JamesLHollyMD.com

	James L. Holly, M.D.

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Letters - Project REV -- Reduce Readmissions From the Primary Care Perspective

From: James L. Holly
Sent: Monday, August 14, 2017 6:17 AM
To: 'Jim Maxwell'
Cc: Angel Bourgoin
Subject: SETMA.com | EPM Tools | Physician Consortium for Performance Improvement Care Transition Data Set Tutorial

Jim Maxwell, PhD
Director of Research & Policy
John Snow Inc.

The following are links to important parts of SETMA’s practice. An explanation of changes follows:

Physician Consortium for Performance Improvement Care Transition Data Set Tutorial

Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan Tutorial

NQF - Summary of Dr. Holly's Comments - September 2nd, 2010 -- The Data Centric continuity of care allows for the development of a “Patient Portrait” a granular, precise, in-depth, health picture of a patient rather than the “Patient Silhouette” of a patient which has been the result of medical records for the past 150 years. It allows for the growth and refinement of that “portrait” with each encounter, as each provider contributes new insights to the patients' health picture. -- The Post-Hospital Visit should include at least the following:”

Preventable Readmissions: Predictive Modeling, Nurse Practitioners and Changes in Models of Healthcare Delivery

A Care System for Effecting Reductions in Preventable Readmission Rates (see fifteen documents linked at the end of this article)

Readmissions and the Medical Home: Re-Visioning Care Management

Financial Reality which has affected our care some

Beginning in 2011 and continuing until 2017, CMS has decreased reimbursement for Medicare Advantage by 4% a year for a cumulative decrease of 28%. Added to that, the Affordable Care Act tax on health plans has passed down to healthcare providers who take full risk for patient care, which for SETMA has been a $1,700,000 decrease annually since 2014, These two events have resulted in our having to decrease certain services.

We have not decreased care to our patients most of whom are poor and vulnerable, and thus far we have not had to decrease our support of patients who can not afford care, including ACA beneficiaries who can not afford deductibles and co-0pays. SETMA has continued to fund these services out of our Foundation which is funded totally by the partners of SETMA. None of the Foundation’s funds are allowed to benefit SETMA but only pays for care given by others who refuse to see patients without being paid co-pays or deductible.

I mention this because this has resulted in two years of severe financial stress to SETMA to the extend that for extended periods our partners have not been paid. We have almost worked through this and expect by 2018, we should be stable again. This has resulted in slight staff reductions and over 50% decrease in salaries to our partners. We are hopeful for relief from at least the ACA tax which would help a great deal.

I mention this not as a complaint but simple to introduce the fact that we have had to modify some of our care management due to the financial pressures.

I would be happy to speak with you on the telephone. I can be reach at XXX-XXX-XXXX or XXX-XXX-XXXX.

James (Larry) Holly, M.D.
C.E.O. SETMA
www.jameslhollymd.com

Adjunct Professor
Family & Community Medicine
University of Texas Health San Antonio
The Joe R. and Teresa Lozano Long School of Medicine

Clinical Associate Professor
Department of Internal Medicine
School of Medicine
Texas A&M Health Science Center

From: Jim Maxwell
Sent: Sunday, August 13, 2017 11:59 AM
To: James L. Holly
Cc: Angel Bourgoin
Subject: AHRQ Project on Improving Care Coordination

Dear Dr.Holly ,

I hope you are well. My name is Jim Maxwell, and I am the Director of Research and Policy at John Snow, Inc., and PI of an AHRQ-funded project to re-engineer the primary care visit ("Project REV") to reduce readmissions from the primary care perspective.

Given your leadership role at Southeast Texas Medical Associates and participation in the LEAP project, Katie Coleman and Brian Austin at the MacColl Center suggested that your expertise related to improving post-hospital discharge care transitions would be highly informative and valuable. Would you be willing to participate in a 45min interview for Project REV in the next few weeks?

Thank you for your consideration.

Best regards,

Jim Maxwell, PhD
Director of Research & Policy
John Snow Inc.

Related Letters

	Follow-up to Drs Maxwell and Bourgoin telephone conversations on August 16th

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