The Users' Guide to the Health Reform Galaxy

From a doctor's point of view: making billing better, for better care

James E. Bailey, M.D., M.P.H., is a practicing internal medicine physician, director of the Healthy Memphis Data Center and a professor of medicine at the University of Tennessee Health Science Center.  In this post, he riffs on a topic covered by a recent RWJF-supported study, about how streamlining billing procedures will increase efficiency and help improve the quality and cost of health care.

Between the recession and new health reform law, Americans have been thinking a lot about what health care costs. I’ve heard many stories of patients and their families suffering because of the cost of getting care. I also know many primary care doctors and hospitals that do their best to provide everyone the care they need most are finding it difficult to keep their doors open. Again and again, I’ve seen how the health care people receive is often of poor quality, despite its high, and rising, cost. Sadly, Americans end up getting expensive, sometimes even dangerous procedures they don’t need while their most essential health care needs are overlooked.

The health reform debate tended to focus on big, divisive issues—and rightly so. Real change in our health care system will require hard choices to be made by everyone. But there is another big issue—not quite as divisive but nonetheless worth our attention—which is the system’s misuse of time.  Any physician can speak of large amounts of time—and frustration—spent dealing with administrative issues such as billing. As a doctor, I want most to spend my time with my patients. And so every minute I spend on administrative tasks is one less minute I have for seeing patients. And instead of an efficient system that empowers doctors to best do their work, we’ve created a time hog that dictates the priorities of our practices, inhibiting us from doing what we are called to do as physicians—provide care for those who need it.

This is why reform efforts must address issues like the simplification of billing and paperwork. A new study from RWJF's Changes in Health Care Financing and Organization initiative, “Saving Billion of Dollars—And Physicians’ Time—By Streamlining Billing Practices” suggests that it is possible to streamline the billing process, increase the quality of care and eliminate some unnecessary costs. The study examines the U.S. system of billing third-party payers for health care services, arguing that the system of third-party payment is excessively cumbersome, complicated and costly. We spend about twice as much on the billing bureaucracy in America than in any other country in the world.  While it is unlikely that we will be able to eliminate third-party middlemen from the system any time in the near future, there is much that can be done now.

Rx for Primary Care

Sheldon D. Horowitz, M.D., a special advisor to the president of the American Board of Medical Specialties and principal investigator of the Improving Performance in Practice (IPIP) initiative, writes about an effort to give small physician practices the tools they need to improve quality.

Today is National Doctors Day, a day set aside to thank physicians for all they do in applying modern medical science and technology to the special calling of preventing and treating people’s injuries and illnesses. It seems appropriate, then, to recognize a program devoted to helping doctors in primary-care practices do that more effectively.

The program, called Improving Performance in Practice (IPIP), provides practices with tools, support, coaching and a collaborative learning environment in which they can assess their performance and engage systematically in quality-improvement activities using their own practice data. Doctors can also compare their data to others in their cohort groups as benchmarks.

As everyone involved in quality improvement knows, translating the latest and best medical techniques and protocols into practice is easier said than done. That’s especially true for the small offices where 60 percent of U.S. physicians work. Compared to big hospitals and integrated group practices, they typically have fewer resources available for quality-improvement efforts. IPIP fills the resource gap for small practices in seven states by giving them process-improvement kits based on the Chronic Care Model and providing quality-improvement coaches, typically registered nurses, to guide practices through the steps involved in taking full advantage of the program’s resources.

To enroll, practices choose a focus area—asthma or diabetes in most cases—and commit to using a registry or electronic medical records to manage their patient populations, if they don’t already. Then they begin providing monthly data on a set of quality measures covering care processes and outcomes.

Such measurement and reporting are essential. As one Colorado doctor told IPIP staff, “Until I saw my data, I thought I was providing excellent care. Now I see we have a lot of work to do.”

Among other things, coaches help practices improve their division of labor and work flow by relentlessly asking the question: “Is this physician work or non-physician work?” If a doctor isn’t needed for a particular task—say, administering an annual sensory exam to diabetics to test for nerve damage—then someone else in the office should take care of it so doctors can focus on the things that only they can do. These work-flow improvements help practices get more done—and also improve job satisfaction. “I was considering leaving the profession,” Dr. Tracy Hofeditz of Lakewood, Colo., told IPIP staff. “But now I have rediscovered the joy of practicing medicine.”

One key benefit of participating in the program is that it helps practices comply with ABMS Maintenance of Certification®, professional recognition for quality and pay-for-performance programs.

Patients, meanwhile, get more effective care. For example, in the 16-month period between June 2008 and October 2009, Pennsylvania IPIP practices saw a 15-percentage-point increase in the share of diabetes patients with blood pressure of 140/90 or less—an important threshold level to stay below.

That kind of success helps explain why IPIP, which began as a small pilot program in Fall 2006, has quickly grown to serve more than 350 practices with 1,400 doctors and 350,000 asthma and diabetes patients from Colorado to North Carolina.

For more about IPIP, which is sponsored in part by the Robert Wood Johnson Foundation and convened by the American Board of Medical Specialties, download a copy of its recently released program brief.

Health Reformer’s Lexicon: Patient-Centered Medical Home

The Health Reformer’s Lexicon is a regular feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit.

The term: Patient-centered medical home

The National Committee for Quality Assurance (NCQA) provides the following definition:

The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients and their personal physicians, and, when appropriate, the patient’s family.

It is a model of care that aims to provide structured, proactive and coordinated care for patients rather than episodic treatments for illnesses.

In a medical home, the primary-care doctor operates as a “home base” for patients, overseeing all aspects of patients’ health; scheduling regular tests and check-ups by tracking health records electronically; advocating for patients with specialists; and, with nurses and other personnel, helping patients navigate the medical system so they don’t fall through the cracks or neglect to care for a chronic condition such as heart disease.

Why it matters: The medical-home model promotes coordinated care—especially for patients with chronic conditions. This in turn cuts costs while improving the quality of care.

