Insurers and ED Visits

I can’t tell you how many people sent me the article last week regarding Blue Cross and Blue Shield of Georgia stopping coverage for ED visits that they deem unnecessary.  I am not sure as to all of the fuss since insurers serving their members in western Maryland have been denying payment for what they deem unnecessary care for the last several years.  If BC /BS of Georgia is like our local insurers, they will do little to nothing to educate their members on when and when not to use the ED, but hold the hospital accountable for the care that it rendered to their member.  

When a patient presents in the ED, we are required by law to provide care.  We have been working to educate patients on when to use their physician versus urgent care versus the ED.  We have had some success over the last few years, but we still have to fight denials on a continual basis.  We have increased visits to urgent care while reducing the number of ED visits; but again, that responsibility has fallen to the hospital.  We can’t be providing expensive emergency level care knowing that we won’t be paid.  

I certainly do not begrudge insurers seeking to reduce their costs, but their solutions need to be well thought out and applied as such.  Simply removing the proverbial monkey from their back and placing on the back of the hospital isn’t a viable solution.

Reducing Healthcare Spending While Preserving Jobs

As you may know, I am a contributor to FierceHealthcare's Hospital Impact, an online publication that is a peer-to-peer forum for hospital executives, physicians, and other hospital leaders that addresses clinical and operational issues.  

Below is my latest post about the challenges involved with addressing healthcare spending while preserving jobs in the community.


FierceHealthcare

Status of Clinical Affiliation with UPMC

In an effort to keep everyone informed as to the progress that we are making in our discussions and negotiations with UPMC on our clinical affiliation, let me offer the following:

The discussions for a clinical affiliation with UPMC are progressing well.  The next step is finalizing the letter of intent, which summarizes the contractual agreement between WMHS and UPMC.  We anticipate that this letter should be signed in the next few weeks. Once the letter of intent is signed, we will negotiate the definitive agreement, which specifies the details for the clinical affiliation between WMHS and UPMC.

The following areas have been identified as part of the first phase of the clinical affiliation:  vascular surgery, thoracic surgery, cardiac surgery, neurosurgery, medical oncology, and behavioral health. We have established clinical services work groups for these areas, and we are in the process of identifying dates for a series of site visits by UPMC’s clinical leadership in theses areas.

Kim Repac, WMHS CFO, is in Pittsburgh today giving a presentation to UPMC leadership and staff on the Maryland Rate Regulation System.  Since our affiliation is their first in Maryland, they would like to have a better understanding of our rate system and our current payment model.

UPMC leadership will be presenting at the WMHS board meeting in April as to their plans for our affiliation and also will provide an update on other affiliation activity currently underway within their system.

Last Friday, I had the opportunity to meet and spend some time with six hospital CEOs from throughout Pennsylvania whose hospitals all have a clinical affiliation with UPMC in some form.  To a person, they were exceedingly complimentary of UPMC and how they are delivering what they say that they will provide in each of their relationships.

All in all, the process continues to proceed very well.  I am very much encouraged by our continued interaction and their commitment to WMHS.  

DEA Presentation on Heroin and Opioids

All that I can say is WOW!  This afternoon at WMHS, we had a continuing medical education session with well over two hundred attendees, most of whom were clinicians.  The presentation was made by Charles “Buck” Hedrick, who works in Intelligence for the U. S. Drug Enforcement Administration and is based in Baltimore.  Buck provided a wealth of information and answered many great questions that followed from the audience.  

Virtually everyone who is involved with the Opioid / Heroin Crisis facing our community was in attendance.  There were law enforcement officers, psychiatrists, trauma surgeons, primary care physicians, hospitalists, nurse practitioners, dentists, ED staff, nurses, crisis counselors and Allegany Health Department staff in attendance.  

