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Christiana Care Quality Partners Connections  |  Vol. I, Issue 2

Message from the Medical Director

What does it mean to be a Clinically Integrated Network?

  Dan Elliott, M.D., MSCE
 

Dan Elliott, M.D., MSCE
Medical Director,
Quality Partners Network

 

As Quality Partners continues to gain momentum, conversations lately have turned to what it means to be a Clinically Integrated Network (CIN). Though the concept can feel distant and vague, the Federal Trade Commission (FTC) has specified key components that define a CIN. These include demonstrated clinical coordination, data sharing and quality reporting, reimbursement structures that promote value over volume, selective clinical participation criteria and the ability to directly contract with payers. As a network, we are moving rapidly toward meeting FTC requirements over the next year, and your colleagues on the Quality Partners’ Committees are actively engaged in working out the details. Without a doubt, we need to make the leap to being a true CIN in order to be positioned to engage in the health care marketplace of the future.

You and I both know that there is so much more to being a CIN than checking off the boxes to meet the FTC definition. To be successful, we must understand and be driven by what being a CIN will ultimately mean to us as providers as well as to our multiple stakeholders including payers and patients.

For providers, being part of a clinically integrated network means being part of a larger team, specifically one that allows us to practice more efficiently effectively, collaboratively, comprehensively, and successfully. The system works for the CIN removes burdens and barriers to effective treatment, and helps patients track with the plan of care we work so hard together with them to lay out. In a network, we have support for services that challenge our practices and likely can be performed more efficiently at the network level, such as accessing support from social workers, pharmacists or disease-specific educators. Being part of a network means support for our patients to access the evidence-based treatments and diagnostic tests we recommend as necessary. In the CIN, we can take a broader view toward the overall patterns of care we provide, how we relate to our peers and what we can do to improve the care to both individuals and populations. Importantly, as the health care landscape continues to change rapidly, being part of a CIN means we can engage in new contracts and opportunities that allow our practices to move from volume to value, successfully.

For payers – including individuals, employers, federal and state governments and insurance companies – working with a CIN often means having a partner whose goals are aligned with delivering a high-value “product,” and whose commitment to value is backed by a willingness to share financial responsibility. As confusing as our health care system is from the inside, it is even more confusing from the outside. As a result, payers are particularly attuned to simplifying the “Value Equation” to such things as the per-member-per-month (PMPM) cost and the quality measures, often HEDIS metrics. Payers will certainly measure our value as a network using these simplified calculations. For a patient, engaging with a CIN means knowing that your doctors are communicating and practicing the highest-level of evidence-based medicine. They are pro-actively working to understand your needs, and committed to making your health care experience more efficient and more effective, providing only the care that is necessary and helpful. Patients expect that we, their doctors, are coordinating care, sharing information and helping them make the best decisions possible, particularly as the share of health care costs born by patients is increasing rapidly.

Understanding what we and our future partners expect from partnership as a CIN is critical to building our future.

What does becoming a CIN mean to you? Your feedback is encouraged and appreciated.

Best regards,

Dan Elliott, M.D., MSCE

Medical Director, Christiana Care Quality Partners

On the line – news from our Quality Partner Service Line Leads

 
  Scott Roberts, M.D.

Building partnerships on the pathway to better bones

by Scott Roberts, M.D., Christiana Spine Center and Quality Partners Leader for the Musculoskeletal Health Service Line

Christiana Care’s Musculoskeletal Health Service Line has charted a clear pathway to provide consistent, evidence-based osteoporosis treatment to improve bone health and lower the risk for secondary fragility fractures.

The fragility fracture pathway standardizes care for inpatients with a vertebral compression fracture, and leverages the resources of Christiana Care’s Strong Bones program for secondary prevention of further fragility fractures.

The Strong Bones program can help primary care providers and their patients detect and treat bone fragility. This partnership enables us to address the first fracture in optimal ways and help prevent subsequent fractures.

