• Principle Healthcare Associates


    Principle Healthcare Associates is an expert resource and dedicated advocate for Nurse Practitioner, Physician Assistant, Physician and Healthcare Executive job seekers. With many years of recruiting experience, we deliver strategies to help clients identify diamonds in the rough and candidates stand head and shoulders above the competition.

    Contact us at PHA email and be sure to visit us at PHA Website

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Collaborating for Care Management Innovation

Collaborating for Care Management Innovation

With the onset of sequestration, Texas stands to lose funding for Head Start services, children’s vaccines and meals for seniors.  Add to this potential losses in law enforcement and education funding, one can see that programs, once aiding children, seniors and the homeless by keeping them out of the emergency room, might cease to address this critical need.  Compound these losses with the pressure being exerted by value based purchasing, and the dilemma becomes magnified tenfold.  As if accountable care organizations, medical homes, hospitals and healthcare systems did not have enough on their plate, one wonders where they will find the resources to supplement these activities?

One enterprising non-profit has tackled this challenge head-on.   Billed as a nine-year old strategic initiative with a mission to improve the quality, capacity, and accessibility of the healthcare system for vulnerable populations in the City of Camden, the Camden Coalition has analyzed local healthcare system claims data for the purpose of building a repository and sharing data with regards to this typically transient population.  In addition, they operate several health project initiatives that demonstrate a collaborative approach to improving care delivery and patient outcomes in their area.  And by building relationships with executive leadership of the hospitals, social service/public health agencies, state government agencies, leaders at the statewide Medicaid health plans, and policymakers, they have taken a discretely modern approach to healthcare delivery.

Current innovative initiatives garnering attention include the Coalition’s Care Management and Care Transitions programs, aimed at reducing hospital utilization by directing outreach to the ‘high flier’ population whom frequently lack appropriate access to primary and mental health care.  Designed to target high cost, complex patients for improved care transitions and care coordination, the Coalition is steadfastly working to move these patients into a medical home model.  Upon presenting at the emergency room, patients are divided into one of two groups:  a) those with no primary care access and significant mental/social issues and b) patients with more stable primary care and mental health status.

In the Care Management program, patients meeting specific criteria receive assistance from a social worker, a health outreach worker/medical assistant and a nurse practitioner with primary/specialty care coordination, applying for government assistance, finding temporary shelter and enrolling in medical day programs.  Through stabilization of their social environment and health conditions, the team’s ultimate goal of finding a primary care medical home for the patient can begin.

Patients participating in the Care Transitions program are enrolled in and receive assistance from embedded care management nurses and health coaches from one of two Camden Federally Qualified Health Centers (FQHC) – CAMcare and Project HOPE.  On the path to becoming patient-centered medical homes, these FQHCs are fostering better care transitions and coordination with their hospital and health system partners.

These bold programs have been facilitated by city-wide use of health information exchange and electronic health record use for this targeted population, thereby allowing providers to share information and analyze data for additional care coordination.  Data analysis also remains integral for the monthly Care Management Committee meeting, held at rotating hospitals, in order to review and refine current processes for these programs. And by bringing together emergency room physicians, hospitalists, specialists, social workers, and nurse discharge planners across the city, more efficient and effective discharge planning and care coordination can help decrease utilization and improve safety, experience and ultimately, quality of care.

Principle Healthcare Associates is an expert resource and dedicated advocate for Nurse PractitionerPhysician Assistant, Physician and Healthcare Executive job seekers. With many years of recruiting experience, we deliver strategies to help clients identify diamonds in the rough and candidates that stand head and shoulders above the competition.

Contact us at PHA email and be sure to visit us at PHA Website

Transforming Medicaid via the Medical Home Model

Transforming Medicaid via the Medical Home Model

With the March 1st sequestration deadline looming, the budget battle continues. Facing potential cuts to public health and reduced federal relief, ignoring Medicaid expansion could be hazardous to a state’s health.  At least, some states have come to this conclusion.

