Category Archives: X PRIZE

Single Sentence Statement: Health Value as a messaging challenge

This is a cross post to some of my writing over at the Healthcare X PRIZE blog

The focus on health care value is a powerful organizing principle, but communicating this concept in an elevator pitch is challenging

The Healthcare X PRIZE continues to build momentum as we receive a steady stream of inquiries regarding this $10MM competition. While many of the inquiries are regarding timing, application, and registration process, we have also been receiving a number of high quality request for information from technology companies, academic organizations, and communities who are interested to understand how they can participate. In fact, the most passionate inquiries seem to come from community based organizations who have a clear vision of how the community can be architected to function as a single entity that maximizes health value.

It is great to see how the X PRIZE can inspire this type of thinking. However, we have received some feedback that the health value story is a little difficult to grasp. Admittedly, it feels like it takes two or three sentences to explain what we mean by health value, how community health is related to that, and how individuals are connected to and influence the community. This is in contrast to the single statements of other prizes that immediately evoke a powerful and clear notions of what is the prize is about. As an example of the single sentence statements that create a singular focus:

These are all clear and compelling; single statements that can be pitched in an elevator and understood by a child. They also represent significant scientific and technical breakthroughs that are understood and can be systematically worked through. However, the Healthcare X PRIZE is a different animal. It is actually a prize designed to change a system (and a very complex one at that). With approximately 20% of the GDP involved in the industry we are trying to reform, it is worthy of an X PRIZE type effort although many believe we are pushing the boundaries of the X PRIZE framework in designing a systemic prize versus something more confined, constrained, and ultimately more conservative.

But it is a challenge we are willing to take on.

We believe that health value is the right organizing principle, but perhaps we communicate the same message in a different way that drives home the point in a more singular fashion. Perhaps we need to focus more on the “healthy community” aspect (using the health value measurement framework), ala the huge success we are seeing with initiatives like Shape Up Rhode Island. Perhaps we need to shift to focus on a leading indicator condition like the Heart of New Ulm (which to impact would still require the systemic changes we seek). Or, perhaps, we just need to keep preaching the Health Value story with direct outreach, clear examples, and compelling case studies.

We look forward to your feedback as we continue to evolve the messaging of the Healthcare X PRIZE. Given the potential impact of the prize to demonstrate that radical transformations within health care are possible, we look forward to developing the most compelling single sentence statement.

Would love to get your feedback.

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X PRIZE Overview – Initial Design and Prize Guidelines

Overview (ō’vər-vyū) n.

  1. A broad, comprehensive view; a survey.
  2. A summary or review.

I am blogging and tweeting from #WHCC09 and am just preparing to head into the X PRIZE Announcement session.   It has been quite a whirlwind six weeks and a pretty harried run up to the event. We have been in startup mode with a rush to synthesize information, draft and prepare documents, and put on as much last minute polish as time would allow. It has been a blast and I am pretty pleased with the results thus far.

The following is a slide overview and Prize Guideline document of the proposed $10MM+ Healthcare X PRIZE. Lots of details to follow which can be found on the Healthcare X PRIZE site as well as in the Health X PRIZE blog.

Looking forward to your comments:

Initial Prize Design – Executive Summary

Initial Prize Design – Prize Guidelines

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Press Release: Healthcare X PRIZE release Initial Prize Design for Public Comment

As I mentioned yesterday, I have been actively involved in the development of the Initial Prize Design for a potential Healthcare X PRIZE. Today I was able to attend a star studded event as described below and have enjoyed the early buzz and feedback thus far.
Looking forward to your comments and ongoing interest as we refine the Prize over the coming months. The Press Release:

WASHINGTON (April 14, 2009) — The X PRIZE Foundation, a nonprofit organization that drives innovation through large incentive competitions, in collaboration with the WellPoint Foundation, one of the nation’s largest private foundations, and WellPoint, Inc. (NYSE: WLP), the nation’s largest health benefits company in terms of medical membership, announced today the initial competition design for a $10M+ Healthcare X PRIZE.

The Grand Challenge for this Healthcare X PRIZE will be to create an optimal health paradigm that empowers and engages individuals and communities in a way that dramatically improves health value. Following today’s announcement, the public is invited to comment on the approach and provide feedback to ensure that the competition results in affordable, high-quality health care for all communities. An overview of the initial prize design and guidelines are available for public comment at www.xprize.org/wellpoint.

