Putting Your Mission to the Test: Managing the Health of a Population
Revised Trustee Governance Manual Now Available from KHA
Efforts to Expand KanCare Continue – Trustee Support Needed
Provider-Sponsored Risk: Insights for Trustees
KHA-PAC Campaign 2015 – Trustee Contributions Are Essential
U.S. Supreme Court Hears ACA Arguments
Help KHA Award Individuals that Make a Difference
HHS Reports Confirm Positive Economic Impacts of Expansion
KHA Annual Convention and Trade Show in Wichita – Sept. 10-11
HHS OIG's Re-Examination of the Swing Bed Program ... Why?
Kansas Health Matters Website Redesigned and Enhanced
April and May Bring Awareness to Organ Donation and Hospitals
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Improving the health of the community is the driving mission for most, if not all, hospitals. The goal of population health management is closely aligned with that mission and may seem to be a logical and perhaps easy step for hospitals and health systems to take. Managing the health of a population has significant implications for hospitals and health systems that are important for trustees to understand.
The topic of population health has become a hot topic as hospitals and health systems seek to transform health care. Accountable for hospital and health system strategic success, trustees must have a solid grasp of the meanings and implications of population health management and why it's important to the future of their organization and the community as a whole.
What is Population Health?
In the American Hospital Association's Signature Leadership Series report, Managing Population Health: The Role of the Hospital, population health is defined as "a strategic platform to improve the health outcomes of a defined group of people, concentrating on three correlated stages:
Population health resides at the intersection of three distinct health care mechanisms. Improving population health requires effective initiatives to: 1) increase the prevalence of evidence-based preventive health services and preventive health behaviors; 2) improve care quality and patient safety; and 3) advance care coordination across the health care continuum."
AHA also notes that a common description of population health is "the health outcomes of a group of individuals including the distribution of outcomes within a group." Very simply put, population health management means improving the overall health of a population. This includes identifying individuals with the highest-risks (the most acute and complex conditions) and those with chronic conditions, and determining the best means for keeping them healthy. It also means determining and addressing the preventive and wellness needs of the rest of the population.
Why is Population Health so important?
One of chief drivers behind today's efforts to manage population health is the shift from a volume-based, fee-for-service payment system to a system based on value. New payment structures with shared savings and risk, bundled and capitated payments, and penalties for low quality of care scores and high readmissions contribute to the rising investment in population health management by healthcare organizations.
The ability to deliver high quality care and improve health outcomes while managing costs will significantly affect hospitals' and health systems' ability to succeed in a value-based healthcare environment. The Institute for Health Technology Transformation predicts that population health management will be a required core strategy for healthcare providers, and nearly all hospital CEOs responding to AHA's Annual Survey of Hospitals believe hospitals need to be implementing population health strategies.
What is in the "population"?
One of the first and most important steps in managing the overall health of a population is to define who's included in the "population," or group of people whose health is to be "managed." A population can be defined in multiple ways, including: 1) individuals within a specific geographic area such as the hospital or health system's community or service area; 2) a patient population such as a physician practice group's patients or a hospital's discharged patients; or 3) a payer group including Medicare patients assigned to an Accountable Care Organization, patients covered under a particular insurer's benefit plans or employees of a particular employer. A population may also be defined by a particular health condition such as diabetes, asthma or cardiac conditions.
There are a number of ways to define a group of individuals whose health the hospital or health system wants to best manage and improve. The key is to ensure a clear definition of the population in question from the start. The ability to measure the impact and outcomes of various healthcare interventions is dependent on knowing exactly what the target population is. Without the ability to establish a credible baseline and demonstrate measured improvement, the hospital will sacrifice financial reimbursement in a value-based system.
What does it take?
Many hospitals are already taking steps to improve the health of various populations including focused attention on improving quality and patient safety, better coordination of care, and delivery of preventive and wellness services. The size and resources of a hospital or health system and its community may define the scope of the population health strategies the organization is able to undertake. Regardless of scale, below are several primary factors to consider.
Common Vision: When the board and the CEO agree upon a common vision for community and population health, and all key players, including the medical staff, are working toward that same vision, the path to achievement becomes a little easier and the outcomes are more effective. To get there, the board and CEO must agree upon and clearly articulate the extent of the commitment and engagement of the organization in community and population health efforts.
Targeted Health Needs: Identifying targeted health needs is a first step in population health management. Hospitals and health systems may choose to target quality and patient safety by selecting an area in which the organization's health outcomes measures fall short. A hospital or health system also may want to focus its efforts on one or more of the health needs identified in a community health needs assessment, or where it experiences a high rate of admissions. Many organizations also are working to improve the coordination of care between providers.
