September 2014 The Role of Hospitals in
t a t e e a l t h o l i c y riefing p r o v i d e s a n o v e r v i e w a n d a n a ly s i s So f e m eH r g i n g i ssPu e s a nB d d e v e l o p m e n t s in s t a t e h e a l t h p o l i c y Medical Home Initiatives . The rapid proliferation of patient- centered medical homes (PCMH) has placed tremendous pressure on and Strategies to Secure hospitals to adapt to the payment and delivery system reforms brought Their Support and about by these initiatives. Although there has not always been a clear role for hospitals in a PCMH, Participation their absence as a partner can be detrimental to an initiative’s success given their place within the medical neighborhood. This State Health Policy Briefing, made possible through support from The Commonwealth Fund, makes the business case for hospital participation, clarifies roles for hospitals in a PCMH, and offers strategies to successfully secure hospitals’ support and participation.
Nearly every Medicaid programBy Charles in the countryTownley has and pursued Kimm one Mooney or more patient-centered medical home (PCMH) initiative, and almost half are working with commercial payers in multi-payer initiatives.1 As PCMH models spread, hospitals face tremendous pressure to adapt to the payment and delivery system reforms brought about by these initiatives. The medical home is a model of team-based, advanced primary care that seeks to support patients, coordinate care and reduce unnecessary and inappropriate utilization of acute, specialty, and hospital care. Although the evidence is still emerging,2 recent literature indicates PCMH initiatives can reduce emergency and inpatient hospital utilization.3 While keeping patients out of the hospital is a welcome outcome for most patients, families, and insurers, hospitals face reduced revenue under many existing payment arrangements. The Role Of Hospitals In Medical Home Initiatives And Strategies To Secure Their Support And Participation
There has not always been a clear role for hospitals in a system reforms are inevitable, some hospital leaders may medical home initiative, yet their absence as a partner still see PCMH as a model of care that will jeopardize can detrimentally affect a PCMH initiative’s success. The their solvency. purpose of this paper is threefold: Reduced utilization does not always mean reduced 1. Make the business case for hospital revenues. In some cases, reduced utilization is the participation within medical home initiatives; business case for participation—particularly for 2. Help the conveners and other stakeholders hospitals that have a high level of uncompensated care. leading medical home initiatives to improve or One goal of the Affordable Care Act (ACA) was to clarify the roles for hospitals in PCMH initiatives; provide coverage to the uninsured, which would, among and other things, reduce the amount of uncompensated 3. Offer conveners and other stakeholders care hospitals provide. However, the Supreme Court’s strategies to successfully engage hospitals and decision making Medicaid expansion optional for 4 secure their support and participation. states has placed additional pressure on the safety net. Disproportionate share hospitals and other safety Overall, the objective is to help align the goals of net hospitals could reduce costly and unnecessary hospital executives and primary care providers so emergency and inpatient services by diverting uninsured the two sectors can become better partners and 5 and underinsured patients to the appropriate care collaboratively support delivery models that improve settings for primary care services. outcomes, lower costs, and help all providers meet their bottom line. Reduced utilization as a business case for participation in a PCMH extends beyond the safety net. Large a c k g r o u n d a n d e t h o d o l o g y B M and urban hospitals can also benefit from diverting unnecessary emergency room visits to primary care This paper was written, in part, as technical providers. Children’s National Medical Center in assistance for four states (Montana, Nebraska, Washington, D.C., for example, negotiated contracts Pennsylvania, and West Virginia) that are developing with two of their four Medicaid managed care plans to multi-payer PCMH initiatives as part of the National shift low acuity emergency room visits to the hospital’s Academy for State Health Policy’s Multi-Payer seven NCQA-recognized PCMHs. As part of this Medical Home Learning Collaborative, supported initiative, Children’s National receives $1.50-4.00 per- by The Commonwealth Fund. The paper was member per-month (PMPM) payments, enhanced visit primarily informed by a series of key informant rates for extended hour visits and “ER redirects,” and 6 interviews and a scan of relevant literature. For a volume-based incentive payments in addition to their complete list of the interviewees, please see the Acknowledgements existing primary care capitation rates. This approach Ma k i n g t h e Bu s isection n e s s C ata the s e endf o r of H theo sbrief. p i t a l has resulted in increased access to primary care as well Pa rt i c i pat i o n i n PCMH as a reduction in the hospital’s risk of nonpayment or recoupment of charges for low acuity emergency room 7 visits by state Medicaid programs and commercial providers. Depending on market conditions, a hospital’s business case for participation in PCMH can vary. The needs and motivations of a small critical access hospital that is the “If better primary care after discharge sole provider for a rural community can be very different reduces preventable readmissions, from an urban medical center with multiple competitors then hospitals participating in a within their service area. And while those interviewed for this brief generally believed that most hospital PCMH initiative may face fewer National Academy for State Health Policy administrators are aware that payment and delivery : 2 :readmission penalties.”
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Also, while hospital initiatives to reduce readmissions Strong partnerships established through PCMH predate the ACA, new payment incentives to reduce participation can foster relationships that lead to and prevent hospital readmissions may further make greater resources, such as enhanced payment rates, the case for a hospital to participate in PCMH. In fiscal preferred network status, or grant opportunities. year 2013, CMS penalized more than 2,200 hospitals Similarly, the relationships built through increased 8 by reducing Medicare payments to those hospitals by coordination between the hospital and independent an average of $125,000. The maximum penalty for providers may increase referrals for specialist and the first year was a one percent reduction in payments; ancillary services not provided by those primary care 9 these fines are to double to two percent in fiscal year practices. 2014 and will rise to three percent in fiscal year 2015. If participation in a PCMH initiative improves a hospital’s While these penalties are assessed on hospitals, quality metrics (improved outcomes, fewer readmissions, 10 research indicates that much of what determines etc.), the hospital may attract new patients in states 14 a readmission is out of a hospital’s control, and with public reporting programs (e.g., Illinois’ Hospital 11 15 investments in primary care can help lower readmissions Report Card ). Even in states without a public reporting 16 that are not preventable by the hospital. If better program, consumers may use Medicare’s website or the primary care after discharge reduces preventable Leapfrog Hospital Survey to identify high-performing readmissions, then hospitals participating in a PCMH hospitals. Furthermore, payers and purchasers can use initiative may face fewer readmission penalties. Mount value-based insurance design to steer their patients 17 ,18 Sinai Hospital in New York City, for example, has to high-performing hospitals by removing or reducing partnered with a network of federally qualified health patient cost sharing. Results from one study, where centers (FQHCs) and other community providers to a large self-insured manufacturer provided financial expand their Preventable Admissions Care Team (PACT), incentives for employees to choose hospitals deemed a social worker-led program that reduced 30-day “safer” by the Leapfrog Group, showed evidence that 19 readmissions by 56 percent and emergency department these programs can influence patients’ choices in where use for high-risk patients by 51 percent. The program they seek care. expansion included an emphasis on ensuring patients 12 Still, it is important for program leaders to recognize visit their primary care provider within 10 days of a that one of the primary goals of PCMH (and other discharge. delivery reforms) is to reduce unnecessary hospital use, Participation may give a hospital competitive and some hospitals are better equipped to handle this advantage. In competitive markets, participation revenue loss than others. Addressing this through the in a PCMH initiative can illustrate a commitment to payment methodology (discussed later) may be the population and community health, which may create a most critical component of securing hospital support 13 competitive advantage by distinguishing a participating and participation. hospital from their non-participating competitors.
