Monday, June 27, 2016

Value Based Purchasing/Value Based Payment (VBP)

VBP has had more than one evident goal since its inception. There continues to be speculation concerning the degree to which one or more dominate the impetus for the model’s emergence. For example, in 2003, CMS began to pilot a hospital VBP model, which has since also been utilized by private insurers to discourage “inappropriate, unnecessary, and costly care” (Sultz and Young, 2014, p. 152). Two parameters, i.e. “clinical processes of care measures and “patient experience of care measures” (p. 152) as modifiers to hospital reimbursement. Hospitals performing well would receive financial benefit, while the reverse would be true for poorly performing hospitals (Advisory Board, 2015).
A “Triple Aim” for the VBP model is captured with the following introductory statement in the VBP publication from CMS, from Sylvia Mathews Burwell, Secretary of the U.S. Department of Health and Human Services: “Whether you are a patient, a provider, a business, a health plan, or a taxpayer, it is in our common interest to build a health care system that delivers better care, spends health care dollars more wisely and results in healthier people (CMS, 2015, p. 1).” Similar and yet somewhat different are the Institute for Healthcare Improvement’s Triple Aim elements of: population health, per capita cost and the patient experience (Institute for Healthcare Improvement, 2016). Of interest, that while the patient experience is not specifically mentioned with the HHS statement, it is prominent in the VBP model.

In addition to quantity of care, other measures include: “The quality of care provided to Medicare patients; How closely best clinical practices are followed…How well hospitals enhance patients’ experiences of care during hospital stays. How well they perform on each measure; or How much they improve their performance on each measure compared to their performance during a baseline period” (CMS, 2015, p. 1).
For 2016, the “domains” include: clinical process of care, patient experience of care, outcome, efficiency (p. 2).  These differ somewhat through 2018. For a fuller description please see the entire CMS document listed in the reference list.
In reading the elements contained within process of care, it appears they would be included within the concept of evidence-based clinical guidelines. The application of evidence based medicine is an attempt to standardize care, with the expectation that by doing so, there will be less variation in patient outcomes (Sultz and Young, 2014, pp 228-229). Outcomes can refer to what effects did providers have on their patients. Did they get better; did they get worse; were they cured; did they die; how did you change their quality of life; did you keep them healthy or make them healthier (Sultz and Young, (2014).
The measure for efficiency with the CMS VBP model is “Medicare Spending per Beneficiary” (CMS, 2015, p. 4). Of interest, the denominator is not cost divided by outcome or by process.
            Patient experience is measured by HCAHPS scores (CMS, 2015). The question arises as to how does the patient experience fit in with the other domains, and to what extent is it congruent with better care, healthier populations, greater efficiency, providing the right care or obtaining the best outcomes?
To what extent has VBP been successful relative to outcomes: Researchers, evaluating 100% Medicare inpatient claims data from 2008 through 2013, for patients admitted with “acute myocardial infarction, congestive heart failure, and pneumonia” concluded:  “Evidence that HVBP has led to lower mortality rates is lacking. Nations considering similar pay for performance programs may want to consider alternative models to achieve improved patient outcomes” (Figueroa et al, 2016).
In its first three years of implementation, GAO reported in a report from late 2015: “Medicare's Hospital Value-Based Purchasing Program has not yet led to increases in care quality overall… even before the program began in October 2012, hospitals had been improving in how consistently they followed basic clinical guidelines… improvement continued but did not increase with the advent of the financial incentives. The same was true for patient ratings, on such items as the quality of communication from doctors and nurses, and for mortality rates for heart attack patients. Heart failure and pneumonia death rates stayed roughly the same” (Rau, 2015). GAO further concluded “Our analysis found no apparent shift in quality measure trends during the initial years of the program, but such shifts could emerge over time as the program implements planned changes (Rao, 2015).”
The principles of VBP have become more pervasive in their application to more than just Medicare and to more than just hospitals, but have been adopted by many insurers and now apply to many types of providers. Miller (n.d.) provides an extensive analysis of VBP in terms of evident issues and makes suggestions for how these issues could be resolved. Below are some “cases” illustrative of some of these issues:
Issue: Physicians are penalized for caring for complex, high risk cases.
Case: A patient with diabetes and hypertension has been non-compliant with medication usage and diet. The physician practices evidence-based medicine, ordering all the “right tests,” all the
“right medication,” all the right “education and counseling.” The physician is employed by a health network and some part of “pay,” is linked to “productivity.” While the physician has practiced evidence-based medicine, the patient has poor outcomes. The patient continues to be unhappy with the care, because he does not like the restrictions the physician is trying to impose on his diet. Because patients such as this require an extensive time commitment from the physician, taking on such patients severely hamper the physician’s ability to meet productivity targets for enhanced “pay.” What is the likely reimbursement “penalty” because of likely poor outcomes and patient dissatisfaction? How likely is the practice to continue to make such high risk patients a major part of its care, knowing the likely reimbursement penalties?
Advisory Board Company (October 6, 2015). One of Medicare's big value-based programs has delivered little value so far, GAO says
Department of Health and Human Services, Centers for Medicare & Medicaid Services. (September 2015). Hospital value-based purchasing. Retrieved from
Figueroa,J., Tsugawa, Y.,  Zheng, J.,  Orav, J., &  Jha, J. (May, 9, 2016).   Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: Observational study. BMJ 353 doi: Retrieved from
Institute for Healthcare Improvement (2016). IHI triple aim initiative. Retrieved from
Miller, H. (n.d.). Measuring and assigning accountability for healthcare spending: Fair and effective ways to analyze the drivers of healthcare costs and transition to value-based payment. Retrieved from
Rao, J. (October, 2, 2015). Hospital care unaffected by quality Payments, GAO finds. Kaiser Health News. Retrieved from
Sultz, H., & Young, K. (2014). Health care USA (8th ed.). Burlington, MA: Jones and Bartlett.

