Seeing clearly at MedStar

I was pleased to be invited to the quarterly Quality and Safety/Risk Management Retreat at MedStar, a hospital system that has adopted audacious goals for improvement in these arenas.   My topic was on the power of transparency in helping to bring about the kind of organizational change needed to deliver consistently high quality care to patients.  I found an attentive and engaged audience of people from all of the MedStar hospitals, hosted by David Mayer.  David (below, left) was brought into the system in the last year to lead its quality and saftey transformation.

My theme, as regular readers of this blog will expect, is that transparency's major value is in providing creative tension within hospitals so that they hold themselves accountable to the standard of care in which they believe.  This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

For me, a measure of how well a hospital system is doing is the degree of modesty displayed by the leaders and staff when you ask, "How are you doing?"  Here, David asked the question of the attendees:  "On a scale of 1-10 (10 being the most transparent), how transparent is MedSatr compared to other hospitals and health systems?"  Also, "Provide one example of how MedStar can become more transparent with its patients and with its associates."  The discussion groups met for a while and returned with the following verdict:

I actually think the participants were a bit hard on themselves.  I think their assumption about the level of transparency at other hospitals was too high.  From my view, MedStar is already above average.  Of course, as I noted today, there is no virtue in benchmarking yourself to a substandard norm!  MedStar has a ways to go on the transparency front, but it is off to a good start.

I left with a terrific impression of the energy and good intentions of those in the room.  The level of participation and engagement was exemplary.  This is a system worth watching over the coming months and years!

Beautiful: Teaching girls soccer

By now, anyone reading this blog knows of my passion for coaching soccer and especially for coaching girls soccer--going on now for over 20 years.  This has been an exceptionally rewarding part of my life, with extensions to my professional life as well.  I have also been incredibly lucky to have created friendships with hundreds of girls and their families over the years.  Many of my alumnae are still in touch, and I find myself writing recommendations for them for college and graduate school and for jobs (and hiring several of them!)

Now comes a fantastic Kickstarter project entitled, Beautiful: Teaching girls soccer the Boston Breakers way.  This professional women's team has joined up with producer Ralph Ranalli to produce two videos--one for coaches and one for parents--chock full of ideas for effective coaching of girls.  These are products that will become the standard for years to come, but only if we fund it.

There is only a short time left.  Please help with a generous contribution.

I dare you to watch the video on the site and then not contribute!  Here's a sample:

(Click here if you cannot see the video.)

 

John Toussaint provides a roadmap to Lean success

This should be an excellent (and free) webinar, given by John Toussaint, one of the true experts in hospital process improvement.  Here's a description from Joshua Rapoza at the Lean Enterprise Institute.

I'd like to invite you to join us April 16, 2013, at 2:00 pm (Eastern) for the 60-minute, free webinar "A Roadmap to Lean Healthcare Success" with John Toussaint, MD, CEO of the ThedaCare Center for Healthcare Value, author of On the Mend, and a national leader in improving healthcare through lean principles.

As CEO of ThedaCare, Dr. Toussaint introduced the successful ThedaCare Improvement System, a lean healthcare system.

In this webinar and Q&A, he'll describe a roadmap to lean healthcare success, based on his visits to 120 healthcare organizations as well as many visits to leading lean manufacturing companies.

Learn what Dr. Toussaint will cover and how to register.

It's time to vote!

Ok, I need some serious Boston-style (early and often) voting to help a worthy website win first prize.  Maybe you remember my post back in November about a great website to help kids get ready for hospitalization?  Kinderwebsite was produced by a couple of people at Jeroen Bosch hospital in the Netherlands.

Well, now the site is in a competition to be named one of the top five websites for children in the Netherlands.  You can vote from anywhere in the world.  Go to this site.  Find the category that lists the Kinderwebsite --> Halloziekenhuis.nl.  Click on the box that says stem.  It will take you to the voting page.  Then vote for our candidate.  It will then make you do one more step where you enter your email address and agree to some privacy clause.

Thanks!

