Tuesday, September 24, 2013

Value-Based Health Care Is Inevitable and That’s Good - HBR

http://blogs.hbr.org/2013/09/value-based-health-care-is-inevitable-and-thats-good/?utm_source=Socialflow&utm_medium=Tweet&utm_campaign=Socialflow


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Value-Based Health Care Is Inevitable and That’s Good

by Toby Cosgrove  |   10:00 AM September 24, 2013
Vaccines. Anesthesia. Penicillin. Bypass surgery. Decoding the human genome. Unquestionably, all are life-saving medical breakthroughs. But one breakthrough that will change the face of medicine is being slowed by criticism, misunderstanding, and a reluctance to do things differently.
That breakthrough is value-based care, the goal of which is to lower health care costs and improve quality and outcomes. It will eventually affect every patient across the United States. Not everyone, however, is onboard yet, because part of the value-based equation is that hospitals will be paid less to deliver better care. That’s quite a challenge, but one that Cleveland Clinic is embracing as an opportunity to do better. Others must, too.
How the Health Care World Will Change
We all know that U.S. health care is too expensive, too inefficient, and the quality is too varied. The goal of value-based care is to fix that.
A major component of the Affordable Care Act is to change the way hospitals are paid, moving away from a reimbursement model that rewards procedures to one that rewards quality and outcomes. No longer will health care be about how many patients you can see, how many tests and procedures you can order, or how much you can charge for these things. Instead, it will be about costs and patient outcomes: quicker recoveries, fewer readmissions, lower infection rates, and fewer medical errors, to name a few. In other words, it will be about value. And that is good.
Whether providers like it or not, health care is evolving from a proficiency-based art to a data-driven science, from freelance physicians to hospital-employed physicians, from one-size-fits-all community hospitals to vast hospital networks organized around centers of excellence. Each step in this process leads to another.
When hospitals employ physicians on an annual salary as we do at Cleveland Clinic, a doctor is paid the same no matter how many patients he sees, how many procedures he performs, or how many tests he orders. One-year contracts hold our doctors accountable, with yearly performance reviews that include each doctor’s quality metrics, clinical outcomes, and research. And having all your doctors on the same team makes it easier to coordinate patient care among different groups of specialists.
As more independent physicians begin to be hired by hospitals, the opportunity for large group practices and hospital consolidation grows. As consolidation expands, data and transparency become increasingly important, as a way to ensure that caregivers across the system are providing comparable care.
All of this, of course, leads back to quality, which requires an effort to achieve standardization, reduce variation, and eliminate unpleasant surprises. It’s analyzing processes, measuring outcomes, and changing practices until you get it right.
To remain viable in today’s rapidly evolving environment, health care systems must reduce costs while continuing to improve quality and outcomes.
The Cleveland Clinic’s Journey
In the October issue of Harvard Business Review, Michael Porter and Tom Lee cite six components of high-value care-delivery systems: integrated practice units; cost and outcomes measurement; bundled payments; integrated care delivery across facilities; expanded services across geography; and an information technology platform to enable those processes.
As they note, Cleveland Clinic is one of two medical centers worldwide that has implemented all six, beginning with integrated practice units, which we call “institutes.” A patient-focused institute combines medical and surgical departments for specific diseases or body systems. All of our institutes are required to publish outcomes and measure costs. With bundled payments, we combine all the services provided before, during, and after a complex procedure like joint replacement, into a single charge. We have integrated care through shared protocols and the electronic medical record at all of our 75 care-delivery sites. And our expansion across Northeast Ohio into Florida, Nevada, and overseas allows broad geographic access to our services.
What makes Cleveland Clinic different stretches back to our founding 92 years ago as a physician-led group practice that runs a hospital – not a hospital that employs doctors. This distinction is important. Decisions from the CEO on down are made by physicians based on what is best for the patient.
Mining Data
As a leader in the electronic medical records, we have a wealth of data that can tell us what’s working and what’s not. For instance, we were able to comb through data of heart-surgery patients to find that those who received blood transfusions during surgery had higher complication rates and lower long-term survival rates. This finding – mined from our own data – changed the way we do things; we now have strict guidelines in place to limit transfusions.
We’ve made similar strides in many other clinical areas, using data to drive quality. By collecting data on provider performance and making that data transparent, central-line infections have decreased by more than 40%, while urinary-tract infections have dropped 50%.
Data can help identify variations in clinical practice, utilization rates, and performance against internal and external benchmarks, leading to improved quality and a sustained change in culture. Last year, we established a values-based care team, which seeks to eliminate unnecessary practice variation by developing evidence-based care paths across diseases and to improve comprehensive care coordination so that patients move seamlessly through the system, reducing unnecessary hospitalizations and ER visits.
Lowering Costs Without Compromising Quality
American health care is on an unsustainable path. Health care spending topped $2 trillion in 2011. The Centers for Medicare and Medicaid Services predicts that without major change, it will account for more than 20% of GDP by 2021, up from 5.2% percent in 1960. What that means is that if we continue on our current path, $1 in every $5 spent in the U.S. economy will go toward health care.
We can choose a different path, though. At Cleveland Clinic, we’ve been engaged in an ongoing effort to trim costs across the entire system. Through a concerted focus on our supply chain, we use rigorous value-based purchasing protocols, market intelligence, and business analytics to examine every purchase from the standpoint of value, utility, and outcomes. Over the past two years, this has resulted in cost savings of more than $150 million.
Our electronic medical records are also programmed with a “hard stop” function to reduce unnecessary duplicate tests. This led to a 13% reduction in blood-gas determinations, generated $10,000 in monthly savings for laboratory tests, and resulted in savings of $117,000 in just the first month for genetic testing.
A key part of the cost solution is to educate all caregivers, including doctors, about what items cost. Earlier this year, we created a Cost Repositioning Task Force to work with all caregivers across the entire Cleveland Clinic system to assess everything we do and everything we spend. Now, as part of the purchasing process, dozens of doctors gather to discuss the merits of certain products: Which ones provide the best outcomes for patients? How many are needed? How much does it cost?
Traditionally, knowing the cost of a stitch or a catheter or a bone screw — or any of the thousands of other supplies used during surgeries — hasn’t been part of doctors’ medical consciousness. To remedy that, we’ve taped price lists to supply cabinets in some ORs. In others, posters remind everyone to choose supplies carefully, stressing this message: “Without compromising quality, consider cost-effective alternatives.”
As health care reform kicks into high gear, providers are facing a difficult challenge: being paid less to produce better outcomes. We must view this as an opportunity, not a burden. After all, the providers who make the transition early will be rewarded with more satisfied patients, lower expenses, and pride in a job well done.
Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us athealtheditors@hbr.org, and sign up to receive updates here.
Leading Health Care Innovation
From the Editors of Harvard Business Review and the New England Journal of Medicine




