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Saturday, June 2, 2018

Rehab hospitals call on CMS to trash payment changes


Rehabilitation hospitals say a proposed change to how the CMS will reimburse them for care could lead to inaccurate payments as new system pulls patient data from a new source.
In the 2019 inpatient rehabilitation proposed pay rule, the CMS proposed to retire the current patient assessment tool that helps categorize the level of care needed by a patient. The CMS used the information since 2002 to help determine IRF’s care reimbursement. But now the agency wants to switch to a new patient assessment tool that’s similar to one in place for other post-acute care settings to create a more uniform evaluation for patients’ care needs. The change will kick in on Oct. 1, 2019 if it’s finalized.
Clinicians use the tool in question to rank the severity of the patients care needs and develop a treatment plan.
The new assessment tool was introduced last year and it’s unclear if it tracks patient needs sensitively enough to determine reimbursement accurately. “The limited analysis CMS has made available to stakeholders is insufficient evidence as to the data’s validity or reliability as a basis for payment purposes,” Richard Kathrins, chair of American Medical Rehabilitation Providers Association’s board of directors, said in a comment letter.
Providers are worried about whether the new tool asks the right questions and helps them evaulate patients as thoroughly as the assessment method they’ve been using for years. The tool is still too new to answer those questions, according to rehab providers.
“Too little is known about the accuracy, consistency and clinical efficacy of the new clinical data and information that CMS is proposing to utilize,” Mark Tarr, president and CEO of Encompass Health, one of the largest providers of rehab hospital services in the nation said in a comment letter. “These clinical data and information have not been sufficiently studied, understood or validated to determine payment or patient care implications for rehabilitation hospital services.”
The Kentucky Hospital Association suggested the CMS should study and evaluate the accuracy and reliability of the new data source as well as its implications before changing the reimbursement model.
Jane Snecinski, president of consultancy Post-Acute Advisors, said these providers have a valid reason to be concerned.
“The dangers of moving from a validated system to one that doesn’t have that history may put providers at risk,” Snecinski said. “With limited validation and no piloting of a new system, how can the risk be evaluated?”

