In Alameda County, A Big Data Effort To Prevent Frequent ER Visits

Almost every day, a patient comes into Dr. Arthur Sorrell's San Francisco emergency room still wearing a wristband from another hospital nearby.

“There are folks who have a life of going from emergency department to emergency department, and that's how their day is spent,” said Sorrell, an emergency physician and administrator at Sutter Health. “It's sad and tragic, but that's what happens.”

The wristband is at least a hint.

Without it, emergency room staff often have no idea they are sharing patients with other hospitals just a mile away. So they treat those patients completely independently, often repeating tests unnecessarily, assigning them multiple case managers when only one is needed and offering contradictory advice.

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Some patients have chronic health problems that send them repeatedly to the ER, while others are seeking food, a warm bed or someone to talk to.

Even if ER staff do know about visits to other hospitals, sharing information about the patient is a struggle. “I have to tell my unit coordinator to call over to the other hospital and have them fax over the records,” said Sorrell. Sometimes, a 50-page fax will arrive, which Sorrell must sift through while juggling dozens of other patients.

But that vexing reality may soon change for hospitals in Alameda County, as they team up to share patient health records and other data in real time among their emergency departments.

So far, their partnership includes four Sutter Health hospitals and two Alameda Health System hospitals. Since the program began on March 31, Alta Bates and Highland Hospitals have learned that they shared more than 2,000 patients, and over a third of them made six or more ER visits in the past year.

The hospitals share a system called PreManage ED, which tracks all of their ER patients. When an emergency department enters a patient's name into the system, it gets an alert if that patient has visited other hospitals. If so, the emergency department staff can view information about the patient's recent treatment and find out whether he or she already has a case manager somewhere else.

The system can also benefit the many patients who end up visiting multiple hospitals. If a patient already had an x-ray, CAT scan or other test at one hospital, for example, the shared database can help ensure he or she doesn't get the same test again.

Some experts, however, say competition among hospitals can be a deterrent to data sharing.

Whether a hospital is willing to share information with competitors depends on how it gets paid, said Dylan Roby, an assistant professor at the University of Maryland School of Public Health.

Hospitals that want to avoid having their payments reduced by federal penalties for readmissions, for example, have a strong incentive to collaborate in order to avoid unnecessary ER visits by Medicare patients. Hospitals participating in collaborative care networks that are paid monthly amounts for patient care also have an incentive to share information.

“But it's not always in [hospitals'] financial interest to share data about patients,” said Roby. Facilities that still depend on fee-for-service payments they receive for each individual patient visit, for example, may prefer to fill their beds rather than collaborate with competing hospitals.

PreManage ED already is being used by hundreds of hospitals nationwide, primarily in the Pacific Northwest. Twenty California hospitals use the system, and dozens more are in talks to do so.

But what sets Alameda County's effort apart is that it also plans to include community health clinics and other social service organizations, so they too will receive alerts from the hospitals when their patients seek emergency care.

The idea for the collaboration arose in 2015 from the experience of a single patient - a 57-year-old Oakland woman with a history of mental illness and chronic substance abuse. In just three years, the woman visited local emergency rooms more than 900 times.

“We really thought we were her favorite hospital. She knew the names of everyone, from the doctors to the security guards,” said Tracy Schrider, who coordinates the care management program at Alta Bates Summit Medical Center in Oakland and had assigned the woman a social worker. “We had no idea she was already in a case management program and was going to Highland even more than she was going to us!”

The teams at the two hospitals sent the woman to different agencies and gave her conflicting advice, Schrider said. “Everybody meant well. But she was being referred to three different substance abuse clinics and two different mental health clinics, and she had two case management workers both working on housing.” It was not only bad for the patient, it was also a waste of precious resources for both hospitals, Schrider said.

Elsie Kusel, an emergency medical services coordinator for Alameda County, helped discover the connection. The patient had taken hundreds of ambulance rides in the previous year.

”We brought everyone to the table. There were more than two dozen people in one room, talking about one person,” Kusel recalled. They included representatives of both hospitals, several community-based organizations, the paramedics, the Berkeley public health department and the fire department. All of them had helped care for the woman at some point - they just didn't know it.

The PreManage ED project will make patients like that 57-year-old woman known to all the providers who can help coordinate her care, wherever she seeks treatment.

“We've made visible a group of patients with unmet needs throughout our community,” said Sorrell.

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California Insurance Commissioner Urges Feds To Block $54 Billion Anthem-Cigna Deal

California Insurance Commissioner Dave Jones urged federal officials Thursday to block the merger of health insurance giants Anthem Inc. and Cigna Corp., declaring the $54-billion deal anti-competitive and harmful to consumers.

The state insurance department doesn't have the authority to thwart the merger on its own, but Jones' recommendation could carry considerable weight in Washington and hinder the companies' efforts to win federal antitrust approval.

Jones said the Anthem-Cigna merger would likely result in higher costs for consumers and businesses, fewer choices for coverage and a lower quality of medical care. He said the California health insurance market was already highly concentrated among four large companies, and this deal would only make matters worse.

