An Interview with Dean Augustine Choi of Weill Cornell Medicine by Associate Editor Samara Rosenfeld.

Talking Diversity in Academic Medicine

Our popular podcast, Data Book, features a discussion on bringing EHRs to surgery centers.

Making Tech Ambulatory 

Megan Coder, Pharm.D., M.B.A., discusses the next steps for digital therapeutics to have a permanent place in the health landscape.

Making Digital Therapeutics Last

 spoke with Matthew Michela, president and CEO of Life Image. We discussed Life Image’s recent 

 on whether providers have put measures in place to reduce information blocking in compliance with the new rules that went into effect April 5, 2021 from the Office of the National Coordinator for Health IT (ONC). We also talked about how the COVID-19 pandemic has influenced the adoption of such measures.

Podcasts

Matthew Michela, president and CEO of Life Image, discusses his company’s survey that found that most health care organizations are contributing to information blocking despite being aware of regulations put in place to eliminate it.

Podcast: Data Operability Rules and Confusion with Matthew Michela

 conducted by Avant Healthcare Professionals on the state of 

 in 2021 compared data from 2019 and 2020 to explore shifts in nursing trends in the United States.

In part due to older nurses retiring, current registered nurses (RNs) burning out, educational resources for new nurses decreasing, and turnover rates increasing, nursing shortages are expected to grow in the years to come. However, an aging US population, the opioid crisis, lack of frontline workers and COVID-19 have all contributed to the rising demand for health care professionals, researchers wrote.

To better understand this imbalance, a survey was sent to Chief Executive Officers (CEOs), Chief Nursing Officers (CNOs), and Human Resources (HR) executives at various health settings across the country between January and February 2021.

Over 100 responses from critical access hospitals, state facilities, and other settings were included in the analysis. Although executives reported they rely on new graduates (71%), internal recruitment (45%) and external advertising to fill nurse openings, an average of one in five nurses will leave their first job within 12 months of starting, amounting to $7 million in hospital losses annually.

Survey results show 36% of respondents anticipate more than 25 RN job openings in 2021 compared with 17% in 2020, while 21% of respondents said they had over 50 openings, and 11% reported over 100 vacancies in 2021. Eighty percent of those surveyed reported losing current RNs to other hospitals for travel assignments.

Compounding the issue, nursing school enrollment is not keeping pace with projected demand and many hospitals are turning to monetary incentives to fill RN openings. Nearly 30% of respondents plan to improve pay packages to meet the shortage and nearly 40% said they offer sign-on bonuses. Of those surveyed, 81% believe volume of nursing school graduates will decrease due to the COVID-19 pandemic.

Respondents indicated medical-surgical, emergency room (ER), intensive care unit (ICU), and operating room (OR) specialties need nurses the most while over 90% said they currently employ traveling RNs to assist with influxes of COVID-19 patients. Survey results show an increase in pediatric nurse demand from 8% in 2020 to 13% in 2021.

Demand for traveling nurses also led to increased rates, and “a majority of respondents said they were spending between $100-$150 an hour for travel RNs.” Because of this, some health care systems struggled to keep nurses who instead sought higher-paying travel assignments.

“Hospitals were not only paying double the rates for travel nurses but also increased RN staff pay and offered incentives to keep staff at their facility,” authors wrote, “58% of respondents said they offered staff a COVID-hazard pay increase while 56% offered bonuses.”

More cost-effective ways to combat increases in staffing costs could include tuition reimbursement, individuals seeking temporary to permanent work, and employing international nurses who are contracted for two to three years. In comparison, travel nurses typically are employed for 13-week commitments.

Suspension of routine operating room procedures to conserve capacity, supplies, and staff for COVID-19 patients also resulted in hospitals furloughing OR staff, while 20% of respondents reported they have not been able to bring back 100% of their OR RNs. Fifty-Five percent of respondents reported cross training these staff in different departments.

When it comes to the COVID-19 pandemic specifically, responses revealed:

70% of respondents reported that they lost anywhere between 5%-30% of their staff due to COVID-19 while 49% of respondents said they lost 5%-15% of their staff to higher-paying travel assignments.

70% of respondents said COVID-19 has impacted their onboarding capabilities, while 63% of respondents said COVID-19 increased new graduates’ orientation timeline.

Some respondents said nurses were coming in with less clinical experience, they had orientation online rather than in person, they had to rush the orientation process and some even had to cancel their RN nurse residency program.

33% of respondents believe COVID-19 will have a long-term impact on the health and well-being of their staff over the coming months and there will be a great loss of bedside nurses to other careers in the years to come.

