Robert Pearl: Kaiser Permanente modifies ER staffing to meet patient demand, improve efficiency -AND- Unequal Medicare payments fuel health care consolidation trends at at
Sun Mar 11 17:39:57 PDT 2018



February 13, 2018


Robert Pearl: Kaiser Permanente modifies ER staffing to meet patient demand,
improve efficiency



R1E4MDAyeUJ4T29HZ1Y5ZnJPY1wvbnEifQ%3D%3D&mrkid=905528> Fierce Healthcare



By Paige Minemyer


Patients often face long waits for emergency care, so the Permanente Medical
Group set out to improve patient flow in Kaiser Permanente emergency rooms
by deploying staff members more efficiently at high-volume times.


ERs are the busiest on nights and weekends-the least desirable shifts for
clinicians-so KP took steps to adjust what its ER nurses were doing and
added nontraditional ER doctors to these shifts to avoid delays, wrote
Robert Pearl, M.D., a clinical professor of plastic surgery at Stanford
School of Medicine and former CEO of the Permanente Medical Group, in a
column for Forbes. 


The triage process is often redundant and results in nurses asking many of
the same questions that patients will answer a second time for admitting
physicians. KP made doctors the first point of contact in the ER to move
nurses more directly into patient care, especially during high-volume,
low-staff times of day, which got more clinicians involved in treating


KP emergency rooms also brought nonemergency clinicians to the ER during
high-volume times, Pearl wrote. The organization paired board-certified ED
doctors with other physicians, such as pediatricians or family medicine
practitioners, who would also be able to treat patients with minor illnesses
or injuries. 


"By staffing appropriately for the acuity of patient problems, doctors can
treat and discharge those with less-emergent issues faster," Pearl wrote.


Other hospitals have looked at re-engineering the triage process to make
emergency care more efficient, as patients with nonemergent conditions often
face long waits in the ER. A pilot program at a Chicago hospital streamlined
the process so that the sickest patients were treated more quickly, reducing
wait times by two hours. 


The pilot set a goal of patient admission within one hour of arrival in the
ER. In addition to cutting down wait times, the updated triage pilot
improved communication between clinical teams and fostered more
collaboration on care. 


Baptist Health South Florida adopted a "tele-triage" program to reduce
overcrowding and treat patients with non-life-threatening conditions more
quickly. Patients meet remote physicians in a video conference,
significantly boosting the hospital's ER capacity. 


Parkland Memorial Hospital took a different route to improve ER efficiency:
a partnership with Toyota. The car manufacturer identified a number of
inefficiencies in how the Dallas-based hospital operated its ER, including
an inconsistent discharge protocol for nurses, that Parkland has adjusted.




February 16, 2018


Unequal Medicare payments fuel health care consolidation trends



ayments-fuel-health-care-consolidation> The Hill



In a recent hearing, the House Subcommittee on Oversight and Investigations
examined health care consolidation, a growing trend in the health care
marketplace. The hearing focused on the true costs of consolidation and the
key factors increasingly driving smaller, independent care providers out of
the health care system. 


One principle factor fueling marketplace consolidation is the disparity in
payment across different health care sites of service, which incentivizes
hospital systems to purchase small physician practices and charge more for
providing care, ultimately creating higher costs for patients, employers and


As consumers, we expect to pay the same price for a service regardless of
where we buy it. If your car dealership charged $1,200 for changing your
tires when the local mechanic only asked for $400, you'd rightly question
the large discrepancy in costs. 


So why then are hospitals allowed to charge insurers, taxpayers and patients
as much as triple what an independent physician practice would charge for
the same health care services?


Vertical health care consolidation-the phenomenon through which hospitals
acquire and absorb physician practices-is a major contributing factor to the
rising cost of health care in the United States.


At $3.3 trillion per year and growing, America's health care expenditures
need to be closely scrutinized to determine where savings are possible
without harming care or limiting patient access.  There are reforms on the
table that could save billions of health care dollars by improving
efficiencies and leveling the playing field for all health care providers.


Medicare and other payers reimburse hospital outpatient departments (HOPD)
at vastly higher rates than community-based physician practices for
providing the exact same services.  For the administration of chemotherapy
drugs, for example, the payment to a hospital outpatient facility is more
than double the rate paid to a community cancer clinic ($281 vs $136). 


Sensing an opportunity to generate more revenue, hospitals have exploited
the disparity in payment by scooping up freestanding, independent practices
and integrating them into larger hospital systems. According to a study
commissioned by the Physicians Advocacy Institute, "the number of physician
practices owned by hospitals/health systems rose 86 percent between
2012-2015, with 32,000 additional physician practices acquired."  


When it comes to oncology practices specifically, the rate of hospitals
acquiring freestanding practices doubled from 30 percent in 2003 to 60
percent in 2015, according to a study recently published in Health Affairs.
Because the payment for chemotherapy at HOPDs is 76 percent higher, on
average, than at standalone cancer clinics, the fiscal windfall for
hospitals is enormous.


Misaligned reimbursement rates also force patients to pay higher
out-of-pocket costs for treatment at HOPDs. In its June 2013 report to
Congress, the Medicare Payment Advisory Commission (MedPAC) noted that
beneficiary co-payments at hospitals were nearly triple that of freestanding
physicians' offices. MedPAC estimated that equalizing payments across all
providers could save Medicare beneficiaries as much as $380 million per
year. Allowing the nonsensical payment disparity to continue would be
irresponsible and inimical to caring for cancer patients.


On an individual patient level, patients can experience an estimated $650 in
higher out-of-pocket costs annually when care is delivered in the outpatient
hospital facility, demonstrating how these disparities in payment are
negatively impacting consumers.


We are seeing steps in the right direction.  Just this week, President Trump
released his fiscal year 2019 budget, which calls for the expansion of site
neutral payments for all hospital-owned physician practices.  Under his
proposal, Medicare would pay all hospital-owned physician offices located
off-campus at the physician office rate, which would save an estimated $33.9
billion over ten years. 


Payment parity across health care settings is the right thing to do for so
many reasons. It will reduce marketplace consolidation, preserve patient
choice and reduce health care spending for patients, insurers and taxpayers




Jeff Wells
Deputy Editor, CAL/AAEM News Service


Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service

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