Interventions: Once a target health care need has been identified, the contributing causes or factors must be identified, and possible strategies for addressing them must be evaluated. Hospitals and health systems must assess and prioritize efforts to pursue. This includes consideration for where the organization can have the most critical impact or influence. It also is an opportunity for trustees to consider the long-term goals for a healthy population, to challenge common assumptions and the status quo, and to seek out new and creative partnerships and collaborations that will engage, motivate and inspire patients and the community.
Partnerships and Collaborations: Multiple factors influence the health of an individual or population including socio-economic factors, which often affect access to care or ability to comply with treatment plans. Many factors are outside the hospital's control or they may exceed the hospital's resources. This reality is prompting many healthcare organizations to consider the partnerships or collaborations they will need to succeed. The network of partners and collaborative relationships that were established when the hospital conducted its community health needs assessments is a good place to begin when identifying opportunities to address a population's health concerns. Public health departments and other social service agencies have years of experience and expertise to contribute to collaborative public health efforts.
Trustees should recognize that they themselves are a good resource for identifying potential partnerships and collaborations. Lay trustees in particular can contribute new, different and community-based views of unique partnerships and collaborations. Trustees generally have networks of community contacts that can lead to new and innovative alliances for improving the community's health.
Clear Accountabilities: As hospitals and health systems forge new relationships with others in the community, the ability to navigate a path to success is often dependent on clear expectations set from the beginning, which are understood and agreed to by all parties. Expectations should include roles, responsibilities, goals and objectives, and project plans, all well-defined and agreed upon.
Measured Outcomes: To demonstrate improvement and ultimately earn revenue in a value-based system, the organization must have the ability to establish a baseline of measurement and track and measure outcomes and improvements in quality, patient safety and health.
Data and Technology: Data and technology may well be among the most important resources for successful population management. In its report on population health management, the Institute for Health Technology Transformation noted that electronic health records and automation support "essential population health management functions including population identification, identification of care gaps, stratification, patient engagement, care management and outcomes measurement." A great resource in Kansas for state and county data and resources is KansasHealthMatters.org.
Available Resources: Investment in hospital infrastructure in support of population health comes at a time when hospitals also are facing lower patient volumes, reduced operating revenue and growth in expenses that outpace revenue. Hospitals must carefully assess their resources and prioritize health improvement initiatives accordingly. The board must lead the way in establishing partnerships with others who will share the responsibility for improving the community's health and best maximize the benefit of scarce resources.
How is success defined?
Ultimately, the hospital or health system's board of trustees is accountable for the organization's success. In a value-based system, success is increasingly defined not only by financial viability, but by the organization's ability to fulfill its promised mission to positively impact and improve the health of its community.
Special thanks to The Walker Company for use of: Putting Your Mission to the Test: Managing the Health of a Population. Additional trustee resources from the Kansas Hospital Association are available in the Trustee Section of the KHA website. Additional resources from Larry Walker can be found at www.walkercompany.com.
New trustee orientation has never been more important. Health care is the most complex, demanding, fast-paced and rapidly changing industry in America. The Kansas Hospital Association's Hospital Governance Task Force has been working on a number of revisions to the Board of Trustees Governance Manual.
The manual, instruction guide and appendixes linked below are all in Microsoft Word templates that enable Kansas hospitals to quickly and easily add and delete content to customize the manual and appendix's to your hospital's unique needs.
Thank you to The Walker Company who assisted this task force in revising this online governance manual. A PDF version highlighting the areas of major content change is available to help you update your current manual. New sections address:
KHA commends hospital trustees for their dedication to Kansas hospitals and the health care of Kansans. We hope you find this resource helpful. Additional resources to help hospital trustees in their important leadership positions can be found online.
As you may be aware, in March, hearings were held on House Bill 2319, the KanCare expansion legislation introduced by the Kansas Hospital Association earlier this year. This legislation would direct the Governor to develop a budget-neutral KanCare expansion waiver and submit it to the Centers for Medicare & Medicaid Services. The turnout of those in favor of the legislation was tremendous. On the day the proponents of the legislation were heard, there was an overflow crowd that went out into the hallways. In addition, more than 160 healthcare providers, healthcare organizations, businesses, economic development organizations and individuals provided testimony in support of the bill. While each of those individuals and organizations was not able to provide verbal testimony, the lineup did a superb job of getting across the message that this can be done in a fiscally responsible way benefiting patients, providers, businesses and the economy.
