers for Medicare & Medicaid Services and other government agencies have attempted to emulate. These health systems positioned themselves to manage care by moving down one of four integration pathways.

For Mayo and the Cleveland Clinic, the integration path was paved by their century-old multispecialty group practice model in which team‑based delivery of coordinated care wasn’t an option but a requirement. Intermountain, Baylor Scott & White and Sentara’s path toward integration involved owning a health plan, while Geisinger had the benefit of an already well-developed multispecialty group practice model when it stepped into health plan ownership. Advocate’s path ran through development of its physician-hospital organization and clinically integrated network. For Banner, the path involved creating a tight operating company model for every piece of the system, including hospitals and physician practices. These four paths have coalesced as they’ve converged on the same destination – integrated care.

Two shared characteristics stood out in all eight systems. First, each had a well-established reputation for delivering high-quality care. This reputation often had been resident in star physicians and flagship hospitals before the systems were built out.

The second common point of differentiation was wide geographic distribution, usually developed as a result of acquisition and mergers. Such wide distribution expanded access, created leverage with insurers and pushed the health systems’ brand identity into new markets. Wide geographic distribution also diversified the systems’ portfolio of markets, so a slowdown or setback in one could be averaged out among the others.

Strategic choices

Focus is an essential characteristic of any truly strategic organization. These health systems demonstrated an ability to home in on those strategic commitments that made the greatest contribution to their value proposition of integrated care.

Ten driving strategies can be seen at the eight health systems over the past decade. The emphasis on each strategy has varied over time and by organization. They are interrelated and not in any particular order:

Offer advanced capabilities to sustain consumer awareness and preference. Advanced clinical capabilities in the form of physician expertise and technology were legacy commitments emphasized from the onset at Mayo, Cleveland Clinic and Geisinger and were embedded in the flagship hospitals of the other five health systems.

Fortify a quality brand. Advanced clinical capability carried with it an expectation of higher quality outcomes. But to be sustained, differentiation on the basis of quality had to be demonstrated with data showing superior outcomes. Because of their higher levels of integration, these systems have been able to provide such evidence.

Standardize care processes and management. Key to quality and affordability is driving out variation wherever possible. And moving beyond variation requires standardization. Quality of care, quality of leadership and quality of management all rely on a degree of standardization. It is impossible to deliver a high-quality service without the reliability and consistency that standardization delivers.

Require teamwork. Addressing the U.S. tradition of independence in medicine is fundamental to delivering coordinated care. Teamwork is essential to bringing to bear multiple sources of expertise and experience. To have an impact, teamwork can’t be optional, and it must be facilitated by structure and technology.

Develop partnerships of trust with physicians. There is absolutely no way to effectively manage the quality, access and cost of care without physicians’ active and committed involvement. And there’s no way to foster productive physician involvement without including physicians as trusted partners in the system’s most important work.

Create proximity and productivity through electronic connections. It’s not practical to move all physicians and patient care into close physical proximity. The benefits of proximity and connection have to be created electronically. Providing the right information at the right time to the right people in the right place is the highest use of information technology in health care.

Manage risk. It’s never a good idea to turn your back on risk. Risk invariably has two traveling partners: danger and opportunity. These health systems embraced and managed risk in its many forms — in new ventures, in innovation and in business arrangements. When they began their pursuit of integration, there were few maps to guide them.

Pursue growth that expands access and influence. The best use of size is to make expertise and services more broadly available. For a health system, market influence arises from the number of individuals served. More patients and enrollees mean more influence. Access is obviously critical to market share. And suitable market share growth is the surest way to improved financial performance and deeper experience.

Restructure to enhance integration. Strategy drives structure, or at least it should. These health systems either designed themselves from the onset for integration or fundamentally restructured themselves to enhance connections, communication and coordination systemwide.

Cultivate network effects. The most recent phase in integrating these health systems has been their investment in extending themselves beyond their core campuses and facilities through networks of affiliation. Bricks and mortar are notoriously immobile, expensive and difficult to merge. Knowledge, on the other hand, is inherently portable and malleable. Through arrangements that resemble franchising of intellectual property, these health systems are leveraging their deep investments in expertise and innovation.

