Why does the U.S. spend so much more on healthcare? It’s the prices

Dr. John Cullen’s four-physician family medicine practice in Valdez, Alaska, employs three full-time staffers who work on insurance and patient billing. A fourth full-timer focuses on obtaining prior authorizations from nine private and public insurers.

Even then, Cullen and his partners often must call and write letters to convince insurers to approve coverage or pay claims.

“It’s an incredible bureaucratic mess to get anything done for patients,” said Cullen, president-elect of the American Academy of Family Physicians.

In contrast, Dr. Trina Larsen Soles’ 12-physician general practice in Golden, British Columbia, has one full-time staffer assigned each day to billing the province’s public medical services plan, its public workers’ compensation plan and its quasi-public auto insurance company. She and her colleagues don’t get involved in billing or utilization-review issues.

“It’s not a big hassle,” said Larsen Soles, president of Doctors of BC, which represents British Columbia physicians in fee negotiations with the provincial health plan. “I can focus on patient issues, not administrative issues.”

The sharp difference between the two doctors’ experience partly explains why the U.S. healthcare system has much higher administrative costs than Canada and other countries. Those costs, plus much higher prices for medical services and pharmaceuticals and much higher pay for physicians and nurses, were the major reasons the U.S. spent a larger share of GDP on healthcare in 2016 than 10 other wealthy nations, according to a recent study in JAMA.

The authors said the huge spending gap—17.8% of GDP in the U.S. versus an average of 10.8% in the other 10 countries—was not primarily driven by the factors that often get the blame. Those commonly cited culprits include excessive utilization caused by the U.S. fee-for-service payment system, defensive medicine prompted by liability worries, underinvestment in social programs, and a low mix of primary care to specialty care.

The JAMA study findings reinforce doubts about whether the current U.S. policy mantra of shifting from fee-for-service to value-based payment, plus adopting high-deductible health plans to squeeze out unnecessary care will be the silver bullet to reduce spending. Instead, the authors suggest the need for measures aimed directly at bringing down the prices of drugs and medical services.

“We do have some overutilization, and value-based programs can help,” said Dr. Ashish Jha, a professor of global health at Harvard and a co-author of the article, which was based on data from the Organisation for Economic Co-operation and Development. “We completely have a price problem. MRIs cost twice as much in Kansas as in London, and that makes no sense.”

“We don’t want to tackle the issue of prices so we defer the discussion to things we think we can deal with, like the differences in quantity,” added Gerard Anderson, a health policy professor at Johns Hopkins University who has studied international systems.

More administrators

Eight percent of U.S. healthcare spending went to administrative costs incurred by private and public insurers, compared with an average of 3% in the 10 other wealthy countries, the JAMA authors found.

That 8% figure doesn’t include billing and insurance-related activities by hospitals and physician offices. Including those costs would bring the share of U.S. healthcare spending on administrative costs up to about 14%, according to Dr. Steffie Woolhandler, a health policy professor at Hunter College.

A 2013 Health Affairs study co-authored by Woolhandler found that administrative costs accounted for 25.3% of U.S. hospital spending in 2010, compared with 19.8% in the Netherlands, 15.5% in England, and 12.4% in Canada.

For example, Minnesota-based HealthPartners employs about 200 full-time staff to handle back-end billing and collection work for its one hospital and 36 clinics and specialty locations, a HealthPartners spokesman said.

In contrast, the University Health Network in Toronto, which has six hospitals including Toronto General and 1,272 beds, has just 5.5 full-time-equivalent employees handling insurance billing and patient collection activities, a UHN spokeswoman said. Meanwhile, its CEO was one of the highest-paid hospital managers in the province of Ontario with a 2017 salary of $558,000 (C$720,000) at recent currency rates, according to the Canadian Broadcasting Corp. The median base salary of a stand-alone hospital CEO in the U.S. in 2017 was $550,000 and with bonuses and incentives that rises to $648,000, according to Modern Healthcare’s Executive Compensation Survey.

It’s the same story for doctors. Physician practices in Ontario spent just 27% as much per physician per year on interactions with insurers as U.S. physician practices spent, according to a study published in Health Affairs in 2011.