Please nominate for Compassionate Caregiver Award

It's time to think about possible nominees for the Schwartz Center Compassionate Caregiver Award.  Petra Langer writes:

We’re accepting nominations for the 2013 award from all six New England states until May 3^rd.  Both individual caregivers and caregiver teams are eligible.  The award recipient or team receives a cash prize of $5,000, and the four finalists receive $1,000 each.  All five are honored at our annual dinner on November 21^st at the Boston Convention Center before an audience of more than 2,000 people.  More details are at http://www.theschwartzcenter.org/ourprograms/cca.aspx. You should know that this is the 15^th anniversary of the award. Since its inception, more than 1,200 caregivers have been nominated and 70 honored.  Here’s a link to a video about last year’s honorees: http://bcove.me/3mwhwotk.

What was said, and what wasn't

The existence of an organization called the Association of Health Care Journalists is an indication of the resources being allocated across America and other countries to the coverage of this field.  I think it is a great thing that the group exists and is able to come together--virtually and physically--to build skills, compare notes, and bring in expert speakers, as they did recently in Boston.

Members of the association, though, may not have realized the danger of drawing stories from panel discussions.  Comments made by panelists are often designed to further promote the story lines of their organizations, lines carefully crafted over the years to support corporate objectives. There can be inadequate time to check the assertions made by panelists before writing summations of such sessions.

Here's one such story, about efforts by Massachusetts to contain health care costs.  Read it and see how the two dominant health care organizations in the state--an insurer and a provider network--coordinate the story lines on which they have joined hands.

First, the insurer expounds on its favorite capitated, or global, payment methodology, the one that ostensibly controls costs.  The "new payment method has not lowered overall spending, but it has controlled the rate of cost increases – below 2 percent annually," according to the story.

Taken at face value, this sounds good, until we remember two things.  First, the insurer padded first-year global payment budgets a few years ago to entice a number of hospitals and doctors to sign on.  It sure is easier to show a lower annual increase when you have an inflated base.  In addition, we need to remember what this insurer gave away to the dominant provider group.  As noted here:

Recall that the state's largest insurer gave away a huge rate increase to the state's dominant health care system  --  a 2-3% increase on a base that is, what, 15 to 20% higher than the rest of the market.

Think about the arithmetic.  The only way to give achieve an overall rate of cost increase below 2 percent while giving away a rate increase above that level to the largest provider is to give smaller increases to the subordinate providers in the state, thereby enhancing the market power of the dominant provider.

Oh, but what did the dominant provider agree to in return?  According to the AHCJ story, the dominant provider has "has changed its payment structure."

Really?  Let's go back to the deal that was signed, as reported by Robert Weisman in the Boston Globe:

Under the agreement, Partners agreed to participate in Blue Cross’s alternative quality contract, a so-called global payment that gives health care providers a budget for patient care and incentives for healthy outcomes rather than billing for each visit and procedure.
 
Th[at] new contract . . . covers only about 25 percent of the Partners patients insured by HMO Blue.

As noted, we can't blame the reporter in this case for reporting what was said in a panel discussion.  Perhaps, though, we can blame the conference organizers for creating a panel that was so likely to produce unsupported--and unrebutted--public relations story lines.

"All change begins with one small test."

Anna Roth, CEO of Contra Costa Regional Medical Center, wrote me the other day with a summary that is revealing about what we are all trying to do.  It is all the more powerful because CCRMC is a safety net hospital, short on resources but strong on mission.  The context was her description of a “Change Agent Fellowship" program, modeled after her own IHI fellowship, which couples mentoring and experiential learning with traditional learning such as didactic sessions.

The fellows were chosen by an executive leader who assumed the role of their sponsor and general support throughout the fellowship year.  Fellows were also assigned mentors. These were strong leaders from within and outside our system who could work with fellows and comfortably provide feedback to executive sponsors. I recruited an accomplished executive who had recently retired to run the program.

Each executive makes a promise to the fellow that they will look for learning opportunities and experiences. We have weekly seminars where fellows and their sponsors meet and have speakers join. They discuss projects individually and in a group setting. Though the fellows work on extremely diverse things such as; getting patients and families engaged on all improvement teams; eliminating infections in the hospital;  creating a social impact bond to bring diverse stakeholders together to eliminate suffering in Richmond neighborhoods near the refineries; embedding primary care and respite services within our homeless shelters…it goes on. These discussions often lead to identification of barriers.