More commonalities

It’s often suggested that strategic success depends not only on the quality of the strategy but also on the quality of execution. There have been a consistent set of behaviors that have characterized the execution of strategic commitments by each of the eight health systems:

Continuity and consistency over extended periods of time. These organizations stuck to their commitments, even through periods of significant uncertainty and disruption. They also extended their strategies throughout their systems, along with the operational activities needed to support them. Longevity in leadership was key. CEO tenures ranged from seven to 21 years, with an average of about 14. Ultimately, an organization’s strategic mindset must emanate from its leaders.

Flexible persistence gave rise to purposeful agility and opportunism. Mayo Clinic was born out of a storm — an F5 tornado hit Rochester, Minn., in 1883. That disaster precipitated the formation of the clinic and solidified the core beliefs of its founders. The Cleveland Clinic burned to the ground about the same time as the nationwide bank collapse in 1929. Instead of walking away, the founders rebuilt the clinic and added two floors. None of the systems progressed in quick, bold strokes. Instead, they experimented their way forward. They gradually invented their own paths toward integration.

Nonnegotiable commitments were essential to fighting fragmentation. Each of these organizations demonstrated tightness not found in most other health systems. Some things were beyond negotiation. Driving out variation was not optional. Executives, physicians and staff were required to adhere to standards that yielded integration and value.

Focused accountability in pursuit of value ran through each of the health systems. Constructive competitiveness drove them to demonstrate superior performance against a worthy standard: value. Because of the clarity of their intentions, including their establishment of measurable goals, accountability for value became a reality rather than a nebulous and unfocused aspiration.

It’s taken at least 30 years for these eight health systems to deliver on their value proposition of integrated care. I believe that many other health systems can accelerate and strengthen their commitment to value by emulating the lessons these eight embody. No commitment will serve U.S. health care better.

Dan Beckham is the president of The Beckham Co., a strategic consulting firm based in Bluffton, S.C. He is also a regular contributor to H&HN Daily.

3 alternative payment models that may work in the ER

by Paige Minemyer

Aug 19, 2016

http://www.fiercehealthcare.com/population-health/how-emergency-departments-can-transition-to-alternative-payment-models

As more hospitals and healthcare facilities move away from a fee-for-service model, they may find it difficult to apply alternative payment models to the emergency department, frequently a safety net for patients who may be uninsured or unable to pay for care.

The ED also presents challenges because emergency care isn’t set up to follow patients after discharge, which makes it difficult for organizations to obtain a full grasp on care costs, according to new study published in the American Journal of Managed Care. Furthermore, ER doctors may order a large number of tests to rule out life-threatening conditions for patients, so payment reform may lead to misdiagnoses as care patterns change, study authors note.

Despite the unique challenges the ED presents to payment reform, the report’s authors examine how payment models under the Department of Health and Human Services’ four-category framework could work.

In addition to using the existing fee-for-service model, they suggest that organizations could:

Connect the fee-for-service model to quality benchmarks. In this model, according to the study, EDs would still operate under a fee-for-service system, but they could earn additional payments by achieving certain goals, like improving patient satisfaction or better care coordination. Being paid directly for coordination of care can lead to better outcomes and lower costs, according to the study.

Build a new payment model based on fee-for-service. One way this could work is for providers to establish frequent use programs, which cut costs by personalizing plans for patients with more complex medical, psychological and social needs. EDs could also offer bundled payments for more episodic conditions, which may reduce both costs and unnecessary readmissions, according to the study.

Create a population-based payment system. Under this model, ED providers would be paid a fixed sum based on local population, previous emergency care use or projected costs across a certain window of time. Basing payments around population gives incentives to providers to address inefficient care and to prevent unneeded ER visits for acute care.

Here’s the link to the AJMC Study:

http://www.ajmc.com/journals/issue/2016/2016-vol22-n8/aligning-payment-reform-and-delivery-innovation-in-emergency-care

EMS1.com, Fitch & Associates and the National EMS Management Association just published their EMS Trend Report.

Click below to view and download a copy.

2016_EMS_Trend_Report-1

If your organization would like to join AIMHI, the membership application is now available. You can access the application at the “Join Us” tab, or download it here. Please email the completed application to ariordan@ambulance.org.