The fragility fracture pathway offers two entry points. First, patients diagnosed in the ED with a vertebral compression fracture enter the pathway in the hospital. If the patient is admitted, the pathway provides guidance on the appropriate use of imaging and physical therapy and when a consultation for spine surgery is appropriate. The pathway leads to a Strong Bones consultation and, when possible, a Strong Bones nurse practitioner will see the patient in the hospital.

For all patients, a nurse navigator will ensure that the primary care provider is aware of the diagnosis. Based on the preference of the patient and the primary care provider, the nurse navigator may simply provide information, or can arrange appropriate testing and consultation with an osteoporosis provider.

A second point of entry opens beyond hospital walls. The Strong Bones program can serve primary care physicians as an osteoporosis management center offering resources for screening and outcomes-based guidelines for treatment, as well as referrals to their network of osteoporosis specialists for outpatient bone health management.

As the Quality Partners Network representative to the Musculoskeletal Health Service Line, I encourage our community providers to use me as a conduit to present ideas and concerns regarding musculoskeletal health. For providers in Orthopedics, Physical Medicine and Rehabilitation, Rheumatology, Sports Medicine and other related specialties, I am your link to the Service Line for any initiatives or new pathways you would like to see introduced.

At present, nine service lines throughout the health system are in the process of building a library of evidenced-based care pathways that will ultimately be shared with community providers though the Christiana Care website. If you would like to offer your expertise to our pathway development process, we welcome your input and your participation.

Send comments or inquiries to Dr. Scott Roberts. For more information or referrals to the Strong Bones program, call 302-733-5592.

Clinical Vignettes - Musculoskeletal Health

Vertebral Fragility Fracture Management

Eric Russell, D.O.by Rheumatologist Eric Russell, D.O., Associate Physician Leader for the Musculoskeletal Service Line

Acute back pain after a vertebral fragility fracture (VFF) in the majority of patients will resolve or significantly improve over the course of several days to a few weeks.

Time, rest and a short course of analgesics (i.e. NSAIDs) or narcotics are often the only intervention needed in the acute setting, as pain will usually resolve. Often vertebral fragility fractures are asymptomatic and not detected. The focus of treatment is bone health management to optimize bone strength and prevent subsequent fractures. An immediate orthopedic spine or neurosurgery consultation usually is not required in the vast majority of patients with a new compression fracture.

Bone density testing

A baseline bone density evaluation (DXA scan) is in order when initiating osteoporosis treatment and/or in any patient with a fragility fracture. Subsequent bone density testing can be considered one to two years after treatment initiation to assess treatment efficacy.

Consider ordering a DXA scan with a Vertebral Fracture Assessment (VFA).

A VFA snapshot of the entire spine at the time of DXA testing may detect other sites of an occult vertebral fragility fracture not previously imaged. Consider a VFA with DXA testing for females older than age 70 or males older than age 80, as part of their routine bone density evaluation, regardless of a previously sustained vertebral fragility fracture.

Bone health management

Key interventions to optimize bone density and minimize the risk of future vertebral fragility fractures include:

  1. Timely initiation of an antiresorptive agent after the fracture, i.e., bisphosphonates: alendronate Fosamax), zoledronic acid (Reclast), and risedronate (Actonel); or denosumab (Prolia), a RANK ligand inhibitor.
    • These agents have been shown to increase vertebral bone density and reduce vertebral/hip fracture risk. All are acceptable first-line agents for management of a vertebral fragility fracture. b. Ibandronate (Boniva), a bisphosphonate, and raloxifene (Evista), a selective estrogen receptor modulator, have not been shown to reduce non-vertebral fracture rates so are not considered an ideal first-line agent.
    • The anabolic agent, teriparatide (Forteo), a recombinant DNA parathyroid hormone, also improves vertebral bone density and reduces vertebral/hip fracture risk. However, this agent is expensive and more cumbersome to administer (daily subcutaneous administration) and should be considered a second-line treatment when antiresorptive agents have failed or are not tolerated. Some limited data have demonstrated that teriparatide can help reduce pain associated with an acute spinal fracture, but there is insufficient evidence of its superiority over first-line treatment with a bisphosphonate or denosumab.
    • There is limited evidence that nasal calcitonin reduces acute spinal pain, but it has no role in the primary treatment of osteoporosis. However, nasal calcitonin can be considered as an adjunct treatment in patients with more severe or refractory spinal pain due to a compression fracture.
  2. Optimize vitamin D and calcium supplementation. According to current guidelines, patients should get 1000-1200mg of calcium a day. Calcium supplements are recommended if diet alone does not provide adequate calcium intake. The National Osteoporosis Foundation recommends 800IU of vitamin D daily in postmenopausal women with osteoporosis. Low vitamin D levels (<30 ng/ml) should be repleted with replacement doses of vitamin D for at least three months (2000IU daily or 50,000IU weekly of vitamin D) until levels normalize.
  3. Identify osteoporosis risk factors (i.e. high-risk drugs, smoking, prior fracture history).
  4. Determine falls risk. If the patient is a suspected falls risk, home physical therapy may be of benefit for gait training, ambulatory assist device training and home safety evaluation to eliminate contributors to falls.
Vertebral augmentation procedures