Submitted by Dr. Walter Markowitz, Adjunct Faculty, Saint Joseph's College

Tuesday, May 03, 2016

National Nursing Home Week!

National Nursing Home Week will be observed May 8-14 this year.  Each year, the week that begins with Mother’s Day is recognized as National Nursing Home Week.

This year’s theme, established by the American Health Care Association, is “It’s a Small World with a Big Heart.”  The theme celebrates the great diversity found among nursing home residents and staff.  Increasingly, nursing homes are becoming educated on the provision of culturally appropriate care.  A few years ago, I talked with an administrator from New York City who said, “I’m the Catholic administrator of a Jewish nursing home where I have Muslim employees providing care to Buddhist residents.” 

In another urban nursing home, there were several employees in housekeeping and laundry who were immigrants from the same country.  They wanted to become United States citizens.  Several residents were retired teachers.  They made a deal:  tutoring in exchange for lessons about their native culture.  These ladies gave sessions on their native food, dress, dance, art, music, holidays, etc.  It was a great experience that strengthened their relationships.  The residents celebrated with them when they became citizens.  Indeed, big hearts know no cultural, geographic, or religious boundaries.

Nursing home residents are increasingly using the internet.  They can keep up with family members who live at a distance, share with friends through social networking, and learn from educational sites.  Internet availability is shrinking the world of seniors. 

Residents are often honored for the contributions that they have made to their families, communities, and the world.  By listening to their stories, we can often discover extraordinary talents and influence that they have had. 

During this week, nursing homes around the country will celebrate in a variety of ways.  We recognize and honor both residents and employees.  Often, devoted long-term care workers put in long hours under challenging circumstances to assure that residents get the care they need and deserve.  Be sure to express your appreciation to long-term care staff, residents, and volunteers this week.  

Contributed by Phil DuBois, CNHA, FACHCA, SJC Program Manager, LTCA

Tuesday, April 19, 2016

Good Samaritan Laws

What do you think of when you hear about Good Samaritan Laws?  A duty to help those in need?  Protection when you provide CPR to a stranger?  Many people have heard of the law, but few are aware of how different the laws are from state to state.

Good Samaritan Laws are state statutes, which means that individual state governments have approved these laws in their states.  Some states choose to use the law to provide immunity to those who assist in emergency situations while other states actually require bystanders to help.  Here is a relative breakdown:
  • Most of the 50 states provide immunity to those who administer care in emergency situations
  • 8 states provide no immunity to private individuals not meeting certain criteria
  • 24 states provide immunity for physicians rendering emergency care in a hospital
  • 6 states exclude rendering emergency care in a hospital from Good Samaritan coverage
  • 2 states require a duty to assist; if it is a reasonable emergency, physicians must assist
  • (Source:
What does this mean for the average citizen who wishes to help out in emergency situations?  The answer is not clear, unfortunately.  A quick internet search will help you find the Good Samaritan Law in your state.  Most states will protect individuals who choose to assist injured people in emergency situations, as long as they use reasonable precautions and are of sound mind (i.e., have not been using drugs or alcohol).  The best advice is to offer help if you feel comfortable doing so at the time, but always be aware of your safety, as well.