Although data projects two million new nurses will join the workforce in the future, another one million will be lost, researchers said. “There is now more than ever, a sense of urgency to fill the gaps of the amount of experienced, tenured nurses who will retire in the coming years,” they concluded.

Articles

Survey responses from health care facilities across the country outline current nurse shortages and foretell of future vacancies. 

Health Care Facilities Report Significant Nurse Shortages, Concern About Future Vacancies

Kulmeet Singh, the chief executive officer of Albuquerque, N.M.-based Twistle, believes in putting the patient at the heart of the healthcare journey.

 has invested in automated patient communication software that can offer personalized, step-by-step guidance to improve outcomes, safety and satisfaction, keeping patients engaged, on track and supported every step of the way.

“A care plan is often a handout that can range from a single page to the size of a book, and we are turning that information into turn by turn guidance for the patient through messaging in an automated way,” he says. “In the event that a patient asks a question that the automation hasn’t anticipated, the care team gets alerted to take over from the automation and continue supporting the patient.”

Remote patient monitoring was already a growth area before the pandemic, with one estimate published 

 predicting a $16 billion surge by 2023. The need to keep patients safe for the past year—and away from hospitals and waiting rooms—has only increased interest.

 of such systems, so that health systems or payers would be willing to invest.

To address this, Singh and his Twistle team have developed a quantifiable and reliable way to measure return on investment (ROI), using years of data on the impact of reducing readmission rates, average length of stay, no shows/same day cancellations, emergency department (ED) bounce back visits, and phone call volume.

For example, clinical leaders at ChristianaCare, a network of private, non-profit hospitals in the MidAtlantic states, were looking to improve early detection of postpartum hypertension by overcoming low attendance for follow-up office visits, so they deployed Twistle’s remote patient monitoring platform to engage new mothers after discharge. Patients were prompted to report their blood pressure reading and answer a short survey.

“The program has successfully reduced postpartum hypertension-related readmissions and eliminated long-standing racial disparity,” Singh says. Although only 30 percent of patients attended in-person postpartum office visits, the remote monitoring program drove 91 percent of new mothers to submit at least one blood pressure reading—a 203 percent increase in hypertension screening, and decreased 30-day readmissions by 55 percent.

Another successful case study involved Washington-based Providence St. Joseph, which collaborated with Twistle to build digital care plans for total hip replacement and total knee replacement surgeries. These care plans were designed to automatically deliver the right information to patients at the right time, including education, reminders, surveys, checklists, and messages from their care team. Patients enrolled in the Twistle pathway experienced a 44 percent reduction in hospital readmissions, a reduction in surgical complications and the length of stay was reduced by 15 percent.

Twistle offers hospital leaders the peace of mind that the patient engagement solutions they adopt will generate the promised return on clinical, financial and operational outcomes.

“Measuring ROI is very difficult, especially since health systems are straddling fee-for-service and value-based care business models,” Singh says. “The same value that Twistle might bring in a value-based care context may not deliver value in ROI in a fee-for-service context and vice-versa. We generally take a patient-first approach to arrive at a good outcome, independent of what the business model is. If you don’t have a patient enrolled and engaged in an ROI tool, there’s no opportunity to influence ROI. Patient satisfaction, leads to additional revenue.”

Twistle's CEO, Kulmeet Singh, says he's come up with a reliable way to measure return on investment for his company's remote monitoring software solutions.

Measuring the ROI of Remote Patient Monitoring

Results of a longitudinal survey study offer new insights on how patient-reported data could be collected and used in hospital quality improvement. 

, also open the debate about the use of real-time focused data when capturing vulnerable 

“Patient-reported data (satisfaction, preferences, outcomes and experience) have been increasingly studied with the aim of providing excellent patient-centered care,” researchers wrote. “In particular, the collection of patient experience data is emerging as an increasingly key component in assessing the quality of delivered health services.”

Patient experience data collected throughout different points in a patient’s stay at a hospital (i.e. patient journey) could help discern whether there are discontinuities within units and between different units. In the absence of a complete view of the whole process, inter- and cross-organizational gaps like obstructed data flow and lack of service synchronization can occur, authors explained.

In order to explore which data collected from patients could be useful in improving the patient journey and to analyze whether gathering timely patient experience data can capture areas for improvement, patients in the orthopedics department at a 250-bed Italian university hospital participated in a longitudinal survey study.

As the unit of analysis was the patient’s journey from first outpatient visit to hospital discharge, all individuals who underwent major or minor orthopedic surgery between January and February 2019 were considered for inclusion. Participants received two different questionnaires assessing patient-reported outcomes, patient-reported experience, patient-reported satisfaction, and patient-reported preferences at two different stages of the hospital patient journey: at the time of admission before surgery and at discharge.

