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Julie Mickles Agan

Program Manager

Louisiana Senior Medicare Patrol

The arrests in early May of more than 100 people accused of health care fraud is a vivid reminder that fraudsters are as much a part of the health care system as doctors and patients. In my community of Baton Rouge, LA, the most recently accused are associated with two mental health clinics, and are believed to have bilked Medicare out of $225 million by filing false claims.

The feds think this Baton Rouge-based scheme has been operating since 2005, meaning that an average of more than $35 million per year was stolen by recruiting fake patients from hospitals, nursing homes and homeless shelters as far away as Tennessee.

As the program manager for the Senior Medicare Patrol in Louisiana, I was invited to accompany the Medicare Fraud Strike Force at the courthouse when the seven accused were brought before the judge for their initial arraignment.

The investigation that resulted in these arrests occurred because of the coordinated work of many agencies, including the FBI, the HHS-Office of Inspector General, multiple state Medicaid Fraud Control Units and state and local law enforcement agencies.

Individual citizens can also play just as vital a role in preventing fraud as government agencies and police forces. Often times, it is a call from an elderly Medicare patient to the police or to an agency like ours, the Senior Medicare Patrol, or SMP, that starts an investigation.

In Louisiana and other states, SMPs work to educate seniors on how to detect possible fraud. Volunteers are also taught how to file a report if they see something that appears suspicious. Thus, when an arrest like this is made, it demonstrates to our volunteers that their efforts get results.

Our SMP office has received several complaints regarding community mental health centers (CMHC) that have recruited seniors to participate in what appear to be illegal schemes. When our volunteers make these reports, they are forwarded to the Health Care Fraud Prevention and Enforcement Action Team, known as HEAT. I believe there are at least two cases currently under investigation by HEAT that were referred by Louisiana SMP.

These recent cases also show how innocent beneficiaries can be unwittingly used to assist the fraudsters. Although getting questionable mental health care may not compromise a healthy beneficiary’s physical health status, the beneficiary might now have a medical record that contains an incorrect mental health diagnosis. This could later prove problematic when that person truly needs care and discovers they have already used up some benefits under a fake diagnosis.

For our citizens who already may have an addiction, who are perhaps living in a nursing facility or who may be homeless, this is particularly heinous.

Whether it is the vast sums of money that is being stolen, or the damage done to innocent citizens, health care fraud presents one of the greatest threats to our health care system. As our company works to improve health care by enhancing the quality of care … with an ultimate goal of making care more cost-effective … it is disheartening to see the impact of fraud. It seems that just as quickly as we implement quality improvement efforts that save money and improve health care, fraudulent providers are stealing multi-millions of dollars that could be used to improve people’s lives.

The SMP program was established by federal law in 1997 and is administered by the federal Administration on Aging. The goal of the SMP program is to recruit and train retirees to educate seniors in their communities to detect and report health care fraud and abuse and to help persons with Medicare and Medicaid to correct billing errors.

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eQHealth Solutions has been selected by Peoples Health Network (PHN) to provide training support to PHN’s team members who provide assistance to hospitalized members. The training program pairs a health coach with a Peoples Health nurse case manager, and guides them through the educational program that helps each individual throughout their hospitalization and following discharge.

In 2011, eQHealth created and successfully completed a pilot coaching program for Peoples Health members and nurse case managers at East Jefferson General Hospital. The success of that pilot led to Peoples Health selecting eQHealth to provide training support for all of its nurse case managers network-wide.

The key role of the Peoples Health nurse case manager, who will be trained by eQHealth, will be patient coaching. The coach helps the patient to understand their illness, learn the warning signs, understand their prescriptions, schedule and attend post-discharge follow-up appointments. The coach also supports the patient in their home environment to ensure the patient fully recovers at home, lessening the chance for a readmission to the hospital.

Carol Solomon, Chief Executive Officer for Peoples Health, said her company selected the eQHealth coaching program after carefully reviewing several similar offerings.