The majority of patients with acute spine pain from a compression fracture will have resolution of pain with conservative treatment. Therefore, an orthopedic spine or neurosurgical consultation should not be an automatic referral.

Kyphoplasty and vertebroplasty are common interventions for an acute vertebral fragility fracture; however, the data are mixed regarding sustained pain relief long-term in the minority of patients who have chronic spinal pain from a fracture. Christiana Care spine surgeons recommend waiting at least three weeks to assess pain response with conservative treatment prior to consideration of a spine surgery evaluation for these procedures.

Resources for bone health management

A patient’s other co-morbidities can overshadow interventions to address fragility fracture risk and overall bone health. Christiana Care offers a number of resources to assist the primary care provider in managing a patient’s bone health both in inpatient and outpatient settings including the Strong Bones Program.

References: National Osteoporosis Foundation. 2013 Clinician Guide to Prevention and Treatment of Osteoporosis. 2013 ISCD Official Positions. AAOS Clinical Practice Guideline: The Treatment of Symptomatic Osteoporotic Spinal Compression Fractures. Journal of the American Academy of Orthopaedic Surgeons: March 2011 - Volume 19 - Issue 3 - p 176–182.

Case presentation

A 70-year-old, thin, white female with a past history of a wrist fracture (5 years ago) presents to the emergency department with acute lumbar pain. The pain was immediately subsequent to a fall when she slipped on a rug in her kitchen and fell on her buttocks. She was able to stand back up, but a few hours, later her pain was so severe she was unable to walk.

She was taken by ambulance to the Christiana Hospital ED, where spinal x-rays demonstrated a compression wedge deformity of the L2 vertebrae. She was diagnosed with an acute vertebral compression fracture and subsequently admitted for IV narcotic pain control.

Once the patient was admitted to the hospital the floor nurse placed a consult to the Strong Bones team. The team ordered appropriate bone health labs that revealed a low Vitamin D level. Vitamin D repletion was ordered. The patient’s back pain decreased with a short course of IV narcotics, after which she transitioned to an oral narcotic regimen.

In the hospital, a physical therapy consultation provided a falls assessment and gait evaluation. There was no immediate indication for a spine surgery consultation. The Strong Bones nurse practitioner ordered an outpatient DXA scan. The team provided osteoporosis educational material and coordinated with the primary care provider to hand off bone health management.

After discharge, the Visiting Nurse Association conducted a falls assessment of the patient’s home environment. Home physical therapy determined after one visit that she could proceed to outpatient physical therapy. The patient rapidly switched to non-narcotic analgesics to control her pain. The DXA scan was completed. At the follow-up visit with her primary care provider, bone health labs and the DXA results were reviewed, and her provider started the patient on a bisphosphonate.

To contact a Strong Bones nurse navigator, call 302-733-5592.

Go to PowerChart to request a Strong Bones consult for patients admitted to the hospital with a fragility fracture. For outpatient referrals, use Centricity (keyword: Strong Bones) or an eComm.