The opposing testimony was quite different. Opponents relied heavily on out-of-state organizations who are opposed to the concept in general and are not as knowledgeable about the Kansas program. For example, several opponents mentioned that Medicaid is broken and should first be reformed, apparently not understanding that KanCare is Governor Brownback's reformed Medicaid program. It was disappointing to KHA and other supporters that it seems like the price tag for expansion goes up every time we seem to make progress. The Governor's office made it clear in their testimony that they would not accept any kind of KanCare plan unless and until the waiting lists for the physically and developmentally disabled are fully funded. As a result, the administration has added the cost of funding those waiting lists to the fiscal note for expansion.
Another suggestion coming from the Kansas Department of Health and Environment is that expansion doesn't really help rural hospitals as much as it has been suggested. Our analysis of the hospital-specific impact shows that it tracks with the population variance between urban and rural parts of the state. As such, there are many rural hospitals that are significantly benefited by expansion. This attempt to guide attention away from the importance of this program to rural hospitals shows a lack of understanding of the nature of rural health care in Kansas. Quite simply, these newest arguments by the state are attempts to distract from the reality that Kansas has an opportunity to craft a fiscally responsible program unique to our state that supports our economy, and most importantly, serves thousands of Kansas citizens.
Despite the opposition, there has been excellent grassroots advocacy from Kansas hospitals. KHA has crafted new talking points to assist our members in upcoming conversations with elected officials, as well as a new Action Alert on KanCare expansion. We encourage trustees to use this template to send letters to your elected Senate and House members, as well as the Governor's office. A strong grassroots effort will ensure that this issue remains at the forefront when the legislature reconvenes for the annual Veto Session on April 29. Thank you for your important efforts, and keep up the good work!
New business models are emerging to transform and align healthcare delivery and payment models. The transition from managing sick patients to managing the health of populations is underway in many communities across the country. Trustees must understand the capabilities that health systems require to manage population health and how to best manage risk in the new care delivery and payment environment.
The most recent Center for Healthcare Governance webinar on provider-sponsored risk can be downloaded for free on demand. This webinar, presented in two 20-minute segments, is a conversation led by Paul Keckley, PhD, managing director, Navigant Center for Healthcare Research and Policy Analysis, with Karen Hohenstein and Rich Bajner, Navigant Healthcare managing directors in the Value Transformation practice.
In part one, presenters discuss the transition from fee-for-service to fee-for-value and various provider-sponsored risk models now being developed. Part two covers factors trustees and senior leaders must consider in assessing where to best position their organizations on the risk continuum and in implementing a risk strategy. Presenters also review mechanisms healthcare organizations need to have in place to successfully manage risk and create competitive advantage.
This program breaks down complex issues and risk strategies for trustees and includes discussion questions board members and senior leaders can use to apply program content to their organizations. Presenters also can be contacted directly to participate in question-and-answer sessions with webinar participants or for additional information about webinar content.
These pre-recorded webinars offer the flexibility of on-demand viewing by individual executives and trustees or by full governing boards as an educational resource during board and committee meetings, retreats or orientation sessions. Boards are encouraged to consider the webinar content in the context of their own situations and needs. To obtain the webinar recording, follow the links below (registration required).
The Kansas Hospital Association Political Action Committee 2015 campaign is in full swing. This year, the KHA-PAC Steering Committee would like to get support from every hospital. Participation in the KHA-PAC is an important part of our advocacy program. We are pleased to report that more than $18,000 has been contributed toward this year's goal of $74,000. Contributions from hospital trustees are essential to make sure our voices are heard. Contributing to the KHA-PAC has never been easier. You can even submit your contribution online. If you need additional information or solicitation supplies, please contact Cindy Samuelson at (785) 233-7436. Thank you for your support.
The U.S. Supreme Court heard arguments in a second challenge to the Patient Protection and Affordable Care Act. The plaintiffs are arguing that the wording of the law prohibits the federal government from offering subsidies for people in the 34 states, including Kansas, using a federal healthcare exchange. Obamacare supporters were pleased by Justice Anthony Kennedy's tough grilling of the law's challengers. Kennedy, who is presumed to be the swing vote on this case, engaged the attorneys in an argument that goes something like this: "If the plaintiffs prevail, the federal exchanges will go out of existence. States will then have to decide to either create their own exchanges or allow the health insurance market to go into a 'death spiral.' This presents the states with a false choice that is unconstitutionally coercive." (Note the similarity of this argument to the original Obamacare decision that held involuntary Medicaid expansion was unconstitutionally coercive to the states.)
