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Toward a Multistakeholder Approach to Payment Reform


MACRA. QPP. MIPS. Value-based payment. If you feel lost in the sea of acronyms, reporting requirements and systems-level change, you aren't alone. Years of ongoing effort to transform the health care delivery system are now aligning with Medicare's commitment to paying for high-value care, and the change process seems dizzying at times.

Almost everyone agrees that the cost of health care is unsustainable and we must change the way we pay for care. Yet providers, health plans and other stakeholders face significant barriers as they strive to implement and sustain new payment models. System changes come with innumerable intricacies and nuances, including concerns about who wins and who loses. A major challenge is how to obtain and share reliable data to inform and test new models, and to reassure providers who are asked to accept accountability for improving quality while reducing cost. In the midst of these swirling changes, practices have to keep working hard to ensure high-quality care that satisfies their patients.

As I've worked in system change initiatives with multiple stakeholder groups over the years, I've noted all too often that stakeholders tend to work on addressing challenges within their individual spheres—be it a clinical practice, an organization or a network—even though adjustments in one part of the system have an impact on all others. Sustainable change depends on making all adjustments mesh effectively for all stakeholders.

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What is Return on Investment for the QIO Program?

2016 QIO Program Progress Report

Thoughts from a fiscally conservative taxpayer

I have been working for HealthInsight since 1995 and most of that time has been spent operationalizing the Medicare Quality Improvement Organization (QIO) contracts over the years. During this journey, there have been numerous times when the QIO program has been assessed by various entities to determine whether it produces value for Medicare beneficiaries, health care providers and ultimately the U.S. taxpayer who funds the program.

In the effort of being transparent, I believe any taxpayer funded program should be thoroughly reviewed to determine value to the ultimate funder. After all, the U.S. has a national debt approaching $20 trillion or about $60,000 per citizen, so all dollars need to be cherished. If the QIO program is funded in the $1 - $3 billion range—an educated guess—for this contract cycle, what is the estimated return on that investment? What impact, if any, does the QIO program have in driving change?

Being part of the QIO program for over two decades, I have sometimes struggled with my own internal debates and have been defensive when it appears the QIO program has received criticism from various entities for failing to "transform" the health care system or failing to be a cost effective program. I argue of course the QIO program is producing change and transformation. I pull out pre and post measures and data over time to show localized impact as well as community engagement levels. On the other hand, I ponder: is the QIO really a primary lever in any observed changes? Would any of these observed and measured improvements have happened without the QIO program?

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A National Epidemic; Local Experience


Katie has been my dental hygienist for the past 20 years. At my most recent "clean and check" visit, she told me about an encounter she had with the health care system.

She said that after experiencing a headache for a couple of days, she started to notice an odd crackly sound in her ear. She decided to have it checked out at the local quick care clinic. The quick care doctor told Katie she had an ear infection that would require antibiotics.

"What is your antibiotic of choice?" he asked her. "A Z-Pac, antibiotic A or antibiotic B. What do you prefer?"

Stunned, she said she just wanted what would be best to treat the infection. When she got to the pharmacy to pick up the antibiotic, the pharmacist began with an apology.

"I'm sorry," he said, "but we don't have enough hydrocodone to fill the doctor's prescription."

Now confused, Katie asked the pharmacist what he was talking about. He told her that the doctor had ordered 50 hydrocodone to treat her headache. She told the pharmacist not to worry about it, because although she mentioned to the doctor she had a headache, she had not sought treatment for it.

Lying in the dental chair with my head below her hands and a metal tool in my wide-open mouth, she asked, "Does this sound odd to you?"

Where to start?

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HealthInsight: A Top Workplace in New Mexico

Albuquerque Journal Top Work Place

Each year the Albuquerque Journal offers the opportunity for businesses to be considered for inclusion among the state's "Top Workplaces." This opportunity is offered throughout the country and HealthInsight Utah has been recognized before as well. This year and previously in 2013, HealthInsight New Mexico was named a Top Workplace.

