Bridging Business & Healthcare : Healthcare Management Consultants for Dispute Resolution, Valuation & Clinical Compliance

This week Modern Healthcare released its annual list of the top 100 most powerful people in healthcare. It’s populated with many people who most would agree are quite powerful –Barack Obama, Nancy Pelosi, Bill Gates, and the list goes on.  Perhaps more interestingly, however, are the people who topped the 2008 list of healthcare’s power brokers – Steve Case (founder of AOL and Revolution Health), Eric Schmidt (CEO of Google) and Hillary Rodham Clinton – who have dropped off of the list entirely. If they had such enormous power two years ago, why are they seemingly no longer even in the equation?

Webster’s dictionary defines power as “the possession of control or command over others; authority; ascendancy.”  Power is fleeting. Exerting power may allow you to achieve your short-term goal, but it has a downside – it gets used up. If your only approach is to exert or impose your will to achieve your ends, there will always be another waiting to take your place.

Influence is another thing entirely. It is the capacity or power of persons to be a compelling force, to produce effects on the actions, behaviors or opinions of others. In short, to influence is to cause long-term, meaningful change.

For better or worse, we now have an outline for change to our healthcare system, but we have yet to see the type of long-term influential leadership needed to sustain and implement meaningful change. There are some new and creative ideas out there; some of which just might work, but unless we can identify consistent, passionate, and effective leadership in healthcare at the highest levels, the door will continue to spin.

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As all of us who work in healthcare know, we are all swinging for the fences to hit the home run of Electronic Health Record ("EHR") implementation. Practices and hospitals across the country are racing to make sure all of the myriad of boxes are checked, T’s are crossed, and I’s are dotted to be sure that their version of the EHR meets all of the new standards for meaningfulness. There are core measure items and menu measure items – pick all from column A and some from column B and you now have meaning. The search for meaning has been defined, but achieving it still seems a very distant reality for many of us that are just stepping up to the proverbial plate.

In the midst of this mad scramble toward meaning, two very different studies on IT were released this week. On Monday, a study was published stating that only “fully functional” emergency department EHR’s led to lower lengths of stay and lower waiting times. The study goes on to say that only 1.7% of the systems surveyed met the definition of “fully functional”. In fact, if you ended up in an ER with an EHR that was of the more basic variety, your wait time was likely to be longer than the majority of hospitals with no EHR at all. (A swing….and a miss.)

On Thursday an article in the Boston Globe's health blog, White Coat Notes, highlighted a new study being undertaken by the Emergency Department ("ED") in Boston’s MetroWest Medical Center. The program allows patients to text the ED to check on wait times. One of the goals of this program is to “promote better customer service” by decreasing waiting times. At the time of publication of the article, over 450 patients had sent text messages to the two emergency departments in the MetroWest system. The average wait time was 24 minutes to see a physician. (A bunt down the third base line…and he scores!)

Like many other parts of the new healthcare reform world, many of the goals may be admirable, but seem unobtainable and overwhelming to many hospitals and healthcare providers. Successful implementation of the EHR across the healthcare system may be the home run we are all looking for, but if we want to achieve true meaning for IT in healthcare, we may have to hit a few singles first.

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This past week, Nevada’s state board of health found itself in the middle of an all too familiar debate – just how much information should hospitals be required to share directly with the public.  The debate arose over a new regulation that would require Nevada hospitals to report hospital acquired infections to the CDC’s infection database. That information would then be available to state regulators to track, trend, and respond to as needed.  The information would not, however, be available directly to the public. In leading the debate against full public disclosure, Bill Welch, the president of the Nevada Hospital Association, stated that although he was against allowing the public to identify which hospitals had which infections, he was in favor of “meaningful transparency.”
 
This debate over how much to share already has taken place in at least 27 other states. But as I read how others had solved this, I began to believe we aren’t looking for the right answer as much as we are asking the wrong question.
 
As an industry, healthcare is going through a transition in the realm of quality.  It is moving (or in some cases being moved) from only measuring processes of care – did the patient get an aspirin - to measuring outcomes of care – did the patient live or die?  Forces from within the industry, such as doctors Pronovost and Gawandi, and external forces as great as the new healthcare law itself are driving healthcare quickly toward this goal. While progress is being made, we are far from the end of this transition. 

Focusing on “how transparent we are” misses the point.  When we can focus on and achieve meaningful quality as demonstrated by consistently improved outcomes, debating over who sees the data won’t seem very meaningful at all.

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Recently, a friend of mine went out to his car late one night to run an errand, only to find that it would not start. He was immediately concerned as he had an early AM meeting that he couldn’t miss. He had just replaced the battery so knew it must be something else. Knowing nothing of cars, he did what any of us would do, he Googled it. One brief phrase – “Infiniti QX56 won’t start battery new”—and presto, up popped three online mechanics, one at $15, one at $25, and one at $45. Choosing the middle of the range, he clicked on the link and there was his trusty online mechanic at 11:30 PM to answer his questions and hopefully solve his dilemma. After a brief history of the problem, the mechanic quickly shared with him what he thought to be the most likely answer – it was a relay switch. Fortunate for him, this particular model has 6 other relays that are identical, one of which was to the fog lights. The fix was simple; he would just need to switch out the two parts. Knowing that my friend was not adept in the ways of car repair, the mechanic, e-mailed him a diagram of where to find the correct part, he switched it out, and like magic, his car started up. Thirty minutes after getting online – Problem solved.