A total of 254 participants completed the pencil and paper questionnaires, and more than 80% were older than 50 years. Knee replacement and hip replacement were the most common major surgical operations completed.

Overall, analyses of the patient-reported data showed “greater or less negative satisfaction may not reveal pathology-related needs, but patient experience data can detect important areas of improvement along the hospital journey,” authors wrote.

“As clinical conditions and the context of care change rapidly within a single hospital stay for surgery, collecting data at two different moments of the patient journey enables researchers to capture areas of potential improvement in the patient journey that are linked to the context, clinical conditions and emotions experienced by the patient,” they added.

Results revealed the five most important aspects for a good hospital journal experience, including:

Receive the best treatment for the related health conditions

Have clear instructions on how to prepare for surgery (therapy, fasting, surgery aids)

Have clear instructions on how to check in at the hospital

Have clear indications on the treatment pathway I will also have to take

Receive explanations from staff in case of waiting

In comparison, the least important aspects included:

Have explanations and understand everything that happens to me

Be involved in all decisions concerning my care

Feel comfortable in the environments where I have to be

Wait as little time as possible for a visit or for assistance

Have a room where I am not disturbed and with hotel services (TV, landline, etc.)

“By timely and simultaneously gathering preferences, satisfaction, outcomes and experience data, it is possible to have a complete picture of the hospital patient journey,” researchers wrote. Furthermore, results show how “at the beginning of the journey, patients might consider an issue as not critical, but while living the hospital experience, it becomes important.”

Authors concluded results emphasize that personalized medicine should not only refer to targeted therapy but requires management teams to be able to customize the patient’s journey and identify different patient profiles.

As the study was conducted at a single center, results cannot be generalized, marking a limitation to the study. Because the orthopedic surgical journey is relatively shorted compared with the oncological one, for example, this aspect could have influenced the results and methodology should be tested on difference clinical pathways. Futures studies should also explore the impact of the patient-health care staff relationship in the hospital journey experience.

Responses collected from longitudinal surveys show how patient-reported data can help improve hospital quality. 

Real-Time Patient-Reported Data Help Assess Hospital Quality 

Mary Caffrey is the Associate Editorial Director of AJMC/Managed Care for MJH Life Sciences. Her editorial responsibilities include 

Digital health has exploded over the past decade, from health technology meetings such as HIMSS and at major scientific conferences, as well as the consumer sector, as seen in best-sellers like the Apple Watch. Projections for the size of the global market are huge, with 

 from $220 billion to $295 billion over the next five to eight years. But the excitement has been tempered 

 that results can be uneven, as early excitement for an app or wearable may wane over time. Remote-patient monitoring, which has received more attention during the COVID-19 pandemic, is of interest to health systems and payers, but the challenge here has been making the data-sharing process easy for patient and provider alike.

Enter AMAZE, AstraZeneca’s disease management platform, which will be part of a collaboration with Massachusetts General Hospital (MGH). AstraZeneca and MGH 

 earlier this month, saying it would allow them to pair a patient app with a clinician dashboard to deploy remote patient monitoring and evidence-based patient care with greater efficiency, improved patient engagement, better communication—and most of all, better outcomes. The collaboration will start by focusing on heart failure and asthma, two of the more expensive conditions in healthcare.

To learn more about AMAZE, and what makes it different from earlier digital solutions

™ spoke with Karan Arora, MBA, chief commercial digital officer for AstraZeneca.

This interview has been edited lightly for clarity.

Could you give us a brief summary of what AMAZE is and why represents a step forward in chronic disease management?

 We know that 97% of chronic care management happens outside of a clinical setting. Our vision is to provide better evidence-based care to patients, and instead of it being episodic, it should be proactive—and it should be driven through data. So, this is a wider monitoring platform coming into play.

We've been hearing more and more about remote monitoring, especially during the pandemic; as you said, most chronic care management doesn't happen in the doctor's office—it happens when the patient is by himself or herself. We've been hearing about this for several years now, so obviously a lot of science went into AMAZE. Could you walk us through the process that led this point of launching the program with MGH?

 Three parts went into AMAZE, if I could just put them in buckets. One is the clinical thinking. Instead of taking an approach to just launch a digital app, and be technology driven, the approach was, “What actually drives the best usage for patients and delivers both efficient outcomes and also efficiency for the clinicians that treat those patients?” That was the fundamental North Star that was common for MGH and for us.

