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Veterans from Iraq and Afghanistan withmental health disorders are more likely to use,and possibly abuse, prescription opiates thanthose without mental illness, according to an

article in the most recent edition of theJournal of the American Medical Association.

As a result, providers in the Midwestsometimes struggle to confront the issue.

The study looked at more than 140,000veterans in the VA Health Care system withpain diagnoses that were not cancer relatedbetween autumn 2005 and the end of 2010.

A total of 11% were prescribed opioidsfor 20 or more consecutive days. Researchersfound that patients with mental healthdisorders, particularly post-traumatic stressdisorder, were the most likely to receiveopioid prescriptions.

The individuals who were most likely tobe prescribed opiates (33.5%) were veteranswho had comorbid PTSD and drug usedisorders.

These results are not surprising to me,said Sujatha Ramakrishna, M.D., a psychiatristin private practice outside of Chicago.Someone with a mental health disorder ismore likely to have an addiction becausethere is a mind/body connection.

Pain medication relieves pain, but alsohas a psychological affect, she said. It canrelieve the feelings of stress that come along

with anxiety, depression and, particularly,PTSD.

If you take Demerol and it makes youcalmer, you will make that connection and

want to take more and more, Ramarkrishnasaid. People develop a tolerance to it andhave to increase it and that is how addiction iscreated.

This addictive trend was borne out in thestudy. Veterans with post-traumatic stressdisorder were more likely to have high-riskbehaviors like receiving greater doses ofopioids, getting two or more at the same time,taking hypnotics concurrently and obtainingearly rells.

PTSD, especially for soldiers, stems fromsome sort of physical trauma being hit by abomb or jumping out of a plane, said E.

Cameron Ritchie, M.D., a retired Armycolonel now working as chief clinical ofcerof the District of Columbia's Department ofMental Health

She said the issue of pain and addictionwas brought to the attention of the Army sometime ago, eliciting the creation of a PainManagement Task Force. The group completeda report in May 2010 providing 109recommendations to standardize Army-provided pain care.

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June 11-13

April 25

Calendar

13 March 2012

April 27-28

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Midwest Edition

Veterans Struggling With AddictionVA, Other Providers Confront Issues With Opiates

Continued on Next Page

E-Mailinfo@payersandproviders.comwith

the details of your event, or call(877) 248-2360, ext. 3. It will be

published in the Calendar section,space permitting.

WEBINAR Thursday, March 29, 2012 Noon CD

REDUCING READMISSIONS:COLLATERAL EFFECTS

Please join Warren Hosseinion, M.D., chief executive officer, Apollo Management ExecutiveDirector, Association for Community Health Improvement, and Daniel Cusator, M.D., vicepresident of The Camden Group, to discuss the upcoming changes on avoiding preventablereadmissions and their financial impact on hospitals, physicians and patients.

http://www.healthwebsummit.com/pp032912.htm

http://www.ihi.org/offerings/Training/ScienceofImprovement/SOIApril2012/Pages/default.aspxhttp://www.ihi.org/offerings/Training/ScienceofImprovement/SOIApril2012/Pages/default.aspxhttp://www.ihi.org/offerings/Training/ScienceofImprovement/SOIApril2012/Pages/default.aspxhttp://www.ihi.org/offerings/Training/ScienceofImprovement/SOIApril2012/Pages/default.aspxhttp://www.ihi.org/offerings/Training/ScienceofImprovement/SOIApril2012/Pages/default.aspxhttp://www.ihi.org/offerings/Training/ScienceofImprovement/SOIApril2012/Pages/default.aspxhttp://www.ihi.org/offerings/Training/ScienceofImprovement/SOIApril2012/Pages/default.aspxhttp://www.ihi.org/offerings/Training/ScienceofImprovement/SOIApril2012/Pages/default.aspxhttp://www.ihi.org/offerings/Training/ScienceofImprovement/SOIApril2012/Pages/default.aspxhttp://www.ohanet.org/http://www.ohanet.org/http://www.ohanet.org/http://www.ohanet.org/http://www.ohanet.org/http://www.ohanet.org/http://www.ohanet.org/http://www.ohanet.org/http://www.ohanet.org/http://www.mbgh.org/MBGH/NewItem1/Events/EventDescription/?CalendarEventKey=16435153-3324-490c-8589-2fffc740f647http://www.mbgh.org/MBGH/NewItem1/Events/EventDescription/?CalendarEventKey=16435153-3324-490c-8589-2fffc740f647http://www.mbgh.org/MBGH/NewItem1/Events/EventDescription/?CalendarEventKey=16435153-3324-490c-8589-2fffc740f647http://www.mbgh.org/MBGH/NewItem1/Events/EventDescription/?CalendarEventKey=16435153-3324-490c-8589-2fffc740f647http://www.mbgh.org/MBGH/NewItem1/Events/EventDescription/?CalendarEventKey=16435153-3324-490c-8589-2fffc740f647http://www.mbgh.org/MBGH/NewItem1/Events/EventDescription/?CalendarEventKey=16435153-3324-490c-8589-2fffc740f647http://www.mbgh.org/MBGH/NewItem1/Events/EventDescription/?CalendarEventKey=16435153-3324-490c-8589-2fffc740f647http://www.mbgh.org/MBGH/NewItem1/Events/EventDescription/?CalendarEventKey=16435153-3324-490c-8589-2fffc740f647http://www.mbgh.org/MBGH/NewItem1/Events/EventDescription/?CalendarEventKey=16435153-3324-490c-8589-2fffc740f647http://www.healthwebsummit.com/pp032912.htmhttp://www.healthwebsummit.com/pp032912.htmhttp://www.healthwebsummit.com/pp032912.htmhttp://www.ohanet.org/http://www.mbgh.org/MBGH/NewItem1/Events/EventDescription/?CalendarEventKey=16435153-3324-490c-8589-2fffc740f647http://www.ihi.org/offerings/Training/ScienceofImprovement/SOIApril2012/Pages/default.aspx