Often even though the projects are quite different, the barriers are common across projects. Frequently one barrier is lack of leadership engagement or support to overcome local conflicts of interest or simple things that an executive sponsor can do to help such as authorize a purchase or extra staffing to conduct a test to learn.

What happens?  What is learned?

In terms of the leaders, they will tell you the experience of taking the journey with the frontline staff is both humbling and transformational. Most of us leaders don’t know about improvement or how to lead change. We are promoted because we are masters of the current system. It isn’t easy to stop, listen and let others guide/lead us. This can also be seen by some as weakness. Health care is notorious for charismatic heroes. Faster and more is often seen as better.

The truth is the most important decision made in my organization is not made by me in a board or conference room, but by one staff member at a time, one patient at a time, far away from the board room and far from me. My job is to help create circumstances that will allow our team to easily do what is right. Our mission is what guides us and that is why people come to work. They don’t come to work to cause harm which we hear so much about and is happening far too frequently. They come to help people.  I’m not trying to boast or ring our bell. We have a great deal of work to do. We have only scratched the surface. There isn’t a day that goes by I don’t think about how much more we need to do.  

All change begins with one small test. For us, the fellowship is one strategy designed to systematically deliver an experience that enables leaders and the front line to offer and accept help and to begin doing this on a regular basis with one person. We have seen leaders begin connecting with employees, patients and family members in a very different way after sponsoring a fellow and the fellows go deep into the operation or to the front-line and influence and amplify the voice and ideas of those around them. 

Janice pleases through poetry

Janice Lynch Schuster, @medicaring, who writes very well about health issues (especially aging and end-of-life issues), has another skill.  Check out her haiku here.

I like a recent one, entitled "Grandmom," which subtly ties her various interests together:

I see my Grandmom
Settled in her favorite chair
Comfort in what’s passed

Community needs on WIHI

April 4, 2013: 

Community Health Needs Assessments Part 2:
Lessons from North Carolina

(2:00 – 3:00 PM Eastern Time)

Featuring:
Dorothy Cilenti, DrPH, MPH, MSW, Senior Investigator, North Carolina Institute for Public Health; Clinical Assistant Professor, UNC Gillings School of Global Public Health
John Morrow, MD, MPH, Pitt County Health Director; Incoming President, North Carolina Association of Local Health Directors
Craig James, MPH, President and CEO, Highlands-Cashiers Hospital

One of the reasons it’s so hard to transform US health care into something that’s safe, value-driven, and patient-centered, but also focused on improving the health of the local community, is that the responsibilities and the responsible parties have grown up completely separately. For example, it is not a naturally occurring event for the local public health department to coordinate its efforts with local hospitals… except in cases of disease outbreaks or disaster. So, imagine how rare it is to sit down together to craft overlapping goals for population health or to hatch new initiatives to keep residents from needing expensive acute care. It helps to have a convener to bring parties together… which is why we’re going to be examining one such coalition that has formed in North Carolina… on the April 4, 2013, WIHI, Community Health Needs Assessments Part 2: Lessons from North Carolina.

WIHI host Madge Kaplan invites you to hear what’s been going on under the auspices of the North Carolina Institute of Public Health (NCIPH), and the leadership of Dr. Dorothy Cilenti and her team. They’ve brought together local health directors like Dr. John Morrow, who now leads the statewide health directors association; and hospital leaders like Craig James who sees the mission of one small, critical access facility as part of something larger. They’re all laying the groundwork for the future of health and health care in the state. The effort has become especially relevant and pressing because of new federal requirements for nonprofit hospitals to engage in robust community health needs assessments, with help and input from other groups and agencies. These new IRS rules, and how to make them meaningful, were the focus of the March 21 WIHI, which we invite everyone to listen to as background and context for the April 4 discussion.

One of the more intriguing dimensions to the work in North Carolina is its explicit mission to create multiple “community health systems” throughout the state to build and model best practices for population health. The collaborative driven by NCIPH is also working on analyzing return on investment and economic impact to “create the business case for working collectively on improving community/population health.” We’ve got a great case study to learn more about on April 4. Please join us, and make your own work on population health and community health needs assessments all the richer. See you then!

Please join us on the April 4 WIHI! Click here to enroll.

Spike out Sepsis

Dr. Jim O'Brien sends this announcement about a 6-on-6 sand volleyball tournament to support the Sepsis Alliance, to be held at The Bogey Inn in Powell, Ohio, on June 22.