The second thing that went in this is understanding, “What are the gaps that exist with remote monitoring today?” There were two: one was that the number of users or patients using these digital applications is low, and reuse is also very low. And second, we find with healthcare providers that they don't like it, because it's fragmented. When the data come to them, it seems like more work than less. So, we had to solve for those challenges as well.

The third element was the business model doesn't really exist today. If you ask the providers to pay for remote monitoring, they want to use it, but then have no money to pay for it. You have to solve for adoption. And then for the payers, the market is still developing where they're reimbursing, so it is not widely in place. We have a couple of plans that are starting to reimburse for remote care, but it’s not happening at scale. You have to solve for that gap and make sure you drive the incentives for adoption.

It sounds like one of the problems you’re trying to solve is one we’ve seen in studies—people will often adopt a digital therapeutic or mHealth solution initially, but then there's a drop off. Can you talk about innovations you are making to address this?

 First, we have found that instead of going at it with the B2C route, which is what a lot of the digital health companies have done—they’ve gone directly to the consumer, and then vertically integrated and had to add clinicians. We actually took that learning and said, we have to 

 with the clinician. So, we integrated the platform into the electronic health record (EHR). It is part of the existing clinical workflow—there’s not a separate web app, there's not a separate application that clinicians need to look at. Second, we made sure that the clinicians were the ones that were onboarding the patient on to the application. It didn't feel like, “Hey, you need to go download this digital app,” it was more, “This is the continuation of how your care is delivered going forward.”

As a patient is discharged, for either a heart failure patient or asthma, the person is told, “This is how the clinician will remain in touch with you.” Because a clinician is giving it to the patient, the level of use and reuse is much higher. Typical usage rates are about 3% to 5%, but we're finding users rates closer to 60% to 70%.

Second, the patient doesn’t experience the platform as a black box. As soon as some information is put into the app by the user, it goes into the clinician portal, which has a series of algorithms that are clinician derived; based on those algorithms, there is risk stratification that [reacts based on the] condition. There’s someone physically looking at this and interacting with the patient, based on the condition, in a timely manner, and that’s closing the loop. It really drives the usage high, because the patients feel that, “Oh, someone's looking at this.” This is unlike other digital health interactions, where you put in information, and sometimes you get no response or an automated response.

 If it integrates into the EHR, that's hugely helpful. It’s still an app, and the patient still inputs data on the phone, but they get the immediate feedback that somebody saw their data.

 Within the dashboard, the clinician gets a view of all the patients assessed against the risk criteria that they have inputted. If patients are flagged, clinicians can click and look at all the patient data, both what’s been collected from the app or from any connected device, including their EHR data in one longitudinal view. So, it gives them a full assessment of their patient—they can assign it as part of a case, they can chat with the patient, right from the platform, or they can examine the information to follow up or schedule them to come in. And all of those components are right at your fingertips. So, it makes the clinical workflow very efficient.

 Does the platform talk to other apps or devices that the patient might be using already, like a Fitbit or an Apple Watch, or their Peloton?

 At the moment, it doesn't. Given that you're treating these chronic patients, one of the core things the clinicians said was they didn't want a lot of false positives. So, say you use an Apple Watch—remember the 

 that was done? There were a lot of false positives, and the clinicians were quite frustrated. We’re only using medical grade devices. Given that these are chronic patients, most of them are discharged with these devices, whether it's a COPD patient that needs to use a specific oximeter, or it's a heart failure patient that needs to use a Bluetooth enabled weighing scale—that’s where the clinician wants to make sure the data coming into them is clinically valid. And they can use the data for figuring out what the right clinical therapy should be for them. We will have the ability by September to have 400 on-market medical approved devices be able to connect into the platform, which covers pretty much the whole universe.

 You selected heart failure and asthma as the conditions to start the collaboration with MGH. Why were these conditions selected?

 These conditions represent the some of the top cost burdens in the health system and, second, they are very different in the way they're treated. With asthma, it's managed as a life disease. When patients are discharged [from a hospital], it’s mainly when they're having episodes or exacerbations. If they need to tweak or change therapy, it’s a shift from a steroid to a biologic. By contrast, a heart failure patient is quite comorbid, and there are a lot of interdependencies.

We wanted to test one disease state that perhaps was a little less complex like asthma, and then test one that was significantly more complex that has many underlying conditions. We were trying to see if we could handle those different clinical experiences with a unified application. Today, many of our chronic patients must deal with multiple applications—they have a diabetes app, they have a renal app, they may have an asthma app if they're comorbid. One vision we had when we created the platform is that if you chronic disease with comorbidities, you will only have to deal with one application.