“This model works well with our hospitalized plan members. We are pleased to be able to expand this coaching model to all of our nurse case managers through the effective coaching that eQHealth offers. We believe that our members will be better prepared to return home and manage their conditions, which will lessen the likelihood that they will need a return trip to the hospital.”

Ron Ritchey, eQHealth’s Chief Medical Officer, said Peoples Health is a progressive insurer that is committed to giving its members the tools they need to best recover from a hospitalization.

This coaching program will work alongside their nurse case managers in the hospital setting to help educate the members on their health conditions, how to best manage their associated health issues, and to ease the transition back into their home setting ensuring an optimal recovery,” Ritchey said.

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Ron Ritchey, MD, Corporate Medical Officer, eQHealth Solutions 

In this op-ed Dr. Ritchey discusses block grants as a possible funding source for state Medicaid programs. This post is part of a forward looking series, Game-Changing Events, that examines several scenarios that might soon have dramatic impacts on state Medicaid agencies and their approaches to controlling costs.

In my last posting, I looked at the possible future of more states adopting Medicaid managed care. But, in spite of several scenarios that will shine the light on this strategy, I remain convinced that managed care will not take over as the dominant strategy of choice in most states. So, what are the other options?

Here is one scenario: As we look forward into this year, the Great Recession of 2009 continues (possibly even into 2013). Even though we’ve seen some signs of economic recovery characterized by corporate profitability, unemployment remains high, consumer optimism low, and the economic recession grinds on into its fourth year.

In 2011, we saw a few states and municipalities that were struggling to pay their bills. Without a sudden and strong upturn in the economy, it is not unlikely for this situation to worsen, with financial meltdowns occurring in quick succession. If a handful of states and municipalities begin to default on their bond obligations and are downgraded to junk status, can or will the federal government step in to help. I don’t think so.

No matter who is elected President, there is no end in sight to partisanship and gridlock in D.C. Dysfunction prevents the federal government from coming to the aide of local governments in the form of another bailout. Investment banks won’t be able to help as they will be caught up in a swamp of illiquidity. Then, the financial world comes to a halt as one bank will not lend to another for fear of risk, and the Fed will be powerless to help as its balance sheet is hopelessly over-extended.

Washington might print more money, but the result would be the value of the dollar falling precipitously. Finally, the U.S. debt rating will be downgraded from AA+ to A+, thus taking the country’s rating out of the high-grade category. International reaction is swift and devastating: treasuries are dumped on the market, interest rates rise alarmingly. The bond yield curve inverts. Congress is shocked.

It will be at this point that congress might respond to the call from the states to make fundamental changes that make Medicaid more nimble and less bureaucratic. In this “Be careful what you ask for” scenario, the result could be block grants to states that replace the current Federal Financial Participation (FFP) approach.

With this block grant lump sum, states would then have to fund all Medicaid costs internally, regardless of the escalation over time. Faced with this harsh reality, state Medicaid administrators search for new payment options to stretch reimbursement dollars ever further. Of course, they will have greater flexibility than ever before.

Federal block grants to states for Medicaid would produce swift and dramatic changes. Programs would have to be significantly reduced in cost. All Medicaid programs are costly and complex. Each state would have to figure ways to reduce costs, size and complexity by near complete program redesign.

Some have argued that the present cost and complexity of states’ Medicaid programs are a function and result of federal rules and regulation that have driven these costs. To the extent that is true and to the extent that block grants would free states from onerous federal regulations, Medicaid administrators would be free to explore, experiment and devise new options for services.

Should this occur, states will need assistance in program redesign, analyzing care patterns and designing clinically effective cost and/or quality improvement programs. I would also look for transformational attempts to change how we pay for long term care for the aging and for people with disabilities.

