Published on NJSpotlight.com

Experts largely agree on steps New Jersey should take to create a more effective and efficient Medicaid system and reform plans have already been drafted for some changes, like reforming how doctors are paid for their care and improving services for those with complex needs.

Now state officials have launched an office whose specific job will be to institute some of these changes, which have been long under discussion. And the project will have the support of independent policy experts backed by a foundation dedicated to improving care for those in under-served communities.

New Jersey’s Department of Human Services announced Thursday that it has created the Office of Medicaid Innovation to “improve quality, delivery and cost of care” within the massive system, which provides health insurance for nearly one in five state residents. Advocates have long said that it would take a dedicated effort — independent of daily operations and focused on change — to achieve real reform.

And on Friday, the New Jersey Health Care Quality Institute, a nonprofit advocate for safety and cost control, said it had created its own Medicaid Policy Center to pursue similar goals. That program is funded by The Nicholson Foundation, which has backed several studies and planning initiatives focused on improving Medicaid.

The DHS said the state’s Medicaid innovation office will lead efforts to implement changes like a shift to value-based payments, in which physicians and other healthcare providers are reimbursed based on patient outcomes, not the number or type of procedures they perform. It will also look to improve the system of care for patients covered by Medicaid and Medicare, who often have complex and costly healthcare needs.

DHS Commissioner Carole Johnson told NJ Spotlight that one opportunity for payment reform involves addiction treatment; the innovation office will build on new efforts to expand access to the most effective techniques, like medication assisted treatment, through the primary-care system, she said. The model involves new financial incentives for community-based providers to expand treatment services where people need it most.

“As it begins its work, the new Innovation Office’s immediate goal is to look for opportunities to use our available levers to drive the best possible care and value,” Johnson said, and the new addiction treatment model “is an example of how we are thinking anew about what we pay for, where, and when, so that we can better leverage our dollars to drive the best possible health outcomes.”

To lead the state’s efforts — which will also focus on creating a more sustainable system — the DHS hired Gregory Woods, who recently led a federal initiative to reform Medicaid in Baltimore. Woods, who will be paid $122,000 a year, will lead a staff of 11 for the program.

“With Greg’s extensive background on issues and policies directly impacting (our Medicaid program) we look forward to this new office helping to expand on our work to date and opportunities to transform our health care delivery system,” said Meghan Davey, the DHS division director who oversees Medicaid.

At the quality institute, Matthew D’Oria, a former deputy commissioner at the DHS, will lead the Medicaid reform work, along with Kate Shamszad, a former clinical director at Cincinnati Children’s Hospital Medical Center. The team will work in consultation with the state’s Medicaid innovation office helping government officials behind the scenes to implement shared strategies, D’Oria explained.

Medicaid covers more than 1.8M NJ residents
“We’re really trying to work in partnership with [the state] and not trying to duplicate efforts,” D’Oria said. While the quality institute program will continue to identify new strategies for improving the Medicaid system, most of its work will be focused on implementing existing plans, he explained, adding, “We want to help get to the finish line.”

After expanding significantly in recent years, New Jersey’s Medicaid program — also known as FamilyCare — covers more than 1.8 million residents, including roughly 40 percent of the state’s children. Funded by a mix of federal and state dollars, Medicaid is slated to cost $17 billion this year and absorbs nearly 20 percent of the state’s total spending, according to the quality institute.

For policy experts, the aim is to improve care while better controlling costs. To do so, Medicaid reform plans call for expanding preventive care and instituting best clinical practices, changes that many want to see applied to benefit maternity care in particular. (New Jersey has a comparatively high rate of maternal mortality, especially among black women.)

The quality institute identified dozens of opportunities for change in its Medicaid 2.0 report, published nearly two years ago with funding from Nicholson. As a blueprint for reform, the document recommended testing value-based payment models for maternity care and other services, greater integration of mental and physical health systems, and administrative efficiencies, like streamlining the credentialing process for doctors who participate in multiple Medicaid managed-care plans.

Some of the changes, recommended in that report and in other forums, have been implemented or are underway in the Garden State. The DHS has significantly expanded Medicaid coverage for preventive care — like smoking cessation, diabetes care and family planning — and also created a Medicaid data dashboard, a step toward greater transparency that is also a priority for reformers.

Changes made in other states
Other states, like Ohio, have institutionalized these quests for change by establishing healthcare or Medicaid transformation programs within the government structure. In New York, a charitable organization, the United Hospital Fund, formed the state Medicaid Institute in 2005 in an effort to build a more effective healthcare system for low-income residents.

Now New Jersey will join the ranks of these organized Medicaid reform efforts. The state’s innovation office demonstrates the administration’s commitment to long-term change and the use of evidence-based models for care, DHS said, and will also allow officials to identify new opportunities for improvements and savings.

“This new office will prove beneficial to consumers and providers alike,” said DHS’s Johnson. She said the department is “delighted” by the creation of the quality institute’s reform program, which she said, “will create opportunities for us to collaborate and advance the best health care outcomes.”

