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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

Pills

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

waterfall

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

Nurses

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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More staff please. California staffing ratio bill heats up dialysis industry.

Doctors and Nurses

There is a lot of debate happening these days in California around a proposed staffing ratio bill that has been introduced. It has led to considering the impact this would have on the quality of care for the dialysis patient in California. The Conditions for Coverage that govern dialysis providers nationally give this guidance: "Adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of the patients." Now that is adequately vague.

SB 349, the Dialysis Patient Safety Act, introduced by state senator Ricardo Lara, D-Bell Gardens, proposes a 1:8 nurse to patient ratio, a 1:3 patient care technician to patient ratio, and a 1:75 social worker to patient ratio. When compared to the nine other states that have already passed laws with some kind of staffing ratio language included, California would hold the most stringent ratios.

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Keeping You Updated: Working Toward a Transparent Health Care System

Provider taking blood pressure

Encouraging, creating and improving transparency in health care is a priority for us here at HealthInsight. So much so that transparency is a major part of our Ends policies that guide and direct the work we do here. Transparency in health care means having the right information available to the right people when they need it.

As part of the work to create a transparent health care system, we have created and worked to continually improve our UtahHealthScape website. Late last year, the website underwent a major renovation, which included reworking the look and feel of the site, improving mobile optimization and adding new data to better serve patients, providers, health care facilities and the community in general.

UtahHealthScape is continually being updated to better serve our community. Data from the Centers for Medicare & Medicaid Services Nursing Home Compare, Home Health Compare and Hospital Compare has been updated and added to UtahHealthScape. We have also added locally sourced information about HealthInsight Quality Awards, Community Health Information Exchange (cHIE) participation and nursing home participation in a community coalition to reduce potential adverse drug events for new patients.

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Saving for your Retirement – and your Health

Piggy bank with money

When it comes to satisfying our immediate needs and desires versus focusing on important future needs, the here and now usually wins out. And whether it's saving for our future retirement security or taking important, incremental actions now to achieve better, future health security, our innate, psychological tendency is to prioritize the present over the seemingly far-away future. People tend to allocate their limited time, resources and attention to immediate, pressing events, rather than focusing on important things that will happen at some much later point.

What can make wise behavioral health actions even more challenging than saving money is that the hoped-for improvement in our future health outcomes is much less tangible and predictable than, say, the size to which one's retirement fund balance will grow over time.

Here are a few ways that you can motivate yourself to act sooner in your own, long-term interest - whether your goal is a healthier retirement nest egg or achieving better health throughout your retirement years.

Envision the Future

Academics and behavioral psychologists are discovering ways that you can change your point of view and thereby create essential tension you will need to change your behaviors.

In one study, researchers at Stanford University were able to make the future feel more vivid, real and immediate by "age-morphing" photos of study participants into avatars of their older selves. (Just what we all want to view, right?) When those participants stared their future, aging selves in the face, their short-term perspective shifted. They became much more motivated to save for the future.

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Focus on the fundamentals

Kids playing basketball

Round the back, under the legs, and...It's a miss!

Don't you love March Madness? Go Cougars, Ducks, Beavers, Lobos, Bruins, Trojans, Rebels and Utes (if your team is missing, please add them somewhere in between the Cougars and the Utes).

I love to play and watch basketball. From ages 13-15, I would get up at 6 a.m. nearly every day to practice the fundamentals of shooting foul shots and layups at the hoop outside my home. With the ultimate goals of scoring and winning the game, the fundamentals are the best way to ensure that the ball will go in the hoop.

I love quality improvement too. You set your aim and goal; create your plan; use outcome, process and balance measures to guide the effort; put it in practice; and study the outcomes. When it works, you save people from mistakes, help them realize how to manage their care better and catch people before they fall through the cracks.

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Who knows us best?

Providers and Patients

Why concerned family members matter.

We talk a lot about patient and family engagement at HealthInsight. I'm sure it is on the mind of most health care professionals at some level. But building this into our day-to-day muscle memory of how we respond in situations is still pretty rare. I would like to tell a story of a dear friend of mine who recently dealt with the lack of patient and family engagement and all it is intended to prevent.

This is a 75-year-old man, overweight, not in horrible shape but who has long suffered from breathing problems (frequent bronchitis, sleep apnea, etc.). He has desperately needed a knee replacement for as long as I've known him but was very reluctant to take such a drastic step. Finally, he knew he didn't have any choice and made the decision to proceed. He researched local surgeons and settled on one with full confidence that he had picked the best in the area.

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Are We Providing Patient-Centered Care?

Providers and Patients

There are many definitions of "patient-centered care" or "shared decision making" floating around. But most agree that it ideally includes certain aspects such as:

  • Consideration of the patient's preferences and needs
  • Integration of care through the teamwork of all providers involved
  • Respect for the non-medical needs of the patient and family
  • The patient's physical comfort
  • Free flow of communication among the patient, family members and medical team members

When I first heard of patient-centered care, I was somewhat perplexed. It reminded me of my own situation when I was 12 years old and had just been found to have a chronic medical condition. Our family internist sat down with me and my parents and explained that this was a problem that I would have for the rest of my life. He told us that there would be ups and downs, but that it was manageable. He went over the treatment options and asked what we thought would work for us. I have always considered that situation to be an example of patient-centered care.

Since then, there have been two big changes. The first change is the formation of care teams working together for the benefit of the patient and family. This has been a great help, but at times someone tries to force members of the care team on the patient. When that happens, we start to negate the positive effect of the team. The patient's perspective always needs to be considered. The second change is the free flow of information found online. Half of patients, both old and young, have already looked up their provider's credentials on the Internet before their first visit. Sometimes the patient will get false or dangerous information about either their provider or their ailment. This information must not be brushed aside, rather explained why it is not correct or appropriate for their condition. Then the patient should be directed to good, evidence-based care websites for more information. The Internet can be an ally in the patient care, almost like a team member when used correctly.