Roots: Pediatricians were first to coin the term “medical home.” Concerned that the care of children, especially kids with chronic conditions, was not being coordinated effectively between specialists and the child’s pediatrician, the American Academy of Pediatrics advanced the concept of coordinating care through one doctor in 1967.

Thirty years later, in 2007, leading primary-care doctors’ organizations—the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and American Osteopathic Association—listed requirements for a medical home in a formal statement.

Among these requirements is the idea that insurers recognize doctors’ additional work and the added value to patients for “work that falls outside of the face-to-face visit” and reward it with more compensation.

In the last few years, the American Medical Association has backed the medical-home concept; and by last year, 10 states had bills promoting medical homes.

Where the term appears: The president’s health reform proposal, like the Senate bill, sees the medical home more as an answer to shortages of primary-care doctors, nurses and others. It would spend money on training medical personnel in more efficient ways to deliver primary medical care, such as medical homes.

NCQA has established a recognition program to evaluate whether practices are operating as medical homes. Select health plans are using recognition standards like these to reward qualifying practices for improving health care quality.

Previous Lexicon entries include:
- Sustainable Growth Rate
- Accountable Care Organization
- Meaningful Use

Health Reformer’s Lexicon: Meaningful Use

The Health Reformer’s Lexicon is a regular feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit. 

The term: Meaningful use – assuring that health information technology (HIT) is used in a meaningful way to provide better patient care.

Congress earmarked billions of dollars to spur investment in “health information technology” (HIT) and electronic health records technology by health care providers, but money came with a string attached known as “meaningful use.” To qualify for these subsidies, doctors and hospitals must put the HIT they purchase to “meaningful use,” to improve the quality, efficiency, safety and coordination of care, and reduce disparities and engage patients and families in their care.

Why it matters: There is a lot of money at stake. Estimates are that between $14.1 billion and $27.3 billion in subsidies could flow to qualifying providers. These funds will help providers invest in HIT infrastructure. As results from the 21st  annual Healthcare Information and Management Systems Society leadership survey indicate,

Asked to identify their single IT priority during the next two years, 42 percent of respondents identified meeting meaningful use criteria.

But as we’ve noted previously on this blog, HIT in and of itself will not improve health care, it is how we implement and use it to engage with providers and patients that truly matters.

Roots: The Health-e Information Technology Act of 2008 was introduced as a bill “to promote the adoption and meaningful use of health information technology.” But the term “meaningful use” was put on the map by the American Recovery and Reinvestment Act of 2009, aka the “stimulus bill” under the bill’s Health Information Technology for Economic and Clinical Health Act provisions.

Where the term appears:  The usage that has mattered most of late came just two days before the end of 2009 when the Centers for Medicare & Medicare Services and the Office of the National Coordinator for Health Information Technology issued proposed rules that can be read here and here to define “meaningful use.” At 700 pages, at least one wag at Modern Healthcare deemed them "meaningful obtuse.“

CMS expects to finalize its meaningful use rule later this year.

New County Health Rankings Highlight Opportunities for Quality Improvement

Lisa Letourneau, executive director of Quality Counts, considers the implications of a new series of reports on county-by-county health variations.

No matter how healthy a community is, there is always room for improvement. For proof, just look at the County Health Rankings released recently by the Robert Wood Johnson Foundation and the University of Wisconsin’s Population Health Institute.

At first glance, the report on my home state of Maine in many ways confirms what health reformers have long understood: health follows wealth. With a few exceptions, the more affluent counties on the comparatively urbanized, southern coast of our state have better overall health profiles than the less-affluent counties in the densely wooded, rural parts of the state. For example, in Lincoln County, a coastal community in the mid-coast area, 9% of the population reports itself to be in “poor” or “fair” health. By comparison, that is a relatively low level and puts the county in the 90th percentile of results overall. But in Aroostook County, all the way at the rural north end of the state, the figure is 18%, twice the target level.

Health Reformer's Lexicon: Accountable Care Organization

The Health Reformer’s Lexicon is supposed to be a weekly feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit.  But what can I say?  Snowstorms, and other developments, all can get in the way. 

The term: Accountable care organization (ACOs)

In a recent policy brief that examines the ACO concept, Urban Institute researchers Robert Berenson, M.D., and Kelly Devers, Ph.D., provide the following definition:

 A local health care organization and a related set of providers (at a minimum, primary care physicians, specialists, and hospitals) that can be held accountable for the cost and quality of care delivered to a defined population.

Why it matters: As Berenson and Devers note,
 
Proposing a new entity with the word “accountable” in its title begs the question of who is becoming more responsible for what, when it comes to delivering high-quality and efficient health care.

Policy makers are looking at ACOs as they search for ways to deliver well-coordinated care that produces positive outcomes while also slowing the rise in health care costs.

Roots: The term ACOs emerged publicly in a 2006 Health Affairs article where a footnote traces its etymology as follows:

The idea of using the term ‘accountable care organizations’ … grew out of an exchange between Elliott Fisher and Glenn Hackbarth at a Medicare Payment Advisory Commission meeting in November 2006.” (Fisher leads the Dartmouth Atlas Project, Hackbarth is the chair of MedPAC.)

Usage: The more fully refined ACO concept appeared nearly three years later, and a similar concept –“accountable care systems”– was explored in JAMA. 

But the references that may matter most at this point are the ones found in health reform legislation.

The Senate Finance Committee’s bill would:

Allow providers organized as accountable care organizations that voluntarily meet quality thresholds to share in the cost-savings they achieve for the Medicare program. To qualify as an ACO, organizations must agree to be accountable for the overall care of their Medicare beneficiaries, have adequate participation of primary care physicians and specialists, define processes to promote evidence-based medicine, report on quality and costs measure, and coordinate care.

 

How Maine Used Its Clout to Press for Higher-Value Health Care

Bruce Siegel, director of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care, recounts how a big health care purchaser applied its considerable leverage to insist on public reports about hospital performance. This post is part of our continuing effort to shine a light on local laboratories of health care reform.

