Category Archives: Health Insurance Issues

8 ways hospitals are cutting readmissions

Written by Megan Knowles | August 15, 2018 | Print  | Email

As hospitals work to reduce readmissions, healthcare experts are looking at why patients return to the hospital and strategizing ways to keep discharged patients from becoming inpatients again, according to U.S. News & World Report.

1. Rapid follow-up. Congestive heart failure patients are some of the patients who have the highest risk of early hospital readmission, and patients who see a physician soon after their hospital stay or receive a follow up from a nurse or pharmacist are less likely to be readmitted, a study published in Medical Care found.

graph of top causes for hospital readmissionAfter researchers looked at about 11,000 heart failure patients discharged over a 10-year period, they found the timing of follow-up is closely tied to readmission rates, said study co-author Keane Lee, MD. “Specifically, it should be done within seven days of hospital discharge to be effective at reducing readmissions within 30 days,” Dr. Lee said.

2. Empathy training. When clinicians are trained in empathy skills, they may better communicate with patients preparing for discharge, and encouraging two-way conversations may help patients reveal their care expectations and concerns. Providers at Cleveland Clinic, for example, receive empathy training to better engage with patients and their families.

3. Treating the whole patient. When a patient suffers from multiple medical conditions, catching and treating symptoms of either condition early may prevent an emergency room visit. Integrated care models make it easier to give patients all-encompassing, continuous care, said Alan Go, MD, director of comprehensive clinical research at the Kaiser Permanente Division of Research in Oakland, Calif.

4. Navigator teams. A patient navigator team of a nurse and pharmacist can help cut heart failure patient readmissions. Patients who are discharged may be overwhelmed by long medication lists and multiple outpatient appointments. A patient navigator team of a nurse and pharmacist can help cut heart failure patient readmissions.

One study examined results of these teams at New York City-based Montefiore Medical Center. The navigator team helped reduce 30-day readmission rates by providing patient education, scheduling follow-up appointments and emphasizing patient frailty or struggle to comprehend discharge instructions.

5. Diabetes home monitoring. For high-risk patients with diabetes and coronary artery disease, home monitoring can help avoid readmissions. In a study examining a Medicare Advantage program of telephonic diabetes disease management, nurses conducted regular phone assessments of patients’ diabetes symptoms, medication-taking and self-monitoring of glucose levels. The study found hospital admissions for any cause were reduced for the program’s patients.

6. Empowered patients. It is critical for patients to understand their care plan at discharge, including medications, physical therapy and follow-up appointments, said Andrew Ryan, PhD, professor of healthcare management at the University of Michigan School of Public Health in Ann Arbor. “Patients don’t want to be readmitted, either,” Dr. Ryan said. “They can take an active role in coordinating their care. Ideally, they wouldn’t have to be the only ones to do that.”


How to make sure your vacation isn’t a medical disaster

Recently while traveling overseas, I found myself in a predicament not often encountered nor taught to health professionals. I was requested to address an emergency at 30,000 feet in the air. This got us thinking: How many patients consider the possibility of a medical emergency in the air?

photo of person in beach chair with full body cast for article, How to make sure your vacation isn’t a medical disasterPeople with chronic illnesses and the older population (who find themselves retiring and having more time to travel) need to be prepared so their vacation isn’t ruined by a health crisis.

Below are a few tips to stay safe while traveling:

If you have serious medical conditions, be sure your travel companion is prepared to help in case of an emergency. In the event you lose consciousness you need someone to convey information to those on board trained to help you, primarily the flight attendants, or, if you are lucky enough, a medic, emergency medical technicians (EMT), nurse, nurse practitioner (NP), physician assistant (PA) or physician.

This cannot be overstated enough — pack ANY medications you might need in an emergency in a carry-on bag. This includes an epi-pen, albuterol, aspirin, nitroglycerin, antihypertensives, non-steroidal anti-inflammatory medications, insulin, glucose supplement, anti-emetics, oxygen, etc. If you’re not sure if you should carry certain medications on board, discuss it with your primary care physician prior to traveling. TSA states, “Medications in pill or other solid forms must undergo security screening. It is recommended that medication be clearly labeled to facilitate the screening process. Check with state laws regarding prescription medication labels.” Make sure to have plenty of medication for your trip, plan to have your primary care physician call these into the pharmacy at least one week prior to travel. Be prepared for anything. Most airlines only carry a basic first-aid kit, oxygen and a defibrillator.

