Medicare APMs at a crossroads.

Reaching the goals set by the Health Care Payment and Learning Action Network requires an unyielding and unrelenting focus on encouraging providers to adopt advanced alternative payment models (APMs). Many of these models will continue to be voluntary because they either are in early stages or have not yet proven their effectiveness. The models that have proven their effectiveness should become permanent, comprising the new way that providers are paid in the Medicare program. Either way, getting today's high performers into those programs and keeping them engaged to continue to innovate and set new benchmarks is as important as attracting and improving the performance of poorer performers. That will require a shift in Medicare's policy on pricing and evaluating APMs.

A cluster-based approach for integrating clinical management of Medicare beneficiaries with multiple chronic conditions.

BACKGROUND: Approximately 28% of adults have ≥3 chronic conditions (CCs), accounting for two-thirds of U.S. healthcare costs, and often having suboptimal outcomes. Despite Institute of Medicine recommendations in 2001 to integrate guidelines for multiple CCs, progress is minimal. The vast number of unique combinations of CCs may limit progress. METHODS AND FINDINGS: To determine whether major CCs segregate differentially in limited groups, electronic health record and Medicare paid claims data were examined in one accountable care organization with 44,645 Medicare beneficiaries continuously enrolled throughout 2015. CCs predicting clinical outcomes were obtained from diagnostic codes. Agglomerative hierarchical clustering defined 13 groups having similar within group patterns of CCs and named for the most common CC. Two groups, congestive heart failure (CHF) and kidney disease (CKD), included 23% of beneficiaries with a very high CC burden (10.5 and 8.1 CCs/beneficiary, respectively). Five groups with 54% of beneficiaries had a high CC burden ranging from 7.1 to 5.9 (descending order: neurological, diabetes, cancer, cardiovascular, chronic pulmonary). Six groups with 23% of beneficiaries had an intermediate-low CC burden ranging from 4.7 to 0.4 (behavioral health, obesity, osteoarthritis, hypertension, hyperlipidemia, 'other'). Hypertension and hyperlipidemia were common across groups, whereas 80% of CHF segregated to the CHF group, 85% of CKD to CKD and CHF groups, 82% of cancer to Cancer, CHF, and CKD groups, and 85% of neurological disorders to Neuro, CHF, and CKD groups. Behavioral health diagnoses were common only in groups with a high CC burden. The number of CCs/beneficiary explained 36% of the variance (R2 = 0.36) in claims paid/beneficiary. CONCLUSIONS: Identifying a limited number of groups with high burdens of CCs that disproportionately drive costs may help inform a practical number of integrated guidelines and resources required for comprehensive management. Cluster informed guideline integration may improve care quality and outcomes, while reducing costs.

Use of the Triple Aim to improve population health.

CaroMont Health has embraced the Triple Aim initiative to implement its core vision and competencies of delivering health care, promoting individual wellness, and creating vibrant communities. An imperative to achieve success has been aligning the corporate goals with the processes and outcomes that foster the Triple Aim.

Progression of strategies used by a healthcare system preparing for healthcare reform: past and present.

Strategies used by CaroMont Health to improve quality, decrease cost, and increase operational efficiency have ultimately aligned our system to address the present and future challenges confronting healthcare. Beginning with To Err is Human (Institute of Medicine 1999) and continuing with the healthcare reform bill of 2010, CaroMont Health has responded to challenges by striving to provide excellent patient care in a cost-effective manner. In this journey, CaroMont has discovered several key success factors essential in navigating this transformation. Our strategies reinforce the fact that improved quality and patient outcomes will ultimately reduce overall healthcare costs. In an ongoing collaboration with the Premier healthcare alliance, CaroMont Health has evolved from focusing on process metrics to delivering value-based care. CaroMont is now positioned to enter the new world of value-based delivery leading to accountability for community health.

Straight talk--new approaches in healthcare. The best starting point for performance improvement: a healthy bottom line. Panel discussion.

Bon Secours Health System's South Division launched a multitude of performance-improvement projects in 2004 even though it boasted a 9% margin. Why? Officials at the Catholic healthcare system wanted to increase the amount of money available for its nation-wide charitable commitments as well as to invest in capital projects critical to its mission. In this installment of Straight Talk, we look at the performance-improvement initiatives of the South Division of Bon Secours Health System, Inc., which saved $8 million in just five months and expects to gain a total of $41 million after it completes all projects. Modern Healthcare and PricewaterhouseCoopers present Straight Talk. The session on performance improvement was held on March 22, 2005 at Modern Healthcare's Chicago headquarters. Fawn Lopez, publisher of Modern Healthcare, was the moderator.