There will be lots of news about SOS 2013 to come.  To get on the mailing list click here.

Two intriguing summer courses at Tufts Medical School

Lisa Gualtieri, @LisaGualtieri, with the Department of Public Health and Community Medicine at Tufts Medical School, is again running two great summer courses.  One is online and the other is on campus.  I had a chance to sit it on one of Lisa's classes a couple of years ago.   She is an engaging teacher, and the courses attract a diversity of students.

Here's a description of the two summer courses, with a link leading to more details.

Mobile Health Design examines the impact and potential of mobile devices for consumer health at a national and global level. The focus of the course is on how to design evidence-based health apps that incorporate mobile user experience, predictive analytics, and big data to help people achieve their health goals. The online course runs May 22—June 26, 2013

5th Tufts Summer Institute on Digital Strategies for Health Communication covers how healthcare and public health organizations develop and implement digital strategies to drive the success of their online presence, with a focus on how to use web, social media, and mobile technologies to reach a target audience. The case study is Massachusetts Medical Society. The course is offered July 14-19, 2013 on Tufts' Boston campus.

e-Patient Dave does it again

Dave deBronkart, @ePatientDave, and his doctor, Danny Sands, have published a new book, Let Patients Help.  Well, almost.  It is still in its pre-broad distribution mode.  Version 0.91, Dave calls it.

You can (should) order it directly from Createspace, here.  It is very good.

The dangers of risk-taking

Several weeks ago, I suggested that the MA Division of Insurance was not doing its job properly in implementing a provision of recent state legislation.

There is a provision of the law ("Chapter 176T, Risk-bearing Provider Organizations") that was written to provide some assurance that provider organizations--physician organizations, physician-hospital organizations, independent practice associations, provider networks, accountable care organizations and any other organization that contracts with carriers for payment for health care services--would be financially capable of bearing the risk of alternative payment contracts.

A recent post on Disease Management Care Blog, reprinted later on The Doctor Weighs In, shows that this is not an academic concern.

"Wellspan" is a highly regarded and well-run hospital system that is local to the DMCB. This recent news report is telling because Wellspan's success and challenges probably apply to other emerging integrated institutions that have an appetite for risk contracting. 

According to the press report, Wellspan garnered an excellent credit rating because... 

"766 physicians — more than 75 percent of those in the hospital's market — are affiliated with WellSpan, which [was] counted as a key credit strength."

 But the bad news is that the rating also.... 

.....noted that WellSpan's physician group, which employs 411 of those doctors, generated losses of $19.6 million in 2011 and $21.4 million in 2012 (bolding DMCB). 

The DMCB has heard similar statements from seasoned health system administrators both locally and nationally.  If "physician integration" is supposed to be the bedrock of ACOs, how is it that the docs are responsible for millions of dollars in losses?  What is the likelihood that these organizations will finish December 31, 2013 in the black?

A few Massachusetts hospitals and physicians have long experience with risk. Others are new to the concept and, according to the word on the street, do not have in place the kind of care management regime and data sophistication needed to avoid a deficit in these plans.  That is especially the case because Blue Cross padded first-year global payment budgets to entice hospitals and doctors to sign on.  Now that those plans are starting to bite, look for losses to emerge. 

Let's explore "consumer-driven" health care

In a previous post, I covered some of the non-intuitive aspects of designing health insurance products for employees of a company.  I said:

I bet that if you were to look at the trends in medical insurance premium growth for companies in the US, you would find a bimodal distribution.  Some will have experienced a rate of premium growth lower than the average, and others will have experienced a rate above the average.  What might account for this?

I'd like to suggest that a factor in the differential premium growth rates relates to whether companies have affirmatively counteracted the strategic plans of health insurers to migrate employees to plans that correspond to greater use of health care services.

Several commenters questioned this conclusion, noting that many employers self-insure and so would not be affected by the strategic aims of insurers.  Well, the answer to this is that self-insured employers tend to listen to the advice given by the insurance company that administers their plan.