o l e s o r o s p i t a l s in a a s d e n t i f i e d b y t h e m e r i c a n o s p i t a l s s o c i a t i o n R F H PCMH I A H A (2010) • Convening affiliated physicians and building relationship between providers; • Offering information technology and capital resources to primary care providers; • Leveraging staff resources to assist in care coordination and transitional care; • Providing leadership and administrative expertise; and • Administering bundled payments—particularly in accountable care models that build on PCMH. Source: American Hospital Association, 2010 Committee on Research, AHA Research Synthesis Report: Patient-Centered Medical Home (PCMH) (Chicago, IL: American Hospital Association, September 2010), available at: http://www.aha.org/research/cor/ content/patient-centered-medical-home.pdNational Academy forf. State Health Policy : 3 :
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Th e Ro l e f o r Ho s p i t a l s i n Pa t i e n t - Ce n t e r e d Me d i c a l Ho m e In i t i at i v e s
24 through the Rhode Island Chronic Care Sustainability Initiative (CSI-RI). Engaging hospital clinics with PCMH designation—or those willing to undergo practice In 2010, the American Hospital Association (AHA) wrote: 20 transformation—can increase the number of patients “The definition and structure of most PCMH initiatives served by the initiative. do not include a unique role for hospitals.” However, the AHA went on to identify five key—although Furthermore, hospitals can ensure that their outpatient primarily administrative—ways that hospitals are able specialty clinics work closely with affiliated and non- to support PCMH development (see text box, page 3). affiliated primary care providers to ensure warm handoffs The rapid proliferation of public, private, and multi-payer and follow-up after patient referral. State policymakers can foster linkages between community hospitals and PCMH initiatives has given hospitals ample opportunity 25 to demonstrate both the capabilities discussed in the FQHCs to strengthen the safety net’s capacity for 2010 report and well as new and expanded roles. These providing comprehensive and coordinated care. In can be grouped into three main categories: Lincoln, Nebraska, two competing hospitals partnered to form a new FQHC to serve as a PCMH for low-income 1. Providing direct PCMH services; and uninsured residents when it became cost-prohibitive 26 2. Engaging patients, providers and the community; for the local public health department to continue and providing those services. 3. Influencing the market as an employer. r o v i d i n g i r e c t e r v i c e s Transitional Care. Hospitals can develop and implement P D PCMH S care transition protocols designed to provide seamless PCMH initiatives emphasize comprehensiveness, 21 care that engage primary care providers during patient-centeredness, coordination, accessibility, admissions, discharges, and transfers. Studies have quality, and safety. Hospitals have an integral role to shown that only 17-20 percent of primary care providers 27 play in ensuring these care features, both as providers reported receiving routine notification of hospital of primary care and as a partner in the medical discharges, and less than half reported receiving 28 neighborhood. discharge summaries within two weeks of their patient leaving the hospital. Further, when sent, discharge Hospital Clinics as Participating PCMH Providers and 29 Neighbors. If a PCMH initiative’s goal is to reach as many summaries often lack important information on pending patients as possible, stakeholders will need to consider tests, discharge medications, and follow-up plans. the proportion of primary care services already being States are actively working to improve care transitions provided by hospital outpatient departments. The between hospitals and primary care practices through growth of accountable care organizations (ACOs) and new and expanded staff roles and better use of health 22 integrated delivery systems has caused a resurgence in information technology: hospitals’ acquisition of primary care practices, and • Rhode Island’s two health home programs for as a result, hospitals are providing a higher percentage individuals with behavioral health conditions require of direct primary care services. For example, the participating community mental health organizations primary care clinic at Boston Children’s Hospital serves and opioid treatment programs to employ hospital 23 30,31 more children than any other primary care practice in liaisons that provide transitional care services and Boston. assist in discharge planning. Rhode Island is one state that has formally engaged • As part of the Michigan Primary Care Transformation hospital-based primary care practices in a multi-payer Demonstration Project (the state’s multi-payer PCMH initiative—both Memorial Hospital Family Care PCMH initiative), practice-embedded care managers Center and South County Hospital Family Medicine are receiving real-time hospital admission, discharge, receive PCMH payment incentives and supports and transfer notifications through a new program National Academy for State Health Policy : 4 :
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o u t h o u n t y o s p i t a l a k e f i e l d h o d e s l a n d S C H (W , R I ) South County Hospital’s participation in the Rhode Island Chronic Care Sustainability Initiative (CSI-RI) began with their outpatient primary care clinic, South County Hospital Family Medicine. Motivated by a mission of improved community health and an understanding that broad delivery and payment reforms were on the horizon, the hospital expanded its role in CSI-RI and implemented a “Patient-Centered Medical Community (PCMC).” The hospital hired nurse care managers and shared their services across both the outpatient primary care clinic and independent CSI-RI practices. South County Hospital received a $90,000 grant from the Rhode Island Foundation to launch the PCMC. Under the original CSI-RI contract, the hospital also received $1.50 per-member per-month from public and private payers to cover the nurse care managers’ time—although the hospital has supplemented these payments with their own funds. A behavioral health care manager was added to the PCMC after an additional $65,000 in grant funding was received in 2013, and the hospital received an additional $75,000 from CSI-RI as part of a community care team pilot. Source: Phone interview with Louis Giancola, February 24, 2014; http://www.rifoundation.org/InsidetheFoundation/OurBlog/ TabId/106/PostId/19/foundation-makes-163-million-in-grants-first-half-of-2013.aspx; http://www.pcmhri.org/files/uploads/ CHT%209%2013%2013.ppt Note: A sample copy of the South County PCMC/Specialty Compact can be found at: http://www.pcmhri.org/files/ uploads/04%20Sample%20Compact-South%20County_0.pdf.