If you have medical conditions, see if your primary care physician prior to take off for a travel clearance. If your physician detects early warning signs of illness then the risks of travel may far outweigh the benefit.

If you have serious food or environmental allergies (e.g., anaphylaxis — a multi-organ, life-threatening allergic reaction) alert the flight attendants as you board (and have your EpiPen!). Though awareness of serious allergies to peanuts has increased they are still served on some flights. Other commonly served food products include soy and wheat.


Blue Shield of California Commits to Work with Providers to Bring Health Care into the Digital Age

LAS VEGAS–(BUSINESS WIRE)–Blue Shield of California today announced an important step to bring health care into the digital age. Beginning this year, it will require network providers, including those participating in the nonprofit health plan’s nationally recognized Accountable Care Organization (ACO) program, to agree to participate in Manifest MedEx, the largest nonprofit health information network that is creating comprehensive, real-time digital health records for all Californians.

Blue Shield logo for article, Blue Shield of California Commits to Work with Providers to Bring Health Care into the Digital AgeManifest MedEx facilitates the secure exchange of 11 million patient claims records and 5 million patient clinical records for over 200 participating partners. Manifest MedEx supports physicians, nurses, hospitals and health plans in sharing critical health information to ensure that patients receive safe, high-quality care.

Blue Shield’s decision aligns with the Centers for Medicare & Medicaid Services’ announcement today that outlines steps to increase the interoperability, portability and availability of medical data. These efforts should empower patients, improve care and lower health care costs.

“Manifest MedEx delivers real-time, comprehensive health care data to providers and payers on a secure, open platform. It is a crucial prerequisite to transforming our fragmented health care system,” said Paul Markovich, Blue Shield of California’s president and CEO. “This is part of our commitment to provide health care that is worthy of our family and friends and sustainably affordable. We encourage others to get on board.”

“Providers have made enormous investments in technology and infrastructure,” Markovich added. “These investments will be even more valuable when the data they collect is shared and combined with other health information to create a comprehensive patient record that helps improve the quality of care.”

Blue Shield is asking its ACO providers to sign a participation agreement with Manifest MedEx by Aug. 31, 2018 and other network providers to do so as a part of their next contract renewal. It plans to work closely with all its providers to complete the implementation in the optimal time and manner.

“Manifest MedEx delivers the information that helps hospitals, medical groups and ACOs do the hard work of improving care coordination, reducing inefficiencies, addressing gaps in care and enhancing the patient experience,” said Claudia Williams, CEO of Manifest MedEx. “Manifest MedEx gets you the information you need, in the formats you need, when you need it. We break down silos, so California providers can focus on what they do best: improving health care, not assembling data.”

Created through collaboration among California’s leading providers and health plans, Manifest MedEx makes it easier for doctors, hospitals and other care providers to securely review, analyze and share medical information across the health care system.


Healthcare spending growth slowed in 2016

Private health insurance continues to be the largest payer for healthcare goods and services, accounting for just over one-third of total spending.

Susan Morse, Senior Editor

Healthcare spending grew at a slower rate in 2016 than during the previous two years, according to new analysis released Wednesday by the Office of the Actuary for the Centers for Medicare and Medicaid Services.

In 2016, U.S. healthcare spending grew at a rate of 4.3 percent to $3.3 trillion. This compares to spending increases of 5.1 percent in 2014 and 5.8 percent in 2015.

Spending growth in 2016 was more in line with the rate of 4.2 percent from 2008 to 2015.

chart for article, Healthcare spending growth slowed in 2016The slower growth is primarily due to decelerated spending for retail prescription drugs, hospital care, and on physician and clinical services, according to the Office of the Actuary report.ntions]

Spending growth also fell among the three major payers: private health insurance, Medicare and Medicaid.

The last time there was a spending drop of this type was in 2010, when there was a decrease in the three area of goods and services – retail prescription drugs, hospital care, and physician and clinical services, CMS said.

This is the first time in memory CMS has witnessed a slowdown in  goods and services spending, and among the three major payers.

For private health insurance and Medicaid, the slower growth was influenced by decelerated enrollment growth, while Medicare spending slowed because of lower enrollment increases due to defections to Medicare Advantage plans.

Medicare Advantage now makes up a third of all Medicare enrollment. This means slower growth in fee-for-service Medicare spending as MA is value-based.

CMS said it didn’t have details on how other value-based models such as bundled payments have played a part in slower healthcare spending increases.