So, let's spend a little time talking about self-insured companies.  First, it will certainly be to the advantage of employers, once Obamacare kicks in, to self-insure.  Estimates call for dramatic increases in insurance premiums with the cost add-ons that result from the Affordable Care Act.  Today, there is about an 8 to 12% difference in the cost of carrier-provided insurance and self-insurance, and this difference will be amplified in coming years.  In the past, some employers have shied away from self-insurance because of the possible volatility in claims year to year.  Those with self-insurance often buy aggregate coverage, which creates a band around that volatility, but there was always the potential (even with that insurance) that the costs paid would have exceeded the higher, but more stable, carrier insurance.  With the increases from Obamacare, the chance of even volatile costs exceeding the carrier insurance costs will be dramatically diminished.

But that still leaves the question of plan design. Our goal as an employer should be to encourage younger, low-cost staff to join our plan and to encourage older, high-cost staff to join their spouse's plan at another employer or to go to an exchange.  (Age is the primary determinant of utilization.)  We want to minimize the number of claims we have to pay and also the size of those claims.  This will put us on the path to be in the left-hand side of the bimodal distribution, facing increases in healthcare costs well below the regional trend.

But many self-insured employers undercut this objective.  For reasons of perceived employee equity and in the name of "consumer-driven health care," they offer two or three options to their staff.  The one that is often offered at a discount is a high deductible plan with a moderate annual out-of-pocket maximum--let's say a $500 deductible with a $2000 OOP maximum.  This plan might have a predicted actuarial value--the percentage of total average costs for covered benefits that the plan will cover--of say, 80%, leaving the consumer responsible for 20% of the costs.  This plan is not attractive to healthier workers who are unlikely to be hospitalized but are likely to incur the deductible in office visits. It is extremely attractive, though, to staff members who expect to have lots of medical bills, and especially those who expect hospitalization.  The employer has given a discount to precisely the wrong people, the ones who will end up driving up the firm's health care cost trend because of their higher utilization of services.

Instead, imagine a plan with zero deductibles, but with an OOP maximum of $5000.  The actuarial value might be in the range of 95%, leaving the consumer responsible for only 5% of the costs. This is much more attractive to the younger, healthier group.  It is clearly unattractive to the high-risk segment of staff, and they will seek alternatives.  It does not take many of them to move out of the company's plan to make a huge difference in costs and the cost trend. Indeed, even if the actuaries predicted that the zero-deductible plan would be more expensive to the company than the first design described above, the ultimate expense would actually be lower because of this out-migration.

If you consider that the younger workers also tend to be the lower paid workers, you see also that the typical discounted program is playing reverse Robin Hood, assigning higher costs to the lower income staff and lower costs to the higher income staff.  In terms of equity, its application is actually backward--all in the name of consumer-driven health care.

Does it make you feel uneasy to think of firms encouraging some (older, less healthy, more highly paid) staff out of their self- insurance plan?  Recall what I said in the last post on this topic:

You may ask, where will they go? Well, here is an unpleasant aspect, but one that is inherent in the employer-based insurance system we have in the US.  As a colleague has said to me, "If I invite bad risk, it comes from somewhere.  If I encourage it to leave, it goes somewhere.  This is a zero sum game."  Specifically, a working couple will sit around the kitchen table comparing the health plans offered by their respective two employers.  They will transfer coverage to whichever spouse's firm offers the larger subsidy for their high-risk plan. That company will find itself shifted to a higher cost curve and will find itself moving up that cost curve at a rate greater than the average trend.  The company that has systematically acted to reduce untoward subsidies will find itself shifted to a lower cost curve and will find itself moving more gradually up that cost curve.  Simple mathematics drives this result.

Stand up. Disagree. Debate.

An open letter to @commonwealthfnd  and @CPR4healthcare:

I published an article here on Tuesday suggesting that a report issued by the Commonwealth Fund was deeply flawed.  As a courtesy, I tweeted the post on Twitter to the Fund for your reaction.

Imagine my surprise when you quickly seemed to walk away from the report.

Ok, maybe I got it wrong.  It wasn't a Commonwealth Fund report after all.  You just helped fund it.  But, after all, it was consistent with policy prescriptions offered by the Fund.

