A new study shows that in patients with acute ischemic stroke, every 15 minutes counts when talking about the time it takes to begin intravenous tissue-type plasminogen activator (tPA) therapy.

According to a report in JAMA, patients who received tPA treatment within 4.5 hours of symptom onset and had faster onset to treatment (OTT) had reduced in-hospital mortality and symptomatic intracranial hemorrhage rates (odds ratio for each, 0.96). Each 15-minute reduction in OTT also increased rates of independent ambulation at discharge and discharge to the home.

"This study emphasizes and characterizes better than before the fundamental importance of rapid start of thrombolytic therapy for acute ischemic stroke," says lead author Jeffrey Saver, MD, professor of neurology at the Geffen School of Medicine at the University of California at Los Angeles (UCLA) and director of the UCLA Stroke Center. "[For] every 15-minute delay of start of therapy, two fewer of out of 100 patients benefit. And this means that hospital systems need to be optimized to ensure that the target of door-to-needle time for start of tPA being under 60 minutes is achieved more often."

Dr. Saver says door-to-needle times under one hour have improved in recent years to nearly 50% from 25%, but hospitals can do better.

Recommended steps to improve that figure include having ambulances provide pre-arrival notification of stroke patients, having everyone on a stroke/hospitalist team paged at once to prepare all physicians who would potentially interact with the patients, premixing thrombolytic drugs to allow for quicker use, and having a data feedback system so institutions can figure out where the obstacles are to achieving improved performance.

"This is the type of system change that occurs by evolution, not revolution," Dr. Saver adds. "You need to bring your team together, you need physician champions to take the lead, and then you need to slowly drive system change based on the data in your institution. This is not an easy task, but it’s the type of task that hospitalists are perfect for."

Visit our website for more information on stroke treatments.

A new study shows that in patients with acute ischemic stroke, every 15 minutes counts when talking about the time it takes to begin intravenous tissue-type plasminogen activator (tPA) therapy.

According to a report in JAMA, patients who received tPA treatment within 4.5 hours of symptom onset and had faster onset to treatment (OTT) had reduced in-hospital mortality and symptomatic intracranial hemorrhage rates (odds ratio for each, 0.96). Each 15-minute reduction in OTT also increased rates of independent ambulation at discharge and discharge to the home.

"This study emphasizes and characterizes better than before the fundamental importance of rapid start of thrombolytic therapy for acute ischemic stroke," says lead author Jeffrey Saver, MD, professor of neurology at the Geffen School of Medicine at the University of California at Los Angeles (UCLA) and director of the UCLA Stroke Center. "[For] every 15-minute delay of start of therapy, two fewer of out of 100 patients benefit. And this means that hospital systems need to be optimized to ensure that the target of door-to-needle time for start of tPA being under 60 minutes is achieved more often."

Dr. Saver says door-to-needle times under one hour have improved in recent years to nearly 50% from 25%, but hospitals can do better.

Recommended steps to improve that figure include having ambulances provide pre-arrival notification of stroke patients, having everyone on a stroke/hospitalist team paged at once to prepare all physicians who would potentially interact with the patients, premixing thrombolytic drugs to allow for quicker use, and having a data feedback system so institutions can figure out where the obstacles are to achieving improved performance.

"This is the type of system change that occurs by evolution, not revolution," Dr. Saver adds. "You need to bring your team together, you need physician champions to take the lead, and then you need to slowly drive system change based on the data in your institution. This is not an easy task, but it’s the type of task that hospitalists are perfect for."

Visit our website for more information on stroke treatments.

A new study shows that in patients with acute ischemic stroke, every 15 minutes counts when talking about the time it takes to begin intravenous tissue-type plasminogen activator (tPA) therapy.

According to a report in JAMA, patients who received tPA treatment within 4.5 hours of symptom onset and had faster onset to treatment (OTT) had reduced in-hospital mortality and symptomatic intracranial hemorrhage rates (odds ratio for each, 0.96). Each 15-minute reduction in OTT also increased rates of independent ambulation at discharge and discharge to the home.

"This study emphasizes and characterizes better than before the fundamental importance of rapid start of thrombolytic therapy for acute ischemic stroke," says lead author Jeffrey Saver, MD, professor of neurology at the Geffen School of Medicine at the University of California at Los Angeles (UCLA) and director of the UCLA Stroke Center. "[For] every 15-minute delay of start of therapy, two fewer of out of 100 patients benefit. And this means that hospital systems need to be optimized to ensure that the target of door-to-needle time for start of tPA being under 60 minutes is achieved more often."