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Unless you have a plan to ensure the coordination of care for your patients

Laurie Robinson, RN

Director of Care Coordination Services, eQHealth Solutions

 The latest “next-greatest-idea” to improve health care quality is the Accountable Care Organization (ACO). This idea follows the integrated health system, the patient-centered medical home, case management, disease management and a myriad of other solutions. Each of these held out the promise of slower growth in spending or reductions in the cost of care, health system efficiencies and, ultimately, healthier patients who will lead a better quality of life.

So, the question for today is, “Will the ACO deliver on its promise when other ideas have not?”

According to most experts, the keys to the success of an ACO hinges on a motivated and strong network of primary care providers, high quality care from all members of the ACO team, aligned financial incentives among all providers, electronic health records and the ability to exchange information, and on informed and activated patients.

How will care be coordinated?

But, I see one more requirement for success, care coordinators. Working on behalf of the patients, care coordinators are members of the ACOs team. They provide the link between the patient and each member of the medical, support and social service team members. 

In this model, the care coordinator becomes the heart of the ACO. They provide the day-to-day assistance to patients as they move from one medical professional to another. The care coordinator helps the patient sort through medical data and assists with social issues that might contribute to poor health outcomes. 

Face-to-face interventions are recommended

The most effective care coordinators work face-to-face with the ACO’s patients. Although more costly in the beginning, this approach gets results because it improves rapport between providers and their patients, and because the care coordinator can develop an accepting, trusting and collaborative relationship with the patient in a relatively short period of time. Care Coordinators ensure that the doctor’s orders are followed and the patient is an active participant in his/her care. 

Many ACOs will include a case management component that relies solely on periodic telephonic interactions with a case manager. Our experience, where our care coordinators helped to lower the rate of hospital readmissions for high-cost patients with chronic complications (from 19% to 13%), demonstrated the effectiveness of this face-to-case, care coordinator model.

ACOs that take shortcuts and rely only on telephone operators to successfully educate, motivate and activate their patients will not share in much savings. I suspect many will fail.

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Ron Ritchey, MD, Chief Medical Officer, eQHealth Solutions

In this op-ed Dr. Ritchey discusses managed care as the strategy of choice for many states. This post is part of a forward looking series that examines several scenarios that might soon have dramatic impacts on state Medicaid agencies and their approaches to controlling costs.

Let’s fast forward to 2014:  Many states have new governors and the increased sizes of Medicaid rolls are forcing state leaders to find innovative ways to reduce costs.

In Illinois, for example, the new governor takes office faced with a struggle to control the increasing costs to the state’s Medicaid program. The combined effect of inflation, expensive health care advancements, additional Medicaid-eligible patients (because of the recession and health reform), and years of heavy state payrolls have created a retirement system nightmare. The state is struggling to pay retirees, teachers, state employees, Medicaid providers and government contractors.

Attending a Governor’s Conference, the new Illinois chief executive listens as Louisiana governor, Bobby Jindal, outlines how his approach to lowering Medicaid spending, which started back in 2012, is now paying off.

Gov. Jindal touts multi-million dollar savings in the program’s first six months and projects increased savings in future years. He describes how the Louisiana model, coordinated care networks, is a statewide approach in which all recipients – other than the aging and disabled – are enrolled in managed care. To control the program, Louisiana has allowed five large corporations to manage care and control the flow of dollars and cap the cost to the state.

Impressed by this seemingly simple solution, the Illinois governor does the same, moving all Medicaid recipients into managed care.

Although many states have had some type of Medicaid managed care in place since 2010, Gov. Jindal’s nationwide speaking tour positions Louisiana’s model as an effective improvement on other models. Soon other states that are dealing with serious financial crises of their own begin to consider the Louisiana model.

So is it likely that by 2014 managed care will have become the panacea for everyone?

Probably not.

Managed care is not a new concept and several potential challenges could make long-term success tenuous.

Already in place in other states since 2011 actual success has been limited. Recently, Connecticut decided to drop its for-profit managed care plan after finding that costs were not lowered and care had not improved.

States with managed care may find that after a few years of savings, the for-profit managed care organizations (MCO) demand greater reimbursements. Savings are lost or these firms leave the states altogether.

