May I Speak to the Doctor's Computer?

By Kim Bellard, June 25, 2014

There's a new provocative study in Computers in Human Behavior that suggests we may be more likely to tell the truth about personal matters, such as health problems or medical history, when talking to a virtual human instead of to an actual human.  I'm not sure if these findings threaten to set back the patient-physician relationship 10,000 years, or promise to advance it fifty years.

The article -- It's Only a Computer, by Lucas, Gratch, King, and Morency -- tested participants' willingness to disclose information to a "virtual human" on a computer screen.  When the participants believed the virtual human was fully automated instead of being controlled by a human, they reported lower fear of self-disclosure, were less likely to shade the truth in order to create a good impression ("impression management"), and were rated as being more willing to disclose information.  The key to the behavior was their belief that no human was involved, whether or not a human was actually acting behind the scenes.

The virtual human idea is not pie-in-the-sky, good only for research studies.  Versions of it are already being tested, such as by Sense.ly, whose digital health avatar was profiled by MIT Technology Review a year ago.  It captures patient information via an avatar, which can respond to patient statements or data and can even answer questions.  

Clearly, we're entering a new world.

The kind of artificial intelligence that might power these avatars/virtual humans can also be used to assist physicians instead of competing with them.  IBM, of course, has been touting Watson in health care for several years now.  As Wired recently reported, there are a number of AI efforts out there to assist physicians. 

Wired also notes that companies are trying to keep their products viewed as offering recommendations instead of making decisions, which would push them over into FDA approval and regulation.  We probably will get there, but that step will be a big gulp.

Some experts believe people will improve their health behaviors -- e.g., get more exercise or lose more weight -- if they know they are being monitored.  Others fear people will end up forgetting about their trackers and will slide back to their previous behaviors. 

The plethora of tracking devices poses issues not only with the sheer volume of data generated, but also with integrating the disparate data from multiple operating systems into a unified record. 

The idea that health information is only collected at a medical office or lab, and that patients should wait to act on it until a human can talk to them, is simply no longer viable.  The data are increasingly going to be available 24/7, and when it means something important there have to be mechanisms to act upon it in real-time.   Maybe that is through alerts to physicians, who then initiate contact with patients, or maybe the wearable ecosystem can trigger its own alerts and advise the user what is going on using avatars and other automated mechanisms.

A recent op-ed by Dominic Basulto in The Washington Post stated that "Google and Apple want to be your doctor, and that's a good thing."  Mr. Basulto concluded:

Companies like Apple and Google can help to break down the notion that health has to be something offered by a monolithic company with a confusing set of rules and terms. It might just be the case that mobile health care facilitated by wearable tech will turn out to be better than traditional doctors.

I think it is a stretch to say that mobile health will be "better" than traditional doctors, but I think these and other technological options can certainly radically change when, why and where people need to see physicians or other health care professionals.  And that's good.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Stopping on Green

By Laurie Gelb, June 9, 2014

The intersection greets you with a green light, but an accident blocks your lane. You brake instinctively, disregarding an official signal to proceed. Contradictory stimuli define our lives. 

Cut to health care’s adherence doctrine. “Ask your doctor. Take your medication as prescribed.” In what other subject area is it optimal for end-users to follow instructions without having internalized a rationale and therefore knowing when and how to ignore them? If you’re repairing something and the instructions say “use an inch of duck tape” and it takes two, do you stop working or use more tape?  You make a split-second decision in the moment. 

We expect to kludge. Every day, most people take action that is unprecedented for them, slightly different, under new circumstances or seen in a new light. When a wall-mounted sink falls off, most of us can imagine that we should use the main water shutoff even if we’ve never used it before. And if we came to a screeching halt at every choice about food, drink, OTC, rx, exercise, surgery, medical equipment, caregiving, parenting, safety, environmental controls, etc., we couldn’t function. Certainly, some health decisions merit more than a second for consideration, but that doesn’t mean they get it, whereas some receive more consideration than they deserve.

You might ask, why is understanding the rationale for and exceptions to instructions so important, considering that patients can consult a clinician that knows both well? But you know the answer: seldom is the clinician or the network next to patients as they make critical choices to act, avoid, deny, even everyday re-evaluation of instructions about meds, diet, exercise, procedures, lifestyle, rehab.The vast majority of decisions that drive health outcomes are unknown, unseen and uninfluenced by content and service providers. And our constituents, knowing their own context better than anyone while facing their own toppled sinks, must often take what is for them unprecedented action. 

As the green light illustrates, we haven’t abstracted information until we can act optimally when things go wrong, or when conditions differ from a perfect world. The necessity of lifelong learning applies to health care in spades, while the evidence base for preaching “follow” (along with paternalistic clinicians and arsenic cosmetics) reeks of mold.

Memorizing that 2x2=4 doesn’t mean that you understand arithmetic. When a toddler repeats words, she hasn’t yet learned the language. We should want health care choices made by reason, not rote. Since any ongoing regimen, including observation, should be re-evaluated periodically, the notion of “set it and forget it” doesn’t apply. 

Few life choices entail a greater emotional investment than your own and loved ones’ health, while typical messaging dispassionately informs you that following the rules offers the best odds.  Yet the “exceptions” are so ubiquitous as to be cliché. Long-distance runners drop dead of early MIs as grizzled sun-worshippers light up into their 80s.  The “what you get is what you follow” thesis merits growing skepticism as truisms (fats block arteries, calcium strengthens bones, exercise prolongs life) emerge as increasingly complex and non-curvilinear propositions. Moreover, today’s patients face competing risks and lifestyle choices that their ancestors never knew. 

Instead of preaching reliance on catechisms that may or may not apply to a given situation, how about skill-building in decision-making directly, including the rationale for caring at all, transcending health calculators and guidelines. Economic studies show lower costs for the “engaged.” It can’t be an innate urge to obsess about health care that engages them, since hypochondriacs entails higher costs. The truly engaged understand enough to add value to their care.

Let’s not seek “informed consumers” a la the cereal aisle, who can only consume the information and care we provide, but informed patients, caregivers, clinicians, administrators and payors, who can collectively lift all boats. Clinicians can ask better questions to optimize outcomes, while EHR designers find better ways to incorporate the answers. Payors can better align provider and patient incentives. Patients and caregivers can ask better questions as well, while acting optimally on the stimuli life presents. 

Our “best” patients are not necessarily the most compliant with our every word. Instead, they ask realistic questions and probe for the best kludges so they can best apply what they know to what they don’t. Indeed, exploring disease information on one’s own has been associated with greater adherence in the traditional sense, time and again. Our “best customers” and the caregivers that support them understand that intention is not action, there is no free ride in health care and sometimes they must preserve their own health and even lives by stopping on green. 

Last week’s Modern Healthcare piece on the Cleveland Clinic illustrates, hardly for the first time, that even marquee institutions mislay part of the achievable.  By the same token, the lives we can save or improve by helping decision-makers to do their best work are incremental to the followers who leave more to chance.

Next installment: what are quick wins for patient satisfaction [sic], disease management and e-health if/as we rethink the adherence doctrine?

How do you Define Population Health?

By Clive Riddle, March 7, 2014

This week, the inaugural issue of Population Health News was published. In their Thought Leaders Corner, a number of members of their national advisory board answered the question – how do you define population health? Here’s what the experts had to say:

Fred Goldstein, M.S., Founder and President of Accountable Health, LLC; and Executive Director of Population Health Alliance says “A population health management program is one that strives to address health needs at all points along the continuum of health and well-being through the participation of, engagement with and targeted interventions for the population. The goal of a population health management program is to maintain or improve the physical and psychosocial well-being of individuals through cost-effective and tailored health solutions.” (Fred cites this description is from Population Health Alliance, formerly the Care Continuum Alliance)

Thomas Graf, M.D., Chief Medical Officer, Population Health and Longitudinal Care Service Lines at Geisinger Health System offers this definition:  “Population health is the ability to define and understand the health status of every individual patient and proactively deploy medical resources to support those patients, whether it is to push resource to them where they are, or effectively connect them to the optimal resource in a patient specific manner, accelerated by technology.”

Paul Grundy, M.D., MPH, FACOEM, FACPM, the Global Director of Healthcare Transformation for IBM and President of the Patient-Centered Primary Care Collaborative (PCPCC) elaborates that  “population Health is ‘the health outcomes of a group of individuals, including the distribution of such outcomes within the group.’ For me, the ability to deliver population health requires a place in the delivery system that acts as the system integrator where the data flow about the population and is held accountable. We ask the house of primary care to give us a set of principles for this system integrator that is known as the patient-centered medical home (PCMH).  The medical home is defined as a ‘healthcare setting that facilitates partnerships between individual patients and their personal providers and when appropriate, a patient’s family. It lies at the center of the effort to address population health through the provision of integrated and coordinated, team-based care. It is a delivery organization that fosters clinician-led primary care with comprehensive, accessible, holistic and evidence-based coordination and management. PCMH builds the infrastructure through which data flow and is held accountable as the system integrator for POPULATION HEALTH.”

David Nash M.D., MBA, Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University observes that "population health recognizes that the social determinants of healthcare, like poverty and education, are the key drivers of a society's well-being. Medical care is responsible for 15% of a society's quality of life.”

Vince Kuraitis, J.D., MBA, Principal and Founder of Better Health Technologies, LLC explains that “definitions of population health usually focus on improving the health and health outcomes of a population. That said, the understanding and point of view of population health managers will vary greatly. Consider three highly variable factors in populations: 1. What's the COMPOSITION of YOUR POPULATION? The answer will vary depending upon whether you are a health plan, a physician practice, an employer or the government. 2. How STABLE is your population? How long do you expect it to remain with you? If you are a health plan, you will expect 18% to 20% annual churn in membership and an average tenure of around three years. If you are Medicare, your members will be with you for the rest of their lives. 3. Are you at FINANCIAL RISK for the health of your population? Upside risk? Downside risk? What are the details?   These factors will affect the economics of a population and in turn, the type and timing of potential interventions. Population managers will consider ROI as a primary metric for evaluating success. While this might seem narrow, it's very real. For example, if you are a health plan, you are more likely to invest in a congestive heart failure disease management program that has potential to identify patients and interventions that will keep patients from being admitted to a hospital within the next one to three years. If you are Medicare, you might consider a diabetes prevention that promises to reduce eye or foot problems over the course of 15 years.”

Finally, Al Lewis, Founder and President of the Disease Management Purchasing Consortium International, Inc. informs us that “population health is the provision of free (or financially incentivized) health-related tests, education and support services to groups who are (rightly or wrongly) believed—due to demographics, claims history or even company/health plan policy—to be at risk for chronic disease or chronic disease exacerbations absent those interventions, whether or not such interventions are requested by the employee or member.”

The second issue of Population Health News will include additional responses from Population Health Thought Leaders. Stay tuned.

Effectiveness of SMS in healthcare

By Krista Burris, January 28, 2014

Healthcare is at a tipping point and as such, unprecedented efforts are being made to improve health outcomes and foster efficiencies in healthcare delivery. What seems promising with the current reform and transformation efforts is the convergence of existing mass markets influencing healthcare innovation. For example, leveraging mobile phones to track, monitor, and engage patients in lifestyle and self-health management. Mobile text messaging communication in particular has proven to be an effective way to foster desired behavior change in patients and improve the way in which care is delivered by capturing important data that is actionable.

