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Try a Little Mindfulness

Brain

I like to think I have an analytical mind. I've built a career in accounting and finance, with side interests in technology and programming, and I've worked with health-related organizations for a number of years. Given that context, what I'm about to share may come as a surprise.

Daily meditation has had a greater impact on my wellbeing than any pharmaceutical drug or diagnostic test. It has also been a valuable resource in my professional life. Best of all, it costs nothing but my own time and dedication.

In our quest for the "quick fix," we may overlook the power of mindfulness. As often as we talk about engaging patients in their own care, we may not recognize the potential for healing within ourselves.

Migraines and epilepsy have run in my family. I was young when my migraines began, and I was given opioids to treat them from age 12 on. Sometimes I had to visit the emergency room for higher doses of morphine to find pain relief. My epilepsy required me to undergo semiannual electroencephalograms (EEGs) to maintain my driver's license, and to take medications that had negative effects on my personality. Yet all of this seemed normal and sustainable until I found a better solution.

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Board Retreat - Value and the Voice of the Patient

Three Generation Family In Park

On Oct. 6-8, HealthInsight held our annual Board of Directors Retreat in beautiful Deer Valley, Utah. The meetings brought together board members and leadership from our four state-based affiliates in Nevada, New Mexico, Oregon and Utah, along with our two End-Stage Renal Disease Network affiliates in Southern California and the Northwest. Two main threads wove together the variety of presentations, panels and discussions: value in health care and the voice of the patient.

Jean Moody-Williams, the Deputy Director of the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS), encouraged our board and leadership when she said that as part of the push that CMS is making towards quality and value in the health care system, Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) will be helping to lead and support patients and families, along with the providers we serve. She shared a very personal and touching story of her mother's battle near the end of life and her desire to see her experience used to motivate providers and stakeholders. "Patients at the center of care is better care," shared Jean Moody-Williams. "As part of the move to value, all stakeholders in the health care system need to be concerned with moving beyond patient attribution and reaching for true patient engagement and patient motivation."

Karen Feinstein, founder and president of the Jewish Health Foundation addressed how HealthInsight, in our role as a regional health improvement collaborative, along with other members of the Network for Regional Health Improvement, are working to convene stakeholders to take on issues to increase the value of health care in our communities. Our greatest value is in partnering together with others that share our vision to drive improvements at the community level.

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Blockchains and Health Care

Computers and People Connected

As the CIO for HealthInsight, I'm often researching new tools and technology to help keep our organization secure. The further immersed in health care data research I become the more I hear the following words repeated over and over: data management, interoperability and security. Nobody wants to become the next news story about a security breach or data exposure, and with ever increasing public scrutiny, neither do the businesses housing the data. Patients, on the other hand, also want their data protected and available to their physicians when needed most.

What is one way health care can go about protecting all of this data? Enter the blockchain.

A blockchain, in its most basic definition, is a distributed database that provides a semi-public record of digital interactions - like pages in a book, sequentially ordered with information about itself and links to previous pages. Perhaps another way to visualize it would be to think about how some people balance their bank accounts with written ledgers. In this case, all of the expenses would be tracked by the owner and then copied instantaneously to a small number of identical copies across the internet. Having multiple copies makes it more difficult for hackers and thieves to gain access to the data or corrupt it through encryption.

So how do blockchains apply to your health care?

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Sustaining Medicare into the Future

Group of Seniors

Fifty years ago this summer (1966), the federal Medicare program was born. For the very first time, guaranteed health insurance coverage and benefits were in place for seniors 65 and older. To date, nearly 140 million Americans–retired or disabled–have relied on the retirement security and benefits of Medicare. Few would disagree that this program has blessed the lives of our parents/grandparents and markedly reduced the poverty rate among seniors. If you are a baby boomer like I am, you also recognize the fact that Medicare will need to play a vital part in our strategies to not only survive, but to enjoy our retirement years.

Fast forward to 2016: Medicare's sustainability and future success in providing health care coverage and access will be challenged by some serious, growing fiscal concerns. One might call the drivers of these concerns "inconvenient trends". They include:

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Desperately Seeking Support: Motivating Myself and the Link to Active Involvement in Health

Couple on bikes

I like "to do" lists. I was reminded of that last weekend as I was planning a remodel of my bathroom. This is a change I have been thinking about for a while – nearly two years, actually – ever since I purchased the vanity. I know it needs to happen. I know what's involved, as I've done it before. I'm in charge. So, why have I waited so long?

That process got me thinking about motivation and a term we have been talking about at HealthInsight: patient activation. There is actually a way to measure patient activation and it is the basis of many self-management programs for diabetes and other chronic diseases that we are involved in.

Designed for persons with chronic conditions, the Patient Activation Measure (PAM) is a 13-item scale that asks people about their beliefs, knowledge and confidence for engaging in health behaviors and then assigns them to one of four levels:

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Civilizing Medicine

Nurse and patient holding hands

When I first started working in nursing homes, I was struck by the sheer volume of rules and regulations governing the care of residents. Unfortunately, those rules often inhibited patient-centered care rather than offering protection. The result was an institutional approach to care with strict rules based on the diagnoses of the resident. For some residents, food was one of life's simple pleasures they could still enjoy. Despite this reality, most residents were placed on a special diet, based on their medical condition, instead of one based on their individual goals. Many residents would awaken to the smell of bacon cooking in the morning only to be told that they were not allowed to have it because of their low sodium diet. Of course, medical conditions must be taken into account, but the goals of each person must be considered—first and foremost.