In some cases managed care programs are really only primary care case management (PCCM) programs in which some doctors get an enhanced fee to coordinate care. Yet, emergency department usage is not reduced, there is no after-hours care, and there are no measureable improvements in outcomes or quality.

In addition, the high cost recipients (those requiring long term care) are often not included in the Medicaid managed care models. States are therefore left with the almost impossible task of squeezing cost savings from the lowest cost recipients.

Nonetheless, in the coming years state leaders that are motivated by perceived cost savings will continue to pursue Medicaid managed care to reduce spending. But ultimately I believe it’s doubtful that states will find a simple solution in managed care.

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Hospitals have until October 2012 before the penalties for high readmissions take effect but the clock has already started ticking. CMS began monitoring readmission rates earlier this year and hospitals are preparing for the rollout.

It’s an opportune time to review some of this year’s best discussions on reducing readmissions and care coordination. Below is a list of resources we’ve found that will help your understanding of today’s conversations:

1.  Atul Gwande for The New Yorker on one example of how medical costs, such as unnecessary re-hospitalizations, can be lowered by zeroing in on health care “hot spots” and focusing on coordinating care at the community level.

2.  Becker’s Hospital Review – Ten proven strategies for reducing readmissions

3.  Kaiser Health News – Stats from the national VA health system illustrate that even with focused reduction efforts combating patient ‘rebound’ is going to be difficult

4.  American Medical News – How three hospitals reduced their readmission rates: Successful interventions from Atlanta, San Francisco, and Kirkland, Wash. hospitals

5.  Fierce Healthcare reports on recently released NEJM study that highlights a lesser known factor in predicting high readmissions – high hospitalizations

6.  The Health Care Blog – Lack of coordinated care is at the crux of preventable readmissions and controlling health costs

7.  Disease Management Care Blog – Without reliable scientific models for predicting readmissions will hospitals be unfairly penalized?

8.  Commonwealth Fund – Report on lessons learned from four top-performing U.S. hospitals with exceptionally low readmission rates and the key factors that contributed to their success

9.  Kaiser Health News – Conflicting incentives for hospitals to reduce readmissions

10.  Urban Institute report on the savings opportunities in improved care coordination for chronic and long-term care

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Ron Ritchey, MD, MBA
Chief Medical Officer, eQHealth Solutions

Physicians across the country are letting Congress know the centralization of medical decision-making will be harmful to patients and health care quality. The removal of state-level physician oversight from health care quality improvement work that was included as an offset in the Trade Adjustment Assistance Act of 2011 (HR2832) is raising concern from national physician leaders.

The American Medical Association House of Delegates passed a resolution of support for maintaining the state-based focus of Medicare quality improvement organizations at its Interim Meeting in New Orleans earlier this month.

The local relationships that quality improvement organizations (QIOs) have with physicians and other providers are considered essential to quality improvement work. QIOs currently work with physicians practicing in the state to review the quality of care delivered by their peers. This perspective from local physicians who understand the local health care environment ensures that patients receive appropriate, quality care.

The QIO amendments in the trade legislation have opened the door for nationalization of the QIO program, which could lead to a one size fits all approach to health care quality improvement.

Physician leadership from quality improvement organizations will continue to work together with the AMA to restore local physician involvement in health care quality review.

Removing state-based structure of QIOs was one of the changes that Senate Finance Committee staff said would “streamline burdensome contract requirements in order to align QIO contracting with practices the government uses widely today.”

What do you think? Is the state-level focus unnecessary? Would centralization enhance QIOs ability to improve health care for patients?

If you are a physician, you can contact the AMA for more information or to let them know that you are concerned about this issue.

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5 Functions Your Care Coordination Tool Must Have

By Marina Brown, BSN, RN, CCM, eQHealth Solutions Product Development Manager

Breaking down provider silos is going to require a practical tool that can drive coordinated care delivery. We cannot expect the traditional case management software systems to support a care coordination program. Care coordination software that is a few steps beyond care management software will also:

Make it easy for patients to adopt healthier lifestyles. Care coordination software makes it easier to follow the treatment plan and access providers by having one place for patients to:

• View their personal care plan, including all of their diagnoses and providers, and instructions for their medications.