Continue reading Healthcare spending growth slowed in 2016

Why Insurance Companies Are Saying No to Generic Drugs

By Kate Seamons,  Newser Staff      Posted Aug 9, 2017

It flies in the face of conventional wisdom: insurance companies that won’t pay for generic drugs, essentially forcing patients to opt for pricey brand-name drugs. And yet that’s exactly what’s happening, report ProPublica and the New York Times.

illustration of generic drug capsule and brand drug capsule with boxing gloves for article: Why Insurance Companies Are Saying No to Generic DrugsIt’s “befuddling,” says one 41-year-old who says he has to foot a $90 co-pay for Adderall XR because the generic isn’t covered by his plan. How’d we get here? The report pins it on pharmaceutical companies trying to “squeeze the last profits from products that are facing cheaper generic competition,” and asserts they’re doing it by shaking hands on back-room deals that may be happening more and more often.

Though they’ve uncovered evidence this is happening with more than a dozen drugs, including Aggrenox (a stroke preventative) and Zetia (for cholesterol), the report dives into Adderall XR and its “continued success … long after generic competitors arrived on the market.” In a move designed to cling on to market share, maker Shire began sweetening the deal for pharmacy benefit managers and insurers.

The list price didn’t budge, but the insurers and “middlemen” like CVS Caremark were paid rebates. And the report explains why patients might not opt to just pay for the generic themselves: In the case of one Brooklyn mother, it costs an extra $600 a year to pay for her son’s Adderall XR versus a generic, but paying for it through insurance is the only way to make it count toward her family’s $3,000 health insurance deductible. Read the full report here.


Want to Decrease Disability by 53%?

According to a recent issue of Health Affairs, all we have to do is completely eliminate five risk factors: smoking, obesity, diabetes, high cholesterol, and hypertension.

Easy, right?

 graph showing risk factors ofsmoking, obesity, diabetes, high cholesterol, hypertension leading to disabilitiesI find it amazing that these risk factors contribute to (potentially, depending on the credibility you lend the study) more than half of all disability in this country.

And given that the study (Preventing Disability: The Influence of Modifiable Risk Factors On State and National Disability Prevalence) is written from a non-work comp perspective, I view this as more of challenge in our industry (where we accept the whole person and have relatively little influence over pre-injury behavior).

If the theoretical elimination of all five risk factors is a bridge too far for you, consider a more conservative analysis contained in the study: If each risk factor was reduced to the level of the “best performing” state (i.e., if all states mirrored the nation’s lower obesity rate of Colorado), we would observe a decline in disability prevalence of approximately 7%. And disability rates in regions where prevalence is highest (South, Appalachia, and Great Lakes) would drop more than 10% under such a scenario.

But our starting point is grim. In the 18-54 age cohort, nearly 70% of US adults have more than one of the five risk factors. In the 55-64 cohort, it’s about 90%. And in the 65-79 category, about 95%.

This isn’t just clinical, it’s cultural.


Negotiating Drug Prices: Should CA State Agencies Band Together?

California Drug Price Relief Bill, logoCiting budget-busting drug costs, a California lawmaker wants state health programs to band together to negotiate better prices with drug companies.

Assembly member David Chiu (D-San Francisco) has introduced a bill that would strengthen intra-agency collaboration on drug cost-saving strategies. Lawmakers will consider the bill at an Assembly Health Committee hearing on Tuesday.

“Californians and Americans are frustrated with the lack of progress around drug prices,” Chiu said, citing the uproar over EpiPen and hepatitis C medications.

He said state agencies should pool their efforts “so that we can leverage that consumer power and get the best deal for our money.”

While the proposed California Drug Costs Reduction Act does not mandate that various California health programs such as Medi-Cal or Covered California purchase drugs together, it would require administrators of those programs and 17 other state agencies to convene twice a year to strategize about ways to keep costs down.Through the California Pharmaceutical Collaborative (CPC), state officials would consider a uniform state drug formulary and look at paying for drugs based on the value they bring to the health system.

A pharmaceutical collaborative by that name already exists within the California Department of General Services and purchases drugs for state prisons, hospitals and universities. This bill would expand on those efforts.

Chiu says it’s unclear what the current program is doing, and if it has been successful in bringing down drug costs. The 2002 legislation that created the collaborative required only a few agencies to participate, and only one report back to the legislature in 2005.

Continue reading Negotiating Drug Prices: Should CA State Agencies Band Together?

Is PSA Now “OK”?