Provided by Valerie J Connor, MA CCC-SLP, Adjunct Faculty, Saint Joseph's College.

Wednesday, April 06, 2016

Technology and Health Risk

Technology is proliferating our world.  It has many great uses and it has made our lives easier in many ways; however, it can cause significant health problems if it not used within moderation.  These problems can affect both children, teens and adults, but technology overuse can be more harmful to developing brains.

Technology Statistics

u  56% of children 8-12 years old have cell phones; all but 4% have data phones (National Consumers League, 2012).
u  72% of children 8 and under have used a mobile device for a media activity
u  38% of children under 2 have used a mobile device
u  Children average 7.5 hours of entertainment technology time per day (American College of Pediatricians, 2014)

As of March 2013
u  78% of American teens have a cell phone (98% of adults ages 18-29)
u  47% of American teens have a smart phone
u  32% of American teens own an e-reader
u  23% of American teens own a tablet computer
u  74% use their phones to surf online
u  93% of teens have a computer or access to one(Pew Research Internet Project)
u  94% of teens were on Facebook
u  91% had posted a personal photo
u  92% posted their real name
u  75% of all teens text with 60 texts per day being the median number of texts in a day
u  Many teens sleep with their phones(Pew Internet Research Teenage Fact Sheet)

Technology Disparities
u  In 2013 access to smart phones for low income families from 27% in 2011 to 51%
u  Access to high speed internet increased 4% from 42% to 46%
u  Tablet ownership has increased from 2% in 2011 to 20% in 2013
u  In 2011 only 22% of lower income children had ever used a mobile device; in 2013 65% have done so.
u  In 2013 35% of lower income parents had downloaded apps for their children (Common Sense Media, 2013)

Technology’s Effect on Physical Health
u  Cognitive and neural functioning (Brain Health)
u  So much has yet to be determined—particularly about students who begin technology interactive in infancy
u  Young brains are more malleable than adult brains
u  Piaget constructivist theories: Piaget noted adaptation to environment is a biological function.  This includes assimilation and accommodation which directly involve the nervous system of a child.  Piaget felt the development of individual children should not be artificially “rushed (Chirico, 1997).
u  In 1989 Hyson, Hirsch-Pasek & Rescorla (Academic Environments in Early Childhood: Challenge of Pressure) studied 4 year olds and taught a control and experimental group academic and non-academic concepts.  The academic group overwhelmingly had less creativity which is an important component of problem solving later on. There were no difference in intelligence. This is an example that changes in brain development may in fact be detrimental in some other way.  When stimulus is presented at the wrong time or in an inappropriate manner, the neural connections may accommodate in a non-preferred way.  This is thought to be one of the causes of increases in attention deficit disorder. Media and technology can also do this.  Primarily studies have been on excessive television usage which negatively affect health and academic performance.  However, students engaged with technology do not engage in physical play as their ancestors did.  Some researchers feel this lack of interaction in the physical environment can be negative.
u  Potential Negative Effects
u  Much of the research in children and technology at young ages is based on television viewing
u  Negative Effect on Enterprise skills in preschoolers:  Lilliard and Peterson (2011) in Pediatrics found just 9 minutes of viewing something fast-paces (such as a video game) for 9 minutes caused immediate negative effects on executive function tasks (such as delay of gratification and building a tower).
u  Technology is being used to entertain toddlers (such as games on a Smartphone).
u  2010  Attention Disorders: Baveliar, Green and Dye (2014) In Neuron; American College of Pediatricians noted technology causes long-term changes in behavior/brain function.  However this can be positive or negative depending on what the stimulator is.
u  Excessive multi-tasking can impact attention
u  -7 studies have shown language delays in infants exposed to excessive technology  (Strasburger et al., 2010)

Additional Negative Effects
u  Sleep disorders
u  Disordered eating
u  Tendonitis in the thumb
u  Back/Neck problems
u  Generalized health complaints (technology overload)
u  Texting when driving a car (more accidents)
u  Lack of Activity
u  Obesity (has doubled)
u  Diabetes
u  Early Onset Heart Disease
u  Decreased motor development
u  Lack of Interaction Within their Environment
u  Decreased sensory stimulation
u  Failure to achieve child development milestone (contributing cause)
u  Increased risk of smoking due to media exposure
u  Drug and alcohol abuse
u  Early sexual activity (due to exposure to media, predators, sexting, etc.)