Those administrative cost disparities arise from starkly different payment systems. While the U.S. has hundreds of private and public payers that each set their own rates with providers and drugmakers, the other 10 countries either have a single public health plan or have private insurers that pay the same nationally negotiated prices.

“We have a much more complicated healthcare system than anyone else, so it’s no surprise that the cost of administering it is so much higher than in any other place,” Jha said.

The profit motive

Some analysts say the mandate to maximize revenue is an inseparable part of a U.S. system that is more profit-oriented than systems in other countries. “It’s the ideological model,” said Aaron Katz, a lecturer in global health at the University of Washington who has studied the U.S. and Canadian systems. “The system is perfectly designed to provide opportunities for organizations to make money.”

At the urging of business consultants, U.S. providers have boosted revenue by breaking out separate fees for every service item, such as OR recovery room time, in contrast to much simpler billing in other countries, Rosenthal said. At the same time, U.S. patients have come to expect fancy, hotel-like facilities and amenities, far different from the utilitarian facilities abroad.

Even so, she and others say identifying villains is not productive. “How did we get to this crazy place nobody likes?” Rosenthal said. “Everyone wants to name a bad guy—insurers, drugmakers, high salaries. But it’s kind of all of the above.”

Nevertheless, many experts agree with the JAMA study’s conclusion that high prices and administrative costs, more than overutilization, are to blame for this country’s singularly high healthcare spending.

That won’t change until the people who pay the bills start using their clout to push down prices, Johns Hopkins’ Anderson said.

Indeed, it may be starting to happen with the January announcement that three corporate powerhouses, Amazon, Berkshire Hathaway, and JPMorgan Chase, are teaming up to tackle healthcare costs.

“When American corporations say we are no longer willing to pay 50% more than Medicare for the same service, we’ll have a discussion about healthcare spending,” he said. “Until then, we’ll be talking around the edges.”

Jha’s preferred solutions are for Medicare to take the lead in trimming provider payments for certain overpriced specialist services, and for the government to more aggressively enforce antitrust laws to prevent providers from consolidating to raise prices.

The University of Washington’s Katz, who sees no evidence that market competition works in healthcare, wants to see the government set overall spending levels and payments to providers and drugmakers, as other advanced countries do. “But that would impair everyone’s revenue and profit growth, and the U.S. players don’t want to hear that story,” he said.

Any spending reduction effort would have to lighten the crushing administrative burden associated with the numerous U.S. payers each setting their own payment rates and coverage policies.

Cullen, the family physician in Alaska, said he tried to persuade a Canadian doctor who works a few months a year at his office to join his practice full-time. She turned him down flat due to the hassles she’s experienced in dealing with U.S. insurers.

“She’s just horrified with what we do here,” Cullen said with a laugh. “This is a crazy system.”

By: Harris Meyer

Epic CEO Judy Faulkner reveals two new EHR versions are in development

The new versions will provide pathways for providers who don’t need the full version of Epic.

What a difference one year can make. In the world of Epic founder and CEO Judy Faulkner, where creating new technology meets with a delight for words, 2016 was a productive and rewarding year.

How so?

“We’re developing some really nifty new software,” she told Healthcare IT News on Sunday after attending the daylong CHIME-HIMSS CIO Forum at HIMSS17.

“There’s going to be three versions of Epic,” Faulkner said. “That’s what we’re working on now. There’s Epic Sonnet.” She pauses to note that an “epic” is a long poem – as in Homer’s Odyssey. As she put it, “even though we’re computer scientists, we can still be literate.”

Sonnet, she said, is the smaller poem. She describes Sonnet, which is now in development, as Epic technology with some of the features removed. It has a lower price point, and it can be just the right technology for organizations who don’t need the features of the full Epic EHR. Then, there’s yet another version, one between the full Epic EHR and the Sonnet. Both will provide a path toward upgrading to the full product.

“We’re finding that people need different things,” she said. “So, if you are a critical access hospital, you don’t need the full Epic. The two new versions of Epic in development can provide a pathway to adding all the features at a later time.

And then there’s “Caboodle” – the name of Epic’s data warehouse. “I don’t like boring words,” Faulkner said.