32 that leverages the state’s health information of five full-time-equivalent staff—operate within each exchange. of the state’s health service areas. Public and private payers share the $350,000 annual funding for each Shared Care Coordination and Case Management Services CHT, which assist local PCMH providers and provide a to Independent Primary Care Practices. The investments 33,34 connection between primary care and community-based and infrastructure needed for a primary care practice to 35 services. Local hospitals have primarily undertaken undergo PCMH practice transformation are significant, this role. and many smaller independent primary care providers simply lack the resources to hire care managers or invest n g a g i n g a t i e n t s r o v i d e r s a n d t h e in a new interoperable health information technology. E o mm u n it P y , P , Hospitals may be in a position to create an economy C of scale for smaller practices by reallocating or hiring Given their size and scope, hospitals have ample new staff and offering shared services across the opportunities to engage patients, providers, and the different providers in local community as a the community. These whole. By leveraging these services can either be “Hospital-based care team members can opportunities, hospitals provided centrally at help identify patients who may be eligible or can take on communication the hospital or co- benefit from the model and connect them to roles that have the located within the primary care.” potential to both improve primary care practices. the design of a PCMH initiative and increase patient participation. In addition to Rhode Island (see text box, above), Vermont is an example of a state where hospitals Patient Outreach and Enrollment. Hospitals are in a provide shared wrap-around services for smaller unique position to identify, educate, and enroll patients practices—particularly those in rural settings. The in a PCMH initiative, particularly those patients that Vermont Blueprint for Health requires that one multi- inappropriately utilize the emergency room. Hospital- disciplinary community Nationalhealth teamAcademy (CHT)—comprised for State Health Policy based care team members can help identify patients : 5 :
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l l i s edicine c h e n e c t a d y e w o r k E M (S , N Y ) After a state commission consolidated Schenectady’s three hospitals into one, Ellis Medicine (the remaining hospital) centralized outpatient services at one of the former hospitals to create a “medical mall.” Through a community-driven process, additional services connecting patients with local resources were added, such as a free shuttle van from soup kitchens, homeless shelters, and mental health facilities. The campus’ primary care clinic (Ellis Family Health Center) has also received Level-3 NCQA PCMH recognition. Ellis Medicine has since partnered with a local FQHC and visiting nurse service, which were together recognized as one of New York’s first health homes under the state’s Section 2703 health home state plan amendment. Sources: Email from David Smingler, Received January 20, 2014; Phone Interview with Margaret Meagher, David Smingler, and Kellie Valenti, February 3, 2014.
39 who may be eligible for or benefit from the model and meet National Committee for Quality Assurance (NCQA) connect them to primary care. States have begun to PCMH recognition standards. pay for outreach; for example, New York Medicaid pays Community Engagement. Ongoing community engagement health home providers (which include hospitals) 80 during program planning and implementation is integral percent of the full care management payment for up to 36 to a successful PCMH initiative. Due to greater available three months to fund patient outreach and engagement resources and a broader scope, hospitals may be activities. better equipped than primary care providers to survey Reducing unnecessary and inappropriate use of the the needs of the community (see text box, above). emergency department is especially beneficial for This is particularly true after the ACA, which required hospitals that provide a disproportionate share of tax-exempt non-profit hospitals to conduct similar uncompensated care. Hospitals have had nurses, social community health needs assessments and adopt an 40 workers, and community health workers identify super- implementation strategy to address those needs at least utilizers and connect them to primary care. For example, every three years. community health workers at the University of Cincinnati Furthermore, hospital discharge staff may have existing Medical Center identify patients with 25 or more annual relationships with community-based service providers visits to the emergency department. These patients are and most hospitals already employ social or community connected with a local non-profit community service health workers familiar with resources available to provider that works to address the patients’ health 37,38 patients. Northeastern Vermont Regional Hospital, for care needs and connect them to a PCMH to reduce example, leveraged their Community Connections program inappropriate trips to the emergency department. when launching the state’s first CHT (described earlier). Provider Training. Successful PCMH initiatives require a As part of their work, the hospital employs community workforce trained to operate in inter-professional care health workers who assist at-risk patients navigate the teams. Hospitals are well positioned to educate their staff health care system, including helping patients obtain 41 on the roles and responsibilities in such an initiative. In insurance, find a primary care provider, and connect with particular, teaching hospitals have a unique opportunity financial and transportation support services. to incorporate PCMH education into their curricula for n f l u e n c i n g t h e a r k e t a s a n m p l o y e r residents and fellows in both primary care and specialties. I M E The New York Department of Health received a $250 As discussed in a previous NASHP issue brief, individual 42 million grant from the Centers for Medicare & Medicaid organizations with size and clout have the power to 43 Services (CMS) to launch a Hospital-Medical Home influence the marketplace. As the second largest source Demonstration program, which provides funding for the of private sector jobs in the nation, hospitals have state’s teaching hospitals to train primary care residents National Academy for State Health Policy tremendous purchasing power that may be leveraged to and transform their outpatient primary care clinics to : 6 : promote and grow PCMH.
