Category Archives: Healthcare

Microcapitation: Prometheus Catches Fire

Prometheus (prə-mē’thē-əs) n.

  1. A Titan who stole fire from Olympus and gave it to humankind, for which Zeus chained him to a rock and sent an eagle to eat his liver, which grew back daily.
  2. A personification of the unconquerable will opposing greater power, forever chained and suffering but confident of the ultimate triumph of his cause.

The second health financing innovation with relevance to the Healthcare XPRIZE was highlighted in the most recent New England Journal of Medicine article. The Prometheus Payment Model has been a longstanding project of Francoise De Brantes (of Bridges to Excellence fame) and folks like Doug Emery who have been beating the “episodes of care based” financing for years. I have had some great conversations with Francois and Doug over the years and I am pleased to see their ideas actually being implemented in some pilots sponsored by the Robert Woods Johnson Foundation.

Prometheus is a payment concept based on clearly defined episodes of care  wherein all the services provided can be bundled together in discrete “Care Packages” (not everything fits neatly into this construct as they note). These Care Packages are then assigned a global budget from which all care providers must deliver their services (technical term is Evidence Informed Case Rate). The Care Packages are further adjusted for patient severity as well as for Avoidable Patient Complications (APC). These are things like hospital acquired infections, exacerbation of chronic conditions, or other events that if optimally managed would not have occurred.  This payment model rewards providers for organizing along the entire episode of care. It clearly is a move away from independent, discrete payments for disconnected care to a new model of continuous view of all the events that make up the episode. The global budget for a clearly defineable event creates financial incentives toward high performance and quality outcomes.

I was the first to call this new payment model “Microcapitation“, and describe further in another post. The NEJM article is a good read, and highlights many of the talking points that I strongly believe in:

  • Rewards for value not volume
  • Rewards for quality not quantity
  • Rewards for the organization and coordination of care
  • Provides a financial integration mechanism for non-integrated providers to work together
  • Provides financial incentives to reward the above
  • Leaves plenty of room for innovation and improvements underneath the global budget.

I  hope to see the Prometheus model gain additional traction. A variation of this concept and much simpler to follow is the highly successful “Proven Care” model employed by Geisinger (see their excellent website describing the development process and the elements of their Angioplasty episode of care). I am encouraged to see these begin to flourish as part of the ongoing efforts of health care innovators.

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The Myth of Prevention and EHR’s?

Prevention (prĭ-vĕn ‘shən) n.

  1. Preventing or slowing the course of an illness or disease
  2. Intended or used to prevent or hinder; acting as an obstacle
  3. Carried out to deter expected aggression by hostile forces.

I was just referred this article which I found to be thoughtfully crafted. Abraham Verghese is a Professor and Senior Associate Chair for the Theory and Practice of Medicine at Stanford University. I found the article interesting, by somewhat anachronistic in terms of his perception of prevention and electronic medical records.

First, he raises an important point about the many overstatements as they relate to prevention. When we talk about how effective screening programs could be in identifying people for early interventions we have to realize what we are saying and what tools we are using for identification. Some tools can be too blunt, and not find the people we are looking for (false negatives), while other tools can be too sensitive and capture too many who actually may not have the disease (false positives). This is brought home in the example Dr. Verghese uses around the pitfalls of new diagnostic imaging equipment (and the situation is much worse with genetic testing at this point in time!). With these newer, more sensitive imaging studies you can pick up calcium deposits in a health individual can lead you down a pretty wild (and expensive) goose chase for someone who is completely asymptomatic. He also demonstrates that the “value” of some prevention recommendations as somewhat questionable  – meaning – that while taking cholesterol lowering drugs has clearly shown to be efficacy reducing cholesterol levels and cardiac risk, is it really worth $150K/additional life year extended?

Well, that depends on if it is your life I assume. My point being, that you need additional information to be able to make these difficult, complex decisions. You need to not only know the relative efficacy of the regimen, but also the cost of the regimen to truly get at the “value” of the intervention. In addition, patients have modifiers to which they will place on the intervention in terms of cost in time, pain, and other inconveniences that are unique to their own values. This is where shared medical decision making can have such an impact – lay out the good, the bad, and the ugly and allow the patient to make a decision based on all the available evidence according to their own value system.

