Monday, December 17, 2012

A shift in how healthcare is paid for

CHELMSFORD, Mass. — It's hard work being one of Dr. Damian Folch's diabetic patients.

If a lab test shows high cholesterol, Folch is quick to call or email. No patient can leave the office without scheduling an annual eye exam, a key preventive test. A missed exam or an appointment leads to another call.

"We are a real pain in their necks," joked Folch, a primary care physician in suburban Boston. "We track them down."

That kind of attention has always been good medicine. For Folch, 59, it's now good business. He is among thousands of physicians in Massachusetts whose pay depends on how their patients fare, not just on how many times they see them. If patients stay healthy and avoid costly medical care, he gets more money.

This simple shift in how healthcare is paid for — long seen as key to taming costs — has been occurring in pockets of the country. But nowhere is it happening more systematically than in Massachusetts, the state that blazed a trail in 2006 by guaranteeing its residents health insurance. Now Massachusetts, a model for President Obama's 2010 national healthcare law, may offer another template for national leaders looking to control health spending.

"There have been few greater periods of change in American medical history … and this is the epicenter," said Dr. Kevin Tabb, a former chief medical officer at Stanford Hospital and Clinics in Northern California who now heads Beth Israel Deaconess Medical Center, one of Boston's leading hospitals. "It is striking how different Massachusetts is from the rest of the nation."

In the last three years, commercial insurers in the state have moved nearly 1 million patients into health plans that reward doctors and hospitals that control costs while improving quality.

About 180,000 Massachusetts seniors are on track to get care from physicians paid this way by Medicare through a new initiative included in the national health law. And this summer, state lawmakers passed legislation aimed at moving 1.7 million government employees and Medicaid recipients into similar health plans.

Within a few years, close to half of the state's 6.5 million residents could be in a health plan that pays for medical care in a fundamentally different way.

Massachusetts' move to reshape how healthcare is financed is still in its infancy. And the state continues to have the nation's highest medical costs, spending nearly 50% more per person than the national average.

That has fueled skepticism from conservatives who see too much government involvement and from liberals who say the state should more aggressively set medical prices. "I don't see how we can rely on market forces," said Nancy Turnbull, associate dean of the Harvard School of Public Health.

But early research in Massachusetts suggests the approach may be slowing health spending. And medical providers, business leaders and elected officials are increasingly hopeful they are making headway.

"Whether this is sustainable remains to be seen," said James Roosevelt Jr., president of Tufts Health Plan, one of the state's largest insurers. "But there is a broad consensus that it makes more sense to pay for healthcare this way."

The building block of the Massachusetts experiment is a contract between insurers and groups of doctors known as a global payment. In such contracts, physicians receive a budget to care for a cohort of patients. If doctors can care for their patients more economically, they keep a portion of the savings. If patient care exceeds the budget, they pay a penalty.

That is supposed to encourage physicians to keep their patients healthier and direct them to lower-cost hospitals and specialists.

If poorly designed, the arrangement can create a financial incentive to skimp on care. That perceived problem undermined earlier experiments with global payments and provoked a backlash against managed care in the 1990s.

"The most widespread attempts to do this failed," acknowledged Andrew Dreyfus, president of Blue Cross Blue Shield of Massachusetts, the state's largest health plan and a leading proponent of the new generation of global payment contracts. "There was no quality measurement.... It was really just about dollars."

In a key change, Blue Cross now links its contracts to dozens of quality metrics that track whether patients get the right screenings and exams, whether doctors and hospitals prescribe the correct drugs — even whether patients are satisfied with their care. That means a doctor who withholds care in hopes of saving money faces a penalty if patients suffer or are unhappy.

In Folch's suite outside Boston, these measurements have been transformational.

On a shelf in his tidy office are reams of spreadsheets, updated constantly, that outline how each of his patients is faring, which tests they have taken and which are due. With bonus payments from Blue Cross, he has hired new aides and installed a new computer system to better track his patients.

"We had to change the way we practiced," Folch said.

Folch also had to explain to patients why he wants them to get X-rays, eye exams and other routine care at the community hospital rather than at one of Boston's famous teaching hospitals, where an MRI that normally runs about $1,100 can cost as much as $1,650.

That wasn't easy.

"I try to explain that I'm not throwing them to the lions. I am referring them to people that I go to," Folch said. "If you have some rare form of cancer, then of course we're going to, say, get a second opinion.... But I had a lot of difficult conversations at first."

Some patients quit his practice.

Change has not come easily around the state, particularly for hospitals that depend on filling beds, not on keeping patients healthy enough to prevent hospitalizations.

"It's a dramatic reorientation," said Dr. Tom Lee, an executive with Partners HealthCare, the state's dominant hospital group.

Medical practices like Folch's are already making significant strides, however.

Between 2008 and 2011, the percentage of Folch's patients getting recommended colorectal cancer screenings increased from 61% to 82%. The share of patients with cardiovascular conditions managing their cholesterol jumped from 75% to 89%. And last year, all of Folch's diabetic patients successfully managed their cholesterol and had their yearly diabetic eye exams.