What does a heavyweight look like in the fight for high-value health care? Take a look at how the state of Maine has used its muscle as the administrator of health plans for 34,000 employees, retirees and their families. It is an especially noteworthy story since the health care reform bills before Congress include a number of provisions to encourage the use of quality measures and value-based purchasing.
 
Maine’s State Employee Health Commission, responding to a call from the state legislature to contain health care expenses, developed a new health-benefits plan in 2006. No ordinary plan, its goals included engaging employees and retirees in the health care process, improving quality of care and encouraging providers to publicly report their performance information.

The upshot has been a value-based purchasing strategy based on public reports developed by the employer-led Maine Health Management Coalition, which works closely with the Robert Wood Johnson Foundation’s Aligning Forces for Quality grantee, Quality Counts, and the state government’s quality-improvement initiative, called the Maine Quality Forum.

Teaming Up to Improve Care of Diabetes Patients in Minnesota

As Congress and the president figure out their next steps on national health care reform, we want to continue shining a light on local laboratories of reform. Here, Bruce Siegel, director of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care, writes about the effort to encourage high-performing health care providers in the Land of 10,000 Lakes.

Quality reformers have a mantra: You can’t improve what you don’t measure. But in Minnesota, the local team that the Robert Wood Johnson Foundation tapped to manage its Aligning Forces for Quality initiative, also knows you can’t lose weight by just standing on the scale. You have to act on what you learn.

The Foundation’s grantee, Minnesota Community Measurement, operates the scale. Its HealthScores project gathers performance data from Minnesota health plans as well as 300 medical clinics statewide. But it is part of a multi-pronged action team that is driving change in Minnesota by helping providers improve on their performance and then rewarding them when they do.

I'm dreaming of a white paper ...

David C. Colby, vice president of research and evaluation at the Robert Wood Johnson Foundation, shares his favorite health reform policy papers in the spirit of regifting.

While many of you might already have visions of sugar plums dancing through your heads, I (not surprisingly) have health reform on my mind.  That doesn’t mean I am not in the holiday spirit. In fact, I propose a “white elephant” holiday gift exchange here at the foundation. ‘Tis the season of regifting.  The best part of the gift exchange is how it highlights that value is truly in the eye of the beholder.  Many recycled gifts are still perfect gifts.

In that spirit, I want to regift to you some of this year’s health reform policy papers that are as good as stocking stuffers today as when they were released last February, April, June or October. I started with 12 gifts of policy analysis, but with Hanukkah wrapping up tomorrow, feel free to pick your favorite eight…

America’s Uninsured Crisis
Released in February by the Institute of Medicine (IOM), this report addresses three key questions: (1) What are the dynamics driving downward trends in health insurance coverage? (2) Is being uninsured harmful to the health of children and adults? (3) Are insured people affected by high rates of uninsurance in their communities?

Crossing Our Lines: Working Together to Reform the U.S. Health System
In June, three wise men, former Senate Majority Leaders Howard Baker, Tom Daschle and Bob Dole completed The Leaders’ Project on the State of American Health Care, a two-year consensus-building process resulting in a plan for reforming America’s health care system.  This report outlines their key recommendations.

How Do We Pay For Health Reform?
Conducted by Urban Institute researchers and released in July, this analysis reports that savings from many popular health reform ideas would finance the lion’s share of the cost of comprehensive health care reform. The authors also conclude that a combination of revenue options would provide more than enough money to fill the gap between the cost of reform and the savings resulting from it.

How Does the Quality of U.S. Health Care Compare Internationally?
This analysis from the Urban Institute, which we released in August, looks at the evidence on how quality of care in the United States compares to that in other countries and highlights the implications for health reform.

How Will the Uninsured Be Affected by Health Reform?
In this four-part series, released in August by RWJF and the Kaiser Commission on Medicaid and the Uninsured, the Urban Institute’s Lisa Dubay and Allison Cook calculate how many uninsured people could gain coverage through a health reform scenario that draws on proposals being discussed on Capitol Hill.

Bending the Curve
Released in September, this report is not about making candy canes. Compiled by the Engelberg Center for Health Care Reform at the Brookings Institution, the paper proposes that health care reform should include comprehensive efforts to achieve higher-value care. The report was co-signed by a distinguished group of scholars and policymakers: Joseph Antos, Ph.D., (American Enterprise Institute for Public Policy Research); John Bertko (Brookings Institution); Michael Chernew, Ph.D., (Harvard Medical School); David Cutler, Ph.D., (Harvard University); Dana Goldman, Ph.D., (RAND Corporation); Mark McClellan, M.D., Ph.D., (The Brookings Institution); Elizabeth McGlynn, Ph.D., (RAND Corporation); Mark Pauly, Ph.D., ( University of Pennsylvania); Leonard Schaeffer (University of Southern California); and Stephen Shortell, Ph.D., (University of California, Berkeley).

Is Massachusetts Reform Working for Doctors?
This study, published in the Oct. 21 issue of the New England Journal of Medicine, finds that 70% of practicing physicians in Massachusetts support health reform three years after its passage in 2006. We partnered with Blue Cross Blue Shield of Massachusetts Foundation to fund the research, which was designed and conducted by researchers at the Harvard School of Public Health.

Trust for America’s Health Prevention Poll
The poll, conducted for RWJF and Trust for America’s Health by Greenberg Quinlan Rosner Research and Public Opinion Strategies, indicates the majority of Americans support disease prevention investments as a part of national health reform. Poll findings were released in November.

A State Policymaker's Guide to Federal Health Reform
These three documents released by the National Academy for State Health Policy (NASHP) last month identify the most challenging health policy issues that states are addressing; describe the tools they have at their disposal and how federal health reform may affect those tools. It also describes the support they would need to implement federal health reform legislation.

County and City Health Departments: The Need for Sustainable Funding and the Potential Effect of Health Care Reform on their Operations
This report, released earlier this month by Health Management Associates, analyzes the effects that substantial funding cutbacks from local, state, and federal sources have had on already-strapped local health departments.

