Scott A. Berkowitz

Accountable care at academic medical centers--lessons from Johns Hopkins.

Academic medical centers must address financial and cultural barriers to the implementation of new care and payment models such as ACOs. The steps that Johns Hopkins has taken may offer useful lessons for other academic medical centers.

Medical-Imaging Stewardship in the Accountable Care Era

Though often essential for diagnosis and management, medical imaging is known for low-value uses and as the single largest source of per-capita radiation exposure. The framework used to reduce overuse of antimicrobial agents can help inform imaging-stewardship efforts.

Medicare beneficiaries most likely to be readmitted.

Recent legislation requires reducing Medicare payments to hospitals with higher than expected 30-day readmission rates, but there is no consensus strategy to identify patients who should optimally be targeted with care coordination services to mitigate this risk. To determine which hospital and patient factors predict variation in all discharge hospital readmission rates, a 5% sample of all Medicare fee-for-service beneficiaries with continuous Part A and B coverage was examined for the first 9 months of 2008 in combination with other administrative data available to the Centers for Medicare and Medicaid Services. We included age, sex, race, dual-eligibility status, number of comorbid conditions, geographic region, hospital case mix, and reason for entitlement in the multiple regression model to assess how they influenced the 30-day readmission rate. Beneficiaries with 10 or more chronic conditions were more than 6 times more likely to be readmitted than beneficiaries with 1 to 4 chronic conditions. These beneficiaries represent only 8.9% of all Medicare beneficiaries (31.0% of all hospitalizations), but they were responsible for 50.2% of all readmissions. The 31.8% of beneficiaries with 5 to 9 chronic conditions (55.5% of all hospitalizations) had the second highest odds ratio (2.5) and were responsible for 45% of all readmissions.

Academic Medical Centers Forming Accountable Care Organizations and Partnering With Community Providers: The Experience of the Johns Hopkins Medicine Alliance for Patients.

Academic medical centers (AMCs)--which include teaching hospital(s) and additional care delivery entities--that form accountable care organizations (ACOs) must decide whether to partner with other provider entities, such as community practices. Indeed, 67% (33/49) of AMC ACOs through the Medicare Shared Savings Program through 2014 are believed to include an outside community practice. There are opportunities for both the AMC and the community partners in pursuing such relationships, including possible alignment around shared goals and adding ACO beneficiaries. To create the Johns Hopkins Medicine Alliance for Patients (JMAP), in January 2014, Johns Hopkins Medicine chose to partner with two community primary care groups and one cardiology practice to support clinical integration while adding approximately 60 providers and 5,000 Medicare beneficiaries. The principal initial interventions within JMAP included care coordination for high-risk beneficiaries and later, in 2014, generating dashboards of ACO quality measures to facilitate quality improvement and early efforts at incorporating clinical pathways and Choosing Wisely recommendations. Additional interventions began in 2015.The principal initial challenges JMAP faced were data integration, generation of quality measure reports among disparate electronic medical records, receiving and then analyzing claims data, and seeking to achieve provider engagement; all these affected timely deployment of the early interventions. JMAP also created three regional advisory councils as a forum promoting engagement of local leadership. Network strategies among AMCs, including adding community practices in a nonemployment model, will continue to require thoughtful strategic planning and a keen understanding of local context.

Cardiology and Accountable Care

Cardiovascular disease is the leading cause of death in the United States and accounts for ≈17% of national health expenditures and 30% of Medicare spending.1 Among physician groups and professional societies, cardiologists have been among those leading efforts to create evidence-based guidelines and to measure quality of care. In the post-health reform era, national efforts have expanded beyond quality to include innovative delivery models, such as the patient-centered medical home (PCMH), the medical neighborhood, and accountable care organizations (ACOs). This next generation of care models and the payment strategies that support them incentivize efficiency, patient-centeredness, and care coordination with an emphasis on primary care. We propose strategies for cardiologists to create collaborative opportunities within these new models drawing from examples from around the country within the context of a framework developed by the American College of Physicians.2 Pursuing these approaches or others along similar lines will enable cardiologists to lead and to be active participants in shaping delivery system transformation. These innovative delivery models share similar features. The PCMH is a model of care that emphasizes additional support for primary care providers within a patient-centered team, whereas a medical neighborhood represents a broader collection of primary care doctors, specialists such as cardiologists, hospitals, and other stakeholders within a region that seek to reduce fragmented care by sharing accountability.2,3 The ACO, too, is a broader care delivery arrangement, but in this case, groups of providers are accountable for the quality, cost, and overall care of a particular population, typically defined by the payer. In the Medicare Shared Savings Program (MSSP), an ACO model for Medicare beneficiaries, the ACO can capture shared savings if it reduces its healthcare expenditures and meets certain quality performance standards, nearly half of which are related to cardiovascular disease.4 Within the …

Accountable Care Organizations and Otolaryngology

Accountable care organizations represent a shift in health care delivery while providing a significant potential for improved quality and coordination of care across multiple settings. Otolaryngologists have an opportunity to become leaders in this expanding arena. However, the field of otolaryngology–head and neck surgery currently lacks many of the tools necessary to implement value-based care, including performance measurement, electronic health infrastructure, and data management. These resources will become increasingly important for surgical specialists to be active participants in population health. This article reviews the fundamental issues that otolaryngologists should consider when pursuing new roles in accountable care organizations.