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“Bigger is not better for California consumers,” Jones said at a press conference in Sacramento. “I find that the Anthem and Cigna merger will harm California consumers, California's businesses and the California health insurance market.”

Anthem criticized Jones' decision and expressed confidence it would obtain the necessary government approval for the merger.

“We do not believe that the California Department of Insurance's opinion is based on the true merits of this transaction,” Anthem said in a statement Thursday. “We are confident that the highly complementary nature and limited overlap of our organizations that will benefit the complex and competitive health insurance markets will be reviewed on the facts by the Department of Justice and appropriate state authorities.”

The U.S. Department of Justice is investigating the merger, and federal officials could seek divestitures to reduce market power or try to block it entirely on antitrust grounds.

The deal also remains under review by a number of state agencies. California's other insurance regulator, the Department of Managed Health Care, is still examining it as are other states, such as Connecticut, which plays a critical role since Cigna is based there.

The decision in California was being watched closely across the country by consumer groups, medical providers and Wall Street investors. Jones said he was the first state insurance regulator to formally oppose the Anthem deal.

In addition to Anthem's proposed acquisition, another merger proposal between Aetna Inc. and Humana Inc. would consolidate the U.S. health insurance market from five major players down to three. Jones hasn't issued a decision yet on the Aetna-Humana tie-up.

The insurers contend that their mergers will enable them to eliminate unnecessary costs and deliver more affordable benefits to employers and consumers.

But Jones soundly rejected that argument from Anthem, saying its claims of $2 billion in savings were “vague” and “not credible.”

“There is simply no guarantee that these savings would benefit policyholders,” Jones said.

Jones also expressed concern about Anthem and Cigna gaining a significant share of the market for administering benefits of self-insured employers. He said the combined companies would have 61 percent of that employer market in California.

“This suggests Anthem would gain a monopoly share of the market,” Jones said.

Some big employers nationwide have raised similar worries about having fewer competitors to choose from.

Jones also cited Anthem's prior history of big rate hikes and said increased market power could trigger even more.

If the Anthem-Cigna deal is completed, the combined company would have 54 million members, making it the largest U.S. health insurer. It would generate $117 billion in annual revenue. Anthem would also become California's largest health insurer, topping HMO giant Kaiser Permanente.

The Anthem-Cigna merger has been rocky from the start. The two sides bickered publicly during negotiations last summer before finally reaching a deal.

Industry analysts have been growing more pessimistic about the chances the Anthem-Cigna deal will actually be consummated.

Ana Gupte, a health care analyst at Leerink Partners, said even without direct jurisdiction over the deal, the California insurance department's opposition spells further trouble for it.

“California is an important state for this merger, and we expect it to be material to the broader antitrust scrutiny,” Gupte said.

This story will be updated.

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

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For Doctors-In-Training, A Dose Of Health Policy Can Help The Medicine Go Down

Doctors-in-training learn a lot about the workings of the human body during medical school and residency. But many are taught next to nothing about the workings of the health care system. One university in Washington, D.C., is trying to change that.

The three-week fellowship in health policy for medical residents is run jointly by the George Washington University schools of medicine and public health. In addition to hearing lectures from policy experts in and around the nation's capital, the residents take field trips to Capitol Hill, the Supreme Court, other federal and local health-related agencies, as well as local health care facilities.

Dr. Fitzhugh Mullan is a pediatrician and GW professor who has led the program since it began more than a decade ago. He said when he went to medical school in the 1960s, learning how the health system worked was barely an afterthought.

“Things such as public health were recognized with a one credit course in the curriculum that everybody thought was terrible, partly because it was and partly because they discounted it as being important,” he said. “The notion of engaging with public policy or being concerned with the state of the future of [health care] service delivery in the U.S. was not remotely a part of our training.”

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That's changing, though. On a Tuesday afternoon in early spring, the 20 or so medical residents in the current class are getting a tour of a community health center run by Unity Health Care, a local nonprofit health and social services organization.

They stop at the dental clinic, which can accommodate six dentists and a dental hygienist.

“If you think that the crisis of medically uninsured is high, the crisis of dental uninsured is even higher,” said Andrea Anderson, Unity's medical director. “So many of our patients suffer for not having proper dental insurance.”

It's not just dental services that gives the health center added value. For example, instead of just telling patients to eat more vegetables, staff members give out vouchers for local farmers' markets and demonstrate how to cook the veggies their patients buy in an onsite kitchen.

“So we use the test kitchen to say 'here's how we chop it up, here's how we cook it,'” she said. “Look, here's your kid chopping it up, having fun.”

Mullan said medical residency is a particularly good time to teach policy because the newly minted doctors have seen enough of the health system close-up to get an idea of where its flaws are.

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“They're in the game, and the opportunity to stop and talk about the game and how the game could be played better is very appealing to them,” he said.

That's certainly true for fellow Chris Cahill. He's a third-year pediatric resident at Children's National Health System in the District. He said he got interested in policy as a medical student at the University of Vermont a few years ago. At the time, the state was debating whether or not to create a new single-payer health care system. That didn't happen. But Cahill said now that he's later in his training, the policy aspects are even more relevant.