The need for improving outcomes and creating efficiency becomes increasingly important in the context of the coverage expansion in the Affordable Care Act where millions of Americans will enter the system, utilizing more healthcare resources. In particular, the Medicaid expansion is projected to result in a total of 75.6 million enrollees for 2014, an increase of roughly 19.5 million as a result of the ACA[i]. Leveraging mobile text message communication to facilitate convenient and efficient communication among patients and providers, as well encouraging desired behavior change by providing patients with educational tools to improve health outcomes, is encouraging to achieve on the triple-aim objective of healthcare reform[ii].

The opportunities to innovate using mobile technologies among the low-income and underserved populations are robust. A review of several research publications as well as surveying key constituents within the healthcare ecosystem serving these populations[iii], it is clear that the unmet needs plaguing the healthcare safety-net and contributing to waste include poor appointment attendance[iv], poor medication adherence[v], and poor health literacy[vi].

Extending the successes of current mobile text message patient engagement strategies to each of these unmet needs has the potential to reduce waste and inefficiencies in the system by improving health literacy and self-health management of low-income and underserved populations.

SMS text-messaging has shown a positive impact on fostering the desired behavior change in patients. A review of existing studies show that text messaging can support improvement in appointment attendance, increased medication adherence, and enhanced literacy through educational content outreach.

SMS text message appointment reminders

Patients failing to attend their scheduled doctor visits contribute to inefficiencies and misused resources[vii]. In general it is found that a reminder, whether it be by text or phone, is helpful in improving attendance, however SMS technology is a more cost-effective approach[viii].

A 2012 study analyzing the effect of SMS text reminders to reduce nonattendance for hospital outpatient visits found a significant difference in the attendance rate of patients who received a text reminder compared to patients who received no reminder[ix]. The results concluded that the attendance rate for patients who received text message reminders over the 4 month period were significantly higher (79.2%) compared to the attendance rate of those who received no reminder (35.5%).

Another study measuring the impact of SMS appointment reminders for outpatient clinic visits in Brazil found that text message reminders reduced nonattendance rates, improving patients’ care and ensuring the right care at the right time[x]. The nonattendance reduction rates for appointments at the four outpatient clinics studied were 0.82% (p= .590), 3.55% (p= .009), 5.75% (p= .022), and 14.49% (p= < .001).  These results suggest that text is an effective and efficient way to ensure patients attend their scheduled clinic visits and do not have interrupted care.

SMS text message medication reminders

Patients’ failure to adhere to their medication regimen can lead to unnecessary disease progression and complications. This contributes to waste in the healthcare system including preventable visits to the emergency room and increased utilization of other healthcare resources. Researchers have evaluated the impact of SMS text reminders on promoting medication adherence. The results are promising, suggesting text as an efficient and effective way to ensure patients take their medication.

The World Health Organization conducted a review of trials and studies that evaluated the effectiveness of mobile text medication reminders for HIV patients on anti-retroviral therapy drugs[xi]. The overall conclusion was that patients who receive text message reminders had a significantly higher adherence rate to their medications compared to patients that did not receive any kind of reminder. For conditions such as HIV where medication adherence is critical in preventing or stalling disease progression towards AIDS, as well as other comorbidities, the use of SMS technology can enable proper compliance of medication needs.

A study reviewing SMS reminders for diabetic patients concluded that text reminders improves adherence to oral antidiabetics[xii]. In the study 56 patients were confirmed to receive text reminders to take their medication, compared to 48 patients who received no reminder. Medication of both groups was measured using Real Time Medication Monitoring (RTMM) of oral antidiabetics in terms of (1) days without dosing; (2) missed doses; (3) doses taken within predefined standardized time windows. Patients' experiences were surveyed through questionnaires. The results found that patients who received reminders had a higher rate of adherence including a higher rate of taking their medication in the predefined time interval of receiving the reminder. The study also concluded through the patient survey questionnaire that patients found the reminders helpful.

SMS text message delivering educational content

SMS text-based education is emerging as an effective way to engage patients in better self-care. Lack of education around basic health information leads to approximately $106 billion to $238 billion in economic burden each year[xiii].  Text message outreach with educational content can be an efficient way to improve patients’ health literacy.

The Center for Connected Health in Boston reported in a study that text messaging improved treatment adherence and self-care for dermatology patients suffering from atopic dermatitis[xiv]. In the study, 25 patients received daily text messages over a period of six weeks. The text messages included treatment reminders and educational content pertaining to their health condition. At the end of the six week study, patients reported and improvement of treatment adherence of 72% and roughly 68% of the patients reported an improvement in self-care behaviors to help their conditions.

Two other studies evaluated the use of text messaging in improving self-care and desired behavior change for Type 1 diabetic patients[xv]. One study tailored text message communication to self-management goals, as well as untailored content such as newsletters and tips from other patients. The results showed that the patients enrolled in the text program were engaged in interacting with the technology. The participants seemed to enjoy the community aspect of the technology through the ability to connect with their provider and peers. The second study evaluated the use of text message technology among families of children with type 1 diabetes. In this study, the parents received informational messages pertaining to their children’s care needs. The study results concluded that the text messages were helpful and aided in better dialogue between parent and child around the disease condition.

Ensuring proper self-care is important for patients living with chronic disease as much of the care needed to manage these diseases occurs outside of the clinic and provider supervision. Providing patients with easy and consistent access to information to better understand their conditions and comply with proper care practices can lead to improved health outcomes.

Conclusion

Mobile text communication can be a cost-efficient and effective way to engage patients in the desired behavior change to improve appointment attendance, medication adherence, and self-care management of disease. As the healthcare system transitions to a focus on improving health outcomes, engaging patients in the management of their health is critical. SMS text messaging is a low-cost way to facilitate engagement and enhance the health literacy of individuals living with chronic conditions and other health challenges.

---

[i] National Health Expenditures Projections 2010-2020. Forecast Summary. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/proj2010.pdf.

[ii] The triple-aim is a framework developed by the Institute for Healthcare Improvement to address experience of care, population health (improving outcomes), and per capita cost of healthcare services; It is generally accepted that the Affordable Care Act uses the triple-aim as a core principle to design healthcare transformation: “Moving toward the “triple-aim”: The Affordable Care Act and the implications for payment and quality reform”. http://www.ehcca.com/presentations/pfpsummit6/dentzer_1.pdf.

[iii] Feedback from the healthcare community includes discussions with senior leadership of San Francisco Community Clinic Consortium, including St. Anthony’s Foundation.

[iv] Kaplan-Lewis, E. Percac-Lima, S. “No-show to primary care appointments: why patients do not come.” Journal of Primary Care and Community Health. July 2013. http://jpc.sagepub.com/content/early/2013/07/26/2150131913498513.abstract.

Anecdotal feedback from St. Anthony’s Foundation reported an approximate $250 loss in revenue from each no-show appointment.

[v] Nichol, M.B. Knight, T.K. Priest, J.L. Wu, J. Cantrell, C.R. “Nonadherence to clinical practice guidelines and medications for multiple chronic conditions in a California Medicaid population.” Journal of the American Pharmacist Association. 2010. http://japha.org/article.aspx?articleid=1043767.

[vi] Somers, S. Mahadevan, R. “Health Literacy: implications of the Affordable Care Act.” The Institute of Medicine, Center for Health Care Strategies, Inc. 2010. http://www.iom.edu/~/media/Files/Activity%20Files/PublicHealth/HealthLiteracy/Commissioned%20Papers/Health%20Literacy%20Implications%20of%20Health%20Care%20Reform.pdf.

[vii] Hasvold, P.E. Wootton, R. “Use of telephone and SMS reminders to improve attendance at hospital appointments: a systematic review”. Journal of Telemedicine & Telecare. 2011. http://www.ncbi.nlm.nih.gov/pubmed/21933898.

[viii] Chen, ZW. Fang, LZ. Chen, LY. Dai, HL. “Comparison of an SMS text messaging and phone reminder to improve attendance at a health promotion center: a randomized controlled trial.” http://www.ncbi.nlm.nih.gov/pubmed/18196610.

[ix] Prasad, S. Anand, R. “Use of mobile telephone short message service as a reminder: the effect on patient attendance.” International Dentistry Journal. 2012. http://www.ncbi.nlm.nih.gov/pubmed/22251033.

[x] da ,Costa TM, Salomão, PL. Martha, AS. Pisa, IT. Sigulem, D. “The impact of short message service text messages sent as appointment reminders to patients' cell phones at outpatient clinics in São Paulo, Brazil.” 2010. http://www.ncbi.nlm.nih.gov/pubmed/19783204.

[xi] Sharma, P. Agarwal. P. “Mobile phone text messaging for promoting adherence to antiretroviral therapy in patients with HIV infection.” The WHO Reproductive Health Library. The World Health Organization. 2012. http://apps.who.int/rhl/hiv_aids/cd009756_sharmap_com/en/index.html.

[xii] Vervolet, M. van Dijk, L. Santen-Reestman, J. “SMS reminders improve adherence to oral medication in type 2 diabetes patients who are real time electronically monitored” In J Med Inform. 2012;81(9); 594-604. http://www.ncbi.nlm.nih.gov/pubmed/22652012.

[xiii] Vernon, JA. Trujillo, A. “Low Health Literacy: Implications for National Health Policy.” Rep. Washington: George Washington University, 2007. http://sphhs.gwu.edu/departments/healthpolicy/CHPR/downloads/LowHealthLiteracyReport10_4_07.pdf

[xiv] Pena-Robichauz, V. Kvedar, J. Watson, A. “Text Message as a Reminder Aid and Educational Tool in Adults and Adolescents with Atopic Dermatitis: A Pilot Study.” Dermatology Research and Practice. 2010. http://www.connected-health.org/programs/dermatology/research-materials--external-resources/text-messages-as-a-reminder-aid-and-educational-tool-in-adults-and-adolescents-with-atopic-dermatitis-a-pilot-study.aspx.

[xv] Franklin, V. Greene, A. Pagliari, C. “Patients’ engagement with ‘Sweet Talk’- A text messaging support system for young people with diabetes.” Journal of Medical Internet Research. 2008. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2483928/#!po=2.50000.

Wangberg, SC. Arsand, E. Andersson, N. “Diabestes education via mobile text messaging.” Journal of Telemedicine and Telecare. 2006. http://www.ncbi.nlm.nih.gov/pubmed/16884582. 

A Stitch In Time…Will Cost A Lot of Money

By Kim Bellard, December 5, 2013

It almost seems like piling on to pick on hospital pricing anymore, following such incisive articles already this year such as Steven Brill’s Time article “Bitter Pill” or Elizabeth Rosenthal’s “The $2.7 Trillion Medical Bill” in the New York Times, but there just continue to be more examples of how irrational health care charges are in the U.S. health care system. 