Reigniting the physicians arms race, insurers are buying practices


In the turf war between hospitals and health insurers over physician practices, hospitals are winning by a long shot. But they’d be ill advised to get too comfortable.
A slew of recent activity shows that insurers are clawing their way back, whether by outright purchases of medical practices or targeting outpatient facilities that employ doctors.
UnitedHealth Group has long led the charge to buy medical practices, absorbing several a year into its OptumCare subsidiary. National insurers Centene Corp., Humana and, most recently, Anthem have also gotten into the game.
Why are insurers more engaged? Most see owning physician practices as a way to control spending. Others are defending their influence and revenue stream from rampant hospital-physician practice consolidation. Some, such as St. Louis-based Centene, are buying medical groups out of necessity to expand healthcare access to plan members.
“It’s the provider that’s in the catbird seat. From the payer side it’s definitely a defense mechanism to have more of a relationship with the patient,” said Sheila Talton, CEO of Gray Matter Analytics, a firm that uses data to help providers and payers reduce costs.
The uptick in deals is also part of a broader movement of health insurers seeking to better align with physician groups—particularly primary-care doctors—to closely manage patient care and improve quality and outcomes.
“Payers want to invest in making sure we have best access to primary care and management for our members with physician groups that are closely aligned with us contractually or through ownership,” said Denise Hanna, co-chair of law firm Locke Lord’s healthcare group. “The hope is that it makes it easier to implement best practices in primary care.”
UnitedHealth’s Optum in December 2017 agreed to buy dialysis provider DaVita’s medical group for $4.9 billion. The medical group employs more than 750 primary-care physicians directly or through associated groups, but contracts with thousands more.
The same month, Humana and two private equity firms announced they would buy post-acute provider Kindred Healthcare for $4.1 billion. For $800 million, Humana gets a 40% stake in the company’s home health, hospice and community-care division, which employs physicians and includes 40,000 caregivers who serve approximately 130,000 patients daily. The same trio in April moved to buy hospice operator Curo Health Services for $1.4 billion to combine with Kindred’s home division.
Humana also acquired Orlando, Fla.-based Family Physicians Group, which owns 22 clinics serving Medicare Advantage and Medicaid patients, in April for $190 million. Humana is moving its health clinics and doctor practices in Florida and Texas under a new brand called Conviva.
Medicaid managed-care insurer Centene Corp. in March said it was buying Community Medical Group, a primary-care provider in Florida with around 200 doctors serving 70,000 patients. And in May, Indianapolis-based insurer Anthem got into the game when it announced a deal to buy Aspire Health, a non-hospice palliative-care company that employs about 700 people, including physicians and other clinicians.
Despite the seemingly high pace of activity, relatively few physicians are employed by health plans. The American Medical Association found about 2% of all physicians in 2016 were employed directly by a health insurer or worked in a practice that was owned by one. The American Academy of Family Physicians also said the number of its members employed by a health insurer has remained steady in recent years at 2%.
Since insurers still lag in the total number of employed physicians, most experts don’t see the strategy as a threat to hospitals, which are buying practices at a much faster clip, acquiring 5,000 independent practices between July 2015 and July 2016, according to a study by the consulting firm Avalere Health and the Physicians Advocacy Institute. The number of doctors employed by hospitals grew by 14,000, or 11%, over the same time period, the study found.
And a 2017 AMA study showed that less than half of practicing physicians—47.1%—owned their medical practice in 2016. About 32.8% of physicians were in hospital-owned practices that year, according to the AMA.
Insurers are playing defense by buying doctor groups, some industry experts said. When hospitals buy physician practices, they are able to keep patients in their health systems and protect their revenue. Insurers that buy doctor groups are able to reduce their spending by exerting more control over how those physicians practice medicine, where they refer patients, and what medications they prescribe.
“Health insurers believe this is a defensive strategy to control the premium streams,” said Paul Keckley, industry consultant and managing editor of the Keckley Report. “A doctor and an insurer can substantially ratchet down what’s spent in hospitals.”
But there are other reasons insurers eye physician practices, and they differ from health plan to health plan. Many aren’t buying physician practices for the sake of employing doctors, but to further another goal. Humana’s stake in Kindred’s home health and hospicedivision is likely to help reduce costs for its large Medicare Advantage population of 8.6 million. Analysts have also noted that Aspire Health’s medical providers are unlikely to be Anthem’s motivation for buying the palliative-care operator. Anthem CEO Gail Boudreaux said in a statement that the deal furthers its strategy of providing integrated care to improve outcomes.
Large-scale deals between companies from different parts of the supply chain, including those between CVS Health and Aetna, and Cigna and Express Scripts, also aim for improved care integration.
Centene’s bid for Community Medical Group, which owns 12 primary-care and specialty clinics in Florida, was a strategic move to improve access to care in an area where it was lacking, CEO Michael Neidorff said.
“I don’t have interest in owning a lot of doctors,” Neidorff explained. “I think patients get better care when the vast majority of physicians are independent. However, there are times where we need to ensure our population has access to high-quality care,” and that’s when an acquisition may make sense.
Some doctors who once balked at the idea of working for an insurance company have come around to the idea. Dr. Amir Bacchus, chief medical officer of Henderson, Nev.-based population health management startup P3 Health Group, was sought out by UnitedHealth to help manage a group of employed doctors several years ago when he was a regional chief medical officer at HealthCare Partners of Nevada. He turned them away. HealthCare Partners later was bought by DaVita Medical, which late last year agreed to sell the group to UnitedHealth. 
Bacchus said there are both good and bad examples of managed-care organizations that employ physicians. Organizations like Kaiser Permanente that manage both sides of the healthcare equation have excelled because they treat their physicians like assets and allow them to lead, he said. But there’s a danger in treating physicians like a commodity to leverage against hospitals.
“For places that do things like that, you see high physician burnout because autonomy begins to wane, and then physicians feel like they’re cogs in the wheel,” Bacchus said.
Patient choice could also dwindle in markets where insurers employ most doctors. In Nevada, for instance, Bacchus said UnitedHealth’s Optum and DaVita Medical Group doctors, who must sign strong noncompete contracts, would together treat hundreds of thousands of patients in the state, whose population totals about 3.1 million.
Across the country in Connecticut, some insurers and money management firms have taken to buying just the administrative side of physician practices, including claims processing, billing and technology, and they leave the clinical side of the practice alone to focus on patient care.
Optum in December 2015 bought the administrative and back-end operations piece of ProHealth Physicians. The Connecticut primary-care group with 370 doctors at the time would continue to be physician-owned. That sort of arrangement can be a sweet deal for doctors, said Matthew Katz, president of the Connecticut Medical Society.
“If they have someone else doing the collection and management of the business, they see they’re better off focusing on what they’re good at,” he said, adding that insurers are able to reap profits in such deals by streamlining billing and collecting more revenue. Physician practices, he said, have struggled with heavy debt loads as the number of patients enrolled in high-deductible health plans has grown.
Still, many insurers are looking to collaborate more closely with doctors but aren’t interested in employing them. Dr. Michael Cropp, CEO of Buffalo, N.Y.-based not-for-profit insurer Independent Health, spent much of his career as a family physician practicing at staff model HMOs, including HealthPartners in Minneapolis. He decided the processes developed at staff models could be used in an environment where doctors kept their independence so long as some organization was able help with capital and infrastructure. Independent doctors have more room to try innovative things, he said.
“You’d get the best of both worlds,” Cropp explained. “You’d have a sense of ownership in the practice with the drive to be patient-centered, and room to continue to improve, with the ability to invest in these new models of care.”
Independent Health began collaborating with primary-care physicians to create, back in 2012, a new care and value-based payment model in which doctors were accountable for the whole continuum of care. That initiative led to better care coordination and cost savings. Later, once most primary-care doctors in the area received most of their payments through a value-based care model, Independent Health led efforts to include Buffalo in the CMS’ Comprehensive Primary Care Plus program starting in 2018.
It launched a company called Evolve Practice Partners last year to help local physician practices succeed in that program, which aims to improve patient outcomes and lower costs. “If we don’t have strong practices, we don’t have a product to sell,” Cropp said. “And if we don’t make these investments, who will? They don’t have capital, they don’t have human resources or access to these new ideas without us.”
For-profit insurer Cigna Corp. has also largely opted to take the collaborative route, as employing doctors tends to restrict patient choice, CEO David Cordani said. The Bloomfield, Conn.-based insurer has struck 500 accountable care arrangements under which it rewards physicians for meeting cost and quality targets when managing a group of patients.
“We don’t want to design products that are proprietary to our access points. We think that restricts choice,” Cordani said. “We would prefer to partner and afford broader choice and broader accessibility for the individuals and then partner and enable the physicians, as opposed to try to control them through ownership.”