D’Oria explained that the quality institute’s center will assist the state with certain “administrative and infrastructure-type work,” like collaborating with insurance providers to iron out changes to managed-care contracts, or to set up new value-based payment programs. The state will always have the sign-off, he said, but the institute’s team can help with legwork — and quickly hire contractors to conduct key tasks, without going through the same complicated contracting process required for state agencies.

Linda Schwimmer, president and CEO of the quality institute — a collaborative effort involving healthcare providers, payers and other stakeholders — said the Medicaid center will also serve as a resource to private institutions. The institute recruited national healthcare leaders to serve as an advisory committee to the new program, including a vice president from the New York Medicaid Institute.

“Medicaid is a vital part of New Jersey’s healthcare safety net,” said Arturo Brito, Nicholson’s executive director. “By bringing to light the best policy ideas and research, the policy center will help New Jersey make the structural changes necessary to strengthen and sustain Medicaid for the future.”

Published on the Intelligencer.com

On Jan. 1, the U.S. Centers for Medicare and Medicaid Services began requiring all hospitals across the country to post machine-readable lists of their standard charges, also known as chargemasters, on their websites.

$106,744.84

That’s the difference between the top charge for the same thing at two area hospitals.

At St. Mary Medical Center in Middletown, the top charge for 200 milligrams or a 40 milliliter vial of ipilimumab, a monoclonal antibody used in the treatment of certain types of cancer, is $172,169. Across the Delaware River at Virtua Memorial Hospital in Mount Holly, New Jersey, the top charge for the same treatment is $278,913.84.

The difference is significant, but according to hospitals and groups that represent them, it also doesn’t mean much. That’s because they are standard charges and not typically what patients, insurance companies and others pay.

However, they are not meaningless, according to some experts.

On Jan. 1, the U.S. Centers for Medicare and Medicaid Services, also known as CMS, began requiring all hospitals across the country to post machine-readable lists of their standard charges, also known as chargemasters, on their websites. While the goal of the rule was to promote price transparency, some experts say the charges have mainly caused confusion.

“It’s the right idea but it’s just the wrong execution,” said Linda Schwimmer, president and CEO of the New Jersey Health Care Quality Institute, which advocates for quality, cost-containment and other changes in health care. “If the point was to tell people what they’re going to pay or what their insurance companies are going to pay, it really doesn’t give you any of that.”

CMS Administrator Seema Verma has acknowledged as much, and wrote in a November blog post that the rule is just a first step.

“We also need to drive towards consumer-friend tools presenting information that is both personal and actionable at the time people seek care,” she wrote. “We need to meet patients where they are and integrate cost information into their health care decision-making, making it easy for patients to analyze cost differences across all care options.”

CHARGES & COSTS

In response to the rule, more than a dozen area hospitals posted their chargemasters between mid-December and early January. Some are easier to find than others, commonly under links for patient information, and page titles like “Price Estimates” or “Financial Information.” Site searches for terms like “chargemaster” or “hospital charges” usually return the right result.

All area hospitals provide Excel files with hundreds or thousands of rows of technical descriptions of products and services and their charges. But along with the lists, most also provide definitions of terms like charges and costs, as well as disclaimers about the chargemasters.

“There can be variations, sometimes large ones, in the charges that hospitals set for the same item or service — even within the same health system. This is due to the many factors that go into determining the hospital’s cost of delivering those items and services. Some hospitals have higher cost structures due to the complexity and expense associated with the services they provide (such as trauma, transplant and neonatal intensive care services). Others have higher mission-related costs, such as teaching, research and providing care for low-income populations,” Jefferson Bucks (formerly Aria) Hospital’s page states.

“No one pays these specific charges, including uninsured patients and those who pay their own costs out-of-pocket. Medicare and virtually all other health insurance companies pay inpatient and outpatient costs based on various fee schedules, and their policies have different requirements for deductibles and co-payments or coinsurance,” Doylestown Hospital’s page states.

In light of the CMS rule, health care advocates and industry groups have encouraged hospitals to post such information as well as provide resources to help patients figure out their individual costs based on insurance coverage, income and other factors.

Most area hospitals already have such resources in place, including financial counselors who are available by phone or in person to go over patients’ insurance information and provide them with estimates.

“While we charge all patients the same, regardless of whether they have insurance or not, charges, by themselves, do not tell a patient what their personal liability will be for a service,” said Kim Roberts, vice president of revenue cycle at Abington-Jefferson Health.

For those with insurance, the health system estimates their financial responsibility based on their plan and out-of-pocket coverage, the hospital’s typical charges for the services, and the health system’s contract and expected payment from their insurance company.

“All of those three elements help to determine our best ‘estimate’ of the patient’s liability,” Roberts said.

For those who are uninsured, the health system will work with them to determine self-pay rates and whether they are eligible for financial assistance, as well as help them to get coverage.

St. Luke’s University Health Network also offers a PriceChecker tool online that allows people to search for tests, procedures and other services, then plug in their insurance information, and receive estimates as well as discounted cash prices.

Some area hospitals also linked to a video created by the Hospital and Healthsystem Association of Pennsylvania that explains the chargemasters and how to utilize the hospital resources as well as contact their insurers to figure out their individual costs.