The trade name for Epic’s analytics suite is Cogito, from the Latin phrase “cogito ergo sum” – “I think, therefore I am.” In mid-2016, Epic renamed the data warehouse portion of the suite  “Caboodle” and Faulkner is now working on Kit – as in Kit & Caboodle. “Kit is making everything very open,” Faulkner said.

Faulkner seems to relish her work and is buoyed by it. Is there any time when it becomes a grind?

“Some parts do,” she replied. “Sometimes what becomes a grind is not the work itself, but how long it takes and how much of my life it takes and how little I have for other things.”

However, there are rewards – for example, knowing that there are so many drug-to-drug interactions – a quarter million – averted through Epic system alerts.

She’s also pleased that Epic customers have done well financially, she said. Yes, Epic EHR installations are known to cost millions of dollars. But, Faulkner has done the math and created charts. Over the years 2004 to 2015, and across all healthcare organizations, she believes that Moody’s and Standard & Poor’s statistics demonstrate that Epic customers reaped profitability unsurpassed by clients who implemented her competitors’ EHRs.

For Faulkner, 2016 was a very good year, indeed. From June through December, family members from around the world visited her and her husband in Madison, she engaged in work she loved, and she was often inspired.

Who inspired her the most in the past year? It was Mona Hanna-Attisha, MD, the doctor who — with the help the Epic EHR at Hurley Medical Center in Flint, Michigan — discovered the extent of the Flint water crisis.

“If we did not have Epic, if we did not have EMRs, if we were still on paper, it would have taken forever to get these results,” Hanna-Attisha was quoted as saying.

Healthcare organizations praise CMS’ overhaul of EHR incentive programs

LAS VEGAS — After CMS administrator Seema Verma announced plans to overhaul of the federal electronic health record incentive programs, healthcare organizations are wondering how those plans will unfold and whether they’ll meet the stated goal of boosting interoperability.

Details on the changes have been few and far between. The Office of the National Coordinator for Health Information Technology will continue to work with the CMS to figure that out, said ONC head Dr. Donald Rucker.

“The goal is to really get information flowing and to put patients in control,” Rucker said. The government might do that by pushing open APIs, which Rucker has called the “most transformative” tool for interoperability.

Whether the overhaul will achieve that depends on what it includes and on how providers and others react to it, according to some healthcare organizations. Here, a sampling of what the industry had to say about what it wants to change and whether it can expect the changes to affect interoperability.

“If they still push interoperability and the C-CDA and have good API requirements, the overhaul will work well.”

— Micky Tripathi, CEO, Massachusetts eHealth Cooperative

“The focus is on interoperability and patient access to data. But I don’t see how it could be easier if we’re going to focus on the things that are toughest. TO me, what needs the overhaul is the quality payment program.”

— Naomi Levinthal, practice manager, Advisory Board

“The overhaul and interoperability go hand in hand.”

— Kathy Mosbaugh, vice president of healthcare analytics, LexisNexis RiskSolutions

“It’s exciting to see the federal government taking such significant action to ensure data follows the patient. We’ve long known the value of understanding claims data at the clinical point of care and hope other sources of data—such as that with commercial payers—will soon follow suit and better support needs of individuals.”

— Meg Marshall, senior director of public policy, Cerner

“Interoperability requirements were deferred for many years. The thing that made me optimistic is that there’d be no more deferrals. But I worry about the Trusted Exchange Framework and Common Agreement, which could set back interoperability by years.”

— Carl Dvorak, president, Epic Systems Corp.

“We applaud the freeing of CMS data for patients, and we echo CMS’s sentiment that the deep burden afflicted on healthcare that is associated with documentation must be alleviated. While we wish CMS would also take this opportunity to recognize and work with ONC on the burden that the EHR certification program places on users of those products, we recognize CMS’s objective as being well-meaning.”

— Kyle Armbrester, chief product officer, Athenahealth

“We are hopeful the ACI overhaul outlined today will move us away from prescriptive measurements and toward using technology to improve patient health outcomes and patient access to data. We look forward to working with the administration in fleshing out the details to ensure that physicians get to spend more time caring for their patients and less time on administrative tasks.”

— Dr. David Barbe, president of the American Medical Association

“CMS’s announcements this week underscore the growing importance of health IT in care delivery as the move to value-based reimbursement continues to accelerate.”

