Posts filed under ‘Nursing Home Care’

Pioneer ACO Model

On Monday, December 19, 2011 the Department of Health and Human Services announced 32 organizations that will take part in the Pioneer ACO model. As you can read in this article linked here ( there was a competitive selection process to see which organizations would participate in the project to be monitored by the CMS Innovation Center.

This model was started in January 2011 and is meant to show how particular ACO payment arrangements can best improve care and generate savings for Medicare. It also tests alternative program designs for future rules that are developed for the Medicare Shared Savings Program. Organizations that partake in this model should have experience operating as ACOs.

The first two years of the Pioneer ACO model are shared savings payment arrangements with higher levels of savings and risk than in the Shared Savings Program and other ACO initiatives. Year three, organizations showing a certain minimum of savings since starting the program will be able to transition away from a fee-for-service model to a population-based arrangement. Pioneer ACOs must negotiate outcomes-based arrangements with payers by the end of year two and are typically responsible for at least 15,000 beneficiaries.

The evolution of healthcare delivery could have an effect on MedSpan’s clients, no matter what segment of the healthcare system within which they function. Improving care while managing costs is a common goal among most businesses involved in healthcare, so staying informed on a potential process that will help accomplish this is of great interest to many.

The 32 organizations adopting Pioneer ACO structures will test various payment arrangements in aims of providing higher quality care at a lower cost. The project hopes to produce $1.1 billion in savings over five years and improve care for approximately 860,000 Medicare beneficiaries by ensuring that each healthcare dollar is spent more wisely. The goal is that patients, especially those that are chronically ill, receive the right care at the right time and unnecessary duplication of services is avoided.

The ideal result of the Pioneer model is to offer more coordinated, patient-centered care. Patients with multiple doctors will have an easier time communicating with each one. Pioneer ACOs aim to decrease the level of fragmented or disconnected care by providing better information to doctors about patients’ medical history and making it easy for them to communicate with their patients’ other doctors. Eventually this mindset will expand to all healthcare organizations, but changing the methods of delivery that have been practiced for so long will certainly not be easy.

Developing adjustments like this to the healthcare industry may bring forward new challenges for everyone. The near future will be an important time for these participants and their potential achievements with the model will affect other healthcare providers and consumers. If they succeed in providing higher quality care at lower costs, others will want to do the same. The results will be closely watched as changes are implemented. Although future success is uncertain, this program could lead to a significant shift in the industry which could hold increased benefits for all.

Primary care providers and other healthcare providers are the decision makers when it comes to participating in an ACO. Data manufacturers will benefit from this model because of the importance that patients and doctors place on the information available from ACOs.  But the organizational information must be well organized and easily accessible to all parties within a particular Pioneer ACO.  If the Pioneer ACOs model is successful, these organizations are likely to be well-accepted throughout the entire country.

Please share your thoughts.


Author: Jamie Notaro

Editors: Robert Kaminsky & Ken Chiang


February 3, 2012 at 11:44 AM Leave a comment

What are Accountable Care Organizations (ACOs)?

Hello again!

Since our last blog post, the leaves have turned green, the summer months have passed, and we have just begun to enjoy the crisp autumn air.

Lately there has been much debate surrounding the launch of Accountable Care Organizations (ACOs) under President Obama’s Patient Protection and Affordable Care Act. ACOs are one of the key provisions in the 2010 health reform law designed to help reduce the cost of medical care. There is so much talk about this concept, but what exactly are ACOs?

An ACO is a network of providers and hospitals that share responsibility for delivering healthcare to a minimum of 5,000 Medicare beneficiaries for at least three years. It is based on the idea that hospitals, doctors, and other health care providers should work together to coordinate care for their patients. By coordinating care, the ACO will reduce costs by avoiding unnecessary tests and procedures. Those organizations that produce better outcomes will be rewarded, and for those that don’t, financial penalties will be incurred. In a recent study of ours, we found that with the development of ACOs, providers will take on responsibility for not only delivering actual medical care, but also providing some level of medical management between appointments.