So, last night I tweeted a bit more:

And also sent a direct message to the CEO of the Fund:

As a reminder, here is a repeat of my direct disagreement:

Here's my take--and I am open for correction:  I know of no substantive analysis that shows that the clinical variation that exists in the United State and across the world, across all methods of payment and institutional delivery systems, is tied to the rate design used to pay for care.  I know of no substantive analyses that shows that the use of methods included in the "reform" definition offered by the Commonwealth Fund have made a difference, over time, in the health care costs incurred in various regions.

I continued:

I do know that a substantial portion of society's health care costs are spent on an incredibly small percentage of the population.  Rather than trying to redesign an entire system, why not focus on improving case management of that small percentage?  Rather than trying to transform an entire payment regime into a risk-based system that has incredible complexity--in terms of allocating that risk across and within a provider network--why not simply pay cognitive specialists more, so they can spend more time with patients and keep the patients away from expensive tests and hospital admissions?

There is no monopoly on insights in this field.  I again invite correction. Will you respond?  Will you stand by your work?  Will you engage in debate?  You are not alone in your views.  But there are many who disagree, too.  This is too important to let stand unanswered.

Catching on to patient safety and quality at MedStar

The folks at MedStar Health have engaged in an extensive and intensive effort to be the safest, highest quality, and most transparent system in the country.  You'll here more about that over the coming months and years.  Like some other hospitals, MedStar has introduced a "good catch" award.  More than just recognizing the call-outs of front line staff, this kind of program builds team spirit and a sense of community.  I print below the announcement of the most recent award.  It is a very nice description, but, as a friend relates, the human story behind this is that the patient, who thought she would have to live on medication, is "a terrific young woman just happy she could rock climb, be a mom and have her nails done without having to worry about the risks associated with a life on Coumadin."

When Sorrel King heard about this call-out, she contacted Donna and sent her one of the Josie King necklaces in appreciation--"a reminder of all things positive."  Such a nice gesture that, I'm sure, was warmly appreciated!  Here's the story:

Donna Shifflett at MedStar Montgomery Hospital Awarded “Good Catch” Patient Advocacy Award December 2012

Throughout all our MedStar hospitals, we know our associates are constantly working to contain potential harm to our patients. It is this type of constant mindfulness that will move MedStar from Good to Great, as well as prove ourselves to be a highly reliable healthcare organization. 

In 2013, MedStar Health is looking for every opportunity to reward those who go above and beyond in their vigilance for patient well-being. As such, we have launched our system-wide Patient Safety Hero Recognition Program and want to hear about all the good things happening in our hospitals.  Look for more information on the full program in next month’s Patient Safety & Quality Newsletter. 

Our first Good Catch Award goes to Donna Shifflett, a senior coder at MedStar Montgomery Hospital, who was recognized in December of last year for catching a coding discrepancy that had direct impact on a patient’s quality of life. When Donna noticed that a young woman had been diagnosed with a pulmonary embolism, but that the corresponding radiology report negated that diagnosis, she contacted the attending physician immediately alerting him of the contradicting information. The patient was subsequently called back in for evaluation, and when Donna’s suspicions were confirmed, the anti-coagulant medications that had been started were discontinued. 

Thanks to the mindfulness of Donna Shifflett, this young woman’s life was returned to normal. She is truly a leader and patient safety hero, and we look forward to hearing similar stories throughout MedStar.

Join a Dialogue: Legalizing Aid in Dying

@medicaring Janice Lynch Schuster and the New York Times both invite you to participate in "Invitation to a Dialogue: Legalizing Aid in Dying."  Here's the link.

Here's an excerpt of Janice's piece:

In this modern world, millions of us will live for two or three years with a condition that ultimately kills us; millions more will have our minds fail from dementia or stroke. In the course of such illnesses, people want to live as well as they can, despite increasing dependence on others for basic care, and the subsequent loss of dignity and independence. But we do not have services adequate to meet their needs, or their families’. Creating such a system requires much more than modest Medicare reforms; it requires fundamental changes in how medical treatment and supportive services collaborate.  

In general, where it is legal, physician-assisted dying is available only to people who are competent, who have physicians’ verification that they will die soon and who can wait for a period of time before receiving a lethal prescription. For those few, having a sense of control can ease fear and anxiety. 

But for those of us on our way to a less predictable end, urgent issues remain to be solved. The inadequate and disconnected services we have now will fail us. We need to find better ways to care for the dying and, ultimately, for ourselves.

