McKesson : The Business of Health Care March 2017

As value-based care and reimbursement models proliferate in the health care industry, the challenge for health care providers is how to control or reduce utilization costs while at the same time maintaining or improving patient outcomes.

Eight new industry developments tell providers what they need to know about mining the value from accountable care organizations, bundled payment arrangements, care coordination and oncology care.

Accountable Care Organizations

35% of ACOs have formal strategies to manage their prescription drug costs

That's according to a survey of 141 ACOs conducted by the Pharmacy Benefit Management Institute. In Pharmacy Trends in Accountable Care Organizations, the PBMI documented the current level of the medication management capabilities of the surveyed ACOs. Some 54 percent reported having no formal plan to manage their drug expenses. Of those with formal plans, the most common features were prescribing generic medications when available (94 percent), following clinical pathways (78 percent) and standardizing prescribing patterns (59 percent). Some 63 percent directly employed or contracted with pharmacists as part of their ACO care team.

ACOs say collaborating with local social services is crucial to population health improvement

That's according to 18 of 19 ACOs that took a population health survey conducted by the Premier Research Institute. In Performance Evaluation: What is Working in Accountable Care Organizations?, surveyors asked 19 ACOs what actions they are taking to improve the overall health of their communities. The most frequently cited actions were 'working with the social service organizations in the community,' 'working with schools' and 'offering wellness programs to the entire community.' 'The top three services needed to improve the overall health of their communities, according to the ACOs, were behavioral health services, substance abuse services and prescription assistance.

Bundled Payments

Bundled pay shaves nearly $1,200 more off joint replacement procedures than did traditional FFS pay

Medicare paid 176 hospitals in Medicare's Bundled Payments for Care Improvement (BPCI) demonstration project an average of $1,167 less per hip and knee replacement than a comparable group of non-participating hospitals without an adverse impact on patient outcomes, according to a study in the Journal of the American Medical Association. In 'Association Between Hospital Participation in a Medicare Bundled Payment Initiative and Payments and Quality Outcomes for Lower Extremity Joint Replacement Episodes,' researchers compared changes in payments for hip and knee replacements for Medicare patients performed at 176 BPCI-participating hospitals and a peer group of about 800 non-BPCI hospitals. Payments at non-BPCI hospitals dropped by $2,119 per case from an average of $30,057 to $27,938 between the two study periods (October 2011 through September 2012 compared with October 2013 through June 2015). Payments at BPCI hospitals dropped by $3,286 per case from an average of $30,551 to $27,265. The researchers found that the greater savings achieved by the BPCI hospitals were '…primarily due to reduced use of institutional post-acute care.'

Bundled pay drives down Medicare payments for joint replacements by nearly 21%

That's according to a separate study published in JAMA Internal Medicine. In 'Cost of Joint Replacement Using Bundled Payment Models,' researchers analyzed the changes in Medicare reimbursement per joint replacement procedure performed on Medicare patients at the Baptist Health System in San Antonio, Texas. Baptist participates in the BPCI program. From July 2008 through June 2015, some 3,942 patients had their knees or hips replaced with the average Medicare payment dropping 20.8 percent from $26,785 to $21,208 over that period. The rate of adverse outcomes was unchanged. 'Most of the hospital savings came from implants and supplies and most of the post-acute care savings came from decreased use of institutional care,' the researchers said.

Coordinated Care

18.7% of Medicare patients discharged by ACO-affiliated hospitals to SNFs readmitted within 30 days

That represents a 4-percentage point drop in the 30-day readmission rate from skilled-nursing facilities between 2007 and 2013, according to a study in the journal Health Affairs. In 'ACO-Affiliated Hospitals Reduced Rehospitalizations From Skilled Nursing Facilities Faster Than Other Hospitals,' researchers compared changes in the readmissions rates of Medicare patients discharged to SNFs by 226 hospitals in Medicare's accountable care organization program and 1,844 comparable non-participating hospitals. They found that ACO-affiliated hospitals reduced their SNF readmission rates faster and lower than non-ACO affiliated hospitals. 162 hospitals in the Shared Savings ACO track cut their readmission rate from 22.7 percent in 2007 to 18.7 percent in 2013. It dropped from 22.3 percent to 19.3 percent for non-ACO hospitals.

'The reductions suggest that ACO-affiliated hospitals are either discharging to the nursing facilities more effectively compared to other hospitals or targeting at-risk patients better, or enhancing information sharing and communication between hospitals and skilled nursing facilities,' the researchers said.

Choice of rehab setting following surgery, not intensity of rehab care, biggest influence over cost

That's according to a study in the journal Health Affairs that looked at the post-acute care costs of Medicare patients who underwent hip replacement, heart bypass and colectomy surgical procedures from 2009 through 2012. In 'Spending On Care After Surgery Driven By Choice of Care Settings Instead of Intensity Of Services,' researchers found wide variations in 90-day post-surgery rehab costs for each of the procedures and analyzed causes for the variations. They found that the setting chosen for the patient's surgical rehab had more to do with cost variations than the intensity of care in each setting. For example, the cost of post-acute care following hip replacement surgery ranged from $4,608 to $12,765 per case-a difference of $8,157. After adjusting for intensity of care, the difference was still $5,856. But after adjusting for setting of care, the difference dropped to $1,162. 'Health systems seeking to improve surgical episode efficiency should collaborate with patients to choose the highest-value post-acute care setting,' the study said.

Oncology Care

Most cancer patients say they've not heard terms 'clinical pathway' or 'clinical practice guidelines'

That's according to a survey of 1,046 cancer patients conducted by the Cancer Support Community patient advocacy organization. In its report, Access to Care in Cancer 2016: Barriers and Challenges, the group said 73 percent of the surveyed cancer patients said they've not heard the term 'clinical pathway,' and 54 percent said they've not heard the term 'clinical practice guideline.' Oncologists use both to make treatment decisions for their patients. Some 38 percent of the cancer patients said they would have liked to have been more involved in medical decisions about their care and available treatment options. 'This speaks to a clear need for enhanced engagement between patient and provider,' the group said.

U.S. cancer mortality rate drops by more than 20% from 1980 to 2014

The rate of cancer deaths in the U.S. declined 20.1 percent from 240 for every 100,000 people in 1980 to 192 for every 100,000 people in 2014, according to a report in the Journal of the American Medical Association. In 'Trends and Patterns of Disparities in Cancer Mortality Among US Counties, 1980-2014,' researchers studied deaths and death rates by U.S. county from 29 different types of cancer. Tracheal, bronchus and lung cancer topped the list in 2014 in both number of deaths and death rates with 183,000 and 54.2 per 100,000, respectively. The study uncovered wide variations in cancer mortality rates by county. For example, the breast cancer mortality rate ranged from a low of 5.2 deaths per 100,000 people to a high of 29.5 per 100,000 people. 'The study was able to identify clusters of high rates of change among U.S. counties, which is important for providing data to inform the debate on prevention, access to care and appropriate treatment,' the researchers said.