Leveling the Field - Ensuring Equity Through National Health Care Reform
Bruce Siegel, M.D., and Lea Nolan, M.A., from the Center for Health Care Quality, The George Washington University School of Public Health and Health Services, published this piece in the Dec 3 edition of the New England Journal of Medicine. The paper discusses how health reform legislation would reduce racial and ethnic disparities by extending coverage to disadvantaged groups.

The Cost of Failure to Enact Health Reform: Implications for States
Released at the end of September, researchers from the Urban Institute used their Health Insurance Policy Simulation Model to estimate how coverage and cost trends would change in every state between now and 2019 if the health system is not reformed.

Wishing you a happy and healthy holiday season. May all your policy papers be white!

Health reform could hurt minority groups if not done right

Bruce Siegel, director of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care, writes that equity should be an important component of health reform.

Health care reform could actually hurt minority groups unless Congress makes some fixes. Without an explicit focus on equity, reform could leave millions of these Americans behind.

The goal of the reform bills in the House and Senate is to dramatically expand access to coverage, including for minority groups, which are traditionally under-insured. But the bills also envision measuring doctors’ and hospitals’ results and paying them based on how well they perform. And while that is a laudable goal, it could also hurt minority groups if not done right. If, for instance, we start measuring and penalizing hospitals depending on how many patients need to be admitted again, hospitals could have incentives to turn away the poorest and sickest patients; who tend to also be people of color. And safety net hospitals that underperform, already overburdened and underfunded, would be further deprived of resources.

The issue looms large given that racial and ethnic minority groups will be in the majority in the U.S by 2050. They already account for half the uninsured, are poorer in health, suffer more disease and are more likely to get inferior care. There are also equity implications in the transformation taking place in provider reimbursement as the notion gains ground that we need to systematically and rigorously examine how well our doctors and hospitals perform and pay them accordingly.  Especially important, in the interest of attaining quality care for all patients, is measuring how well the system treats minority groups.

Making health care quality information easier for patients to grasp

Chris Queram, president and CEO of the Wisconsin Collaborative for Healthcare Quality, describes an "all-or-none" measure for reporting on the quality of diabetes care. This post is part of our continuing effort to shine a light on local laboratories of health care reform.

Last year alone, the number of people with diabetes in Wisconsin jumped by a quarter, to more than 400,000. The Wisconsin Collaborative for Healthcare Quality, where I work, is taking a new approach to fighting this epidemic.

Managing a chronic disease like diabetes can be tough for patients — besides taking steps to live a healthy lifestyle, there are the regular medical tests for blood sugar and cholesterol, not to mention feet exams and other important checkups.

The Collaborative, which the Robert Wood Johnson Foundation supports as part of its Aligning Forces for Quality initiative, decided to simplify matters by developing an “all-or-none” measure for diabetes. This method has been catching on as reporting on quality has become more extensive and more complicated.

Consider the Joint Commission, which accredits and certifies more than 17,000 hospitals and other health care organizations:  It measures care for acute heart-attack patients nine ways. It has five measures for pneumonia.

Measurement experts started asking whether it wouldn’t be far better to simply tell patients if a clinic or hospital meets a specific set of quality measures rather than making the patient sort through a long list of measures, some of which their doctor or clinic may meet and some of which they may not.  Hence the “all-or-none” name for this innovative and patient-centered approach.

Performance Measurement and Public Reporting Are Driving Tangible Quality Improvements in Minnesota

Jim Chase, president of MN Community Measurement, argues that results from six years of measurement and public reporting in Minnesota and other regions have boosted quality, with clear implications for national health care reform. This post is part of our continuing effort to shine a light on local laboratories of health care reform.

Last year, doctors at the HealthEast Care System in St. Paul noticed something interesting: After starting to meet monthly to focus on the dozen health care quality measures that MN Community Measurement reports publicly each year, they found they were among only a handful of Minnesota medical groups to get above-average grades on at least half the measures.

The annual measurement report “demonstrated that we could achieve better outcomes for our patients -- because others were doing it,” said Linda Walling, medical director for clinical informatics at the 14 HealthEast clinics. “Our clinicians want the best for their patients and this appealed to their competitive nature.”

Where's the magic with electronic medical records?

Mike Painter writes about health information technology and when might be the right time to assess its impact on health care quality and cost.

Last week a new article from The American Journal of Medicine entitled, “Hospital Computing and the Costs and Quality of Care:  A National Study” by Himmelstein, et al. appeared in my Twitter stream.  In fact, Brian Ahier (@ahier), whom I and about 3300 other tweeps like me follow, sent me a DM asking for thoughts.  In that article the authors sort of breathlessly conclude that current hospital computing has minimal impact on quality and no impact on cost.  Shocking.   Actually, it’s the kind of gotcha article that really grates—the kind that isn’t particularly helpful to anyone as the authors seem intent on drawing sweeping conclusions from pretty limited data. 

For starters, how can we draw any conclusions about the impact of widely adopted, meaningfully used electronic records until they’re, well, widely adopted?   As research by  Ashish Jha et al. highlighted in Chapter One of the recently released 2009 RWJF HIT Adoption report (results from that research also published in April NEJM) show that only 1.5% of hospitals have a comprehensive EHR system—and only another 8% have a so-called basic system.  I’m not sure how one can draw important conclusions about national hospital computing given such an unbelievably low national rate of adoption. 

More importantly, though, most do not think that simply adopting, even widely, a technology would ever magically on its own improve quality or lower costs.  I’m not sure why these authors seemed to say otherwise.  The point as many have noted over and over again is for health professionals to adopt and then USE (remember our year long discussion regarding meaningful use?) the technology FOR improved quality, including improved efficiency.  As I discuss extensively in Chapter Five of the 2009 HIT Adoption Report, one important use of the technology will be, for instance, automation of performance measurement and public reporting.   The automation enabled by widely adopted, meaningfully used EHRs will hopefully accelerate the creation of results oriented information—information that will facilitate payment reforms as well as improvement.  We absolutely cannot do the kind of payment reforms that the nation needs without creating measures from the automated collection and aggregation of clinical data.  Bundled payment reforms, like the Prometheus model for example, will not work without this kind of automation—and to get to that automation we need widespread adoption and meaningful use of the technology.  But the adopted technology is only an important step.

