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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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We Can’t Let Inertia Set In!

Hands in a circle

Many of you may be wondering what will happen with federal legislation to either repeal or replace the Affordable Care Act. And we’re equally curious when it will happen. Many people have told me, “Surely, by the fall we will have some legislative fix around repeal or replace.” I don’t think that’s very likely. In fact, I don’t think it’s even very likely to happen in this calendar year. There are too many special interests and not enough working across party lines to reach consensus or alignment around the core issues impacting health care. The current discussion has essentially focused only on health care coverage – which is critical, but it hasn’t even touched the areas of changing how we provide health care, how we pay for care, the supply of health care professionals, and the innovative part of health care that we need as we move into this new health care environment. We have seen lots of talk but, as of yet, no real movement over the last couple of months. So, for now the Affordable Care Act is still the law of the land.

It’s anyone’s guess as to whether the gridlock in Washington will be resolved any time in the near future. For this reason, we must not allow inertia to set in. We have a broken health care system and we can’t expect that any one federal or state policy will fix it. There is so much uncertainty in all sectors of health care that you can almost sense the inertia beginning. We can’t let that happen: we need to continue to push and innovate transparency in the system around quality and cost; we need to continue to support and fund innovation; we need to continue to pilot and experiment with different payment models; and ultimately, we need to continue to push for the new health care system of the 21st century.

It’s hard work, but those of us in the trenches must roll up our sleeves and identify new partners to align with in order to drive toward a new agenda for health care. We must support our colleagues and providers on the ground in their day-to-day efforts to create a higher quality, more efficient system and walk hand-in-hand with them in a spirit of experimentation. We can’t go backward: we need to continue to look forward in our vision of how health care can and should look. We’re the torch bearers and we must continue to carry the torch forward.

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The Path of Totality—Did You See It?

Solar Eclipse

A young man, transported from 20th century Connecticut to King Arthur’s court, finds himself in a pickle, and tied to a stake for performing acts of sorcery. He happened to have an almanac with him and knew that a solar eclipse was about to occur. He warns the king that he will make the sun disappear, and on cue, the sky darkens and the sun sinks into a black hole. The king pleads with him and the young man agrees to make the sun reappear in return for his freedom.

Whenever I hear about a solar eclipse, I can’t help but think about Bing Crosby in the 1949 movie, “A Connecticut Yankee in King Arthur’s Court,” an updated version of Mark Twain’s 1889 novel. That particular scene portrays a historical representation of omens and superstition that have accompanied solar and lunar eclipses for centuries.

Today, we know that a total solar eclipse occurs when the new moon passes between the earth and the sun at a distance where the moon and the sun appear to be the same size. If in the path of totality, you would see the sun disappear for a short while, followed by images that are described as truly magnificent. The hype leading to the 2017 eclipse led millions of people to flock to the path of totality to observe what could be a once in a lifetime experience.

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Working Upstream

Granddad and granddaughter fishing

Summertime in the Pacific Northwest is a great time to catch a glimpse of salmon making the life and death journey swimming upstream back to the place of their birth.

We often talk about working “upstream” with patients with kidney failure and how critically important, yet difficult, this work can be. One out of seven Americans (30 million!) has chronic kidney disease (CKD), often referred to as the “silent killer,” due to symptoms that are undetectable until it is too late. Not only is CKD a growing public health threat, but the health care costs associated with CKD and end stage renal disease (ESRD) represent more than a quarter of all Centers for Medicare & Medicaid Services (CMS) claims.

Nephrologists who care for kidney patients have increasingly expressed their concern for the lack of care for patients in the early stages of ESRD (stage 1-4) before kidney failure (stage 5). Dr. Louis Cotterell, a nephrologist and member of the ESRD Network board of directors, relayed the importance of working “upstream”, he said:

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Medicare Payment Reform Ramps Up: How Are We Doing?

It’s been five years since the first Pioneer Medicare Accountable Care Organizations (ACOs) formed, marking the beginning of Medicare payment reform and now one year of the Quality Payment Program (QPP) is up. So, how are we doing? And what can we still learn as it rolls out? The QPP was created to implement Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and if we’ve learned anything in the first year, it is that practices need support to make the changes needed to be successful. I want to highlight three recent articles that have given me pause and can give us direction for our efforts on the path from volume to value.

In the past quarter, a few interesting reports on MACRA and QPP have been published, framing the current status of provider participation, understanding, and potential impact of payment reform. Two reports take a pulse of American physicians. First, the American Academy of Family Physicians (AAFP) self-report Annual Member Survey of 2017 looked at member family physicians and found that 83 percent of reporters take Medicare patients, a record high in the last decade for family docs, yet only 50 percent consider themselves “somewhat-to-very-aware” of QPP/MACRA. And earlier this year, 45 percent reported being “undecided” on their plan to participate in MIPS or APMS.

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Medicare, Up Close and Personal

Senior Couple Gardening

Several months ago, I began receiving a flood of letters and phone messages from health plans, insurance brokers and others, reminding me—as if I needed reminding—that I was about to turn 65. “It’s almost time!” they said. “Congrats in advance!”