 One other thing I wondered—when you test heart failure and asthma, you're capturing heart failure, which tends to be an older group, whereas asthma can be many different age groups. Was that part of your thinking as well?

 Absolutely. From a human factor standpoint, your patient profiles are different. What we're finding with the heart failure patients is many times it's the son or the daughter or daughter-in-law or son-in-law who's actually helping do it for them. For some, the digital savviness is not there, What is surprising, however, is although the initial hypothesis was that older patients may not be able to use the application, sometimes their digital savviness is pretty good. Many times, we find inequities—sometimes people of color or those in low-income communities may not have access to the internet or a mobile phone. Some of the thinking at MGH is, how do you partner with governments to provide local subsidies, in addition to digital monitoring, so there’s a phone that’s offered at discharge or they’re being offered internet on the spot? So, those are things I don't think we have solved for, and that's an industry issue, frankly, with any digital solution.

What does a successful pilot look like? Are you going to measure by engagement levels?

: There are three things: For the patient, we're looking at usage, which is, to your point, engagement levels. Are they using it? What's the drop off looking like? We know the industry benchmarks. If we do anything north of that, that’s success.

For the physicians, we're looking at operational efficiency. Has this saved them time? Did it help them risk-stratify the right patients so they can proactively deliver care to them? Does it help sort (or stop) episodic treatment of chronic patients; for example, the heart failure patients discharged [from] coming back at 30- 60- 90-day intervals? If the patient is actually showing risk at 10 days, let's bring them in, versus the patient that is showing no risk. If there's no need to bring them in at 30 days—you can do just remote checking.

Finally, there are some anecdotal clinical inputs we want to see—that the physician looked at the data and changed clinical therapy to optimize the outcome for the patient. Did we see reduction in hospitalization, or did we see readmissions go down? All of this is measured versus control of patients that are not using the remote monitoring platform. So even though it's a quality study, we can pick up on that through the PRO questions of to the clinicians.

So, you have you have the PRO questions built into the process as well?

 We have technical validated PROs for these use cases. We're also picking up some quality of life data like for asthma patients. We know whenever they do a log, we know exactly what ZIP codes they are in, what are the weather conditions, what is the humidity, the pollen counts, all of that is shared back with a physician so they can know what may have triggered the event.

And diagnosed further into that, with heart failure patients, we have integrations with some devices that look at weight measures and heart rate, because we know fluctuation in weight is a high-risk factor for heart failure patients that have just discharged. For these different use cases are different elements. But we collect both PROs and some other biometric data, as well as some other quality of life data that provides a full longitudinal data set back to the clinician.

Have you learned from the taper off phenomenon? Have you learned from some of the other projects about strategies for what to do when patients start to lose engagement? How do you keep them engaged?

 Yes, we have learned. There are a few that we should assume already: once patients start feeling better, they stop engaging. It’s the same issue we have with medication adherence—as soon as you take medication and you start doing well, you don't finish your dosage, and then potentially, you still get sick, which is why adherence and compliance is a big issue in the industry.

With digital therapies or digital health applications it’s the same challenge. You have to do behavioral modifications within the applications themselves. And you have to create incentive mechanisms. There are two ways to do that. First, you drive personalized content. You’ve got make sure that based on what they are dealing with, whether it's social content, behavioral content, disease content, you have to tailor that content. We’re looking at ways to tailor content to the patient to make it more usable for them and then to trigger incentives. So, if they don't log in, we're sending triggers for them to come back and log in, or we're sending a direct clinician text, “Hey, we haven't seen any data in the last three or four days, please check back in. Is everything okay?”

If that doesn't drive it, and we're trying to provide some gamification in the platform itself. It's still early, and we're trying to modify it as we learn. But the idea there is just like your Apple Watch, how many days you have gone logging in information? Or did you meet your streaks for the day in terms of logging in, or are you giving them kudos for completing an activity. Apple, Noom—all of these platforms have done phenomenal jobs around behavioral modification triggers and incentives. We've learned from those, and we're trying to incorporate some of those same elements.

Well, I do take days off from my Apple Watch, I have to admit

We’ve covered a lot of ground. Is there anything we haven't covered that you'd like to add?

What's unique here is that we started with a clinical focus on how to drive better outcomes for patients and then reverse engineered on how we would deliver that to the right experience and tools and platforms. That’s why this partnership with MGH is unique. Both MGH and AstraZeneca pride ourselves on clinical expertise. We're not digital people, nor are we IT experts. But what we knew is, “How will drive efficiency in a remote monitoring situation? And what are the elements that are needed for the clinicians to provide the best care? And what are the elements needed for the chronic patients to actually manage their care most efficiently? And once we figured that out, that’s what we built into the platform to go test. What makes me hopeful as our North Star is patient outcomes. And if we stay true to that, then the technology will do its work.