Positive Social and Emotional Effects of Technology
u  Computer/internet access in the home can enhance academic achievement and happiness
u  Exposure to educational media at a young age has positive effects (science-based versus quasi educational); in order to be effective they must elicit direct participation and should not be passive
u  Increases feeling of social connectedness which can positively impact well-being (when done with friends and not strangers) (Strasburger et al., 2010).

Negative Social and Emotional Effects
u  Technology stress: Mental Overload (Berntsson, 2000; Haugland, Wold, Stevenson, Aaoroe & Woynarowska, 2001; Rimpela et al., 2004) includes isconnecting people from nature, play and people.
u  Lack of social boundaries
u  Lack of sexual boundaries
u  Lack of social skills
u  Decreased sense of time
u  Lack of future thinking/decreased academic performance
u  Multi-tasking with negative effect on performance
u  Increase impulsivity (Park & Hyun, 2014)
u  Isolation/loneliness
u  Depression/lack of self-esteem
u  Lack of privacy
u  An altered sense of reality
u  Increased aggression
u  Decreased well-being

Technology Addiction
u  Under consideration for inclusion in DSM V
u  Knows an Internet Addiction Disorder
u  Prevalence between 0.3 and 38%
u  China and Korea have id’ed it as a significant public health threat(Cash, Rae, Steel & Winkler, 2012; Cao & Su, 2014; Leung & Lee, 2011))
u  Similar to a gambling addiction in the way it is viewed and treated
u  Boys are more prevalence than girls (Tang et al., 2014)
u  Technology addiction treatment centers popping up through Asia
u  Includes computer addiction, Internet dependence, compulsive Internet use, pathological internet use, problematic internet use.  The anonymity factor impacts behavior and causes people to do what they might not do otherwise
u  Activated pleasure pathway in brain

4 Components of Technology Addiction
u  Excessive internet use with a loss of a sense of time and neglect of basic drives
u  Withdrawal, including feelings of anger, tension and/or depression when the computer is not accessible
u  Needing better equipment, software, hours of use
u  Negative repercussions include arguments, lying, poor achievement and social isolation (Block, 2008)

  • American Academy of Pediatricians. (2014, February).  The media, children and adolescents.  Retrieved from
  • Block, J. J. (2008). Issues for DSM-V:iInternet Addiction. American  Journal of  Psychiatry, 165, 306-307.
  • Cash, H. Rae, C.D., Steel, A.H. & Winkler, A. (2012).  Internet addiction:  A brief summary of research and practice.  Current Psychiatry Review, 8 (4), 292-298.
  • Cawley, J. (2010, March).  The economics of childhood obesity.  Health Affairs.  Retrieved from
  • Common Sense Media.  (2013, Fall). Zero to eight:  Children’s media use in America 2013.  Retrieved at
  • Chirico, D. (1997).  Building on shifting sand:  The impact of computer use on neural and cognitive development. Donna M. Chirico. Waldorf Education Research Institute Bulletin. 2 1997: 13-19. Retrieved at
  • Health and Human Services. (2013, Nov).  Teen media use part 1:  Increasing on the move.  Retrieved from:
  • iNACOL. (2013, February).  Key K-12 online learning stats.  Retrieved at
  • Ipsos Marketing Research. (2012). One in ten (12%) parents online, around the world say their child has Been cyberbullied, 24% say they know of a child who has experienced same in their community.  Retrieved from
  • Leung, L. & Lee, P. S. N. (2011).  The influences of information literacy, internet addiction and parenting styles on internet risks.  New Media and Society, 1-21.
  • Lilliard, A. & Peterson, J.. (2011) The immediate impact of different types of televisions on young children’s executive function, 128 (4), 644-649.
  • National Consumers League.  (2012, Julu 10).  Survey:  Majority of “tweeners” now have cell phones with many parents concerned about cost
  • No (2014, September 18).  Cyber bullying statistics 2014.  Retrieved at
  • OFCOM. (2013, October 3).  Children and parents:  Media use and attitudes report.  Retrieved from
  • Park, C. J. & Hyun, J. S. (2014).  Internet literacy vs. technology addiction:  Relationship analysis with time perspectives of secondary school students.  Advanced Science and Technology Letters, 59, 23-26.
  • Pew Research Internet Project.  (2012, September).  Teens fact sheet.  Retrieved at
  • Strasburger, V. Jordan, A.B. & Donnerstein, D. (2010, March 1).  Health effects of media on children and adolescents. Pediatrics, 125(4), 756-767.
  • Tang, J., Yu, Y., Du, Y., Ma, Y., Zhang, D., & Wang, J. (2014). Prevalence of internet addiction and its association with stressful life events and psychological symptoms among adolescent internet users. Addictive Behaviors, 39(3), 744-747.
  • U.S Department of Justice. (2013)  Fact and statistics:  Raising awareness about sexual abuse.  Retrieved at

Contributed by Dr. Colleen Halupa, Adjunct Faculty, Saint Joseph's College

Monday, March 14, 2016

Long-Term Administrator's Week!


