A less rosy view of ACOs and global payments

This post at Disease Management Care Blog brings back memories of concerns raised by Dr. Robert Galvin at a recent MA Health Data Consortium seminar, about the complexity of implementing new payment regimes and also about the unintended consequences of market domination by accountable care organizations (ACOs).  The author,  Jaan Sidorov, summarizes a recent article by Richard Stefanacci, as follows:

Hospitals and physicians will continue to pursue merged arrangements characterized by a) shared risk, b) less physician autonomy and c) greater efficiency. Yet, it's still too easy for these first generation ACOs to underestimate the downsides of risk contracting and it's even easier for them to under-invest in care management programs. Add to this the a) "dismal" track record of past physician-hospital collaborations, b) disappointing Physician Group Practice Demo results and c) disconnect between inferred savings and hard dollars, and there is every reason to be skeptical about the ACOs' future.

Even worse, there's a government-generated health care bubble. The looming budget crisis will force Washington DC to retrench.  Many large provider organizations and ACOs, caring for tens of thousands of patients with thousands of full-time employees, will be deemed "too big to fail."  That "popping" noise will announced the start of a very destabilized market.

Jaan then predicts in a manner that leaves me wondering whether he is optimistic or pessimistic:

Coming in the wake of all this underfunded wreckage will be second generation provider-led accountable organizations. They’ll use the 2012-2014 time period to build a patient-centered culture, learn about insurance risk, invest in care management and prepare for the lean times ahead. They will focus on a) the 20% of patients who are responsible for 80% of the costs, and b) understand bundled payment arrangements.  That’s when having strong physician leadership, fully aligned care management-medical homes and enterprise-wide medical decision support will mean the difference between merely surviving and thriving.

A friend, who defines himself as a closet radical said, upon reading all of this, "Throw all the balls in the air and something good might happen, but it will be messy."  That's one word.

Tribute to teachers

Two of our daughters' favorite elementary school teachers are retiring this year, and their school held a celebration in their honor.

Stephanie Hoff, seen above with long-time colleague Joyce Richmond, is retiring after 36 years of service.  As a fourth grade teacher, she was unsurpassed in working with the children on their writing.

Kemp Harris, the city's most beloved kindergarten teacher, and also a terrific musician, is retiring after 33 years of service.

300 to 500 extra calories per day!

In a post below, I wrote of my concern about the deterioration in physical conditioning of children ages 9 to 14.  I have received a couple of expert responses I  would like to share with you.

The first is from Brenda Rooney, a clinical epidemiologist and medical director for Community and Preventive Care Services at Gundersen Lutheran Health System in Wisconsin.  She specializes in obesity and notes:

I would agree with the observations that kids today are in worse shape than they were 5 years ago.

I think that our youth are worse off today due to many factors:

·       no one walks or bikes to school

o   due to non-bike-able/walk-able schools

o   due to irrational safety concerns

·       calorie consumption is 300-500 cal/day more today than 5 years ago
·       more screen time
·       less PE in school
·       less incidental activity outside of school (kick the can, capture the flag, pick-up baseball game, etc.)

o   due to dual parent working households

o   due to single family households

o   due to irrational safety concerns

·       Parents not role-modeling active behavior

Much of this is evidence based: A little is my opinion.

Hopefully some of the work we are doing in the community will affect some of these issues and ultimately improve outcomes.

Another comment is from an expert coach, a person who serves as a mentor to many volunteer parent coaches.  He says:

I'm astounded on a weekly basis at the lack of cardiovascular capacity many (but not all) of our kids demonstrate. And I'm not only talking about kids who have "less athletic" or "bigger" body shapes but oftentimes kids who at first look seem to have the perfect physique for an endurance sport like soccer where keeping their body in constant motion is pretty much part of the game. Frankly, it's both scary and a little embarrassing.

I remember being met with looks of sheer confusion when I suggested at a coach education session not long ago that we should be looking to leave our kids on the field for at least 10-12 or even 15 minutes at a time in order to help properly educate them on the roles associated with playing a certain position. The general consensus was that most coaches felt that the majority of their kids wouldn't be able to last anywhere near that length of time on the field before becoming exhausted and that 4-6 minutes was much more realistic. Unbelievable - 4-6 minutes!

Your colleague's recollections of his youth are very similar to my own where my friends and I would play outside every day after coming home from school (and taking care of whatever homework had to be done). At a guess, I have to believe my typical week (during the school term at least) would have included at least 15-20 hours per week of active recreational exercise. This might have been riding our bikes around the neighborhood, playing pick up sports, making up games or even just walking to see friends in other close by neighborhoods, but it was pretty much exclusively outdoors and there was NEVER a parent involved in any level of organizing our activities. As long as we were home by curfew, we were good!

I can't help but shake my head in disbelief sometimes when I show up to some of the beautiful open spaces and fields we have here at a time when the local neighborhood kids should be out in their masses having fun, playing and running around, only to find those same fields virtually deserted. I can't decide if the world we live in now is one where parents are so full of fear that something bad might happen that they won't allow their own children to go out and play unsupervised at all or if kids today are so over-scheduled and burdened with all the things they've got going on that they just have no interest in going "out to play" anymore. Either way, it doesn't bode well for the long term health of these young people.

Ohio marks stretch past 39 weeks

Between 1990 and 2006, the rate of U.S. babies delivered before 39 weeks of gestation rose sharply, from 30.3 percent to 41.7 percent. Infants delivered before they have reached full gestational term, 39 to 41 weeks, are more likely to get sick or die. The last few weeks of gestation are vitally important in a baby’s development. Major organs such as the brain, lungs and liver are in the final crucial stages of growth.