We are still nowhere near that kind of use in an environment of ubiquitous electronic records.  Given that small fact, to conclude that there is “evidence” that hospital EHRs “don’t” improve quality or lower costs seems pretty silly.  That’s like saying a stethoscope should, but shockingly doesn’t, improve the quality and cost of care just because an intern buys one and hangs it around her neck. 

The authors end their article asserting that predictions about cost and efficiency improvements from widely adopted EHRs “are premature, at best”.  To me that statement is pretty disingenuous, at best.  What’s premature is expecting magic transformation when folks are just getting the tools out of the box—and trumpeting the lack of that magic transformation as if it’s evidence.

 

Recommended reading, on top of all that other reading

There's been an interesting debate brewing about costs and efficiency in health care.  Here's the latest salvo from Jack Wennberg and Shannon Brownlee, published on the Health Affairs blog.  As Jack points out, it's not that people can really object to the Dartmouth Atlas data, per se (although some certainly do keep on trying to poke holes in the research itself), it's more that they object to what actions can possibly happen in an effort to address unwarranted variations in cost and quality of health care.  It would be interesting to keep track of all the controversies that have cropped up during this national health reform discussion and someday point out which fears came true and which ones didn't.  I guess it's impossible to try and re-shape an industry that makes up so much of our country's economy without kicking a few hornets' nests along the way.

Reform's secret weapons: quality measures and the nurses who act on them

Valerie Overton, a nurse practitioner at the Fairview Rosemount Clinic in Rosemount, MN, writes about how nurses are helping clinics improve their quality scores and saving lives along the way.

Measuring and publicizing the quality of health care in communities is crucial to reforming our dysfunctional health care system because it forces doctors and hospitals to improve the care they deliver. A recent Wall Street Journal article showed how this is happening in my state, Minnesota, thanks to the efforts of an organization called MN Community Measurement (MNCM).

Nurses are key players in the reforms unfolding here. As the article rightly noted, doctors “started letting nurses call patients back in if the physicians forgot to order tests during a visit.”  But at Minnesota’s Fairview Rosemount Clinic, where I work, we don’t wait for Twin City-area women to come to us. We write them urgent reminders to get Pap, breast and colon check-ups as well as talk face-to-face about screening. 

Those calls can save lives. Just ask Jean Shanley and Amanda Franco.

What health reform looks like in the real world, right now

Susan DeVore, the CEO of the Premier healthcare alliance, writes about the lessons health reformers can learn from its efforts to drive quality improvement and costs savings in hospitals.

A year ago, 157 hospitals in the Premier healthcare alliance set out to see if they could deliver better care to save lives, while simultaneously saving money.

As it turns out, they can. And there is a lesson from this effort for Congress as it struggles to find practical solutions to improve health care quality and control spending. Cutting costs while improving care is the holy grail of healthcare reform. If we can bend the curve of healthcare costs, we stop the system from careening toward insolvency and make coverage more affordable.

Premier, an alliance of 2,200 not for profit hospitals, created QUEST (for “Quality, Efficiency, Safety and Transparency), in partnership with the Institute for Healthcare Improvement, to find ways to holistically improve healthcare. To participate, hospitals joining the collaborative agreed to transparently share data and results with one another; adopt tough measures; and then observe and implement new ways of providing care to enhance quality.

This wasn’t some academic study. We pulled performance statistics on deaths, costs and effective care. We then figured out what is driving deaths, errors and excessive costs, devising the best ways to prevent them and setting aggressive improvement goals. After just one year, we estimate QUEST saved 8,043 lives, or 14 percent fewer deaths than expected. At the same time, hospitals also saved $577 million, or $343 per patient discharge.

Where were you?

Mike Painter, senior program officer at RWJF, writes about the latest report released by RWJF on the adoption of electronic medical records.  He contributed a chapter in the report on quality measurement and how it relates to health information technology.

I distinctly remember the first time I heard the title, “National Coordinator for Health Information Technology”.  It was 2004.  That’s, of course, the year that RAND released its important national report card highlighting the overall mediocre state of health care quality.  You know the one that told us “it’s a flip of a coin.”  I was an RWJF Health Policy Fellow working on the Hill with then Majority Leader Bill Frist’s health policy staff.  There was a flurry of staff activity regarding the president’s pending executive order pushing adoption of the electronic health record and creating a new federal health information technology, dare I say, czar. . . . But what to call this new position?  To be honest, when I initially heard folks say the words, “national coordinator for health information technology,” my first thought was, “Well, that’s a mouthful.”  My second was “It sort of sounds like a character from that TV show, ‘The Love Boat’”.  But I kept those smart remarks to myself and quite quickly got on board—and, to be honest, never looked back. 

At RWJF in 2005, several of us worked with then National Coordinator, Dr. David Brailer, on a partnership effort between the Office of the National Coordinator and RWJF.  With this project we extended a grant to Dr. David Blumenthal, then in Boston, to create a series of national reports that would track the national adoption of the electronic health record over several years as the nation progressed toward wider and wider adoption.  This week we’re issuing our third report in that series. 

Of course, the news is sobering.  This third report highlights yet again that overall adoption of the electronic record is stubbornly, almost shockingly, low in virtually all clinical settings.  This current report also highlights that without focused attention, adoption of electronic health records might make disparities even worse.  Terrific. 

Trick or Treat

This week’s Health Wonk Review is hosted by Boston Health News and features Halloween health care horror stories, including our recent post from National Committee for Quality Assurance President Margaret E. O’Kane on the state of U.S. health care quality.  For more on the good, bad and ugly of the quality of U.S. health care, you can go trick or treating here, where you can take your pick from our slide deck of statistics, facts and messages about the state of health care quality today.

Are accountable care organizations the answer to our problems?

Kelly Devers and Bob Berenson of the Urban Institute write about the latest policy brief by Urban and RWJF, which focuses on the concept of creating more accountable entities in health care.
 