What the task force really said about the evidence on prostate cancer screening

by Kathlyn Stone  |  An associate editor with You can find her tweets at @KatKStone

illustration of PSA test, to screen or not to screenReading the headlines on the US Preventive Services Task Force’s (USPSTF) update to its prostate cancer screening guidelines, you might come away with the idea that the task force has completely reversed its 2012 recommendation against broad-based prostate-specific antigen (PSA) screening.

But that would be the wrong impression.

What the revised guideline does is make a slight change. It changes the recommendation for routine prostate cancer screening from a “D” (which discourages the service since “There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.”) to a “C (which means that physicians should “Offer or provide this service for selected patients depending on individual circumstances,” and that “There is at least moderate certainty that the net benefit is small.”)

The main point is that men who are candidates for testing (ages 55 to 69) should discuss the benefits and harms of the test with their doctors and make a personal decision about whether to take it.

Some news outlets engaged in grade inflation contributor Saurabh Jha, MBBS suggested, somewhat cheekily, that some urologists might want to temper their jubilation over this modest adjustment:


The prize for most misleading framing of this news comes from the Washington Post whose headline proclaimed: “The federal panel that opposed prostate cancer screening just changed its mind.”


Study Says PT as Effective as Surgery for CTS


EDITORS NOTE:  Fortunately for our patients, we have one the finest Physical Therapists in the Santa Maria Valley, Ed Donahue!

info graphic of how to avoid carpal tunnel computer workSacramento, CA – Physical therapy is as effective as surgery in treating carpal tunnel syndrome, according to a new study published in the Journal of Orthopaedic & Sports Physical Therapy® (JOSPT®).

Researchers in Spain and the United States report that one year following treatment, patients with carpal tunnel syndrome who received physical therapy achieved results comparable to outcomes for patients who had surgery for this condition. Further, physical therapy patients saw faster improvements at the one-month mark than did patients treated surgically.

Carpal tunnel syndrome causes pain, numbness, and weakness in the wrist and hand. Nearly half of all work-related injuries are linked to this syndrome, which can result from repetitive movements. Although surgery may be considered when the symptoms are severe, more than a third of patients do not return to work within eight weeks after an operation for carpal tunnel syndrome.

The study demonstrates that physical therapy – and particularly a combination of manual therapy of the neck and median nerve and stretching exercises – may be preferable to surgery, certainly as a starting point for treatment.

“Conservative treatment may be an intervention option for patients with carpal tunnel syndrome as a first line of management prior to or instead of surgery,” says lead author César Fernández de las Peñas, PT, PhD, DMSc, with the Department of Physical Therapy, Occupational Therapy, Rehabilitation, and Physical Medicine at Universidad Rey Juan Carlos, Alcorcón, Spain.


An Interesting Opioid Red Flag

By Mark Pew 01/20/2017

red flag with word opioid on itI love Uber rides. I learn so much (my profile picture should actually be a sponge) because I’m typically engaged in conversation with the driver. I learned something unexpected during my ride to the Oklahoma City airport yesterday,

My colleague and I started with the standard small talk (after all, riders are being rated by the drivers) about why we were in OKC, who we worked for and what we did. When I mentioned opioids as part of the description, the driver had his own story (which happens often when I mention my focus as the RxProfessor).

He is 73 years old and had a total knee replacement last year. As he helped us with our luggage, I did not notice a limp so he obviously had recovered fully. The surgery was on May 1. He used a highly reputable orthopedic surgeon in OKC (where he’s lived all of his life).

The surgery was a success. He was walking – painfully – the day after the surgery (part of the focus on quick post-surgical activity that has taken hold over the past decade or so). He was given Vicodin 7.5mg to help with his pain. As he tolerated the therapy and regained mobility and capabilities, he titrated down to Vicodin 5mg. He took his last pill on August 3, after a week with his wife and young grandchildren on vacation. By all accounts – granted, his was the only account I heard – the surgery and therapy was a success and his new knee provided life opportunities that had diminished with his formerly bad knee.

I did not ask about any co-morbidities, but he appeared physically, cognitively and emotionally healthy. I did not ask him about his ongoing drug regimen, but it was obvious opioids were not part of whatever he might be taking. I did not ask about any substance abuse history, but he appeared to be fully aware of the dangers of opioids as he took them last year and was actively engaged in not only getting better but getting rid of the drugs and moving on in life.

So … Absolutely no red flags.

Except he just got denied for a life insurance policy. The reason?
Opioid use.

I totally understand why insurance companies, especially life insurance, are really worried about opioids. When used long-term for non-malignant chronic pain (legitimately prescribed by doctors) they often decrease function and increase side effects and decrease quality of life and increase dosage / number of drugs.