Despite this, the state with the largest number of uninsured seeking medically necessary healthcare chooses to stand tall.  With emergency relief in mind, House Bill 10 was introduced in the Texas legislature this past week to address a shortfall in Medicaid and the Children’s Health Insurance Programs.

As one reporter for the Texas Tribune pointed out, “the federal government is offering to pay all of the costs of expanding the Medicaid program to some of the state’s uninsured population for three years, then to pay 90 percent of the costs for several years after that. Texas could, according to a report commissioned by Texas Impact, an interfaith public policy group, spend $15 billion over the next 10 years and pull down $100 billion in federal funds as a result. (So), here’s the business question: Why leave that kind of money on the table, especially if it’s going to be spent elsewhere if Texas opts out?”

While the article goes on to point out that federal monies would provide relief to local taxpayers currently subsidizing uncompensated care and potentially turbocharge the state’s medical economy, what I found most intriguing was the statement about running healthcare like a business.  Having just had a similar conversation with a colleague from the finance industry, I lamented that healthcare is a unique industry, dangerously siloed with imminent challenges to data access and ultimately, provider alignment – U.S. healthcare’s primary economic engine.

Now, some might argue that alignment becomes null and void in the absence of an adequate number of providers to address the incoming flux of under and uninsured persons.  Imagine instead, the opportunity to increase the number of providers by establishing advance practice nurse led clinics for participation in medical homes.  Equipped with patient registries, data analytics and health information exchange, physicians become liberated to focus on chronically ill patients and specialist provider coordination.  And perhaps the most galvanizing of all, instead of penalizing patients for visiting the emergency room, engage them in their care by developing a personal contract with specific achievable goals, provide a personal health record (PHR), mobile apps and texting to help monitor their health while keeping them incentivized via a loyalty program that offers redemption for health related items.

Not only is it the right thing to do, but by embracing this transformational change… perhaps savings similar to Chemung county’s Medicaid Medical Home could be achieved.

Principle Healthcare Associates is an expert resource and dedicated advocate for Nurse PractitionerPhysician Assistant, Physician and Healthcare Executive job seekers. With many years of recruiting experience, we deliver strategies to help clients identify diamonds in the rough and candidates that stand head and shoulders above the competition.

Contact us at PHA email and be sure to visit us at PHA Website

Advance Practice Nurse Led Clinics – Coming to Your Medical Neighborhood Soon?

Advance Practice Nurse Led Clinics – Coming to Your Medical Neighborhood Soon?

In celebration of National Nurse Practitioner week, Drs. Norah Johnson and Kristin Haglund provide a glimpse into a developing trend between academic nursing institutions and nurse led clinics.  In their overview of Marquette Neighborhood Health Center (MNHC) in Wisconsin, they illustrate the symbiosis that can be found between a nursing school seeking resident NP training and the desire to improve the communities that they serve.  Through its affiliation with the Marquette University College of Nursing, MNHC delivers primary care, health promotion, physical exams and diagnosis and treatment of common illnesses in a federally designated primary care health professional shortage area, located in downtown Milwaukee.  Since 2007, this NP led clinic has treated local residents, Marquette University students and employees, clients of the Salvation Army, and clients of the Milwaukee Center for Independence.

Predominantly serving a Medicaid population, this nurse-managed health center now finds itself facing many issues regarding sustainability.  Not meeting the current requirements of a federally qualified health center (FQHC), no matching federal funding opportunities exist.  Rather, nurse led clinics often rely on the support of university funding via an academic partner, leaving it in competition for dwindling dollars.  And while Medicaid does reimburse for Nurse Practitioner services, it is generally at a rate one-third less (66%) of a standard primary care visit.  Medicaid reimbursement rates are projected to improve for 2013/14; however, only those delivered by a physician specializing in family medicine, internal medicine, pediatric medicine OR a nurse practitioner working and billing under the supervision of a qualifying physician. While this is a positive step for increasing the Medicaid provider panel, it will not generate additional revenue for MNHC since the NPs bill under their own Medicaid provider numbers.