Jillian and Joseph Bernstein just published a study in JAMA Internal Medicine, focusing on the difficulty in getting hospitals’ prices for electrocardiograms (ECGs) – and comparing that with the ease of obtaining those same hospitals’ prices for parking.  This followed a study published earlier this year that looked at the difficulty of getting hospitals to quote prices for hip replacement.  The Bernsteins were testing the hypothesis that perhaps hip replacements included too many variables, thus making quoting prices difficult, and so chose the more standardized ECGs. 

The results will probably not surprise anyone.  They contacted twenty Philadelphia area hospitals to ask for the two kinds of prices.  Nineteen of the hospitals were easily able to provide the cost for parking, but only three could come up with a price for the ECG (and don’t you want to know what hospital couldn’t even quote its own prices for parking?).  It’s also interesting to note that the three ECG prices they got ranged from $137 to $1200, almost a tenfold difference.

The authors conclude that “hospitals seem able to provide prices when they want to; yet for even basic medical services, prices remain opaque.”

Meanwhile, Ms. Rosenthal of The Times was at it again, this time in “As Hospital Prices Soar, a Stitch Tops $500.  The article points out not only simple stitches that cost $500 in ERs but also IV bags that cost under $1 but for which hospitals charge $137, or $20 neck braces for which that hospitals want $154.  And these are not the most egregious examples cited. 

Few people pay full charges, of course – except for the people without insurance, who are probably least able to pay them – but the hospitals build their charge structures due to what one physician told The Times was the Saudi sheikh problem: “you don’t really want to change your charges if you have a Saudi sheikh come in with a suitcase full of cash who’s going to pay full charges.”  That’s what passes for pricing strategy in U.S. hospitals?

The Times attributes the seemingly unfettered hospital pricing to increasing market dominance, using Sutter Health in California as a prime example.  Indeed, a recent study in JAMA found that price increases – not increased demand or aging of the population – accounted for 91% of the increases in overall health care costs since 2000, with market consolidation blamed as one of the key drivers of these price increases. 

We’ve been waiting for patients to care about prices for some time, especially with the advent of high deductible plans, and there is some evidence perhaps that is starting.  A survey by TransUnion Healthcare found that 55% of insured consumers have started to pay more attention to their medical bills in the past year, and that 67% claim they want to know not just how much services cost them directly but also how much their insurance is paying on their behalf. 

The TransUnion survey also found that, when it comes to choosing providers, consumers rated “makes it easy to see the cost of services” right below “world class specialists and technology,” and – amazingly -- above high quality scores or proximity to home.  Even more interesting was that the survey found some correlation between consumers’ perception of quality of care with their satisfaction with the billing experience, a fact to which one hopes providers are paying close attention. 

Ironically, health plans now are expressing some concern over exactly what type of transparency they support.  AHIP, their trade association, indicated that calls for an all-payer claims database, which would facilitate comparisons between providers and across payors, could backfire, raising the spectre of lower paid providers demanding higher reimbursements once they started seeing what other providers were being paid.  Having once led transparency efforts for a large health plan, I can affirm that this concern is very much on the minds of provider contracting staff.

At the same time, many physician specialty organizations, including the AMA, continue to balk at many forms of transparency.  Lately they have questioned the wisdom of a proposal to make public the Medicare payments to physicians, something the Wall Street Journal, among other organizations, has long been pushing for.  They worry that the data could be confusing or misleading to consumers, although it’s hard to see what could be more confusing or misleading to what we’re doing now.

Still, not everyone is a fan of transparency, at least not as it has been attempted so far.  The ever-quotable, always insightful Uwe Reinhardt, writing recently in JAMA, throws cold water on many previous efforts.  In his words, “[T]he idea that American patients should 'shop around for cost-effective health care' so far has been about as sensible as blindfolding shoppers entering a department store in the hope that inside they can and will shop smartly for the merchandise they seek,  In practice, this idea has been as silly as it has been cruel." 

Reinhardt does think that health IT can change the game by more easily making pricing available to consumers, citing such innovators as Healthcare Blue Book and Castlight Health.  He likes the reference pricing approach (which I discussed recently), which involves setting a uniform payment limit and making providers compete for anything they want to try to charge above those limits. 

Of course, simply disclosing costs is only a necessary, but not sufficient, change to bring about true competitive pressures for pricing.  We’re moving to ICD-10 codes, and a cottage industry has emerged to find the funniest examples.  For example, there are separate codes for being struck by a turtle, orca, or duck, not to mention for walking into a lamppost.  You know that in back offices of provider organizations and health plans, diligent bean counters are coming up with prices for each of these. 

If we merely made visible the existing pricing structures, which are built for billing and diagnostic accuracy rather than for consumer understanding, it’d be liking going to Dr. Reinhardt’s metaphorical department store and finding that each item showed the cost of every party involved in the manufacture, marketing, and distribution of the item, plus costs for a variety of additional variables based on the consumer’s needs.  No exactly an Amazon one-click kind of experience.

Despite the big challenges ahead for it, I do believe that, whether it is AHIP, AMA, AHA, or any other providers making a living in the current arcane system, there is a danger that if they don’t get on the transparency bus, they may get run over by it.  The Saudi sheikh strategy can’t last.

Patient Engagement Health Literacy

By Krista Burris, November 12, 2013

The importance of patient engagement is buttressed as healthcare transitions to outcomes-based models where patients’ involvement in their health is necessary to achieve the objectives of care delivery transformation. Empowering patients with tools and resources that enable individuals to better manage their healthcare needs is a promising approach to encourage patient accountability in improving their own health outcomes. However, the notion of patient engagement relies on the idea that once patients become engaged, they are well-informed enough to know how to interpret and act upon the health information presented to them; in other words to maximize the value of having patients engaged in their health, they actually have to have a good enough understanding of their health conditions, terminology, and treatment in order to make the appropriate decisions around their health needs.

The IOM defines health literacy as “ the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” According to a National Assessment of Adult Literacy report, it is found that approximately 36% of US adults have basic or below basic health literacy, resulting in an economic burden of $106 billion to $238 billion annually.[1] The same report found that low-health literacy rates are almost double for underserved populations with approximately 62% of minorities, 53% of the uninsured and 60% of Medicaid beneficiaries having limited health literacy.

Given that individuals with low-health literacy tend to have poorer health outcomes and create costs in the system through the misallocation of resources (for example: more likely to forgo preventative care while more likely to be hospitalized)[2], there are implications with respect to the coverage expansion provisions of the ACA that will bring millions in this demographic into the system. The virtue is that these individuals become somewhat more captive facilitating outreach and education efforts. The challenge is how to implement patient education policies efficiently to reduce the administrative burden of increasing demand with somewhat static supply in an already taxed infrastructure.

This is where I believe the unprecedented government and private market collaborations to foster efficiencies and innovations become hopeful. There is an incredible amount of effort in the digital and technology space to leverage the existing social and cultural norms of the mainstream including those in the low-health literacy demographics. For example, mHealth technologies that leverage the 91% mobile (56% smartphone) penetration rates among US adults[3] making access to patient & health information, biosensors and tracking that use smartphone technology, and communication with providers nearly automated.

I recently started working with a non-profit start-up that does SMS patient education by disease condition, appointment, event, and medication reminders, as well as group messaging, all designed and tailored for low-income individuals. Early results are showing a positive impact on improving attendance of a chronic-disease self-management program through event reminders, and we will have more information on the improvement of knowledge and outcomes, along with the engagement aspect of the technology in early- to-mid 2014.  

Patient engagement, though relatively early in its life-cycle, has shown promising results which lends itself to continued exploration and investments to determine how to best leverage effective approaches moving forward.  

---

[1] Vernon, JA. Trujillo, A. Rosenbaum, S. DeBuono, B. “Low Health Literacy: Implications for National Health Policy” 2007.
http://sphhs.gwu.edu/departments/healthpolicy/CHPR/downloads/LowHealthLiteracyReport10_4_07.pdf. 

[2] National Network of Libraries of Medicine. “Health Litercy”. 2013.
http://nnlm.gov/outreach/consumer/hlthlit.html>.

[3] Smith, A. “Smartphone Ownership 2013” Pew Internet and American Life Project. 2013.
http://pewinternet.org/Reports/2013/Smartphone-Ownership-2013/Findings.aspx. 

CMS Pronouncements on Pioneer ACO Results and 2014 HIX Premiums

By Clive Riddle, July 18, 2013

This week CMS announced results from the first performance year of the Pioneer Accountable Care Organization (ACO) Model, along with a new report that finds premiums in the Health Insurance Marketplace will be nearly 20 percent lower in 2014 than previously expected.

Here are the Pioneer ACO results that CMS is touting:

• Costs for the more than 669,000 beneficiaries aligned to Pioneer ACOs grew by only 0.3 percent in 2012 where as costs for similar beneficiaries grew by 0.8 percent in the same period.
• 13 out of 32 pioneer ACOs produced shared savings with CMS, generating a gross savings of $87.6 million in 2012 and saving nearly $33 million for Medicare
•  Pioneer ACOs earned over $76 million in compensation.
• Only 2 Pioneer ACOs had shared losses totaling approximately $4.0 million.
• All 32 Pioneer ACOs successfully reported quality measures and achieved the maximum reporting rate for the first performance year, with all earning incentive payments. 
• Overall, Pioneer ACOs performed better than published rates in fee-for-service Medicare for all 15 clinical quality measures for which comparable data are available.
• 25 of 32 Pioneer ACOs generated lower risk-adjusted readmission rates for their aligned beneficiaries than the benchmark rate for all Medicare fee-for-service beneficiaries.
• The median rate among Pioneer ACOs on blood pressure control among beneficiaries with diabetes was 68 percent compared to the comparison value of 55 percent as measured in adult diabetic population in 10 managed care plans across 7 states from 2000 to 2001. 
•  Pioneer ACOs performed better on clinical quality measures that assess low density lipoprotein (LDL) control for patients with diabetes. The median rate among Pioneer ACOs for LDO control among beneficiaries with diabetes was 57 percent compared to 48 percent in an adult diabetic population in 10 managed care plans across 7 states from 2000 to 2001.
• Pioneer ACOs were rated higher by ACO beneficiaries on all four patient experience measures relative to the 2011 Medicare fee-for-service results.

CMS did disclose that seven Pioneer ACOs that did not produce savings intend to switch to the Medicare Shared Savings Program, and two Pioneer ACOs have indicated their intent to leave the program. 

The Wall Street Journal  didn’t interpret these results as rosily as did CMS. Here is the WSJ take, from their July 16^th article Mixed Results in Health Pilot Plan: “All of the 32 health systems in the so-called Pioneer Accountable Care Organization program improved patient care on quality measures such as cancer screenings and controlling blood pressure, according to data to be released Tuesday by the Centers for Medicare and Medicaid Services. But only 18 of the 32 managed to lower costs for the Medicare patients they treated—a major goal of the effort. Two hospitals lost money on the program in the first year. Seven have notified CMS that they intend to move to another program where they will face less financial risk. Two others have indicated they intend to leave the program,”

On the Health Insurance Marketplace front, CMS touted findings from a just released twelve-page ASPE Issue Brief: Market Competition Works: Proposed Silver Premiums in the 2014 Individual and Small

Group Markets Are Nearly 20% Lower than Expected. CMS notes the report found that:

• In the 11 states (including the District of Columbia) that have made information available for the individual market, proposed premiums for 2014 are on average 18 percent lower than HHS’ estimate of 2014 individual market premiums derived from CBO publications.
• In the six states that have made information available in the small group market, proposed premiums are estimated to be on average 18 percent lower than the premium a small employer would pay for similar coverage without the Affordable Care Act.
• Preliminary premiums appear to be affordable even for young men. For example, in Los Angeles - the county with the largest number of uninsured Americans in the nation - the lowest cost silver plan in 2014 for a 25-year-old individual costs $174 per month without a tax credit, $34 per month for an individual whose income is $17,235, and a catastrophic plan can be purchased for $117 per month for an individual.