As I thought about this story, it made me wonder about how we continue to care for patients today. My physician’s office is one of the very few places in my life that I have to wait for an appointment in order to receive the information I want or need. A friend of mine called last week for an appointment as a new patient with a specialist she needed to see. First available appointment – 6 weeks.

Much of the discussion we are seeing is about how physicians must change the way we practice in response to healthcare reform and the new law. Although that is undeniably true, there are other forces of change at work in the world of healthcare. Given that nearly everything else in our lives has become designed around immediate access, it is only a matter of time until physician practices must find a way to get on board. 

• New models of care, using social media tools and immediate access such as hellohealth are emerging. Follow @jayparkinson on twitter to see more.

• Jennifer Shyne Dyer, MD, [@endogoddess] is using texts and tweets to monitor her diabetic patients. 

• The Mayo Clinic recently launched its new Center for Social Media with the tagline Bringing the Social Media Revolution to Healthcare.  

If physicians are to survive and thrive in this new healthcare world, they will need to join in this “revolution,” developing new and creative ways to care for their patients and make information immediately available to them.  How long will it be till your patients are really able to see you…now?

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This past week, CMS announced a public comment period on several newly released quality metrics focused on stroke outcomes – 30-day all cause mortality and 30-day readmission rates. As I spend most of my day working on healthcare reform and quality, I spent the weekend diving into these metrics, wanting to be sure exactly which clinical improvements CMS was looking to incentivize physicians and hospitals to achieve. I quickly scrolled down through the 30-page “Measure Information Form,” looking to find the definition of the metric and why it was chosen. I had to go about 10 pages into the document, but there it was.  I came upon the section titled “Measure Justification” with the subtitle "Importance.” Under this impressive heading, CMS went on to say it would define this "Importance” by the "Extent to which the specific measure focus is important to making significant gains in healthcare quality (safety, timeliness, effectiveness, efficiency, equity, patient-centeredness) and improving health outcomes for a specific high impact aspect of healthcare where there is variation in or overall poor performance.” OK. Makes sense so far.

Not too much further into the document, CMS goes on to define the Summary of Evidence of High Impact. Perfect. This is just what I am looking for. Let’s see – Affects Large Numbers. I can buy that. Stroke affects almost 800,000 people every year in the U.S. Next. Leading Cause of Morbidity/Mortality. Stroke is the third leading cause of death in the U.S. after heart disease and cancer. Well said. CMS seems to be right on point. Next. Severity of Illness Stroke survivors frequently experience significant long term disability. And finally – High Resource Use. The estimated direct and indirect cost of cerebrovascular disease for 2010 is $73.7 billion. Hey, wait just a minute. I thought we were talking about improving clinical quality. How did this get in here?

When I was a young physician in training, we spent hours learning to read and interpret clinical studies, always keeping current on the latest trends to assure we were providing the best clinical care to our patients. It wasn’t that we were trained to ignore the cost of care, but we didn’t include it as we defined whether or not quality was improved. Quality was on one hand, cost on the other, and we weighed them together in our decision. Now it seems as if that line has become a bit blurred. 

In 2007, CMS released a report to Congress entitled “Plan to Implement a Medicare Hospital Value-Based Purchasing Program.” The report's goal is defined by moving more towards a value-based system of care as follows:

CMS recommends replacing the current quality reporting program with a new program that could include both public reporting and financial incentives for better performance as tools to drive improvements in clinical quality, patient-centeredness, and efficiency.

When you critically examine current demonstration projects, the trend continues. Right alongside of "Post-operative stroke” you will find "Average and median length of stay” both listed as metrics to measure quality.

When the definition of whether or not quality is achieved is dependent on the resources consumed, are we limiting our focus to only those outcomes that also provide financial savings? Has cost become the new sine qua non of quality? Maybe the new line isn’t that blurred after all….

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“I read the news today, oh boy"

The outlook for Medicare has improved substantially, or at least so say the Trustees of the Social Security and Medicare trust funds in their recently released report. According to this latest report, Medicare will now be solvent until at least 2029. The good news is, this is 12 years longer than previous estimates. The bad news is, I will only be 64 – 2 years short of eligibility for my full Medicare benefit. Paul McCartney's words – “Will you still need me, will you still feed me?" – suddenly have taken on a very personal meaning.

According to the report, this windfall for Medicare is entirely due to “...program changes made in the Patient Protection and Affordable Care Act.” It goes on to say that “If health care efficiency cannot be substantially improved through productivity gains or other measures, then over time the statutory Medicare payment rates would become inadequate.”