• Send messages directly to their physicians and care coordinator.

• Locate and get directions to providers and community resources that are close to their home.

• Learn about their specific disease(s).

Quickly identify and monitor high risk patients. Care coordination software can track patients with higher usage of inpatient and emergency department services to focus resources on the neediest patients.

• Care coordinators can assign acuity levels based on patient assessments.

• Care coordinators can also assess patients’ health literacy levels throughout the course of the program.

• Changes in patients’ acuity and health literacy levels can be tracked over time to determine the effectiveness of interventions.

Increase time available for direct patient contact. Care coordinators can spend more time coaching patients on their conditions and better self-care with shortcuts, such as:

• Patient dashboards that provide a snapshot of medical history, the status of labs, clinical notes and personal issues that could be affecting the patient’s health.  The care coordinator does not have to go through multiple tabs to find all this information.

• Built-in locator tool to find specialists and community resources, and work around barriers, such as transportation.

• Integration with benefits management, claims systems and Electronic Health Records (EHR) so that care coordinators do not have to view multiple systems for information.

Eliminate communication barriers between members of the care team. The primary care physician, for example, should be able to log into the program and instantly download a patient’s X-ray report that was ordered by another provider.

• Care coordination software brings together patient data in a central web-based information exchange where the primary care physician, specialists and the care coordinator can monitor patients referrals, access test results and physicians notes from the entire health team.

Drive best practices and efficient care with built-in features, including:

• Guidelines on national standards of care that providers can look up using a search tool or can be set to automatically trigger alerts when there are gaps in care.

For example, if there is no record of a patient having a cholesterol test within the last 12 months, the system will prompt a reminder to the physician that this test should be ordered.

• Physician profiles to monitor utilization, costs and quality measures.

• Pharmacy database that alerts when patient medications overlap and when there could be potentially life threatening interactions.

• Real time documentation of all team members’ activities to reduce duplicative procedures.

• Reports that track performance on multiple levels – from entire populations to individual providers and patients – to identify areas where quality and efficiency can be improved.

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Marina Brown has been designing these types of systems for years and has become quite a subject matter expert. If you want to see first-hand what you should expect from care coordination software, she can give you at tour of at least one product that delivers all that and more, email her at mbrown@eqhs.org.

More on how to use care coordination software to reduce costs and improve quality is available here.

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Major changes to Medicare quality improvement tucked into trade legislation

Ron Ritchey, MD, MBA
Chief Medical Officer
eQHealth Solutions, The Medicare Quality Improvement Organization for Louisiana

Local level control and physician involvement in health care quality improvement in the U.S. was jeopardized by the passage of the Trade Adjustment Act of 2011 (HR 2832) through the House last week.

Changes to how Medicare Quality Improvement Organizations (QIOs) across the country operate were tucked into this legislation with no discussion from other members of Congress.

Removal of physician membership requirements. Currently, QIOs contracting with Medicare are required to enlist 20% of the practicing physicians in the state as members. In the new law, any organization competing for a QIO contract is only required to have one healthcare representative on its board.

Loss of state-level governance. Currently, Medicare QIOs are required to be state-based organizations. The new law allows regional or national companies to conduct quality improvement work and review. Centralizing medical decision-making could result in providers from Florida working remotely to improve quality in Louisiana for example.

These amendments threaten decades of quality gains and the safety of Medicare beneficiaries. As Louisiana’s QIO, the upward climb in health care quality in our state is a testament to our local providers’ commitment to working with us on continuous quality improvement. See a compilation of Louisiana provider accomplishments and national quality gains in CMS’ QIO Program Progress Report.