Here a chart provided in the ASPE report, comparing the ASPE premium estimate for Individual Silver premiums compared to actual premiums for applicable states:

Infographic: Chronic Care is a Team Sport

By Cyndy Nayer, June 13, 2013

Chronic care is a long-term management strategy, and it requires a focus on outcomes, especially in reimbursement for the team of providers that manage the complex conditions. Diabetes, hypertension and high cholesterol get a lot of attention, but there are more, such as depression, cancer, arthritis. While the ACA will attempt to manage the escalation of premiums, it requires a team effort to manage chronic care. Lifestyle, treatment adherence, and regular primary care visits are a must. Value-based designs will work to get better engagement from the beneficiaries, but the plan sponsors, especially the employers, must pay close attention through regular data reporting, coordinated care, and communication across all of the team members, including the patient and his/her family. Chronic care is a team effort, and to be a member of the winning team, coaches and players must be headed for the same goals!

For more blog posts by Cyndy Nayer, visit www.cyndynayer.com/category/cyndys-voice/

Boston: Coincidences, Complexity, Continuity, Care

By Cyndy Nayer, April 25, 2013

America's Freedoms Are Our Vulnerabilities

There is no doubt that the terrorism of the Boston Marathon 2013 was heart-stopping, heart-rending, and a cruel reminder that America's freedoms are also our vulnerabilities.  It's also a bit ironic that, because of a family emergency, both of my daughters had flown down to our house and were with us when the bombs went off.  Why is this important enough for me to mention here?  Because if my older daughter hadn't come down to help, she would have been exactly at the finish line where the bomb went off. Coincidence?

I don't believe in coincidences.

The week, and the socialmediasphere, have been resplendent with coincidences, the most poignant of which was the story of the couple who both were in the health care provider space, both came to cheer the runners of the marathon, both had a portion of their left legs blown off in the explosion.  They were separated by the blast, and they remain separated in different hospitals, but they are recovering and they are talking by phone to each other (see below for how you can help).

Who were the terrorists, what was their motivation, what will happen to the survivor, I have to leave to the sleuths and judicial systems to discover and decide.  My work is to uncover the learnings that we can all ingest to fortify our health promotion and business recovery.  Here are some thoughts.

1.  Boston has terrific hospitals, prepared for trauma management.  I've managed many fitness events, and, of course, a key component was the clinical staff onsite.  They volunteered their time for running injuries, dehydration, and the sort.  Some of them on April 15 had seen combat duty in Afghanistan and Iraq, and they were able to flip into mash-unit mode quickly.  All of the injured who made it to the hospitals have survived, albeit many have much rehabilitation to work through.

2.  Boston has moxie and motivation.  Bostonions have been described recently as gritty, defiant, and strong, and this makes great sense since this is the birthplace of the American Revolution--the shot heard round the world--and of the freedoms that would coalesce into the US Constitution.  When the explosions came, the runners ran INTO the crowds to help those who were hurt, ran to the hospitals to give blood (another 2.5 miles after their 26.2 mile run), and reached out to one another.  They may fight like family, but when the pressure is on, Boston is one big supportive family. For more on the grittiness of Bostonians, and a chuckle, click here to see Colbert's Report for April 16, one day after the bombs.  

3.  Boston finishes what it starts. Samuel Adams (not the beer, but the revolutionary) said, “Nil desperandum, Never Despair. That is a motto for you and me. All are not dead; and where there is a spark of patriotic fire, we will rekindle it.” There were people around the nation, and now, around the world (London) running races for Boston over the past 10 days, and there will be more.  There are calls for boosting the economy and taking Boylston Street back--it opened today--and for helping those who were locked out of their homes and businesses for these days.  This is the Boston that warned of the Red Coats, rode the Freedom Trail, waited 86 years for the Red Sox pennant.  When folks were hurt, people did what they could:  one woman baked oatmeal chocolate chip cookies for the police/troopers/FBI/ATF, etc. to eat when the 2nd suspect was arrested.  Grit and defiance demand food, too, after all.

4.  Boston wears its patriotism and small-town love proudly.    Read this excerpt from one of the London marathoners, who also ran in Boston:

“I had a hard day out here,” said Neynens, who wore a 2013 Boston Marathon hat during his London run and finished in 2:48:09. “I was hurting, but obviously I was not hurting near as much as the injuries that I saw, people who lost their legs. I finished for all those people who were hurt and those people who couldn’t finish last Monday...

There was a banner we passed around Mile 25 that said, ‘Run if you can. Walk if you must. But finish for Boston.’ That meant a lot to everybody. It was great to see the support of everybody out there for the runners and for Boston."

 There were lessons for health, healthcare, and healthcare reform, too.

1.  Interoperability of electronic medical records could have been a problem.  In the marathon were runners and family-watchers from around the world.  What if there were a diabetic runner who, because of the bombings, was delayed in his/her sugar control?  There are so many other "what ifs" that the message is clear:  we need to quickly find a way to make these EMR-EHR-PHR talk to one another for the safety and security of the providers, patients, and communities.  We cannot afford to waste time finding a knowledgeable relative when life hangs in the balance.  [I wrote about this lack of interoperability in my post "EHR Is Speechless"].  There is no magic about data, the rules engines can be preserved as proprietary to each company, but the data must be accessible.

2.  Teamwork. Who will ever forget the masses of security forces closing in on the final suspect?  Or the video of the Chief of Police of Watertown MA saying his troops were never trained on counterterrorism, so they just did what was they thought was right?    Those of us riveted to the scenes will remember the ATF, FBI, fire departments, EMT, Boston police, State Troopers, and so many more.  But how many noticed that hot food was brought by the NY-NJ Port Authorities?  How many could ever forget the cheers and singing and clapping by the Watertown citizens when the ambulances and security cars crept slowly back into the city?  Now, imagine those kinds of teamwork in communities of care, with warm "handoffs" from primary care (Watertown police) to specialists (BPD, ATF, FBI, MA troopers) to recovery and long-term care (Red Cross, Boston Globe, and so many other watch-dogs and care providers).  Everyone had their job and new exactly what they had to do.

3.  Continuity and safety.  Recently I saved an article on the rates of hospital infections in the US compared globally, sent to me from my colleagues at MCOL.com.  Because of the trauma training, the warm handoffs, and the sense of accountability, continuity is a given in Boston.  It's the accountability that will guard the injured, the fallen and the recovery.  There's a new sense of "we share in this," and it's this sense that carry Boston through.  That's the real message of accountability:  we all own at least a portion of the problem, whether it's economic recovery or health promotion, and we all have a responsibility to step up to manage our community better.

Of course, in the land of the Red Sox, with the frame of David Ortiz' opening moments in Fenway Park, and the surprise visit from Neil Diamond to lead Sweet Caroline, the poignant moments caused tears and love and hugs.  For us who weren't in Fenway, or Boston, or Watertown, I treasure the picture that went viral on twitter and other social outlets:

 I don't think there are any coincidences.  I abhor terror, bloodshed, violence.  But these moments that I've called out remind me, and I hope all of us, of the goodness of people.  Who could possibly convey it better than Fred Rogers?  We needed to hear his words, "Look for the helpers," right then, right at that moment.  It opened our hearts and made us feel safe again, and we spotted more helpers and lavished praise, because we all needed to heal.

And then Boston Daughter (who had returned to Boston) sent me an email and a picture that she took, the one that starts this blog post, the site that amazed and tore and then opened her heart.  She told me she couldn't sleep, walked to the memorial Monday morning at 5am to pay her respects, and left her pink running shoes because she wanted to be part of the healing, too.

If you want to be one of the helpers, here are two ideas for you for donations.  There are many more, I simply had intersections with each of these here:

If you, like me and my Boston daughter, are an avid fitness participant, then you may want to make a purchase at @unitedwestride UnitedWeStride will donate all the proceeds from the purchase AND AN ADDITIONAL DOLLAR

@JetBlue  I audaciously sent a tweet on 4.22 to @JetBlue asking for serious discounts to Boston so we could boost the economy--I'm betting others did, too. On 4.23 I received an email with serious discounts.  Help those most affected by the Boston tragedy through The One Fund Boston, and JetBlue will match up to $100K. http://www.jetbluegives.org

 I hope peace comes to those who mourn and to those who heal.  I hope strength comes to our leaders and our protectors.  I hope our communities come together for health.

Getting Healthy

By Cyndy Nayer, April 1, 2013

In January 2013, US News published a report on why Americans aren’t healthier and gave us the concept of a health lag.  In fact, the gap between America’s health status and that of other industrialized nations is a 30-year trajectory of lower outcomes.

Last week, Modern Healthcare published a review of Kaiser Family Foundation findings in which the highest hospital readmissions were directly correlated to the unhealthiest counties in the US.

On the same day as the MH-KFF release, I was privileged to receive a tweet on patient engagement that highlighted the blog of Gilles Frydman  on PatientDriven.org, which highlights the real engagement and outcomes of patients who seek to understand their conditions and treatment by conversing with others.  The point here is in the definition of engagement, per the blog, “An engaged patient is someone deeply involved in the scientific understanding of their disease, fully aware at all times of the entire spectrum of available therapeutic options. It requires a set of learning, cognitive and psycho-social tools that can only be acquired by conversing often with a real network of peers who are similarly involved in this complex endeavor.“ 

This, says the author, is exactly opposite of the current definition of patient engagement as used by HIT, care professionals, benefits personnel, and service providers:  “the engagement flows from the various professional stakeholders of the health care system to the patients. It is a direct extension of the concept of consumer engagement.”

It’s exactly the discussion I am most involved in, most of the time, in which the (choose one) doctor/ IT developer/ hospital administrator/ national thought leader talks about patient engagement as the patient behaving according to the “guidance” he/she is provided.  But what if the guidance reaches the patient at the same time she is dealing with her teenager who had a car accident, or her husband who may lose his job? What if the “guidance” is a follow-up visit or test, but the office isn’t open late when she is off work? What if the “guidance” is the purchase of a pharmaceutical that she either can’t afford or that may cause side effects for her?  What if she simply didn’t understand the instructions or, three months later, is feeling better and stops the medication or falls off her nutrition plan?