Having recently written about the dwindling number of Medicaid providers in the state with the highest uninsured rate, I would be curious to know how the Centers for Medicare and Medicaid Services (CMS) would view the inclusion of nurse led clinics in the medical home?  By developing affiliations with accountable care organizations, nurse practitioners gain access to referral sources for higher acuity services and capital for infrastructure and improvements.  Additionally, drawing this vulnerable population into a continuum of care paves the way for reducing inappropriate utilization of more expensive outlets for primary care – namely the emergency department.  Thus, savvy hospitals, healthcare systems, physician groups and payers participating in or modeling new payment arrangements not only reap the benefit of prevention, wellness and subsequent reduced readmissions, they also have the opportunity to engender loyalty amongst an influential group of expanding primary care providers and expand their recruitment pool.  Most importantly, with a new entry point into these redesigned delivery mechanisms, increased numbers of un/underinsured persons have the potential to receive care; albeit not without the changes to the Medicaid reimbursement rate for the NP led clinic clinician in a medical home.

In addition to funding challenges, MNHC struggles with a high no-show rate.  In working with a medical home, MNHC would have the ability to employ an electronic medical record and participate in direct messaging or a health information exchange, services not typically found in a siloed NP led clinic.  Layer in population health management tool and these front-line providers begin to have the ability to improve their breadth and depth of services rendered.  Marry this with appropriate messaging for appointment reminders, medication maintenance and others identified in the webinar below and the potential exists to transform the manner in which this critical population accesses healthcare – a fundamental necessity for bending the cost curve and transforming the way healthcare is delivered today.

Principle Healthcare Associates is an expert resource and dedicated advocate for Nurse Practitioner, Physician Assistant, Physician and Healthcare Executive job seekers. With many years of recruiting experience, we deliver strategies to help clients identify diamonds in the rough and candidates that stand head and shoulders above the competition.

Contact us at PHA email and be sure to visit us at PHA Website

Driving Down the Real Cost of Healthcare: Pediatric and Teen Medical Homes

Driving Down the Real Cost of Health Care:  Pediatric and Teen Medical Homes

At last, the presidential race has concluded and, as a nation, we can prepare to move forward.  With President Obama’s election to a second term, implementation of the Accountable Care Act (ACA) moves full steam ahead.  In light of the fiscal cliff – perpetuated by the expiration of the Bush tax cuts, the 2009 Economic Stimulus provisions, the payroll tax holiday and 67 other tax provisions – the question still remains, how do we make a significant impact on cost reduction in healthcare?

While much has been written about the spiraling cost of chronic care, I found it surprising to learn that spending on healthcare for commercially insured children under age 18 grew faster than spending for adults from 2007 to 2010. After examining more than three billion insurance claims from three major carriers, the Healthcare Cost Institute reported that consumer spending on pediatric and teen healthcare increased 12% to nearly $88 billion dollars from 2007-2010, while spending on adults increased at a slower rate of 8%.  Even more intriguing, it seems that spending for children’s healthcare increased despite decreasing numbers of children covered and a utilization of expensive healthcare services, such as hospital stays and brand-name drugs.

If utilization is not driving this increase in healthcare cost, then what is?  According to the report, a number of activities are contributing to this trend, including increased use of consults, procedures and testing facilities. Digging deeper into the data, the study also revealed that two groups are incurring the highest cost:  infants, three years and younger and teenagers, aged 14-18.  While the increasing expense associated with pre/peri/post-natal births and associated outcomes is comprehensible for the infant cohort, what makes les sense is the skyrocketing expense for prescription drugs for central nervous disorders, such as anti-depressants, anti-anxiety disorders and drugs used to treat ADD or ADHD in the teenage population.