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44 n i q u e o l e s a n d onsiderations f o r i ff e r e n t Promising evidence shows PCMH provides a return Uy p e s o fR o s p i t a l s C D on investment for employers. In their roles as large T H employers and purchasers of health care, hospitals There are many different types of hospitals, and have an opportunity to design their employees’ benefit each hospital’s role within a PCMH initiative can vary packages to promote PCMH by waiving or reducing cost depending on circumstances (see Table 1). For example, sharing when seeking care from participating providers. rural and critical access hospitals are likely to have very For example, South County Hospital in Rhode Island different priorities and resources compared to large has designed their employees’ benefits package so that urban hospitals. Nearly a quarter of all Americans receive Ke y Considerations45 t o In f o r m 46 co-payments are waived when visiting designated PCMH Ho s p i t a l En g a g e m e n t a n d Pa rt i c i pat i o n care from rural hospitals, which are often the sole source providers. of care in a community. As such, these hospitals already provide a greater share of non-traditional outpatient services, including primary care, home health, skilled nursing, and assisted living. Before discussing how policymakers and other As one of the primary sources of care in their local stakeholder can engage hospitals in a PCMH initiative, delivery system, rural and critical access hospitals may it is important to address a few key considerations that be in a position to take the lead in developing the inform the process. Specifically, PCMH program leaders PCMH initiative. In some communities, such as those need to understand which types of hospitals are being with very few or even no primary care providers, these engaged, determine whether the PCMH initiative will 47, 4 8 hospitals can be the only providers in a position to take place within a larger accountable care program, and lead such an initiative. However, these hospitals identify and address any legal concerns that would arise typically serve more vulnerable populations and receive from their participation. lower reimbursement for their services, so they often
Table 1: Overview of Unique Roles and Key Considerations by Hospital Type
Hospital Key Considerations for Securing Support and Unique Roles and Opportunities Type Participation
Already provide a greater share of non-traditional outpatient services, including primary care, home health, Rural/ May require a greater level of financial support from skilled nursing, and assisted living Critical stakeholders to invest in the new technology, facility Access May be in a position to take the lead in the development upgrades, and care coordination necessary to implement of a PCMH initiative given role as the primary source of the PCMH model due to lower reimbursement care in local delivery system Market conditions may influence willingness May be in a position to create economies of scale Large/Urban to participate in initiative with competitors; for smaller practices by reallocating or hiring staff alternatively, participation may create competitive or investing in technology advantage for those that choose to participate Opportunity to train the next generation of Providers’ competing priorities of clinical care, Academic providers on interdisciplinary teams and the PCMH research, and teaching make it more challenging to model find time to implement and sustain a PCMH model Non-Profit/ Required by the ACA to conduct a community Supporting PCMH model can help mission-driven Community needs assessment and adopt an implementation hospitals provide whole-person care and meet the strategy to address those needs every three years medical and psychosocial needs of the community National Academy for State Health Policy : 7 :
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49 lack resources necessary to invest in new technology If an ACO—either hospital- or physician-led—can or upgrade their facilities. In order to successfully achieve success without working with their partners in 57 implement a rural PCMH initiative, payers, policymakers, the larger medical neighborhood, there is a reduced and grantmakers may need to provide greater financial incentive to better coordinate and integrate care. support to these small hospitals. However, ACOs may achieve even greater success when hospitals and physician groups work together. Many Similarly, as discussed earlier, academic medical centers 58,59,60 experts believe that a strong primary care base is key may find themselves with unique opportunities and to an ACO’s success, and physician groups benefit concerns compared to non-teaching hospitals. The Ohio from strong hospital partnerships when their patients General Assembly capitalized on this opportunity by require emergency services or inpatient admission. creating a PCMH education advisory group tasked with Stakeholders have opportunities to structure ACO working with medical and nursing schools in the state to 50,51 contracts to incentivize coordination, such as dedicating develop curricula to prepare graduates to work within the payments for enhanced primary care services and PCMH model. However, while teaching hospitals have 61 aligning physician performance measurement with the an opportunity to train the next generation of providers tenets of PCMH. For example, Illinois’ Accountable Care on working within interdisciplinary teams and the PCMH 62 Entities will be measured on their members’ access to model, competing priorities of providing clinical care, primary care providers, well-care visits, and screenings. research, and teaching make it more challenging to find 52 Program leaders may also wish to encourage hospitals time and resources to implement and sustain these and physicians to develop shared governance models for models. 63 ACOs to better identify and overcome barriers to working h e r o w t h o f c c o u n t a b l e a r e o d e l s across the continuum of care. T G A C M The rapid growth of ACOs is o t e n t i a l e g a l o n c e r n s an important consideration P L C As hospitals formalize relationships for PCMH initiatives. PCMH “If an ACO—either hospital- with non-employed primary care and ACOs are complementary or physician-led—can achieve providers in a PCMH initiative, models. ACOs provide enhanced success without working with stakeholders must ensure the connections between primary their partners in the larger initiative abides by federal and care providers and specialists, state consumer protection laws. hospitals, and other community medical neighborhood, then The two sets of laws that have providers, and PCMH provides a there is a reduced incentive to 53,54 the greatest potential to affect strong primary care base for the better coordinate and integrate a PCMH arrangement are anti- ACO. As the models evolve, kickback and self-referral laws: policymakers and stakeholders care.” 64 may find themselves building PCMH into an existing ACO • Anti-kickback laws, most notably the federal anti- program or leveraging their PCMH initiative to launch kickback statute, prohibit providers from paying 65 ACOs, as opposed to starting an entirely new program. or receiving anything of value to induce or reward referrals. 66 Although hospitals drove the initial growth of the model 55 from 2011-2012, physician groups have since taken over • Self-referral laws, including the oft-cited Stark Law, as the most common sponsor of ACOs. Both types prohibit providers from referring patients to entities 67 of ACOs have the ability to break down silos and align with which they or a family member have a financial incentives to better coordinate care across providers. To relationship. date, however, ACOs have tended to prioritize improving While these laws are necessary to protect consumers from care within the system of the sponsoring entity (i.e., the 56 improper business relationships, the penalties associated physician group or hospital) as opposed to increasing with these statutes and their corresponding regulations coordination across the continuum of care. National Academy for State Health Policy can deter providers from participating in legitimate : 8 :