I don’t think these types of decisions can be made with the type of information we have today within the current clinical infrastructure. First, the physician gets paid to order the test and not talk to you about whether or not pros and cons of whether you should get it. Furthermore, the doctor has very little to no data upon which to inform that conversations anyway. In the relatively rare areas in which we have evidence, we might not have other components required for decision making in terms of cost and experience of patients undergoing regimen. In the case of prevention items mentioned above, we might choose not to go on statins at $150K per year but instead invest $10,000 in a personal trainer who is going to get rid of the root problem anyway. Without the underlying information, this would never even surface as part of the decision making process. We absolutely must be gathering, comparing, and sharing result outcomes in order to increase our capacity as healers who use the right treatments for the right patients at the right time and in the right way.

Which leads me to my final point – you absolutely need EMR’s to function as an 21st century physician knowledge worker. We are purveyros, translators, and mediators of medical information for our patients. They can get most of it on their own now, but we can still add significant value through our interpretation, personal experience, and ability to process the myriad data points with our clinical acumen (the sum total of our diagnostic prowess which comes from experience, practice, expertise, and intuition). The EMR can be a very effective tool to help us gather, process, and present this information in a way that is meaningful and useful to our patients (actually most EHR’s don’t do this natively today, but with little effort a physician can lift the required information and present it in a format that is highly useful [alling all designers – get into health care!]). Furthermore, I truly dislike the characterization that the EHR makes the relationship cold and sterile.  I believe the current  generation of physicians, who have all grown up with the internet, see the EHR as an indispensible tool that helps them be more effective, efficient, and caring for their patients.

My sense is that I am more optimistic that we will get there with prevention, and that EHR’s will play a vital role to give us the clinical feedback to know whether our treatments (or prevention) efforts are having the impact that we hoped. Furthermore, I am hopeful, that efforts like the X PRIZE and others will help drive us to associate those outcomes with the total costs required to help us acheive the results so we can begin to understand the true value of the intervention. It is in this setting of data liquidity and information transparency, that they myth dissipates into a new reality of next generation medicine.

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Transcript to Transformation: Twitterview with @Berci

Twitterview (twĭt’ər vyū) n.

  1. A twitterview is a combination of the terms Twitter and interview.
  2. The Twitter medium of 140 characters forces a concise style of interviewing and response.
  3. The public can join in on the conversation and become participants themselves by following along or tracking hashtags.

On March 26, 2009 the leading health care bloggers (see list below) throughout the blogosphere participate din a Blog Rally to raise awareness for public participation in the Healthcare X PRIZE design. Bertlan Mesko, leading Medicine 2.0 Advocate and author of the popular Science Roll blog, also conducted a “Twitterview” in support of the effort.

Berci: Can we start the twitterview now? I’d have 10 short questions, you may have 10 short answers. So everyone can enjoy it.

HealthXPRIZE: Thanks for taking the time. We appreciate your help in getting the word out. This Twitterview will complement the Blog Rally. Ready!

Berci: Great! First, what is the X PRIZE Foundation? What is the X PRIZE model?

HealthXPRIZE: The X PRIZE Foundation is a non profit organization that conceives and operates large incentivized prizes that lead to revolutionary breakthroughs. The X PRIZE model is based on leveraging a large purse, with a clear set of rules, that allows innovators to break through barriers.

Berci: Please tell us more about Healthcare X PRIZE!

HealthXPRIZE: The Healthcare X PRIZE is intended to be a competition to redefine health and demonstrate how new models of care can dramatically increase health value. We chose to focus on health value as opposed to a new wonder drug or device as our sponsor (WellPoint and WellPoint Foundation) & advisors were most interested in a systems prize. Systems prizes are much more difficult to conceive and operationalize than technical competitions like going to space or even replicating the genome rapidly. We are expecting that teams will need to innovate around health finance, care delivery, and individual incentives to increase health value. We are currently developing a clear set of rules, which provide the parameters of competition, as we believe that “creativity loves constraints”.

Berci: Reforming the US healthcare system is quite a brave mission, isn’t it? Why the focus on health value?

HealthXPRIZE: The US Health reform gets serious this summer and the HXP is well timed to actually demonstrate and prove in practice the principles of reform. Value is powerful organizing principle for reform efforts – we cannot just reduce costs, nor can we just attempt to improve quality without financial accountability. The focus on health value highlights the need to focus on both sides of the equation. Since Value =outcomes/cost, we are challenging teams to improve both simultaneously.

Berci: Why use an incentivized competition?

HealthXPRIZE: Incentivized competitions are very efficient, highly leveraged, and create an “X” factor within the competitive framework. Sponsors only pay the winner, a $10MM purse typical spurs >$100MM of investment, and the X factor creates global media attention to a key problem, inspire hero’s, encourage non-traditional thinking, and creates a powerful incentive for innovation.

Berci: And how can you properly measure health value? I guess you need pre-defined parameters. What are these?