Does this mean that the case is over and that Obamacare has survived another legal challenge? The short answer is "no." First, Justice Kennedy also asked some very difficult questions of the Obama administration, especially when it comes to the issue of the ability of the IRS to broadly interpret statutory language. Second, it's simply unwise to draw conclusions about the outcome of a case based on a particular court member's questions. The job of a justice at oral arguments is to ask difficult questions of both sides, and it's been proven time and again that the line of questioning is not necessarily a predictor of the outcome. Third, the argument made by Justice Kennedy is still somewhat untested, and whether it will survive further examination by the Court is unknown. Finally, Chief Justice Roberts, another potential swing vote on the court, largely kept quiet during the oral arguments, which lasted about 20 minutes longer than normal. As a result, court watchers are having trouble placing him into any particular camp regarding this case.
While many felt that the government had a better day in court than did those challenging the law, others saw some signs that the court could still decide to rule against the administration's interpretation of the statute. Bottom line: there's enough uncertainty about the outcome of the case to guarantee that the survival of Obamacare will be in doubt until the Supreme Court rules in June.
We know many individuals in Kansas are instrumental in making a difference for hospitals in Kansas and the health care they provide to our communities. The Kansas Hospital Association wants to recognize those individuals and their efforts. In order to honor those who have gone above and beyond the call of duty, we need you to nominate them. The five categories of awards are:
The Charles S. Billings Award is the top honor given by KHA. Individuals are recognized as hospital leaders who have dedicated their working lives to hospitals and health care. The award recognizes a hospital leader for his or her lifetime of service and continuing contribution to the health care of Kansas.
The Distinguished Health Care Advocate Award honors individuals, organizations or groups that have provided an exemplary contribution to the health and well-being of the people of Kansas through their leadership in the political or policy arena.
The Donald A. Wilson Visionary Award recognizes hospital-related individuals who have made an outstanding, innovative contribution to healthcare delivery, healthcare financing or initiatives that improve the health and clinical outcomes of their community. The award recognizes a hospital-related individual who has been a change agent in the hospital industry.
The Trustee of the Year Award honors a hospital board member who is a leader, gives back to the community and routinely goes beyond the call of duty. KHA members are encouraged to recognize a trustee who has served with distinction and made significant contributions to the betterment of their hospital and community.
The Health Care Worker of the Year Award recognizes and honors the excellence of healthcare workers statewide. All nominated employees will be recognized by KHA for making a significant contribution to the betterment of their hospital. Only one nominee per hospital, please.
We thank you in advance for your assistance in helping us identify those individuals deserving of recognition. Please submit your nominations online by June 1. Visit the KHA website and click on award category of your choice.
More evidence points to the positive impacts of expanding the Kansas Medicaid program, KanCare. Two fact sheets recently release by the U.S. Department of Health & Human Services highlight information on the economic impact of Medicaid expansion on individuals' financial circumstances, uncompensated care costs and state Gross Domestic Product. Research confirms that expanding Medicaid will benefit states both directly and indirectly by generating additional federal revenue, increasing jobs and earnings, increasing Gross State Product, increasing state and local revenues (via provider taxes and fees and increased prescription drug rebates), and reducing uncompensated care and hospital costs.
The Economic Impact of the Medicaid Expansion fact sheet demonstrates how Medicaid plays an important role in helping to financially protect low-income enrollees. Research shows that Medicaid is the third largest poverty-reducing program in the country and the second-largest program in reducing the rate of Americans in extreme poverty (greater than 50 percent of the federal poverty level).
Additionally, hospital financial reporting suggests that expansion efforts are contributing to a national reduction in hospital uncompensated care costs. In particular, volumes of uninsured/self-pay admissions and emergency department visits have fallen substantially in Medicaid expansion states. Expansion has been shown to have a positive effect on a state's economy. Research shows that in a 10-state study examining the economic impacts of expanding Medicaid, on balance, Medicaid expansion would be financially advantageous in each of the states.
The Insurance Expansion, Hospital Uncompensated Care, and the Affordable Care Act fact sheet highlights analysis of hospital financial reporting and member surveys from hospital associations. Hospital financial reporting suggests that the payor mix shifted significantly during 2014 in ways that will likely reduce hospital uncompensated care costs. Medicaid expansion states account for $5 billion of the estimated $7.4 billion reduction in uncompensated care costs attributed to coverage expansions.
Did you know that Kansas hospital trustees can attend the Kansas Hospital Association Annual Convention and Trade Show for a mere $25? This is an excellent opportunity for trustee education and networking. The 2015 KHA Annual Convention, Breaking New Ground, will be Sept. 10-11 at the Hyatt Regency Hotel-Century II, in Wichita. Hotel information and an agenda can be found on the KHA website.