"If he sees something he doesn't like, he contacts me right away," said Bill Wooster, a 59-year-old sales representative who began seeing Folch after having a stroke four years ago. "I'm his patient, but I feel like more of a friend."

Those results are mirrored elsewhere. Statewide, the quality of care provided by physicians in a Blue Cross contract like Folch's — known as an Alternative Quality Contract — outpaced that of other medical providers, according to an analysis by Harvard Medical School researchers published in the journal Health Affairs.

Although the cost savings were modest, healthcare spending increased more slowly for the Blue Cross medical practices compared with others. Patients were hospitalized less and used fewer expensive services like advanced imaging. "These results suggest that global budgets with pay-for-performance can begin to slow underlying growth in medical spending while improving quality of care," the researchers concluded.

It's unclear whether other states, especially those where political resistance to the national health law remains fervent, will follow Massachusetts' lead on cost control. "Much of the rest of the country is still battling over the merits of covering everybody," said Alan Weil, president of the National Academy for State Health Policy.

In Massachusetts, however, the reforms remain very popular. "This has allowed me to be a better doctor," Folch said. "And it's better for my patients."

A simple idea that is not news as I have pointed out on several occasions
Universal Health Care – Pay While You are Healthy and Reassessing Primary Care.
The Chinese principle of paying the local doctor while you are well may seem like an oversimplification but as Einstein said

Everything should be made as simple as possible, but not simpler

This seems like a really simple and a great strategy - it would help to capture data in sufficient detail to be able to demonstrate value and quality in the population. The capture of this data would be secondary to the actual health management and delivery of care that is keeping patients well. Unlike the current system which focuses on the documentation as verification of clinical activity and consumes much of the doctors time. I'm willing to bet most clinicians would be supportive of any system that focuses on the care and generates sufficient information to demonstrate the health improvement rather than burdening the care providers with data entry tasks.


Posted via email from drnic's posterous

Wednesday, December 12, 2012

My list of 12 things for healthcare in the next 12 months for this day 12-12-12

Here's my list of 12 things coming to Healthcare in the next 12 months

  1. Pastedgraphic-1
    - in particular the iPad Mini which has captured the imagination and is ready for prime time in a perfect balance fo form factor
  2. Pastedgraphic-2
    Voice Enablement
    - it's everywhere and quite right too but expect it to get a whole lot better as medical intelligence comes to the voice interface
  3. Pastedgraphic-3
    ICD10 solutions
    that don't crush your clinicians and require them to become data entry clerks - the technology is here to provide tools to deal with all the data requirements on the back end
  4. Pastedgraphic-4
    Data Analytics and Big Data
    - we are only scraping the surface of this area but as we get more data and understand more expect more tools and discoveries to emerge
  5. Pastedgraphic-5
    Home Healthcare Management
    - the medical home is playing an ever larger part in the care and management of patients and tools and technology will expand past the current set fo home health devices and be better connected and integrated into the care system
  6. Pastedgraphic-6
    Patient engagement
    - still in its infancy but we have seen a major push towards patient engagement and enablement 
  7. Pastedgraphic-7
    Mobile Health
    - we've seen the FDA move quicker than ever to license the AliveCor ECG application and expect this trend to accelerate with more tools and devices emerging
  8. Pastedgraphic-8
    Social Media
    - almost did not put that in here since it has been exploded onto the scene but that trend is only going to continue
  9. Pastedgraphic-9
    - with the expanding connectivity comes all the associated risks and expect major failures in securing of clinical data to hit the headlines
  10. Pastedgraphic-10
    - will increasingly impact healthcare with more pervasive use throughout the system, not all of it will work well but it will become part of most practices
  11. Pastedgraphic-11
    - I expect we will still be waiting for true open sharing of data and that won't come until the incentive model changes are fixed to encourage sharing of the intervening time patients will become the biggest drivers pushing for interoperable medical data
  12. Pastedgraphic-12
    Customized Medicine
    ; Genotype and Phenotype - increasingly available, better understood and now been applied in more and more areas - we've seen the emergence of mobile apps to help analyze your genome and now seeing the analysis applied to the MicroBiome - expect to hear much more about this

Posted via email from drnic's posterous

Monday, December 10, 2012

Microbiome: Cultural differences


This article helps detail some of the new findings emerging relative to the effects of the Microbiome and perhaps start to explain the significant differences found in populations based on where they grow up. In a controversial claim from the Irish study

the study also suggests that this microbial make-up is driven by a diet high in fat and lacking in fibre, and that a decline in our microbial community underlies ill health as we grow old

This does run back to the challenge of correlation vs causation but there is a suggestion that altering your microbiome can ave significant positive effects...unfortunately we don't know how:

We just don't have a very good idea yet of the specific parameters that could set the microbiota in a good direction versus a bad direction

It puts an interesting perspective on the increasing incidence of cesarean deliveries which remove the exposure of the infants first exposure to the microorganisms that would have occurred as they passed through the birth canal.
The current study focusing on the "Mediterranean" diet will offer not only insights into the value proposition that people from those areas seem to have benefitted from a longer healthier life with a diet rich in olive oil, fish and fresh vegetables but perhaps help explain this effect

Posted via email from drnic's posterous

Wednesday, December 5, 2012

In the Spirit of the Holiday Season I offer this Question and Answer Set for the Informatics Exam

These questions and answer sets came directly from
Joe Boyce, MD - CIO/CMIO at Heartland Health. St. Joseph, Mo 64506, who has kindly allowed me to share. Hope you enjoy it as much as I did.