Our journey began with an employee first nominating the organization to be considered, which was gratifying in itself. Following the nomination, management has to agree to support the nomination by allowing employees to participate in a survey. Employee responses are what determine an organization's success in the process.

The survey focuses on characteristics of an organization that are related to organizational health and employee engagement.

Among the strengths that emerged from our survey data were that employees believe they are part of something meaningful and that they feel enabled to work to their full potential. Those are powerful statements.

When I'm asked about what's important to me about where I work, the first thing I talk about is that the organization is mission driven. It's heavily focused on improving health status and health care in the locations we serve. New Mexico probably faces some of the greatest challenges, and every day I see staff dedicated to that mission because they feel they are part of something important.

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Finding New Vistas in Health Care


A couple of weeks ago, I was talking with a neighbor who had just completed a 100-mile race across the Bonneville Salt Flats in Utah. He is an adventurer who loves river running, skiing and most any outdoor activity. I enjoy hiking, so we often talk about different trails in Utah. I've lived in Salt Lake City most of my life and feel I'm pretty knowledgeable about local treks, until he told me about the Heughs Canyon waterfall. I had never heard of this waterfall and was intrigued since the trailhead was less than 10 minutes away from my neighborhood.

My wife and I hiked to this beautiful waterfall last weekend and were surprised to find a cave, lean-to and fun bridges on the trail. As I was returning from the hike, I was reminded of the knowledge (and adventures) right under our noses that we often overlook because we don't know where to find them. I was grateful for a friend who pushes beyond the status quo and finds new adventures in the outdoors.

In health care, we are constantly pushing beyond the limits and looking for transformation and innovation to propel our health care system to heights never seen before. Currently, payment reform is big focus. Medicare is taking a leading role with bipartisan support behind the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation and is beginning to roll out the Quality Payment Program (QPP). There is a lot of information and resources about payment reform and QPP that clinicians may not know are available.

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Inspiring Leaders in an Environment of Change

Young Adults

Rapid organizational change can be both exciting and unsettling at the same time. HealthInsight has experienced its share of this kind of rapid change in the past few years—so much so that exciting and unsettling seems to describe just about every day around here. We've seen:

  • Significant corporate growth, most recently by expanding our programs into Oregon and into End-Stage Renal Disease work.
  • Challenging new initiatives on top of our already large portfolio of work for the Medicare program—including but not limited to helping improve the quality of care in Indian Health Service hospitals across the nation, integrating behavioral health screening into primary care and preparing Medicare providers for value-based payment.
  • Regionalization of several of our programs, requiring new ways of engaging stakeholders and coordinating regional activities while maintaining essential local focus.
  • Persistent and pervasive uncertainty and change in the health care environment we seek to influence.

This rapid change in our organization and in the world is very likely to continue into the future as well. But the pace and intensity of efforts to keep up and reinvent our organization has led at times to "change fatigue," similar to the burnout that many of our stakeholders have reported experiencing as they implement multiple, simultaneous and sometime overlapping quality improvement activities.

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United to Save Lives

Man and woman looking at meds

A few weeks ago, I was privileged to join 2,250 other attendees at the 2017 National Rx Drug Abuse & Heroin Summit in Atlanta, put on by Operation UNITE. Billed as "the largest annual conference addressing the opioid crisis," this event brings together professionals from across the nation to discuss how to respond to the epidemic of opioid abuse, misuse and overdose.

Attendees of this summit are acutely aware of the grim statistics. The Centers for Disease Control and Prevention reported more than 33,000 deaths in 2015 from prescription opioids and heroin. That's an average of more than 90 deaths a day of Americans from all parts of the country, all walks of life and all age groups.

As a non-health care professional, I listened for three days as advocates, researchers, providers, clinicians, law enforcement and government officials—including my HealthInsight Oregon colleagues—described efforts to reverse the current trends and save lives. I heard about many initiatives, ranging from prevention of opioid abuse and misuse to addiction services and diversion tools. Several focus areas emerged for me.