In Action – following the work of our Quality Partners Committees

Quality Partners Reimbursement Committee tackles the challenges of “costing out” quality care

Reimbursement Committee Members

Reimbursement Committee members, left to right: Alan Micklin, M.D., Theodore Saad, M.D., Timothy Manzone, M.D., Robert Kopecki, D.O., Shilpa Mehta, M.D., Todd Harad, M.D., Matthew Cooper, M.D., Patrick Grusenmeyer, Sc.D., Vinay Maheshwari, M.D., Gregory DeMeo, D.O. Not pictured Joseph Bennett, M.D., and David Bauman, M.D.

The task of the Reimbursement Committee is to work in conjunction with Quality Partners’ leadership and committee members to align payment for services with quality care. Those who serve on the committee represent a productive blend of both community-based and hospital-employed physicians from primary care and diverse specialty backgrounds. The group meets regularly and, often jointly, with the membership of the Quality Improvement Committee.

“The reality is that health care’s traditional fee-for-service model is broken, and rising health care costs do not correlate with better outcomes for our patients,” said Committee Chair Shilpa Mehta, M.D, a Med-Peds specialist with Bear Internal Medicine and Pediatrics, P.A., in Newark, Del. “Our expenditures are related to quantity of care, without real attention to quality of care or outcomes measures. What is exciting for our committee is the opportunity to think outside the box about novel ways to change this paradigm.”

The Quality Partners Reimbursement Committee has been working closely with the Quality Improvement Committee to craft an equitable cost-sharing model that integrates evidence-based performance with pay for value among Christiana Care-affiliated providers. This is mission critical today as the Quality Partners umbrella opens wider to serve some 30,000 Medicare beneficiaries around the state through the newly launched Accountable Care Organization Medicare Shared Savings Program.

“The standard in medicine is change,” said Dr. Mehta, “and change can be discomforting for a time, but if we all do a better job financially to achieve better health care outcomes, it is a win for everyone.”

Dr. Mehta invites readers to contribute their ideas and insights as the Reimbursement Committee moves forward. “Ours is a physician-driven mission, and there is a lot of passion for the subject matter we are tackling,” she said. “We welcome input from our community providers as we continue the journey.”

We welcome your feedback.

Reimbursement Committee Members

Joseph Bennett, M.D., Surgical Oncology
David Bauman, M.D., Christiana Care Family Medicine
Matt Cooper, M.D. , Anesthesia Services, P.A.
Gregory DeMeo, D.O., First State Women’s Care
F. Todd Harad, M.D., Christiana Care Vascular Specialists
Robert Kopecki, D.O., Internal Medicine Associates
Vinay Maheshwari, M.D., Christiana Care Pulmonary Associates
Shilpa Mehta, M.D., Bear Internal Medicine and Pediatrics, P.A., Committee Chair
Timothy Manzone, M.D., Christiana Care Nuclear Medicine Physicians, P.A.
Alan Micklin, M.D., Cardiology Physicians, P.A.
Theodore Saad, M.D., Nephrology Associates, P.A.

Christiana Care Offers CT Scan Lung Screenings

This screening can help detect lung cancer at an early stage in current or former heavy smokers. When used as part of a coordinated program, lung cancer screening has been shown to reduce lung cancer specific mortality by 20 percent.

The Christiana Care Lung Health & Screening Program offers serial low dose chest CT scans to screen apparently healthy individuals at high risk for lung cancer.

Patients are eligible if all of the following apply:

  • Are ages 55-77.
  • Have a 30 pack-year smoking history, who currently smoke or have quit less than 15 years ago.
  • Are free of any signs or symptoms suggestive of lung cancer.
  • Have no severe co-morbidities that limit life expectancy.
The Christiana Care Lung Health and Screening program has evaluated more than 600 patients. The program offers:
  • A nurse practitioner who presents the opportunity for an informed, shared-decision making visit with the patient to discuss the goals of early lung cancer detection, along with the risks and benefits of low-dose CT screening.
  • A low-dose CT lung scan–a protocol that was found to be effective in the National Lung Screening Trial (NLST) performed according to the American College of Radiology guidelines.
  • A smoking cessation counselor to assist patients in quitting smoking.
  • A dedicated nurse navigator who will verify patient eligibility and coordinate initial, annual and interim low-dose CT scans.
All results, including any incidental findings, are communicated to the patient’s primary care physician and discussed with the patient.