In a December blog post about the rule, association President and CEO Andy Carter outlined similar information for patients.

Like Verma, he explained that chargemasters are an incomplete tool and simply give the total amount that a hospital can bill.

“The chargemaster shows a hospital’s ‘list prices,’” Carter wrote. “These charge rates represent standard or regular prices, not the actual — and typically much lower — payment rates that hospitals receive from health insurers, Medicare, and uninsured patients with low incomes.”

Michael Keen, chief financial officer for Grand View Health, said the West Rockhill hospital calculates charges based on purchase price, the time involved and resources utilized.

“We also consult any available sources of already established fee schedules with a department manager,” he said.

Other factors such as pharmaceutical costs and vendor pricing also can play a role in the charges. And Schwimmer noted that chargemasters don’t include charges for other providers or facilities that may be involved in procedures and services, however.

For example, a pregnancy in some places can cost between $9,000 and $16,000 and a C-section between $16,000 and $25,000, but there are a lot of providers, services, tests and other charges included in those amounts that wouldn’t be captured on chargemasters.

“It’s not a number that anybody pays and it’s not a complete number so it doesn’t really do much,” Schwimmer said.

Niall Brennan, president and CEO of Health Care Cost Institute in Washington, D.C., agreed that the charges, by themselves, aren’t helpful to people.

“Charges are arbitrarily high fantasy numbers produced by hospital accounting departments as all part of the cat-and-mouse game that exists between both public and commercial payers and hospitals,” he explained.

But based on her research, Ge Bai, an associate professor of accounting at the Johns Hopkins Carey Business School, said that’s a myth.

“Most hospitals say (it) is not relevant but it is in fact very relevant,” she said.

Especially for two groups: one includes patients covered by automobile, workers’ compensation and other non-traditional commercial health insurers, which typically have less negotiating power with hospitals. And the other includes patients with traditional commercial or private health insurance, such as what many employers offer.

“On the surface, (patients in the second group) are not affected by the chargemaster prices because the insurance plans are negotiating a price for us,” she said. “However, fundamentally, the chargemaster prices do play a large role in the price we pay. Higher chargemaster prices give hospitals leverage when they enter the negotiations.”

If insurance companies don’t agree to pay more for services, Bai explained, their members may not have in-network access to hospitals, and they may be balance billed based on the higher chargemaster prices.

“It’s a credible threat,” Bai said.

And, when insurance companies pay more for services, members ultimately pay more for things like premiums, she added.

Bai said patients with rare or complicated conditions also are affected by high chargemaster prices because there are fewer places for them to go and shop around.

“Due to the emergent nature of the episode or due to the complexity of the service, the patients don’t have options and they are more likely to face a high chargemaster price,” she said.

“(The chargemaster) is really a revenue-generating tool for hospitals.”

Medicare and Medicaid pay standard rates for services, so patients with those types of coverage are not affected, but Bai added that there are “definitely” others facing chargemaster prices, or close to them.

In a 2014 blog post, former New Jersey Hospital Association president and CEO Betsy Ryan wrote that at the time about 4.5 percent of the state’s hospital patients, most of whom were uninsured, were being charged the prices.

Most uninsured patients in New Jersey are protected, however, by a state law passed in 2009 that prohibits hospitals from charging those who earn below 500 percent of the federal poverty level more than 115 percent of Medicare rates.

“Yes, it’s complicated, and we admit that hospital charges don’t make much sense,” Ryan wrote. “No one actually designed this system; it just evolved over time as hospitals tried to adapt and survive in our broken reimbursement system.”

PRICE & TRANSPARENCY

No area hospitals reported an increase in calls from people about the charges since they’ve been posted on their websites, but chargemasters have been publicly available, and a source of confusion, for years.

“There’s no doubt that hospital charging, physician charging, is confusing to the end user,” said Doug Hughes, chief strategy officer for Grand View.

“Unfortunately, every scenario is different,” Hughes said.

There are a lot of questions that have to be answered, the first being about insurance.

“Is your deductible paid up for that year? Are you in an in-network hospital or an out-of-network hospital?” Hughes continued.

Throughout his career in health care, Hughes has seen copays and deductibles go up, and recently there’s been a greater shift in costs onto patients. It’s also resulted in a rise in people’s interest in charges and costs.

“Suddenly that factor means so much more now because you’re sharing some of that expense,” Hughes said.

Schwimmer agreed.

“If people are paying more, or if they’re going to have a (health savings account), they really have to have a sense of what they’re in for in terms of what they’re going to pay,” Schwimmer said.

In 2018, nearly half of people under age 65 who had private health insurance were enrolled in a high-deductible plan without a health savings account, according to an August report from the U.S. Centers for Disease Control and Prevention’s National Center for Health Statistics.

The percentage increased more than 21 percent since 2010. And over the same time period, the percentage of people under 65 who were enrolled in a similar type of high-deductible health plan with a health savings account nearly tripled, according to the report.

That’s one of the reasons CMS passed the rule and is taking further steps toward price transparency, according to Verma.

