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Are you interested in helping NAON grow and expand even more? Are you interested in assisting with the development of NAON’s 43^rd Annual Congress in Pittsburgh, PA? Are you interested in additional networking opportunities? If you said yes to any of the above questions, consider serving NAON!!

How do you sign up to serve NAON, you ask?? Complete a Willingness To Serve Form on the NAON website! 

There are several Committees and Task Forces with available positions that need to be filled! The ACORN Committee serves as the voice of the early career nurse members and plans fun activities for Congress. The Chapter and Affiliate Team (CAT) help to strengthen and promote chapter and affiliate growth. The Education Committee has four different ways to serve: The AAOS Unit, the Congress Unit, the Advance Practice Nursing Unit, and the Activities and Products Unit. The Research Committee brings research to the forefront of NAON and provides grants for promising research projects. And There are several more opportunities to serve NAON in different capacities and roles! Learn more information on the Committees and Task Forces.

Healthy Tips from ANA's Healthy Nurse, Healthy Nation™: Keeping in Our Cool This Summer!; Submitted by Laura Hixon, MSNE, RN-BC, ONC

Many areas are experiencing super high temperatures this summer. In order to protect ourselves and our patients from heat illness, the CDC has provided important information for the consumers. Extreme heat, high humidity and other personal factors can impact the risks of heat exposure, so here are some tips to be safe this summer:

1. Stay cool- limit outdoor activity during the hottest parts of the day. In Texas, this may be in the afternoon to dusk! Even when swimming, the heat and air quality can be harmful.
2. Remain hydrated- drink water throughout the day and electrolytes. More if heavy sweating.
3. Avoid using ovens, stoves and dryers during the day- they can increase temperatures in the home and make it harder to stay cool.
4. Schedule workouts when earlier in the day when temperatures are cooler. Frequently hydrate and take breaks when needed.
5. Know signs of heat exhaustion- heavy sweating, cold and clammy, fast pulse, nausea, dizziness, headache (if symptoms persist over an hour, call for help)
6. Know signs of a heat stroke- high body temperature (>103), nausea, confusion, fainting, weakness, or loss of consciousness for any period of time (Call 911)
7. Also, your skin is important! To protect against sunburns and heat illness- wear sunscreen with high SPF, hats, and other UV protective wear like lightweight, loose-fitting clothing.

Have a wonderful time this summer and stay safe!

CDC. (2022). Keep your cool in hot weather! https://www.cdc.gov/nceh/features/extremeheat

Movement is Life Contribution Blog: CMS Begins Examining Effects of Implicit Bias in CJR and Other CMMI Models; Submitted by Matt Reiter and Donna Kurek MSN, RN, MHA, ONC, CMSRN 

In a recent article in Health Affairs Forefront (DOI: 10.1377/forefront.20220630.238592), two staff members for the CMS Centers for Medicare and Medicaid Innovation (CMMI) describe how CMMI is examining the effects of implicit bias in several of its Medicare value-based payment models, including the Comprehensive Care for Joint Replacement (CJR) model.

This initiative is part of CMS’s overall Strategic Plan on Health Equity. CMMI is still in the early stages of this work, but the article gives us plenty of insight into the direction CMMI is expected to take in its review.

In the article, CMMI acknowledges many concerns that have been held by Movement is Life, an organization for which we serve on the Leadership Committee. MIL is a nonpartisan, multi-disciplinary non-profit organization that is dedicated to eliminating health disparities.

CMMI defines “implicit bias” as “a differential impact created or exacerbated, without intention, by an algorithm, set of sequential rules, or standard processes within a model, with a particular focus on racial and ethnic groups.” According to the authors, “The goal of the Innovation Center’s review was to inventory potential biases in these three models (CJR, Million Hearts, and KCC) to better understand how to detect potential implicit bias in existing and future models, a necessary precursor to mitigating or eliminating such bias.”