Unfortunately, the problem here is that the engagement and persistence (which, by definition is part of engagement) did not occur because people have other parts to their lives than the body parts with issues.  They have financial needs, emotional needs, social needs, even transportation needs that interfere with engagement. While the most-influential people in the patient’s life, according to surveys, is the clinical “face” (doctors, pharmacists, nurses, etc.), these people do not follow the patient everywhere, and others in her sphere of influence take precedence.

Emergency department visits drop when medical practices extend hours. There are examples of patient engagement strategies that work and that translate directly to saved dollars.  In surveying more than 9,500 people with steady sources of care, the Center for Studying Health System Change focused its results on 1,470 individuals who had tried to contact their primary care practices after normal business hours in the past year. The study, published online in Health Affairs on Dec. 12, found that nearly 21% had difficulties reaching their physicians after hours, and those who reported more difficulty accessing after hours had higher rates of emergency department use (37.7%  and higher rates of unmet medical needs (13.7%).

As I’m on my relentless pursuit of solutions that deliver better health outcomes, I have to  emphasize this, re-emphasize it, and then state it many times more.  Those who doubted the power of value-based benefit design or outcomes-based clauses did not fully understand the suite of services and, what I call surround-sound messaging, that is necessary for patient engagement in health.

We cannot be paternalistic, nor maternalistic, in making health the end goal.  We have to meet people where they are and stop treating body parts separately (you know, hypertension over there and depression over here and diabetes…).  We have not only organize in patient-centric efforts but, perhaps more importantly, in patient-driven circles.  This is the success of the senior-citizen breakfasts that promote Medicare health plans, of the breast-health discussions that occur in churches and hair salons, and of the Dr. Oz and Dr. Phils of the world who reach through social media (including TV) to their audiences.

Transparency will only matter if the patient is seeking healthcare.  If, instead, she is seeking a carpool for her kids or the money for rent, then transparency of treatments may not be as meaningful, if it’s on the radar at all.  ”Entitlement programs,” as Medicare and Medicaid are increasing called, cause splits in peer groups and often in the same family, pitting seniors against young working adults in the “subsidy” allotment.

These are not directly related to the delivery of treatment from the health system, but they are distractions to the patient decisions.  If the incentives to the prescriber are different than the incentives to the patient, the patient will more often seek the treatment recommended by the doctor, as this is the trusted relationship.  In survey after survey for many years, the clinician advice trumps the insurance benefit advice, yes, but it also relieves the patient of asking price or quality or convenience questions of the physician.  To this point, in my March 15 2013 I sent out the Health Affairs link to the Kaiser study showing that consumers do not want to be responsible for their healthcare costs, and they don’t want their doctors to be responsible, either.  

If we want to close the health valley that we are in, if we want to use the amazing healthcare resources in our country wisely and widely for all of us, then we have to stop this narrow focus of hospital v doctor v benefit plan v pharmaceutical manager v insurance and get back to the basics:  making healthcare understandable, actionable, and most of all, relevant WITH the patient not TO the patient.  Patient engagement IS the holy grail for healthcare and health improvement.  But it can’t be done around the patient, it must be done with the patient fully present and asking questions and envisioning the future of his or her health.  If he or she can’t see it, he or she can’t achieve it.

But Which Half?

By Kim Bellard, January 30, 2013

Advertising lore credits John Wanamaker, the department store magnate and marketing pioneer, with the famous quote: “Half the money I spend on advertising is wasted; the trouble is I don't know which half.”  It turns out he could have been talking about spending on health care.

The British Medical Journal, through their Clinical Evidence initiative, recently reported that they’d analyzed 3,000 medical treatments that had been studied in controlled, randomized studies.  It turns out that for half of those treatments, we have no idea how well they work.  Indeed, only about a third of the treatments were found to actually be beneficial or likely to be beneficial.  The rest are likely to be harmful.

Sadly, this does not come as a surprise.

We know we don’t know enough.  The vast number of medical treatments have never even been studied in a true clinical trial.  Worse yet, sometimes even when there is clear empirical evidence about which treatments are most effective, that information does not always sway physician behavior, or does so only very slowly (for example, see this study on the use of heart stents versus medication therapy).

There is no shortage of reports of unnecessary or even harmful care.  It’s even scarier when that care is associated with high costs.  In no particular order, one could cite recent controversies with spinal fusions, hip replacements, or chemotherapy drugs.   There can be lots of money at stake for manufacturers, drug companies, and health care providers.  That kind of money can distort the question of what is truly in the best interests of the patient.

Many employers, payors, and researchers have been pushing for “evidence-based medicine” for many years now.  EBM focuses on making sure that treatments have appropriate research to support their effectiveness, and in getting the word out about such treatments.  One of the many initiatives from ACA was the Patient-Centered Outcomes Research Institute, which is charged with conducting research to provide such evidence and funded by a $1 head tax on people covered by insurers.  And, of course, AHRQ probably is wondering why we need a new organization to focus on EBM, given their many efforts on effectiveness.

In time, this may all become much easier, as more patient data become electronic and more connected, and we can make more use of computing power to track what truly happens to patients under various courses of treatments.  I mentioned a couple examples of this in my last blog, citing Optum/Mayo’s new initiative and meta-research studies in lieu of clinical trials.  Another example comes from Archimedes Inc., a firm founded by David Eddy, who was one of the early pioneers of evidenced-based medicine.  Archimedes claims to use its advanced mathematics and computing prowess “to run clinically realistic virtual trials on any population and create compelling evidence to make decisions in health and economic outcomes research, policy creation, clinical trial design, and performance improvement.”  Apparently HHS thinks they can, as it hired Archimedes last year.

Most physicians I know are very bright, care very much about their patients, and work hard to stay current on the medical literature.  Unfortunately, the latter is virtually impossible to do, given the sheer volume of that literature.  Even when there are clear results about which treatment is truly the most effective, the research doesn’t usually come with a guide as to how physicians can implement the associated changes to their practice routines.  It’s as much of a question of change management as it is the evidence to make the change.

It would seem that the situation is tailor-made for clinical decision support tools, which seek to provide clinicians with information on treatment options, potential outcomes, and possible contra-indications at point-of-care.  Unfortunately, we may not quite be ready for them.

Last summer The Annals of Internal Medicine published a study on clinical decision support systems by Bright, et. al.  They did a meta-analysis of studies on CDSSs, and found ample evidence of their efficacy in improving process measures, but sparse results on their impact on clinical or economic outcomes.  Whether this is due to the limitations of the underlying studies, the CDSSs themselves, or how they were used by clinicians is unclear. 

Similarly, KLAS Research recently released results of their survey of health care providers on their satisfaction with clinical decision support tools.  The results cited a general level of frustration, especially due to lack of integration with EHRs and “alert fatigue” caused by ineffective targeting of alerts. 

Worst yet, according to new research from the University of Missouri, patients don’t seem to trust treatment recommendations from physicians who use CDSSs, believing them to be less capable than physicians who make decisions unaided.  Patients don’t even like it when physicians consult with other physicians before making a recommendation!  They think their doctor should know everything.  I blame television for this – on medical shows like Grey’s Anatomy or House physicians pull up the most obscure diagnoses and treatments strictly from memory, without ever having to consult any reference materials.  Nobody’s memory is that good. 

Clinical decision support systems aren’t going to replace doctors; they are simply tools to aid health care professionals, much as a stethoscope or a thermometer does.  One can imagine a future where CDSSs -- and EHRs -- fit seamlessly into patient visits, providing real-time, interactive information while with the patient.  The line between evaluation, documentation, and clinical decision support should blur, in order to more accurately diagnosis patients and determine the best course of treatment.  

In the meantime, it’s somewhat of a crapshoot.

A recent study by Deloitte indicates that 62% of Americans believe that, in fact, over 50% of U.S. health spending is wasted, which is up from the already high 51% in 2009.  The message about necessary spending may be getting out, but consumers may be getting the wrong idea – only 18% thought the problem was not using evidence-based treatments, versus 69% who blame fraud and abuse in the payment system.  In other words, the problem can be blamed on greedy crooks, not on well-meaning health care providers.  Defensive medicine and unnecessary paperwork were each also cited by about a third of respondents. 

I agree that fraud, defensive medicine, and inefficient administration contribute cause us to spend money we shouldn’t, and each should be addressed, but I suspect more of unnecessary spending comes from well-intentioned treatments that aren’t really best for the patients.  As professionals, health care providers should be more stringent about basing their treatment recommendations on evidence that truly supports them.  More importantly, as the people whose health is going to be impacted by those treatments, it’s incumbent on us to demand that evidence.

Maybe one day we’ll have Star Trek’s tricorder to non-invasively diagnosis or even Star Trek Voyager’s holographic doctor to treat.  Maybe someday nanobots will fix all our ills without our even being aware of their work.  All that is in the future.  For right now I’d settle for simply being able to know the odds that a recommended treatment will actually benefit me.

Accenture on Independent MDs in the near future: Fewer of Them; With More Performing Subscription Based Services

By Clive Riddle, November 2, 2012

Accenture has just released a new report: Clinical Transformation: New Business Models for a New Era in Healthcare. They found that  “over the past decade, the number of independent U.S. physicians has dropped dramatically, from 57 percent in 2000 to 39 percent in 2012. By the end of 2013, Accenture predicts this number will likely drop further, to 36 percent.” More interesting, it that “by the end of 2013, Accenture also estimates that one-in-three doctors remaining independent will offer patients with subscription-based services, such as telemedicine or online consultations, for sustaining profit – a trend that is expected to increase three-fold over the next three years.”

Accenture’s Kaveh Safavi, M.D., J.D., tells us “More independent physicians are offering subscription-based services as a way for patients to customize their care experience. Meanwhile, patients appreciate the opportunity to supplement their existing coverage with premium, subscription-based services, such as same-day appointments and online prescription refills.”

While this blends with concierge medicine concepts, but the possibilities for what physicians potentially could develop as supplemental premium services could be quite interesting. Of course, for those doctors under health plan managed care contracts preventing balance billing, chartering into premium service waters might require considerable navigation.

Here are some other findings from the Accenture physician survey:

• 87 percent of physicians surveyed cited the cost and expense of running a business as a chief concern.
• 65 percent joining health systems said they expect to make the same or less compensation than in private practice.
• 61 percent cited business operations as a main reason for seeking hospital employment rather than remaining independent.
• 53 percent cited electronic medical record requirements as a main reason for leaving private practice.

Remember Who the Customer Is

By Kim Bellard, October 17, 2012

An organization called OpenNotes – primarily funded by the Robert Wood Johnson Foundation – recently released a very interesting study that supports the concept that patients do want to participate in their care with their physicians.  This probably doesn’t surprise patients, but may surprise many physicians. 

In brief, the study allowed patients of three geographically disparate primary care practices to access their doctor’s notes (electronically).  The study included over 13,000 patients from 105 physicians.  The vast majority of patients did view at least one note, and survey results indicate that such viewing notes made them feel more in control of their health and improved their medication adherence.  Contrary to physicians’ concerns, such viewing did not lead to longer visits or to more questions outside of visits.  About 60% of patients wanted the ability to add their own comments to the notes, while one-third wanted to approve the notes’ content (something adamantly opposed by the physicians).

It goes back to one of what I think is one of the central problems in health care: those in the business of health care are doing things about patients, but not necessarily for patients.   