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Saturday, September 21, 2013

Redefining the Patient Experience with Collaborative Care - HBR

http://blogs.hbr.org/2013/09/redefining-the-patient-experience-with-collaborative-care/

by Leonard L. Berry and Jamie Dunham  |   9:30 AM September 20, 2013
It’s a common patient complaint about the people involved in their care: “Sometimes the left hand doesn’t seem to know what the right hand is doing. I don’t feel everyone is working together.” To address this issue, nurses at ThedaCare employed lean techniques to create a patient-centered, team-based model that’s producing solid results.
Based in Appleton, Wisconsin, ThedaCare is a five-hospital health system with 26 clinics, other allied services, and more than 6,000 employees. It has been a pioneer in applying lean methodology in health care in order to tackle quality and cost issues. It began its lean journey in 2003 and has made considerable progress. For example, its accountable-care-organization partnership with Bellin Health, a health care system in Green Bay, Wisconsin, presently has the lowest cost per Medicare beneficiary among 32 pioneer ACOs, and the ThedaCare Physicians group was ranked first in quality performance statewide in 2013 by Consumer Reports.
ThedaCare opened its first “collaborative care” hospital unit in a medical-surgical unit at Appleton Medical Center in 2007 after 18 months of interdisciplinary planning led by nurses. A second was introduced in a medical-surgical unit at Theda Clark Hospital in Neenah in 2009, and a third in another medical-surgical unit at Appleton Medical Center in 2010. By 2013, all eight medical-surgical units in the two hospitals had been converted to the collaborative-care model.
The results to date show that the inpatient-care model is succeeding in improving safety, efficiency, and effectiveness. For the first three units, costs and length of stay declined, and quality and patient and nursing satisfaction improved. Some metrics improved immediately (within the first month); others over a period of six to nine months. A new process that required the pharmacist, rather than a nurse, to be responsible for “admission medication reconciliation” (a process that ensures that the patient’s list of medications that he or she is taking at home is accurate and can be used as a baseline for prescribing medication during his or her hospital stay) reduced the errors per patient admission to zero from between 1.25 and 1.5.
Benefits of Collaborative-Care Chart
Team Care at the Bedside
The collaborative-care model replaces inconsistent, fragmented hospital care. A bedside-care teamcomposed of a physician (“medical expert”), nurse (“care-progression manager”), pharmacist (“medication expert”), and discharge planner (“transitional-needs coordinator”) collaborates — with patient and family input — to develop a single care plan that is continuously updated in daily team huddles. On admission, the team gathers the patient history, performs a physical assessment, determines an anticipated discharge date, and works backward from this date to build a coordinated plan of care.
Using evidence-based guidelines linked to the electronic medical record, the nurse manages the patient’s care progression, and the bedside pharmacist contributes to optimizing management of the medication. The physician leads the clinical assessment and planning process but as a team member/partner. The discharge planner assists the team in devising the best transition plan post hospitalization.
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This patient-centered approach minimizes duplication of effort, puts people in roles that leverage their skills and accelerates clinical learning as teammates teach each other. Staff use “tollgates” — purposeful timeouts that are a lean concept — to analyze the patient’s status and remove obstacles in delivering care.
Struggles — and Lessons — from the Journey
Despite the progress, the collaborative care model has had its challenges and remains a work in progress. For example, program designers learned belatedly that the new model requires a different kind of unit leader: a team-builder, coach, and mentor. A “collaborative-care spread team” consisting of clinical experts in the model, a project manager, organizational development specialists, and others guide the nurse managers through their unit’s preparation and implementation phases, supporting their leadership development every step of the way.