HealthXPRIZE: Health Value has never really been measured within the US Health Care system. There are many efforts underway right now to properly define and measure health value. Many innovators are leading the way and we are attempt to build on their work or actively collaborate with new/ongoing initiatives (Dartmouth, IHI, AHRQ, etc) to solidify the health value measurement framework. In the context of competition, we are trying to make our measurement framework as concrete as possible by focusing on outcomes (mortality, specific morbidity, ED visits, hospitalizations, sick days etc.). Effectively communicating the notion of “health value” remains a challenge; we are considering focusing on aspects of health value (like decreased hospitalizations and sick days) as a more effective way to communicate to the public the hoped for prize breakthroughs.

Berci: How are the Teams and Test Communities Selected?

HealthXPRIZE: Teams will be selected by through a series of concept design and testing evaluations. They will be required to demonstrate or model the impact of their proposed interventions against test database provided by WellPoint. Independent judges will evaluate the merit/validity of the concept in order to advance. Communities will be selected based on specific criteria that are still being worked through. Intent is to have a defined population of 10K participants from which Teams will voluntarily enroll in the intervention. Test community will be matched against a geographically adjacent control group. Both the team and community selection requires further design, detailed analysis, and expert opinion which we are soliciting at this time through our network of national measurement experts.

Berci: When does this competition start and when will it end?

HealthXPRIZE: The “competition” has several phases: Design, Selection, Competition. We are currently in Design phase through our anticipated Launch later this fall. The Design phase includes soliciting public comment on how we can improve our initial concept/construct to create the most viable competition possible. After official “Launch”, we will begin recruiting teams to compete. Teams will then be narrowed as described above through late Spring 2011 when 5 finalist selected. After a brief integration period into test community, HXP competition is planned to officially begin in January 2012.

Berci: How does this shift the paradigm? What kind of outcome do you expect?

HealthXPRIZE: Great question – we believe the current paradigm is based on volume not value, on process not results, and incents the wrong behaviors while delivering bad outcomes. We want to shift the paradigm to rewarding the reduction of hospitalization / sick days and begin to pay for overall health improvement (this is the outcome we want!). We also want to not focus solely on disease care, and aren’t interested in just improving health care; but believe that we must move to an entirely new notion of engaged, activated health called “Vitality”. We want to demonstrate that this CAN be done at scale, with new entrants / new ideas, and want to set the HXP up as a framework from which these efforts can be tackled in the real world. By focusing on outcomes, instead of regimenting care processes or dictating care delivery, let providers/patients innovate and create rewards for those who obtain the best outcomes.

We believe incentivized competitions are a great vehicle from which we can accelerate change, shift the paradigm, and be a catalyst for the transformation that is required for the US healthcare system. We hope the outcome is a new way to think about health, measure health value, and demonstration of new models of care that demonstrate how to improve community health and individual vitality.

Berci: My last question, regarding X-PRIZE – first rockets, then genomics, now healthcare. What do you think? What’s next?

HealthXPRIZE: XPRIZE is a mission driven organization seeking to inspire the very best in human kind for the benefit of all – this isn’t just a nice quote. It is inherent in the DNA of the organization. We are attempting to be the catalyst in any “stuck” industry by creating incentivized competitions that can lead to radical breakthroughs to the grand challenges of humanity. HXP is now looking at education, energy (some really cool stuff), and developing world initiatives that can truly have major impacts. Fortunately for me, HXP is our focus for launch this year. It is quite challenging work, deals with multiple hard to think through issues, but includes the privilege to work with great people and teams including our sponsor WellPoint.

I have been thrilled with the level of commitment to this process and this prize development process has been tremendous experience. They have a very talented innovation team, led by Chad Pomeroy, who is fully supported by senior executives all the way up to Chief Executive Officer Angela Braly. They have been driving this initiative forward far beyond the $10MM prize purse; they are providing operational resources, sharing data, working to create appropriate test communities, altering business practices to accommodate the prize, and are committed to transparency as part of the HXP process. Their commitment to the project is the reason I became involved as I saw an unprecedented opportunity to really implement the innovation in an idealized but competitive test environment. We appreciate WellPoints leadership, foresight,and commitment to engage X PRIZE in developing the Healthcare X Prize for benefit of all. Very cool stuff.

Berci: Thank you very much for the interesting answers! I will publish the transcript on Scienceroll.com in a few minutes.

HealthXPRIZE: Berci, again, thank you for this twitterivew. We hope to have everyone visit our website, download the initial prize design, comment on our blog, and add their input to the Prize Design process.