“The case for price transparency throughout the health care system is clear, and the need to shop is growing ever more compelling as high-deductible plans become the norm,” she wrote in the November blog post.

The chargemasters rule may not go far enough, but it is reigniting the conversation about price transparency, Schwimmer said.

“If (the chargemasters rule) is where the conversation ends or if the execution means let’s give up on price transparency, then it’s a failure. But I don’t think that’s the way it’s going to go because there’s enough voices saying … let’s look at transparency and discuss it and see where transparency can lead,” she said.

Carter, of the Hospital and Healthsystem Association of Pennsylvania, agreed.

“This mandate and the public discussion it will likely engender does indeed have the potential to foster a better understanding of what useful health care price transparency might look like — if policymakers, the media, and consumers can agree on some basic realities of how we in America pay for our health care,” he wrote in the December blog post.

He added that it will take time, effort and collaboration.

“Let’s start by developing a common understanding of concepts like hospital charges as compared to hospital payments and what consumers pay out of pocket for health care, as determined by their health plans,” he wrote.

The need for price transparency has led to startups and sites like the Health Care Cost Institute’s Guroo, which allows people to search for services and find bundled costs for their area.

It gives people more power over their health care decisions, but it’s indicative of a broader issue, Brennan said.

“The first thing consumers should do is take a step back and ask why they, as the weakest actor in the health care system, are suddenly having the important decisions of pricing and choices of where to go foisted upon them,” he said. “While I’m in support of transparency and more consumer empowerment, it is indicative of how badly payers and providers have failed to adequately address rising costs.”

He added that not every service is shoppable.

“If you get hit by a car the last thing you want to do in the back of an ambulance is whip out your phone and figure out who has the best rates for car trauma,” Brennan said.

It’s not all just about the cost, but that’s another, broader issue, Brennan said.

“Most people would say you shouldn’t base your decisions purely on cost and you should base them on cost and quality, but I think we’ve struggled to present consumer-friendly information about that cost/quality continuum,” Brennan said.

Schwimmer agreed. There’s a lot of quality information out there, but not as much as is needed, and there’s a disconnect with cost.

“Just because something is the highest cost place doesn’t mean it’s better in terms of quality, and the other way as well,” she said. “It’s so murky, this is not in anyway a transparent, free market.”

It’s something CMS also wants to move toward improving, according to Verma.

“Putting patients in the driver’s seat means we also need to integrate quality information with price transparency,” she wrote. “Once consumers can see the whole picture, they will be truly empowered to seek out high value care among providers competing on both cost and quality.”

Published in Philadelphia Business Journal.com

The number of area hospitals reporting safety and outcome data to the Leapfrog Group continued to climb last year to a new record level.

Thirty hospitals — out of a possible 55 — in southeastern Pennsylvania and Delaware submitted survey data, according to the Greater Philadelphia Business Coalition of Health. The GPBCH serves as a Leapfrog regional roll-out organization in a partnership with the Delaware Valley Health Care Coalition.

The information is collected by the Leapfrog Group, a independent group of employers and health experts working together to improve health care quality and efficiency, to enable people and business to make more informed purchases of health care services.

Neil Goldfarb, President and CEO of the GPBCH, said the number of Philadelphia-area hospitals that submitted surveys last year represents a 10-fold increase since the coalition first began advocating 2012.

Just three hospitals participated in the survey three years ago.

“Over the last four years, we have been able to make considerable impact on the number of hospitals reporting their data to the Leapfrog Survey because [the coalition] has employer members that represent more 750,000 lives in this region,” Goldfarb said. “That is a significant portion of the population who utilize our region’s hospitals.”

Nationwide, 1,750 out of 2,500 hospitals completed the Leapfrog Hospital Survey in 2015, a 17% increase over 2014.

Here’s the list of local hospitals that submitted surveys in 2015:

Abington Health Lansdale Hospital and Abington Memorial Hospital;
Alfred I. duPont Hospital for Children;
Aria Health – Bucks County, Frankford and Torresdale divisions;
Beebe Healthcare;
Cancer Treatment Centers of America at Eastern Regional Medical Center;
Christiana Care Health System – Christiana Hospital, Wilmington Hospital;
Crozer Keystone Health System – Crozer Chester Medical Center, Delaware County Memorial Hospital, Springfield Hospital, Taylor Hospital;
Doylestown Hospital;
Grand View Hospita;l
Hahnemann University Hospital;
Jeanes Hospital;
Lower Bucks Hospital;
Mercy Health System – Mercy Fitzgerald Hospital, Mercy Suburban Hospital, Nazareth Hospital, Mercy Philadelphia Hospital;
Nanticoke Memorial Hospital;
Roxborough Memorial Hospital;
St. Christopher’s Hospital for Children;
St. Mary Medical Center;
Temple University Hospital; and
Thomas Jefferson University Hospital – Center City and Methodist Hospital campuses.

