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The Upstream Parable: What’s High School Graduation Got to do With it?

Classroom desks

I come from a background in public health where the upstream parable is often used to discuss the importance of prevention. The parable goes something like this:

A medical professor and his student are walking together along a river. As they walk, they discover a drowning man. The student immediately jumps in to save him. Farther along, a woman is drowning. Again, the student jumps in while the medical professor stands and watches. They continue walking and encounter two more people drowning in the river. Once again, the student dives in to save the people, and he barely survives with his own life. The professor just continues walking along the river.

Exhausted and infuriated, the student confronts the professor and asks, "Why didn't you help me? Those people were dying, and I barely made it out alive!" The professor keeps walking and says, "I'm going upstream to see why all these people are falling in the river."

Soon enough, the professor and student come across a bridge. People need the bridge to get to their farmlands across the river, but they are falling into the river because the bridge is in poor condition. The professor sets to work repairing the bridge.

Last October, the HealthInsight Management Corporation Board of Directors, and the respective Boards in each state, voted on a series of True North Measures to guide the work of the organization. The boards selected high school graduation rates as a True North Measure. This is an example of an upstream measure as there is a clear association between educational attainment and future success and health status.

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HealthInsight Embarking with Lean to Propel the Boat Forward

Crew Rowing

Recently, I've been enjoying a book called "The Boys in the Boat," which is the story of nine Americans who beat the odds and found hope in desperate times in their quest for gold at the 1936 Berlin Olympics. The crewman in this story worked hard to improve their technique and effort to be successful. Speaking of the magnitude of the effort, the book mentions "Physiologists, in fact, have calculated that rowing a two-thousand-meter race—the Olympic standard—takes the same physiological toll as playing two basketball games back-to-back. And it exacts that toll in about six minutes." The rowing techniques of "catch," "leg drive," "layback," "release" and "feather," if not performed precisely, can cause the rower to "crab out" which, embarrassingly, might throw him from the boat. In addition to their individual efforts, a crew needs to find a rhythm as a team – the "swing" as they call it. They seek to combine efforts into one smoothly working machine.

As with rowing, so it is in our work process, there is no substitute for hard work in the office. We also are continuously seeking to fine-tune both our individual processes and our team processes. HealthInsight has expertise in human factors, causal analysis, and the Model for Improvement, and these are the basis of much of our improvement, training and work. Recently, HealthInsight has begun looking at lean as a model of efficiency for both team processes and individual processes – we are just beginning our lean journey. We have been focused on seeking value by reducing waste in our company processes. For example, our communications department is looking to streamline multiple newsletters to increase value for our external and internal customers, and to enhance processes and delivery methods in order to become more efficient and leaner in our work. They are implementing lean principles such as just in time production and elimination of waste.

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Refocusing Your Business Strategy

Man looking through binoculars

Often we are so caught up in our day-to-day routine, we lose focus of our project goals. Three years ago, I began working at HealthInsight as the Admissions and Transitions Optimization Program (ATOP) director, fulfilling one of my professional ambitions to be part of health care policy decision making. Initially, you could not contain the excitement I had about the ATOP program and the development of an ironclad strategy with the help of my business associates motivated by the outcomes we hoped to achieve. Detailed steps were identified to achieve those outcomes. All was good until one day I discovered that some of the targeted goals for ATOP had not been reached. We had been successful, but could we have progressed more? Maybe we set our sights too high? Did we take the wrong path at the fork in the road? Then I had an epiphany. I needed to reflect, research, refocus and redirect.

It was time to take a pause and retrace my steps. It was time to REFLECT.As part of my reflection, I also reviewed the literature on "goal-setting". There are multiple reasons for not reaching your goals, whether they are work-minded or personal in nature. One of the first techniques I came across was the use of S.M.A.R.T. goals: Specific, Measurable, Achievable, Relevant and Time-bound. This term was familiar to me because I use this formula for setting annual employee goals. After reviewing the original ATOP program goals, I felt that all of these measures had been considered. Article after article about goal-setting revealed multiple reasons for not achieving goals: unrealistic expectations, conflicting goals, procrastination, too challenging, incorrect goals, too many goals and not reviewing progress. In the case of ATOP, the two reasons that stood out for me as potential culprits were "being too specific" and "not setting the correct goals".

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Providing Practice Transformation in Nevada and Utah

Doctor and Nurse Charting

The future of independent practices remains uncertain, except for one truth—change. Across the nation, some practices have been bought by integrated systems and many others have signed up with Accountable Care Organizations (ACO), all of which offer a wide array of services. HealthInsight continues to educate providers in our community about their options, as alternative payment models through the Centers for Medicare & Medicaid Services (CMS) emerge. We are committed that they make the best decisions for their practices and their patients.

As opportunities arise, HealthInsight will facilitate introductions with ACOs and/or Practice Transformation Networks. ACOs may utilize some of HealthInsight's experienced staff to supply onsite technical assistance as practices prepare to start Medicare Shared Savings Programs in 2017. (See recent blog by Sharon Donnelly)

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Doctors are Lazy

Doctor with Patient

I just read an article in Medical Economics by William M. Gilkison, MD, an older physician, entitled, "Opinion: Doctors are lazy". He pointed out that patients complain to him that physicians have very little contact with them during exams: they come in for five minutes and leave. Some physicians even tell patients that they can only discuss one problem at each visit. Certainly, if the physician was the patient, he or she would not tolerate being treated in this manner. What if he or she had diabetes with a comorbidity such as high blood pressure, high cholesterol, heart disease or depression?