One challenge that’s currently being addressed is how to both maintain essential standard work across units and accommodate the requirements of clinical specialties. Some adaptation for certain patient types, like the short-stay surgical patients, has been needed to continue to meet the model goals. As with the original design, these adaptations were made using lean tools for ongoing process improvement.
Another ongoing challenge is getting private-practice physicians who use ThedaCare hospitals to fully engage. To help address this issue, hospital medical directors meet with independent physician groups to share essential elements of the model and determine how they can be applied to doctors’ workflows. (Garnering the full participation of ThedaCare-employed physicians has gone more smoothly.)
ThedaCare’s experience with collaborative care offers salient lessons:
Start from scratch. ThedaCare started by designing a new delivery process rather than adding to the existing process. Starting fresh sparks uninhibited creativity; it encourages “why can’t we” instead of “we can’t” thinking.
Follow a methodology. The design team fully used lean methods such as rapid-improvement events, value-stream maps, and visual-management concepts. That ThedaCare turned to hospital nurses to lead the program design reflects the lean tenet of asking people closest to the work to improve it. (For more information on how to apply lean techniques in health care, see this article.)
Fully use the talent. Collaborative care addresses one of health care’s greatest sources of waste and defects: the underutilization of skilled labor. Too often, highly trained staff work below their scope of expertise — for example, doctors doing what nurses not only can do but also probably do better. Nurses coordinating patients’ care progression and pharmacists managing medications represent big wins for patients and other stakeholders.
Involve the patient. The voice of the patient was a critical input in developing the collaborative-care approach. Patients participated in rapid-improvement events and were members of the development team. Patients anxious to know when they would likely go home were the impetus to providing a discharge goal on admission and focusing on the course of care needed to meet that goal. Patients voicing distrust because they were asked the same question multiple times by different clinicians during their admission laid the foundation for an admission process conducted jointly by the care team.
Invest in intentional thinking. Another lean tenet is assessment before action. Two examples: the 18 months that ThedaCare spent planning the new model and the care team huddles before, during, and after patient visits to assess and reassess the patient’s care plan.
Support strategy with infrastructure. Changes in the hospital facility were made to implement the new approach. They included converting semi-private patient rooms to private rooms and replacing the traditional nursing stations with decentralized alcoves located just outside of the patient rooms, where teams can huddle  before and after visiting patients. A whiteboard was put in the patient’s room so staff could summarize the care plan, timeline, and other relevant information for patients and families. And the supply server was redesigned so it could be restocked outside patient rooms but would be easy for care providers to access medications (kept in locked compartments) and other things. This reduces the time that it takes for nurses to gather supplies, allowing them to spend more time with patients.
Communicate quality. In general, patients have basic expectations about their hospital experience — they want reassurance that providers care about them, communicate with one another, and are competent. Involving the patient in care planning, summarizing the plan on the in-room whiteboard, and following work standards that provide reliable outcomes communicate to patients that they are receiving quality care.
The progress to date of ThedaCare’s collaborative care model is evidence that patient-centered teamwork can improve the quality and lower the cost of care.
Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us athealtheditors@hbr.org, and sign up to receive updates here.
Leading Health Care Innovation
From the Editors of Harvard Business Review and the New England Journal of Medicine

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Commonwealth shows 'stark' care divide Health IT, innovation could help close gap

http://www.healthcareitnews.com/news/commonwealth-shows-stark-care-divide?single-page=true

David Blumenthal, MD, president of the Commonwealth FundDavid Blumenthal, MD, president of the Commonwealth Fund