By and large, families were spending the greatest amount on primary care visits, immunizations, and preventive medicines (40.3%), followed in short order by outpatient procedures (24%), inpatient procedures (22%) and prescription drugs (14%).  Sufficed to say, this study did not include children participating in the Medicaid or CHIP programs, so it is difficult to discern if similar trends occurred in this population.  As the author points out, regardless of payer, children with exponential healthcare costs grow into adults with unsustainable expense.  Recognizing the benefit of medical homes for low risk pregnant women and children, it would be a fascinating case study to enroll willing participants currently attending a MindUp program that were committed to learning how to cook healthy food options using locally grown fruits and vegetables and engage in healthy exercise regimens.  Last but not least, reaching this critical and vulnerable population will be key.  Incorporating text messaging, voice, email, video and animation in efforts to successfully communicate important healthcare messages, similar to the program below, will ensure that mothers, infants and teens seek wellness and prevention, in efforts to reverse this frightening trend.

Principle Healthcare Associates is an expert resource and dedicated advocate for Nurse Practitioner, Physician Assistant, Physician and Healthcare Executive job seekers. With many years of recruiting experience, we deliver strategies to help clients identify diamonds in the rough and candidates that stand head and shoulders above the competition.

Contact us at PHA email and be sure to visit us at PHA Website

Innovating Medicaid for Healthcare Reform

Innovating Medicaid for Health Care Reform

With two short weeks to go before an unprecedented presidential election, healthcare continues to remain on the forefront.  And while most of the focus has been on healthcare delivery for the Medicare population, there is reason to be very concerned about the future of the Medicaid program.  According to the Kaiser Commission on Medicaid and the Uninsured, “Medicaid is the nation’s public health insurance program for low-income Americans.  Currently, to qualify for coverage a person must not only be low-income but also must fit into specific eligibility categories.  The Children’s Health Insurance Plan (CHIP) complements Medicaid by covering uninsured low-income children with family incomes above Medicaid thresholds. Many low income children, families, and people with disabilities would be uninsured without these programs.”

In an interesting development, the commission’s recent report noted that Medicaid enrollment and expense dropped in the year 2011.  While on the surface, this appears to be a positive trend, additional probing might be warranted.  Are the decreases in enrollment truly due to an improved economy stimulating job opportunities that now offer health insurance or have these individuals grown tired of being placed on a waiting list for one of the few available slots due to the diminishing number of participating physicians? And while select market leaders are experimenting with new and innovative delivery models, is this enough to account for the expense reduction?  One remains hopeful that these efforts are not in vain, but could it simply be that fewer participants require less care?  Or, have the hassles of being dropped from the program and repeating enrollment convinced recipients that it is much easier to access the emergency room for their healthcare needs?

Faced with the option of significantly reducing the number of uninsured through Medicaid expansion, a requirement of the Affordable Care Act (ACA), or maintaining the previous untenable expense for this population, states with the highest uninsured rates should be paying close attention.  At the top of the list (33%) with a mere 30% of physicians accepting Medicaid, Texas, in particular, has a cross to bear.  Factor in the fact that Governor Perry staunchly supports Medicaid expense reduction and has refused additional monies for expansion, one begins to wonder where will these people go to obtain care?  In a vicious cycle, likely right back to the place they started, and often, the most expensive site of care.   Given that safety net hospitals typically serve this patient population, these hospitals, in an unforeseen turn of events, are now positioned to lose millions in reimbursement.

So, how do we avoid this calamity?  For the good news, recent Texas Medicaid policy actions have been driven the approval of a section 1115 waiver that expanded managed care, ended the former Upper Payment Limit payment methodology, and created two funding pools to help offset uncompensated care costs and encourage delivery system reform.  Specifically, the Delivery System Reform Incentive Payment (DSRIP) program will be used to make incentive payments to encourage delivery system reform in four broad areas – infrastructure development, program innovation and redesign, quality improvements and population-focused improvement. Reform activities will be conducted by Regional Healthcare Partnerships (RHPs) that are financially anchored by a public hospital or local governmental entity; RHPs will collaborate with a variety of healthcare providers to evaluate current challenges in the delivery system and propose a course of action to address those challenges.