Atrium Health to merge with Navicent

Atrium Health, previously Carolinas HealthCare System, and Navicent Health signed a letter of intent to merge, the organizations announced Thursday.

The merger of not-for-profits would give Atrium Health a regional presence in Georgia, opportunity to expand to other areas and bolster its service lines. Macon, Ga.-based Navicent, which would become part of Atrium, would gain access to capital and benefit from spreading costs over a wider patient base.

The announcement came a day after Carolinas HealthCare changed its name to Atrium, in part because it wanted a name that didn’t limit it to a certain geography.

“As not-for-profits continue to come together to build scale to drive affordability, care quality and cost savings, we are doubling down on that idea, and shouldn’t be limited to inside the state lines,” said Gene Woods, president and CEO of Charlotte, N.C.-based Atrium. “Navicent has a regional hub in Georgia and we can help broaden the community they serve, and possibly create a model for further expansion.”

Both organizations, which operate on Cerner’s electronic health record, are committed to caring for vulnerable communities and improving access, said Navicent President and CEO Dr. Ninfa Saunders. Saunders also co-founded Stratus, a collaboration of physicians and hospitals that aims to fill information gaps to better care for rural communities.

“This gives organizations around us an opportunity to join us,” she said. “Hopefully there is a catalytic function to this strategic combination.”

Whether it’s a certain service line, a favorable payer mix or additional access points, health systems have targeted particular regions to grow, picking up where national players have struggled to manage costs and realize a return.

Navicent is building Beverly Knight Olson Children’s Hospital in Macon, Ga., which complements Atrium’s Levine Children’s Hospital in Charlotte, Woods said. There are also opportunities to expand oncology lines, post-acute care, telemedicine and behavioral health services.

“Sharing our infrastructure and analytics will give us the ability to better manage populations and identify best practices,” Woods said.

Atrium, the largest hospital system in North Carolina, is also pursuing a mergerwith UNC Health Care, based in Chapel Hill, N.C.

2018 Outlook on Politics and Policy: Insurers will come out ahead

Despite a year of policy delays, glitches and uncertainty, insurers may be the ones to come out ahead of other segments of the industry in 2018. Uncertainty and policy confusion will no doubt continue this year since House and Senate Republicans are already on different pages when it comes to healthcare reform.

Now that the GOP’s $1.5 trillion tax overhaul is done, House Speaker Paul Ryan (R-Wis.) is setting his sights on entitlement reform as a way to rein in costs. This could mean trimming welfare, Social Security and Medicaid, but he has signaled Medicare provider cuts are also on the table.

In the Senate, Majority Leader Mitch McConnell (R-Ky.) and members of the GOP leadership consortium—Sens. John Thune of South Dakota and John Cornyn of Texas—say they want to go the bipartisan route and look at individual market stabilization measures proposed by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.)

But then GOP Sens. Bill Cassidy of Louisiana and Lindsey Graham of South Carolina want to revive their proposal to block-grant federal money for Medicaid and the Affordable Care Act exchanges. This idea was killed last summer during the Senate’s failed attempts to repeal the ACA.

Medicaid, which Republicans wanted to convert to a capped per-person payment structure, could get new attention.

“It makes a lot of sense,” Thune said.

Meanwhile, President Donald Trump could use executive branch power to continue striking major blows to the ACA’s individual market risk pool.

So 2018 is shaping up to be another sink-or-swim year in healthcare: Adapt to the new rules—or lack of rules—or try to write them yourself.

Who’s going to do well in this environment? Whether you look at Centene Corp. in the individual market or the likes of UnitedHealthcare, CVS Health and Aetna competing for greater market share, including the Medicare Advantage space, the payer community is poised to fare well in the new Wild West of policy. This despite the fact that last year’s tax overhaul effectively killed the individual mandate by eliminating the penalty for people who fail to obtain coverage.

For other stakeholders—hospitals and providers who have watched helplessly as key programs lapsed without Congress mobilizing to fund them, or the Trump administration pivoting on value-based payment initiatives—the future isn’t necessarily so bright.

As we tumble into 2018, Congress still has a long must-pass, way-beyond-deadline healthcare agenda. But from what’s known, here’s an early look at Modern Healthcare’s projected winners and losers in 2018.