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p e n i n g a i a l o g u e e t w e e n o s p i t a l s a n d collaboration and communication central to the PCMH Oo mm u n i t yD r o v i d e r sB H model. Federal and state law provides a number of C P exemptions and safe harbors that allow hospitals and As described earlier, hospitals and primary care providers other PCMH stakeholders to pursue the model while do not always effectively communicate with one another. also protecting consumers. For example, payment However, clear and open communication between arrangements for PCMH services from the hospital to hospitals and community primary care providers is the provider (or vice versa) can fall under the personal integral for truly coordinated care. State policymakers services exception, provided the parties enter into a and program leaders are well positioned to facilitate and written contract that clearly stipulates the legitimate strengthen these relationships. 68,69,70 business purposes of the arrangement and uses fair- 75 PCMH initiatives—especially multi-payer initiatives—are market rates determined in advance. Stakeholders developed with strong multi-stakeholder engagement. may also wish to explore development of a new entity, Ensuring that hospitals have a seat at the table is an such as Primary Care Institute, in which the hospital and 71 important first step in connecting hospital leadership physicians partner to form and co-manage a new and with engaged providers and assures program leaders can distinct legal entity. address any concerns raised by hospitals during program The second major legal consideration for hospitals and design. providers is patient privacy, notably the protections 72 In Colorado’s multi-payer HealthTeamWorks PCMH afforded under the Health Insurance Portability and initiative, program leaders established a PCMH-Hospital Accountability Act (HIPAA) Privacy Rule and federal 73 committee charged with improving communication Confidentiality of Alcohol and Drug Abuse Patient 76 and coordination between hospitals and PCMH Records regulations (better known as 42 CFR Part 2). practices. Parties drafted a hospital-physician If not already in place, hospitals and providers will need compact that enumerated the components of care to sign business associate and data use agreements to transitions and catalogued the mutual care management share protected health information for care coordination 77,78 agreements between physicians, hospitals, and skilled purposes. Program leaders will also need to develop nursing facilities. Three key takeaways from the a method to obtain patient consent for sharing the HealthTeamWorks experience include: information. The New York State Department of Health developed a single consent form that covers all patient • Secure buy-in at the executive level, but engage 74 informationSt r a t e gi protected e s t o E nunder g a g state e H ando s p federal i t a l s lawa n and d additional hospital staff during planning— maySe c serveu r e ast ha eresource i r Su p for p o rother t states and programs. particularly quality improvement staff; • Engage and secure buy-in at the corporate level when hospitals are part of a larger corporation; and • Frame conversation from the patients’ perspective— 79,80 Acknowledging that there are unique challenges and the committee loses effectiveness if parties use it as considerations for different states—or even within an opportunity to defend their turf. different regions of a single state—policymakers and PCMH program leaders can use a few overarching To the last point, conveners can directly engage patients strategies to successfully engage hospitals to secure their by including them in the initiative’s governance structure, participation: developing a patient advisory group, or inviting consumer representatives to participate in planning • Opening a dialogue between hospitals and meetings. Initiatives in which FQHCs participate have an community providers; opportunity to draw from the consumers that sit on the • Providing new payment for new (or unfunded) FQHCs’ boards. services; and
• Including hospital andNational specialty Academy participation for State Health Policy requirements. : 9 : Download this publication at: www.nashp.org The Role Of Hospitals In Medical Home Initiatives And Strategies To Secure Their Support And Participation
85 r o v i d i n g e w a y m e n t f o r e w o r n f u n d e d Pe r v i c e s N P N ( U ) clinics. That same year, NCQA launched their Patient- S Centered Specialty Practice Recognition standards, which extended medical home concepts to specialists, As discussed in the Roles for Hospitals section, hospitals 86 may be uniquely suited to provide shared services for including outpatient specialty clinics owned and small, independent providers that cannot afford care operated by hospitals. The Patient-Centered Specialty coordination and management staff. In order for this Practice Recognition standards build off NCQA’s PCMH arrangement to be sustainable, however, the hospital recognition standards by measuring the specialty must be appropriately reimbursed to cover the direct and practice’s ability to manage and coordinate care with primary care providers and other specialty providers, indirect costs of providing these services; in other words, 87 the new services should be at least cost-neutral to the provide enhanced access and communication, and track hospital. As providers move toward more accountable and coordinate referrals. While these programs are still models of care, policymakers and payers will likely in their early stages, program leaders that choose to 81 place greater emphasis on risk-based payments such as adopt national practice standards may want to consider bundled global or episode-based payments. However, Sincludingu mm a rthese y sets in their participation requirements as some hospitals and provider groups may not be ready to well. take on risk-based payments. While shared savings arrangements can be used as an intermediate payment option, there are limitations— 82 Hospitals are key partners in the medical neighborhood most notably the lack of up-front or pay-as-you-go and have important roles to play in PCMH initiatives. reimbursement to cover new costs. Additionally, without First, hospitals may be in a position to either directly supplementary payments made in addition to shared 83 provide enhanced primary care services through their savings, the hospital’s financial incentives end after owned-and-operated outpatient clinics and/or provide the savings have been realized. Pay-for-performance shared wrap-around services for smaller independent methodologies based on utilization metrics may be more providers. Second, hospitals can also use their influence appealing to hospitals than traditional shared savings. to educate and engage patients, train providers, and Hospitals that lower utilization would receive enhanced survey community needs. Lastly, hospitals can use their funding to offset revenue loss, and hospitals that did not significant market power as an employer to influence the would not lose the revenue in the first place—although marketplace to promote and grow PMCH. this removes part of the incentive for hospitals to actually Although there are unique considerations for lower utilization. 84 different types of hospitals—as well as potential legal Most states have used direct care management fees to considerations to keep in mind—state policymakers, pay for care coordination services. Whether these fees payers, and other stakeholders can utilize key strategies are paid for an entire population (e.g., PMPM payment) to engage hospitals and secure their support. These or only for patients who receive their services (e.g., strategies include making the business case for fee-for-service or case rate payments), hospitals have participation, opening a dialogue between the hospital an opportunity to replace lost emergency and inpatient and community providers, implementing sustainable revenue through rate negotiation. payment reforms, and including hospital and specialty n c l u d i n g o s p i t a l a n d p e c i a l t y articipation participation requirements. Collaborative partnerships I e q u i r e m e nH t s S P between hospitals and community providers will increase R coordination and integration across the continuum of There may be a clearer role for hospital participation care, and will also lead the way to create and strengthen if program requirements include specific standards and accountable care models. expectations for hospitals, specialists, and other PCMH- neighbors. In 2013, the Joint Commission launched a PCMH certification optionNational for hospital-based Academy for State ambulatory Health Policy : 10 :