AstraZeneca and MGH announced their digital health partnership earlier this month, saying it would allow them to pair a patient app with a clinician dashboard to deploy remote patient monitoring and evidence-based patient care.

AMAZE Seeks Better Outcomes Through Digital Health, Driven by Clinicians

The Biden administration moved late Friday to reverse a January extension for Texas’ Medicaid program, saying that CMS officials “materially erred” in allowing the $100 billion approval that would have pushed the largest waiver of its kind into the next decade.

, CMS’ Acting Administrator Elizabeth Richter said that extending the waiver allowed Texas to bypass the federal rulemaking process, thus depriving “beneficiaries and other interested stakeholders” the chance to weigh in on the future of Texas’ Medicaid program. The waiver covered both funding to hospitals for uncompensated care and innovation projects; the latter were set to expire later this year.

Reaction from Texas Governor Greg Abbott, a Republican, was swift and harsh.

“By rescinding this waiver extension, the Biden administration is obstructing healthcare access for vulnerable Texans and taking away crucial resources for rural hospitals in Texas,” Abbott said 

. “The state of Texas spent months negotiating this agreement with the federal government to ensure vital funds for hospitals, nursing homes, and mental health resources for Texans who are uninsured. With this action, the Biden administration is deliberately betraying Texans who depend on the resources made possible through this waiver.”

The action was seen as the stick finally coming down on Medicaid expansion, following the administration’s offer of financial carrots to the 12 states that have refused to extend coverage of those earning up to 138% of the federal poverty level. About 2 million people are estimated to be in the “coverage gap,” which means they earn too much to qualify for their state’s Medicaid program, but not enough to qualify for premium tax credits under the Affordable Care Act (ACA). One-third of this group lives in Texas, according to a Kaiser Family Foundation 

Texas’ January 15, 2021, extension was one of three such waivers granted in the Trump administration’s final days, allowing the state to continue to use federal funds for an uncompensated care pool, thus side-stepping the ACA’s preference for expanding Medicaid coverage. The other two waivers were granted to Florida and Tennessee.

Uncompensated care waivers were approved by CMS under the Obama administration after 2011, when hospitals still needed funding to cover the cost of caring for the uninsured but before the full ACA had taken full effect. The law viewed them a stop gap until the working poor could gain access to healthcare coverage under Medicaid expansion. However, once the Supreme Court allowed states to opt out of expansion, the waivers remained.

 published Friday by The Commonwealth Fund, hours before the Texas letter was released, argues that extending these waivers another 10 years “could shape the Medicaid programs in these three states for the next decade,” while denying coverage for up to 1.3 million people.

Paying hospitals to care for the uninsured is justified for these institutions, writes Cindy Mann, a partner at Manatt Health, but paying for acute care in the emergency room on an inpatient visit “is no substitute for coverage that provides access to primary and preventive care,” she writes. Too many poor people end up in the emergency room because they lack access to diagnostic tests or prescription drugs that would manage chronic conditions like heart disease or diabetes. Over the long run, lack of preventive care for chronic disease is more costly to Medicare once these adults reach age 65.

“For this reason, hospitals themselves have continued to press for Medicaid expansion,” Mann writes.

In addition, she said, that directing federal funds for uncompensated care instead of Medicaid expansion results in higher spending. In the three states granted late waivers, she writes, the extensions would result in an additional $17 billion in spending, including $12 billion in federal funds.

For these reasons, the Biden administration included in its American Rescue Plan additional 

 for the 12 holdout states to expand Medicaid, as well as a specific incentive to encourage states to extend postpartum care to a full year after childbirth instead of 60 days, to address high rates of maternal mortality, particularly among minority women.

So far, however, the administration has found lawmakers in some Republican states are not enticed by the additional funds. Mississippi, for example, could only get the expansion on postpartum care through its state Senate, not the House. However, a 

 said the extension may happen administratively through 2021.

Regardless of hospitals' overall support for Medicaid expansion, the sudden about-face on the waiver—and its potential effect on safety net funding—did not go over well with Texas Hospital Association, which released a statement late Friday.

“The Texas Hospital Association is extremely disappointed by today’s action by CMS to abruptly rescind the previously approved waiver extension for Texas. With an ongoing pandemic and millions of uninsured Texans, Texas hospitals have been stretched like never before and clearly have a critical role in protecting the health and wellbeing of all Texans,” the statement said.