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Payers & Providers Page 2

Top Placement...Bottomless Potential

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In Brief

Cap On InsuranceBenefits Lifted For

Millions Of Americans

The U.S. Department of Health and

Human Services has estimated that105 million Americans no longer havelifetime limits on their health insurancebecause of prohibitions on spendinglimits in the Affordable Care Act.

According to HHS, approximately95 million of these people hademployer-sponsored plans; the rest hadprivate insurance. Individuals on theprivate market were more likely tohave benet limits, with 89 percenthaving some sort on their plans in2009, according to statistics from theKaiser Family Foundation.

The mandate to get rid of lifetimelimits has impacted approximately 28million children, with the remainder of

the 105 million split almost equallybetween adult men and women.Midwestern states with the largestnumber of individuals whose planshave changed include Illinois, with 4.6million; Ohio, 4.1 million; Michigan,3.5 million; and Indiana with 2.2million.

Minneapolis NamedNations Healthiest City

The metropolitan area surroundingMinneapolis ecently ranked as thehealthiest in the nation on Forbesmagazinesannual ranking of fitcities.

The rankings are based on theAmerican College of SportsMedicines Fitness Index. The reportgrades 50 metro areas across thecountry and creates a compositescore based on factors includingpreventive health behaviors,prevalence of chronic diseases,

Continued on Page 3

NEWS

Vets (Continued from Page One)

These suggestions included creating a cultureof pain awareness through education andintervention, encourage and support research

in pain management and build a suite of bestpractices for acute and chronic pain care.

Ritchie said the task force recommendedusing alternative methods of treating pain like acupuncture or NSAIDs. This is a viableoption, but one that is not always easy toprovide.

Take acupuncture, which we know hasgood data in treating pain and is helpful withPTSD, she said. The challenge is there arenot enough people in the military system, oranywhere, to provide enough treatments. Also,we dont have a rigorous database to supportcomplementary medicine.

By contrast, opioids appear to work moreeffectively and quickly. Therapies such yogatake time and willingness on the part of apatient and physician, according to Ritchie.For acute pain, things like opioids are veryappropriate, she said. For more chronicpain, thats where we need to start looking atalternatives.

About half of all veterans go to the VA forcare. That means the other half use civilianproviders, making this an issue for everyone.But if the extensive medical record system atthe VA cant curtail the issue, it will be thatmuch more difcult elsewhere.

Catherine Johnson, a pharmacist at thWilliam S. Middleton Veterans MemorialHospital in Madison, Wis., said she is alert

if she tries to ll a prescription early.It is easier in the VA because we have accto the data, she said. It would be moredifcult to coordinate in private institutionthere was movement in the private sector fhigh alerts, it would help reduce abuse.

Providers can be proactive in stoppingissue as well.

Patients looking to abuse medicationtypically have tells if a physician knows whto look for, Ramakrishna said. Sherecommended watching for patients whofrequently make excuses (like losingmedication, or saying they didnt get the ri

number from the pharmacist) for getting reearly. Another indication is someone whofrequently asks for increased doses.

The best way to know if someone mighave an issue is to screen them well beforewriting a prescription. Ask questions like hfrequently they drink alcohol, if they havetried illegal drugs (if they say no, they areprobably lying, Ramakrishna said). If thereany question, alternative medications ortreatments are best.

A careful history is very important interms of weeding out who might have aproblem and who wont, Ramakrishna sa

A Closer Look At The Safety NetReport Makes Post-ACA Recommendations

A report released last week by theCommonwealth Fund Commission on a HighPerformance Health System offersrecommendations to sustain and supportsafety net hospitals facing changes underhealth reform.

