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How’s Your Heart?

Heart and Stethoscope

I just had my birthday … and it’s Heart Month. This has gotten me thinking about what my heart might look like. I’m curious: does it look like that of a 30-year-old or is it more like a 70-year-old’s? I would imagine there would be a lot of variation and many Americans may have hearts that appear older than their actual age. Imagine that!

To assess your heart age, the Centers for Disease Control and Prevention and others offer tools that generate an estimate based on your risk factors. Putting in your weight, cholesterol level, blood pressure, diabetes and smoking history allows the tools to calculate your heart age and perhaps get you thinking about ways to reduce that age and live longer. As the daughter of a man who had his first heart attack at age 53 and who was 14 when he lost his father from a heart attack, I am happy that we now know so much more about how to prevent this from happening.

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Equip Yourself to Thrive During Times of Change

letter tiles

“It’s only after you’ve stepped outside your comfort zone that you begin to change, grow, and transform.” ― Roy T. Bennett

“The only way to make sense out of change is to plunge into it, move with it, and join the dance.” ― Alan W. Watts

“Welcome change.” – Fortune in cookie I opened on January 29, 2018 (no kidding).

Like many others, our organization is undergoing a transformation. There are exciting times ahead, as well as periods of change and uncertainty. But let’s be real – for many of us, we are creatures of habit and change is hard. When attending a multi-day meeting, do you tend to sit in the same area of the room each day? Do you have a typical routine for breakfast or getting ready for work? There is nothing wrong with a certain amount of predictability in life, but change can be an impetus toward excellence, a teacher, an opportunity for growth and a lesson in thriving or resilience.

As Juliana Preston mentioned in her recent blog, our amount of resilience isn’t fixed. Quoting Sheryl Sandberg, “Resilience is the strength and speed of our response to adversity [or change]—and we can build it. It isn’t about having a backbone. It’s about strengthening the muscles around our backbone.”

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Recommendations for Medicare’s Future Quality Improvement Initiatives

Group meeting

In my last post, I put forward some core “change principles” to guide our communities in working to transform the U.S. health care system. In this installment, I’ll try to apply those principles in recommending ways to enhance the value of the quality improvement work that HealthInsight and similar organizations perform for the Medicare program.

As the nation’s largest single purchaser of health care, the Centers for Medicare & Medicaid Services (CMS) has long been a pacesetter and incubator for change. The Quality Improvement Organization (QIO) program represents the largest sustained investment in large-scale quality improvement in history. HealthInsight has served as a contractor for this program since 1984, and our mission has evolved throughout the decades, at the leading edge of change in this national effort, to address changing goals, changing theories about what drives improvement, and changing models of care and care delivery support.

CMS is now designing its quality improvement initiatives for the Quality Innovation Network-QIOs (QIN-QIOs), spanning the 2019‒2024 contract period. These new initiatives give CMS a crucial opportunity to propel the health care system toward meaningful transformation.

At HealthInsight, we believe that sustainable quality gains and cost reductions will not occur without active participation from every segment of the health care system. Multiple stakeholders need to work together and employ diverse, but aligned, strategies and approaches to drive transformation.

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Change Principles for Health Care Transformation

Doctor, Patient and Family

HealthInsight has worked with providers and patients for more than 40 years to improve health and health care. We feel both proud of and humbled by this experience. Proud, because our services have improved health outcomes and helped transform the care delivered to millions of people. And humbled because experience has taught us that real transformation takes time and sustained commitment—and it is hard. We also know our efforts often fall short of the vision of what is possible. So, in quality improvement terms, we seek to design better models.

In support of our core business of improving health and health care, we seek to be a thought leader, shaping the future of our communities and nationally. We are continually considering and reconsidering the best ways to help our system work better. In that spirit, we’d like to share some of our ideas.

Broadly, we believe that sustainable improvement will happen only when patients, providers, payers and purchasers come together at the community level to promote, demand and support transformation based on the following change principles.

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Look for the Lean Routine

People taking Notes

This past month I was lucky to attend a workshop on Lean Rapid Process Improvement hosted by Qualis Health, the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) serving Washington and Idaho. As our organizations hold similar contracts in Oregon and Washington to perform external quality review of the states’ Medicaid programs, Qualis invited me and three of my HealthInsight colleagues to provide an outside perspective on their efforts to “lean up” their workflow processes, with the goal of providing better value to the State of Washington.