UNFINISHED BUSINESSLawmakers return to the nation’s capital with a lot of work left over from 2017.

• Children’s Health Insurance Program: The short-term budget patch approved in late December added $2.9 billion to CHIP, funding it through March.

• Medicare extenders: The enhanced low-volume adjustment and the Medicare dependent hospital program were lost in the shuffle in the weeks leading up to the short-term spending deal.

• Affordable Care Act taxes: There have been some bipartisan conversations about delaying the Cadillac tax, the employer mandate, the health insurance tax and the medical-device tax, but both sides are still talking about compromises to pay for them.

• Individual market stabilization: The government is paying out more in premium tax credits now that cost-sharing reduction payments are gone. There’s a rift within the GOP on how to handle CSRs.

• Opioid epidemic: Leading senators on both sides want to give President Trump’s public health emergency declaration heft with funding, but so far they haven’t agreed to a number.

• Drug pricing: Health committees in both the House and Senate have started to look at drug pricing and HHS Secretary-designate Alex Azar addressed the issue at length in his first Senate confirmation hearing.

Providers and vendors team up for user-friendly EHRs

Before an Allscripts electronic health record appears on screen, it first appears on a storyboard—sometimes even a paper one. That’s where Allscripts developers can test new ideas on providers, figuring out what should go where.

“The design on paper is still at the basic level where we can change on a dime,” said Ross Teague, director of user experience for Allscripts Healthcare Solutions. Users usually feel more comfortable offering feedback on a design when it looks unfinished.


THE TAKEAWAYElectronic health records are notoriously clunky. Vendors, with the help of their provider clients, are out to change that.
Such interaction is crucial, given that clinicians spend about half the workday working with EHRs. And many of those hours are during patient encounters. A study in the Annals of Internal Medicine found that ambulatory physicians spent more than a third of their time with patients on EHR and desk work tasks. That makes many providers unhappy, and not just because it affects their face-to-face time with patients.

“The challenge of established EHRs is that so much functionality gets piled onto these complex systems,” said Dr. Titus Schleyer, a research scientist with the Regenstrief Institute.

But as providers complain, vendors respond. Allscripts, Athenahealth, Cerner Corp. and Epic Systems Corp. are among those constantly tweaking their software after getting feedback from the source of those complaints. They’re consulting with and observing users inside and outside of their natural work environments to build EHRs for efficient—and pleasant—workflows, layouts and functionality.

Most, if not all, major EHR vendors rely on a combination of formal user testing, informal feedback, and what might be called ethnographic research. The result isn’t just happier clinicians but safer healthcare delivery.

“Many of the same issues that can lead to clinician frustration with EHRs can also lead to safety problems,” said Ben Moscovitch, manager of health information technology for the Pew Charitable Trusts. For instance, if a clinician accidentally orders a medication for the wrong patient, correcting the error can be cumbersome, requiring multiple steps, he said. The EHR can be tweaked to address that.


A partnership

With healthcare perpetually inching toward value-based care, EHRs are more important than ever in helping patient care. Vendors are working with providers to improve their offerings, going beyond meeting the bare minimum federal requirements for their software.

Athenahealth, Allscripts and others have formal programs to gain insight from their provider users both while software is in development and after. “That relationship has really improved the way the system works for us and, I would presume, because of the way Athena works, for all of its customers,” said Steven Kelley, CEO of Ellenville (N.Y.) Regional Hospital, which, as an Athenahealth development partner, tries out prototypes with new features.

That kind of relationship also helps vendors, which learn from their users early on what kinds of features they’re interested in and how those features should work.

“In a good user-centered design process, you’re involving your users early and often,” Allscripts’ Teague said. His company does formative testing with its users during which they engage in the aforementioned and try new versions of the software. “This is the No. 1 method by which we collect patient-safety issues before they ever become patient-safety issues,” he said.

Allscripts also gets new product ideas by observing clinicians in care settings. Sometimes, for instance, to get an objective sense of how well its software works, Allscripts will measure how many users can complete a certain task without any training.