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Filed under Health Finance, Healthcare, Industry, Innovation, Leadership, Quality, Rational Choice, Transparency, Uncategorized

The Geisinger Experience: Realizing The Health Value Vision

Realization (ə-lĭ-zā’shən)

  1. The act of realizing or the condition of being realized.
  2. The result of realizing.

Today, I am meeting with the X PRIZE Foundation at our 2nd Health Advisor Summit meeting in Washington, DC. We have gathered a small subset of health care thought leaders, innovators, providers, payors, patients, and employer groups to discuss the design of an incentivized competition for our health care system. It has been and continues to be fascinating work.

I have been privileged to talk to some of the luminaries within the health care field, individuals that I have read about for years (Weinstein, Nussbaum, Schwartz, Pardes, etc), but now have the privilege to interact with on a near daily basis.  One of those, Dr. Glenn Steele from Geisinger Health, has been particularly enjoyable to work with. I have been impressed with the incredible work they have done at Geisinger, not just their outcomes, but their thought process and the leadership behind making the required changes to achieve the results they have.   Glenn has actively participated in the X PRIZE design, and I have been impressed with his insight, his approach to problem solving, and what his team has accomplished to date.

They are the rubber hitting the road for the value driven health movement. Dr. Steele recently presented to Congress, and the entire body of his comments are included below because they are that good . . . and provide some insight into some of the transformative new deliver and new payment models that the X PRIZE hopes to catalyze. It is a bit long, but well worth your time (highlights are mine). For those who need to go right to the punchline, here it is:

The money quote: “We have improved outcomes and have reduced costs. This is because we have systematically researched how best to deliver care, hardwired the process steps into our electronic health record to prompt us on what best practices are, decreased unjustified variation, and taken financial risk to decrease related complications.”

Healthcare Reform – Changing Reimbursement That Reflects Value

April 1, 2009

Chairman Rangel, Ranking Member Camp, and members of the Committee,

Thank you for the invitation to testify at your hearing on healthcare reform and national system changes that can support quality and value in healthcare delivery. At Geisinger Health System, we serve a population that is poorer, older and sicker than the national averages. Most of our patients have multiple chronic diseases, such as diabetes, high blood pressure and lung disease. Our patients have difficulty navigating through a complex healthcare system. They need help and we have made a concerted effort to put into place electronic and other innovative methods that will provide them with the assistance to maximize their ability to get care.

At Geisinger, we hold ourselves to high standards of assuring quality outcomes in serving these patients. For example, if a patient is readmitted to a hospital after a procedure or an in-patient stay, we believe we have failed that patient. Consequently, we have committed significant resources and have worked aggressively to bring value to healthcare and eliminate failures by redesigning how we provide care. The innovations we have instituted at Geisinger that bundle payments for acute care procedures, enhance support for primary care physicians and their care teams, better manage chronic disease and the transitions of care for patients from caregiver to caregiver, have produced significant cost savings and improved quality. Admissions for our patients with multiple chronic diseases have been reduced by as much as 50% in community sites. I believe that what we have accomplished can be adopted nationally and will achieve similar cost savings while improving quality. This would result in significant positive consequences for large payors, particularly Medicare.

Background

I am Glenn Steele, the President of the Geisinger Health System, an integrated healthcare organization located in central and northeast Pennsylvania. Before coming to Geisinger, I spent 20 years as a practicing cancer surgeon at several Harvard hospitals and served as a Chairman of the Department of Surgery at the New England Deaconess Hospital. I then became Vice President for Medical Affairs and Dean of the Division of Biological Sciences and the Pritzker School of Medicine at the University of Chicago. Consequently, I have firsthand experience with patients, their access (or lack of) to care, issues that affect physicians and other caregivers in providing adequate and timely care, and the difficulties in juggling medical education and research, while facing ongoing changes in healthcare reimbursement.

In 2001, I came to central Pennsylvania because Geisinger offered the potential as an integrated healthcare system of developing cutting-edge approaches to increasing efficiency, value, and quality in healthcare. In short, we could attempt to transform healthcare using both our healthcare insurance product, and our clinical delivery system working together to benefit our patients. We serve a population of 2.6 million located in central and northeastern Pennsylvania. And we have an electronic health record (EHR) that was implemented 14 years ago with now more than 3 million individual patient records. Geisinger has been named as “Most Wired” by Healthcare’s Most Wired magazine six times.

