Health Care Current: August 9, 2016

Innovation in health care: Getting more for less

This weekly series explores breaking news and developments in the US health care industry, examines key issues facing life sciences and health care companies and provides updates and insights on policy, regulatory, and legislative changes.

Innovation in health care: Getting more for less

As someone who accumulates close to 200,000 frequent flier miles each year, I recently had a chance to do something I could not pass up: pilot a Boeing 737 out of John F. Kennedy Airport. After we lined up on runway 31L with the engines at full power, the acceleration pressed me firmly back into my seat, even with 130 passengers and 15,000 pounds of fuel on board. My co-pilot and experienced instructor, Jim, called out critical speeds. First, “80 knots” (to which I replied “checked”), then “V1.” And, finally “rotate,” easing back on the yoke. “Positive rate,” Jim said, indicating we were, in fact, climbing. “Positive rate, gear up,” I replied. We continued to climb as the gear retracted, and Jim called out when we’d reached 400 and 1,000 feet. Turning toward the southern tip of Manhattan, the view was amazing. So was the sensation of banking and climbing as we passed the Statue of Liberty, flew over the Verrazano Narrows Bridge, and leveled off above the clouds.

Seconds later, we were back on the ground again, looking down runway 31L preparing for take-off. Such is the miracle of simulation. Utilizing an authentic 737 cockpit, wraparound video screens, and full-motion hydraulics, the experience is amazingly realistic. Through this experience, I had been safely immersed in the essentials of instruments, checklists, and callouts needed to function as part of a team.

Since the earliest days of flight – even as far back as 1910 – innovative technologies such as simulation have not only improved teaching the mechanics of flying, but have also addressed crucial communication, information-sharing, and critical thinking skills crews need.1 It is this holistic approach to problem-solving that can unleash the true value of innovative technology.

Innovation in health care is no different – developments that impact broad aspects of care can provide the greatest impact.

Recently, the Deloitte Center for Health Solutions surveyed leaders across the health care system to determine what 10 innovations in health care were most likely to accelerate the transformation toward achieving the Triple Aim over the next 10 years. For the analysis, we defined innovation as activities or technologies that can result in getting more for less. More value, better outcomes, greater convenience, access, and simplicity all for less cost, complexity, and time required by the patient and the provider. Like the airline industry, many of the industry leaders we surveyed and spoke with believe that the health care industry will be able to break traditional constraints of medicine through innovation.

One innovation that tops the list is virtual reality (VR), or simulated environments that could accelerate behavior change in patients and train clinicians in a way that is safer, more convenient, and more accessible. VR is being used to help soldiers with post-traumatic stress disorder, and many clinics and hospitals use VR simulations to help veterans who are, in many ways, continually reliving the traumatic events. In a safe and controlled environment, the soldiers can learn how to deal with instances that might otherwise be triggers to behavior that could be destructive to themselves and others. VR has also been used to support clinician training via surgery simulation. Surgeons can learn new survey methods, and new residents can practice techniques without putting a patient at risk.

And, just as the airline industry uses technology to monitor the health of planes as they fly through the air, using sensors, scales, compasses, and more to help ensure the plane is on track, another innovation that the leaders we spoke to mentioned was biosensors and trackers. These technology-enabled activity trackers, monitors, and sensors are often incorporated into clothing, accessories, and devices and allow consumers and clinicians to easily monitor health. More and more, these technologies are included in rapidly shrinking wearables and medical devices. Now, they allow consumers and clinicians to monitor and track more aspects of patients’ health, enabling earlier intervention – and even prevention – in a way that is much less intrusive to patients’ lives.

The report, Top 10 health care innovations: Achieving more for less, explores eight other innovations that could help expand the frontier of health care. These innovations will likely lead to new care delivery models to proliferate at rates unseen before now.

But, incorporating these top 10 innovations into business models may require changing how health care organizations currently prevent, diagnose, monitor, and treat disease. Industry leaders should consider building ecosystems that embrace non-traditional players and sources of knowledge outside their own four walls. Building pilots before expanding programs to scale, learning to embrace change, and evaluating new revenue sources can also help organizations succeed. And, organizations should strive to be agile in anticipating and adjusting their strategies as innovations continue to evolve.