Vegetarian diet reduces heart disease death risk by 40 percent

The latest in a long line of papers on the many health benefits of reducing meat intake concludes that a plant-based diet is great news for your heart.
Plate of veggie food
A new review concludes that plant-based diets improve heart health.
Currently, in the United States, vegetarianism and veganism are steadily becoming more popular.
Touted as a more healthful option, many people are working to reduce their meat intake.
In the past few decades, numerous studies have demonstrated that restricting meat impacts the body in a number of positive ways.
For instance, a plant-based diet has been shown to reduce the risk of obesitytype 2 diabetes, and metabolic syndrome. Vegetarianism and veganism may even protect against certain cancers.
A recent review, now published in the journal Progress in Cardiovascular Disease, focused on the benefits of a plant-based diet on cardiovascular health, specifically.

Plant-based diets and heart health

The researchers — from the Physicians Committee for Responsible Medicine in Washington D.C. — scrutinized reams of recent, relevant studies.
Collating information from a host of clinical trials and observational studies, they found that a plant-based diet was consistently linked with improved measures of heart health.
They concluded, for individuals following a plant-based diet, that:
  • Risk of death from cardiovascular disease is reduced by 40 percent.
  • Coronary heart disease risk is reduced by 40 percent.
  • Blocked arteries are unblocked partially or fully in as many as 91 percent of patients.
  • Hypertension risk drops by 34 percent.
Also, total cholesterol and low-density lipoprotein, or “bad,” cholesterol levels are much lower in vegetarians compared with non-vegetarians. Moreover, a plant-based diet was shown to be associated with weight loss.
A plant-based diet has the power to not only prevent heart diseasebut also manage and sometimes even reverse it — something no drug has ever done.”
Study author Dr. Hana Kahleova, Ph.D.
Dr. Kahleova also notes that more healthful diets and lifestyles lower the risk of heart attack by 81–94 percent, while drugs can only lower this risk by 20–30 percent.

How does vegetarianism protect the heart?

