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Duke Medicine prepares for health care reform

The Duke University Health System is changing the way it conducts business since the Supreme Court upheld the Affordable Care Act in June.

On October 1, two major aspects of the ACA were put into motion. One penalizes hospitals if a patient is readmitted within four weeks for reasons that should have been treated on the previous visit. The other, known as Value Based Purchasing, reimburses hospitals based on the quality of their care. The provisions of the Act have forced DUHS to look at ways to reduce patient readmissions.

“I don’t want to be penalized for a variety of reasons, not the least of which is the ability to improve our process for patients,” said Dr. William Fulkerson, vice president for DUHS. “It takes work, but at the end of the day I’m completely confident that we will perform well.”

Value Based Purchasing aims to reward hospitals for providing high-quality care. The federal government withholds 1 percent of payments for hospitals that deliver acute care—short-term treatment for illness, medical conditions or recovery from surgery.

This money enters a pool that the Centers for Medicare and Medicaid Services draw from to reimburse hospitals based on their score. The score is based om a set of guidelines that measure the quality of a hospital’s care.

Strategizing care

Although it is “too early to tell” if penalties have accrued because of patient readmissions, DUHS have taken precautions to prevent patients from returning, Fulkerson said.

“We are focused on [what] we can do to reduce unnecessary readmissions and a lot of that has to do with patient education at the time of discharge,” he said.

Physicians are informing patients of outlets outside of the health system that will provide follow-up care, he added. To do so, DUHS must work with community facilities so that their physicians treat the patients instead of sending them to the hospital.

Fulkerson noted that this collaboration requires DUHS to focus on expanding primary care in communities. Patients would, then, have access to treatment when they first start seeing symptoms rather than waiting until symptoms worsen to the point of needing hospital readmission.

“In the next five to 10 years, we’ve got to continue our commitment to quality, but also focus on some slightly different areas, and part of that is the post-discharge environment for patients,” Fulkerson said.

An emphasis on utilizing community facilities began prior to the Supreme Court decision, Fulkerson said, adding that this strategy has resulted in “some reductions” in the amount of patients needing hospital readmission.

“We’ve seen some success, but it’s a work in progress,” he noted. “We have the opportunity to continue to improve that process.”

Mary Ann Fuchs, vice president of patient care and system chief nurse executive, said the ACA has looked toward nursing to help fulfill the act’s goal of providing higher quality care that is more cost-efficient.

Duke was one of five medical centers selected by the Centers for Medicare and Medicaid Services to participate in the Graduate Nurse Education Demonstration project, which provides $200 million over four years to increase the number of advance practice registered nurses and design more health care models, Fuchs noted.

DUSON has also changed its curriculum to train nurses to work within the parameters set by the ACA, including giving nurses greater knowledge on insurance programs and what payers require.

Nurses are also trained to increase communication with patients both before and after their discharge to decrease the likelihood of hospital readmission. Communicating over the phone—and eventually online—will help accomplish this goal, Fuchs added.

“We monitor that rate of readmission and then look back to see why that patient is coming back in,” Fuchs said. “We are trying to build systems to prevent those types of things.”

DUHS has also assembled teams to look at very common diagnoses and procedures to evaluate how to design them in a more cost-efficient and patient-friendly manner, Fulkerson added.

“The idea is that you get the clinical leaders in the room and begin to challenge ourselves about how we can re-engineer in certain areas and do better,” Fulkerson said. “We are responsible for how we will continue to thrive in an area of health care reform—we have to deliver the very highest quality, and we can’t waste money doing it.”

Points of concern

Dr. Joseph Moore, medical director of the Duke Raleigh Cancer Center, said the partisan nature of the act concerns both physicians and patients.

“One of the concerns is that the ACA, regardless of what your political persuasion, has become a political entity,” he noted. “I don’t think everyone totally understands all of the implications of it and I’m in that group too.”

As a result, there are a large number of misconceptions surrounding the act, Moore said. For example, people are concerned that the act promotes an increased number of patients, which will ultimately limit access to physicians.

“The concern that I’ve heard from people is that the number of physicians is fairly static,” he said. “There would be a large number of patients that should be cared for and a concern about whether that volume can be appropriately seen.”

Moore added that physicians are also worried about how the act will affect them, but that the rhetoric surrounding whether “to continue or torpedo” makes it difficult to discuss areas of the provision.

There are also problems within the act itself, he said, adding that the readmission penalization does not take into account the particular needs of different medical fields. For instance, a hospital should not be penalized for a readmission that is medically necessary, like a cancer patient receiving scheduled chemotherapies within one month of the previous treatment.

“Regardless of what the reimbursement model is five years from now, we must deliver the highest quality,” Fulkerson said.


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