Deborah Bachrach and colleagues atManatt Health Solutions created the reportwith the anticipation that low Medicaidpayments, an inux of Medicaid patients anda reduction in disproportionate share fundingunder the Affordable Care Act may bringchallenges to the already-strapped institutions.

Medicaid is currently the largest payer atsafety net hospitals, according to the report. In2014, the number of Medicaid patients willincrease an estimated 17 million of thosecurrently uninsured will become Medicaidrecipients.

The report, Toward a High PerformanceHealth Care System for VulnerablePopulations: Funding for Safety NetHospitals, offers ways to reward performaat and target public dollars toward safety nhospitals.

One of the commissionsrecommendations is to increase Medicaidrates to safety net hospitals that meet qualtargets and deliver accessible, reasonablypriced care.

While targeting enhanced Medicaidpayments to hospitals based on their safetystatus is far from ideal, the report said, thedo contend that tying payments toperformance and improvement targets, woffer a means to address quality and accesconcerns at a time when state Medicaid raare otherwise low and state resources limit

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Page 3Payers & Providers

Longer ALOS!*

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(877) 248-2360, ext. 2

*For our ads, not your hospital

NEWS

In Brief

access to care, policies supportingphysical activity and crime levels.Minneapolis ranked first becauseof its benefits like low poverty andunemployment levels, lowprevalence of chronic conditionslike cardiovascular disease, asthmaand diabetes. They also have

abundant parkland andplaygrounds, farmers markets andpublic transportation. The residentstend to be physically active, havelower smoking rates and are apt tobike or walk to work.

Other Midwestern metro areasranking in the top 50 include:Denver at 5, Cincinnati, 14;Milwaukee, 21; Kansas City, Kan.,22; St. Louis, 26; Chicago, 28; andIndianapolis, 45.

Worth Named Payers &Providers Editor

Veteran journalist Tammy Worth hasbeen named editor of the Midwestedition ofPayers & Providers.

Worth, who is based in KansasCity, replaces Duncan Moore. Herwork has appeared in The Economist,the Los Angeles Times, WebMD,Health.com, Todays Hospitalistandthe Kansas City Business Journal.

Worths work has receivedhonors from the SuburbanNewspapers of America and theKansas Press Association. In 2008, shewas named a fellow of the Association

of Health Care Journalists.Worth earned a masters degreein journalism from NortheasternUniversity and a bachelors degree inEnglish from the University ofMissouri at Kansas City.

Tammys deep experience incovering healthcare business issueswill make her an invaluable asset toPayers & Providers, particularly as wemove forward with a publication andwebsite redesign and expand thewebinar offerings to our Midwestreadership, said Publisher RonShinkman.

The U.S.Department of Health and HumanServices last month released rules regardingtransparency for health insurers. The mandatesare for insurance plans not grandfatheredunder the Affordable Care Act; they are meantto provide clarity regarding benets forenrollees and applicants.

Implementation of some of theseprovisions is taking place currently and otherswill be phased in over time. Following is anoutline of the provisions:

Uniform summary of coverage Whenhealth plans are renewed this coming fall,insurers will have to provide applicants and

enrollees a uniform summary of benets andcoverage. This will provide information about

coverage, limits, exclusions and cost-sharing.This rule is in part meant to help consumersevaluate plans to be provided in the insuranceexchanges in 2014.

Transparency in coverage disclosures Plans will also be required to disclose otherpertinent information on plans including:claim reimbursement reliability, adequacy ofprovider networks, enrollment data, number ofclaims denied and information on cost-

sharing and payments to out-of-networkproviders.

Quality reporting for private healthinsurance This Secretary of HHS must creareporting requirements for group andindividual health plans dealing with coveredbenets, reimbursement to improve outcomand implementing wellness activities. Thegovernment is hoping that providing this levof transparency will increase competitionamong insurers in the exchanges and helpindividuals compare plans.

Healthcare.gov was launched in July2010 by HHS to help individuals and small

businessesnd affordable health insurance.The site provides information about private

policies in ones insurance market, Pre-Existing Condition Health Insurance programstate high-risk pools, Medicaid and theChildrens Health Insurance Program.

Healthcare.gov will offer standardpremium information for plans, rejection ratand surcharges based on underwriting andcost sharing. It will soon provide the numbeof policies that are rescinded, percentage ofdenied claims and appeals on denied claims

outward to 60 and 90 days, the rates werealso about 25 percent lower.

Other studies have borne out theseconclusions as well. A 2010 study fromAmericas Health Insurance plans four a 12percent to 18 percent lower 30-dayreadmission rate for Medicare Advantage thtraditional fee-for-service when comparing ahandful of states data.

To explain these differences, the studyauthors hypothesize that Medicare Advantarecipients may have healthier behaviors andstronger support networks because the planbuild in incentives for these things. MedicarAdvantage plans may be more likely to payfor things like transitional care, posthospitalization care coordination, pharmacyreconciliation efforts and disease-specicprevention programs.