There seem to be many reasons why a plant-based diet is more healthful for the heart than a meat-heavy one. It seems that plants impart some benefits, while meat increases certain risks.
For instance, plants are rich in fiber and phytonutrients, which are known to reduce inflammationand oxidative stress. Also, animal products are often high in fat, cholesterol, heme iron, and environmental pollutants.
However, this is a complex interaction, and there may be many more factors involved that are, as yet, unknown.
Heart disease is responsible for the deaths of more than 600,000 U.S. individuals each year, and it remains the leading cause of death, globally. However, these findings show that if society could be gently nudged toward plant-based diets and away from excessive meat consumption, humanity’s heart health could be substantially improved.
As Dr. Kahleova notes, with more than a dash of positivity, “Heart disease is the world’s leading cause of death. This study proves it doesn’t have to be.”

NantHealth presents sequencing study at #ASCO18


Results to be presented during the tumor biology session at the American Society of Clinical Oncology (ASCO) 2018 Annual Meeting
NantWorks, LLC today announced that its affiliate companies, NantHealth, Inc., (NASDAQ: NH), a leading next-generation, evidence-based, personalized healthcare company and NantOmics, LLC, the leader in molecular analysis and a member of the NantWorks ecosystem of companies, will present findings on how 17 percent of next generation sequencing (NGS) 50 gene panel variants are not expressed in RNA sequencing during the tumor biology session at the American Society of Clinical Oncology (ASCO) 2018 Annual Meeting, an event bringing together 30,000 oncology professionals from June 1-5, 2018 at McCormick Place in Chicago, Illinois. NantWorks will be exhibiting at booth #7147 during the event.
“By determining the frequency of non-expressed variants that would be tested by a standard NGS panel, our data shows that the identification of these genes can yield improved testing algorithms and treatment strategies,” said Patrick Soon-Shiong, MD, founder of NantWorks. “We’re excited to share this data and look forward to further exploring how NGS can be used for target therapy in oncology.”
Presentation Details
Seventeen percent of NGS 50 gene panel variants are not expressed in RNAseq, Abstract #12118
WHO: NantHealth, LLC and NantOmics, LLC
WHAT: Tumor Biology Session
WHEN: June 4, 1:15-4:45 PM CST
WHERE: Hall A, McCormick Place
Presentation Summary
This study analyzed the frequency of non-expressed variants that would be tested by a standard NGS panel through retrospective analysis of a database from a commercial DNA tumor: normal and RNAseq platform. In the 992 samples that were identified with paired DNA (WGS or WES) / RNAseq NGS, a total of 225,727 SNVs were detected. Across 37 tumor types the range of expression was 57% (melanoma) – 100% (uterine). In this analysis, 17 percent of detected variants were not expressed in the RNA sequence. As a result, the lack of RNA expression may contribute to less than expected clinical benefit with molecularly targeted therapies. Since the distribution is non-uniform, identification of these genes can yield improved testing algorithms and treatment strategies.

New heart attack category more common in women than previously thought


A whole new category of heart attack, not caused by obstructed arteries, is more common and higher risk–especially in women–than previously thought, according to a University of Alberta study.
“We followed roughly 36,000 patients within a 12-year interval and found that close to a surprising six per cent have a heart attack without any blockage in the arteries,” said Kevin Bainey, a U of A interventional cardiologist who launched the study after seeing an increase in these mystery patients in his practice.
The umbrella term used to describe these heart attacks is “myocardial infarction with non-obstructive coronary arteries,” or MINOCA.
“Historically, MINOCA has been seen as a benign condition, and patients are commonly sent home without any treatment or lifestyle advice,” he explained. “Yet we found that after one year’s time, five per cent of patients either had another heart attack or died of a heart attack. This is striking, since patients with a plugged coronary artery have a nine per cent chance of a repeat attack or death within one year.”
The study is the first in the world to look at MINOCA over a long term. Bainey said the condition includes a range of less-understood heart attack causes that have been largely treated as benign.
“Not only did we find that prognosis only worsens over time, after five years, 11 per cent of MINOCA patients were likely to die or have a second heart attack compared with 16 per cent of heart patients with blocked arteries,” noted Bainey.
MINOCA patients were twice as likely to be female, according to the study.
“We found roughly 25 per cent of common heart attack patients are female, whereas 50 per cent of MINOCA patients are female,” said Bainey, adding that it is not clear why this is the case.
“Traditionally, because we haven’t seen plaque ruptures or blockages are not seen, physicians have tended to downplay the heart attack and provide limited information, and have sent patients home and told them not to worry,” said Bainey. “However, many of the MINOCA causes that are known do respond to targeted therapies.”
Yet the study showed that only 40 per cent of MINOCA patients are provided with suitable medications–for example, cholesterol-lowering drugs–that could potentially reduce the risk of a second heart attack or death.
“Patients need to know that this condition is real, it is associated with adverse outcomes and they need to probe their physicians for more information about the condition and ways to prevent a second heart attack, including making important lifestyle changes like eating healthier and exercising,” said Bainey.
“From a physician standpoint, there is no question that when we identify this condition, we need to be more vigilant about trying to investigate and pin down the cause.”
Last year, the condition was recognized in guidelines by the European Society of Cardiology for major heart attacks.
The study was published in the International Journal of Cardiology and funded through the Canadian VIGOUR Centre.
What is MINOCA?
Women are more susceptible to a group of heart attack causes not related to blocked arteries, although it’s not clear why, according to U of A interventional cardiologist Kevin Bainey.
Though researchers are still investigating potential causes, they have identified the following:
  • a tiny rupture or tear in the artery, known as SCAD (spontaneous coronary artery disruption), that isn’t visible without specialized equipment
  • small amounts of plaque buildup and clot not visible during a coronary angiogram
  • inflammation of the heart muscle
  • stress-induced heart muscle dysfunction