Several months ago, I wrote about some new efforts in Massachusetts to avoid pre-39 week elective births and cited some previous work along those lines done by Intermountain Health.  Now, Barbara Rose, from Cincinnati Children's hospital, who is program director at the Child Policy Research Center and the Ohio Perinatal Quality Collaborative, writes to say:

We are one of many statewide perinatal collaboratives using QI science and methods to improve perinatal outcome at the population level.  Our colleagues in Tennessee, North Carolina, New York and other states are doing similar terrific work.

Here is a summary of the process:.

From September 2008–June 2010, QPQC worked closely with 20 Ohio maternity hospitals, which deliver more than 47 percent of babies born in the state, to prevent unnecessary scheduled early deliveries. Some of the strategies that OPQC helped hospitals and providers implement included:
• Recommending best practice pregnancy dating with an ultrasound before 20 weeks gestation;
• Establishing a peer-reviewed written policy that provides clear guidelines and criteria about when deliveries can be scheduled;
• Recruiting physician champions who can manage and reinforce the policy systematically;
• Publicly sharing hospital-level data on the prevalence of scheduled deliveries less than 39 weeks.

Not to beat my favorite dead horse, but please note the importance of transparency in this list. The QPQC understood that public reporting of results helps hospitals hold themselves accountable to the standard of care they are trying to meet.  Here is a slide show used in presentations by the QPQC, showing the overall methodology in more detail. 

As seen the the chart above, to date, nearly 23,000 babies that would have been delivered at 36-38 weeks were delayed to 39 weeks, representing an increase of 8 percent in full-term deliveries. This shift helped prevent approximately 500 admissions to neonatal intensive care units and 34 infant deaths. In addition, this project has saved approximately $27 million in health care costs through avoided NICU (neonatal intensive care unit) admissions.

Funding for these efforts is blended, with various state and private entities providing.  Three states (including Ohio) have CDC funding from the Maternal and Infant Health Branch in the Division of Reproductive Health at the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), headed by William Callaghan.  Bravo to the CDC for providing important support to this effort!

Writing off the public interest

I'm starting to think there are not a lot of differences between the financial mechanisms used by managers of private equity companies that own hospitals and those used by managers of dominant non-profit hospitals.  But the source of funds is very different.

In a letter to the editor of the New York Times, Timothy Green, from Wellesley, MA, responded to an earlier op-ed by columnist David Brooks.  This is his letter:

I’d like to make three points in response to David Brooks’s defense of private equity. 

First, when you load a company with debt, you remove any margin for error. I can think of legions of companies with stodgy managements and tired business models that invited buyouts because they could theoretically generate predictable cash flows to justify excessive leveraging. They failed when ambitious projections were not met; without a buyout they might have muddled through. 

Second, look at whose capital is at risk. When a private equity firm recoups up front much of its investment through hefty management fees and upfront dividends, they drain cash and cease to have the same “skin in the game.” 

Third, these firms are often driven by short-term objectives: maximize profits to flip the company through an initial public offering or strategic sale. They may bring in expertise, but the executives are disproportionately compensated, particularly when the company fails. 

A couple of days later, I read this report by Robert Weisman in the Boston Globe:

Taking a nearly $110 million write-off on an electronic health record system it will scrap, Partners HealthCare System Inc. reported Thursday that its second-quarter operating income dropped to $5.3 million from $71.2 million in the same period last year.

“The game’s going to be won in the future off the flow of information,” said Partners' chief financial officer.... Partners officials believe the new information system, which is expected to cost between $600 million to $700 million, will lead to more coordinated patient care and have a life cycle of at least 10 years.

Does anyone else out there join me in having trouble imagining a non-profit that has the financial capability to write off $110 million and then spend $600-700 million more?  Unlike private equity -- which is able to invest in companies and write off loses because of large underlying capital commitments from investors -- the sources of funds for a non-profit hospital system are mainly patient care revenues received.  We have previously learned that this particular health care system has the ability to spend a billion dollars on new facilities.  Now, we add this write-off and immense investment in information systems to "win the game."  It seems to me that they have already won the game, having drawn the card for monopoly rents from the so-called "health care market."

Zane: I remain deeply unsettled by wishful thinking

As Massachusetts legislators consider whether the health care "market" works well without more state supervision, they would do well to read this opinion piece by Ellen Zane, former CEO of Tufts Medical Center.  Some excerpts:

In what has become an annual rite, Massachusetts will hold public hearings on health care costs in early June. This year if you listen closely, you will already hear some providers and insurers warming their engines and arguments to proclaim “cost control is working, just give us time and don’t interfere with the market through government intervention or regulation.”

For the well-heeled, the system is working. The reality is that for most providers, and more importantly, for most consumers, it is not. An inconvenient truth about Massachusetts health care system is the fact that the income profile of where you live is a better predictor of what insurers will pay for your health care than almost any other factor. This reality has not been changed by any of the payment reform experiments currently under way, nor by anything that has been recently proposed. So I remain deeply unsettled by wishful thinking that our market will solve our health care cost problem if left to its own devices.

The belief in market-based solutions is predicated on the proposition that the parties most responsible for creating a two-tiered market — health insurers — will voluntarily change course. The reality is our state’s health insurers have long been the de facto regulators of the marketplace. ...In most instances, these disparities exist even though providers deliver the same services in largely the same way, with equal if not better quality. To dispute this is to argue that the extensive, groundbreaking cost and quality research done by the Massachusetts Attorney General’s Office and the Massachusetts Department of Healthcare Finance and Policy over the past few years is without merit. 