We have our own health care insurance product – Geisinger Health Plan – that has nearly 235,000 members, 35,000 Medicare beneficiaries, 18,000 empanelled physicians, 90 hospitals (not including our Geisinger hospitals) and spans 43 of Pennsylvania’s 67 counties. We also lead our area’s regional electronic health information sharing platform1, called the Keystone Health Information Exchange, with (currently) ten hospitals and approximately 700 private practices sharing valuable medical information. This secure, patient-approved sharing of information means that our doctors, and more than 1,500 non-Geisinger caregivers can access patient information 24/7 from anywhere – a remote two-doctor primary care office, a multispecialty clinic, an operating room, or at 3:00 am from home.

Our patients access their own electronic health record. They can see their lab results, radiology results, request prescription refills, and email their doctors, nurses, and staff with questions anytime. And, they schedule their own appointments on-line. Geisinger has a large number of elderly patients (many greater than 80 or 90 and more and more now exceeding 100 years of age). Most have multiple chronic diseases and have family living outside of our area who follow their parents’ care through the electronic record (with appropriate patient approval). Geisinger employs about 800 physicians who see patients in more than 50 clinical practice sites; 38 of which are primary care sites in local communities. As clinically appropriate, physicians in these clinical sites admit their patients to nearly 20 local community hospitals – ensuring that patients receive most of their care near where they live. Only if necessary, are Geisinger patients treated at one of our three specialty hospitals.

Geisinger’s innovation2  is intended to attack fundamental flaws in our country’s payment for and delivery of healthcare. The U.S. suffers from a variety of reimbursement and care delivery issues that do not produce good clinical outcome. There is wide and unjustified variation in care. Fragmentation of care is rampant; our “hand-offs’ (that is, transferring important medical and family information as patients are moved from one environment to another) are disjointed and most often result in patient care that is not coordinated and is confusing to the patient. We have a perverse method of payment – one that rewards units of work regardless of patient outcome.

At Geisinger, we invest in quality and pay accordingly. Doctors who have better clinical outcomes are rewarded (financially and by recognition) and we constantly measure our outcomes against our peers, both within Geisinger and nationally. Physician, staff and site incentives are built into our system. And we reward quality and value, not just numbers of patients seen or numbers of procedures performed.

GEISINGER’S ACUTE EPISODIC CARE PROGRAM (THE “WARRANTY”) 1, 2 ProvenCare®

A great paradox in U.S. healthcare is that we get paid for making more mistakes. For example (with few exceptions), if a patient develops a post-operative complication that might have been avoided by proper care, we often receive more reimbursement for that case than for a comparable case without a complication. This does not happen in other industries. Why are healthcare services an exception? Consequently we believe our care design should be based on best evidence. In 2006, we started tackling the perverse payment incentives noted above by redesigning how we provide elective cardiac surgical care – what is known as coronary artery bypass grafts (or CABG)3. CABG is an episodic acute event – an event with a determined time frame from diagnosis through rehabilitation and recovery (unlike chronic disease, which stays with you for life). Our cardiology service line reviewed the American Heart Association and the American College of Cardiology guidelines for cardiac surgery and translated these into 40 verifiable best practice steps that we could implement with each patient undergoing this surgery. We hardwired these into our electronic health record so that we would be prompted to meet each identified step – or document the specific reason for any exception. We then established a package price that included costs of the first physician visit when surgery was deemed necessary, all hospital costs for the surgery, and related care for 90-days after surgery, including cardiac rehabilitation.

We named this program “ProvenCare”, since it is based on evidence or consensus of best practices by our heart experts. Pre-operative, post-operative and rehabilitation are part of the single charge. And we take the financial responsibility for any associated complications and their treatment. While our cardiac surgery outcome was already well above the national average, (and near the top of Pennsylvania’s PHC4 data set) upon initiation of this program only 59% of patients received all 40 best practice steps. Three months into the study, 86% were receiving best care. We raised that to 100% and, with few exceptions, have kept it at that high rate. As a result of implementing this “warranty” program, our patient care was better – using comparative, standardized data from the Society of Thoracic Surgery. We had a reduction in all complications of 21%, sternal infections were down 25%, and re-admissions fell by 44%. Costs for treatment fell, too. Our average length of hospital stay decreased by half a day4.

For other high volume, hospital-based treatments, we have now considered every step in the patient’s care flow. For instance, in orthopedic surgery, why should one doctor use one set of surgical instruments and prosthetic devices and another insist on a different instrument set-up for the same procedure? That type of variation often has no medical justification, results in unnecessary costs that are passed off to third party payors (such as Medicare) and, we believe, compromises patient outcome. We have expanded our experience with heart surgery to “warranty” programs that include:

  • hip replacement
  • cataract surgery
  • obesity surgery
  • prenatal care for babies and mothers (supported by the March of Dimes) – from an infant’s conception to birth
  • centrally- managed, evidence-based use of high cost biologicals, such as EPO (erythropoietin)
  • heart catheterization

We have improved outcomes and have reduced costs. This is because we have systematically researched how best to deliver care, hardwired the process steps into our electronic health record to prompt us on what best practices are, decreased unjustified variation, and taken financial risk to decrease related complications.