Happy Long Term Care Administrator's Week!!
We extend heart-felt thank yous to Administrators in nursing homes and assisted living centers this week!
Kudos on a job well done!! 

Since 1994, ACHCA has sponsored this national observance each March.  This week we honor and celebrate the important role the administrator has in providing leadership for the delivery of quality, resident-centered care and a supportive work environment for staff. 
 For additional ways to celebrate LTC Administrators week, visit our website

ACHCA is lucky to have a member like you! Thank you for your dedication to advancing the profession and the quality of life for the most vulnerable members of our society!

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American College of Health Care Administrators
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Ph: (202) 536-5120 |

Monday, February 29, 2016

Why is Health Information Management so Important?

The Health Information Management (HIM) professional is an expert in managing all aspects of patient health information. The comprehensive knowledge that the HIM associate possesses assists in all aspects of this position, including managing that health information through health records, administering computer information systems, and collecting and analyzing patient data. Also very important is the ability to comfortably and accurately use classification systems and medical terminologies.

The HIM associate must have the ability to document clearly and support an accurate diagnosis that confirms the patient’s clinical findings, progress, and finally, discharge planning. A clear understanding of the medical foundations of patient care includes basic pathophysiology, abnormal clinical findings, and anatomy and physiology. Understanding this information is paramount to the successful HIM associate’s assurance that coding is precise, and diagnoses and outcomes are exact.

Two courses in an HIM program of study include Pathophysiology and Anatomy and Physiology. An understanding of anatomy (what’s in the body) and physiology (how it works) is the basis of all medicine. If we know how the body works, how it is put together, and what can go wrong, we can then understand the treatments and interventions that are the basis of medical treatment. The study of Anatomy and Physiology bridges the knowledge of the intricacies of the human body to the complexities of managing the data and information to medically manage a patient.

The study of Pathophysiology examines the alterations in the normal functions of the body that affects individuals across the lifespan. Understanding the mechanisms of disease processes essentially give a HIM associate the ability to recognize abnormalities and alterations in function and enable him or her to identify code-able diagnoses and/or procedures. This must be supported by a strong working knowledge of anatomy, physiology, clinical disease processes, medical terminology and even pharmacology. 

It becomes very clear with the study of anatomy and physiology that the body works in a collaborative manner to maintain balance and equilibrium. Understanding the basic knowledge of the components of the body then allows us to recognize in more detail the processes that interrupt that balance and equilibrium. A strong understanding of pathophysiology means having that ability to recognize those interruptions of the normal physiologic processes.

Consider the role of a documentation specialist in an acute care hospital. This professional is considered an HIM associate, and reviews all physician documentation in the medical record on a daily basis while the patient is in the hospital. This review ensures that treatment regimens, diagnosis and plan of care are clearly and consistently present in the record. Upon discharge, this record is then reviewed by another HIM specialist to code, or assign very specific alphanumeric numbers that are tied to how much reimbursement is realized. Everything that happens to that patient must be present and detailed clearly in the medical record. A history and physical, the first time a medical diagnosis is identified in the record, every lab value, x-ray result and treatment plan and regimen must be coded. The HIM associate has skills to not only recognize abnormal lab values and the intricacies of medical intervention, they also begin to anticipate and investigate nuances of care that may lead to even more accurate management of the medical record that results in quality data administration.

Understanding the body in as many ways as possible gives the HIM associate the skills and competencies to become an essential part of a health care team. Never has the management of patient information and data been more crucial. Not only does the HIM professional offer skills that manage the medical record, but is instrumental in ensuring that information is complete, documentation is timely, and the information that is tied to reimbursement for services rendered is accurate. Having an understanding of how the body works, and then recognizing the intricacies of disease processes assists the HIM associate in assuring quality patient care.

 Submitted by Katie Cross, MSN, RNC-OB, Adjunct  Faculty BS HIM Program