Behavioural health interventions in the Johns Hopkins Community Health Partnership: Integrated care as a component of health systems transformation

Abstract Health systems in the USA have received a mandate to improve quality while reining in costs. Several opportunities have been created to stimulate this transformation. This paper describes the design, early implementation and lessons learned for the behavioural components of the John Hopkins Community Health Partnership (J-CHiP) programme. J-CHiP is designed to improve health outcomes and reduce the total healthcare costs of a group of high healthcare use patients who are insured by the government-funded health insurance programmes, Medicaid and Medicare. These patients have a disproportionately high prevalence of depression, other psychiatric conditions, and unhealthy behaviours that could be addressed with behavioural interventions. The J-CHiP behavioural intervention is based on integrated care models, which include embedding mental health professionals into primary sites. A four-session behaviour-based protocol was developed to motivate self-efficacy through illness management skills. In addition to staff embedded in primary care, the programme design includes expedited access to specialist psychiatric services as well as a community outreach component that addresses stigma. The progress and challenges involved with developing this programme over a relatively short period of time are discussed.

Improving regional variation using quality of care measures

There is significant regional variability in the quality of care provided in the United States. This article compares regional performance for three measures that focus on transitions in care, and the care of patients with multiple conditions. Admissions for people with ambulatory care-sensitive conditions, hospital readmissions within 30 days of discharge, and compliance with practice guidelines for people with three chronic conditions (congestive heart failure, chronic obstructive pulmonary disease, and diabetes) were analyzed using data drawn from the Centers for Medicare & Medicaid Services’ Standard Analytic Files for 5% of a 2004 national sample of Medicare beneficiaries which was divided by hospital referral regions and regional performance. There were significant regional differences in performance which we hypothesize could be improved through better care coordination and system management.

American Heart Association's Call to Action for Payment and Delivery System Reform.

The healthcare system is undergoing a transition from paying for volume to paying for value. Clinicians, as well as public and private payers, are beginning to implement alternative delivery and payment models, such as the patient-centered medical home, accountable care organizations, and bundled payment arrangements. Implementation of these new models will necessitate delivery system transformation and will actively involve all fields of medical care, in particular medicine and surgery. This call to action, on behalf of the American Heart Associations Expert Panel on Payment and Delivery System Reform, serves to offer support and direction for further involvement by the American Heart Association. In doing so, it (1) provides baseline review and definition of the present models and some of the early results of these delivery models, including outcomes; (2) initiates a conversation within the American Heart Association on the impact of payment and delivery system reform, as well as how the American Heart Association should engage in the interest of patients; (3) issues a call to action to our organization and to cardiovascular and stroke health professionals across the country to become educated about these models so to as to understand their impact on patient care; and (4) asks the government and other funding agencies, including the American Heart Association, to begin supporting and prioritizing meaningful research endeavors to further evaluate these models.The healthcare system is undergoing a transition from paying for volume to paying for value. Clinicians, as well as public and private payers, are beginning to implement alternative delivery and payment models, such as the patient-centered medical home, accountable care organizations, and bundled payment arrangements. Implementation of these new models will necessitate delivery system transformation and will actively involve all fields of medical care, in particular medicine and surgery. This call to action, on behalf of the American Heart Association’s Expert Panel on Payment and Delivery System Reform, serves to offer support and direction for further involvement by the American Heart Association. In doing so, it (1) provides baseline review and definition of the present models and some of the early results of these delivery models, including outcomes; (2) initiates a conversation within the American Heart Association on the impact of payment and delivery system reform, as well as how the American Heart Association should engage in the interest of patients; (3) issues a call to action to our organization and to cardiovascular and stroke health professionals across the country to become educated about these models so to as to understand their impact on patient care; and (4) asks the government and other funding agencies, including the American Heart Association, to begin supporting and prioritizing meaningful research endeavors to further evaluate these models.

Case Study: Johns Hopkins Community Health Partnership: A model for transformation

To address the challenging health care needs of the population served by an urban academic medical center, we developed the Johns Hopkins Community Health Partnership (J-CHiP), a novel care coordination program that provides services in homes, community clinics, acute care hospitals, emergency departments, and skilled nursing facilities. This case study describes a comprehensive program that includes: a community-based intervention using multidisciplinary care teams that work closely with the patients primary care provider; an acute care intervention bundle with collaborative team-based care; and a skilled nursing facility intervention emphasizing standardized transitions and targeted use of care pathways. The program seeks to improve clinical care within and across settings, to address the non-clinical determinants of health, and to ultimately improve healthcare utilization and costs. The case study introduces: a) main program features including rationale, goals, intervention design, and partnership development; b) illness burden and social barriers of the population contributing to care challenges and opportunities; and c) lessons learned with steps that have been taken to engage both patients and providers more actively in the care model. Urban health systems, including academic medical centers, must continue to innovate in care delivery through programs like J-CHiP to meet the needs of their patients and communities.