Not to sound like a broken record, but the DSRIP appears to be the perfect vehicle to test the advance practice nurse led medical home for children and low risk pregnant women.  With more than one-half of Texas’ 1.2 million uninsured children eligible for enrollment in a public program, engaging them in a medical home would help to eliminate future lapse in coverage and unnecessary healthcare expense.  Treating the total uninsured at a cost of $9.2B (in 2005 dollars), Texas also has the opportunity to reduce the unfortunate ramifications of passing this burden on to taxpayers in the form of higher hospital cost and insurance premiums.  Irrespective of physician or NP direction, the “coordinated care organizations” model is currently being utilized to improve quality and remove cost for the Oregon Medicaid program – to the tune of $11B in projected savings by the end of the decade.  In this model, hospitals, physicians, counties and community organizations will operate under a risk bearing model to integrate services, coordinate care and produce better outcomes at a lower cost.  Not to be taken lightly, what appears to be a plain ol’ vanilla version of the medical home could prove truly revolutionary in its ability to broker public-private partnerships, leverage technology and galvanize the community for a truly collaborative experience.

Principle Healthcare Associates is an expert resource and dedicated advocate for Nurse Practitioner, Physician Assistant, Physician and Healthcare Executive job seekers. With many years of recruiting experience, we deliver strategies to help clients identify diamonds in the rough and candidates that stand head and shoulders above the competition.

Contact us at PHA email and be sure to visit us at PHA Website

Innovating Healthcare System Strategy: Creating the Commercial ACO

Innovating Health Care System Strategy:  Creating the Commercial ACO

Tick tock goes the clock….October 2012 will soon arrive and value-based payment will commence.  In order to prepare for this change, hospitals and healthcare systems are simultaneously improving quality and patient experience, reducing expense and crafting new strategies for growth.  While strategic planning efforts have traditionally focused on modifying or developing new service lines or delivery sites, one healthcare system has forged a different path, forming a commercial accountable care organization via a new payer partnership.

Though the concept of commercial ACOs is not new, the novel approach being taken by Aurora Healthcare, Aetna and Wellpoint subsidiary, Anthem Blue Cross and Blue Shield Wisconsin, is to offer a price guarantee – defined as a potential 10% reduction in cost – to small and mid-size businesses, which typically, are not target markets for insurers seeking large, self-insured groups.  Through the Accountable Care Network, Aurora Healthcare’s 1400+ providers will be poised to deliver care through its 15 hospitals and more than 160 clinics.  Not for the faint at heart, Aurora Healthcare’s new business model is supported by its 15+ years experience as one of the largest employers, with 48,000 covered lives, in the Wisconsin and surrounding area.

With extensive use of care managers for appointment scheduling, assistance connecting with physicians and follow-up for patients who have chronic or complex conditions, this group succeeded in reducing their per-member-per-month cost by 2.4% in 2010, while the national average rose more than 10%.  Coupling personalized care with its use of electronic medical records, claims reviews and advanced analytics, the Accountable Care Network is now confident that they can lower future members cost of care per diagnosis.  Bold statement, indeed.

Bold enough, in fact, to make me wonder…could this price guarantee be replicated for the Medicaid population?  With skyrocketing cost and rampant chronic illness, there exists no better petri dish for testing this hypothesis.  And, as Dr. Nick Turkal, Aurora Healthcare’s President & CEO mentions below, as a national quality and healthcare reform leader, they (and others) are beholden to share their knowledge regarding tools and processes developed to address these critical issues along the way.

Principle Healthcare Associates is an expert resource and dedicated advocate for Nurse Practitioner, Physician Assistant, Physician and Healthcare Executive job seekers. With many years of recruiting experience, we deliver strategies to help clients identify diamonds in the rough and candidates that stand head and shoulders above the competition.

Contact us at PHA email and be sure to visit us at PHA Website

Innovating The Nurse Practitioner Role in Chronic Disease Management

Innovating The Nurse Practitioner Role in Chronic Disease Management

In a special Health Affairs report, Rachel Garfield, PhD, of the Kaiser Commission on Medicaid and the Uninsured, and Anthony Damico, PhD, of the Kaiser Family Foundation, determined that Medicaid’s role in covering the population with diabetes will grow in 2014 when additional low-income, uninsured adults gain eligibility for the program under the Medicaid expansion provisions of the Affordable Care Act.  Since the total annual per-capita health spending on adult Medicaid patients with diabetes was more than three times higher than spending on beneficiaries without diabetes ($14,229 versus $4,568), this could be a disturbing statistic for North Texas residents.  Using data from the CDC, the Institute for Alternative Futures Diabetes model estimates that diagnosed and undiagnosed diabetes cases in this region are expected to rise 78 percent between 2010 and 2025, when the total is projected to exceed 1.5 million.  Sobering, indeed.

While Type 1 diabetes involves a malfunctioning pancreas, Type 2 diabetes develops when one’s own insulin becomes less efficient at moving sugar out of the bloodstream.  Both can be associated with obesity, high blood pressure, cholesterol and depression and are often undiagnosed in the presence of other common complications such as eye, kidney, lower extremity and heart damage.  For the good news, both types can be managed with appropriate drug regimens and lifestyle modifications.  As noted in the ISA report, future diabetic reductions depend upon the promotion of targeted screening for asymptomatic adults, improved access to quality medical care and increased patient compliance with therapy.  Halting the “twin epidemics” of diabetes and obesity will also require greater access to opportunities for physical activity in schools, workplaces, and communities and a significant shift in the American diet away from sugar, salt, refined carbohydrates and saturated fats and toward more fruits and vegetables.

With the North Texas regional diabetes societal and medical related costs already set to balloon 87% between the years of 2010 and 2025, one has to wonder how the pending Texas Medicaid changes will affect this?  Expansion or not, creative healthcare providers have the opportunity to improve this frightening situation.  As Suma Health System discovered, nurse practitioners employing the Chronic Care Model, including the use of planned visits, a patient registry, drug intensification protocols, and collaboration with other members of the team, can improve processes of care and clinical outcomes for this population.

Coupling the activities above with on-site patient education via tablets and additional patient-centered technology beyond the clinic walls, similar to this Southeast Minnesota Beacon initiative, improves engagement and therapy adherence, strategic elements for stage 2 meaningful use demonstration.  Partnering with other healthcare organizations to create green, sustainable buildings in underserved areas for delivery of primary care, psychosocial and wellness services also presents a tangible opportunity to prevent future diabetes development.   Utilizing roof space to install an urban garden and jogging track for inner city or landlocked destinations represents a creative solution for a commitment to physical fitness.  And working with nutritionists and local farmers markets to educate and deliver healthy food choices takes the community one step closer to improving access to care, preventing re/admissions, and reducing prevalence and associated cost of this potentially dilapidating disease.  With a veteran diabetes provider and acute care nurse practitioner in the role of President, Health Care and Education for the American Diabetes Association, is there no better time to illustrate this innovative role for NPs in managing chronic disease?

Principle Healthcare Associates is an expert resource and dedicated advocate for Nurse Practitioner, Physician Assistant, Physician and Healthcare Executive job seekers. With many years of recruiting experience, we deliver strategies to help clients identify diamonds in the rough and candidates that stand head and shoulders above the competition.

Contact us at PHA email and be sure to visit us at PHA Website