Observational research is particularly helpful given how providers talk about what they want from their EHRs. “Sometimes, what people say only reflects part of what their goal is,” said Janet Campbell, Epic’s vice president of patient engagement. “If you give a doctor a list of 10 activities in the record and you say, ‘How many of these would you like to see on the screen?’ they’ll say, ‘All,’ ” she said. “It’s not until you watch how they interact and move back and forth that you realize that they only need three of those things.”

When Athenahealth is testing a feature in the alpha or beta stage, the company uses behavioral analytics to glean how users are interacting with it. “One of the benefits of being cloud-based is that all the data across our network is very accessible, and we can see the actions people are taking,” said Scott Mackie, Athenahealth’s executive director of strategy design and user experience.

For instance, when the company was developing a timeline feature, users complained about how many clicks it took to see everything that had happened to a patient over time. Athenahealth developers watched how the timeline affected workflow so developers could lay it out to highlight the most useful and appropriate events and data. Giving clinicians the information they need when they need it could help them better care for patients, since it would reduce their workload and help identify important elements quickly. “Physicians want the right information at the right time at the right point of care, and that helps them provide better care,” said Rich Berner, Allscripts’ senior vice president of health systems and population health solutions management.

Presenting information, not data

Part of the reason vendors must revise and tweak EHRs is because of their complexity, Schleyer said. It’s hard to design a program that’s usable “right out of the box.”

To deliver a more consistent patient and user experience across its facilities, SSM Health consolidated its three versions of Epic into one. “We called the project that we worked on ‘simple elegance,’ ” said Philip Loftus, SSM’s chief information officer. “If it took you five screens to do something, we tried to bring that down to two or three screens.”

The improvements came from Epic’s collaboration with SSM and from SSM’s own developers, who get regular feedback from physicians and from consumers surveyed after the health system updates software.

One request was to display all information relevant to patients’ care on one screen.

Physicians want all of that information at the top level, Mackie said. “They want less digging,” he said. A solution could be building artificial intelligence into the EHR so it learns the most important information, he said. Another solution might be voice, especially as it becomes more common in consumer life.

Increased population health efforts also have vendors considering how new kinds of data should be presented.

“People aren’t asking for data—they’re asking for information,” Teague said. “That means fitting it into their workflow and making sure it’s presented in a way where they’re not spending a lot of cognitive effort determining what it means.”

Top heart hospitals zero in on continuum of care

Before cardiac surgery patients are discharged from St. Luke’s Boise (Idaho) Medical Center, they are referred to the hospital’s cardiac rehabilitation program.

The 12-week program offers routine monitoring by clinicians for patients who recently underwent open-heart surgery, a valve replacement or any other type of cardiac procedure.

The rehab center is staffed with a multidisciplinary team of healthcare professionals including physicians, nurses, respiratory therapists, dietitians and social workers. The program provides patients additional education about their disease, help with personal issues that might prevent them from following the treatment plan, and exercise and nutrition courses that can help speed their recovery.

About 95% of cardiac surgery patients enroll in the program, and it has contributed to lower readmissions since it launched in 2009. About 14.7% of heart attack patients are readmitted to the hospital after 30 days, below the national average of 16.8%.

“We try to standardize follow-up within our practice,” said Dr. Stefanie Fry, chair of the department of cardiovascular services at St. Luke’s Boise.

The sharp focus on ways to address every aspect of the care continuum is a hallmark strategy of St. Luke’s Boise and other hospitals recognized this year in the Watson Health 50 Top Cardiovascular Hospitals (formerly known as the Truven Health 50 Top Cardiovascular Hospitals) study. Hospitals considered to be leaders in cardiac care standardize and invest in approaches that not only improve the health of their patients during their inpatient stay but long after discharge as well.

Focus on the continuum of care is in line with the move to value-based payment, said Jean Chenoweth, senior vice president of the Center for Performance Improvement at IBM Watson Health.

“Value is starting to increase over time,” Chenoweth said. “When hospitals are focused on the continuum of care and they don’t let it go, they maintain their focus on that quality of care and the industry changes as a whole.”

The 19th annual study reviewed 1,016 hospitals and recognized 50 that provide exemplary care in one of the industry’s largest specialties. Heart disease is the leading cause of death for men and women in the U.S., accounting for 1 in 4 deaths every year. And each year about 735,000 Americans have a heart attack, according to the Centers for Disease Control and Prevention.