ProvenCare – Chronic Disease

In reforming how we deliver care at Geisinger, it isn’t enough to simply address acute episodic care. The major challenge of healthcare in the U.S. is now chronic disease treatment and “secondary prevention”. We identified the most common chronic diseases – diabetes, coronary artery disease, congestive heart failure, kidney disease – and have applied evidence or consensus-based best practice thought to limit disease progression. Called “bundled” care, we have designed each of these steps into our care pathways and strive to achieve as close to 100% adoption as medically appropriate and feasible. In the case of diabetes, we began to track how we performed in meeting 100% of the expected “bundle” of best care for diabetic patients three years ago. Our primary caregivers have chosen to receive compensation based on how many of their 25,000 diabetic patients reach optimal levels in the practice “bundle”, not solely on how many patients are seen each day or how many tests are ordered.

ProvenHealth Navigator (Advanced Medical Home) 3, 4

Geisinger’s patient-centered medical home initiative (called ProvenHealth Navigator) combines traditional medical home models with patient engagement and is designed to deliver value by improving patient care coordination throughout the system. Our Advanced Medical Home currently covers 30,000 Medicare recipients and 3,000 commercial patients, with plans to expand this base. We understand that navigating through the complexities of any healthcare system is not easy, so we have invested in programs and staff to help support each patient’s journey, placing dedicated nurses in each targeted outpatient clinic. Over 200 Geisinger primary care physicians diagnose and treat their patients locally in 38 community practice sites. Our “embedded” nurses are paid for by the Health Plan, becoming critical members of the community practice team and, with the physicians, are expected to know the patients and their families, to follow all of their care, help them get access to specialists and social services as necessary, follow them when they are admitted to a hospital, contact or see them when they are sent home to confirm that they are taking the appropriate medication dosages, and be available for advice 24 hours a day.

Importantly, we don’t just ask these community-based clinicians to “try harder” or “work faster”; we use resources from our health plan to help redesign their work. And, we pay incentives for getting the job done. In our best practices, our sickest chronic disease patients’ admissions were decreased by 25%, days in the hospital decreased by 23%, and readmissions following discharge decreased by 53%. The payback for the health plan occurred within the first year. The benefit to patients and their families avoiding multiple hospital admissions was priceless! For these patients with multiple chronic diseases, transport to and from the hospital or clinic, choosing which doctor should be seen, coordinating their numerous prescriptions, getting their pills, making sure they take their pills at the right time – all of this is what our ProvenHealth Navigator work redesign accomplishes. Increased quality for the patient and their families actually lowers healthcare costs.

Summary

Building on what we have done at Geisinger, I have these recommendations for your consideration:

  • Establish a simple, understandable set of national goals, so we can hold ourselves accountable together for improving the quality and value of health and healthcare for our citizens.
  • Change reimbursement to reward positive outcomes, not units of work.
  • Pay for episodes of care, forcing all providers to work together across physician and hospital boundaries to achieve optimal outcomes.
  • Pay more for delivering high value primary care.
  • Fund innovation to create real or virtual integrated systems of care.
  • Consider capitation payments linked to quality outcome measures for prevention and chronic care services.
  • Help fund enabling information technology but insist on non-proprietary interoperability.
  • Do not pay for mistakes and do not pay for care that is of no known benefit.
  • Help hospitals and communities establish transitions of care programs to reduce unnecessary admissions and readmissions.

Thank you again for the opportunity to testify today and I look forward to your questions.

References

  1. Walker J, Carayon P, From Tasks to Processes: The Case for Changing Health Information Technology to Improve Healthcare. Health Affairs, Vol. 28, No. 2, 467-477, 2009.
  2. Paulus R, Davis K, Steele G, Continuous Innovation in Health Care: Implications of the Geisinger Experience. Health Affairs, Sept/Oct 2008. Vol. 27, No.3
  3. Casale A, Paulus R, Steele G, et al ProvenCareSM. A Provider-Driven Pay-for-Performance Program for Acute Episodic Cardiac Surgical Care, Annals of Surgery. Vol. 246, Number 4, Oct. 2007
  4. Abelson R. In Bid for Better Care, Surgery With a Warranty. The New York Times. May 17, 2007.