Health records are the case in point.  They are maintained about patients, but are written in a jargon that is virtually unintelligible to lay consumers (and, in the case of paper records – often illegible as well!).  The concept that they belong to the patient in any real sense would come as a surprise to the health care professionals who keep them.  Meaningful use requirements are going to quickly force providers towards more patient access to information, such as clinical summaries of visits and summary of health information.  The easiest solution to this is likely to be a patient portal with a view into an EMR, but that in itself doesn’t mean the view is useful.  Please correct me if I’m wrong, but I don’t believe any of the “meaningful use” requirements relate to how meaningful the information is to consumers.  It is telling that the requirements for how many patients actually view or download the information is very weak – only 5%.

Those in the health care business talk in a language of ICD, CPT, HCPCS, DRG, NDC, DSM, to name a few; throw in insurance terminology to complete the task of confusing consumers.  Each of those grows ever-more complex and insular, driven by needs for more detailed analysis, billing, legal protection, and other purposes.  Now we’re increasingly moving towards widespread use of various quality indicators, which are similarly very well-intentioned but may not quite be answering the questions consumers have, or should have. 

As best I can tell, no one in the health business – physicians, hospitals, payors, labs, IT vendors, etc. – really like the complicated languages that have evolved around them, and all would argue that the complexity greatly adds to the expense of running their business, but I don’t see any groundswell to simplify the situation. 

One might have thought that the movement towards consumer transparency might ignite such pressure, but that hasn’t seemed to have happened.  Transparency is one of those things that everyone is in favor of conceptually, but the details of how to do it and whether consumers will use it remain open.  UnitedHealthcare recently found that only 14% of survey respondents use the Internet to comparison shop for health care treatments and services, compared to 75% who use it to comparison shop for other goods and services, a statistic United hopes to improve through its enhanced myHealthcare Cost Estimator.  Aetna, Cigna, Wellpoint and other Blue plans have their own online cost estimator tools.  

In addition to efforts from payors to help consumers with health cost transparency, there are a number of other efforts.  I had been aware of Castlight Health and The Healthcare Blue Book, but was a little surprised to uncover a plethora of other firms, including ClearCost Health, NewChoice Health, and Change Healthcare.  Some of these are aimed at employees of certain self-insured employers, or members of specific health plans, while a few focus on the general public.  It is admittedly an uphill battle to get consumers engaged in thinking about price and quality, and these various organizations all should be lauded for their efforts to give consumers more and better options for doing so.  That being said, it’s somewhat like the talking dog: it is not that it does it well, it’s just that it does so at all.

All the efforts to make costs more transparent have to wrestle with two key problems: what is the “service” being bought, and how can that service be explained in consumer-friendly terms?  E.g., an “office visit” has numerous CPT codes that could apply, each with its own price, and many visits and procedures are accompanied with other services that have their own costs, which the consumer might rightly view as being part of the original service.  How many of us have had, say, a lab test or an X-ray and then been surprised at how many bills we end up receiving for them?  

At the risk of repeating an overused analogy, compare “buying” health care with buying a computer /tablet from the Apple Store or Amazon.  Computers have their own technical language that can be every bit as arcane as health care, but consumers are not forced to use it or fully understand it to complete their shopping experience quite satisfactorily.  When they are shopping, they get lots of options on price and features, with plenty of reviews, customer feedback, and shopping “wizards” to assist them. 

Buying health care, on the other hand, is more akin to getting your own PC back in the 1970s, which required buying a kit and/or components and then trying to assemble the whole thing yourself.  Health care transparency as we know it begins to look more like giving consumers the prices of each component in your PC and quality indicators from the chip manufacturing process.  Those do mean something, but are not really what consumers want.  The problem is that health care professionals are speaking in Greek (or perhaps Latin!) while we want to hear about our health in our own language.

People talk about “disruptive innovation” in health care, by which they often mean use of various forms of technology.  Technology is going to certainly play an even more significant role, but I have to wonder if the disruption will come instead from organizations which can make the health care experience for consumers simpler –much simpler.  I.e., radically rethink what the “products” are, what the processes should be, and how these are communicated to patients. 

Our health care system has many historical practices and preferences that muddle the roles of the various parties involved in it, but it’s helpful to remember that it all boils down to the patient as customer.  It’s their health, after all.

Midwest Business Group on Health’s Quest to Reduce Elective Preterm Deliveries

By Clive Riddle, March 2, 2012

Last week,  Larry S. Boress, President & CEO of the Midwest Business Group on Health was one of three featured speakers in the HealthcareWebSummit event: Managing an Increasing Trend of Elective Preterm Deliveries.

MBGH has taken a keen interest in facilitating a reduction in elective preterm deliveries, and Larry shared why purchasers have gotten involved, and what they are doing about it.

Larry’s opening arguments were:

• Maternity care is the number one reason for hospitalization among employee populations
• The highest cost for maternity care is when underdeveloped infants are treated in the neonatal intensive care units of hospitals
• Preterm infants are less likely to survive to their first birthday than infants delivered at full term
• Those preterm babies who do survive are more likely to suffer long-term costly disabilities than infants born at term

He shared 2009 Data compiled by Thomson Reuters for the March of Dimes, which compared average expenditures for newborn care yielding $4,551 for uncomplicated cases vs. $49,033  for premature/ low birth weight cases.

So what exactly is an early elective delivery. Larry offered these characteristics:

• The newborns delivered with a gestational age between the 37th and 39thcompleted week, that were delivered electively
• Early elective deliveries are performed on women of all backgrounds and incomes.
• These are distinct from early deliveries performed due to clinically-appropriate reasons to avoid health problems facing the mother or the infant

And what is the scope of early elective deliveries? We learned that the national average is up to a rate of 17% of deliveries, while the Leapfrog group has set a current target at 12%. Minnesota, South Carolina, Indiana and Arizona all have rates above 25%. Virginia, Florida, and New York exceed 20%. While 53% of hospitals are at or below the Leapfrog target of 12%, 33% of hospitals have rates of 20% or higher (6% of hospitals have rates of 45% or higher.)

What are the motivations to have an elective preterm delivery, despite the dangers and costs? Larry cites these delivering physician convenience factors: (A) Guarantee attendance at birth;  (B) Avoid potential scheduling conflicts; (C)  Reduce being woken at night; and (D) the NICU can handle it. Furthermore, Larry offered these motivations for the mothers:

• Prior bad pregnancy
• Desire to deliver on special date or holiday
• Special circumstances
• Cultural factors
• Ability to  plan in advance for birth
•  Convenience
• Ability to be delivered by her doctor
• Maternal intolerance to late pregnancy
• Excess edema, backache, indigestion, insomnia

But there are serious quality implications of non-medically indicated early deliveries beyond cost that Larry cited:

• Increased NICU admissions (and separation from mother)
• Increased respiratory illness
• Increased jaundice and readmissions
• Increased suspected or proven sepsis
• Increased newborn feeding problems and other transition issues
• Under developed brain and lungs
• Potential development of cerebral palsy

The good news is this is now a national quality measure for the National Quality Forum (NQF); Leapfrog Group; The Joint Commission; and AMA Physician Performance Consortium Measure.

Larry closed by noting that in the twelve months since MBGH made its initial Call to Action to reduce elective preterm deliveries, over 70% of hospitals reduced their early elective delivery rates below previous levels, and many have set 5% as their goal.

Gabby Giffords Is the Reality Star of US Healthcare

by Cyndy Nayer (cyndyn@vbhealth.org), January 31, 2012

I’m told that one should not mix stories in a blog, but, as a serial disruptor, I’m about to do just that.  I’m inspired by Representative Giffords and see her story as a frame for some ideas that simply won’t rest in my tired brain.

You may remember that I wrote the E Pluribus Unum blog last year just after Ms. Giffords’ near-death shooting in Arizona.  Her story took the nation to a reality-check on guns and mental health, but it also broke my heart for the family of Christina, who went with her classmates to meet the local representative of the US Government (Ms. Giffords).  Christina was one of the victims that day—she died from her wounds.

Still, the sun rose the next day, and Gabby Giffords gave hope back to America.  She began her slow recovery with the amazing care she received from a health care system that was in sync to help her recover.  She was transferred, later, to a center for the intensive therapy needed to regain skills of walking, talking, and more.  She went to Cape Canaveral to watch her astronaut husband lift off on the last space shuttle trip.  She wrote a book about her journey, and we cried with joy.  

This is the promise of America:  all hands form a team that saves a life, all hands who can’t be part of the team cheer the success.  Add the glamour of space travel and romantic love, and the TV-movie industry wishes that it had dreamed up this story—yet who would have believed it, as it was so surreal?  

So where are those everyday heroes?  Because over the last 30 days, my encounters with the health system have been less than heroic, and the stop/start/stop/ halt/restart mess of interoperability-safety-communication has not only caused me anxiety and angst, but also revealed some less-than-lovely realities.

The US health system has surely been going through enormous change.  There are stellar stories of success in electronic medical records for hospitals and physicians, for empowering patients (with personal health records on my phone or iPad), for revealing transparent pricing and quality so I can choose appropriate treatments and know my out of pocket costs.   Or…?

In the last 30 days I’ve met with a new primary care physician so I could establish a medical relationship. My previous physician left her office with no notification of where she might next appear.  No problem, I have my health history, can begin anew. I sought a physician with an electronic health record that is hooked up to a health system and that will also deliver my health information to my personal health record.  I offer to pay for my initial visit because, as I tell the scheduler, I want to interview the doctor to see if our personalities and technology will jive.  When I arrive, they charge me my copay, I remind them I’d like to pay for the visit so I can discuss what I need, and they say, “No need, this is how we do it.”  Well, ok!

We meet, we greet, no ugly paper or cloth “gowns” (may I just insert that my idea of gowns are the kinds that look fabulous in public with brilliantly crafted shoes?).  He asks me some questions about my health (completely fine, thank you, here are my records).  I ask him if he can cope with a person who has a healthy scope on the health system, understands appropriate use of the system, and is the CEO of her health.  “Oh yes, “ says the kindly doctor with the white coat and stethoscope.  We schedule my physical for 6 weeks later.

I am now in the room with Mr. Hyde.  Dr. Jekyll has left the planet.  Charmingly, he begins ordering tests I don’t need (there are no guidelines suggesting the tests), “discovers” a potential “problem” in my EKG (as in “Houston we have a problem” level of problem) and immediately schedules a cardiology visit (folks, relax, there was no problem, there was a misread).  He informs me I need these new tests because just yesterday he discovered a breast cancer in a woman my age (lovely use of calming technique).  There is more, but I will spare you the rest.

Two weeks later I’m called by the nurse and told to immediately get another blood test, it absolutely can’t wait, and no we can’t tell you the lab values but they are “high.” I spend a sleepless night worried, I call back the next day and ask that the doctor please call me as I’m leaving town.  He calls mid-afternoon, says there is no urgency, but it must be done immediately upon return.  He then gives me the values, and I remind him that the numbers he is seeing, only 6 weeks after a perfectly normal blood screen and a record of good readings for 5 years, are not in crisis zone and, (I say, deferentially) that I believe the recommendation is to wait 6 months since I have no risk factors and then retest?  “No,” says the physician, “I want it done now.”