In the often contentious health reform discussions, ideas that are good in theory often gain quick currency, but deserve closer examination as to whether they might actually work.  One such idea is the accountable care organization (ACOs).  Accountable care organization are entities—and we’ll clarify what we mean by “entities” in a second—that are intended to address one of the conundrums of our current health care system:  how to pay providers for high-quality, efficient care.  Under our current fee-for-service payment system, we end up paying for volume, not quality or value, that is better quality for the money we spend. In addition, many of the ways we deliver health care, especially for common chronic conditions like diabetes or heart disease, have become increasingly fragmented and cumbersome for both the provider and the patient.
 
To address these interrelated problems of provider payment and delivery, many health care leaders and experts have become increasingly interested in ACOs as a way to bend the cost curve, i.e., deliver higher-quality care to more people without contributing to our escalating health care tab.  ACOs are commonly understood to be local entities comprised of clinicians—primary care and specialty physicians, hospitals—that are responsible for delivering quality care and controlling health care costs in ways that current providers are not. 
 
However, the concept of what ACOs are and how they might work is still murky.  Therefore, in a new policy paper out today from the Urban Institute and the Robert Wood Johnson Foundation, we try to go to uncharted territory, and wrestle the ACO concept into the real world. 

What Congress Can Do To Boost Health Care Quality

Margaret E. O’Kane, president of the National Committee for Quality Assurance (NCQA), an independent, non-profit organization whose mission is to improve the quality of health care, writes about NCQA’s new report, The State of Health Care Quality 2009. You can also read an interview with O’Kane here.

Just as the health care reform process is speeding up, NCQA has found that progress on important measures of health care quality has slowed down. After 12 years of steady and often remarkable progress in performance, the report we released today documented relatively little improvement in most areas of care during the past year by the nation’s health plans. These findings underscore why provisions to improve quality must be part of any health reform package.

Because reform will most certainly bring more individuals into Medicare and Medicaid programs, it was especially disconcerting to see that for the third year in a row, we found that performance of health plans serving these public programs failed to improve on key quality measures. In fact, Medicare Advantage plans made statistically significant improvements on only five of 36 measures (14 percent). The results for Medicaid plans were somewhat better, but still there was a statistically significant gain on only 18 of 50 measures (36 percent), and most of these were small. Results in the commercial plan sector were slightly better, with improvement on 22 of 51 measures (43 percent).

What Massachusetts docs think about health reform

Gillian K. SteelFisher, a research scientist at the Harvard School of Public Health, writes about a recent poll she and her colleagues conducted with physicians on health reform in Massachusetts, highlighted today in the New England Journal of Medicine.

With the passage of the 2006 health insurance law, Massachusetts has made significant changes in health insurance coverage and now can claim the lowest uninsured rate in the country.  As the debate on health reform in Washington, D.C. unfolds, policymakers at the national level have turned their attention to the state’s health reform; in fact many of the Congressional proposals currently on the table include elements from the Massachusetts plan.  In this process, there have been some criticisms of the reform, with suggestions, for example, that the reform has made it more difficult for people to access care.

We already know from past research that the reforms hold majority support among the public, but what about physicians who are on the front lines of care and directly see the potential impacts of that reform?
To address that question, my colleagues and I polled more than 2,000 Massachusetts physicians.  Our goal was to assess their perceptions in three areas: their overall support for the legislation, their views of its impact on their own practice, and their views of its impact on health care across the state.

Bills would boost quality by shining a light inside the health-care system

Debra Ness, co-chairman of the Consumer Purchaser Disclosure Project (CPDP) and president of the National Partnership for Women & Families, writes about provisions to improve health care quality in pending legislation.

And now there are five. With its vote this week, the Senate Finance Committee reported out the final of five reform bills that hold the potential to transform our broken health care system.

It has been a long road getting here. The National Partnership, for one, has worked for 15 years with a wide range of consumer and patient groups to shine a light on the need for improving the quality of health care, getting costs under control and expanding affordable coverage.

I’m encouraged because the Finance Committee bill builds on the momentum we’ve seen over the past several months to make some sorely needed improvements to our health care system – things that will help Jane Citizen and her family get the care they need. Chief among them are key insurance market reforms that take great strides towards protecting Americans’ health coverage — making it illegal for insurance companies to raise rates based on a pre-existing condition or gender, denying coverage based on health status, and dropping people who get sick.

The long and winding road to reform

Peter V. Lee, co-chairman of the Consumer Purchaser Disclosure Project (CPDP) and executive director for national policy of the Pacific Business Group on Health, writes about provisions to improve the quality of health care in pending reform legislation.

We’re seeing important movement on health care reform front, as the Senate Finance Committee moves its version of a bill to now be part of the debate. Whether or not we manage to get one bill that everyone can agree on, there’s no doubt that some have found the long wrangle in Congress over health reform depressing. But call me an incurable optimist—after looking at all of the different versions of the bills floating around, I’ve taken heart in the fact that while none of the bills are perfect, they all contain good provisions that could help improve the quality of health care and make care more affordable.

For instance, there is very good language in each of the three proposals – in the Senate Health, Education, Labor and Pensions Committee, Senate Finance and House "Tri-Committee" – on measuring and reporting quality. They call for setting national priorities with processes that engage consumers, employers and other stakeholders; make sure the patient’s perspective is at the center of measurement efforts; and require more information on how patients fare. The proposals also focus on comparative-effectiveness research so patients, doctors and insurance-purchasers know which treatments really works.

Following the money: doing health care better at less cost

Thomas Bodenheimer, a physician and professor at the UCSF School of Medicine, and Rachel Berry-Millett, a University of California medical student, preview an upcoming Synthesis report on care management.

As much as we all aspire to an ideal state of health, there are some people who are sicker than others in the United States.  Approximately 10% of patients consume 70% of health care expenditures.  In this group are the patients who have multiple chronic conditions, many medications, frequent hospitalizations, and limitations on their ability to perform basic daily functions. 