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En d n o t e s
1 National Academy for State Health Policy, “Medical Home & Patient-Centered Care,” http://www.nashp.org/med-home-map. 2 Deborah Peikes et al., “Early Evaluations of the Medical Home: Building on a Promising Start,” The American Journal of Managed Care 18, no. 2 (February 2012): 105–116. 3 Marci Nielsen et al., The Patient-Centered Medical Home’s Impact on Cost & Quality: An Annual Update of the Evidence, 2012-2013 (Washington, D.C.: Patient-Centered Primary Care Collaborative, January 2014), http://www.pcpcc.org/download/4741/1%20 -%20Annual%20Report%20FINAL%203-10-2014.pdf. 4 Teresa A. Coughlin et al., “An Estimated $84.9 Billion In Uncompensated Care Was Provided In 2013; ACA Payment Cuts Could Challenge Providers,” Health Affairs 33, no. 5 (May 1, 2014): 807–814. 5 Bianca Perez and Katie Reid, Phone interview with authors, February 21, 2014. 6 Mark Weissman, “ED to Medical Home: Shifting Care and Payment Models” (presented at the Children’s Hospital Association 2013 Annual Leadership Conference, New Orleans, LA, October 15, 2013), http://www.childrenshospitals.net/Content/ ContentFolders34/EducationMeetings2/AnnualMeeting/2013/SessionsTuesday/ED_to_Medical_Home_Shifting_Care_and_Payment_ Models_presentation.pdf. 7 Ibid. 8 Mara Laderman, Saranya Loehrer, and Douglas McCarthy, “The Effect of Medicare Readmissions Penalties on Hospitals’’ Efforts to Reduce Readmissions: Perspectives from the Field,” The Commonwealth Fund Blog, February 26, 2013, http://www. commonwealthfund.org/Blog/2013/Feb/The-Effect-of-Medicare-Readmissions-Penalties-on-Hospitals.aspx. 9 Payments to Hospitals for Inpatient Hospital Services: Hospital Readmissions Reduction Program, 42 USC 1395ww(q). 10 Robert E Burke et al., “Moving beyond Readmission Penalties: Creating an Ideal Process to Improve Transitional Care,” Journal of Hospital Medicine: an official publication of the Society of Hospital Medicine 8, no. 2 (February 2013): 102–109. 11 Center for Healthcare Quality and Payment Reform, Using Medical Homes to Reduce Readmissions, (Pittsburgh, PA: CHQPR, n.d.), http://www.chqpr.org/downloads/UsingMedicalHomestoReduceReadmissions.pdf 12 “Centers for Medicare and Medicaid Services Recognize Mount Sinai for Personalized Follow-up Care for Medicare Patients,” Mount Sinai Hospital (New York City, NY) press release, January 23, 2013, http://www.mountsinai.org/about-us/newsroom/press- releases/centers-for-medicare-and-medicaid-services-recognize-mount-sinai-for-personalized-follow-up-care-for-medicare-patients. 13 Louis Giancola, Phone interview with authors, February 24, 2014. 14 Illinois Department of Public Health, “Find Your Health Care Facility,” Illinois Hospital Report Card and Consumer Guide to Health Care, http://www.healthcarereportcard.illinois.gov/ 15 Centers for Medicare & Medicaid Services, “What is Hospital Compare?” Medicare Hospital Compare Overview, http://www. medicare.gov/hospitalcompare/search.html 16 The Leapfrog Group, “Hospital Safety Score,” http://www.hospitalsafetyscore.org/ 17 A Mark. Fendrick, Bruce Sherman, and Dennis White, Aligning Incentives and Systems: Promoting Synergy Between Value-Based Insurance Design and the Patient Centered Medical Home (Washington D.C.: Patient-Centered Primary Care Collaborative, 2010), http://www.nbch.org/NBCH/files/ccLibraryFiles/Filename/000000000884/VBID-H2R-PCPCC%20v4-1101NBCH%20cover.pdf 18 The University of Michigan Center for Value-Based Insurance Design, Patient-Centered Medical Homes and V-BID: a highly synergistic approach to achieve more health for the money (Ann Arbor, MI: Center for Value-Based Insurance Design, July 2012), http://www.sph.umich.edu/vbidcenter/publications/pdfs/V-BID%20brief%20PCMH%20July%202012.pdf 19 Dennis P Scanlon, Richard C Lindrooth, and Jon B Christianson, “Steering Patients to Safer Hospitals? The Effect of a Tiered Hospital Network on Hospital Admissions,” Health Services Research 43, no. 5 Pt 2 (October 2008): 1849–1868. 20 American Hospital Association, 2010 Committee on Research, AHA Research Synthesis Report: Patient-Centered Medical Home (PCMH) (Chicago, IL: American Hospital Association, September 2010), http://www.aha.org/research/cor/content/patient- centered-medical-home.pdf. National Academy for State Health Policy : 11 :
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21 Agency for Healthcare Research and Quality, “Defining the PCMH,” Patient Centered Medical Home Resource Center, http:// pcmh.ahrq.gov/page/defining-pcmh. 22 Robert Kocher and Nikhil R. Sahni, “Hospitals’ Race to Employ Physicians — The Logic behind a Money-Losing Proposition,” New England Journal of Medicine 364, no. 19 (2011): 1790–1793. 23 Boston Children’s Hospital, “Children’s Hospital Primary Care Center (CHPCC) Overview,” http://www.childrenshospital.org/ centers-and-services/childrens-hospital-primary-care-center-chpcc-program/overview. 24 For a complete list of participating practices as of July 2013, please visit: http://www.pcmhri.org/files/uploads/ Participating%20Site%20List%207%2011%2013%20%282%29.pdf 25 Michelle M. Doty et al., Enhancing the Capacity of Community Health Centers to Achieve High Performance: Findings from the 2009 Commonwealth Fund National Survey of Federally Qualified Health Centers (New York, NY: The Commonwealth Fund, May 2010), http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2010/May/1392_Doty_enhancing_capacity_ community_hlt_ctrs_2009_FQHC_survey_v5.pdf. 26 American Hospital Association, Hospitals Partner with Public Health for a Healthier Community (Chicago, IL: AHA, 2013). http://www.aha.org/content/13/fqhccaseexample-lincolnneb.pdf 27 Sunil Kripalani et al., “Deficits in Communication and Information Transfer between Hospital-Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care,” JAMA: the Journal of the American Medical Association 297, no. 8 (February 28, 2007): 831–841. 28 Chaim M. Bell et al., “Association of Communication Between Hospital-Based Physicians and Primary Care Providers with Patient Outcomes,” Journal of General Internal Medicine 24, no. 3 (March 2009): 381–386. 29 Sunil Kripalani et al., “Deficits in Communication and Information Transfer between Hospital-Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care.” 30 Rhode Island Health Home State Plan Amendment (TN#RI-11-0007), approved November 23, 2011, available at: http:// www.chcs.org/usr_doc/Rhode_Island_2_-_Community_Mental_Health_Organization_Health_Homes.pdf 31 Rhode Island Health Home State Plan Amendment (TN#RI-13-011); approved November 6, 2013, available at: http://www. chcs.org/usr_doc/Rhode_Island_Health_Home_State_Plan_Amendment.pdf 32 “Care Team Connect Launches Integration to Michigan Health Information Network,” Care Team Connect press release, December 19, 2013, http://www.careteamconnect.com/care-team-connect-launches-integration-to-michigan-health-information- network/. 33 Christina Bielaszka-DuVernay, “Vermont’s Blueprint For Medical Homes, Community Health Teams, And Better Health At Lower Cost,” Health Affairs 30, no. 3 (March 1, 2011): 383–386. 34 Agency for Healthcare Research and Quality, “Policy Innovation Provide: Statewide Program Supports Medical Homes Through Multidisciplinary Teams, Easy Access to Information, and Incentives, Leading to Lower Costs and Better Care,” AHRQ Health Care Innovations Exchange, updated July 17, 2013, http://www.innovations.ahrq.gov/content.aspx?id=3640. 35 Department of Vermont Health Access, Vermont Blueprint for Health: 2013 Annual Report (Williston, VT: DVHA, January 30, 2014), http://hcr.vermont.gov/sites/hcr/files/pdfs/VTBlueprintforHealthAnnualReport2013.pdf 36 New York Health Home State Plan Amendments (TN#s: NY-11-56, approved February 3, 2012; NY-12-10, approved December 4, 2012; and NY-12-11, approved December 4, 2012), https://www.health.ny.gov/regulations/state_plans/status/non- inst/approved/docs/app_2012-12-04_spa_12-11.pdf. 37 Kim Vance, “ED Care Coordination Pathway Partnership: Super Utilizer Intervention for Quality Improvement” (presented at the Eighth National Medicaid Congress, Washington, D.C., May 29, 2013), http://www.ehcca.com/presentations/ medicaidcongress8/vance_pc.pdf. 38 Health Care Access Now, “Super Emergency Department Utilizers Pathway,” http://healthcareaccessnow.org/super-ed-user- pathway/.