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Patient Engagement: A Passing Fad or Revolution?

Family

At the end of February, I had the privilege of attending the 2017 Patient & Family Centered Care Conference, presented by PFCCpartners. Immediately, I was struck by the growth in attendance and the depth of the presentations highlighting best practices and innovations in patient engagement. I first attended this conference as the sole representative from HealthInsight in 2012, wanting to start the journey of Patient and Family Advisory Councils for HealthInsight Utah. This year, HealthInsight was represented by eight staff and six patient and family advisors from Nevada, Oregon and Utah-it is safe to say that patient engagement is here to stay.

Wendy Nickel, MPH, from the American College of Physician's Center for Quality and Patient Partnership in Healthcare, kicked off the conference by providing an overview of four key principles of patient engagement:

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A Rallying Call for Value-Based Health Care

stethoscope with money

As a part of my professional development, I was certified by the National Committee for Quality Assurance (NCQA) as a Healthcare Effectiveness Data and Information Set (HEDIS) auditor in 2001. I have kept this certification while expanding my skills to include data validation and Pay for Performance Value-Based Program (P4PVBP) certification as I began to recognize the changing environment and the potential shift to VBP.

With today's uncertainties in health care, the NCQA has joined several health care organizations in a call for a new model of care. In a letter to Congress and the administration, these groups have endorsed a shift from the fee-for-service health care system to value-based care. NCQA and its allies (doctors and specialty societies that represent physicians, health plans and payers) have developed a set of recommendations on how to move our health care system toward innovative, patient-centered care. These recommendations include:

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Patient Portals Wish List

Senior Couple Using Computer

Recently, when I arrived at my new dermatologist's office, I noticed an iPad was sitting on the counter instead of a clipboard, and a patient was working his way through the sign-in process. The receptionist handed me a clipboard with several sheets of paper, instructing me to fill them out. She explained that, by later that afternoon, all of my information would be in a patient portal, a secure website that gives patients 24-hour access to personal health information, and I would be able to update it, if needed.

As promised that afternoon, I received an email with a note telling me how to log in. After clicking the link and following some simple instructions, I arrived at a dashboard that prominently showed my next appointment and links to other areas of my record. The information from the forms I had filled out was there along with the notes from the visit. Two weeks later, I wanted to access the portal to see if my lab results were in. I couldn't remember the link to the site or locate the email, so I went to the clinic's website and found a link to the patient portal. The portal was easy to use, and I had all of my information right at my fingertips.

I am somewhat familiar with patient portals because I have used them before. Another portal I occasionally access, while offering secure emailing, summaries of visits, prescriptions and labs, is a bit "clunky" to use. It provides the basics; it's just not as easy to use.

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Changing the Conversation from Health Care to Health

Senior man sitting with his daughter and grandson

I was excited to hear Dr. Tom Frieden, former director of the Centers for Disease Control and Prevention (CDC), speak at this year's Centers for Medicare & Medicaid Services (CMS) Quality Conference about the importance of moving "upstream" and strengthening the relationship between community-based prevention services and health care. This is a topic near and dear to my heart, as I started my career working in public health to help communities improve the systems that support community health and prevention. Now that I work in health care quality improvement, I see daily the health care community's challenges and opportunities in not only providing good health care, but helping people achieve health.

Most of us who work in health have learned that there are significant limitations to what the health care system can achieve alone. Our systems of care must change to meet the growing burden of chronic disease.

Cardiovascular diseases, pre-diabetes and diabetes are at a record high. According to the CDC, cardiovascular diseases are the leading cause of death in the United States. Nearly one in 10 Americans has diabetes, and without intervention, this number will likely continue to grow. More than one-third of American adults have pre-diabetes, an estimated nine out of 10 of don't know they have it. The good news is many risk factors for these conditions can be prevented or managed with lifestyle changes between visits to the doctor. Success, in many cases, depends as much on lifestyle as it does on quality care.

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The Power of Love

young hands holding older hand

Last month we lost two classics from the silver screen – Ms. Debbie Reynolds and her daughter Carrie Fischer. Their deaths came just one day apart when Ms. Reynolds died from what many have declared as broken heart syndrome, after suddenly losing her daughter the day before. Ms. Fischer, profoundly known as Princess Leia from the epic Star Wars film series, followed in her mothers' footsteps most of her life and just like her mother, she landed in the movie business before the age of 20. Both of these women left behind tremendous legacies and have amazing personal stories filled with both joy and triumph. As the world learned about Carrie's untimely death, just hours later came the news of her mothers' collapse. Carrie Fischer and Debbie Reynolds will always be remembered for their talent and iconic roles in some of Hollywood's finest movies, and their deaths will forever remain synonymous.

Wait a minute, let's back this up. Dying of broken heart syndrome? Is that a real thing? Is it truly possible for somebody to die from a broken heart? As is turns out, yes, there is real evidence that you can die from a broken heart, and in fact, it makes perfect sense. Grief is similar to other powerful emotions such as anger, anxiety or loneliness, which are all just different forms of stress. Stress has a powerful impact on our health, especially the health of our heart. According to the American Psychological Association, stress is a complicated condition that has a huge negative effect on our bodies and almost always manifests itself in physical symptoms. Additionally, and not surprisingly, we understand anger has a direct connection with increased risk of cardiovascular problems. When we see somebody expressing and venting a lot of anger we might think, "Man, this guy's going to have a heart attack!" Grief is really no different. The Mayo Clinic describes broken heart syndrome as a "temporary disruption of your heart's normal pumping function in one area of the heart ... which may be caused by the heart's reaction to a surge of stress hormones."

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