The initial X PRIZE design was announced jointly by Dr. Peter H. Diamandis, chairman and CEO, The X PRIZE Foundation and Angela Braly, president and CEO, WellPoint, Inc. They were joined by the Hon. Bill Bradley, former U.S. Senator, and managing director, Allen & Company LLC, and the Hon. Newt Gingrich, former Speaker of the House and Founder, Center for Health Transformation, for a health care discussion moderated by Susan Dentzer, editor in chief, Health Affairs.

“President Obama has called for bold new ideas to revitalize our health care system. We are answering that call by developing an innovative incentive prize that optimizes the health of all Americans and significantly increases the value from every health dollar,” said Dr. Diamandis. “This is not the situation today and we need to change it. Ultimately, you get what you incentivize. If we can refocus our health care system on helping individuals optimize health, and reward providers who improve outcomes, the implications over the next decade will be profound.”

“I’m very pleased to be part of this developing X PRIZE competition,” said Sen. Bradley, “This prize will bring together people from different elements of the health care system and get them collaborating to devise a new system that will produce the highest quality health care for the greatest number of people at the lowest possible cost. The greatest key is tapping into the American people; if you’ve got a great idea, put it forward.”

The collaboration between The X PRIZE Foundation, WellPoint, Inc. and the WellPoint Foundation to design a $10M+ Healthcare X PRIZE was announced in October 2008. Since then, hundreds of comments from the public and leaders across the health care industry have been collected from The X PRIZE Foundation Web site to create the initial design announced today.

“From across the health spectrum physicians, consumers, entrepreneurs, technology experts, government officials and others have already contributed their time and expertise to developing a meaningful prize design,” said Angela Braly. “Now we ask the public and interested stakeholders to take a look at our initial design and share ideas on how we can use a Healthcare X PRIZE to create a dramatic improvement in the health of our families and communities while simultaneously improving affordability.”

The X PRIZE Foundation’s health care prize development team and WellPoint collaborated with prominent health care providers, thought-leaders, academic and political advisors from across the nation to identify key components for a health care focused incentivized competition. Key advisors include: Dr. Glenn Steele, CEO, Geisinger Health System; Dr. Jim Weinstein, director, Dartmouth Institute for Health Policy and Clinical Practice; Dr. Carol Diamond, managing director, Markle Foundation; Mark Litow, principal and consulting actuary, Milliman; Dr. Dean Ornish, president, Preventive Medicine Research Institute; Michael E. Porter, professor, Harvard Business School; Hon. Bill Bradley, former U.S. Senator; and Hon. Newt Gingrich, former Speaker of the House and Founder, Center for Health Transformation.

The proposed $10M+ Healthcare X PRIZE is designed to improve health value by more than 50 percent in a community during a three year trial. A competition around value measures and compares health outcomes against the total cost of care for a community. Health outcomes would be measured by a “community health index,” which combines functional health (e.g., reduced sick days, improved ability to climb stairs) and clinical events (e.g., visit to ER, rehospitalization). Total cost would include direct costs incurred across health benefits, payroll (sick and disability pay), coupled with out-of-pocket health care.

“We have a challenge of how we pay for things. In many ways, we over pay for acute care and we underpay for preventative care and wellness,” said Speaker Gingrich. “This approach allows for significant improvements that would lead to better health outcomes, which would lead to longer, more active lives and do so at lower costs.”

Under the proposed competition framework, teams would have 18 months to conceive, model, and submit plans to create a new paradigm that can impact the health status of individual participants as well as the overall health status of communities. A later pilot phase will be used to demonstrate that the models can successfully be applied on a small scale. To select finalists, the competitive field will be narrowed to approximately the top five performers as judged by an objective process currently under development. During the competition stage, the five finalists will be matched to a test community of 10,000 individuals and compared against a control group during a three year real-world trial. WellPoint, together with its affiliated health plans, has committed to collect appropriate data and collaborate with employers and providers to set up the test communities, subject to validation by an independent third party. The competing team’s ability to change incentives is expected to drive improved behaviors across consumers and providers.

“We appreciate the tremendous support and advice we’ve received from the health community as we’ve shaped this effort,” said Dr. Vijay Goel, director of Prize Development, The X PRIZE Foundation. “By engaging individuals through the creation of a personal vitality score to help them understand their health options, and then measuring the impact of their choices at the community health level, we can create new approaches to achieve optimal health in a convenient, proactive, and effective way. We see the Healthcare X PRIZE effort as a public-private collaboration that makes affordable health care for working families a sustainable reality.”

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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