If you’ve been reading my blogs, if you know me at all, you know I tend to not react well to that order.  In fact, the Institute of Medicinejust released a white paper on the communication between patient and doctor, with principles that include supportive environment and respect.  But I do get the requisite 2^nd blood test, and once again I get a call to schedule an immediate appointment while no lab values are shared per doctor’s orders.  I respond, as kindly as my heartbeat will allow, that I don’t make appointments without doing my research so that I’m prepared, so I need the values. “Then have him call me.”  And, of course, a part of me prepares to die.

Breathe.  The labs are not life-threatening; but the doctor’s attitude was.  He told me he simply didn’t have the time to call me with lab values, I responded that I didn’t want his call, I just wanted the values and his nurse could have told me.  He told me he’d reveal the values during our face-to-face meeting, I told him I wanted to be prepared with questions so I didn’t waste his time or mine.  He told me that wasn’t how he worked.  I reminded him of our first conversation.  He said “in the office,” I said “empowered patient,” and told him I’d get back to him.  We ended the call.  Then I fired him in my mind.

But I didn’t drop my health.  Yesterday, I made an appointment with my husband’s cardiologist because of his excellent treatment of my husband.  The scheduler said, “Let’s get your records.”  “They are on your interoperable system through the nationally-recognized health information system that you have,” I say, subtly letting her know that I’m an informed patient and I speak electronicmedicalrecord-ese.  

Wait for it.  Get a cup of herbal tea.  Breathe deeply.

“But we can’t pull up records from another doctor, even if the doctor is part of our system.”

I’m speechless, no breath, no words.  This is the second time in 60 days I’ve heard this.

So we have the picture, now, of healthcare done impeccably well through a trusted relationship of patient/family and the team of clinicians, then wrapped in a love story (Gabby Giffords).  And we have a story of healthcare wanting desperately to do it well, putting systems in place that can do the job, but human rules making it so darn difficult that access and quality and that holy grail of “consumer-directed care” are unachievable.

Will reimbursement changes make this go away?  Not likely.  Will promoting primary care make this heal?  I’m skeptical of a health quarterback that can’t hear the plays because the sound is turned off.  

That wasn’t the healthcare reality that I envisioned with all the work that you and I do to improve it.  These are all good people.  In fact, WE are all good people.  We all want to do the right thing.  They are working hard to promote health.  I am working hard to promote health.  Gabby Giffords and her team are the epitome of “Hard work, well done.”  My experience, not quite.

I shared this story with good friend and VP of the Center for Health Value Innovation, Ray Zastrow MD, CMO of QuadMed. Ray paraphrased a statement from Atul Gawande MD:  Medical care should work like the pit crews of NASCAR.  The outcome is the focus—get the car and driver back on the track.  No lag time, no computer outages, or lack of transfer of knowledge.  Diagnose, triage, heal. Seamless engagement and outstanding accountability.

This is the healthcare vision of the US.  Obviously it exists, as Representative Giffords’ teams, and many other teams, including those in our Center for Health Value Innovation, show us day after day.  

So I close another chapter in the quest for US health, with a message to Representative Gabby Giffords:  Keep up the good work, Representative Giffords.  We will miss you in DC.  But you have a grander national duty now.  I know you didn’t campaign for it, but I surely hope you’ll accept it: Show us how this is done with your NASCAR team of clinicians.  Gather your pit crews around you for a stupendous recovery.  We are cheering your success!

I = Innovation

By Laurie Gelb, October 17, 2011

If you thought the 80's were "the Me Decade," consider these the "Me, Myself & I" years. Introspection is in, singly or in groups (witness the Occupy Wall St. Movement).

What does this have to do with managed care? Depends on who's doing the managing (or thinks they are).

A top tier disease management vendor's intake form currently includes the following question:

Do you currently have any of the following conditions:

[list of 12]

where the list includes cancer, pregnancy, poor circulation, heart attack and stroke, among others, in seemingly random order.

So just as they're signing up for a program that invites unknown strangers into their care, the first thing that [mostly seriously ill, some terminal] patients learn about their disease manager-to-be is that it's insensitive to the distinctions between acute and chronic, and between clinical and colloquial dx. There is no clue as to what, if anything, a given patient should write in the "other specify" field.

What exactly would "currently having" a heart attack or stroke mean? That you should call 911, of course. So the first thing you've learned is not to take DM communication literally. It's only a short step to take it for a joke, like most of your mail.

Nor does this invitation reminder letter explicitly mention that program signup is optional, not mandatory. In fact, it finesses the difference "introducing the program...part of your health benefits coverage..." If I were the plan sponsor's risk manager, I'd feel a bit squishy.

So the promise on the accompanying letter that "Your health is important to us" (appearing once on each side of the paper) is ringing a bit hollow, no? And our introspective, seeking-the-good member is blatantly being treated like a number, a bundle of [poorly] specified conditions, from intervention day one.

There isn't a simple declarative, personal, conversational sentence in this enrollment package. The signature is in cursive typewriter font, in the proudest tradition of 1970. I've signed thousands of letters to document I cared enough about someone's behavior to wield a pen my own self.  (And yes, there are scanners, too.)

So as you expend your resources and your members' time, goodwill and wellbeing on DM, consider that for every condition listed in a vendor's portfolio, there is a SNF, a clinic, a university program, an industry pilot, a health system, a single clinician whose DM is state-of-the-art. I'm not talking about 7-8 figure CER, AHRQ style, but the one-patient-at-a-time evidence base that can blossom into something new and improved.

For example, one psychologist (whom I'm proud to say taught me Psych101 eons ago) directs translational research into innovative Alzheimer's care that has been successful in several facilities. To what extent would moving the needle on AD progression and sequelae in any setting benefit your organization and/or anyone you care about?

The corollary question is whether you have appropriate resources allocated to find and leverage this essential intellectual capital. You know that incents -- from money to recognition -- can move the needle when little else can (and let's not pretend the wormy apples of P4P or buy-me pharma grants are the same thing).  If and when you spark something real, that helps create competitive advantage that in turn adds to brand and ally equity.

Did you notice Wendy Schmidt's contest to find better tech to clean up oil spills? The winning team tripled the "industry standard." When they asked the contestants why they hadn't tried these new approaches before, the responses boiled down to, "No one else [e.g. oil company clients] cared. Everyone felt they were doing OK."

What's in your MCO's wallet? Maybe the down payment on improved outcomes for millions.  All it takes is an I for innovation.

Look Up! The Stars Are Aligning for Prevention and Wellness!

By Cyndy Nayer, September 20, 2011

I’m thinking this evening of the amazing journey we’ve begun together, and I’m thinking about the conversation I had with Dr. Joycelyn Elders, former US Surgeon General, who will open our Annual Meeting and Innovation Summit on Nov 14.  Each of our phone calls is such a delight.  Imagine being able to call the woman who “explained” to Congress how teenagers need more guidance, and to ask her some of the hard questions on national health policy!

I’ve been very lucky in this career of mine.  I’ve been blessed to work with some of the most amazing folks at every turn.  What’s remarkable is that so many of us know the real gold in health care is not the care itself, but in making HEALTH the goal of our endeavors.  What’s exciting now is that many of us “passionate idealists” are working hard to make sure that the improvement in health is the #1 priority, and that health care becomes one of the tools to get there.

Each of us approaches this in different ways.  For instance, Brian Klepper, whom you often read about when you read my writings, is passionately moving the needle on Primary Care Providers, blogging on Health Affairs and causing a ruckus with the RUC (the panel that sets clinician reimbursement rates, the panel that is so very much under-represented by primary care physicians).  Brian’s efforts are getting bolder and growing stronger, and I am an ardent supporter of the efforts to be sure that Primary Care gets equivalent pay that shows their importance in the health engagement and promotion that keeps people well, working, and building healthier, prosperous communities.

Another good friend is Ron Loeppke, MD MPH, whom I’ve know for far too many years to remember.  Ron’s passion is now directed to his new job, as Vice Chairman of the Board, U.S. Preventive Medicine, Inc. (traansparency: I have the honor of serving on the board with Ron and so many of our mutual friends).  Ron is also the past Chair of the American College of Occupational and Environmental Medicine (ACOEM), and has chaired the Health and Productivity section for as long as I can remember.  Recently, Ron wrote an op-ed piece on the need for preventionists, and it’s posted on the ACOEM site.  Ron has been a driving force for linking worksite health to worksite performance, and we’ve had the joy of sharing many conferences, slides and ideas together.  As he says in the article:

The clinical science of preventive medicine focuses on wellness and health promotion and health risk assessment to keep people healthy (primary prevention); and early identification/diagnosis of illness through age/gender/risk appropriate screening and biometric testing (secondary prevention); as well as earlier evidence-based intervention/treatment to deter complications and the disabling impact of conditions (tertiary prevention). The preventive health care movement reaches well beyond the four walls of medical facilities to include workplace health and community health initiatives. 

I quote this as others in the space of value-based designs do not see the ROI of prevention and wellness.  But think about it:  if we can prevent the high cost interventions, if we can build intrinsic desire for health and accountability to save our health, the saved dollars will go far to build healthier communities.  The companies that tell me that they cannot focus on health, that they only want to get the costs down, are doing themselves, their families, and their communities a disservice.  Simply stated, if the company gets 80% or more of its workforce from the geographic community, then there is an 80% chance that the next person coming to get a job will have the same risk factors as the person who just left.  Want more proof?  Google Ron and start reading.

And on the topic of value-based designs, another friend I’ve been very much in contact with lately is Mike Critelli, the former CEO of Pitney Bowes who is now the Chair and CEO of Dossia, which is so very much more than a Personal Health Record.  Under Mike’s direction, Dossia is quickly growing into the family and community health management tool that I have been hoping for, building the capacity of families to “gather” into one record that the head of the family health improvement plan (usually the mom, folks, that’s been my story all along!), can manage.  With the strong support of a very talented group of programmers, community health improvement experts, international IT experts, and more that are too many to name, the group at Dossia is getting grand traction around the country, and I am, of course, delighted to have them on the CHVI board.  We share many strong ideas of accessibility and accountability, and then we work with our different constituencies to influence change as far and as fast as possible.

It’s stunning, isn’t it, that we expect an “engaged, accountable patient,” yet the patient gets no records, has virtually no decision-making authority except how much he/she is willing to spend out of his/her own pocket for care.  Yet, that’s not the accountable consumer we want.  We want a consumer who protects the health of herself, her family, her community.  We know, from research published by another renowned colleague, Dee Edington (of Univ of Michigan fame), that an engaged consumer of health has costs 30% lower than one who is unengaged.  We know that reducing risks from hi to moderate lowers costs 33%–that’s what happens when people are engaged, not entitled and waiting for the system to cure them.

Yes, I’m quite lucky, indeed.  Yes, I’ve used this opportunity to highlight the amazing work of my friends and colleagues AND to link to our upcoming summit, because I’m excited about our mission, and I’m excited that they will all be there with us.