As my simulator session continued, we worked on progressively more challenging scenarios: weather deteriorated, systems malfunctioned, engines failed. It was an incredible lesson in teamwork. On our last landing, with a fire in the cargo hold and only one working engine, I was thrown sharply against my seat harness – the landing gear had collapsed upon touchdown and the plane veered sharply off the runway. My heart was racing as we bounced to stop and prepared for an emergency evacuation. In that moment, I felt the real impact that this innovation has had on the airline industry – these simulations have helped create better outcomes at a lower cost than training pilots in the air.

Now, the question before the health care industry is, “Can we apply the latest innovations to derive similar results: better patient outcomes for lower cost and complexity?”

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1, “Pilot at zero altitude: The history of flight simulators,”

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My Take

By Harry Greenspun, MD, Managing Director, Deloitte Center for Health Solutions, Deloitte Services LP


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CMS opens applications and announces launch sites for CPC+ model

Last week, the US Centers for Medicare and Medicaid Services (CMS) opened applications for the Comprehensive Primary Care Plus (CPC+) delivery model. According to CMS estimates, up to 5,000 private physician practices serving an estimated 3.5 million beneficiaries may participate in the program. CMS will launch the initiative in 11 states and three densely populated metro areas, selected based on clinician and payer interest in the program and having a mix of rural and urban areas.

Dr. Patrick Conway, Deputy Administrator for Innovation and Quality and CMS Chief Medical Officer, said that CMS considers “CPC+ as the future of primary care in the US and is pleased to partner with payers aligned in this mission to transform our health care system.” Some estimates show that participating clinicians may earn an additional $100,000-$250,000 per year, depending on how many patients they have. CMS is accepting applications through September 15, 2016, and the program will launch in January 2017.

Background: The new CPC+ model expands CMS’ Comprehensive Primary Care Model initiative, which expires at the end of this year (see the May 31, 2016 Health Care Current). CMS will allow CPC+ physicians and practices to participate in accountable care organizations (ACOs). CPC+ and CPC+ACOs will both be considered advanced alternative payment models (APMs) under the Medicare Access and CHIP Reauthorization Act (MACRA).

The CPC+ program creates two tracks for payments. Both tracks require PCPs to develop comprehensive solutions for chronic care management, provide preventive care, and coordinate with specialists and hospitals. The tracks have different payment policies. Practices participating in Track II will be responsible for all requirements under Track I, as well as additional conditions of participation, including additional focus on high-need patients.

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Implementation & Adoption

Report: 88 percent of the companies affected by ransomware are in health care

A recent report on the cybersecurity threat landscape found that the health care industry is targeted by ransomware attacks more than any other industry. The quarterly threat report by the cybersecurity service provider, Solutionary showed that five industries (retail, health care, education, finance, and technology) face web application, application specific, and malware-based attacks most often. In the second quarter of 2016, the most common ransomware technique was CrytoWall, which was observed 94 percent of the time.

According to the report, health care has become the primary target for ransomware attacks because many health care organizations have been willing to pay ransoms. Health care organizations use many systems and devices that attackers can go after. The report shows that the most important driver to those perpetrating ransomware attacks is monetary rewards.

(Source: Security Engineering Research Team (SERT), “Quarterly Threat Report for Q2 2016,” July 26, 2016)

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ONC: Most hospitals and doctors are using the latest certified EHR technology

The Office of the National Coordinator for Health Information Technology (ONC) released updated data on hospitals and clinicians participating in the Medicare Electronic Health Records (EHR) Incentive Program. As of June 2016, 632 certified health information technology (IT) vendors served more than 337,000 health care professionals (primary care physicians, medical and surgical specialists, podiatrists, optometrists, dentists, and chiropractors) in the Medicare EHR Incentive Program. In addition, 175 vendors supplied certified health IT to 4,474 non-federal acute care hospitals, including critical access hospitals.