“This action undermines the safety net and hospitals’ ability to protect people. It puts the state’s health at serious risk and creates unprecedented levels of uncertainty for an industry that is charged with saving lives. The waiver extension would have helped the state to seamlessly continue support for much-needed health care improvements and would have continued stable funding for hospitals that serve large numbers of uninsured patients.”

The Texas Hospital Association said the unexpected move from CMS brings uncertainty to the state's safety net hospitals. 

Under Biden, CMS Cancels Trump’s Late Extension of Texas Medicaid Waiver

Although there has been a lot of focus on payments from pharmaceutical companies to physicians, medical device companies provide higher payments. The relationships between medical device firms and physicians differ than those between drug companies and physicians, according to a 

The research examines medical device payments across payment types and specialties, as well an examination of pharmaceutical industry payments. While there are justifications for the relationships between industry and physicians, “industry observers and policy makers have raised concerns that physicians’ treatment decisions may be biased by financial relationships,” the authors explained.

Although drug and device companies are grouped together, their interaction with physicians can differ greatly in several ways:

Drugs are taken orally, but devices often are implanted

Almost all drugs are therapeutic, but devices have a greater variety of purposes, including therapeutic or preventive, diagnostic, or used to monitor patients

Drugs are metabolized by the body, but devices may stay in the patient’s body for years

“One way of looking at these differences is that devices may require physicians to learn from firms and firms to learn from physicians in a way that most drugs do not,” the authors wrote.

They used 2014-2017 data from the Centers for Medicare and Medicaid Services Open Payments website, which has information on industry payments to physicians. They analyzed physicians by their National Provider Identifiers (NPIs) for the same time period and matched Open Payments recipients to the NPIs.

On average, medical device vendors paid $905 million each year to 196,624 physicians, while vendors paid $821 million each year to 331,187 physicians. Medical device vendors paid more money to a smaller proportion of active physicians: 30% vs 50%.

In addition, the pharmaceutical industry is much larger, and their payments represented only 0.24% of drug industry revenues compared with medical device payments to physicians, which represented 1.7% of device industry revenue. “Device firms also paid larger amounts to fewer physicians,” they added.

Nineteen percent of payment dollars for drug companies and 7% of payment dollars for device companies was for food and beverage payments. Education payments from device companies was four times payments from drug companies, and those payments per physician from device companies were 24 times what drug companies paid.

Specialists such as cardiologists, urologists, obstetricians-gynecologists, and ophthalmologists received significant payments from both drug and device vendors. Physicians in surgical specialties had the highest payment rates and highest median annual payments from device vendors. The median annual payments from device vendors to neurosurgeons was $454 and to orthopedic surgeons was $410 compared with a range of $14 to $44 for nonsurgical specialties at the bottom.

Meanwhile, nonsurgical specialties receive the highest payment rates and highest median annual payments from drug vendors. Medical oncologists received $846 annually, endocrinologist received $624, and rheumatologists received $707 compared with $31 to neurosurgeons and $35 to orthopedic surgeons.

“Policy makers tempted to extrapolate from the more developed literature on drug payments to the device industry should exercise caution,” the authors warned.

They concluded that there is a need for greater research into the implications of these relationships.

Research shows medical device companies provide higher payments than drug companies to physicians, but greater research is needed to understand the relationships and how they could impact consumer welfare.

Medical Device Payments to Physicians Exceed Those Paid by Drug Companies

 Appalachian Regional Healthcare (ARH) has selected Hollie Harris Phillips as the system’s new president and CEO, making her the first woman to hold the job, according to an April 12 

. Phillips will take the job in May when president and CEO Joe Grossman retires. Phillips, who has been with ARH for 19 years, is currently vice president for Corporate Strategy and chief strategy officer. She joined the organization as director of planning after serving as manager of executive operations for LifePoint Hospitals, Inc. in Nashville, Tennessee. ARH is the largest provider of care, the largest employer in southeastern Kentucky, and the third-largest private employer in southern West Virginia.

 as president and CEO of Children’s of Alabama, the only freestanding pediatric hospital in the state, effective June 1, 2021. Warren, who has been CEO since January 2008, will be succeeded by Tom Shufflebarger, the current chief operating officer and senior executive vice president. Shufflebarger joined Children’s in 1992, having previously served as the budget director and director of physician recruitment and development for Brookwood Medical Center. He has managed the hospital’s daily operations and policy decisions and directs the operations and development of Children’s Physician Services, including the hospital’s primary care practices, ambulatory care services, and business relationships. Warren is credited with strengthening the relationship between Children’s and the University of Alabama at Birmingham; in 2010, six of the hospital’s programs were ranked for the first time among the nation’s best children’s hospitals by U.S. News & World Report. The June 2020 ranking marked the 11th consecutive year that Children’s was included.

 he is retiring after more than three decades with the organization. The Washington, D.C.-based community health network announced that Keane will remain in his role until the end of 2021 while the board of directors launches a national search for a replacement. Unity has grown into one of the largest Federally Qualified Health Centers in the United States during Keane’s tenure, aiding those with low-incomes and the homeless.