Affordable Care Act initiatives mayreduce these numbers in the future.

MA Plans Can Reduce ReadmissionStudy Concludes Double-Digit Reductions Possible

A study in the February issue of theAmericanJournal of Managed Care found enrollees inMedicare Advantage plans had 13% to 20%lower hospital readmission rates within 30days of discharge than those in traditionalMedicare plans.

Researchers compiled MedicareAdvantage readmission rates between 2006and 2008. They compared results with a study

of Medicare fee-for-service rates from thesame time period by Stephen Jencks andcolleagues.

Both studies looked at 30-day hospitalreadmission rates and adjusted results basedon factors including demographics, geography,entitlement status and diagnosis.

Over the three-year period, theunadjusted 30-day readmission rate forMedicare Advantage patients consistentlyhovered around 14.5 percent. TraditionalMedicare rates were 19.6 percent. Looking

HHS Issues Transparency RegulationsInsurers Have to be More Open to Consumers

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8/2/2019 Payers & Providers Midwest Edition Issue of March 13, 2012

4/5

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Payers & Providers Page

That healthcare consumes 17% of U.S. grossdomestic product is alarming, but the changein Americans' health status is equallystaggering. The increasing prevalence ofchronic illness among Americans poses majorchallenges to the medical profession and theentire healthcare system.

Nearly half of all Americans live with atleast one chronic condition. Care for thesepatients is complex. One study found that thetypical primary care doctor has the potential tointeract with as many as 229 other doctors.

The latest Commonwealth FundInternational Survey examines care

coordination, chronic care management, andpatient engagement among"sicker" adults in 11 nations . Inthe U.S., 23% of respondentswith chronic conditions saw fouror more doctors over the lastyear. Medication management forsuch patients is particularly complicated; 46%said they were taking four or more prescriptiondrugs on a regular basis.

Not surprisingly, the survey found problemswith care coordination. Patients said that theyoften experienced problems obtaining medicalrecords and test results, which increased with

the number of doctors seen.Coordination is a multifaceted activity that

requires effective participation among manydifferent professionals and serviceorganizations. While there is strong evidencethat a key to successful chronic caremanagement is engaging patients in their care,only about half of those with chronicconditions in the U.S. say that their regulardoctor always tells them about treatmentoptions and involves them in decisions.Physicians also still function as soloists: studieshave shown that only 35% said that improvedteamwork and communication are very

effective ways to improve quality of care.The chronic care model has been developed

and tested over the past 15 years. So the realchallenge is not what to do, but how to do it. Itis a question of execution, and even more so ofscalability.

Fortunately, medical education is adaptingto the changing landscape. Increasingly youngdoctors in training are exposed to teamworkboth across medical specialties and acrosshealth professions, including nursing andpharmacy.

But the environment in which physicianspractice also needs to change to support thesecare models. The Affordable Care Act provideunique opportunities to organize the deliverysystem and build a strong primary care practicinfrastructure that will help improve carecoordination. For example, the law establishethe Primary Care Extension program, which wbe administered by the Agency for HealthcareResearch and Quality to provide support toprimary care providers.

A number of training demonstrations willinvest in coordinated care teams that includeprimary care physicians, midlevel providers s

as nurse practitioners, and community-basedsocial services providers. Graand contracts will supportmedical homes throughcommunity health teams, therincreasing access to coordinacare.

Given these opportunities, how will we kwhether we are successful? First, we need to sexplicit short- and longer-term targets andmonitor progress. Perhaps we can go from 58patients saying they are engaged in their care 70% in 2013, and 90% by 2023. These measuof coordination and engagement could certai

be tracked as new models of care such as medhomes and accountable care organizations arimplemented.

The important lessons here are that we neconcerted effort and an overarching strategy tsupport the changes in the delivery systemrequired to achieve seamless care and the heaoutcomes we seek. Tracking progress withcomparative information and performancebenchmarking is essential. Attention needs to given to strengthening primary care and todeveloping multidisciplinary teams that canoversee the care of people over time. We neeensure practices receive technical assistance t

help them redesign the way they deliver care.

OPINION

Addressing The Chronic Care CrisisImproving Outcomes Is Linked to Better Coordinatio

Anne-Marie J. Audet, M.D., is vice presiden

health system quality and efficiency at The

Commonwealth Fund. Shreya Patel is a

Commonwealth Fund program associate. T

op-ed is adopted from a blog entry they co

authored.

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By

Anne-Marie J. Audet,

M.D. and Shreya

Patel

Op-ed submissions of up to 600 words are

welcomed. Please e-mail proposals to

editor@payersandproviders.com

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8/2/2019 Payers & Providers Midwest Edition Issue of March 13, 2012

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