The invitation excited me because I had heard a lot about Lean workshops but had never been able to participate. I knew that Lean manufacturing principles―aimed at minimizing waste in a system without sacrificing productivity―could be applied to non manufacturing settings, but I had not actually experienced it.

Over the course of the three-and-a-half-day workshop, we examined a process map that Qualis had developed for one of its workflow processes, with an eye toward reducing waste. We looked for eight types of waste: defects, overproduction, waiting, non utilized people, transportation, inventory, motion and extra processing.

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Tips for Strengthening the Feedback Loop

Doctor viewing scans on a computer

Very early in my career I worked for an organization that placed a high value on building staff skills to communicate effectively, including training in how to give and receive feedback and how to coach others to do the same. I still think about this a lot, and given the headlines about how 65 percent of employees want more feedback (and the number increases for employees under 30), there is a lot of information out there about the importance of improving this skill.

It seems like such a simple thing, but it turns out most of us are pretty bad at giving feedback. There are a lot of reasons – we prefer to avoid conflict, we don’t want to be unkind, we don’t have time. These feelings are largely rooted in assumptions we have about how people feel about receiving feedback, many of which don’t reflect reality.

Here are a few of my favorite resources on feedback – they are all quick to check out and easy to digest!

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Will Mergers and Acquisitions in Health Care be the Disruptive Force We Need?

Doctors

There is still uncertainty about federal funding for the upcoming fiscal year, at least until March 31, the next pending deadline on the federal budget. At the end of December, Congress provided the Children’s Health Insurance Plan (CHIP) with $2.85 billion to keep it funded through March. Will they fully fund CHIP to cover the program for the year or leave it to the states to cover the gap? They have also provided community health centers with $550 million. Will they provide full funding or again leave it to those providers and states to figure it out? Will there be any activity from Congress on reducing drug pricing? Likely not, but the FDA is working to bring lower cost generics to the market in attempts to promote competition. There is also discussion regarding congressional work on entitlements such as welfare, Medicaid and food stamps, but there is not a strong consensus between the House and Senate nor along party lines―particularly with 2018 being an election year. So, we will have to watch congressional activity and await outcomes.

So, with the stalemate we see right now on the policy side at the national level, many private sector players are taking things into their own hands. They have not seen the health care sector transforming as quickly as it needs to, so many private sector players are positioning themselves as intentional disruptors in health care and particularly in the health care delivery system. In the last quarter of 2017 we saw horizontal, vertical, regional, national, large and small scale mergers and acquisitions take place. Many of these mergers appear positioned to shift care away from hospitals in order to reduce medical spending. Will that tactic be the magic bullet? We’ll have to wait and see.

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Radical Resolutions

New Years Resolution

As I reflect on this past year and prepare for new challenges in 2018, I have been inspired by the Institute for Healthcare Improvement (IHI) Leadership Alliance’s 10 guiding principles or simple rules for radical health care redesign. As we move into a new year, it seems appropriate to revisit this simple, yet thought provoking, guidance for quality improvement in health care.

  1. Change the balance of power. Co-produce health and well-being in partnership with patients, families and communities.
  1. Standardize what makes sense. Standardize what is possible to reduce unnecessary variation and increase the time available for individualized care.
  1. Customize to the individual. Contextualize care to an individual’s needs, values and preferences, guided by an understanding of what matters to the person in addition to “What’s the matter?”
  1. Promote well-being. Focus on outcomes that matter the most to people, appreciating that their health and happiness may not require health care.
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The ABCs of Diabetes Education

Students

My father died at age 58 from complications of Type 2 diabetes when I was still in high school. Following his diagnosis, he developed chronic kidney disease, lost two toes to amputation and faced heart challenges that ultimately led to his passing. Because of my family history, my doctor is concerned about my own diabetes lab values and talks to me regularly about the disease.

In my work life, I interact with groups of dedicated Utahns trying to support and help patients with diabetes. The Larry H. & Gail Miller Family Foundation donated $5.3 million to the University of Utah health care system last year on World Diabetes Day to help prevent the growth of diabetes in our state. Larry H. Miller, former owner of the Utah Jazz, died in 2009 from complications related to Type 2 diabetes. A few years ago, HealthInsight worked with the Miller family and the Utah Department of Health to produce a heartfelt TV commercial that aired for six months.