Health care spending for people with five or more chronic conditions is 17 times higher than for people with no chronic conditions. With the projected growth in the Medicare population in the next decade and the far higher prevalence of chronic conditions among this group, the cost of caring for this population threatens Medicare’s future viability. A real way to “bend the curve” is to improve the care and coordination of people with multiple chronic conditions.

Recent research that we conducted for the RWJF Synthesis Project showed us that this challenge may, indeed, be possible to address.  We preview the research in a new NEJM perspective, and our full Synthesis report will be available in a few months. 

The possibilities of aligned interests on health care

Margaret Stanley, former executive director of the Puget Sound Health Alliance, writes about the value of bringing diverse stakeholders into local alliances to reform health care.

As national leaders have learned again and again, assembling a fractious group of doctors, hospitals, insurers, businesses, patients and public officials around something as complex and divisive as overhauling health care isn’t easy.

But nowadays, as reasonable, well-intentioned people try to reach agreement on health reform in the midst of the ranting and clouds of misinformation, reaching consensus is especially important, because everyone’s got a role to play in making our health care better. 

From what I can tell, it may be easier to achieve true consensus around health care reform at the local level.  That’s why much of my hope for a real health care overhaul rests on the power of local organizations, like the one I headed for three years, the Puget Sound Health Alliance.  In a few years, we were able to forge partnerships across stakeholder lines to improve the quality and efficiency of health care across the Greater Seattle region. 

For health reform to work for all Americans...

Bruce Siegel, director of the Robert Wood Johnson Foundation’s (RWJF) Aligning Forces for Quality (AF4Q) initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care (Expecting Success), writes about collecting race, ethnicity and language data.

In the medical profession, we diagnose problems before we attempt to treat them.  It shouldn’t be any different when we try to fix our health care system.

As Congress focuses on expanding health coverage and reducing cost and waste in the health care system, an important question is: how will we make health care not only more efficient, but better for patients and families from all racial and ethnic backgrounds? 

It starts with working with the best possible data. We need to know who’s  not receiving high quality care so we can target our efforts. Reams of research have shown that racial and ethnic disparities persist despite efforts to reduce them. To address these gaps in care, hospitals, medical practices and health plan members  need precise and standardized data on patients’ race, ethnicity and primary language. 

Reducing disparities and enhancing data collection have been discussed in many of the health reform proposals in Congress. If included in the final legislation and as health care systems continue to work to close the gap, guidance and best practices on how to do this will be needed.

The Office of Management and Budget (OMB) has a standard set of race and Hispanic ethnicity categories that are widely used (race categories: Black or African American, White, Asian, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Is¬lander;  ethnicity categories: yes or no in reference to Hispanic/Latino ethnicity), but that is not enough.

A recent report by the Institute of Medicine (IOM) recommends that health care organizations continue to use the OMB categories and add more detailed ethnicity categories (known as granular ethnicity and based on a patient’s ancestry), which will help organizations better identify disparities and move away from broad categorizations of people. For example, in very diverse communities such as Miami, “black” can mean a lot of things and include many cultures, making more specific categories such as Haitian or Bahamian useful. The IOM also recommends using categories to assess language needs (ratings of spoken English language pro¬ficiency and a patient’s preferred language for health-related encoun¬ters).  Understanding a patient’s language needs will increase the ability to communicate in medical settings, which is critical to providing and receiving high-quality care. The report suggests that organizations list location-relevant categories and provide a space for patients to self-identify their ethnicity or language if it is not listed.

With better information, health care organizations can better understand the populations they serve, detect disparities in care, design actual solutions to improve care and evaluate progress. Through our work with two RWJF programs, Expecting Success and Speaking Together: National Language Services Network (Speaking Together), we have done just that. We have found that more detailed data enables us to better develop targeted quality improvement interventions for more specific populations.

As part of the Expecting Success program, we worked with 10 hospitals to develop and share tools for improving cardiac care for African-American and Hispanic patients with acute myocardial infarction or congestive heart failure. Hospital leaders want to believe that their hospitals provide equal care regardless of a patient’s race, ethnicity or primary language, but few know for sure. Without uniform standards for collecting this information, there is no way of knowing if all patients receive the same level of care.

The Expecting Success hospitals established standardized collection of patient race, ethnicity and language data. For the first time ever, the hospitals analyzed 23 cardiac care quality indicators by patient race, ethnicity and language. Although some had to face the reality that there were disparities in care in their hospitals, they were better equipped to address these gaps.

Several questions arose as the hospitals analyzed their race, ethnicity and language data such as “Why are some Hispanic patients consistently not receiving all discharge instructions?” and “Why are readmission rates so much higher for minority patients?”. These questions prompted the hospitals to design interventions to specifically address these issues. As they developed these and other programs, they were able to compare data on core measures before and after implementation to help assess their efficacy and adapt their approach as needed.

In Speaking Together, an initiative modeled after the Expecting Success program, we worked with 10 hospitals to improve the quality and availability of language services. For many patients whose first language is not English, language services are integral to getting the right care at the right time. An organization’s ability to provide appropriate language services depends on its ability to accurately screen for language needs of its patients and to identify patients’ preferred language for health care encounters—data collection is  fundamental. Without this information, we are trying to diagnose and treat a problem with a limited exchange of information.

At the beginning of Speaking Together, several hospitals were collecting language data, but there was room for improvement. To increase screening for patient language needs, hospitals used a combination of efforts, including using data to open a discussion with the leaders of registration and scheduling; training staff on screening for language needs; programming reminders in the registration and scheduling screens to prompt staff to complete the language field; using scripts for language screening; and integrating demographic information with other electronic systems in the organization. At one hospital, screening rates went from 60 percent to more than 80 percent. At another hospital, screening rates improved from approximately half of patients screened to nearly all patients screened. The data collected through these screening efforts enabled the hospitals to more accurately identify which languages were spoken by their patients, improve their overall language services and deliver safer, higher quality care.