Under the “regional roll-out” efforts of the New Jersey Health Care Quality Institute, the following 14 hospitals in South Jersey – out of 17 total – submitted surveys:

Cape Regional Medical Center;
Cooper University Health Care;
Inspira Medical Center – Elmer, Vineland, and Woodbury campuses;
Kennedy University Hospital – Cherry Hill, Stratford, and Washington Township hospitals;
Our Lady of Lourdes Medical Center and Lourdes Medical Center of Burlington;
Shore Medical Center; and
Virtua Hospital – Virtua Memorial Hospital, and Marlton and Voorhees campuses.

Published on NJBiz.com

The New Jersey Health Care Quality Institute, based in Princeton, announced on Thursday that it has launched a new policy center committed to advancing the quality and cost-effectiveness of the state’s Medicaid program.

According to Linda Schwimmer, president and chief executive officer of NJHCQI, The Medicaid Policy Center will deliver independent research, analysis and policy solutions to improve health outcomes while also controlling costs. It will also work in partnership with other organizations and the state government agencies that operate the New Jersey Medicaid program, including the Department of Human Services – Office of Medicaid Innovation.

The MPC is funded by a grant from The Nicholson Foundation.

Quality Institute staff members Matt D’Oria, a former New Jersey Deputy Health Commissioner, and Kate Shamszad, who served as clinical director of Child Life and Integrative Care at Cincinnati Children’s Hospital Medical Center, will lead the center.

“The Medicaid program is essential to so many children, seniors and families in our state, and it’s a significant part of the state budget,” D’Oria said. “We are eager to support state decision makers and state officials as they work to improve the state’s Medicaid program for people today — and also to strengthen the program for the future.”

The new DHS office will provide a platform for collaboration with the MPC to improve the quality, delivery, and cost of care. Common focus areas include developing “alternative payment models and purchasing strategies that drive improvement in patient outcomes,” according to Schwimmer.

“The Department is delighted that the New Jersey Health Care Quality Institute, with support from The Nicholson Foundation, is creating a dedicated Medicaid Policy Center to help bring together thought leaders and expertise to inform our shared goal of strengthening and improving the quality and value of New Jersey’s Medicaid program,” said New Jersey Human Services Commissioner Carole Johnson, in a statement.

According to NJHCQI, New Jersey’s Medicaid program has a $17 billion annual budget, financed by Federal and State government, and accounts for nearly 20 percent of New Jersey’s state budget. To improve the program, the MPC will research health care delivery innovations, including patient-centered models that support and reward providers for good outcomes.

Published on Insider NJ.com

PRINCETON, New Jersey — February 7, 2019 — The New Jersey Health Care Quality Institute today officially launched a new policy center committed to advancing the quality and cost-effectiveness of the state’s Medicaid program, which provides health coverage for nearly 1.8 million of the State’s residents, including forty percent of the State’s children.

The Medicaid Policy Center (MPC) will deliver independent research, analysis and policy solutions to improve health outcomes while also controlling costs — and will work in partnership with other organizations and the state government agencies that operate the New Jersey Medicaid program, including the Department of Human Services – Office of Medicaid Innovation. This new DHS Office provides a unique platform for collaboration with the MPC to improve the quality, delivery, and cost of care. Common focus areas include developing alternative payment models and purchasing strategies that drive improvement in patient outcomes.

The MPC is funded by a grant from The Nicholson Foundation.

“The Department is delighted that the New Jersey Health Care Quality Institute, with support from The Nicholson Foundation, is creating a dedicated Medicaid Policy Center to help bring together thought leaders and experts to inform our shared goal of strengthening and improving the quality and value of New Jersey’s Medicaid program,” said New Jersey Human Services Commissioner Carole Johnson. “New Jersey Medicaid strives each day to provide the highest quality care for millions of our residents, and together with our newly created Medicaid Innovation Office, this new Medicaid Policy Center will create opportunities for us to collaborate and advance the best health care outcomes.”

The new MPC will benefit from the Quality Institute’s tradition of bringing people from all corners of health care together to collaborate on innovative solutions to improve the state’s health care system.

“The Medicaid Policy Center will serve as a resource to both public and private institutions,” said Linda Schwimmer, President and CEO of the Quality Institute. “Through our research and with the support of our members and other stakeholders, we will craft solutions to be considered, developed and implemented into the state’s Medicaid program.”

New Jersey’s Medicaid program has a $17 billion annual budget, financed by Federal and State government, and accounts for nearly twenty percent of New Jersey’s state budget. To improve the program, the MPC will research health care delivery innovations, including patient-centered models that support and reward providers for good outcomes.

“Medicaid is a vital part of New Jersey’s healthcare safety net,” said Arturo Brito, Executive Director of The Nicholson Foundation. “By bringing to light the best policy ideas and research, the policy center will help New Jersey make the structural changes necessary to strengthen and sustain Medicaid for the future.”

The MPC is one of a handful of independent research centers around the nation exploring ways to improve Medicaid in partnership with governments.

Quality Institute staff members Matt D’Oria, a former New Jersey Deputy Health Commissioner, and Kate Shamszad, who served as Clinical Director of Child Life and Integrative Care at Cincinnati Children’s Hospital Medical Center, will lead the center.