Practicing good medicine dictates that all medical problems should be addressed at the visit and it will take more than five minutes. Years ago I might have agreed with the author, but now I'm not so sure. Over time, as more and more physicians became employed by hospitals, insurance companies and large groups, they began to feel pressured to see more and more patients. Then, as they all began using electronic health records (EHRs), they found that they needed to collect more data for others – insurances and government (including the Physician Quality Reporting System - PQRS, meaningful use, and prescriptions by computer only). It seemed that every time they turned around, there seemed to be more time-consuming tasks that they were expected to do.

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Beyond End of Life: Random Thoughts on Coping with Personal Loss

Wildflowers

Caring for ourselves and others after a loss can be challenging. At HealthInsight, our work is focused in several arenas aimed at making sure our health and wellness doesn't fall by the wayside, even in times of loss and grief. HealthInsight, through various projects, is working on improving end of life care; depression and behavioral health screenings, and annual wellness visits in older adults; improving the lives of those with diabetes and other chronic illnesses through self-management classes; and improving care in nursing homes and home health agencies to make sure patients are getting the best care possible right up until the very end.

In previous blogs, I have written about my family's journey through end of life issues and my thoughts on how the health care system and providers can positively impact a family's journey. Death and loss hit all of us at various stages of life and in the end we all deal with these challenges in a different manner. The one commonality is, most likely, the impact the loss can have on our physical and mental health.

One year ago today as I write this blog, I received the call, at 8 p.m., we all dread and fear when a family member or loved one is near death. Mom had died in her sleep after a 7-year battle with Alzheimer's. The flood of emotions for me was significant from grief, denial and fear, all the way to relief that mom is no longer suffering and can now be in peace.

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HealthInsight Begins Exciting New Work with ESRD Networks

Doctor with Machine

HealthInsight is continually working to improve the health and health care of the residents in our area and now we are expanding and moving into new areas of work, with the goal of improving the lives of even more people.

In December, HealthInsight was awarded two new end-stage renal disease (ESRD) contracts from the Centers for Medicare & Medicaid Services (CMS) and work has already begun on improving the care and resources for patients with ESRD. HealthInsight will be working in ESRD Network 16 and 18, serving residents in Alaska, Southern California, Idaho, Montana, Oregon and Washington. CMS awarded $110 million in combined ESRD funding to six Quality Innovation Network Quality Improvement Organizations (QIN-QIOs) and one independent entity for five-year contracts.

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I Choose Joy

Woman in B-W

Two decades ago when Professor Martin Seligman and others decided to focus on exploring well-being instead of human despair the field of positive psychology was born. What makes people flourish? Which factors contribute to a fulfilling life? As more research is conducted in this emerging discipline, light is shone on multiple facets of our day-to-day lives.

JOY: three letters describing a feeling of happiness and well-being. A word I associated with photos of giggling babies or that person standing on a lone mountain top. Recently though, the word has come up several times in different contexts and has really made me think.

Marie Kondo, goddess of organization and decluttering and the subject of a recent national radio segment, says that when you are deciding whether or not to keep something you should think "does touching this spark joy?" Keep only those things that speak to your heart. A different way of looking at the numerous white binders of neatly divided meeting minutes in my office indeed...

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Flight of the Bumblebee – A Soundtrack for Innovation

Flower

Consider the bumblebee – industrious worker, agricultural catalyst, cooperative colonist. When winter's chill is chased away by spring's warm breezes, bumblebees will help ensure we have beautiful flowers and healthy fruit to enjoy this summer. Effecting a valued outcome through deliberate activity, the bumblebee is an apt metaphor for an activity which is highly valued in innovation circles - cross pollination.

For many years, the concept of cross pollination has been considered a mechanism for stimulating creative solutions to challenging problems by working across functional silos to reframe successful approaches in inventive ways. In theory, combining individuals from different disciplines will create fertile ground for innovation and promote visionary thinking. But is this true?

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Medicare Shared Savings Program: What To Do Before You Start

Doctors and Nurses

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) passed last April ended the Sustainable Growth Rate (SGR) formula for determining Medicare payments to health care providers, creating a new pathway to value base payments. Future fee schedule adjustments will be driven by participation in either (1) a Merit-Based Incentive Payment System (MIPS) that combines existing quality reporting and incentive programs or (2) qualified Alternative Payment Models (APMs) that require providers take on a yet to be defined "more than nominal" financial risk. Given the complexity of MIPS and long-term potential higher earnings under APMs, many physicians are interested in preparing for participation in APMs and see the current Medicare Shared Saving Program (MSSP) as a logical stepping stone.

As more physicians in the U.S. move into Accountable Care Organizations (ACOs) and the MSSP their peers are watching their successes and struggles, trying to discern what drives the difference in the 28 percent that are reaping shared savings and the great majority that are not. MSSP requires ACOs to hit savings targets benchmarked from their existing spending patterns, as well as score well on 33 quality measures. What is needed to prepare to successfully engage under these new payments models? A useful reference is the Brookings white paper on "Adopting Accountable Care: An Implementation Guide for Physician Practices". This toolkit identifies four capacities critical for success: (1) identify and managing high-risk patients; (2) develop high-value referral networks; (3) receive notifications of acute events such as emergency room (ER) visits or hospitalizations; and (4) engage patients in self-management and shared decision-making.

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