As we move from traditional fee-for-service models to global budgets, we must make sure that the same disparities that have distorted our fee-for-service payment system are not enshrined in perpetuity in a global payment system.

No need to exaggerate

The folks over at FierceHealthFinance are overly excited by a recent study produced by the Health Care Cost Institute.  That study, you will recall, pointed that out that health care costs have risen faster than inflation in 2009 and 2010.  During that period, inflation was 1.6%, while costs for those younger than 65 covered by employer sponsored, private health insurance rose by 3.3%.

This study was nicely reported by Kaiser Health News on May 21, which summarized it as follows:

Higher prices charged by hospitals, outpatient centers and other providers drove up health care spending at double the rate of inflation during the economic downturn– even as patients consumed less medical care overall, according to a new study. 

But that wasn't good enough for the Fierce folks the next day:

A study by a new non-partisan think tank, the Health Care Cost Institute, concluded that prices rose overall even as demand for services declined during the severe economic downturn. Overall per capita healthcare costs increased 3.3 percent between 2009 and 2010, about three times the annual overall inflation rate, according to the study.

Be well with BeWell

Remember my story about Health Foo a few days ago, where I mentioned a new app being worked on by Tanzeem Choudhury?  Well, it's live now.  You can find it here.

Tanzeem notes: 

This is joint effort by my group and Andrew Campbell's lab at Dartmouth (where I was before moving to Cornell in the Fall of 2011.)

We are looking for critical and constructive feedback so we can keep improving. So any input is good input.  Email at bewellapp [at] gmail [dot] com. 

It is described as follows:

BeWell: the next generation in mobile health apps.

A key challenge for mobile health apps is assisting people in maintaining a healthy lifestyle by automatically keeping track of their everyday behaviors without burdening them.

The BeWell app continuously tracks user behaviors along three key health dimensions without requiring any user input — the user simply downloads the app and uses the phone as usual

How does it do this? Classification algorithms run directly on the phone to automatically infer the user's sleep duration, physical activity, and social interaction. In addition to classifying activities that influence health, BeWell also computes a weighted score between 0 and 100 for each health dimension. A score of a 100 indicates that the user is matching or exceeding recommended guidelines (averaging eight hours sleep per day, for example). BeWell also promotes improved behavioral patterns via persuasive feedback as part of an animated aquatic ecosystem rendered as an ambient display on the smartphone's wallpaper screen.

BeWell is continuous sensing app that runs in the background and may impact your battery lifetime. BeWell is currently designed to run on newer, top end phones with better battery life. The user can remove the active wallpaper and run BeWell+ in the background to minimize battery draw if this is an issue.

BeWell has been tested on a limited number of Android phones: Nexus S, Nexus Galaxy, HTC one. We can't guarantee the performance of the app on other phones.

Heal this broken body. Cut grass.

Check out this post by Dr. Susan Shaw from the Saskatoon Health Region.  It presents a compelling story, worth reading about the goals established by one of her patients.  She relates:

On Saturday morning I came in to the ICU and started rounds. When I entered Mrs. C’s room, her daughter jumped up with excitement and said, “Look at what Mom wrote for you!”  She showed me a piece of paper on a clipboard, with two goals written in somewhat shaky writing.

Here's Susan's summation:

The daily goals I set with my team focus on the medical management: a negative fluid balance, a specific level of wakefulness, followup with a pathology report, moving to the next step on the ICU mobility protocol.

These goals are important. They provide direction for the ICU nurses and therapists. But they aren’t inspirational or motivational. They are simply small steps that must be taken to get us to what really matters: the goals set by our patients.

Who decides how much doctors are paid?

A friend once asked me to explain why primary care doctors, neurologists, nephrologists, and other “cognitive” specialists earn less than surgeons, GI doctors, and other “proceduralists."

I answered that there is a secret cabal of doctors, dominated by proceduralists, who advise the Medicare agency (CMS) on what the rates should be.  That same rate formula is also used as the basis for physician fee schedules by all the private insurance companies.  My friend was incredulous. 

But, in fact, that’s the way it is.  This process has been documented many times in the media and on my blog.  It is directly responsible for the fact that well-intentioned young doctors who otherwise would consider careers in primary care instead go into other specialties.  It also explains why your primary care doctors only has 18 minutes for each visit, because he or she has to see many patients per day to earn a living.

In a forthcoming Medscape article, health care analyst Brian Klepper gives some insights.  This incestuous relationship began when President Clinton’s director of health care finance agreed to a plan by which the American Medical Association would be the convener for this session, called the Relative Value Scale Update Committee (RUC).  This relationship was continued under the Bush administration.  Later, though, Tom Scully, CMS administrator for Bush would say,  

One of the biggest mistakes we made … is that we took the RUC… and gave it to the AMA. …It’s very, very politicized. I’ve watched the RUC for years. It’s incredibly political, and it’s just human nature…the specialists that spend more money and have more time have a bigger impact… So it’s really, it’s all about political representation, and the AMA does a good job, given what they are, but they’re a political body of specialty groups, and they’re just not, in my opinion, objective enough.

There was recently a lawsuit challenging this relationship filed in the Southern Maryland Federal District Court by six Georgia primary care doctors.  Brian reports that Judge William Nickerson ruled against the doctors on May 9:

The opinion did not weigh the substance of the case, but instead focused on a procedural provision in which Congress bars the judicial system from considering how the relative value units (RVUs) of medical services are determined.