National Academy for State Health Policy : 12 :
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39 New York State Department of Health, “Hospital-Medical Home (H-MH) Demonstration Program,” https:// hospitalmedicalhome.ipro.org/ 40 Donna C. Folkemer et al., Hospital Community Benefits after the ACA: The Emerging Federal Framework (Baltimore, MD: The Hilltop Institute, January 2011), http://www.hilltopinstitute.org/publications/HospitalCommunityBenefitsAfterTheACA-HCBPIssueBrief- January2011.pdf 41 Agency for Healthcare Research and Quality, “Service Delivery Innovation Profile: Community- and Practice-Based Teams, Real-Time Information, and Financial Incentives Help Medical Homes Improve Care, Reduce Utilization and Costs,” AHRQ Health Care Innovations Exchange, last updated June 19, 2013, http://www.innovations.ahrq.gov/content.aspx?id=2666 42 Charles Townley and Rachel Yalowich, Five Key Strategies to Engage Health Care Payers and Purchasers in a Multi-Payer Medical Home Initiative (Portland, ME: National Academy for State Health Policy, September 2013), http://www.nashp.org/sites/default/ files/pcmh.payer_.purchaser.engagement.pdf. 43 American Hospital Association, “Cuts Threaten Hospitals’ Ability to Cure and Care: Hospitals as Employers” Fact Sheet (Chicago, IL: AHA, September 2011), http://www.aha.org/content/11/110909-employer.pdf 44 Bailit Health Purchasing, LLC, Payment Matters: The ROI for Patient Centered Medical Home Payment (Princeton, NJ: Robert Wood Johnson Foundation, February 2013), http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf404563/ subassets/rwjf404563_3 45 Louis Giancola, Phone interview. 46 American Hospital Association, Trendwatch: The Opportunities and Challenges for Rural Hospitals in an Era of Health Reform (Chicago, IL: AHA, April 2011), http://www.aha.org/research/reports/tw/11apr-tw-rural.pdf 47 John Supplitt and Matthew Fenwick, Phone interview with authors, February 6, 2014. 48 Jeff Mero, Phone interview with the authors, February 6, 2014. 49 American Hospital Association, Trendwatch: The Opportunities and Challenges for Rural Hospitals in an Era of Health Reform. 50 http://www.legislature.state.oh.us/bills.cfm?ID=128_HB_198 51 The curricula can be found in the Final Work Product Report, available at: http://www.ohioafp.org/wp-content/uploads/Ohio_ HB198_PCMH_Education_Pilot_Project_Final_Work_Product_Report.pdf 52 Clese Erikson and Scott Shipman. Phone interview with authors. February 10, 2014. 53 Diane R. Rittenhouse, Stephen M. Shortell, and Elliott S. Fisher, “Primary Care and Accountable Care — Two Essential Elements of Delivery-System Reform,” New England Journal of Medicine 361, no. 24 (2009): 2301–2303. 54 Samuel T Edwards et al., “Structuring Payment to Medical Homes After the Affordable Care Act,” Journal of General Internal Medicine (April 1, 2014). 55 David Muhlestein, “Accountable Care Growth In 2014: A Look Ahead,” Health Affairs Blog, January 29, 2014, http:// healthaffairs.org/blog/2014/01/29/accountable-care-growth-in-2014-a-look-ahead/. 56 David Muhlestin, “Continued Growth Of Public And Private Accountable Care Organizations,” Health Affairs Blog, February 19, 2013, http://healthaffairs.org/blog/2013/02/19/continued-growth-of-public-and-private-accountable-care-organizations/. 57 Ibid. 58 Mark McClellan et al., “A National Strategy To Put Accountable Care Into Practice,” Health Affairs 29, no. 5 (May 1, 2010): 982–990. 59 Diane R. Rittenhouse, Stephen M. Shortell, and Elliott S. Fisher, “Primary Care and Accountable Care — Two Essential Elements of Delivery-System Reform.” 60 Farzad Mostashari, Darshak Sanghavi, and Mark McClellan, “Health Reform and Physician-Led Accountable Care: The Paradox of Primary Care Physician Leadership,” JAMA 311, no. 18 (May 14, 2014): 1855–1856. 61 Samuel T Edwards et al., “Structuring Payment to Medical Homes After the Affordable Care Act.” National Academy for State Health Policy : 13 :
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62 Illinois Department of Healthcare and Family Services, “Attachment C: Quality Measures,” Solicitation for Accountable Care Entities – ACE Program 2014-24-002, August 1, 2013, 63 David Muhlestin, “Continued Growth Of Public And Private Accountable Care Organizations.” 64 Criminal Penalties for Acts Involving Federal Health Care Programs: Illegal Remunerations, 42 USC § 1320a 7b(b). 65 Health Care Fraud Prevention and Enforcement Action Team (HEAT), “Comparison of the Anti-Kickback Statute and Stark Law,” Office of Inspector General, https://oig.hhs.gov/compliance/provider-compliance-training/files/StarkandAKSChartHandout508. pdf. 66 Limitation on Certain Physician Referrals, 42 USC § 1395nn. 67 Health Care Fraud Prevention and Enforcement Action Team (HEAT), “Comparison of the Anti-Kickback Statute and Stark Law.” 68 Exceptions to the Referral Prohibition Related to Compensation Arrangements: Personal Service Arrangements, 42 CFR 411.357(d). 69 John Kirsner and John Wyand, “Memo: The Development of a Primary Care Medical Home Institute,” The Advisory Board Company, October 10, 2010, http://www.advisory.com/Research/Health-Care-Advisory-Board/Blogs/The-Blueprint/2010/10/The- Development-of-a-Primary-Care-Medical-Home-Institute 70 John Kirsner, Phone interview with authors, February 18, 2014. 