Making the Rounds
Published Online: December 12, 2013
Cyril Tuohy, BA
Even before the US Supreme Court ruled the Affordable Care Act (ACA) constitutional in June, the Hackensack Alliance Accountable Care Organization (ACO) was well on its way to implementing the fundamental changes required of the ACA—President Obama’s landmark attempt to change the way healthcare is distributed and reimbursed in the United States.
For the Hackensack Alliance ACO and the 104 doctors who have signed on with the organization, meeting the test set forthby the ACA began in April, 2012. That was when the Medicare Shared Savings Program (MSSP) signed a contract with Hackensack Alliance ACO to share in the millions of dollars the ACO could save by delivering better healthcare services at lower prices to the 14,000 Medicare patients within the ACO network. “In the first 5 quarters we have saved in excess of $14.5 million,”said Dr Morey Menacker, president and chief executive officer of Hackensack Alliance ACO, in a telephone interview.
Hackensack Alliance administrators had targeted savings of between $5 million and $10 million across the 20 disciplines practiced by healthcare professionals with privileges at 685-bed flagship Hackensack University Medical Center (UMC) in Hackensack, NJ, and the 2 other northern New Jersey hospitals within the Hackensack University Health Network: 128-bed HackensackUMC at Pascack Valley in Westwood, NJ, and the 365-bed HackensackUMC Mountainside in Montclair, NJ (Table 2). Even using the most aggressive estimate, savings have exceeded Menacker’s expectations by about 50%. The amount saved would have been even reater had the MSSP contract included Medicare Part D, which covers prescription medication, Menacker said. How Hackensack Alliance ACO and the 3 hospitals under its auspices far exceeded its savings target offers a case study in what one ACO has done to lower costs and improve services.
Menacker said one of the first things Hackensack Alliance managers did was to make the 20 hospital practice areas patient-centered medical home (PCMH) compliant. Once that was sealed, the ACO then went off and trained the staff to become PCMH compliant.
Because the PCMH model is grounded in care coordination and communication among the different healthcare disciplines, each PCMH was required to have an electronic medical system, which the ACO then linked to a population management software program capable of gathering data from the separate electronic medical systems. Gathering the data allowed the ACO to target the top 10% highest cost patients for intervention using the concept of “nurse navigators” embedded within the PCMH setting, he said.
Nurse navigators at Hackensack University Medical Center (UMC) play a similar role to that of account managers in a large corporation. Like account managers responsible for every part ofthe client relationship across multiple departments, nurse avigators are charged with overseeing the patient’s relationship with the array of services within the healthcare system: the primary care physician, the hospital, the pharmacist, and the physical therapist.
At the end of the day, these special nurses supervise the inpatient population to make sure the care they receive is “seamless.” “A big problem is that patients go from home to the hospital and all the medications get changed because they don’t have the formulary with them,” Menacker said. “We’ve created 2 major interventions that have been dramatically successful in that area.”
One intervention involves following patients to make sure their medication reconciliation is complete, he said. The second intervention allows hospitals to supply patients with 30 days’ worth of medication, and patients are told to toss out what is left in their medicine cabinet. Nurse navigators, meanwhile, get in touch with hospital pharmacists and retail pharmacies to tell them about the changes.
With the bulk of the ACO’s patient population being 65 years or older, many on limited budgets, giving them the fewest medications at the lowest cost is essential, said ACO director Denise Patriaco. “We continually speak to them,” she said. “We have the nurse navigators come in for high-tech, hightouch with the patients. We ask, ‘Did you take your meds this morning? Tell me what you took?’ Patients need to be aware of what they are taking and why they are taking it.”
The number 1 cause of hospital readmittance is medication noncompliance, so the ACO follows up with a barrage of calls, from the day of discharge right through to subsequent office visits with primary care doctors and specialists, she said.
The average cost of a visit to the emergency department (ED) for more than 8000 patients in the United States was $2168.1 Keeping patients out of the ED simply by reminding them to take their medication is the best way to zap hospital costs out of the system, literally at the price of a pill.
Hackensack UMC in Hackensack last year alone had 92,182 ED admissions, 12,532 inpatient surgeries, and 2.93 million outpatient visits, according to hospital statistics (Table 1).
Making the Rounds
Because Medicare Part D was not part of the MSSP contract with Hackensack Alliance, it is hard to say exactly how much the ACO’s stricter pharmacy management procedures have contributed to overall savings. It is safe to say, however, that no ACO can hope to achieve the kind of big savings delivered by Hackensack without implementing reforms around the pharmacy piece of the healthcare equation.
Medication Therapy Management (MTM) techniques show treatment costs for patients were lower by as much as $5500 per patient than for patients in the control group,2 and more than 7 out of 10 physician visits resulted in at least 1 prescription medication, according to a 2006 study.3
Not long ago, it was the doctors who were best known for making the rounds and visiting dozens of patients on different hospital floors. Doctors still do that, but it is now much more common to see pharmacists making the rounds as well.
“In my experience pharmacists have not traditionally come to the floor and talked to patients,” Patriaco said.
At Hackensack UMC, though, pharmacists are just as likely as nurses to be appearing at patients’ bedsides and talking to nurses and doctors. Nor does the pharmacist’s role end at discharge following the all-important medical reconciliation.
Pharmacists, she said, “are calling nurses and physicians all day long” to make sure patients are on the proper blood thinners, and if they are on more than 1, how they got there, who made the decision, and why.
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