He notes:

The physicians argued that this flawed process has resulted in an over-valuing of specialty care, an undervaluing of primary care and a distortion of health care markets, utilization and cost. But the ruling ignored their argument, explicitly avoiding any evaluation or discussion of the requirement that federal advisory bodies adhere to [the Federal Advisory Committee Act.]

Brian elaborates:

Ironically, the previous week a Health Affairs study confirmed that CMS has accepted almost 9 of every 10 RUC recommendations. When combined with information about the RUC’s non-adherence to FACA – its lack of transparency, shoddy scientific methodologies, conflicts of interest, and non-representative panel composition -- this finding validates concerns about the RUC’s tremendous influence over public payment policy. Where this goes from here is unclear.  

He reports, “It is unclear at this writing whether the plaintiffs will appeal. Important legal challenges like this one are expensive and typically funded by large organizations, but this one was mounted by a few private physicians.”

Regardless of where this goes from here in the courts, I would like to make a simple proposal to President Obama, Secretary of HHS Kathleen Sebelius, and CMS administrator Marilyn Tavenner.  Keep the RUC but insist that all of its meetings and deliberations be made public.  That is within the immediate power of the Executive branch, requiring no judicial review.  This is an administration that has prided itself on transparency.  Surely they can insist that one their key advisory panels, one that will help determine the success or failure of health reform, should perform its functions in the open.  Let’s shine some sunshine on the process and logic used.  If the RUC’s methodology is sound, we will all learn from that.  If it is flawed, the public outcry will make it change its ways. 

Terry Wise pulls people out of the darkness

On Christmas day 2000, I didn't just peer over the edge of a rooftop.  I jumped off, feet airborne with the cement blocks of depression shackled to my ankles.  The final thing I recall was swallowing the last fistful of Percocets.  I did not make an an attempt to commit suicide.  I killed myself.

This how Terry L. Wise starts her book Waking Up: Climbing Through the Darkness.*

Further along in the book, she writes about the scene two days later:

I began to discern the shocking reality. Contrary to the laws of science, I was still alive, seated on the bathroom floor a few feet from my bed--an anatomical aberration that was nothing short of miraculous.  One of my worst fears had become a reality.  I had woken up from committing suicide.

My free fall back into life had begun. ....Netted by fate, I had woken up.

Terry documents all this and more in her book but also spends her time addressing audiences of all types about her experience and what can be learned from it.  She has won a National Mental Health Award and spoken in over 200 cities in the 9 years she has been dedicated to this effort.  Waking Up has been distributed to caregivers, returning veterans and communities that have been dealing with the many issues of mental health. It has become a widely used book in undergraduate and graduate clinical psychology programs, primarily because it is one of the few works that provides transparency to effective therapy from a patient's point of view.

Rabbi Harold Kushner says, "Terry saves lives and pulls people out of the darkness that envelops them."

--
*This is the 2012 updated edition, with a slight title change from the previous version.

Spike Out Sepsis

You have only until June 1 to order the 2012 Spike Out Sepsis t-shirt.  This is part of a unique 6-on-6 sand volleyball tournament designed to raise awareness and funds for Sepsis Alliance. It takes place on June 23 at The Bogey, in Dublin, Ohio (near Columbus).

Can't make it there?  You can still donate to support awareness of early and proper treatment of sepsis, something that could save lives across the country.

Huffing and puffing

I haven't wanted to write this piece because of its implications, but I have now received confirmation from a number of other observers.  What I have been seeing in the last year or two on the soccer fields is that the boys and girls aged 9 to 14 are in noticeably poorer condition than their counterparts were several years ago.  I see a 12-year-old boy run down the field to chase down a ball and then have to walk back, breathing heavily.  I see a 14-year-old girl give up trying to catch an opposing player because she doesn't have the stamina to keep at it for 30 yards.  I see a 9 year-old-boy asking to be subbed out after eight minutes of play.

I asked some of my fellow referees if they have noticed the same thing.  All have.  This week, a young man said that he has seen a marked deterioration in just the last few years.  His explanation:  "These kids sign up for the town soccer league, and they use it as their sole source of exercise.  They and their parents think that showing up two or three times a week for 90 minutes will get them in shape or keep them in shape.  They are sedentary for the rest of the week, especially now that everyone has iPhones and computers."

Another colleague said, "In my day, you were outside all the time playing with your friends, making up games of all sorts in your neighborhood.  If you were part of organized sports, that was just a small segment of your physical activity.  Also, you only signed up for an organized sport if you were passionate about that specific sport.  It was not a parental expectation.  You worked hard at getting in shape off the field during the rest of the week -- and you spent hours practicing your moves at home and in street play -- because you wanted to be noticed by the coach and get as much playing time as possible during your formal games."

I'm worried. Have we inadvertently contributed to this problem by focusing our children too much on organized sports?  Do parents sign up their children less for the child's love of the game than as a kind of prescription for a weekly dose of exercise?  In so doing, have they bought into the 3x90 minute regime?   If children are this sedentary at such young ages, what will happen as they get older?

On the nature of decision-making

A colleague reminded me of this quote by Peter de Noronha:

The safest refuge when dealing with urgent, ticklish problems is sought in shirking responsibility, in gaining time by the formation of Committees, with the requisite Sub-Committees to tackle the problem. It is the well-known practice of Promise, Pause, Prepare, Postpone and end by letting things alone. But this cannot last for ever. Now the secret of these Committees is that they consist of a group of men, who individually can do nothing, but collectively can meet and decide that nothing can be done, whilst they know that the best Sub-Committees consist of three persons, two of whom are always absent!

Not exactly PDSA.