Key findings from the report include:

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CMS finalizes 2017 Medicare payment rates for inpatient and long-term care hospital payments

CMS published the final rule for fiscal year (FY) 2017 Medicare payment rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital Prospective Payment System (LTCH PPS). The rule annually updates Medicare payment rates for approximately 3,330 acute care hospitals and 430 LTCHs. It makes several key changes to payments for these providers:

Industry leaders have mixed reviews of the final rule. The Federation of American Hospitals supports the DSH payment methodology, saying that it helps to preserve hospitals’ ability to provide care to uninsured patients. The American Hospital Association (AHA) supports reversing the two-midnight policy. However, AHA raised concerns with the 1.5 percent payment reduction for coding and documentation. MACRA held the payment cut at 0.8 percent, and AHA says that the higher cut is unjustified and conflicts with congressional intent.

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On the Hill & In the Courts

FDA has lower user fees, more use of real-world evidence in new MDUFA guidance

The US Food and Drug Administration (FDA) published the third iteration of the Medical Device User Fee Amendments (MDUFA) earlier this month. Like the Prescription Drug User Fee Act (PDUFA), which addresses prescription drugs, MDUFA aims to provide the medical device industry with support and consistency throughout the FDA approval process and generates funds to support this activity through user fees.

MDUFA III is consistent with the goals set forth in PDUFA VI last month – increased hiring goals, support for real-world evidence (RWE) in decision making, and lower user fees. This is the first time the FDA has requested authorization to increase its workforce, citing an increase in applications and the need for specialized centers to keep up with rapidly innovating medical technology. The FDA also says that the investment will help it consider using RWE in the review and approval pathways.

Standard fees for medical device premarket application, reports, and efficacy for FY2017 will be $235,000 – a $27,000 decrease from FY2016 levels. Panel-track supplement fees will be $176,000 – a $20,000 decrease from FY2016 levels. Small businesses and other device developers may be eligible for even lower fees.

Related: The FDA published the goals and procedures for PDUFA VI last month, which received broad support from industry leaders and stakeholders (see the July 26, 2016 Health Care Current). In addition, earlier this month, the FDA Center for Drug Evaluation and Research (CDER) announced that it had met its goal of reviewing 90 percent of the backlogged applications a year ahead of schedule, as specified by the Generic Drug User Fee Amendments (GDUFA) of PDUFA V (see the August 2, 2016 Health Care Current). While PDUFA is not up for reauthorization until October 2017, many industry leaders have said they support Congress voting to reauthorize it ahead of schedule this year.

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Small increase in Medicare Part D prescription drug premiums for 2017

Last week, CMS released its projection for Medicare Part D prescription drug premiums for 2017. CMS predicts that, on average, premiums will increase $1.44 from $32.56 per month to $34 per month in 2017. The projection is based on bids from health plans for basic drug coverage for the upcoming benefit year, for which open enrollment begins on October 15, 2016.

Andy Slavitt, Acting Administrator for CMS, said that while stable Medicare prescription drug plan premiums help Medicare beneficiaries afford their prescriptions, he is still concerned about the impact of rising prescription and specialty drugs cost on the overall Medicare program.

Related: As described in Getting to value: What policies are on the table to manage drug prices?, health care industry stakeholders and policymakers have proposed several options for getting better value from prescription drugs, including those related to drug prices. The policy brief is intended to help readers understand the policy landscape and possible implications around emerging value-based strategies to manage drug price and spending. It describes the major policy proposals and outlines the key elements of each – the mechanisms, goals, unanswered questions, and potential unanticipated consequences – one of which is Medicare price negotiation for Part D drugs and how value may play a role.

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States make progress on price transparency efforts

Three states received an “A” grade from the Health Care Incentives Improvement Institute and Catalyst for Payment Reform on price transparency. The three states – New Hampshire, Colorado, and Maine – have established easy-to-use websites that offer comprehensive health services price information from all-payer claims databases (APCDs).

Many states have passed legislation requiring publication of health care price information but have struggled with implementation. The report offers suggestions on how states can improve health care price transparency and earn higher grades next year. The group encourages states that already collect data to make it more accessible online and, when quality information is also available, to “call out” high value options. The group also encourages states to consider opening the data to outside groups for quality and cost analysis.

While many states require providers and insurers to disclose their prices to patients prior to a procedure or service, the report says that disclosure is not a substitute for comprehensive publication of price information.

Many health care services can vary in price by more than 50 percent. If states can ensure access to health care services quality and cost data, they may be able to help consumers make more informed health care choices.