For each model CMMI reviewed, it studied several factors for implicit bias including:

• criteria for provider and beneficiary eligibility and selection;
• beneficiary attribution;
• risk assessment and screening tools;
• provider tools likely to be employed;
• payment design and risk-adjustment algorithms; and
• model and evaluation design. 

CMMI’s analysis of implicit bias in CJR largely aligns with Movement is Life’s advocacy on value-based payment models.

For example, CMMI cites a study led by Dr. Said Ibrahim that shows black and low income CJR patients are more likely to be discharged to an inpatient rehabilitation facility than white patients. MIL often cites this study in our comment letters to CMS on this issue. The study’s findings are important because it suggests that black and low income patients are more likely to have higher costs associated with their care compared to white patients. Episode payment models like CJR hold providers accountable for the cost of their patient population’s care. However, these models historically have not adequately accounted for these differences in expected care cost for a hospital’s unique patient risk profile. This lack of risk adjustment creates a financial incentive to avoid complex patients.

CMS draws the same conclusion as MIL from this study, “This presents an opportunity for bias within the model as CJR providers could make fewer offers of joint replacement surgery to Black and low-income individuals in an effort to keep spending below the CJR target price and generate savings under the model.”

In 2016, MIL commented on CMS’s proposed expansion to CJR, “Further, and most importantly, these new models must incorporate protections for patients so that there is no perverse incentive to reduce medically necessary care or exclude medically- and socially-complex patients from these models because of the challenges they pose.”

In the Health Affairs Forefront article, CMMI confirms that it observed evidence of our shared concern, “An evaluation of the CJR Model found that beneficiaries receiving joint replacements at participating hospitals while the model was in effect were less medically complex than those receiving joint replacements at those same hospitals before model implementation began. Additionally, they were less likely to be dual eligible for both Medicare and Medicaid, an indicator of lower socioeconomic status.”

CMMI highlights one action it took in response to this observation. CMMI recently finalized a three-year extension of CJR. In that extension, CMMI decided to factor dual-eligibility status, as well as age and HCC score, into a participating hospital’s target price.

In that same 2016 comment letter, MIL supported adjustments to the target price as a risk adjustment method. We proposed our own “Risk Adjustment Factor” concept that would adjust target prices based on specific social determinants of health. This concept could be applied in many ways.

This is a challenging concept to implement because it is not easy to select social determinants to include and how to weight each determinant. However, the fact that CMMI is adjusting the target price in some way is encouraging. Dual-eligible status is a simple and effective way for CMS to risk adjust payment models. We hope that CMS will continue working towards a more robust risk adjustment methodology, but dual-eligible status should be an effective improvement over earlier versions of the CJR target price policy.

Looking ahead, CMMI says it is planning to take more systemic action to identify and remove implicit biases in value-based payment models beyond the initial steps it has already taken. This includes developing a step-by-step guide to screen for and mitigate bias in Innovation Center models. CMMI will pilot the guide in new models currently in development, with the intention of having all future models screened for implicit bias using this guide prior to launch.

This article highlights encouraging progress that aligns with MIL’s position from as early as 2016. But more work needs to be done. CMS Administrator Chiquita Brooks-LaSure has shown a strong dedication to adding health equity into all of CMS’s work. However, a future CMS Administrator could slow or end this focus depending on their priorities.

Legislation introduced by Senator Cory Booker (D-NJ) in the Senate and Rep. Terri Sewell in the House (D-AL) called the John Lewis Equality in Medicare and Medicaid Treatment (EMMT) Act would require CMMI to consider how every new model will impact access to care for participating beneficiaries. This bill, if passed, would ensure that all future administrations continue this important work to improve health equity in new value-based payment models.

Matt Reiter is a Principal at Capitol Associates, a bipartisan policy analysis and lobbying firm. Donna Kurek is Executive Director Quality and Patient Safety for OrthoVirginia. Matt and Donna both serve on the MIL Leadership Committee.

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