Step aside, Blue

While I am usually not one to provoke intra-regional rivalries in health care, who can resist piling on in the age-old one between fans in Ann Arbor and Columbus?  My regular readers know that I have tremendous regard for the commitment made to quality and safety improvement by the University of Michigan folks, and I have often written about the progress in process redesign being made there.  But I have to report on an even more aggressive approach to these matters by an affiliate of the Ohio State University, Nationwide Children’s Hospital.

Stimulated in great measure by chief medical officer Rich Brilli, this hospital’s board has adopted a goal of eliminating preventable patient harm by 2013.  The hospital is now replete with “Zero Heroes,” a far flung team of clinicians, process engineers, and administrators who live every day focused on this effort.

Anamarie Rayburn (seen here with chief quality officer Rick MacLead, aka Medical Director for Quality Improvement Services) is one, chairing a daily huddle with senior administrators where they ask, “What safety problem have we encountered in the last day?” and who then focus on wiping out that problem before the next daily meeting is convened.  This and other approaches represent real-time process improvement, grabbing at every incremental change to fulfill the mission, “Create a safe day.  Every day.”  There is also a dramatic commitment to transparency, with key metrics posted on the hospital's public website.

The desire to eliminate harm does not just focus on the usual type of adverse events, the reportable and sentinel cases.  The hospital staff rely on uncovering problems indicated by near misses and early signs of harm.  For example, Nationwide is intent on eliminating pressure ulcers in their patients, so the nurses and analysts are tracking the precursors of such wounds, metrics that would not even be on the list of such matters for most hospitals.

I know of only one other hospital that has adopted the pursuit of this kind of standard of care, and that one (ahem!) was in a different region.  So the way I see things, the Buckeyes are now in the lead in the Midwest conference.  While it is great to see both institutions’ progress and commitment to improving patient quality and safety and to broad-based process improvement, we are still in the first quarter.  Not to put on too much pressure, but if “Hail to the Victors” is to mean anything, it is time to step up the game in Ann Arbor.  Let’s go Blue . . . .

They served. We must, too.

They served in an era when it was easy to know whether a war was just.

They lived in a time when a stint in the Army was a welcome break from the Great Depression economy.

They defeated some of the most terrifying and mean-spirited leaders in history.

And they survived not only that war but almost 70 years more and were invited to Washington, DC, to visit the memorial of their colleagues who did not.

We greeted them in the DC airport, over 100 World War II veterans, sponsored by Honor Flight Network, an organization that pays for their travel.

This plane was from South Carolina, but others today were en route from Illinois and Florida.

A brass band played patriot songs and marches.

We applauded as they walked or rolled off the airplane.

We shook their hands and said, "Thank you for your service."  We meant it, too.

Our eyes teared up as they crisply saluted us, even as the rest of their bodies moved slowly, sometimes shuffling.

We all felt like Americans again, joined in common purpose, grateful for the freedoms they secured and for our chance to live in a special country, and feeling like we all lived in a small town.

Degree of challenge and risk

This is a follow-up to my April 12 post in which I summarized aspects of a conference held by the MA Health Data Consortium about possible changes in payment regimes for doctors and hospitals.  The materials from that meeting have now been published and are available here.

I copy one slide for your consideration from Robert Glavin's presentation.  He presents the degree of difficulty and the risk associated with movement from a fee for service payment regime to more bundled types of approaches.  I think it is an excellent depiction of the issue and offer it for your consideration.  I also highly recommend that you take a look at Charlie Baker's comments from the conference.

Eliminate, don't benchmark.

In several earlier posts, I have talked about how the use of benchmarks can be inimical to clinical quality improvement, stating a preference instead for absolute targets, like zero or 100%.  I understand this to be a controversial view, and you can see an excellent discussion on the topic in this post, with thoughtful comments offered by Marya Zilberberg and others.

It is reassuring to me, then, when I see respected health care systems adopting the more targeted approach -- and getting consistently great results.  An example is the University of Michigan Health System, whose Surgical Intensive Care Unit (SICU) and Trauma Burn Intensive Care Unit (TBICU) will receive an outstanding achievement and leadership award for eliminating ventilator-associated pneumonia (VAP).  The award is co-sponsored by the U.S. Department of Health and Human Services (USDHHS) and the Critical Care Societies Collaborative (CCSC), which is composed of the American Association of Critical-Care Nurses, American College of Chest Physicians, American Thoracic Society and Society of Critical Care Medicine.

The award requires consistent performance -- 25 months or longer -- accompanied by national leadership in sharing evidence-based practices with others. Well beyond two years, the U of M teams have shown results for more than 9 years.

The philosophy that is in place is set forth in the University's press announcement.

 

At any given time in the United States, 1 in 20 inpatients have an infection associated with health care they have received, and every year about 99,000 people die from a healthcare-associated infection (HAI).

Can HAIs be eliminated altogether? The University of Michigan says yes.

Transparency is part of this success. Here's the chart showing compliance with the bundle of steps taken to avoid ventilator associated pneumonia in all the ICUs, not just the two mentioned above.  This and other metrics are available for the world to see on the system's website.

Modesty must be inherent in this kind of transparency.  After all, you can't just show good results.  You have to show all results.  The point of transparency is to hold yourself accountable to the standard of care you say you believe in.  You learn from both successes and failures, and the learning is shared broadly throughout the institution. It takes leadership at all levels in the organization to pull this off because there are always folks who will want to retrench and avoid the perceived potential of embarrassment when results are other than stellar (not to mention lawyers who overstate the legal risks of such disclosure.)

As the U of M has shown, this is all worth it.  Hundreds of lives have been saved, people whose deaths previously would not even have been reportable as adverse events.  Congratulations!