This new math is quite telling. With all the new programs and new ideas, why does health care reform only buy us 12 more years in an admittedly optimistic, best case scenario? For all of the talk about continuity and coordination, this plan is largely focused on gaining efficiencies in our current system. New models of payment do not necessarily equal new models of care. There are certainly opportunities to lower our costs, and improve our delivery, but there is a limit to the efficiency you can gain in any system. There is only so much juice in the proverbial orange. 

We are currently living in a system of uncoordinated sick care with the goal being to move to a system of coordinated health care. Although the new law moves us in that direction, it really only gets part of the way – to a coordinated sick care system. Unless we can continue to move toward a model of truly coordinated health care, we are simply delaying the inevitable. We may have a good start, but we still need a better plan.

Title: When I'm Sixty-Four, John Lennon & Paul McCartney

Opening Quote: A Day In the Life Lyrics, Paul McCartney

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"It would be so nice if something made sense for a change.”

Alice in Wonderland

One of the primary challenges of living in the new healthcare world is embracing the concept of value. Value in the world of healthcare means mastering the balance between improving the quality of care while simultaneously decreasing its cost. I frequently am privy to debates on what constitutes “real” quality and how is it going to be defined and by whom, but I am rarely questioned about cost. Cost would seem to be rather straight forward. Not so fast. A recent study published in the Journal of Hospital Medicine showed that only one tenth of hospitalists were within a 10% accuracy rate when surveyed about the actual cost of commonly used inpatient services, tests and procedures. Some were off by thousands of dollars. A recent article on healthleadersmedia.com referred to this phenomenon as “price opacity”. The article goes on to say that It would be almost unheard of for you, the individual patient, to be able get a clear price on a menu before the service is delivered”

One of the key tenants of healthcare reform has been the promotion of transparency, mostly focused on quality. I do agree that transparency is necessary and will ultimately lead to improved care, but if we are ever to get to truly improved value – not just improved quality – we are going to need to find a way to clear the smoke from the costs of care for physicians and patients alike.

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Great Britain and the National Health Service are having a rough week. A total overhaul of the “model” healthcare system with $30 billion in savings targets needed to keep the country from fiscal ruin were announced to a flurry of political wrangling. One paper called the US healthcare effort a “warm-up act” in comparison. Trying to keep up with all things healthcare, I read the summary of the new healthcare proposal for Great Britain, hoping to pull out a nugget or two on centralization of care or significant payment reform. What I found headlining the summary surprised me – “First, we will put patients at the heart of everything we do.”

Now, maybe I shouldn’t have been so surprised. Healthcare is, after all, supposed to be about the patients we care for. My curiosity piqued, I looked at our new law, the PATIENT protection and affordable care act to see how our focus on patients compared. The proposed law in Great Britain is very direct – “The Government’s ambition is to achieve healthcare outcomes that are among the best in the world. This can only be realized by involving patients fully in their own care.” They have dedicated the first section of their new law to ways for the patient to lead his or her own care and focus on shared decision making.

How did we tackle this?  The words “patient decision” are used together a total of 25 times in our new law, 24 of which are contained in a single section outlining a demonstration project on the creation of patient aids to help patients make the “right decision” about their care. The words “shared decision” found a mere 13 times, 9 of which are in the same demonstration project mentioned above.  

I’m not here to say the British have gotten it all right. I do believe however that there is a valuable lesson to be learned. Allowing patients to have a shared decision-making role can be uncomfortable for us in the industry for a myriad of reasons. But without it, will we really be able to make significant change in our system?  More and more research has shown improvement in outcomes as well as cost savings by including patients more directly in their own clinical decisions. With the majority of our discussion focusing on the “affordable care” piece of the puzzle, we may all be better served by realigning our focus on the patient.

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As a father of three teenage boys, my life is rarely dull. Their insights and slant on most things are generally entertaining to say the least. Last night as I was sitting at my dinner table, my 16 year old son caught my attention.  “Dad, the folks who make video games have got it figured out. They are marketing geniuses. They must be rolling in money.” Curious, I asked what he meant. He went on to share with me that on his new gaming system, there was a small avatar that sat in the lower right hand corner of the screen. According to my son, this avatar had no purpose whatsoever. It was not part of the game. It didn’t even move. It just sat there and blinked. The gaming company, it seems, has developed a system of buying “points” as imaginary money and with this money you can customize and dress your avatar in any way you wish. My son, perplexed by this, said “Dad, why would anyone buy something that has absolutely no value?”

My thoughts immediately went to the world I work in every day… the world of healthcare. CT scans for every headache in the ED? MRI for everyone with back pain? The list goes on.

As a physician, I do understand that the thought that goes behind these decisions is complex, but our current system has led some to pursue this type of behavior with incentives that are far from clinical. According to a recent survey by the Commonwealth Fund and Modern Healthcare, 93% of those healthcare leaders surveyed believe that current financial incentives for providers and other stakeholders are “extremely significant” or “very significant” barriers to the growth and adoption of new care models such as accountable care organizations. As we transition to a new system which places a greater value on quality, we as health care leaders have an obligation to ensure that these incentives are designed to assure true value is delivered. Let’s make sure we are no longer just “dressing the avatar."

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