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Filed under Episode of Care, Health 2.0, Healthcare, Innovation, Leadership, Medical Home, Quality, Uncategorized, Value, X PRIZE

Ferrari Medicine: We don’t need more horsepower

Horsepower (hôrs’pouər) n.

    1. A unit of power in the U.S. Customary System, equal to 745.7 watts or 33,000 foot-pounds per minute.
    2. The power exerted by a horse in pulling

    I had the opportunit to present to the Managed Care Executive Group yesterday in Chandler, AZ. In a beautiful desert setting, this group of executive IT folks from regional health plans gather to share ideas that will propel them forward in the year ahead. I was the final keynote of three densely packed sessions. The other key noters did a wonderful job describing in thorough detail with graphs, charts, and well documented trends the challenges in our health care system. Given their depth of coverage, all that was left for me was to highlight as succinctly as I could was my perception of the problem with our current health care system:

    Ferrari Medicine - Overcapacity leads to Worse Outcomes

    Ferrari Medicine - Overcapacity leads to Worse Outcomes

    I call it Ferrari Medicine.  The United States is culturally geared to bigger, faster, stronger mentality that is under-girded by a pervasive me-me-me affluenza that demands the very best (as long as someone else is paying for it!) at all times regardless of the cost. The above Ferrari is an amazing machine – one of the most advanced in the world. It has incredible horsepower, finely tuned instrumentation, plush interior with the finest woods and leathers, and exquisite styling and exterior. Unfortunately, given its expense and care requirements, it is not very useful for the 98% of times that you just need to transport yourself from point A to point B. It would be unthinkable, in fact utterly absurd, to use such a masterpiece as this as a pizza deliver vehicle.

    However, for alot of what we do in health care, we just push on the gas pedal. We build in more horsepower, more features, more functionality, more procedures, more capacity, and more of everything. However, despite all the appeal of the latest and greatest, the evidence shows that all the capacity within are system actually make the care and outcomes worse! More is definitely not better, and in fact, it is often worse. This has given rise to the concept called Slow Medicine, being advanced by the wonderful folks at Dartmouth. We can often do better with less, being more thoughtful, including the patient in the decision making, and doing the simple things that allow each patient to move from point A to point B in the way and manner in which is appropriate and desired by them.

    We should begin to educate patients about the perils of too much horsepower, and instead reserve Ferrari Medicine for the health care equivalent of the Autobahn.

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    Filed under Healthcare, Irony, Quality

    Democratizing Concierge Medicine: First Look at Current Health

    Current Health (kûrənt helth) n.

    1. Membership based, comprehensive primary care practice based in San Francisco area with plans to spread branded clinics throughout the West.
    2. Millennial version of the classic vision of a trusted physician who makes house calls.

    As I have mentioned previously, I have been involved in some really cool projects recently that I believe are at the forefront of the wave of change that will soon wash over the health care industry as the “time for change” appears to be now.

    <i>Current Health - Guardians of Your Health</i>

    Current Health - Guardians of Your Health

    With that preamble, I am thrilled to introduce you to Current Health (formerly San Francisco On Call) – The Primary Care Specialists. I have had the privilege to work with Dr. Jordan Shlain, David McKie, Vy Le, and the excellent team of physicians over the last six months to help transition the practice from a house call / urgent care focus to a membership-based, comprehensive primary care “medical home” for individuals and families who value their health as an asset.

    The macroeconomic reasons for this transition at this time are well known. The American health care systems is in shambles. The United States currently spend 17% of Gross Domestic Produce on health care, a number which is anticipated to balloon to 25% over the next 15 years. Despite leading the world in terms of absolute and relative spending in the health care sector, the United States ranks ~35th in health metrics tracked by the World Health Organization. Serious questions have also been appropriately raised regarding the quality, efficiency, safety, and outcomes achieved by the US health system: 100,000 preventable deaths due to medical errors annually, approximately $700 billion spent in ineffective/unnecessary treatment, and consistent estimates of 30% waste associated with administrative inefficiencies.

    These systemic challenges are compounded by a employment-based insurance model that has continued to fray as companies have been forced to reduce their health care offerings in order to remain competitive in the new global economy. This has resulted in real wage decreases, increased numbers of uninsured individuals, spikes in medical bankruptcies, increased costs due to delayed care, and misallocation of limited health resources. These challenges have directly affected health care providers who have experienced decreases in wages, job satisfaction, and control over the way they deliver care. Primary Care physicians have been particularly hard hit, and their former role as guardians of health has been minimized, displaced, or eliminated. This has lead to current and predicted severe primary care physician shortages at the same time that primary care has been identified as a necessary pre-requisite to low cost, high quality, and best outcome health care systems. Even if this shortage began to be addressed today, it will take approximately a decade to close this primary care gap.