An Advisory Committee of select national health and social science innovators will offer support and counsel. The committee includes Niall Brennan, MPP, President and CEO of the Health Care Cost Institute; Dianne Hasselman, Deputy Executive Director, National Association of Medicaid Directors; Meg Murray, CEO, Association of Community Affiliated Plans; Chad Shearer, Vice President for Policy, Medicaid Institute at United Hospital Fund of New York; Kathleen Noonan, CEO of the Camden Coalition; Dr. Pauline Chen, a physician who has written about end-of-life care issues; and Dr. Nicole McGrath-Barnes, Founder and President, The KinderSmile Foundation.

“The Medicaid program is essential to so many children, seniors and families in our state, and it’s a significant part of the state budget,” D’Oria said. “We are eager to support state decision makers and state officials as they work to improve the state’s Medicaid program for people today — and also to strengthen the program for the future.”

About the New Jersey Health Care Quality Institute

The New Jersey Health Care Quality Institute is the only independent, nonpartisan, multi-stakeholder advocate for health care quality in New Jersey. The Quality Institute’s mission is to undertake projects and promote system changes that ensure that quality, safety, accountability, and cost-containment are closely linked to the delivery of health care services in New Jersey.

Star-ledger Editorial, published by NJ.com.

In a committee room in Trenton today, a group of lawmakers, hospital administrators, infection experts, and the commissioner of the Department of Health will try to untangle the mystery that took the lives of 14 medically-fragile children and infected dozens more in two long-term facilities over the last few months.

At the Wanaque Center for Nursing and Rehabilitation, 11 children died and 34 others have fallen ill from the common adenovirus, which can be life-threatening to those with severe disabilities or compromised immune systems.

At University Hospital in Newark, three premature infants died in the neonatal intensive care unit after a bacterial outbreak.

The root cause analysis from the Health Department is still weeks away, and we may never learn whether the culprit was human failure or tragic happenstance at either facility.

But when they meet before the Senate Health Committee chaired by Sen. Joe Vitale, one thing must happen: They have to agree that when the most vulnerable lives are at stake, there cannot be any acceptable margin for staff error – and that doesn’t always seem to be the case at either facility.

The Legislature needs to take an especially close look at the University Hospital, which has been under intense scrutiny from DOH Commissioner Dr. Shareef Elnahal for months.

He admits to having “concerns” about whether UH has followed proper infection protocols, and when Elnahal sent a survey team to the hospital Tuesday, it learned that UH’s own infection control program “was not even aware” that two children had died the week before. A state-run teaching facility should not have such systemic problems, but it is sadly predictable.

It is a reminder that UH’s last grade from the venerable Leapfrog Group – the transparency advocate that assesses hospitals on avoidable errors, injuries and infections, which studies say kill 500 people every day in the U.S. – was a D.

It was the second-lowest Leapfrog safety rating given to a New Jersey hospital during the Fall 2018 term. Leapfrog has high standards, and participation is voluntary, but 67 hospitals were graded, and 54 of them were rewarded with an A or B.

“Quality measures seem esoteric,” says Linda Schwimmer, president of the New Jersey Health Care Quality Institute, “but they highlight the importance of transparency, particularly with regard to posting a hospital’s infection rate.”

Vitale (D-Middlesex) is more blunt: “Real leadership creates and reinforces a culture of safety and excellence,” he said. “It is woefully lacking at UH.”

Wanaque’s reputation, meanwhile, is not sterling in all areas. The Centers for Medicare and Medicaid Services uses a five-star grading system based on on-site inspections, with 1,500 standards reviewed. And while Wanaque’s overall rating was 4 out of 5 in its last assessment, CMS gave it a 2 for health inspection.

So this is a chance to re-examine protocols and determine where lapses may exist. Health industry experts tend to think that new requirements bring normal hospital functions to a screeching halt, but it is crucial for Vitale’s committee to determine whether the state needs to be granted more authority to enforce these protocols.

It’s true that the Health Department may not be able to pinpoint the origin of these infections and the insidious pattern by which they spread. It is possible that they were the lethal link in a chain of unfortunate events perpetuated by a single employee making a tragic mistake.

But we are certain of this: Children died, and we are obligated to seek solutions. There is no other way to honor the loved and the lost, now linked in our collective memory as a divine kinship, forming a sacred ring of eternity. They deserve our best.

Published in NJ Spotlight

State council reports on the many ways in which life could be made more comfortable for New Jerseyans in their final days

A long-awaited report on what New Jersey should be considering when it comes to end-of-life care had no shortage of recommendations — 26 of them, in fact.

They include the creation of a statewide stakeholder coalition to oversee improvements in end-of-life care; education and training programs for providers, and culturally appropriate public awareness campaigns for state residents; better systems to document final wishes; and allowing intensive-care paramedics to treat chronically ill patients at home in an effort to avoid a trip to the hospital.

The report, from the New Jersey Governor’s Advisory Council on End-of-Life Care, an independent organization that worked under the state Department of Health, was released last week. Some findings echo research by other policy groups that have also highlighted the need to focus more on how the medical system treats patients in their final days. Many agree the issue requires urgent attention.