$300 million was cut from the Quality Improvement budget nationally to pay for the Trade bill — which we can live with. Louisiana’s QIO is no stranger to belt tightening and sustained a 37% cut in budget just this year. But we can’t live with a reform policy that takes quality improvement out of the hands of local providers.

At a time when we foresee reductions in Medicare, now more than ever, we need local practicing physicians to oversee the quality and accessibility of Medicare services.

You can help support the QIO program’s ongoing state-based focus. Soon there will be other healthcare-focused legislation that can be amended to fix what was broken in HR 2832.

Congressman Tom Price from Georgia, also a physician, is leading efforts in D.C. to have an open discussion about this issue. With three physicians currently serving in the U.S. House, Louisiana is helping to lead the way to influence a repair. But these changes affect every patient in the U.S.

With one short email you can ask your congressional representatives to consider meeting with Congressman Price to discuss how we can restore local level control and physician sponsorship to quality improvement. (Sample email message is below.)

Louisiana congressional representatives contact information is available here.

Not in Louisiana? Email Congressman Price’s legislative aide Laura Holland, who is on the Health Policy Committee, directly at laura.holland@mail.house.gov. You can also contact your state’s QIO or the American Healthcare Quality Association for more information.

Sample email message:  I’m concerned about the removal of physician sponsorship requirements from Medicare Quality Improvement Organization contracts in HR 2832. I hope that you will call or meet with Congressman Tom Price from Georgia to discuss how local physician involvement can be reinstated.

Click Here to sign up for email updates on this issue.

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Four reasons why care coordinators must be clinicians

Laurie Robinson, RN, CPUR, Director of Care Coordination Services, eQHealth Solutions

Marina Brown, BSN, RN, CCM, Product Development Manager, eQHealth Solutions

Care coordinators are not health coaches and they aren’t case managers with a new name. Care coordinators do coach patients and perform case management functions. But they are not all the same.

A lot of similar job titles float around when we talk about care coordination. How do you know what qualifies as a care coordinator?

Care coordinators are clinical health care professionals.

We have pointed out in previous posts that while health coaches must have health care experience, they do not need to be clinicians. The same is not true for care coordinators for several reasons.

1. Care coordinators oversee plans of care. A care coordinator develops patient care plans and coordinates them with physician treatment plans. Regulations require that this is done by a licensed health care professional, such as a registered nurse, a certified case manager or a clinical social worker.

2. Care coordinators make clinical decisions. A care coordinator must be able to make independent, clinically-based assessments about care plans and respond to patients’ health needs. To do this they must have in-depth knowledge of the pathophysiologies of different disease processes.

3. Care coordinators activate for patients. Care coordinators manage patients who are not able to do for themselves. This is beyond the scope of a health coach.

For example, care coordinators have the clinical skill set to address medical issues for patients. A care coordinator would walk a heart failure patient through the process of adjusting his water pill dosage. A coach however, would guide the patient by asking him to talk to his doctor about symptoms or medications.

4. Care coordinators are members of the care team. They have to be able to competently discuss medical conditions and advocate for patients with the clinical teams. This includes collaborating with physicians and specialists to develop care plans. Care coordinators then interpret this information for patients in a way that relates to their specific situations. Coaches on the other hand work only with patients and do not directly interact with the clinical teams.

Care coordinators are in for the long haul. Care coordinators manage patients over their lifetime. Health coaches monitor patients for a period of time, such as the 30 days after discharge when patients transition from the hospital to home.

Care coordinators expand the traditional case management and disease management roles.

Care coordinators manage care for multiple chronic conditions. If a patient had diabetes, heart failure and COPD, the care coordinator would be responsible for all three.

Care coordinators use a very high touch approach. Depending on the level of acuity, they may visit patients in their home or even go with patients to physician office visits. This approach may also require care coordinators to have smaller caseloads.

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Additional Resources:

Care Coordination White Paper – Click here to download.

Data points critical for a care coordination program – Watch the video or Read the blog post.

More on how to get started with a care coordination program is available here.

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