Type 2 diabetes is a difficult and costly disease to treat. Though it typically develops after age 40, it has recently begun to appear with more frequency in the younger population. Those with a Type 2 diabetes diagnosis manage their disease through a combination of treatments, including diet, exercise, self-monitoring of blood glucose, and in some cases, medication. Most health problems resulting from the condition can be lessened or avoided altogether, which is why education is key to prevention, reduction and improvement in quality of life.

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Quality Improvement Fundamentals and MIPS

Stethoscope and money

Connecting basic quality improvement (QI) work to new government programs can be a bit of work. A case in point is the Merit-based Incentive Payment System (MIPS), one of two payment tracks for Medicare Part B clinicians under the Quality Payment Program.

If your practice takes part in an Advanced Alternative Payment Model (AAPM), you don’t necessarily need to participate in MIPS unless your AAPM requires it. Most AAPMs do require participation in the same requirements of the MIPS program. So, in most cases you’ll need to participate in MIPS (or prescribed components of it for your AAPM) in 2018 to avoid a negative payment adjustment. And starting in 2020, the cost of care you provide will affect the way you get paid for Medicare services, based on your MIPS performance in 2018.

The four variables of MIPS―Costs, Quality Reporting, Advancing Care Information and Improvement Activities―will all count toward a performance score that can swing your payment as much as 5 percent downward or upward, depending on your performance. Costs will account for only 10 percent of your overall performance score in 2018 (for 2020 implementation), but will increase to 30 percent of your score in 2019 (for 2021 implementation), as it affects your payment fee schedule from Medicare.

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What I’m Grateful for This Holiday Season

family at the park

Three-and-half years ago, my brother-in-law was diagnosed with Amyotrophic lateral sclerosis (ALS) also known as Lou Gherig’s disease. ALS is a progressive, terminal neurological disease.

Believing that laughter is always the best medicine, we made a lot of jokes, including that I, his sister-in-law, was eventually going to kill him (my initials are ALS, Amy Lynn Schmidt).

Over the past three years, ALS has slowly robbed Chris of his ability to walk, feed himself and breathe independently, and yet he has managed to make the most of every day, even from his wheelchair – cruising along the Italian coast to celebrate his 25th wedding anniversary; fishing in Sunnyside with his two sons; and rolling up to the bar at his favorite watering hole to drink as much craft beer as my sister will allow. His mantra has been “do what you can do.” And he’s done more than most.

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Something Is a Foot

Holding hands

In the last month, I’ve suddenly become very familiar with a podiatrist. Two of my sons and my wife needed to be seen for three different health concerns within three weeks, which included outpatient surgery for my wife. All of these visits provided a very intimate picture of our health care system for me, and I was reminded of why HealthInsight is doing the work we are doing. Although, I’ll admit that oftentimes I feel removed from our endeavors by being so focused on the technology and related processes supporting our work, the past few weeks have been a reminder of how closely I’m tied to this work.

Here are a few of my experiences:

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Resiliency: What is it anyway? And Where Can I Find Some?

Hiker at summit

It is pretty difficult to work in the health care setting without hearing about the plague that has infested the majority of the workforce: burnout. The pressures of caregiving, budgets, bottom lines, quality scores and regulatory burden have been named as a few of the causes. As leaders in health care, we have acknowledged the illness and pinpointed the cause of burnout, but continue to struggle to find a cure.

The impact of burnout is widespread. A 2013 study by the Luican Leape Institute at the National Patient Safety Foundation found health care workforce injuries are 30 times greater than other industries, 60 percent of physicians surveyed were considering leaving practices, 70 percent knew a physician who left due to poor morale and 37 percent of newly licensed registered nurses were thinking of leaving their job. It seems that in our efforts to transform the health care system, we have neglected the very people carrying out the transformation. In the search for relief, many health care organizations have worked on building the resiliency of the workforce. Resiliency is the ability of people to cope with stress or crisis, and then rebound quickly.