They were concerned about my future health coverage and wanted me to get the most out of life. They understood my confusion and were there to help. Some even offered me a free meal.

“You have a limited window of time to enroll,” they warned. “You have options, we have answers. Give yourself the coverage you need. You owe it to yourself…”

Not getting enough love from strangers? Join the Medicare marketing cohort!

Joking aside, Medicare is about to get up close and personal for me. Until lately, I thought of it as a nebulous bureaucratic system I would need to engage with “one of these days.” Even as a communicator for a Medicare contractor, I sometimes found it hard to relate to the quality-of-care issues our organization grapples with every day. Now the program and its future have my full attention.

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Health Cost Reform – Whose Ox Gets Gored?

Healthcare costs

There has been much ado in the news about health care reform, health coverage reform, health payment reform and clinical practice reform. All are tangential references to the real elephant in the room — health cost reform.

Why has the elephant grown so large? Is there a combination of diet and exercise that can help our elephant become slim and trim?

Your perspective on the reasons and solutions depends on the part of the elephant closest to you. If near the poor, unhealthy, uninsured patient part of the elephant, mandatory affordable health insurance for all is the ticket. If near the insurer part of the elephant, your focus is reducing the discretionary price-gouging, cost-shifting and wasteful choices of consumers and providers. If near the employer and plan sponsor part, you may wonder whether replacing employees with robots may be the better way to avoid health costs. Those near the care and treatment part fuss about the onerous rules, processes and habits that interfere with engaging patients in achieving and maintaining better health. Those near the social and mental health part of the elephant see a need for allocating more resources to prevention and education than to rescue.

Everybody sees that the big elephant is crowding out other important things desired for the room, such as wage increases, job protection, life choices, equitable access and security.

All parts of the elephant need to shrink to a more normal size. The March 2013 Time Magazine article by Steven Brill - Bitter Pill, Why Medical Bills Are Killing Us describes many wasteful practices that perhaps could be curtailed. But where do we start? Whose ox gets gored?

We Americans tend to prefer "nudges" to affect sustained change rather than voting for more government mandates typical in other lower-cost countries. Therefore, perhaps we should leverage all available resources to favorably influence the choices of health care users and providers to affordably improve our health.

We need to seek first to understand and prioritize what is most important.

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Auditor, Audit Thyself

MW Blog 7 14 2017 Sandia Crest The Needle sm

Numbers. Numbers can tell us many things, including how good or bad something is. When the numbers are low in my bank account, that’s bad. When the numbers are high, that’s good. As a member of the External Quality Review (EQR) team, numbers are part of my daily routine. As a nurse and an auditor, I’m trained to interpret different numbers. In quality review, numbers tell us about the effectiveness of an organization's objectives. In our personal lives, numbers tell us if we are meeting our own objectives or if we’re headed in the wrong direction.

 

Last year, when our staff underwent biometric screening, I had my blood drawn, just like many of my co-workers. Unlike many others, my numbers were bad. As a nurse, I know about lab results and what patients should do when the results are bad. When I saw how high my hemoglobin A1C was, I paid attention. I knew what this number meant – if I didn’t do something soon, I would soon be diabetic and need insulin, just like my parents. I needed to figure out how to do the improvement.

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Behavior Change and Duct Tape – the Stickier, the Better!

Couple walking

Adopting a new behavior, even one that is good for us, can be difficult. I belong to a gym, and I've come to observe each January with interest. That's when the resolutionists, as I affectionately call them, flood the gym for the first several weeks of the new year after making some sort of fitness resolution. The parking lot becomes crowded and exercise machines are busier than ever. (They really like the treadmills for some reason). While I hope a few new faces will stick with it and become familiar over the coming months, most of the crowd has dispersed by the early part of February and continues to taper over the following months until we're largely back to our usual routine. As I looked around the gym recently, I wondered – what would it take to retain a greater percentage of the resolutionists?

We know that individual behaviors are substantial contributors to our health outcomes, representing about 30-50 percent according to a Health Affairs Policy Brief. But how can we effectively take charge of our own health by implementing and retaining more healthy behaviors?

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As Payment Moves to Value, the Circle of Root Causes Expands

Group in conference room

Over the past 20 years at HealthInsight, I've had the opportunity to work with health care providers and organizations on root cause analysis to learn from sentinel events, patient harms and other negative, unwanted and unexpected events. Seeking to prevent future harms, we've learned that the most important answers to the question "why did this happen?" – the root causes – are often far removed in time and space from the events that occasioned the review.

Cause and effect analysis is a technique employed in root cause analysis that pushes you to consider all possible causes of a problem, rather than just the ones that are proximal and obvious. Forms of cause and effect analysis include the "5 Whys" and causal tree analysis. Analyses using these techniques produce cause-effect chains, with each identified cause itself becoming the effect of preceding causes. When learning and applying either of these analysis techniques, it's not always clear when the analysis stops, because one can always propose a preceding cause – even if you have to go back to the "big bang."

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Toward a Multistakeholder Approach to Payment Reform

Doctors

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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