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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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Five Things That Hit Me as I Read the MACRA Proposed Rules

Group of three doctors

The health care world has been buzzing with discussion about the newly proposed rules around the landmark Medicare Access and CHIP Reauthorization Act (MACRA) legislation that passed in April 2015 with bipartisan support. One year later, the Centers for Medicare & Medicaid Services (CMS) unveiled a proposed implementation plan for this new law. MACRA aims to move the U.S. health care payment system from volume-based care to value-based care. The final rule is expected by year-end, which highlights the need to know a bit more about our road to value. I recently spent some time traveling, so I decided to dive in to the 962-page proposed rule. Here are five things I found interesting and wanted to share.

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Payment Reform: HealthInsight’s Work to Support Alternative Payment Models

Stethescope on money

With the recent announcement of the proposed MACRA (Medicare Access and CHIP Reauthorization Act) rules, health care payment reform is moving full steam ahead, away from the fee-for-service model we have all grown accustomed to and towards new, value-based payment models.

HealthInsight strives to keep our communities, stakeholders and local providers up-to-date on the issues that matter to them, and payment reform is no exception. It's not only important for providers to know how these changes impact them, but it's also important for patient's to understand that the way health care is received and paid for care is changing. Here at HealthInsight are working on many activities to help our communities thrive under the emerging models.

We work directly with providers in our communities, providing support through our Quality Innovation Network Quality Improvement Organizations (QIN-QIO) contracts with the Centers for Medicare & Medicaid Services (CMS), including helping to enroll eligible practices into the Transforming Clinical Practices Initiative (TCPI) and other contracts. We align our efforts to support practices in adopting changes to be ready for new payment model and are seeking funding to help both large and small practices be ready for MACRA when the first measurement period starts in 2017.

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Stretch Goals – Compliance or Inspiration?

Darts

It seems we are always being asked to do more with less. Employers expect higher productivity. Coaches and fans expect more wins. Contractors add higher goals for less money. We expect more weight loss and better fitness with less effort. Oh, and yes, make that long term and sustained. How do we get motivated to do all of this? Does "stretching" our goals inspire us to do better for longer?

The manifestations of motivation are persistent attention and effort to a priority or goal. People sometimes seem to have an innate reluctance to do the right thing- take care of their health, seek extra education, save for retirement and create new solutions. Mark Twain noted, "The only way to keep your health is to eat what you don't want, drink what you don't like, and do what you'd rather not." Younger children seem to do things for the fun of it; they bounce back up and charge forward faster after a fall or misstep. Perhaps replacing judgmental restrictive environments with more encouragement and nurturing could restore natural curiosity and enjoyment of learning and growing.

Educators and employers seem to work on the premise that rewards (gold stars, incentives) and punishments (time out, penalties) will drive sustained behavior changes for the better. Indeed, for simple tasks of short duration, they do work. For instance, a national pizzeria chain collaborated with public schools to offer children who read for 20 minutes every day for one month a coupon for a free pizza; more children read. The program's goal was not to feed children; the goal was to get children to do the behavior long enough to experience the intrinsic joy of reading for themselves.

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Measurement has its Place, but Doesn't Always Tell the Whole Story

Basketball Backboard

I love the game of basketball. There are all sorts of statistics collected – 2-point shots scored, 3-point shots scored, free throw percentage, field goal percentage, assists, rebounds, blocks, fouls, steals, turnovers, etc. The statistics often tell a lot of the story. Steph Curry, point guard for the Golden State Warriors, scored 402 3-point shots this season, setting a new all-time record. Most would view this statistic as success and he was voted the most valuable player in the professional leagues this year. Nevertheless, statistics don't tell the whole story in basketball. Rarely do we quantify hustle, such as getting up the court quickly; team work like sharing the ball with others; or sacrifice when a player dives for a loose ball. These efforts, which few track, are often as important as points scored. Statistics can be focused on, to some degree, successfully (e.g. tonight I'm going to try and get more rebounds in this game). But in my opinion, too much focus on the numbers can be debilitating. There comes a point where you have to go play the game, have fun, do the best you can and not worry about the numbers.

Just as the statistics in basketball don't tell the whole story, such is also the case in health care. I was intrigued by a quote I read recently in the New York Times by the scientific health care quality pioneer Avedis Donabedien whose main focus was on measurement. He said during the last days of his life, "the secret to quality is love."1 This was a man who was dedicated to health care statistics. There are areas in health care we don't quantify but are extremely important, such as time spent with a patient discussing end of life care, treating co-workers respectfully and timely follow up with results. Although hard to quantify, few argue against the direct health benefits of the health care professional who spends extra time listening to a patient who has just had a difficult life event.

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25 Years of Advancements: Change at HealthInsight and in Health Care

Open Road

Twenty five years ago I stepped into the HealthInsight office, then called Nevada Peer Review, in Las Vegas and began my career in health care improvement. I was thrilled to have an advanced piece of equipment—an IBM Selectric self-correcting typewriter. Staff used dumb terminals to verify patient information for our Medicaid and Medicare review work, and our health care analysts had very large computers taking up a good bit of space in their office. Within a couple of years, we all upgraded to PCs and before long, cables and cords were draped everywhere as we established our first company-wide network.

We’ve come a long way at HealthInsight, and as I reflect upon my 25 years here, I think about the advancements made in health care over that same time period, and which of those, in my opinion, have had the biggest impact. There are many, and I’m sure each advancement may resonate differently, depending on your own personal perspective. These are just a few that made my list—focused on either public policy impacting an individual’s ability to manage their own care or technology advances.

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