In both of these projects, the ability to reduce disparities began with the knowledge that we gained through data collection. As we work to reform our health system to improve care for all, we need to ensure that our health care organizations are actively collecting information on our patients’ race, Hispanic and granular ethnicity, and language needs. We know the symptoms of poor-quality, unequal care, but to truly diagnose it and treat it, we need the data.

The high cost of health care: getting past denial

      

Jonathan S. Skinner, Elliott S. Fisher, and Jonathan Sutherland of the Dartmouth Atlas Project at the Dartmouth Institute for Health Policy and Clinical Practice at Dartmouth College write about the opportunities to pay for health care reform by reducing unnecessary spending.

The President’s recent speech called on Congress to move forward with much needed health care reform.  He wisely argued that reducing the waste in our current health care system can help provide the savings needed to cover the costs of expanding coverage to the uninsured.  This might appear to be obvious – many studies (including this one from the Commonwealth Fund) have shown the U.S. spends twice as much as other countries on health care, yet often lags behind in quality.  Furthermore, a number of studies from the Dartmouth Atlas group (here and here) have pointed to the dramatic differences in both levels of health care spending -- $16,351 per Medicare beneficiary during 2006 in Miami, compared to $6,604 in Richmond Virginia – and the apparent lack of better outcomes in these higher cost regions.

But not everyone is convinced.  One recent critic today even claimed that all regional variations in spending can be justified by medical need and poverty: The reason why Medicare spends so much more for patients in Newark, N.J. than it does for patients at the Mayo Clinic in Minnesota is because people in Newark are poorer and sicker.   In a recent article published online in the New England Journal of Medicine, we test this hypothesis rigorously using a large nationally representative sample of more than 15,000 Medicare enrollees.  By using individual data reporting income, health status, price-adjusted Medicare expenditures (to account for the fact that cost-of-living in New York is greater than in Oklahoma City), and other factors, we sought to gain the most accurate picture of what explains regional variations in spending – and more importantly, what doesn’t.

What a myth is not

More commentary on recent news and a round-up of recent posts is forthcoming, but in the meantime, Elizabeth McGlynn, associate director at RAND Health, responds to an op-ed about health reform that appeared in the Wall Street Journal on August 31.   

As a researcher, it is my practice to bring the relevant facts to any policy discussion.  My work is specifically designed to provide evidence that can inform policy decisions. One highlight of my career was leading a team of researchers in a set of RAND Corporation studies where we examined the quality of care that Americans receive, concluding that American adults receive 55 percent of recommended medical care. 

Our research results -- especially that 55 percent finding -- have been quoted extensively by leaders and experts who are seeking to improve the way the nation pays for and delivers health care. What we found in this series of studies points to one of the things we need to change about American health care: we need to do a better job making sure people get the care they need. 

In a recent op-ed published in the Wall Street Journal, Jerome Groopman and Pamela Hartzband characterized the 55 percent finding as one “myth” in the current health reform debate. Their comment suggests our finding was something conjured up from someone’s imagination.  Far from it! The study was conducted at one of the nation’s leading research organizations, supported by the well-regarded Robert Wood Johnson Foundation, and vetted through the peer and editorial review process at the New England Journal of Medicine. Hardly the process used to manufacture myths.
 
Groopman and Hartzband dismiss the finding as a myth because of certain “flaws” in the study. I would be the first to admit that, as with any study, ours was not perfect. But our study was a significant undertaking that used the best and most-extensive methods ever assembled to examine the quality of medical care delivered in the United States. We addressed all of the issues they raise about potential shortcomings when we first published the results of the study in 2003. For example, Groopman and Hartzband criticize the study because we didn’t get medical records from everyone and in some cases we didn’t get records from all of the doctors who saw some of our study participants.  However, they chose to ignore the careful testing we did to see whether fixing either of these limitations would have changed our findings significantly. We found that the results would have been the same. They point out that while the medical records in our study showed patients received flu shots just 15 percent of the time, patients in our study reported they got flu shots 85 percent of the time. However, they failed to acknowledge that we used the 85 percent number when arriving at our overall results.  And again, our conclusions and findings were subjected to the tests of our peers and others who ultimately agreed that our methods were sound. 

It appears that the main point of the op-ed is to argue that any health reform legislation will necessarily prevent doctors and patients from talking about who should get what health services.  It seems to me that most people hope that we can find a way to improve the care Americans receive, eliminate unnecessary or wasteful care, and at the same time, do a better job of delivering the care that Americans really need. With that in mind, I find it all the more frustrating that the Groopman and Hartzband opinion piece uses misinformation and misinterpretation to confuse the debate about health reform. This is exactly what the doctor should not order. 

Regulations and health care reform: the devil's in the details

Peter V. Lee, co-chairman of the Consumer Purchaser Disclosure Project (CPDP) and executive director for national policy of the Pacific Business Group on Health, writes about how current efforts to regulate physician reimbursement for Medicare shed light on the importance of the regulatory process that would follow any health reform legislation.

Organizations interested in promoting better, more affordable and accessible health care are not only weighing on the national reform debate – last week, many of these organizations weighed in as a group on regulatory proposals to change how the Centers for Medicare and Medicaid Services (CMS) reimburses doctors.  

“Many of the proposed changes represent steps in the right direction,” the group said in a letter to acting centers Administrator Charlene Frizzera, “but they are incremental and marginal improvements where bold changes are required.”

Don't walk away from reform

Chris Jennings and Mark McClellan, Co-Directors of the Leaders' Project on the State of American Health Care, discuss the importance of bipartisanship around health reform and the feasibility of a bipartisan solution as Congress returns from summer recess.

Tonight, the Robert Wood Johnson Foundation will honor Senators Baker, Daschle and Dole for their work with the Bipartisan Policy Center on the Leader’s Project on the State of American Health Care.  We were pleased to support the Leaders in this important effort, and it has reminded us that what unites us as a nation is far greater than what separates us. 

Yes, the thermometer wasn’t the only thing heating up this past August as members of Congress returned to their districts for recess.  Democracy is often loud and sometimes messy, but we are proud to live in a nation where everyone gets a voice and so many people use it on critical issues like health reform.