Blind results: Will health care reform exclude the efficient providers?

Jesse Mermell is state director for the Massachusetts Association for the Blind and Visually Impaired, the oldest social service organization in the country that serves adults and elders who are blind or visually impaired.  But she is nervous about what might be an unintended consequence of health care reform.  She explained this to me recently.  Here’s a description of what her non-profit agency does.

“We are an extremely small direct service provider that works with individuals (mostly seniors) who are losing their vision and need to learn adaptive techniques to stay healthy and independent. Our services are provided by occupational therapists and optometrists who specialize in low vison, and are covered by virtually every insurance provider, including Medicare and Medicaid.”

A patient is referred to MAB when an eye doctor notes that the patient’s vision has deteriorated to the point that medical treatment is unable to reverse the damage.  At that point, the patient needs life counseling on how to adapt to forthcoming full or partial blindness, as well as certain skill training in mobility and accommodation to the new stage in his or her life.  Trained specialists can help make a home safer and recommend simple devices to make life with low vision easier.  The association is able to provide OT services to these patients at a very low cost.  This kind of supportive program makes it more likely that people are able to maintain healthy life styles.  For example, they learn how to continue to take required medications.  They also learn how to move about safely and avoid falls.

The Association offers part of its services in low vision clinics.  Low vision exams are different from your usual eye exam in that they are highly specialized and include eye charts and tools specifically developed to assess an individual’s remaining vision, and to determine if the client can benefit from optical devices.  They are held on a regular basis in regional locations.  For example, the Low Vision Clinic in Worcester runs weekly low vision clinics on Wednesdays.  MAB also offers an array of other services to help those with low vision, and so the assessment does not end in the clinic, but is taken into the home to help with activities of daily living.

For example, the Association might conduct a home safety assessment; evaluate lighting and eliminate glare; teach adaptive reading, writing and record-keeping techniques; reduce clutter and modify appliances with tape and markings; provide information about vision loss and community resources; help with healthcare routines and medication management; recommend adaptive aids and magnification devices.  And because many clients have diabetes, there is also a focus on offering strategies for adaptive diabetes management.

As Jesse notes, “What we do is 100% in line with the goals of payment reform: offering low-cost, preventive services that ultimately keep seniors out of expensive long-term care facilities.  We do this in partnership with respected community and medical groups to create high impact, cost effective services.”

But she is concerned.  “We are struggling to figure out how we survive in the fast-approaching global payment system. We are so small, that – hard as we try - we aren’t on anyone’s radar screen. We are desperately trying to connect to an ACO (accountable care organization) or even some sort of demonstration project, but with no luck. If we don’t find a place for ourselves in the new model, our referral sources will dry up and we will be forced to reexamine our whole operation, potentially severely limiting our services.” 

It occurred to me that the same concerns might exist for other small service providers who focus on particular segments of the population.

Why the concern?  Well, under capitated, or global, payment regimes, there is a strong incentive for medical provider groups (hospitals and doctors) to set up limited networks of service providers for their patients.  While, those networks could theoretically include organizations like MAB, the institutional framework for making clinical referrals will become more constrained and difficult.  We can envision that clients currently served by MAB would no longer get referrals to the Association, missing out on life-changing adaptations and support that currently keep them out of high-priced hospitals and nursing homes.

As the state Legislature considers changes to the law that will make this unintended result more likely, shouldn’t  they be considering steps that will help preserve these important services?

Taking with one hand and taking with the other

The usual expression is "giving with one hand and taking with the other," but the Massachusetts Legislature and Governor sometimes act as though the version in the title of this post is the way to go, at least when it comes to the state's hospitals.  First, there are proposals in the health care reform legislation to impose new taxes on the hospitals.  Then, the various versions of the state budget take more away, to the tune of about $40 million.

The Senate, the last of the three branches to propose a budget, does not address any of the unjustified MassHealth (i.e., Medicaid) rate reductions the Governor initially recommended. These include doubling a penalty for "preventable" readmissions -- this notwithstanding that the measures used to track readmissions have been rejected by both the state's expert panel and the National Quality Forum.  There is also an outpatient policy that permits MassHealth to not pay for certain outpatient services if they are followed by an inpatient visit within three days, even if the visits are completely unrelated.  There are other technical changes, too, that are too abstruse to summarize here.

I know it is easier for public officials not to raise taxes to the general public, but this whittling away of the resources of the state's hospitals is inherently inequitable.  It is all the more galling when this same state Senate refused to act to alleviate the payment disparities among hospitals.  If you think about it, the kinds of changes summarized above act as an especially regressive form of taxation when the systems that have collected, and are collecting, hundreds of millions in excess revenues are treated with impunity.

More from Health Foo 2012

#healthfoo The self-creating Health Foo camp/conference continued yesterday with many engaging presentations and discussions.  Here you see ePatient Dave deBronkart expounding on different levels of patient-clinician partnership, borrowing a graphic produced by Holland's Lucien Engelen, as Healthcare, etc.'s Marya Zilberberg looks on.  He drew a parallel with the evolution of the Internet, starting at version 1.0, when information was presented to a passively receiving audience -- to version 2.0, described by Tim O'Reilly as "when the web began to harness the intelligence of its users -- to a version 4.0, with constant interaction and collaborative learning between and among web producers and web users.

Later, Cornell's Tanzeem Choudhury offered a talk entitled, "Can phones make you happier?"  She displayed a mobil phone app that provides an engaging visual representation (in the form of the speed and other activities of a fish swimming across the screen -- see below for a quick sample) of physical and social activity and thereby provides an indicator of mental health.  It is soon to be available in the Android market.  Tanzeem envisions her app as possibly providing a context for mental health episodes, maybe becoming a predictor of depression relapses.  She notes that self-reporting by patients has inherent biases, and so the automatic reporting of certain activities might offer a more reliable predictor of mental health status changes.

