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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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Between the Upstream and the Downstream – The Proximal Impact of Social Determinants

Group of Young Adults

Back in March, Margy Wienbar wrote a blog on the Upstream Parable, describing the association between high school graduation rates and health status. In short, improved high school graduation rates are associated with improved health outcomes.

While improving high school graduation rates is a worthy cause for a variety of reasons, there have been a number of studies that demonstrate we can act to improve health and social conditions without having to go so far upstream, as it were. While conversations about the intersection of genetics, health care, and social, behavioral, and environmental influences are heating up, the changing payment environment provides an opportunity for us to 'put our money where our mouths are'.

Social determinants of health (SDH) are "the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life." These conditions include socioeconomic status, education, the physical environment, and social support networks. In a recent article, U.S. states with a higher proportion of social spending relative to health spending demonstrated significantly better outcomes for several population health-type measures. But while SDH can have a substantial impact on health outcomes (estimates as high as 90 percent for some conditions), they are not funded in the same way as other health-related services. There are a number of reasons why these efforts are not aligned, but some recommended policy principles provide opportunities for us to bridge this gap without going very far upstream:

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Practicing What We Preach – Looking in the Mirror to Become Internal Change Agents

Meeting in board room

I have previously written about HealthInsight and to a lesser extent myself being a "change agent". A change agent from my perspective is a person and/or organization that aggressively challenges the status quo in health care to drive transformation, while at the same time understanding the world in which health care providers and organizations function.

The art and science of change management is complex, and the implementation of change is often times a stressful and painful endeavor. Giving up on realizing transformational change often seems the best option after experience resistance and heartache. Sometimes we default to the "devil" we know is better than the scary prospects of a radically redesigned system.

Recently, HealthInsight has experienced a tremendous amount of growth in the number and scope of contracts that involve working with physician offices. Using our historical approaches for designing the work, we formed a new team every time we were fortunate enough to get a new contract. This has resulted in at least five physician office teams at HealthInsight who are working with physician offices in our four-state region.

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Is Good “Old-Style Public Reporting” the Means of Transparency that Aims to Maximize the Quality and Cost of Care?

Doctor typing on laptop

I was always curious about finding the best and most efficient ways of using and disseminating quality and cost data, and this has been the focus of my work for the last 10 years. We first started public reporting efforts in New Mexico 12 years ago with our statewide Takes on Diabetes coalition with health plans. In 2010 we received funding from the Robert Wood Johnson Foundation to expand our public reporting efforts to ambulatory setting and involved our stakeholders and providers in the collection, analysis, and reporting of health care data to patients, providers, insurers, hospitals and policymakers. The question I always have is how we make this data useful for all of our stakeholders.

As a health care analyst, I've seen both the advantages and disadvantages to traditional public reporting. Properly done, public reporting offers several potential benefits: it could reduce information asymmetry between both patients and providers, and payers, promote competition between providers in the health care marketplace, apply pressure to reduce costs and improve quality, empower patients to be more active participants in their own care, and foster a culture of accountability, transparency and efficiency.1 However, to be successful, public reporting must use a framework that has credibility for both those being evaluated and those using the data. In any public reporting schema there are trade-offs between the transparency required for success, and confidentiality required to protect physicians from litigation and from unfair and invalid characterizations of their clinical practices. If public reporting data may be used in litigation, physicians are far less likely to comply, which may undercut public reporting initiatives. Ultimately, patients may be on the losing side of this situation due to the lack of potential quality improvement with traditional public reporting.

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Trouble with the Curve

Father and child playing baseball

My father raised me to have a love for baseball. He made sure I knew each of the Los Angeles Dodgers by name and jersey number, and by the age of seven, he made sure I could play the game. When I was first learning we never bothered with the tee; he would pitch to me and coach me after every swing. He pitched and I swung until I was a master—or until we were hungry. I remember I always had trouble with the curve ball. I could play first base, shortstop, I could bunt, even hit a home run or two, but getting a hit off a curve ball never made the list.

Recently I attended the American Healthcare Quality Association Quality Summit in Baltimore, Maryland, situated directly next door to the home of the Baltimore Orioles, Camden Yards. It's a beautiful stadium that can be seen from the conference hall with many conference attendees catching an Orioles game at the end of their day. Over the years I've attended a number of these conferences and have seen the stadium from the inside, but this year was different. As usual, the conference provided hours upon hours of sitting and information overload, but this year instead of being encouraged to do more, achieve more, and be more—we were encouraged to get comfortable working in difficult circumstances. Let there be no mistake, achieving more was still the goal – that had not changed. What was different was the idea that we can't get into the 'green' unless we can first be comfortable in the 'red'. For a moment it felt as though my father was still standing at the pitcher's mound and I was at bat attempting to hit that curve ball. As speakers from the Centers for Medicare & Medicaid Services (CMS) greeted the audience and set the stage for years to come, they asked us to pause and find comfort in discomfort - to get comfortable being uncomfortable. Not one but three CMS senior executives shared their personal stories of failure and how the transparency of their momentary lack of success encouraged them to learn more – faster.

As I sat there and listened I realized how uncomfortable I was just sitting there! How would I bring this back to my team? For years we've used the familiar 'green, yellow, red' color coding in our performance dashboards to provide quick and intuitive displays of progress (or lack thereof). Suffice it to say, the red was not a place we wanted to be. We did everything to avoid the red. Green was clearly the most desirable form of progress and yellow, while not red, was still a bit scary and safe at the same time. And then it hit me. The closer to red we were, the more creative we became. It wasn't as if our team couldn't manage failure – sure we could, we have. Instead, we were being asked to recognize that it is in time of struggle where we find our true potential. It is where we find sustainability. It is where we should be asking ourselves, "What is good about this seemingly bad situation?"

I left happy to take this refreshing perspective back to my team and wondered if they would be as surprised to hear it from me as I was to hear it from CMS. I know one thing for certain, I may still have trouble with the curve in terms of baseball pitches, but I think this curve ball might just be a home run.

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Complexity Theory of Fixing Health Care

Nurses

When I speak to students I relay the story of graduating from nursing school in the mid-70's and the faculty telling us we were going into a new health care system, it had been fixed-managed care was the answer. Well now 40+ years later I am saying my career has been focused on improving and fixing health care, and guess what we are not there yet!! Don't get me wrong - we have improved longevity in this country, improved diagnostics, technology and treatment, and yes we may even be closer to finding a cure for those long unsolved diseases such as cancer and Hepatitis C. However, this has all come at a cost without evaluating and redirecting the money flow within the health care system. I guess now the question should be will it ever be fixed? At this point I would say no, it will never be totally fixed, we may come up with solutions and address some of the problems but health care is such a dynamic environment and continues to evolve that, quite frankly, I believe we should look at it as a journey rather than a problem to be solved. So pack your bag and be prepared for the long journey (depending on where you are in your career)!

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