Sheryl Sandburg, Facebook executive and author of Lean In, recently found herself in desperate search for resiliency when her husband died suddenly while they were vacationing out of the country. In her latest book, Option B: Facing Adversity, Building Resilience, and Finding Joy, she describes the first few fragile days and months following his death, and her quest for a way to live through the pain. She thought that “resilience was the capacity to endure pain” and wanted to know how much resilience she had. However, she discovered that our amount of resilience isn’t fixed, and we should instead ask how we can become resilient. “Resilience is the strength and speed of our response to adversity—and we can build it. It isn’t about having a backbone. It’s about strengthening the muscles around our backbone.”

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What if we run out of antibiotics?

microscope

Antibiotics were miracle drugs in the 1930s 40s and 50s. After Scottish researcher Sir Alexander Fleming accidentally discovered penicillin in 1928, he was quoted as saying, “One sometimes finds what one is not looking for. When I woke up just after dawn on Sept. 28, 1928, I certainly didn’t plan to revolutionize all medicine by discovering the world’s first antibiotic, or bacteria killer. But I guess that was exactly what I did.” Previously life-threatening diseases became treatable and many new drugs were developed between 1950 and 1970, making this the “golden era” of antibiotics.

Unfortunately, Alexander Fleming’s warning that “overuse may cause mutant bacteria” also started to come true around this time, and, as antibiotics were used more and more both in humans and in animals, even antibiotics developed to treat resistant strains became ineffective. Coupled with the fact that drug companies may not be as focused on developing short-term medicines than those needed for life, new drug development slowed substantially, coming almost to a halt in 2010.

So, what does this mean for us? Will stories about antibiotic resistance become more typical, like one from a HealthInsight staff member who has shared about a very scary time a few years ago when she had an infection that was resistant to all oral antibiotics? This infection required two rounds of intravenous antibiotics and spurred the fear that they may not work. Are stories like the woman in Reno, Nevada, who died in early 2017 of a resistant infection that no U.S. antibiotic could treat going to be more commonplace? I truly hope not. I sincerely believe that the global effort around preserving antibiotics and reducing resistance will succeed. A national action plan was initiated in 2015 in response to an executive order from President Obama. This action plan includes goals to accelerate the development of new drugs and diagnostic tests as well as to increase surveillance of infections and work together with International partners to slow resistance.

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“Just the Facts, Ma’am”

In the 1950s, a popular, long-running TV series titled “DRAGNET” featured two, serious-as-a-heart-attack Los Angeles Police Department detectives: Sergeant Joe Friday and his partner, Officer Bill Gannon. Every week they set out to investigate and solve serious crimes in the big city. After viewing one episode, you could tell that neither of these two, steely, uber-committed police officers had a single political bone in their respective bodies. They were all about getting to and understanding the facts—the truth. And, with the facts and the full truth, they could then do the hard work to solve every otherwise difficult and confounding case.

In our modern times of partisan politics, social media and the daily news cycle, there is often very little focus on objectively examining the facts, on finding common ground and on solving many of the great problems of our day. However, the greatness of our country is demonstrated whenever we and our leaders find ways to unite and to gain principled consensus; to find the best, most practical, if imperfect, solutions to the challenging issues of our day.

So, here are some hard-to-ignore facts on an important and daunting challenge: Federal spending on entitlement programs (Social Security, Medicare, Medicaid, the Affordable Care Act) continues to grow at ever higher rates—as a percent of our gross domestic product (GDP), and as a portion of federal revenues. Also, the cost of interest payments on the national debt will rise precipitously over the coming years as large deficits continue to accrue and as artificially-low interest rates rise to market levels. Eventually, this predictable deficit spending will overwhelm the federal budget and lead to a fiscal crisis—if our national leaders fail to control the growth of spending and the cost-drivers within the system.

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The Power of Prevention

Mom kissing baby

A few years ago, I watched as a childhood friend was diagnosed with diabetes and then multiple other related co-morbidities in rapid succession. It has affected every aspect of her life and was caught much later than it should have been, exasperated by years of lacking access to health insurance and preventative care. As her friend, I knew on some level for that she was at risk of developing a chronic condition and did my best to support her, but was unsure how to help her change her circumstances. I’ve worked in a health related field for most of my career, but this experience has further driven me to want to advance prevention and understand what people truly need to stay healthy.

An alarming 1 out of 3 adults has pre-diabetes. And of those, 15-30 percent will develop Type 2 diabetes within five years. Not only is diabetes emotionally, physically and financially costly for individuals and their families, it accounts for 23 percent of total health care costs annually in the United States and is highly associated with heart disease, which is the leading cause of death worldwide.