Dr. Saver says door-to-needle times under one hour have improved in recent years to nearly 50% from 25%, but hospitals can do better.

Recommended steps to improve that figure include having ambulances provide pre-arrival notification of stroke patients, having everyone on a stroke/hospitalist team paged at once to prepare all physicians who would potentially interact with the patients, premixing thrombolytic drugs to allow for quicker use, and having a data feedback system so institutions can figure out where the obstacles are to achieving improved performance.

"This is the type of system change that occurs by evolution, not revolution," Dr. Saver adds. "You need to bring your team together, you need physician champions to take the lead, and then you need to slowly drive system change based on the data in your institution. This is not an easy task, but it’s the type of task that hospitalists are perfect for."

Visit our website for more information on stroke treatments.

The Center for Medicare & Medicaid Innovation's Rick Gilfillan, MD, will be leaving at the end of June, just as the organization prepares to start accepting round-two grant applications for up to $1 billion in Health Care Innovation Awards. Replacing him as acting director will be Patrick Conway, MD, MSc, FAAP, SFHM, a practicing pediatric hospitalist, former director of hospital medicine at Cincinnati Children's Hospital, and HM13 keynote speaker.

Dr. Conway will continue in his current role as CMS' chief medical officer.

"We applaud Patrick Conway's appointment to the Center for Medicare & Medicaid Innovation," says SHM President Eric Howell, MD, SFHM. "His work, compassion, and vision are tremendous validations of the hospitalist model as both a change agent and as a career path. Patients across the country will be the true beneficiaries of his new work.

"Hospitalists should continue to look toward the CMS Innovation Center as a leader in transforming healthcare."

The center was created by the 2010 Affordable Care Act to offer solutions to healthcare cost and delivery problems. Its first round of 107 innovations awards, averaging $8.4 million each over three years, was announced in 2012 and included several that focused on preventing hospitalizations, avoidable rehospitalizations, and ED visits. One award went to David Meltzer, MD, PhD, FHM, of the University of Chicago to test a model in which the same doctor would see selected high-risk patients both in and out of the hospital.

Round two "provides hospitalists—who have an exceptionally broad perspective—with a unique opportunity to share new approaches to delivering the best patient care at an affordable cost," Dr. Conway told The Hospitalist.

Visit our website for more information on CMS Innovation Center initiatives.

The Center for Medicare & Medicaid Innovation's Rick Gilfillan, MD, will be leaving at the end of June, just as the organization prepares to start accepting round-two grant applications for up to $1 billion in Health Care Innovation Awards. Replacing him as acting director will be Patrick Conway, MD, MSc, FAAP, SFHM, a practicing pediatric hospitalist, former director of hospital medicine at Cincinnati Children's Hospital, and HM13 keynote speaker.

Dr. Conway will continue in his current role as CMS' chief medical officer.

"We applaud Patrick Conway's appointment to the Center for Medicare & Medicaid Innovation," says SHM President Eric Howell, MD, SFHM. "His work, compassion, and vision are tremendous validations of the hospitalist model as both a change agent and as a career path. Patients across the country will be the true beneficiaries of his new work.

"Hospitalists should continue to look toward the CMS Innovation Center as a leader in transforming healthcare."

The center was created by the 2010 Affordable Care Act to offer solutions to healthcare cost and delivery problems. Its first round of 107 innovations awards, averaging $8.4 million each over three years, was announced in 2012 and included several that focused on preventing hospitalizations, avoidable rehospitalizations, and ED visits. One award went to David Meltzer, MD, PhD, FHM, of the University of Chicago to test a model in which the same doctor would see selected high-risk patients both in and out of the hospital.

Round two "provides hospitalists—who have an exceptionally broad perspective—with a unique opportunity to share new approaches to delivering the best patient care at an affordable cost," Dr. Conway told The Hospitalist.

Visit our website for more information on CMS Innovation Center initiatives.

The Center for Medicare & Medicaid Innovation's Rick Gilfillan, MD, will be leaving at the end of June, just as the organization prepares to start accepting round-two grant applications for up to $1 billion in Health Care Innovation Awards. Replacing him as acting director will be Patrick Conway, MD, MSc, FAAP, SFHM, a practicing pediatric hospitalist, former director of hospital medicine at Cincinnati Children's Hospital, and HM13 keynote speaker.