NEW YORK | September 18, 2013
Access to affordable health care and quality of care vary greatly for low-income people based on where they live, according to a new Commonwealth Fundscorecard.
The scorecard provides the first state-by-state comparison of the healthcare experiences of the 39 percent of Americans with incomes less than 200 percent of the federal poverty level, or $47,000 a year for a family of four and $23,000 for an individual. Low-income people account for at least 25 percent of total state populations, and as much as nearly half (47 percent) in some states -- including Arkansas, Louisiana, Mississippi and New Mexico.
The report also compares the healthcare experiences of those with low incomes to those with higher incomes -- over 400 percent of poverty, or $94,000 for a family of four -- and finds striking disparities by income within each state. Yet the wide differences by geography often put higher-income as well as low-income families at risk. The report finds that higher-income people living in states that lag far behind are often worse off than low-income people in states that rank at the very top of the scorecard. For example, low-income elderly Medicarebeneficiaries in Connecticut and Wisconsin are less likely to receive high-risk medications than are higher-income elderly in Mississippi, Louisiana and Alabama.
The stark differences in healthcare access, quality, and outcomes detailed in the report add up to substantial loss of lives and missed opportunities to improve health and quality of care. According to the Scorecard, if all states could reach benchmarks set by the leading states for their more advantaged populations:
  • An estimated 86,000 fewer people would die prematurely each year.
  • Seven hundred and fifty thousand fewer low-income Medicare beneficiaries would be prescribed potentially dangerous medications.
  • Tens of millions of adults and children would receive needed preventive care like vaccines, check-ups and cancer screenings.
  • Nearly 9 million fewer low-income adults under age 65 would lose six or more teeth because of tooth decay, infection or gum disease.
  • Thirty million more low-income adults and children would have health insurance coverage, reducing the number of uninsured by half.
Cathy Schoen"We found repeated evidence that we are often two Americas, divided by income and geography when it comes to opportunities to lead long and healthy lives. These are more than numbers," said Cathy Schoen, Commonwealth Fund senior vice president and lead author of the report. "We are talking about people’s lives, health, and well-being. Our hope is that state policymakers and healthcare leaders use these data to target resources to improve access, care, and the health of residents with below-average incomes."
David Blumenthal, MD, former national coordinator for health information technology, who is now president of the Commonwealth Fund, sounded an optimistic note.
Improvement is clearly possible, he says, citing expanding healthcare coverage and innovation.
"The Scorecard’s startling findings show us where our bright and weak spots are when it comes to providing health care to millions of Americans living on modest or low incomes," Blumenthal said in announcing the scorecard’s findings. "And the timing is important. We are at an unprecedented moment in the history of our nation. We have the potential to raise the bar, unite the country, and realize the promise of a more equal opportunity to thrive by expanding health care coverage and innovating to find the most effective ways to deliver high-quality, safe care for everyone."
The report findings point to the need to strengthen primary care to ensure timely access, reduce reliance on emergency rooms, and improve care for those with chronic disease. The scorecard finding that those living in low-income communities often fare worse points to the need for targeted efforts focused on "hot spots," or communities with very high rates of hospital or emergency room use, to act early, prevent complications and improve population health.
More gaps
The report, "Health Care in the Two Americas: Findings from the Scorecard on State Health System Performance for Low-Income Populations," and an online interactive map rank states on 30 indicators covering issues such as access to affordable health care, preventive care and quality, potentially avoidable hospital use and health outcomes. The report also examines how well the top-performing state in each category does for its high-income residents and sets that as a benchmark in order to assess the potential if all states could do as well.
The report finds substantial variation in health care and health outcomes for low-income people – a two- to five-fold difference. While there was room for every state to improve, states in the Upper Midwest, Northeast, and Hawaii performed best, while Southern and South Central states often lagged.
Some findings of wide geographic disparities and gaps in care include:
  • The percentage of uninsured low-income adults ranged from a low of 12 percent in Massachusetts to a high of 55 percent in Texas.
  • Only 32 percent of low-income adults ages 50 or older received recommended preventive care, such as cancer screenings and vaccines, ranging from 26 percent or less in Idaho, Oklahoma and California, to 42 percent in Massachusetts, the top-ranked state for this indicator.
  • In eight states, 40 percent or more of Medicare beneficiaries received medications considered high-risk for the elderly – rates more than double that of states with safer prescribing.
  • Asthma-related hospitalizations among children from low-income communities in New York were eight times higher than in Oregon, the state with the lowest rate. (477 per 100,000 in New York, compared to 56 per 100,000 in Oregon.)
  • At least one of four low-income adults under 65 in West Virginia, Tennessee, Alabama, Mississippi and Kentucky lost six or more teeth due to decay or disease, compared to less than 10 percent in Connecticut, Hawaii and Utah, the states with the lowest rates.
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Thursday, September 19, 2013

Health Spending Distribution, by Category - CMS


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