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Cost of Medications

Needle and Pills

Over the past year we’ve heard about terrible price increases in the EpiPen® and how horrible this skyrocketing was because it’s a lifesaving medication. There’s no doubt that the EpiPen is lifesaving, but what qualifies a medication as lifesaving? Any medication that controls an acute or chronic medical problem is lifesaving.

As an endocrinologist, to me the most common lifesaving medication is insulin. Let’s look at what has happened due to the costs of insulin. Retail costs of newer insulins can cost up to $500 or even $600 per month. Older ones can cost about half that. And copays can range from $40 to $150. Patients sometimes tell to their physicians that they’ve stopped their insulin because they can’t afford it. In fact, some have reported that they stopped their insulins and ended up in the hospital, but their hospital copay was less than their prescriptions. Older patients have said that they stopped their insulins when they hit the “doughnut hole” in Medicare.

If you go on the Good Rx website, you’ll find that you can get regular or NPH insulin (an intermediate insulin) for around $27 each. I’ve sent patients in two different states to Wal-Mart pharmacies to buy these insulins, and they have all been told that Wal-Mart doesn’t have anything comparable to these prices. Many pharmaceutical companies offer discount cards that enable patients to purchase a month’s supply for $10 to $25 for up to 12 months. But, to get these cards, you must meet eligibility requirements. And if you’re on Medicare, Medicaid, Tricare, VA, Department of Defense or similarly federally or state-funded programs, you won’t qualify. One bright spot is that Federal Employees Health Benefits Program members do qualify.

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Celebrating Achievements in Health Care Quality

Doctors and Nurses

HealthInsight is acutely aware of the challenges health care providers face in improving the quality of care. We work hard with our community partners to advance quality initiatives that sometimes seem to take a step back for every two steps forward. In the midst of our labors, it behooves us to pause now and then to celebrate our successes.

Since 2004, HealthInsight’s Quality Award program has recognized Medicare-certified providers who demonstrate excellent performance on publicly reported quality-of-care measures. We created this program to encourage providers to invest in quality and systems improvement, and to promote transparency in measures of safety, quality and patient experience of care.

Public recognition of top-performing providers not only motivates other providers to improve their performance, but gives consumers information they can use to make choices about their own care. Our awards also tie into the nationwide movement toward paying providers for the quality of care they deliver.

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Pitfalls of Analytical Product Development and How to Escape Them

Data Analytics

Our health care analysts build data-driven products (dashboards, reports, etc.), and they think through all of the technical implementation steps required to make these products successful. The next step determines the success of the product: pinpointing and avoiding the potential pitfalls that can undermine its usefulness. These pitfalls include:

  • Failure to understand what we really mean by "business intelligence"
  • Poor understanding of the users of our product and their needs
  • Poor data management

Often data sources look like a dangerous cocktail of social determinants of health coupled with genetic, environmental and clinical data with other information thrown in. Finding a meaningful way to manage these data and capitalize on the value of the information can be challenging.

Let’s look at the end user of our analytical products – the provider. The volume, variety and velocity of available information can far exceed any professional’s abilities to process and interpret. For example, our Partnership to Advance Tribal Health (PATH) participating hospitals are bombarded and confused by multiple layers of mandatory reporting and dashboards provided by local area offices, their Medicare Quality Improvement Networks, their Hospital Improvement Innovation Network organization, tribal epidemiology centers, state departments of health and many more organizations.

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Why Talking Matters

speech bubbles

Late last year I decided to tackle a topic I had been putting off for quite some time – having the dreaded end-of-life conversation with my family. No, I am not ill (thankfully), nor are my loved ones currently going through a difficult situation. However, I think it’s important to have these discussions while my family and I are in good health, without the added pressure of chronic disease or terminal illness.

I decided to start the conversation with myself and then talk with my husband, adult children, sister, mother and so on. I wanted to make some decisions about what was important to me so that others wouldn’t one day find themselves trying to figure that out for me. I love my family, but do they know what matters most to me?

I live in a house where I am the only female, so history has taught me to be at least a little skeptical that my husband and sons would be in tune with my personal wishes. I’m thinking they could use a little help in that department and would be grateful to receive it – God forbid they would need to act on it anytime soon.

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