Dr. Conway will continue in his current role as CMS' chief medical officer.

"We applaud Patrick Conway's appointment to the Center for Medicare & Medicaid Innovation," says SHM President Eric Howell, MD, SFHM. "His work, compassion, and vision are tremendous validations of the hospitalist model as both a change agent and as a career path. Patients across the country will be the true beneficiaries of his new work.

"Hospitalists should continue to look toward the CMS Innovation Center as a leader in transforming healthcare."

The center was created by the 2010 Affordable Care Act to offer solutions to healthcare cost and delivery problems. Its first round of 107 innovations awards, averaging $8.4 million each over three years, was announced in 2012 and included several that focused on preventing hospitalizations, avoidable rehospitalizations, and ED visits. One award went to David Meltzer, MD, PhD, FHM, of the University of Chicago to test a model in which the same doctor would see selected high-risk patients both in and out of the hospital.

Round two "provides hospitalists—who have an exceptionally broad perspective—with a unique opportunity to share new approaches to delivering the best patient care at an affordable cost," Dr. Conway told The Hospitalist.

Visit our website for more information on CMS Innovation Center initiatives.

Guess what? Physician-driven accountable care organizations with a strong primary care core are working – and, in a historic change, primary care physicians are the most highly compensated group.

The even better news? This trend is predictable and inevitable.

ACOs are working

As earlier posts to this column show, there are eight fairly straightforward elements required to create a successful and sustainable ACO:

• A change in financial incentives from those that reward volume, such as fee-for-service, to those that reward value, such as shared savings, if quality benchmarks are met.

• A primary care core.

• Physician cultural change.

• Patient engagement.

• Robust data collection.

• Clinical best practices.

• Administrative infrastructure.

• Enough scale.

A number of ACOs that do not have these elements will fail; but fortunately, more and more are being set up properly.

Recently, the Boston Consulting Group reported that ACO-like Medicare Advantage plans are reporting positive results. They are all distinguished by having "a selective network of providers, financial incentives that are aligned with clinical best practices, and active care management that emphasizes prevention in an effort to minimize expensive acute care."

Not only are emergency department and ambulatory surgery procedures down 20%-30% at these plans, but analysis of their data on 3 million Medicare patients showed that quality went up. These patients had lower single-year mortality rates, shorter average hospital stays, fewer readmissions, and better sustainability of health over time.¹

Physician-led ACOs are better

If ACOs are good, physician-sponsored ones are better.

At a recent national meeting of health insurance companies, Paul Ginsburg, Ph.D., president of the Center for Studying Health System Change, told the insurers, "I think physician-led ACOs inherently make markets more competitive, because they have an opportunity to shift patients toward high-value hospitals."

Similarly, Charlie Baker, former secretary of health and human services for Massachusetts, told the group that nearly all of the Medicare Advantage risk contracts are with physician groups and not hospitals. Medicare Advantage participants are chosen by insurers, and he indicated that they know that contracting with physician ACOs is the best way to save money.²

As reported in an earlier column, this truth is becoming more evident, and there are now more physician-led ACOs than any other.

Primary care reaping rewards

Primary care is the only discipline mandated to be in ACOs participating in the Medicare Shared Savings Program. This is because ACO success stems from keeping people out of the hospital, avoiding expensive procedures, and reducing unnecessary tests and imaging. The "target-rich fields" for ACOs to accomplish this are primarily prevention and wellness, coordination of high-cost complex patients, reduced hospitalizations, and transition management across our fragmented system. These are all in primary care’s wheelhouse. It is no wonder that you are the darlings of the accountable care movement.

Successful and sustainable ACOs will tie shared savings distributions to relative contribution. A merit system thus likely will be primary care weighted.

For example, one ACO posted this planned distribution of shared savings: 12% to infrastructure; of the remainder, 60% to primary care, 40% to specialists, and 0% to hospitals.

The following small sample survey shows widely varying models; but in all cases where distribution is broken out, primary care receives as much or more than specialists and, with one exception, hospitals.

There are some primary-care-only ACOs that are distributing 100% of savings to their primary care physicians under Medicare Advantage risk or Medicare Shared Savings Program contracts. One interviewed primary care physician ACO member stated that for his full-risk Medicare Advantage patient population, he was seeing half as many patients and making three times the income.

While income recognition for what you do is way overdue, keeping all the savings might be going too far. A fully evolved ACO should incentivize all providers and facilities along the entire continuum of care, but always in proportion to their value-adding contribution.