The Unappreciated Key to Success


The most unappreciated element in success in any area of life–trading or otherwise–is the capacity to sustain effort.  We can think of this capacity as intentionality:  the ability, over time, to exercise free will.
For much of daily life, we follow routines.  This is efficient, allowing us to get the most done with the least effort.  A great example is driving a car.  Being able to do that automatically enables us to carry on conversations, listen to music or podcasts, etc. The problem occurs when we become so immersed in routine–so wedded to getting the most done with the least effort–that we are unable to sustain the efforts that generate distinctive performance.
Important research from the psychologist Mihalyi Csikszentmihalyi identified a “flow state” in which people become capable of high levels of creativity.  The flow state results from being immersed in efforts over time–a kind of hyperfocus.  In that state of superfocus, we become capable of processing information in new ways, seeing patterns and solutions that escape us in our normal state of awareness.
In our ordinary state of mind, we can only achieve ordinary things.  All success comes from the ability to transcend routine.  But that requires effort and the capacity to sustain effort.  Successful people have developed routines that exercise intentionality:  that build the capacity to sustain flow states.  They sustain those efforts by pursuing their strengths: what they are good at and what speaks to them.  We achieve hyperfocus when we are hyper-interested in what we are doing.  If you need discipline to get things done, you know you are not operating in the sphere of your strengths and passions.

Dimon: Health insurers griped to him on Amazon-Berkshire deal


  • Dimon says that irate healthcare companies called him to complain about joint venture
  • Healthcare effort has a 20-year horizon and seeks to lower costs, improve service, he says
  • Dimon: “They’re going to tell me I can’t do a better job for my employees? Isn’t that what they’re supposed to help me do anyway?”
J.P. Morgan Chase CEO Jamie Dimon has been on the receiving end of some testy phone calls recently.
After he and fellow billionaires Amazon‘s Jeff Bezos and Berkshire Hathway’s Warren Buffett announced the formation of a joint venture in January to reduce medical costs for their three companies’ 1.5 million insured employees, several healthcare-related providers reached out to Dimon personally, he said Friday during a New York conference.
“Quite a bit of them were pissed off, which kind of pissed me off,” Dimon, 62, said. “They’re going to tell me I can’t do a better job for my employees? Isn’t that what they’re supposed to help me do anyway? That’s all we’re trying to do, is do a better job for the health of our employees.”
The effort, spearheaded by Berkshire Hathaway executive and J.P. Morgan board member Todd Combs, has yet to settle on a CEO. After that happens, the venture will begin testing ideas to attack the myriad problems related to the rising costs of American healthcare, Dimon said. When the effort was announced January 30, the shares of pharmacy benefit managers, heath insurers and biotechnology companies all slumped.
The effort has a 20-year horizon and seeks to partner with companies within the healthcare ecosystem, Dimon said. Among issues to tackle are related to use of data, lack of consumer choice, high costs related to fraud and administrative costs, end of life care, and lifestyle-related diseases, he said.
“They could attack it one drug at a time, they could attack chronic care, they could attack emergency rooms,” Dimon said. “There will be things we will come up with that we couldn’t possibly think of today that will hopefully make it much better.”