The Times notes:  We invite readers to respond by Thursday for the Sunday Dialogue. We plan to publish responses and Ms. Lynch Schuster’s rejoinder in the Sunday Review. E-mail: letters@nytimes.com

The difference between belief and serious work

I have to hand it to the Commonwealth Fund.  They are true believers.

First assert this:  "We know the current fee-for-service model of payment, in which providers are paid per service or test, incentivizes providers to deliver more, and more expensive, care."

Then, create a scorecard on "payment reform" to assess the degree to which providers are paid in accordance with other methods that purportedly deliver better care.

Then summarize:

The 2013 Scorecard tells us just 11 percent of private health care payments to doctors and hospitals are tied to performance or designed to cut waste. By comparison, 89 percent of payments are made through payment methods that do not have a quality or other performance components and the traditional fee-for-service system.  Among payments tied to value, just 60 percent involve providers taking on a share of the risk, meaning they stand to lose money if they do not meet certain quality and efficiency measures or exceed a budget. The rest are in programs like pay-for-performance, which offer incentives for providing high-quality care, but do little to discourage overuse or inappropriate care.

Oh boy. The lack of analytic rigor with regard to the first assertion carries through to the final exhortation:

Catalyst for Payment Reform, an employer-founded nonprofit focused on creating greater value in health care, has a goal for the nation: at least 20 percent of health care payments will be value-oriented by the year 2020. The Scorecard results show we have serious work to do. 

Here's my take--and I am open for correction:  I know of no substantive analysis that shows that the clinical variation that exists in the United State and across the world, across all methods of payment and institutional delivery systems, is tied to the rate design used to pay for care.  I know of no substantive analyses that shows that the use of methods included in the "reform" definition offered by the Commonwealth Fund have made a difference, over time, in the health care costs incurred in various regions.

I do know that a substantial portion of society's health care costs are spent on an incredibly small percentage of the population.  Rather than trying to redesign an entire system, why not focus on improving case management of that small percentage?  Rather than trying to transform an entire payment regime into a risk-based system that has incredible complexity--in terms of allocating that risk across and within a provider network--why not simply pay cognitive specialists more, so they can spend more time with patients and keep the patients away from expensive tests and hospital admissions?

Yes, we have serious work to do.

Keeping New Orleans musicians healthy

The musicians of New Orleans are a national treasure, with an influence for exceeding their numbers.  If you were governor of the state in which they were located, wouldn't you try to help them obtain and receive proper healthcare?  Based on comments by the New Orleans Musicans' Clinic, that appears not to be the case.  Here are some excerpts from a recent newsletter:

On May 1, 2013 we will celebrate the 15th year the New Orleans' Musicians' Clinic. We shake our heads at the irony that according to Governor Bobby Jindal, it is "prudent" for Louisiana to return to the "good old days" when the uninsured patients in Louisiana suffered the worst health care outcomes in the USA because their only health care option was to be treated in the Charity Hospital System ER. This urgent care, up until the US Army Corps of Engineer's post-Katrina floods closed Charity Hospital in September 2005, was well-funded by federal dollars from the Disproportionate Share Hospital (DSH) program. The only difference is that uninsured patients in 2014 have even fewer options as Charity has been replaced with the much smaller University Hospital . . . and the public clinic at the former Lord & Taylor. The DSH dollars remain a federal "windfall" for Jindal as he "reforms" Louisiana's health care system by refusing the federal Medicaid money that would help us keep our patients alive.

Concurrent with the abandoning of Louisiana's statewide safety net hospitals, Governor Jindal is refusing to accept the federal expansion of Medicaid (Obama care). He has also proposed to the state legislature to increase Louisiana's sales tax, inhibiting the working poor to afford medications and healthy food. Religious leaders from a cross-section of Christian faiths, including clergy from Baptist, Episcopal, Methodist and Unitarian churches from more than 70 Louisiana cities and towns signed the letter opposing the governor's tax plan. Their letter states that even before Jindal's proposed changes, Louisiana already has a regressive tax structure in which families earning less than $16,000 per year pay 10.6 percent of their income in state and local taxes, while families earning over $1 million per year pay 4.6 percent.