Medical treatments are “often misaligned with a patient’s preference and wishes” for how they want to die, according to the state report, in part because too few individuals discuss their wishes with loved ones and codify these requests in writing. In addition, the healthcare system is focused on saving lives and invests too little in hospice care and palliative treatment for those at the end of their lives, it found.

The issue is particularly important in New Jersey, where only 30 percent of residents die at home, despite the fact that most wish to do so. And patients here are subjected to more medically intense end-of-life care than in any other state, consuming more healthcare resources, according to statistics cited in the report.

More ‘aggressive’ care in NJ

“New Jersey patients experience more aggressive care at the end-of-life without evidence to suggest a corresponding medical benefit,” said state health commissioner Dr. Shereef Elnahal. “We are thankful for the experts on this panel for developing these recommendations to improve the delivery of care in this state.”

Improving end-of-life care is a growing priority nationwide, as the number of elderly Americans is projected to double by 2060, with a huge leap anticipated in the next decade, as the baby boom cohort ages, the report notes. With more than 1.35 million seniors in New Jersey, the state ranks ninth nationwide for the size of its population over age 65 — a group that is expected to expand by two-thirds through 2030.

“There is no clear vision of how the healthcare system will be able to meet the obvious growing needs for chronic, palliative, and end-of-life care. This increasing demand, as well as the need for improvements in accessing palliative and end-of-life care, are key challenges,” the council warned.

The council, convened in 2016, was led by Elnahal and included several lawmakers, legislative staff, healthcare providers, and elderly and patient advocates. The council membership also included James McCracken, the state Ombudsman for the Institutionalized Elderly, and Elizabeth Connolly, the former acting commissioner for the state Department of Human Services. It was created in a 2011 law that prompted the state to adopt a unified system for codifying patients’ end-of-life wishes, but the council’s work did not get started for several years.

The 47-page report released last Wednesday, also underscores the importance of a unified statewide system for Practitioner Orders for Life-Sustaining-Treatment, or POLST forms, the primary goal of the 2011 law. Paper forms have been in use since 2013, but they are not universal, and efforts to build an integrated electronic system have progressed slowly due in part to technical challenges. (Earlier this year, the state expanded Medicaid coverage to reimburse providers for some of this planning.)

DOH disagrees with one recommendation

Improving the state’s POLST system is also a priority for the New Jersey Health Care Quality Institute, which released a blueprint on end-of-life care in June. The institute runs the “Conversations of Your Lifetime” program, a public awareness initiative through its Mayors Wellness Campaign, a model the state report also supported. The Goals of Care Coalition — a group of providers, insurance representatives, public officials and patient advocates — is also working to expand public awareness of these issues and POLST use.

The first recommendation of the governor’s council was to create a coalition or workgroup of stakeholders to further study the barriers to appropriate end-of-life care, make additional recommendations, and oversee the implementation of changes. The group would also be tasked with reviewing legislative and policy questions.

The DOH said it “respectfully disagrees” with one of the group’s suggestions — that lawmakers should provide guidance to medical professionals on how to respond to family members’ requests for treatments that may be useless or even harmful to a patient at the end of their life. Elnahal said the state supports the rights and autonomy of patients and their surrogates and would prefer a policy that involves more communication at an early stage before an individual becomes critically ill.

However, the state favored the call for a public awareness campaign in November — which marks National Hospice and Palliative Care Month — that is culturally appropriate for the state’s diverse residents, and other efforts to better engage citizens in the process, like online planning tools.

The report also recommended clear definitions of the terms involved. (For example: palliative care involves treating chronically ill patients to reduce pain and suffering, not the underlying cause of the illness, and hospice is a model of this kind of care for those at the end of life; hospice care can be used in hospitals, nursing homes and private residences.)

Education and training

Many of the recommendations focused on improving education, training and operations around end-of-life care for healthcare providers, including administrative staff at nursing homes, emergency-room personnel and ambulance squads. The group called for partnerships with medical professional organizations to create learning models, education fellowships to train more palliative caregivers, and standardizing best-practice models statewide.

The council also urged New Jersey to look to an example set by Washington State, which adopted legislation to allow drivers to indicate their long-term-care wishes on their drivers’ license. If the driver was in a potentially deadly vehicle accident, emergency responders could scan a code on the license to access the individual’s POLST form and treat them according to their wishes.

In addition, the report called for a change in the law governing mobile intensive care units to allow these trained teams to visit and treat patients with chronic conditions at home for non-life-threatening issues. This would allow for better monitoring of these individuals and could help keep them out of the emergency room.

“Patients nearing the end-of-life want to remain in their homes where personalized care and comfort measures can be provided,” the group wrote.

Published on AJMC.com

With healthcare in the spotlight after this week’s midterm elections, there are a number of things elected officials can do to encourage hospital safety, said the head of the Leapfrog Group as it released its fall 2018 rankings of Hospital Safety Grades.

The ratings, released Thursday, assessed more than 2600 hospitals across the country and found that serious harm or death from medical errors are problematic.