Maybe, too,  as I watch the sun set over the beautiful SW Florida sky this evening, the stars really are aligning.  Perhaps we’ve squeezed as much value out of the delivery system as we can–and remember, most of the dollars, all $2.6 Trillion of them, are focused on the 10-20% of folks who are not so committed to health promotion or prevention.  Maybe now that the economics of health is so very important to understand, the stars are ready to assist.  Perhaps the stars, whose light has to travel so very far to be seen, have finally arrived in sight–and those of us who have spent so very many years promoting health, are finally being seen as well.  Perhaps the focus on outcomes allows all of us to ask the question, “How do we short-circuit the path to achieving these outcomes?”  and we can, finally, all get quiet while the stars’ universe responds, “It’s in the path to health promotion.”

It’s a wonderful night to dream of what could be, to imagine that there is a growing focus on health, outcomes, and healthy communities.  Tonight I’m not going to focus on this paradise’s need for jobs, affordable care, and primary care clinicians.  Tonight I’m going to hope and pray and dream of the US as healthy, prosperous, and job-wealthy.  I believe that’s what the stars are showing us.  If we’ll only look up, they will tell us that nothing is impossible.

Health Net Said: ACEP Said – A Dustup Over Emergency Room Use

By Clive Riddle, September 9, 2011

Yesterday Health Net released what they thought was a benign media statement on Emergency Room use, entitled “Know When the ER is the Right Choice for Care.” The health plan opened by stating “with flu season waiting in the wings, emergency rooms nationwide will likely soon be crowded with those who’ve been bit by the annual bug and who are mistakenly seeking treatment in the ER instead of in their primary care physician’s office or in an urgent care setting. In advance of these yearly throngs, Health Net, Inc. (NYSE:HNT) is working to increase awareness regarding when it’s appropriate to visit an emergency room.”

Jonathan Scheff, MD, Health Net’s Chief Medical Officer tells us “while emergency rooms play a vital role in our communities by providing lifesaving services, many ER visits are unnecessary” and goes on to say   “because the most serious cases are treated first in emergency rooms, those with non-emergency needs can expect extended waits.”

This wouldn’t seem like controversial stuff to most, but Health Net then goes on to state “the American College of Emergency Physicians (ACEP) points out that it’s in everyone’s best interest to reserve emergency rooms for those who are seriously ill or injured” and cites the ACEP’s list of warning signs for adults and for children a medical emergency that should demand immediate attention.

And it would seem Health Net might not have consulted and collaborated with the ACEP on their release.

ACEP fired back a media release the same day:  “ACEP Takes Issue with Statements Made Today by Insurance Giant Health Net, Inc. Regarding Emergency Visits.”  Dr. Sandra Schneider, President of ACEP tells us “the nation’s emergency physicians take issue with the efforts of health insurance companies to prevent emergency visits. It may save some money for them, but it’s bad for patient health and potentially life threatening. It also violates the spirit of the prudent lawperson law, which requires insurance plans to pay for emergency care based on whether an average person would believe they have the symptoms of a medical emergency.  In addition, emergency care represents less than 2 percent of the nation’s health care dollar, so preventing emergency visits will never put a significant dent in the nation’s soaring health care costs.”

The two organizations have different takes on using National Center for Health Statistics data. Health Net states  “according to the National Center for Health Statistics, of the more than 300,000 Americans who are treated in our nation’s ERs each day, the majority don’t require emergency care.”  ACEP cites “less than 8 percent of emergency visits are classified as nonurgent by the National Center for Health Statistics, which also says “nonurgent” does not mean unnecessary. Nonurgent visits can include broken bones and kidney infections that require treatment within two to 24 hours.”

Doctor Schneider closes with “these health plan tactics are dangerous because it puts people in situations of having to self-diagnose their medical conditions — out of fear the plans won’t pay, for example, when their chest pain turns out to be heart burn. Health plans send messages to their beneficiaries not to make any “unnecessary” emergency visits. But it’s not that simple — I’ve seen people with mild symptoms turn out to have life-threatening emergencies. ….This is a very simple message we want to share with all Americans — if you think you’re having a medical emergency, go to an ER immediately. Leave the diagnosis to the experts: emergency physicians.’”

Health Net, in its defense, closes with the tip: “for more information about when emergency care is needed, as well as about injury prevention, visit http://www.emergencycareforyou.org .” This web site, by the way, is operated by the ACEP Foundation.

What, Us Measure?

By Kim Bellard, May 18, 2011

I read with some interest an article in the Wall Street Journal outlining Wellpoint’s new approach to hospital payments, in which future payment increases would be tied to performance on 51 quality measures.  As interesting as that is in itself, what fascinated me even more was the reaction of Chip Kahn, the President of the Federation of American Hospitals.  Mr. Kahn did not appear too excited about the approach.  As he told the Journal: “We don’t have good outcomes measures yet.”

I don’t mean to take a shot at Chip Kahn or the Federation.  They are strong advocates for their members.  To its credit, the Federation has actively been involved in quality efforts for many years, including the Hospital Quality Alliance.  But, seriously – we pay hospitals some $800 billion per year, and we don’t have good outcome measures yet?  What are we waiting for?

A recent study by the Beryl Institute, whose mission is to improve the patient experience, indicated that 31% of hospital executives listed quality/patient safely as their organization’s top priority over the next three years, followed by 21% who cited patient experience/satisfaction.  The Beryl Institute seems to view this as good news, and I suppose it is good that no other single priority topped these two, but I have to wonder: so, almost half of respondents did think something else was their top priority?  

“Adverse events” – injuries caused by medical errors -- have been one of the open secrets in the health care system, and a recent study indicated that the problem may be as much as ten times worse than thought – impacting up to one third of hospitalized patients.   With those kinds of problems, if I ran a hospital, I might not want to track outcomes either, or at least not report them.

Wellpoint isn’t alone in targeting hospital quality.  Many health plans have implemented some version of pay-for-performance, although they tend to be paid as incentives rather than core to reimbursement.  Last month CMS announced the final rules for its Value Based Purchasing Program, which begins in 2012.  Medicare will also pay based on performance, initially as incentives but rapidly moving to reductions for hospitals that do not perform well.  The CMS measures are oriented towards process and patient satisfaction indicators, whereas 55% of Wellpoint’s measures are based on health outcomes, 35% on patient safety measures, and 10% on patient satisfaction.

Of course, quality measures are not just a problem for hospital performance.  Hospital quality measures are more evolved than physician quality measures, and both are far ahead of other parts of the health care system.  As Kenneth Kizer, founder of the National Quality Forum (NQF), said: “There are many areas of medicine where there simply are no measures – or there are, but they aren’t as good as they should be.” 

There certainly is no shortage of organizations working on the issue.  In addition to NQF, one could cite The Leapfrog Group, NCQA, CMS, the Physician Consortium for Performance Improvement, and several medical specialty associations, among others.   Still, the sense from the provider community seems to be that we’re not quite there, certainly not to the point where consumers should be making judgments based on the various indicators, nor having reimbursements materially impacted by performance on the measures.  They like the measures to be voluntary, although the recent CMS report on the Physician Reporting Quality System indicate only one in five health care professionals who are eligible to participate actually do – and only slightly more than half of those earned satisfactory scores which merited bonuses. 

It’s too bad, because it appears that the “standard” measures that consumers tend to look at to evaluate physicians, such as education or board certification, don’t appear to actually distinguish quality performance very well, according to a study by Rachel Reid and colleagues.  As the authors concluded:  “Few characteristics of individual physicians were associated with higher performance on measures of quality, and observed associations were small in magnitude. Publicly available characteristics of individual physicians are poor proxies for performance on clinical quality measures.”

Similarly, a study by Lauren Nicholas and colleagues published last fall indicated that the “process” measures currently reported by CMS on its Hospital Compare website don’t correlate with actual patient outcomes, such as mortality rates or surgical complications. 

How in the world did we get to the point of spending so much money on health care without even being able to measure if we’re doing it well?

I’ve complained about the lack of data in health care in previous blogs (such as in Gambling on Health Care), but it still disturbs me.  Maybe when – or if – we get to a world of electronic medical records and fully realized health information exchange we’ll have a better job of getting the right data; that is the point of “meaningful use.”  Still, I go back to another quote from Kenneth Kizer: “Nothing makes a performance measure better than when it starts being used.”  We need to start using the existing measures more now.

Putting performance data out there is half the battle, and I applaud the many people and organizations working to make that happen, hopefully sooner rather than later.  The other half of the battle – and one that, frankly, worries me even more -- is getting people to use it.

2010 National Healthcare Quality & Disparities Reports

Clive Riddle, March 4, 2011

HHS’ Agency for Healthcare Research and Quality (AHRQ) has just issued the 2010 National Healthcare Quality Report and National Healthcare Disparities Report. The reports are published annually, as mandated by Congress since 2003.

AHRQ tells us the “reports show trends by measuring health care quality for the Nation using a group of credible core measures. The data are based on more than 200 health care measures categorized in several areas of quality: effectiveness, patient safety, timeliness, patient-centeredness, care coordination, efficiency, health system infrastructure, and access.”

AHRQ summarizes the report findings as indicating “that few disparities in quality of care are getting smaller, and almost no disparities in access to care are getting smaller. Overall, blacks, American Indians and Alaska Natives received worse care than whites for about 40 percent of core measures. Asians received worse care than whites for about 20 percent of core measures. And Hispanics received worse care than whites for about 60 percent of core measures. Poor people received worse care than high-income people for about 80 percent of core measures. Of the 22 measures of access to health care services tracked in the reports, about 60 percent did not show improvement, and 40 percent worsened. On average, Americans report barriers to care one-fifth of the time, ranging from 3 percent of people saying they were unable to get or had to delay getting prescription medications to 60 percent of people saying their usual provider did not have office hours on weekends or nights. Among disparities in core access measures, only one—the gap between Asians and whites in the percentage of adults who reported having a specific source of ongoing care—showed a reduction.”

My impression of the state of things is evidenced in a section header entitled: “Quality Is Improving; Access and Disparities Are Not Improving.” The report states found that “across all 179 measures of health care quality tracked in the reports, almost two-thirds showed improvement. However, median rate of change was only 2.3% per year. Access is not improving. Across the 22 measures of health care access tracked in the reports, about 60% did not show improvement and 40% were headed in the wrong direction.”

Of course, patterns of care are regional, not national. The report found that “while every State was in the top 10% for some measure and was part of a benchmark, States in the New England (CT, MA, ME, NH, RI, VT) and Pacific (AK, CA, HI, OR, WA) census divisions were benchmark States most often and States in the East North Central (IL, IN, MI, OH, WI), East South Central (AL, KY, MS, TN), and West South Central (AR, LA, OK, TX) divisions were benchmark States less often.

The full 205 page National Healthcare Quality Report addresses: Effectiveness of Care, Patient Safety, Timeliness of Care, Patient Centeredness, Care Coordination, Efficiency of Care, Health System Infrastructure and Access to Health Care. The full 248 page National Healthcare Disparities Report addresses the same topic plus a section on Priority Populations. There is considerable overlap in the content of the two companion reports.

The reports are definitely worth some clicks to check them out.