This is also true outside of nursing home walls. All too often, care is overwhelmingly curative and narrowly disease-specific instead of goal-focused. My father, who had heart failure and Type 2 diabetes, had his diabetes strictly managed until the end of his life, despite the fact his life expectancy was far less than likely to benefit from strict blood sugar control. If his diabetes would have been managed according to his goals of care, instead of by the results of his hemoglobin A1c, his quality of life would have significantly increased. In fact, the results of strict management interfered with the goals of care as it caused several hospitalizations from hypoglycemia. According to an editorial in British Medical Journal (BMJ), "People with disabling, progressive illnesses expect active care, but they also seek comfort, control, and dignity."

Palliative care offers a potential patient-centered solution for the aging population facing the burden of chronic illnesses. Palliative care is specialized medical care for people with serious illness that focuses on improving the quality of life for both the patient and the family. It employs a multi-disciplinary approach consisting of specially trained doctors, nurses, social workers and other specialists who work alongside patients' doctors to provide an extra layer of support. Unlike hospice care, palliative care does not require a terminal diagnosis and includes curative/life-prolonging treatment. It is also associated with higher quality outcomes at lower costs.

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Growing HealthInsight in Oregon

Portland Waterfront

Today more than ever, success in the quality improvement (QI) business depends on collaboration as well as community-focused teamwork. HealthInsight has a long history of working with health care providers, community partners and patients in Nevada, New Mexico and Utah to improve health and health care.

The past two years have brought us the opportunity to expand our services and expertise, build new partnerships and collaborate with health care leaders in another key western state: Oregon.

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Compassion Fatigue

Nurse holding patient hand

The end stage renal disease (ESRD) Networks of HealthInsight play an important role in helping dialysis patients who have concerns about the quality of care they are receiving. The patient services staff, including three Masters level social workers, is required to be available, per the Social Security Act and the Conditions for Coverage, to mediate, coach, listen, instruct and empathize with our dialysis population that exceeds 60,000 patients. What does this all really mean?

If you walk for a minute in the shoes of a dialysis patient, you might understand that their lives have tremendous potential for "issues". Think about it. Dialysis patients receiving their treatments in center must get to the center, check in, wait to be called in, wash their access, interact with the dialysis staff who provide life-saving treatment to them for three to four hours while they are tethered to a chair, socialize with their fellow patients, return home, watch their diet and fluid intake meticulously. Add to that not feeling well and having to return for dialysis two more times each week just to survive.

While most of our patients are heroes - bringing joy and resilience every time they come to dialysis, many struggle through the challenges that living with a chronic illness can bring. Even the most resilient dialysis patients – hit bumps in the road.

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Health Care Payment Change Highway

Southwest Road

HealthInsight understands that the payment environment for health care providers is more complex than ever as the Centers for Medicare & Medicaid (CMS) continues to implement new payment policies transitioning the system to value-based approaches. The adoption of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will impact the payment structure for the health care community in many ways. MACRA eliminates the Sustainable Growth Rate (SGR) formula and creates a new reimbursement model focused on paying providers for value and better care. CMS has created the Quality Payment Program (QPP) to execute MACRA. Most clinicians in outpatient practices will participate in the Merit-Based Incentive Payment System (MIPS) initially, and eventually more will move into the qualifying Advanced Alternative Payment Models (APMs) arm, although most current APMs will not be qualifying. Implementation rules are still being finalized, but the initial payment adjustments scheduled to be made in 2019 would be based on clinicians' performance beginning in January 2017.

The MIPS combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-Based Payment Modifier) and the Medicare Electronic Health Record (EHR) meaningful use incentive program into a single program. Eligible practitioners will be measured on quality, resource use, clinical practice improvement activities and meaningful use of certified EHR technology, now called Advancing Care Information. Most clinicians in accountable care organizations (ACOs) and the Medicare Shared Savings Program (MSSP) will not be considered Advanced APMs. Only a few existing APMs will qualify, such as the higher tracks of the MSSP that have significant shared risk, some bundled payment arrangements and enhanced versions of patient-centered medical homes. The law also created programs to offer support to physician offices so they can prepare and adapt successfully, with a focus on quality.

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Corporate Medicine and Quality

doctorJust this week I received a call from a pediatrician that he and one of his partners are closing their office and retiring early. Their third partner is quitting and going to work for a corporation. I keep hearing about small practices that are closing. Most all of these are physicians and independent nurse practitioners: non-proceduralists that cite well-meaning rules and regulations that are driving up the costs of running small practices. The small practices are literally being driven out of business.

We all agree that we would like to see a way to measure quality and to find alternative payment forms, but at what cost?  The cost of all of the reporting is becoming so expensive and so time consuming that small primary care practices cannot afford to stay open. Many of these primary care providers are looking for positions that do not involve patient care; some are starting boutique practices; and others are going into corporate medicine.

When was the last time you tried to get a new primary care physician?  If you can find one taking patients, you are fortunate if you only have to wait three months. You may have to wait even longer to see a specialist: five to six months. Then, you need to find one that will take your insurance. Many hospitals and corporations try very hard to find enough physicians to adequately serve their populations. They are also faced with a frequent turnover of physicians working for them. It may be that forcing physicians into large group practices may be the better way to go if we really want to measure outcomes. But will patients like it?  And if they don’t, will it have a negative effect on the individual’s health?

As leaders in health care quality improvement, we have many questions: Will we need to add many more parameters to measure quality? Will quality measures include the patient's point of view? When a patient becomes ill, how long will he need to wait to see his personal physician? Will he need to see the next provider in the queue? Or should he just go to urgent care or the emergency department?  As corporations struggle to try to personalize patient care, more and more obstacles are put in their path. And the cost becomes more expensive.
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