The 50 hospitals on Watson Health’s list scored higher than their peers on clinical outcomes for heart attack and heart failure treatments, as well as coronary bypass and angioplasty surgeries. The hospitals performed better on mortality and complications, as well as 30-day mortality and readmissions. On average, their procedures cost less and patients had shorter hospitals stays.

Similar to previous years, Watson Health divided the top hospitals into three categories—15 teaching hospitals with a cardiovascular residency program, 20 teaching hospitals without such residency programs and 15 community hospitals.

To get its results, Watson Health uses the most recent CMS data from the Medicare Provider Analysis and Review file, CMS Hospital Compare and Medicare cost reports. Watson Health also added two new measures this year to its analysis: 30-day episode payment for heart attack and heart failure patients. The additional measures reflect the movement toward population health management as hospitals are expected to manage the quality of care of patients after discharge, said Julie Shook, 100 Top program director of value-based care at Watson Health.

Chenoweth said it’s increasingly difficult for 50 Top hospitals to beat their peers because cardiovascular care overall is improving. Indeed, the 50 Top hospitals performed less than 1% better than peers on 30-day mortality and readmission rates for heart failure, heart attack and coronary artery bypass surgery patients.

“The fact is quality is improving in cardiovascular care over time,” Chenoweth said. “The hospitals are benefiting from newer technology and treatments.”

The vast majority of the 50 hospitals being recognized for their cardiac care were veterans on the list, but there were also eight newcomers, including Wake Forest Baptist Medical Center, a teaching hospital in Winston-Salem, N.C. The hospital has recently focused on ways to prevent costly readmissions and streamline post-discharge care among its heart patients, said Dr. David Zhao, chief of cardiovascular medicine at Wake Forest.

In 2014, the hospital began to incorporate pharmacy technicians into the discharge protocol. The patients receive a 30-day supply of their prescribed medication before they leave the hospital, up from just a seven-day supply. The longer time period ensures patients stick to their medication regimen and have time to sort out a prescription refill, Zhao said.

Additionally, 48 hours after patients are discharged, a nurse calls to check in on their health status and to make sure they are following the care plan. A mandatory follow-up appointment also occurs at the hospital seven days after discharge.

The hospital has seen its readmissions rate fall since the initiative was launched. “We can understand if there are issues medication-wise, or with their living circumstances like transportation—those are things we can catch earlier and intervene so they won’t be readmitted,” Zhao said.

But ensuring appropriate follow-up with patients after discharge isn’t without challenges. Wake Forest cares for a large rural and Medicaid population, so the hospital needs to coordinate care for complex patients, Zhao said.

“Enough manpower has always been a challenge,” he said. “Who is going to make phone calls to patients and make sure they can care for themselves?”

Anthem CEO Joseph Swedish to retire

Joseph Swedish is retiring from his post as CEO of Anthem, the second-largest health insurer in the nation.  Swedish will be succeeded by Gail Boudreaux, the former CEO of UnitedHealth Group’s insurance arm.   The leadership shift has been in the works for a year, Swedish said, and the company plans to make the announcement Monday. It is unclear when the official transition will occur.

Swedish’s career in healthcare spans more than four decades. He has worked for Indianapolis-based Anthem, a licensee of the Blue Cross Blue Shield Association, since 2013 when he replaced Angela Braly as president and CEO. He became chairman in 2015.  Before Anthem, Swedish was CEO of Livonia, Mich.-based Catholic hospital system Trinity Health, an office he took in 2004.

During his tenure, Swedish saw Anthem’s annual revenue balloon from $71 billion in 2013 to $84.9 billion in 2016. Anthem serves about 40 million members in 14 states.

He led the insurer in its effort to acquire rival insurer Cigna Corp. in a deal valued at $54.2 billion. The contentious tie-up was ultimately abandoned after being challenged by the U.S. Department of Justicce for threatening to harm competition.

Anthem last month announced the formation of its own pharmacy benefit manager, IngenioRx, in the wake up its fallout with long-term PBM partner Express Scripts.

Swedish made $16.5 million in total compensation in 2016, according to documents filed with the SEC.