    Current Health is a response to the health system crisis in general and impending break down of the primary care speciality specifically. Our business focuses on elevating the nature of the patient physician relationship by creating a practice design whereby the patient, the provider, and optimal health outcomes are aligned. Current Health is a membership-based, direct-practice, comprehensive primary care delivery model. Our direct financial, administrative, and clinical relationship with the patient provides both the freedom and the flexibility to deliver optimal health care.  In its most basic form, it is a fresh perspective on the classic vision of a trusted physician who makes house calls.

    Members pay an affordable membership for access to our practice and our physicians and are rewarded with a single point of health care accountability for all aspects of care. Members are assigned a care coordinator who oversees followups and proactive health maintenance. Members are invited to participate in their care through several engagement techniques as well as access to their personal health record which serves as the medium of communication with Current Health. Given our intense focus on delivering an unrivaled customer service experience, we ensure that our Members are informed, empowered, and connected to their physicians and the practice at all times.

    Current Health plans to become a leading primary care brand that delivers on the promise of high touch service paired with unprecedented access to physicians. Our direct practice model, including centralized support of all health stores and effective use of technology, enables Current Health to democratize the concierge medicine experience for an entirely new generation of patients. Current Health creates an environment where clinical excellence, administrative efficiencies, and financial alignment can lead to best outcome care.

    We look forward to documenting our journey in the coming months in this blog and other places. There will be alot of interesting things to discuss – providing conceirge experience for the masses, fee for service model, direct practice model, patient care coordination – and I look forward to helping each of you become Current.

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    Filed under Change Agents, Consumerism, Current Health, Direct Practice, Entrepreneurship, Healthcare, Innovation, Medical Home, Value

    Short Selling: Why the Long View is Critical for Health 2.0

    Short Sell (shôrt sĕl) n.

    1. The sale of a security that one does not own but has borrowed in anticipation of making a profit by paying for it after its price has fallen.
    2. A short seller will make money if the stock goes down in price, while a long position makes money when the stock goes up.

    Health 2.0 has officially transcended from a niche movement to part of a larger national conversation. This weeks Business Week cover article (as well as great slideshow listing many but not all of the key Health 2.0 players) showcases the increasing, ongoing, and long term implications of patients as partners in care.  While this idea is not novel, the infrastructural underpinnings (EMR’s, communication technology, data liquidity, etc) now appear to be coming together to make this a real possibility.

    I highlighted the notion of how Millennial Patients, and their role as partners in care, would help bring about reform within health care in the April Issue of MDNG. I will be speaking next week at the World Health Innovation and Technology Conference on this theme as well (9AM Wednesday with Dr. Jordan Shlain) and look forward to the opportunities for health care improvement that will results as traditional passive patients become active consumers in their care.

    My only quibble with an otherwise excellent article was what I still perceive as a limited definition and role of Health 2.0 in the overall health care reform agenda. The business week definition:

    Health 2.0 is the use of social media and other technologies to improve communication in healthcare. These platforms may be used to connect patients with patients, doctors with other professionals, or patients with doctors. The Health 2.0 movement is about enhancing communication to improve the focus and results of the health system on the patients it serves.

    If Health 2.0 gets pigeon-holed as only a social networking / “connectedness” / communication technology concept then our vision of its potential influence will be similarly and dramatically reduced to a technology infrastructure play. This would be an unfortunate short sell of a concept that can be so much more.

    To me, the burgeoning Health 2.0 movement,  is about the transition to an entirely new health system, wherein entirely new types of relationships are possible – new relationships between patients and their providers; patients and their data; patients and their insurers; patients and their personal health advisors. Clearly the patient is at the center of this, is an active participant, and has taken upon themselves the responsibility/accountability associated with this new found freedom. The transactional friction is removed via transparency, interoperability, commonly accepted standards, agreed upon outcomes measures, and the liquidity of all this information flowing around securely, privately, and at the discretion of the patient.

    This utopian perspective requires one to have a long view. We can’t declare Health 2.0 a success or failure based its earliest manifestions (greater participation by all the players). We need to evaluate its success by its ability to achieve excellent outcomes (better quality, lower costs, improved access, increased patient satisfaction, enhanced system efficiency, or other relevant measures) and then compare that to the price required to achieve that outcome. Ahhh, the return to the old health care value (outcome/price) equation.

    Communication is an interesting part of all this, but only a single instrument in a potentially beautiful Health 2.0 orchestra.

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    Filed under Consumerism, Health 2.0, Healthcare, Innovation, Transparency, Uncategorized