The nurse navigator facilitates referral for patients with suspicious findings to the Helen F. Graham Cancer Center & Research Institute’s Multidisciplinary Thoracic, Esophageal and Lung Cancer Center. At the MDC, patients meet with a pulmonologist and thoracic surgeon for discussion and expert guidance on further evaluation and treatment.

To refer a patient, to the Christiana Care Lung Health and Screening Program, call 302-623-CARE (2273) OR in Centricity send a flag to “Program, Lung Health.”

The Value Equation – Actualized

Overview of Cost and Use Measures*
Overview of Cost and Use Measures*

One of our goals at Quality Partners is to help all of us view and understand the macro trends in our environment, and to use that information to drive our ongoing efforts. As mentioned above, many of our stakeholders, notably payers, are going to be very attentive to our per-member-per-month (PMPM) costs for patients in our network. PMPM is a function of both utilization and unit cost. The table shows cost and utilization for the Christiana Care insured population for several important areas of utilization for the last two years. The relation of utilization and unit cost is most clearly seen in brand medication dispensing, where despite an overall decrease in the number of brand medications dispensed the PMPM went up significantly, reflecting the large rise in unit cost for brand medications. Overall, our PMPM increased in FY15, and we will be working hard to identify and target specific areas to stem the rate of rise of costs. There are many levers to pull to drive PMPM – benefits design including copayments, care coordination support and others – and we will be working aggressively on these. One thing we can do – and must do – is seek ways to control the things that we can, and optimize the care we provide as a network.

Health Care Delivery Transformation

Read this article to see how a large physician practice in Illinois could serve as a model for a new kind of accountable care organization, by demonstrating how to organize physicians into partnerships with hospitals to improve care, cut costs and be held accountable for the results.

Administrative Updates

Electronic Payments from InstaMed

As of Jan. 1, 2016 Geisinger has transitioned its electronic payments to providers from Emdeon to InstaMed. If you have already registered with InstaMed, you can access copies of Explanation of Payments by clicking here and logging in. If you have not yet registered with Instamed, visit: www.instamed.com/eraeft.

If you have questions about the registration process or other specifics, contact InstaMed at 866-467-8263 or via e-mail. If you have concerns or issues with this process, contact your provider relations representative.

Save the Date – April 28: Quality Partners/Geisinger Workshop

Mark your calendars for an upcoming practice staff workshop to learn more about new and upcoming changes with Quality Partners & Geisinger Health Options. This is your chance to ask questions and provide feedback. The workshop takes place the afternoon of April 28. Stay tuned for more information.

Resubmitting Denied Claims

When appealing a denied claim, it is critical that you resubmit the claim using Geisinger’s CRFF form along with your supporting documentation. Simply re-submitting the claim again will result in another denial. Click here for the CRFF form and contact your provider relations representative if you have additional questions.

Who to Call at Quality Partners

Click here for a list of numbers you can call based on your need. Do not hesitate to contact your Provider Relations Representative anytime you need assistance. Unsure who your dedicated representative is? Just give us a call at 302-623-7959 and we will put you in touch with the right person.

Provider Relations Representatives
Martin Weitzman, Provider Relations Representative, 302-623-0363
Angela Williams, Provider Relations Representative, 302-623-0357

The Quality Partners Team
Alan Greenglass, M.D., Chief Executive Officer
Doug Azar, Senior Vice President
Dan Elliott, M.D., MSCE, Medical Director
Mike Cinkala, Director, Provider Relations
Amanda Klockars-McMullen, Ph.D., RN, CPHQ, Program Director, Quality & Performance Improvement
Melissa Maule, Administrative Assistant
Martin Weitzman, Provider Relations Representative
Angela Williams, Provider Relations Representative

 

We welcome your feedback: QualityPartners@ChristianaCare.org