71 Amanda Berra, “Attorney Interview: The “Primary Care Institute” as a Contractual Framework for Hospital-Physician PCMH Support,” The Advisory Board Company, October 7, 2010, http://www.advisory.com/research/health-care-advisory-board/blogs/the- blueprint/2010/10/primary-care-institute-as-a-contractual-framework-for-hospital-physician-pcmh-support. 72 General Administrative Requirements, 45 CFR Part 160; Security and Privacy: General Provisions, 45 CFR Part 45 CFR Part 164 Subpart A; and Security and Privacy: Privacy of Individually Identifiable Health Information, 45 CFR Part 164 Subpart E. 73 Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2. 74 The consent form is available at: https://www.health.ny.gov/forms/doh-5055.pdf. 75 National Academy for State Health Policy, “Medical Home Strategies: Forming Partnerships,” http://www.nashp.org/med-home- strategies/forming-partnerships. 76 Lisa Schneck, “PCMH-Hospital Committee Strives to Improve Quality, Reduce Healthcare Costs,” HealthTeamWorks Blog, July 22, 2011, http://www.healthteamworks.org/blog/General/PCMH@dHospital-Committee-strives-to-improve-quality@c-reduce- healthcare-costs.html. 77 R. Scott Hammond, “The Physician-Hospital Compact: A Primary Care Viewpoint” (presented at the Fourth National Medical Home Summit, Philadelphia, PA, February 28, 2012), http://www.ehcca.com/presentations/medhomesummit4/hammond_ms1_1b. pdf. 78 For an example of the compact, please see the version developed for general distribution with the support of the Colorado Center for Primary Care Innovation, available at: http://www.ehcca.com/presentations/medhomesummit4/gallegos_ms1_h1.pdf 79 Beth Neuhalfen, Phone interview with authors, January 24, 2014. 80 Marsha Parker, Phone interview with authors, February 7, 2014. 81 Harold D. Miller, Transitioning to Accountable Care: Incremental Payment Reforms to Support Higher Quality, More Affordable Health Care (Pittsburgh, PA: Center for Healthcare Quality and Payment Reform, January 2011), http://www.chqpr.org/downloads/ TransitioningtoAccountableCare.pdf 82 Center for Healthcare Quality and Payment Reform, Is “Shared Savings” the Way to Reform Payment? (Pittsburgh, PA: CHQPR, n.d.), http://www.chqpr.org/downloads/SharedSavings.pdf 83 Ibid. 84 Mary Takach, “About Half Of The States Are Implementing Patient-Centered Medical Homes For Their Medicaid Populations,” Health Affairs 31,National no. 11Academy (November for State 1, Health 2012): Policy 2432–2440. : 14 :
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85 The Joint Commission, “Primary Care Medical Home Certification Option for Hospitals, http://www.jointcommission.org/ accreditation/primary_care_medical_home_certification_option_for_hospitals.aspx 86 Mina Harkins, Phone interview with authors, February 10, 2014. 87 National Committee of Quality Assurance, Patient-Centered Specialty Practice Recognition, White Paper (Washington, D.C.: NCQA, 2013), http://www.ncqa.org/Portals/0/Newsroom/2013/PCSP%20Launch/PCSPR%202013%20White%20Paper%20 3.26.13%20formatted.pdf.
About the National Academy for State Health this paper: Mark Albrecht, The Joint Commission; Lon gler, Ellis Medicine; John Supplitt, American Hospital Policy: Berkeley, The Joint Commission; Clese Erikson, Associ- Association; and Kellie Valenti, Ellis Medicine. ation of American Medical Colleges; Matthew Fenwick, The National Academy for State Health Policy The authors also wish to thank Mary Takach and Neva American Hospital Association; Louis Giancola, South (NASHP) is an independent academy of state health Kaye from the National Academy for State Health County Hospital; Mina Harkins, National Committee policymakers working together to identify emerging Policy for their contributions and review. issues, develop policy solutions, and improve state for Quality Assurance; Denise Henkel, The Joint Com- Finally, the authors thank Melinda Abrams and The health policy and practice. As a non-profit, non-par- mission; Jennifer Hoppe, The Joint Commission; John Kirsner, Jones Day; Margaret Meagher, Ellis Medicine; Commonwealth Fund for making this work possible. tisan organization dedicated to helping states achieve Jeff Mero, Washington State Hospital Association; Amy excellence in health policy and practice, NASHP pro- Mullins, American Academy of Family Physicians; Beth Citation: vides a forum on critical health issues across branches Neuhalfen, Vitality Health; Marsha Parker, Community Charles Townley and Kimm Mooney, The Role Of Hospi- and agencies of state government. NASHP resources Memorial Health System; Bianca Perez, America’s tals In Medical Home Initiatives And Strategies To Secure are available at: www.nashp.org. Essential Hospitals; Katie Reid, America’s Essential Their Support And Participation, 2014 (Portland, ME: Acknowledgments Hospitals; Jeffrey Schnipper, Brigham and Women’s National Academy for State Health Policy). Hospital (Boston, MA); Linette Scott, California The authors wish to thank the following key informants Department of Health Care Services; Scott Shipman, who generously gave their time to inform and review Association of American Medical Colleges; David Smin-
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