In yesterday's post, I mentioned Jose Gomez-Marquez, who runs the Little Devices lab at MIT.  He presented some more stories about working with people in developing countries to design and construct useful medical devices from easily accessible materials.  He explained how this process engages nurses and doctors and others and produces lovely results for those communities.

Here, for example, some nurses train a doctor in the use of a new procedural gizmo they have invented out of locally available material, including -- sometimes -- broken toys found in the trash or purchased at a very low price from a local store.  Explaining the process of co-creation, he expounded on parameters of global health device design.  Essential characteristics include:  reliable, cheap, robust, long-lived, accurate, safe, and (often) reusable as opposed to disposable.  He also explained the difference in evolution of producing such devices from the world of appropriate technology -- "We know what you need" -- to participatory design -- "Tell us what you need and we'll design it" -- to co-creation -- "Let's design together."

I was struck by the parallel between these stages of interaction and the presentation mentioned at  the top of this blog post, about the evolution of patient-clinician partnerships discussed by ePatient Dave.

And then a final item, a plug for Access Together, an app created by John Schimmel.  It permits people to report examples of impediments to the disabled in their community.  Whether used by advocates to push for improvements in infrastructure or by municipal governments choosing to make their cities and towns more accessible, it is a handy and valuable tool that came out of John's personal involvement with a disabled friend who had trouble navigating city streets and sidewalks.  It can also be used within structures by employees and customers to report on needed areas of improvement.

Health Foo 2012

After about a year's interval, it is the return of Health Foo to Cambridge.  Organized by O'Reilly Publications (Sara Winge and Tim O'Reilly) and the Robert Wood Johnson Foundation (Paul Tarini), this is a self-organizing conference at which people decide if and when they want to present sessions on whatever topics they choose. You attend whatever you want. You talk with anyone you want. You avoid people you know and try to meet new ones.

Among the new ones for me was Jose Gomez-Marquez, who runs the Little Devices lab at MIT (seen here with Tim O'Reilly). He notes: "We make DIY (do it yourself) medical technologies for affordable health care and lots of stuff for the developing world. I'm interested in empowerment technologies for patients and providers so they can come up with their own solutions. We play with adherence technologies, simple aerosol vaccines delivery systems, and recently, using the global supply chain of toys to prototype medical tech."  Jose also is involved in something he calls "real-time epidemiology," collecting population diagnostics from remote devices, like iPhones, as people go about their daily lives.

Jill Shah of Jill's List is a returning camper.  Her website provides a searchable database that connects patients with local integrative heath practitioners, but goes beyond that and offers a variety of resources to both consumer and practitioners.

I was pleased to meet Meg Wirth, too, who runs an organization called Maternova, devoted to tools and ideas that save mothers and newborns throughout the world.  Her site explains:  "We make it easy for doctors, nurses and midwives to track innovation and to buy prebundled tools to use overseas. Our focus is on tools and protocols that save lives in childbirth. We are a mission-driven for-profit."

A bit less serious in purpose but intriguing is a new application offered by Riley Crane and colleagues at Talkto.  Currently accepting users from the Boston area, you can think of Talkto as an alternative to Siri on the iPhone.  You can punch in queries to any number of question, plus arrange for reservations and other services, with quick connections to and responses from local businesses.

Finally, I ran into a former colleague, Mark Boguski, co-founder of PhotoCalorie, a company with an application that helps you manage your nutrition with assistance with portion control, a food journal, and an optional connection to your physician.

Not enough. Now, to the House.

According to its press release, the health care bill passed by the Massachusetts Senate yesterday does this:

Develops a process to track price variation among different health care providers over time and establishes a Special Commission to determine and quantify the acceptable and unacceptable factors contributing to price variation among providers.

Perhaps the House will offer more, as this Senate provision will mainly allow folks to document -- again -- what has been going on for years, disparate rates paid by insurers for the same services under a system of ratemaking that has no accountability, that is guided mainly by market power.  

While the Senate bill offers much good in other respects, this is a disappointing result for the state's consumers and employers.

Time for a re-hearing on rate issues

Now that radio shows are put on the web, you can listen to things a few times.  This is really handy when you think you hear something that doesn't hold water.  You can check and see if your first impression was correct.

Today, I thought I heard a lot of leaky buckets in a WBUR interview with a hospital president.  Upon listening again, I discovered I had been correct.  As is often the case in such interviews, each statement sounds correct, but important details are left out.

At minute 7:  "We have converted our two major commercial contracts – with Blue Cross and Tufts -- to global payment contracts, so we are doing population health management in a major way."

Compare this to coverage in the Boston Globe when the contract was announced:

"The new contract, while giving fresh momentum to efforts to overhaul how health care is paid for, covers only about 25 percent of the Partners patients insured by HMO Blue."  HMO Blue, a managed care product, is itself but a component of the total Blue Cross subscriber base, which also includes traditional insurance products.  (I think HMO Blue covers about 900,000 of the approximately 3,000,000 subscribers.  I am happy to be corrected on that if I am wrong.)

After being asked for an opinion with regard to the House of Representative's proposed "luxury tax" on high-priced hospitals, offer a "Washington Monument" argument to scare people about required budget reductions:

At minute 11:  "The impact might be to force us and others to cut back on the amount of research we are doing.  I don’t think that for this region that would be a good thing."

If that proposal passed, how would you justify your higher rates?