A changing of the guard at Children's, Alabama's only freestanding pediatric hospital.

MED MOVES: Health System Serving Appalachia Gets First Woman CEO

Four months have passed since the implementation of CMS's price transparency requirements for hospitals. To gain insights into the effectiveness of these rules, 

spoke with Ogi Kwon, a manager in the regulatory team at R1 RCM's advisory and assurance department. 

While some hospitals have gone above and beyond what CMS has asked for, others have failed to do so. In this interview, Kwon discusses whether consumers are using the information gathered in meaningful ways, and offers comments on the future of the consumerization of health care. 

R1 RCM is a revenue cycle management company that offers technology-driven solutions to transform health care providers' patient experience and financial performance. 

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Ogi Kwon, of R1 Revenue Cycle Management (RCM) speaks on the effectiveness of CMS' price transparency requirements and offers insights into the future of consumerization of health care. 

Ogi Kwon Discusses CMS's Price Transparency Rule, Consumerization of Health Care

, researchers outlined both the benefits and potential risks and harms of inpatient units for children. Although there will always be a need for some inpatient beds, for many children and young people intensive community interventions may yield better outcomes, be more cost-effective, and improve 

According to authors, children may require inpatient care for one of three reasons. These patients may present with high risk due to mental health difficulties and cannot be managed safely at home or in social care placement, or these patients require an intervention not available elsewhere. “Rarely, a third reason can be the requirement for an intensive assessment involving 24-hr observation by a specialist team, when a community assessment is not possible,” researchers noted.

However, these criteria may be subject to interpretation and not be consistently utilized across the board, leaving open the question as to whether young people who meet these criteria could be better served through an intensive community-based intervention. Hospital admission among this cohort is often chosen because it is the only option in the absence of sufficiently resourced community services, authors explained, as opposed to the best option.

Overall, research indicates inpatient admission is effective, but comes at the cost for some and holds the potential to cause harm, including:

Separation from family and friends, with a risk of dependence and ‘institutionalization’

Adverse influences from peers, including risk of increased self-harm

Exposure to an environment with high levels of disturbance causing distress and com- pounding difficulties

Families and young people feeling disconnected, deskilled and disempowered

Inpatient treatments are expensive using resources which might be better deployed to intensive community interventions

Children and young people are over five times more likely to be physically restrained than their adult counterparts in the same trust

“There is a range of functions that community services need to provide in order to offer a comprehensive alternative to admission, and/or reduce lengths of stay” which can be provided together or separately, researchers wrote.

Functions include crisis assessment and management for those in acute crisis, intensive outreach services that are designed to encourage early discharge and reduce length of stay or transition to other services, and planned home treatment services for those who need long-term treatment. Specialist treatment services for young people with eating disorders or severe self-harm will also be beneficial when patients’ needs exceed the capacity of regular community services. According to authors, these solutions could be delivered in the patient’s home, a clinic or day hospital.

“Randomized controlled trials when alternatives to admission are compared with admission, evidence of reduced admission rates in localities that have access to high-quality alternatives to admission and data mapping service provision around the country [England] provide further evidence to support the case for developing comprehensive alternatives to admission,” authors said.

Previous research has revealed well-designed community services can reduce admission rates, lengths of stay, result in fewer harms, cost less to provide, and improve patient experience overall.

However, researchers caution against immediate reduction of inpatient beds before suitable alternatives are available. Using England as an example, they note the way National health Service (NHS) funds are distributed for young people’s mental health services has hindered progress in this area. “Highly specialized services such as inpatient care currently have a separate funding stream from regular community services,” they said. “In many places, this has resulted in a funding gap for services that should sit between regular community services and inpatient care.”

Temporarily increasing funding to admission alternatives may provide a simple solution to this roadblock, as once services are established, money will be recouped by reducing beds. Vision and commitment are needed by those in control of funding for a significant acceleration in this progress to take place, researchers concluded.

Researchers weight the benefits and risks of inpatient units for children and young patients. 