It was less than two years ago that the U.S. Department of Health and Human Services Office of Inspector General recommended that Congress allow the Centers for Medicare & Medicaid Services to strip critical access designation from the nearly 1,000 hospitals with "permanent exemption" status under a state "necessary provider" designation. Then, just last October, the HHS OIG doubled down on that idea, suggesting that Medicare beneficiaries would benefit from such an action. So, it's not surprising that HHS OIG issued another report, this time calling for a re-examination of the swing bed program, claiming that it has resulted in overpayments by the federal government.
Not surprising, perhaps, but difficult to comprehend. First, the substance of the report makes little sense in the world of rural health care. Swing beds have been around for quite some time and were designed originally to assist rural areas to fill the gap between the relatively intense medical needs of post-acute care patients and the ability of the system to provide for those needs. Later, in 1997, Congress created the Critical Access Hospital payment system to help preserve access to care in rural areas of the country. The nomenclature was derived from the critical nature of these facilities, not only for the preservation of such access to care, but also in many cases, for the literal preservation of communities. This latest OIG report seems inconsistent with the purpose of both the swing bed and CAH programs.
But this substantive inconsistency pales in comparison to the trend from the HHS OIG to continually question the CAH program. In fact, it seems like more than a trend. An argument can be made that the HHS OIG has concluded it should take every opportunity to undermine the CAH program. Why? It can't be because the program has been ineffective. Without question, the CAH program has been a savior to many small, rural hospitals; and therefore, many communities. It clearly helped to stop the high level of small, rural hospital closures occurring when the program was passed in 1997. So to suggest that the program be undermined at a time when we are starting to see another increase in closures and when those hospitals are trying to stay ahead of the changes being made in the system makes little sense.
The answer lies more in an idea put forth by former CMS Administrator Marilyn Tavenner in her response to this latest HHS OIG report. Tavenner challenged the OIG findings and recommendations and suggested that the auditors didn't understand healthcare delivery in rural areas. They don't understand that swing beds can be the only option for rural patients who want or need to receive care close to home. They don't understand that swing beds can actually help patients return home sooner. They don't understand the many important factors that come into play in rural areas. It is appropriate to ask questions about the CAH program; however, it also is reasonable to expect that those making recommendations about CAHs understand why those hospitals were granted "critical access" designation in the first place.
The Kansas Hospital Association is excited to be a part of the redesign and enhancement of KansasHealthMatters.org. The website now features a new monthly focus area, defines key health indicators, highlights funding sources and is more user-friendly. Video tutorials focusing on community health-related statistical data, local resources, customizable reports and best practices are now available.
Kansas Health Matters has grown to include more than 150 health indicators … but the new key health indicator section on the site features 20 indicators that address health issues that are most prevalent throughout Kansas. The Kansas Health Matters partnership recommends these measures be part of every health assessment and improvement discussion. This new section helps communities focus on areas in which they might be able to make the biggest impact on improving health.
The new SocioNeeds Index section features mapping by zip code and county and highlights the areas of highest need in Kansas. This new site also features funding opportunities that can help hospitals as they are working on initiatives to improve the health and well-being of communities across Kansas.
The Kansas Health Matters Partnership was established in March 2011 to create and provide the vision and leadership for Kansas' most comprehensive online source of state-specific data and relevant health improvement resources. Kansas Health Matters is supported by the following partner organizations: KHA; Kansas Association for the Medically Underserved; Kansas Association of Local Health Departments; Kansas Department of Health and Environment; Kansas Health Foundation; Kansas Health Institute; and the United Way of the Plains.
April is National Donate Life Month. The number of people in need of transplants continues to outpace the number of donor organs. On average, 21 people die each day because the organs they need are not donated in time. The Midwest Transplant Network in Westwood, Kansas, highlights the importance of organ donation with a short video. Visit MTN's website for more information and resources. Register today to be an organ, eye and tissue donor. Find out how by visiting YesTheyWantMe.com or DonateLife.net.
National Hospital Week, May 10-16, is just around the corner. This year's theme, Where Miracles Happen Every Day, perfectly describes the connection between our hospital staff members and their patients. National Hospital Week is the nation's largest healthcare event and is a celebration of the history, technology and dedicated professionals that make hospitals beacons of comfort and care. There's no better time to tell your hospital's story and celebrate this observance in your community. Contact the American Hospital Association at (312) 422-3000 or visit www.nationalhospitalweek.com for more information.
The Kansas Hospital Association is pleased to provide our members with this year's health observances in the 2015 Health Observance Calendar. The calendar is published and copyrighted in cooperation with the Society for Healthcare Strategy and Market Development of the American Hospital Association. Special thanks to the Kansas Health Service Corporation for their sponsorship. All rights are reserved.
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