Primary care physicians tell me that while this economic reward is gratifying and validating, their surprise biggest reward has been empowerment to do health care right and regain control of the physician/patient relationship. They say that seeing happier, healthier patients, and being able to spend more time with them, has returned the fun to the practice of medicine.

References

1. Kaplan, J., et al., Alternative Payer Models Show Improved Health-Care Value, BCG Perspective, May 14, 2013.

2. Pittman, D., Doc-Led ACOs Better Model for Saving $$$, MedPage Today, May 15, 2013.

3. Anderson, G., et al., Critical Business and Design Elements of the ACO, American Health Lawyers Association, Healthcare Transactions conference (April 2013).

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, North Carolina. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at [email protected] or 919-821-6612.

Guess what? Physician-driven accountable care organizations with a strong primary care core are working – and, in a historic change, primary care physicians are the most highly compensated group.

The even better news? This trend is predictable and inevitable.

ACOs are working

As earlier posts to this column show, there are eight fairly straightforward elements required to create a successful and sustainable ACO:

• A change in financial incentives from those that reward volume, such as fee-for-service, to those that reward value, such as shared savings, if quality benchmarks are met.

• A primary care core.

• Physician cultural change.

• Patient engagement.

• Robust data collection.

• Clinical best practices.

• Administrative infrastructure.

• Enough scale.

A number of ACOs that do not have these elements will fail; but fortunately, more and more are being set up properly.

Recently, the Boston Consulting Group reported that ACO-like Medicare Advantage plans are reporting positive results. They are all distinguished by having "a selective network of providers, financial incentives that are aligned with clinical best practices, and active care management that emphasizes prevention in an effort to minimize expensive acute care."

Not only are emergency department and ambulatory surgery procedures down 20%-30% at these plans, but analysis of their data on 3 million Medicare patients showed that quality went up. These patients had lower single-year mortality rates, shorter average hospital stays, fewer readmissions, and better sustainability of health over time.¹

Physician-led ACOs are better

If ACOs are good, physician-sponsored ones are better.

At a recent national meeting of health insurance companies, Paul Ginsburg, Ph.D., president of the Center for Studying Health System Change, told the insurers, "I think physician-led ACOs inherently make markets more competitive, because they have an opportunity to shift patients toward high-value hospitals."

Similarly, Charlie Baker, former secretary of health and human services for Massachusetts, told the group that nearly all of the Medicare Advantage risk contracts are with physician groups and not hospitals. Medicare Advantage participants are chosen by insurers, and he indicated that they know that contracting with physician ACOs is the best way to save money.²

As reported in an earlier column, this truth is becoming more evident, and there are now more physician-led ACOs than any other.

Primary care reaping rewards

Primary care is the only discipline mandated to be in ACOs participating in the Medicare Shared Savings Program. This is because ACO success stems from keeping people out of the hospital, avoiding expensive procedures, and reducing unnecessary tests and imaging. The "target-rich fields" for ACOs to accomplish this are primarily prevention and wellness, coordination of high-cost complex patients, reduced hospitalizations, and transition management across our fragmented system. These are all in primary care’s wheelhouse. It is no wonder that you are the darlings of the accountable care movement.

Successful and sustainable ACOs will tie shared savings distributions to relative contribution. A merit system thus likely will be primary care weighted.

For example, one ACO posted this planned distribution of shared savings: 12% to infrastructure; of the remainder, 60% to primary care, 40% to specialists, and 0% to hospitals.

The following small sample survey shows widely varying models; but in all cases where distribution is broken out, primary care receives as much or more than specialists and, with one exception, hospitals.

There are some primary-care-only ACOs that are distributing 100% of savings to their primary care physicians under Medicare Advantage risk or Medicare Shared Savings Program contracts. One interviewed primary care physician ACO member stated that for his full-risk Medicare Advantage patient population, he was seeing half as many patients and making three times the income.

While income recognition for what you do is way overdue, keeping all the savings might be going too far. A fully evolved ACO should incentivize all providers and facilities along the entire continuum of care, but always in proportion to their value-adding contribution.

Primary care physicians tell me that while this economic reward is gratifying and validating, their surprise biggest reward has been empowerment to do health care right and regain control of the physician/patient relationship. They say that seeing happier, healthier patients, and being able to spend more time with them, has returned the fun to the practice of medicine.