“It's a great time to do it now because we still have those idealistic ideas, but we also have a lot of practical experience,” Cahill said. “We know what the face of these problems looks like much better than we did in medical school or college even.”

There's a growing awareness that doctors need more training in the non-clinical parts of health care.

“You know as a profession we provide the most expensive services that any American will spend money on in their whole lifetime,” said Neel Shah, an obstetrician and gynecologist in Boston and a health policy researcher at Harvard. “And yet at the point of service we can't tell anybody what anything costs. That's crazy.”

Even worse, said Shah, most doctors are trained explicitly not to take cost into consideration.

“Clinical training teaches you to be a terrible steward of health care resources in every way,” he said. “When you're being chastised as a trainee, it's always for the things that you didn't do but could have. It's never for the things you did do but didn't have to do. When, of course, patients can be harmed both ways.”

For now, the program is mostly limited to residents from GW and other Washington D.C.-area facilities. But Mullan is in the process of creating a new version for Kaiser-Permanente at three sites in California.

Those residents won't have the advantage of being right down the street from the White House and the U.S. Capitol. “But we reasoned that in California there would be state-level issues or city-level issues that had an equal relevance,” Mullan said.

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Medicare's Efforts To Curb Backlog Of Appeals Not Sufficient, GAO Reports

Despite interventions by Medicare officials, the number of appeals from health care providers and patients challenging denied claims continues to spiral, increasing the backlog of cases and delaying many decisions well beyond the timeframes set by law, according to a government study released Thursday.

The report from the Government Accountability Office, said the backlog “shows no signs of abating.” It called for the Department of Health and Human Services to improve its oversight of the process and to streamline appeals so that prior decisions are taken into account and repetitive claims are handled more efficiently.

GAO investigators cited significant increases in cases filed at each of four stages of appeals. They found a 62 percent rise at the first level from 2010 through 2014, while appeals filed at the third stage - which are heard by an administrative law judge - had a nearly ten-fold increase during the same period.

HHS officials have acknowledged the problem. Although a judge is required to issue a decision within 90 days, the average time from hearing request to decision is slightly more than two years, Nancy Griswold, the chief administrative law judge of the Office of Medicare Hearings and Appeals, said in an interview.

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Requests for hearings increased “so dramatically and so quickly over the past four or five years - during a period of time when our adjudication capacity was not able to keep up for funding reasons - we were drowning” in appeals, she said. “It is not quite as bad right now, but we are unable to keep up with [those] that are coming in the door.”

The GAO report said HHS attributed the increases in appeals to a greater interest by hospitals and doctors to file appeals and to enhanced efforts on the government's behalf to check for inappropriate payments, including a controversial program known as recovery audits, in which contractors inspect hospital payment records to find any errors.

The report was requested by Sens. Orrin Hatch, R-Utah, Ron Wyden, D-Ore., and Richard Burr, R-N.C., who said the findings underscore the need for Congress to fix the problem. They have offered a bill, approved by the Senate Finance Committee, that they say would address many deficiencies by improving HHS oversight and establishing a voluntary dispute resolution process, among other things.

“The voices of too many patients, providers and states are going unheard because the gears of the Medicare audit and appeals system have ground to a halt,” Wyden said.

In response to the findings, HHS Thursday issued an 11-page “primer” describing how officials have tried to cope with the situation. That included one intervention that that let hospitals settle their claims for 68 percent of the value in 2014. Officials also offered ideas for streamlining the appeals process. These include investing new resources at each level of appeal, administrative actions to encourage resolution of cases earlier in the process, supporting legislation providing additional funding and expanding the agency's powers.

For example, the agency is proposing that cases involving disputes of less than $1,500 should be reviewed by its senior attorneys instead of holding a hearing before an administrative law judge.

However, that idea worries at least one consumer advocacy group.

“We would prefer more judges instead of a stopgap measure,” said Alice Bers, an attorney with the Center for Medicare Advocacy who is handling a class action lawsuit on behalf of beneficiaries.

The appeals office is already working to help curb the backlog by converting to an electronic case management system. Starting in August, appeals can be filed by computer.

For hospitals, the appeals delay has tied up billions of dollars in disputed claims, according to the American Hospital Association, which has sued the government to speed up the decisions. The hospitals have argued that Medicare's recovery audit contractors (RACs) unnecessarily reject payments and that hospitals frequently win the appeals.

“We are skeptical that anything short of fundamental reform that addresses the RACs' contingency fee structure, which encourages them to inappropriately deny claims, will have a lasting impact on the backlog,” said Melissa Jackson, the association's senior associate policy director.

In another intervention, which Griswold called “one of our success stories,” Medicare officials have prioritized appeals from beneficiaries so that they are processed ahead of those from hospitals, doctors and other health care providers. That policy began in 2014, and as a result, the average time for a beneficiary to get a decision from an administrative law judge is 68 days, she said.

Griswold said the policy would continue “as long as there is a backlog.”

KHN's coverage of aging and long term care issues is supported in part by a grant from The SCAN Foundation.

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