Under the Affordable Care Act (ACA), all USA adults who earn 138 % or below of the federal poverty level would be eligible to enroll in Medicaid beginning in 2014, IF A STATE OPTS IN. The federal government initially pays 100 % for the first 3 years of ACA.  The Medicaid expansion is projected to provide health care coverage for between 200,000-400,000 of Louisiana's uninsured poor. That would mean eligibility for all in Louisiana earning up to $1,285 a month, or, for a family of four, the earning level would be up to $2,651. In other words, the majority of the NOMC's patients would be covered for their basic health needs by ACA, with NOMC donations funding additional care.

Wrong approach, but it saves money for the state

Massachusetts is home to health policy researchers of the highest order.  Some have pointed out the flaws and the unintended consequences of applying financial penalties to the rate of readmissions experienced by hospitals.  Beyond Massachusetts, other researchers have pointed out the statistical meaninglessness of such comparisons.  Nonetheless, the state government stubbornly insists on applying such penalties based on the experience of Medicaid patients.

The MA Hospital Association is doing its best to reverse this action, but people on Beacon Hill don't seem to be listening.  Here is the most recent MHA statement on this subject:

Reducing readmissions at hospitals is a goal that every hospital in Massachusetts is committed to. Deliver high-quality care with strong follow-up care and other proven strategies that involve patients and their families and you may be able to prevent readmissions to a hospital. But hospitals can’t control all the factors that can influence a readmission.

That is, a patient may be readmitted to a hospital within days of his discharge, but for an ailment entirely unrelated to the first admission. But these could be counted as a readmission under some measurement approaches. Some readmissions are scheduled readmissions, but they too could be counted. And some patients and their families even fail to follow discharge instructions for taking medicine or avoiding certain foods, and wind up back in the hospital. That’s counted as a readmission too and can result in payment penalties for the hospital.

Couple these pitfalls with the fact that there is not a widely accepted tool for measuring readmissions, and you’re left with ever-increasing penalties against providers for readmissions that are hard to measure and over which they may have no control.

The FY2012 MassHealth acute hospital RFA contract between hospitals and the state introduced a new preventable readmission penalty for certain hospitals that MassHealth has determined to have higher-than-expected preventable readmission rates. More than 20 hospitals were given a 2.20% reduction to their inpatient reimbursement rate in FY2012. In FY2013, the administration increased the penalty to 2.4%, 3.4%, and 4.4% for 31 hospitals. The penalty applies to all the hospital’s discharges, not just readmissions. A score of cases can produce millions of dollars in penalties to an already financially stressed hospital. The MassHealth penalties can apply against hospitals that are doing a lot to address readmissions and which deal with some of the most challenging patient populations. Add to these problems the fact that MassHealth uses data that is several years old and doesn’t reflect the current effectiveness of hospital efforts.

MHA opposes the original penalty as well as the increases and argues that it is time to step back from the penalty mindset and look at a reasonable approach to readmissions.

“The current penalty is seriously flawed from both a public policy and a methodological perspective. It unfairly punishes hospitals without advancing the objective of reducing preventable readmission,” said MHA’s Executive V.P. Tim Gens. “It may work as budget-cutting initiative for the state, but it does little to promote better patient care. It is clear that addressing readmission requires collaboration among the community of participants in healthcare delivery – not arbitrary and punitive measures against hospitals.

“The application of this penalty across all payments for inpatient services results in an unwarranted punishment that is far greater than the amounts actually paid by MassHealth to the hospital for the so-called ‘excess’ readmissions themselves,” Gens continued. “The data the state relies upon to determine each hospital’s performance is three years old, the methodology the state uses to identify preventable readmissions has not been approved by the state’s own panel of experts, and it is clear that hospitals do not control all of the factors that contribute to readmissions.”

In its budget letter to House Ways & Means Committee Chairman Brian Dempsey (D-Haverhill), MHA has requested that the House, in its FY14 budget proposal, direct MassHealth to use a more equitable system for assessing penalties related to preventable readmissions; an appropriate penalty would limit it to only those readmissions above the expected number calculated by MassHealth. Hospitals exceeding the expected number would face up to a 75% penalty for those readmissions that exceed the expected rate. MHA also believes consideration should be given to hospitals that have made important advances in reducing preventable readmissions by requiring EOHHS to limit penalties for those hospitals that have shown demonstrable progress.