References

1. Kaplan, J., et al., Alternative Payer Models Show Improved Health-Care Value, BCG Perspective, May 14, 2013.

2. Pittman, D., Doc-Led ACOs Better Model for Saving $$$, MedPage Today, May 15, 2013.

3. Anderson, G., et al., Critical Business and Design Elements of the ACO, American Health Lawyers Association, Healthcare Transactions conference (April 2013).

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, North Carolina. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at [email protected] or 919-821-6612.

Guess what? Physician-driven accountable care organizations with a strong primary care core are working – and, in a historic change, primary care physicians are the most highly compensated group.

The even better news? This trend is predictable and inevitable.

ACOs are working

As earlier posts to this column show, there are eight fairly straightforward elements required to create a successful and sustainable ACO:

• A change in financial incentives from those that reward volume, such as fee-for-service, to those that reward value, such as shared savings, if quality benchmarks are met.

• A primary care core.

• Physician cultural change.

• Patient engagement.

• Robust data collection.

• Clinical best practices.

• Administrative infrastructure.

• Enough scale.

A number of ACOs that do not have these elements will fail; but fortunately, more and more are being set up properly.

Recently, the Boston Consulting Group reported that ACO-like Medicare Advantage plans are reporting positive results. They are all distinguished by having "a selective network of providers, financial incentives that are aligned with clinical best practices, and active care management that emphasizes prevention in an effort to minimize expensive acute care."

Not only are emergency department and ambulatory surgery procedures down 20%-30% at these plans, but analysis of their data on 3 million Medicare patients showed that quality went up. These patients had lower single-year mortality rates, shorter average hospital stays, fewer readmissions, and better sustainability of health over time.¹

Physician-led ACOs are better

If ACOs are good, physician-sponsored ones are better.

At a recent national meeting of health insurance companies, Paul Ginsburg, Ph.D., president of the Center for Studying Health System Change, told the insurers, "I think physician-led ACOs inherently make markets more competitive, because they have an opportunity to shift patients toward high-value hospitals."

Similarly, Charlie Baker, former secretary of health and human services for Massachusetts, told the group that nearly all of the Medicare Advantage risk contracts are with physician groups and not hospitals. Medicare Advantage participants are chosen by insurers, and he indicated that they know that contracting with physician ACOs is the best way to save money.²

As reported in an earlier column, this truth is becoming more evident, and there are now more physician-led ACOs than any other.

Primary care reaping rewards

Primary care is the only discipline mandated to be in ACOs participating in the Medicare Shared Savings Program. This is because ACO success stems from keeping people out of the hospital, avoiding expensive procedures, and reducing unnecessary tests and imaging. The "target-rich fields" for ACOs to accomplish this are primarily prevention and wellness, coordination of high-cost complex patients, reduced hospitalizations, and transition management across our fragmented system. These are all in primary care’s wheelhouse. It is no wonder that you are the darlings of the accountable care movement.

Successful and sustainable ACOs will tie shared savings distributions to relative contribution. A merit system thus likely will be primary care weighted.

For example, one ACO posted this planned distribution of shared savings: 12% to infrastructure; of the remainder, 60% to primary care, 40% to specialists, and 0% to hospitals.

The following small sample survey shows widely varying models; but in all cases where distribution is broken out, primary care receives as much or more than specialists and, with one exception, hospitals.

There are some primary-care-only ACOs that are distributing 100% of savings to their primary care physicians under Medicare Advantage risk or Medicare Shared Savings Program contracts. One interviewed primary care physician ACO member stated that for his full-risk Medicare Advantage patient population, he was seeing half as many patients and making three times the income.

While income recognition for what you do is way overdue, keeping all the savings might be going too far. A fully evolved ACO should incentivize all providers and facilities along the entire continuum of care, but always in proportion to their value-adding contribution.

Primary care physicians tell me that while this economic reward is gratifying and validating, their surprise biggest reward has been empowerment to do health care right and regain control of the physician/patient relationship. They say that seeing happier, healthier patients, and being able to spend more time with them, has returned the fun to the practice of medicine.

References

1. Kaplan, J., et al., Alternative Payer Models Show Improved Health-Care Value, BCG Perspective, May 14, 2013.

2. Pittman, D., Doc-Led ACOs Better Model for Saving $$$, MedPage Today, May 15, 2013.

3. Anderson, G., et al., Critical Business and Design Elements of the ACO, American Health Lawyers Association, Healthcare Transactions conference (April 2013).

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, North Carolina. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at [email protected] or 919-821-6612.