“We’re hoping to see both at the state level and the federal level better public reporting of all of the measures of safety in hospitals, including infection rates,” said Leah Binder, president and chief executive officer of Leapfrog, in an interview with The American Journal of Managed Care®.

It doesn’t matter if a state leans blue or red, said Leapfrog, which tried to put an electoral spin on the results. In blue states, 33% of hospitals received “A’s,” compared with 32% of hospitals in red states.

New Jersey, which was number 17 in the rankings last spring, rose to first place, while Hawaii, which ranked first in the spring, fell to 20th place. Idaho, which ranked number 2 in the spring, fell to 27.

Leapfrog assigns “A,” “B,” “C,” “D” and “F” letter grades to general acute-care hospitals.  The grades are based on hospital errors, accidents, injuries and infections. Preventable errors and infections in hospitals kill more than 500 people every day in the United States, according to previous research.

Overall, the 5 states with the highest percentage of “A” hospitals this fall are New Jersey, Oregon, Virginia, Massachusetts, and Texas. The 5 states with the lowest percentage of top-ranked hospitals are Connecticut, Nebraska, Washington, DC;  Delaware, and North Dakota.

Binder said she would like to see more public reporting of infection rates from the CDC. For instance, she said, if a healthcare company includes a network of 5 or 6 separate hospitals, infection rates are not broken out by individual institution, but rather are reported in the aggregate.

“We just think there’s a wealth of information out there that consumers deserve to have that they don’t have about the safety and quality of care, particularly safety,” she said.

There are a number of actions elected officials can take make to improve hospital safety, Binder said. As one example, if a state is reviewing government bonds or grants for an institution, they could incentivize the approval by considering the safety record as part of the process.

“There are a variety of ways states could reward excellence and demand improvement when excellence is not available,” she said.

With the results of midterm election known, Binder said she is “cautiously optimistic” about improvements at the federal level. In 2019, Democrats will control the House of Representatives, while Republicans will retain the Senate.

“I think now that the election behind us, the opportunity to restore that kind of conversation is before us and I am excited to see that happen with both houses of Congress,” she said.

The Leapfrog survey is drawn from 28 measures of publicly available hospital safety data, including from the CDC, CMS, the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), and the American Hospital Association’s Annual Survey and Health Information Technology Supplement.

In this report, Leapfrog expanded its rating methodology to include an assessment of hospital use of Bar Code Medication Administration (BCMA), which helps reduce the risk of giving the wrong medication to a patient. But Binder said she did not think the change in methodology would account for some of the shifts that some states experienced, like Idaho.

In a statement, the president and chief executive officer of the New Jersey Health Care Quality Institute said it was the first time the state reached the number one spot in the survey, which relies on voluntary participation from hospitals.

“We’re proud of the high number of hospitals in New Jersey that voluntarily submit their quality and safety data to Leapfrog, and then also use that information to continually improve patient care,” said Linda Schwimmer. “Our experience shows that hospitals committed to creating a culture of safety and quality perform well. That’s the common denominator,” she said.

Published on NJBiz.com

New Jersey led the nation with the highest percentage of hospitals with an A grade in the latest fall Leapfrog Hospital SafetyGrade released Thursday.

Additionally, the state also had the highest rate of participation in the survey with more than 50 hospitals having responded.

More than 56 percent, or 38 of the participating hospitals, received the highest grade of A. In contrast, New Jersey ranked 17th in Leapfrog’s spring survey with 33 percent of hospitals receiving an A grade.

The Leapfrog Group’s independent, nonprofit grading system assigns A, B, C, D, and F letter grades to more than 2,600 general acute care hospitals in the U.S. The safety grades are focused on avoidable errors, accidents, injuries and infections.

Highlights from the Leapfrog Grades for New Jersey include: 38 hospitals, or 56.7 percent, received an A grade; 16 hospitals, or 23.9 percent, got a B; 11 C hospitals, or 16.4 percent, got a C; one hospital received a D and another an F.

In all, 67 New Jersey hospitals were graded this round. Of those, 24 saw their grades go up —four climbed two grades: St. Joseph’s University Medical Center, Saint Clare’s Hospital of Denville, Saint Clare’s Hospital of Dover and Saint Michael’s Medical Center. Five hospitals went down in grade.

The poorest-performing hospitals were East Orange General Hospital, which was graded an F; and University Hospital in Newark, which got a D.

“This is the first time that New Jersey had the most A-rated hospitals. We’re proud of the high number of hospitals in New Jersey that voluntarily submit their quality and safety data to Leapfrog, and then also use that information to continually improve patient care,” said Linda Schwimmer, president & CEO of the Princeton-based New Jersey Health Care Quality Institute (NJHCQI), which serves as the regional leader for Leapfrog in New Jersey.

NJHCQI is an independent, health care advocacy group.

Schwimmer, who also serves on the Leapfrog board of directors, encouraged all hospitals to use the survey to improve their performance.

“Our experience shows that hospitals committed to creating a culture of safety and quality perform well. That’s the common denominator,” she said.