Some of the information that he shared included: 

• the USA has 5% of the world’s population, but we use 80% of the opioids and 99% of oxycodone
• there are 24 health departments and over 500 law enforcement agencies in Maryland so teamwork is key as has been the case in Allegany County
• Baltimore is almost exclusively western Maryland’s source for heroin
• the introduction of Fentanyl has set this epidemic apart from the others that began once soldiers started to return from Viet Nam
• Fentanyl is used to enhance poorly produced heroin and it is a killer
• there are over 100,000 clandestine labs in China producing drugs like bath salts and fentanyl
• the DEA has three offices in China
• one kilo of heroin can be bought for around $50K at the Mexican border but it can be cut 3 to 4 times with items like milk sugar and children’s laxative
• you can buy one kilo of fentanyl online for about $3500
• the world’s heroin comes from Southeast and Southwest Asia, South America and Mexico where the poppy crop grows the best
• the DEA has a drug monitoring program where they buy heroin in Baltimore for the sole purpose of testing it to determine where in the world it is coming from

The most interesting piece of information was that 95% of the heroin coming into the US comes from Mexico via three routes: Interstate 5 to San Diego, Route 85 to El Paso and Interstate 35 to Laredo, Texas. (This should be reason enough to better control our southern border.)

Throughout his presentation, Buck repeatedly emphasized teamwork, the sharing of best practices, the need for medical school training of new physicians on prescribing, the success with using peer recovery specialists who can relate very well to those who are addicted, the benefit of mandatory prescription drug monitoring in Maryland, and law enforcement involving the DEA once leads are obtained.  

When an overdose occurs, it is first a medical emergency and then a crime scene. Sharing information and leads among law enforcement with the DEA can be most helpful in addressing the criminal side of this issue.  I, along with the rest of the audience, could have listened to Buck all day.  Like Jimmy Pyles and Sheriff Robertson, who lead many of local efforts on this subject, Buck was a wealth of information and brought a very global perspective to this crisis.

Preserving Value-Based Care

As you may know, I am a contributor to FierceHealthcare's Hospital Impact online publication, which is a peer-to-peer forum for hospital executives, physicians, and other hospital leaders that addresses clinical and operational issues.  A current topic of discussion is the uncertainty about the fate of the Affordable Care Act.  

Below is my latest post that explains why preserving the value-based care components of the Affordable Care Act is so important to the patients we serve.  

FierceHealthcare

Selecting UPMC as an Affiliate Partner

As the WMHS Administration was finalizing our strategic plan, which will take the health system into 2020, it was determined that WMHS would need an academic medical partner to ensure that we could maintain and enhance the clinical programs and services we provide to our patients.  

After a careful review, the WMHS Board of Directors voted to send a Request for Proposal (RFP) to: UPMC (University of Pittsburgh Medical Center);  West Virginia University Health System (WVUHS); and University of Maryland Medical System (UMMS).  UMMS, although initially expressing an interest, chose not to submit a response to the RFP as they were already heavily engaged with the transition of Prince Georges Hospital into their system.  Both UPMC and WVUHS submitted responses to the RFP.  

The WMHS Board of Directors established criteria to determine which organization best fit with our health system.  The criteria included such items as: clinical breadth and depth, commitment to the community, organizational culture, physician alignment, population health initiatives, and clinical innovation.  After a thorough review of the responses to the RFP, responses to written questions posed by WMHS, visits to WMHS by both UPMC and WVUHS, site visits by WMHS representatives to both institutions, and meetings with the WMHS Medical Staff, the WMHS Board of Directors determined that UPMC had the breadth and depth of clinical services necessary to strengthen and broaden clinical programs here at WMHS.  

Throughout this process, we have maintained that our goal for a clinical affiliation is to maintain and expand the services that we provide to our patients locally.  Our intention is that our patients will continue to receive almost all of their care here, and would have to travel of out of town only for those highly specialized services that need to occur at a tertiary care center.  

We are very excited about this potential clinical affiliation and it is just that, a clinical affiliation.  I have already heard rumors that WMHS has been sold to UPMC, but that is not the case.  We will be working much more closely in a variety of areas, but WMHS will continue to be an independent health system that is part of the Trivergent Health Alliance.