Related: Public Citizen also released a report looking at health care cost transparency across states. The report said that though 19 states have built or are building APCDs, most are not comprehensive, current, or even publicly accessible. Six states publish data on the costs of medical procedures online, but often the information is hard to search.

(Source: Francois de Brantes and Suzanne Delbanco, “Report card on state price transparency laws,” Catalyst for Payment Reform, July 2016; Vijay Das, “Shedding light on health care prices: Patient perspectives on health care price transparency efforts,” Public Citizen, August 2016)

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Around the Country

CMS outlines how states can streamline Medicaid and CHIP eligibility with

CMS will allow states to automatically send people who apply for Medicaid and are deemed ineligible to the federally facilitated exchange (FFE). CMS announced this in a recently released bulletin on federal requirements for timely determination of eligibility and coordination across insurance affordability programs. The goal is to better coordinate eligibility determination and enrollment among Medicaid, Children’s Health Insurance Program (CHIP), and the FFE.

The Affordable Care Act (ACA) required states to establish a coordinated system of eligibility and enrollment. Consumers must be able to submit a single, streamlined application to the state or federal exchange or the state Medicaid or CHIP agency, receive an eligibility determination, and be enrolled in the appropriate program. State agencies and exchanges must coordinate to minimize the burden on consumers and provide a seamless path to the right coverage.

The bulletin is targeted at states that use or do not have a shared eligibility system for determining eligibility to Medicaid/CHIP and marketplace plans. Generally, states are required to refer ineligible applications for Medicaid/CHIP to the FFE and assess whether the individual may qualify for subsidies. However, CMS says that it may be difficult to use Medicaid/CHIP applications for determining people’s eligibility for financial support with the FFE premium and cost sharing.

Moving forward, states can automatically treat people who are ineligible for Medicaid/CHIP as potentially eligible for exchange plans. This excludes people who are denied or terminated for a procedural reason or because they do not attest to US citizenship or lawful presence. Once the state makes a final eligibility determination, it must inform that person and the FFE of the decision.

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Brain games and AI help in the fight against Alzheimer’s disease and dementia

New research shows for the first time that older adults who play computer-based brain training games can cut the risk of developing Alzheimer’s disease and other forms of dementia and cognitive loss even years later. If the research is scalable, this would be the first intervention, including drugs, diet, and exercise, with these results.

Researchers presented the results of the study at the Alzheimer’s Association International Conference in Toronto. The study is from the US government-funded ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly) study, which has been going on for nearly two decades and is tracking almost 3,000 healthy older adults. In the study, the older adults (the average age at the time they started the study is 74) received one of three forms of cognitive training or none. The control group, who received no training, had 14 percent of its participants with a diagnosis of dementia ten years later. In the group that completed up to 10 sessions of computer-based training lasting 60-75 minutes, 12.1 percent developed dementia during that time period. The training tested how quickly and accurately participants could pay attention to, process, and remember brief images on a computer screen. Of those who completed all 10 initial training sessions as well as four booster sessions a few years later, 8.2 percent developed dementia.

In related news, researchers out of VU University Medical Center in Amsterdam recently published research showing that applying artificial intelligence (AI) algorithms to MRI brain scans may help physicians automatically distinguish between patients with Alzheimer's disease and two early forms of dementia that can be precursors to the disease. The research suggests that this approach could eventually allow automated screening and assisted diagnosis of various forms of dementia.

Analysis: More than 5.4 million Americans are living with Alzheimer’s disease. It is the sixth leading cause of death in the US. By 2050, rates of the disease could nearly triple if left unchecked. After decades of research, however, scientists are coming up with significant breakthroughs that treat the disease – not just the symptoms. As new drugs make their way through the pipeline, the health care community is also working to improve early diagnosis.

The National Alzheimer's Coordinating Center's database shows that the median time between the initial onset of symptoms and a clinical diagnosis of Alzheimer’s disease is 4.5 years. Many researchers believe that early intervention is critical to halting the effects of the disease, potentially improving the lives of millions of patients and their families. The Alzheimer’s Readiness Project, an initiative of Eli Lilly and Company, outlines five policy recommendations necessary to reach the goal of early diagnosis and treatment:

(Sources: National Alzheimer’s Coordinating Center, 2016; Alzheimer’s Readiness Project, Eli Lilly and Company, 2016)

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Breaking Boundaries

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