  • Reduce unneeded opioid prescribing. Prescription Drug Monitoring Programs are electronic databases that provide a complete history of controlled prescription medications given to a patient. Almost all states have implemented these programs to help physicians and pharmacists detect worrisome prescribing patterns and reduce harmful drug interactions and overprescribing.
  • Consider alternative methods to treat and manage pain. Non-pharmaceutical treatments and non-opioid medications are preferred over opioids for most painful conditions. There is good evidence that non-pharmaceutical treatments are beneficial, with low cost and minimal side effects. These treatments include physical and occupational therapy, acupuncture, chiropractic and massage therapy as well as cognitive behavioral therapy and guided meditation to redirect painful symptoms. Physicians are seeing the value of these kinds of treatments and insurers have begun paying for them. When opioids are needed to treat serious painful conditions, providers and pharmacists play an essential role in educating patients and their families about the risk of opioids and how to safely use, store and dispose of them.
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New ATOP Director Talks Project Progress and Perspective


I fully embraced the opportunity to join HealthInsight Nevada as the director of the Admissions and Transitions Optimization Program (ATOP) in October 2016 and take the reins of the Phase 2 project. It has been an extraordinary six months of learning and leading for me with invaluable professional and personal growth. ATOP began in 2012 with Phase 1 targeting 24 nursing facilities in Nevada to receive supplemental clinical resources by making RNs and APRNs available to improve the health care outcomes of long-term residents and reduce health care costs without restricting access to care or choice of provider. ATOP nurses focused on the training and education of facility staff (CNAs, LPNs, RNs) as well as providing direct care (in a teaching manner) to facility residents. This project was driven by a Centers for Medicare & Medicaid Services (CMS) measurement showing that a staggering 45 percent of hospital transfers for this population are deemed potentially avoidable.

Phase 1 concluded in September 2016 with impressive results. The ATOP project in Nevada reported that total spending dropped 21.7 percent per resident on average and potentially avoidable hospitalization occurrences declined by 25.5 percent.

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Medication Management: No Simple Task

Closeup pills

$320 billion – this is how much money was spent in 2015 on prescription medications, according to the Centers for Medicare & Medicaid Services' Office of the Actuary National Health Statistics.

10 percent – this is the percentage of people who are taking at least five medications a month, according to the Centers for Disease Control and Prevention's National Center for Health Statistics.

We know that older adults are likely to be on more medications to manage their chronic conditions, and we also know that four out of every 1,000 patients visit the emergency room for adverse events related to their medications. Patients see many different providers. New drugs are coming into the market that may interact with others. Transport to the pharmacy may be an issue. Older patients may not be able to hear the prompts to refill a prescription. And, of course, costs continue to rise. How do patients and their care givers keep on top of all of this?

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The Connected Patient

Runner lacing shoes

Wearable technology and the resultant increase in the potential data they can provide continues to spread and evolve. During the holiday season I saw a large increase in the advertising of virtual reality headsets, especially during the Super Bowl. Several commercials during the big game showed grandparents engaging with a virtual reality headset – some with their family around them watching. They were all having very unique and powerful experiences. It was a poignant reminder to me about the far reaching potential of new technology – not only for entertainment, as the commercials were claiming, but for how we could use this type of technology with health care in the future.

An August 2016 article on CNET by Sarah Tew talked about that very thing. She talked about a pair of wireless earbuds, created by Jabra an intelligent sound solution manufacturer. The earbuds can interface with a HIPAA compliant software and provide health data about a patient's fitness level. The earbuds were provided to certain patients (along with a fitness plan) with a primary focus to use the information to treat obesity, cancer and diabetes. The data provided was shared with the physician and the patient at the same time – everyone had the same data at the same time to help make informed decisions going forward! Wearable devices continue to provide an increasingly strong potential for data collection and are evolving from simple watches to ear buds, and in some rarer instances, some devices that are implanted beneath the skin. The potential uses for wearables seems to only be limited by our imagination.

Physicians will need to continue to explore ways to engage patients and help them become an integral part of their own health. As patients feel more engaged and responsible for themselves, in tandem with an ability to actively view and manage "real time" data, they could become more motivated to keep performing activities that move them toward or continue to support a healthy lifestyle.

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