His post appeared on a listServ and was his suggestion of exam questions for the currently developing Medical Informatics Board Certification

SO question 2729927

  1. Organizational structure – Which is the most effective reporting arrangement for a new CMIO?

    1. CEO who has just been to a paid vendor sponsored conference at end of quarter.

    2. CIO – during a financial systems implementation, after a major downtime, during budget season.

    3. CFO who turns the lights off when he leaves the room (even if you are still there).

    4. Independent contractor reporting to all of the above paid on a “what you kill” basis after last 3 CMIOS quit.

  2. Knowledge management – What is the most effective way to ensure people know what they are supposed to know?

    1. Assume they won’t, and build computer systems to compensate

    2. Video training with subliminal messaging on you tube.

    3. Classroom sessions combined with happy hour and pizza, during BMI measurement enrollment

    4. “First person who sees this message and calls me wins $20” buried in the body of an email

    5. Partial information distorted by least knowledgeable staff member delivered at most disruptive time

  3. Probability theory – Which is more likely?

    1. Team based urologists

    2. Internists who cut to the chase

    3. ED docs who read the information before the meeting

    4. CIOs who “get it” with plenty of budget

  4. Social networking - which environment is most dangerous for CMIOs?

    1. Physicians lounge during a documentation rollout

    2. Surgeon’s Christmas party at last call

    3. Nursing dept meeting after volunteering them to pick up a few more tasks

    4. Facebook after you’ve had a few drinks and a tough week

  5. True or False – if you aren’t confused, you don’t know what is going on

    1. True

    2. False

  6. Futures – After the singularity, how will you change a lightbulb?

    1. Answer – You don’t change lightbulbs that are smarter than you

  7. Quality measures – As CMIO, you have been asked to redefine all workflows for new quality measures, ensure physician input/acceptance/compliance, and implement within a month across a four hospital system? What is the best approach?

    1. Do nothing – another list of measures will be out in a month.

    2. Simply declare salaries will be attached to the metrics, and announce it on twitter.

    3. Spend weekends doing flowcharts, spreadsheets, and education materials, only to find no one comes to dept meetings, they won’t read emails, and their office manager dumps all snail mail directly in trash

    4. Ask AMDIS

  8. Finance – What is the best way to calculate ROI ?

    1. Detailed reductionist analysis of hardware, software, training, personnel and intangibles, pushing the project time past useful implementation

    2. 42 pages detailed with algorithms, charts, embedded spreadsheets, and complicated formulas downloaded off the internet, appended to the “project summary”.

    3. A simple spreadsheet, but password locked and key only distributed to the finance committee members who are on your side

    4. Make sure the dominant personalities in the system are project sponsors

  9. Project mgmt. – As CIO/CMIO, you’ve been asked to cut budget on a critical project by 20%. What is the best approach?

    1. Call a crucial Saturday meeting of all involved parties to discuss in detail, and forget to show up

    2. Offer to cut whatever 20% is most closely associated with the requesting party

    3. Delegate/Defer to a weak link you’d been wanting to handle for a long time

    4. After much wailing and gnashing, cut the 20% cushion you put in long ago

  10. Documentation – which of the following groups are most likely to complete their notes at the point of care?

    1. ED physicians with Scribes (assume the ED physicians still enter the room)

    2. Orthopedics with voice recognition (assume your orthopods have evolved to speaking)

    3. Internal medicine docs with a laptop and selection of branching templates via telemedicine. (assume your network will remain stable for 15 minutes)

    4. Residents with ipads, Bluetooth headsets, Kinect 3d mapping, and cell phones (assume they have not done a startup and retired already)

  11. Management 101 – Which of the following surprises do CEOs prefer?

    1. Project failure realization while rounding in front of an entourage on the floor.

    2. Budget overruns to the board

    3. Parking spot occupied

    4. Being told personal assistant robots don’t exist yet

  12. Planning – Your system has started a new ACO, opened a new hospital, upset the union, and had a security breach while revenues dropped by 10% . What went wrong in your planning?

    1. Nothing. That is the new normal.

    2. You listened to a consultant, who is now somewhere over Denver. For 2 weeks.

    3. Your genba mixed with your karma, and your black belt was in physiology

    4. You forgot to put lithium in the COO’s water again