At minute 12:  “We would try our best to justify the prices we know compared to other top-ranked hospitals around the country that our costs are in line.  But I’d rather devote that effort to improving care and making it more affordable rather than justifying prices that have been negotiated in the marketplace."

But what do you think about the Attorney General's conclusions that that there is a disconnect between rates charged and quality delivered, saying that the negotiated rates are mainly a result of market power?

At minute 13:  "Our ability to measure quality in health care is very rudimentary, and so I respectfully disagree."

Dear legislators, let's take him at his word.  If you can't measure quality differences in health care, there should be a rebuttable presumption that rates should be equal, unless the insurer can demonstrate to a rate-setting body that a differential is warranted.  As noted in that same Boston Globe story:  "The new contract won’t end payment disparities between top-paid providers and struggling community hospitals, which also are being asked to accept smaller pay increases."

The current pricing regime is characterized by secret negotiations between the dominant insurance company and the dominant provider group, which  has led to persistent and pervasive over-pricing of that system's services.  This argument is not solely about the cost of care at, and prices paid to, one academic medical center:  It is about the price paid for care in the entire system (physicians and hospitals) of which that AMC is but a part.  There is a need for independent oversight over parties that clearly are not interested in solving the problem.

How to get people to cycle

Leave it to the French to come up with a totally effective way to get people to exercise.  Take this to your spinning class!

Click here if you cannot view the video.

Crowdsourcing for Professor Westman

Jack C. Westman, M.D., President, Wisconsin Cares, Inc., and Professor Emeritus of Psychiatry at University of Wisconsin School of Medicine and Public Health seeks your advice.  Here's the background:

Jack is writing a book that describes why we all need to care about the 4% of parents who abuse and neglect their kids, and in which he proposes solutions. He asks for help to find a title that would capture the interest of thoughtful people. Please read the synopsis and vote on a title in your comments.

Book synopsis:
This book begins with examples of how parents and fragmented professional care create troubled (and even homicidal) young men and women and contribute to our nation's social and economic problems. It ends with a plan for giving all children born in the United States parents who can give them a chance to become productive citizens.

The social/economic impetus for this kind of plan is that parents who raise a productive taxpayer contribute $1.4 million to our economy. Parents whose child becomes a criminal (or welfare dependent) cost our economy $2.8 million per child. (26% of state & 45% of county expenditures are used for this population). One solution begins with a Parenthood Pledge as a part of a birth certificate.

In your comments below, please let us know your opinion on which title would most attract your attention:

1) A Parenthood Pledge: The key to America's prosperity
2) Parent Power: America's problem and solution
3) Parents Matter: Incompetent parents cause social problems. Competent parents prevent them.
4) The Denigration of Parenthood: How presuming anyone can be a parent undermines our nation's economy.
5) Competent Parents: The foundation of America's economy
6) Any other title? 

Testing on WIHI

May 17, 2012: Testing, Testing! Is This Procedure Necessary?
2:00 – 3:00 PM Eastern Time

Guests:
Daniel B. Wolfson, Executive Vice President and COO, ABIM Foundation
Steven Pearson, MD, MSc, FRCP, President, Institute for Clinical and Economic Review – Institute for Technology Assessment
Amanda Kost, MD, Acting Assistant Professor, University of Washington Department of Family Medicine
Donald Goldmann, MD, Senior Vice President, Institute for Healthcare Improvement
Karen Boudreau, MD, FAAFP, Chief Medical Officer, Boston Medical Center, HealthNet Plan; Former Senior Vice President, Institute for Healthcare Improvement and Medical Director for IHI Continuum Portfolio
 
Of all the sources of excessive health care spending, none may be higher on the list than the habit of ordering lots of expensive tests and procedures. This appetite for the best of what high-tech medicine can offer – whether warranted or not – is a big factor behind estimates that up to a third of health care spending in the US is wasteful and unnecessary. But everyone also has a story of someone, maybe themselves, helped by a diagnostic procedure. There’s no question that one person’s unnecessary test is another person’s lifesaver. So, how do we get closer to more appropriate use? And is there a more active role that physicians can play?

The ABIM Foundation is betting there is a way to bring the ordering of tests and procedures into better balance AND that doctors are key to making this happen. This is the premise behind the ABIM Foundation’s new campaign, Choosing Wisely, and the focus of the May 17 WIHI. Nine medical societies are on board (with eight more joining in the fall), and they’ve each identified five procedures that tend to be overused and that should trigger discussions to ensure that they’re really needed and of value. The American Academy of Family Physicians, for example, has a list that begins with thinking twice before immediately ordering imaging for low back pain.

WIHI host Madge Kaplan has assembled a great group of experts: The ABIM Foundation’s Daniel Wolfson will explain the campaign. Karen Boudreau will help us think through the role of family practitioners, while Steven Pearson will contribute some of the latest and sharpest thinking about evidence-based medicine and comparative effectiveness. Amanda Kost got to put on her “choosing wisely” shoes a bit ahead of the game by being part of the National Physician Alliance’s Promoting Good Stewardship in Medicine project. She’ll provide some key frontline learning on best practices that can help wean doctors and patients alike from reaching for the most expensive solution, first. Finally, IHI’s Don Goldmann, will discuss how Choosing Wisely aligns with other national initiatives and why it’s crucial that the medical profession take a leading role with health care reform.

Whether or not you’re directly in the role of ordering tests or procedures, we invite you to consider that we all have a part in making health care more effective and affordable – in other words, of true value to patients. Bring your hard questions and bring a colleague to WIHI on May 17th. See you then.

To enroll, please click here.