Sounds like a great idea however, a lot skepticism has surrounded the development and launching of ACOs. First, there are very few providers that truly understand the ACO concept. In a recent survey conducted by Beacon Partners, only 15% of 200 provider organizations are “very familiar” with ACOs. Of those 200 surveyed, 92% are in the development stages for an ACO, and nearly all respondents’ budgets are not yet established.

Second, the Centers for Medicare and Medicaid (CMS) have yet to issue the final rules, which will affect the application process that prospective participants have to go through. Prospective participants will need to review the final rules before entering the application process in order to demonstrate their ability to comply with the eligibility requirements. Then, CMS will need to review all applications and offer contracts before the January 2012 launch deadline.

Lastly, the systems that were considered to be the models for a new health care delivery system, namely the Mayo Clinic, the Cleveland Clinic, Geisinger Health System and Intermountain Healthcare, have all declined to apply for the ACO program. Hospital and physician groups complained that the program created more financial risks than rewards and imposed burdensome reporting requirements.

Given the series of events surrounding the development of ACOs, it is no wonder that there is skepticism and doubt. Too much confusion and too many barriers surround the development of ACOs, including high start-up costs and regulatory issues. Add to that the refusal by health system role models to apply to the ACO program and you have a complicated situation.

Referring to our last post, this is one way to reduce the cost of care, a much needed move in our unstable economy. As prices for healthcare keep increasing over the year (health insurance is expected to rise 5.4% in 2012), patients deserve access to affordable healthcare. We urge ACO development leaders to address the barriers that health systems are encountering in order to aid in launching a successful ACO program.

Author:  Nicole Victoria

Editors:  Ken Chiang and Robert Kaminksy


October 26, 2011 at 3:52 PM Leave a comment

Throwing the baby out with the bath water

Sometimes in the name of doing something beneficial, there are unintended consequences.  The innocent gets hurt.  The NY Times article below illustrates such an example.  To minimize the diversion and abuse of pain management medications through nursing homes, the DEA has instituted a requirement for a written prescription.  This seems beneficial, logical and harmless.  However, as the article describes, this simple requirement can cause delays in access. 

Nursing homes are required to order ahead of time, before residents run out of their medications.  This is unlikely to always happen with the overworked staff found at most nursing homes and reliance on consulting medical directors and pharmacists.  The question is how to modify the procedure and still effectively control access to pain management therapies.

A Battle Against Prescription Drugs Causes Pain

Published: October 2, 2010

Roland Lorenz has surgical screws in his back and neck and a pin in his upper leg, and when his pain reared up one recent weekend, he knew he needed something strong. He had just been to a pain clinic, where the doctor ordered an increase in his dosage of Percocet, a narcotic.

It took two days to get the painkiller.

Mr. Lorenz, 75, lives in a nursing home in St. Louis. Until recently, the nurses would have sent an order to the pharmacy for the Percocet, based on instructions phoned in from the clinic — a longstanding practice for nursing homes, which typically do not have a full-time doctor on staff.

But now that practice has come under the scrutiny of the Drug Enforcement Administration. Last November, the pharmacy serving Mr. Lorenz’s nursing home announced that it would no longer dispense certain narcotics without a written or faxed prescription from a doctor.

For Mr. Lorenz, this meant a weekend of pain. The doctor at the pain clinic was not available, and the nursing home’s doctor on call would not write a prescription without examining Mr. Lorenz in person. For the next two days, Mr. Lorenz said, “I was miserable. I needed it to get straightened out. It was killing me.”

Staff members assured him that the drug was on its way at least six or seven times, said Mr. Lorenz, a former Marine and police officer.

“It’ll be there by midnight. It’ll be there by 2 a.m. The pharmacist kept saying he needed to talk to the doctor. It was real, real rough.”

Nursing homes and doctors say patients like Mr. Lorenz have become unintended casualties in the war on drugs because of a new level of enforcement intended to prevent narcotics from getting into the wrong hands. About 1.4 million Americans live in nursing homes.

The D.E.A. is investigating pharmacists in “about five states” for dispensing the drugs to nursing homes without direct written orders from a doctor, said Gary L. Boggs, an executive assistant in the agency’s Office of Diversion Control.

Earlier this year, the Senate’s Special Committee on Aging heard testimony from long-term-care professionals describing delays in delivering pain medications to patients. Two Democratic committee members, Senators Herb Kohl of Wisconsin and Sheldon Whitehouse of Rhode Island, have urged Attorney General Eric H. Holder Jr. to find a solution.

“We keep hearing the right things from the D.E.A. on this issue, but we haven’t seen any action,” Mr. Kohl said through an aide.

Mr. Boggs said the agency was just trying to protect patients. “This isn’t a matter of us being bureaucratic pencil pushers,” he said. “What we see is nurses unilaterally calling in prescriptions, or pharmacists dispensing controlled substances without a prescription, then trying to get a doctor to sign a prescription for a patient he never saw.”

In the meantime, doctors say, their patients suffer — sometimes for half an hour, sometimes for several days.

“There’s just a lot of potential for error in the process,” said Dr. Jonathan Musher, a geriatrician and past president of the

American Medical Directors Association, a trade group of long-term-care doctors and administrators, which has sought a change in the requirements.

The problems are most common when patients first arrive at nursing homes from hospitals, Dr. Musher said.

For example, he recently had a patient move to a nursing home after a hip fracture. At the time, she was not on narcotic pain medication. That night the nurse called Dr. Musher to say that the woman was in pain. “I was told I had to call the pharmacist,” he said. “O.K., what’s the pharmacist’s number? The nurse has to call me back, she wasn’t sure. I get a call back with the number. I call the 800 number and leave a message. I get a call back a half hour later.

“So now there’s been a 45-minute delay. Now he tells me I have to fax in a prescription. I’m not home, so I say I will do it in 15 minutes. After I fax it, I call the nursing home, and they haven’t heard anything from the pharmacist. Finally I told them to send the patient to the hospital.”

She got her medication, “but that’s something we don’t want to do,” Dr. Musher said. “There are health issues with transfer, as well as the costs of transfer.”

Critics of the nursing home industry say the bigger problem is that facilities are not providing adequate medical care to their patients.

“If people are so sick that they desperately need pain medication, they should be seen by a doctor,” said Toby S. Edelman, a senior policy lawyer at the Center for Medicare Advocacy, a nonprofit law firm that provides legal assistance to Medicare beneficiaries. “The absence of doctors in nursing homes has been a problem for decades, and this doesn’t solve it at all.”

According to the medical directors association, a doctor at a nursing home writes an average of 169 prescriptions for controlled substances each month — which means ample opportunities for delays, Dr. Musher said.

Dr. Cheryl Phillips, president of the American Geriatrics Society, said that such delays were “daily” occurrences, especially in rural areas, where doctors might need to travel long distances to reach their fax machines or might not be able to send prescriptions by smart phone.

“I respect the work the D.E.A. is doing to prevent diversion of drugs” for sale or recreational use, Dr. Phillips said. “But the law does not serve seniors well.”

The solution, she said, “is to have the nurse act as agent to the physician,” taking the order and administering it then and there, “the way they do in a hospital.”

The change has put more pressure on nurses, who may have a suffering patient and a doctor’s order but are unable to dispense the painkillers, said Lynda Goldthwaite, a registered nurse and administrator at Elmwood Skilled Nursing and Rehabilitation Center in Claremont, N.H.

On occasion, she said, she has told nurses to go ahead and administer drugs from the center’s emergency kit without waiting for authorization from the pharmacist. “That’s a big no-no,” she said. “I could be in big trouble with the D.E.A. But I do it anyway.”

She added: “I’m a nurse. I know what I have to do for my patient.”

Mr. Lorenz said the Percocet has helped him live with his pain. But he is still angry about having had to wait for days. “I’m too old to be aggravated,” he said, adding, “I’m a victim of bureaucracy.”

October 3, 2010 at 11:24 PM Leave a comment

Newer Posts

Enter your email address to follow this blog and receive notifications of new posts by email.

Like this? Share it!


Twitter Feed

%d bloggers like this: