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Complexity Theory of Fixing Health Care

Nurses

When I speak to students I relay the story of graduating from nursing school in the mid-70's and the faculty telling us we were going into a new health care system, it had been fixed-managed care was the answer. Well now 40+ years later I am saying my career has been focused on improving and fixing health care, and guess what we are not there yet!! Don't get me wrong - we have improved longevity in this country, improved diagnostics, technology and treatment, and yes we may even be closer to finding a cure for those long unsolved diseases such as cancer and Hepatitis C. However, this has all come at a cost without evaluating and redirecting the money flow within the health care system. I guess now the question should be will it ever be fixed? At this point I would say no, it will never be totally fixed, we may come up with solutions and address some of the problems but health care is such a dynamic environment and continues to evolve that, quite frankly, I believe we should look at it as a journey rather than a problem to be solved. So pack your bag and be prepared for the long journey (depending on where you are in your career)!

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Five Things That Hit Me as I Read the MACRA Proposed Rules

Group of three doctors

The health care world has been buzzing with discussion about the newly proposed rules around the landmark Medicare Access and CHIP Reauthorization Act (MACRA) legislation that passed in April 2015 with bipartisan support. One year later, the Centers for Medicare & Medicaid Services (CMS) unveiled a proposed implementation plan for this new law. MACRA aims to move the U.S. health care payment system from volume-based care to value-based care. The final rule is expected by year-end, which highlights the need to know a bit more about our road to value. I recently spent some time traveling, so I decided to dive in to the 962-page proposed rule. Here are five things I found interesting and wanted to share.

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Payment Reform: HealthInsight’s Work to Support Alternative Payment Models

Stethescope on money

With the recent announcement of the proposed MACRA (Medicare Access and CHIP Reauthorization Act) rules, health care payment reform is moving full steam ahead, away from the fee-for-service model we have all grown accustomed to and towards new, value-based payment models.

HealthInsight strives to keep our communities, stakeholders and local providers up-to-date on the issues that matter to them, and payment reform is no exception. It's not only important for providers to know how these changes impact them, but it's also important for patient's to understand that the way health care is received and paid for care is changing. Here at HealthInsight are working on many activities to help our communities thrive under the emerging models.

We work directly with providers in our communities, providing support through our Quality Innovation Network Quality Improvement Organizations (QIN-QIO) contracts with the Centers for Medicare & Medicaid Services (CMS), including helping to enroll eligible practices into the Transforming Clinical Practices Initiative (TCPI) and other contracts. We align our efforts to support practices in adopting changes to be ready for new payment model and are seeking funding to help both large and small practices be ready for MACRA when the first measurement period starts in 2017.

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Stretch Goals – Compliance or Inspiration?

Darts

It seems we are always being asked to do more with less. Employers expect higher productivity. Coaches and fans expect more wins. Contractors add higher goals for less money. We expect more weight loss and better fitness with less effort. Oh, and yes, make that long term and sustained. How do we get motivated to do all of this? Does "stretching" our goals inspire us to do better for longer?

The manifestations of motivation are persistent attention and effort to a priority or goal. People sometimes seem to have an innate reluctance to do the right thing- take care of their health, seek extra education, save for retirement and create new solutions. Mark Twain noted, "The only way to keep your health is to eat what you don't want, drink what you don't like, and do what you'd rather not." Younger children seem to do things for the fun of it; they bounce back up and charge forward faster after a fall or misstep. Perhaps replacing judgmental restrictive environments with more encouragement and nurturing could restore natural curiosity and enjoyment of learning and growing.

Educators and employers seem to work on the premise that rewards (gold stars, incentives) and punishments (time out, penalties) will drive sustained behavior changes for the better. Indeed, for simple tasks of short duration, they do work. For instance, a national pizzeria chain collaborated with public schools to offer children who read for 20 minutes every day for one month a coupon for a free pizza; more children read. The program's goal was not to feed children; the goal was to get children to do the behavior long enough to experience the intrinsic joy of reading for themselves.

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Measurement has its Place, but Doesn't Always Tell the Whole Story

Basketball Backboard

I love the game of basketball. There are all sorts of statistics collected – 2-point shots scored, 3-point shots scored, free throw percentage, field goal percentage, assists, rebounds, blocks, fouls, steals, turnovers, etc. The statistics often tell a lot of the story. Steph Curry, point guard for the Golden State Warriors, scored 402 3-point shots this season, setting a new all-time record. Most would view this statistic as success and he was voted the most valuable player in the professional leagues this year. Nevertheless, statistics don't tell the whole story in basketball. Rarely do we quantify hustle, such as getting up the court quickly; team work like sharing the ball with others; or sacrifice when a player dives for a loose ball. These efforts, which few track, are often as important as points scored. Statistics can be focused on, to some degree, successfully (e.g. tonight I'm going to try and get more rebounds in this game). But in my opinion, too much focus on the numbers can be debilitating. There comes a point where you have to go play the game, have fun, do the best you can and not worry about the numbers.

Just as the statistics in basketball don't tell the whole story, such is also the case in health care. I was intrigued by a quote I read recently in the New York Times by the scientific health care quality pioneer Avedis Donabedien whose main focus was on measurement. He said during the last days of his life, "the secret to quality is love."1 This was a man who was dedicated to health care statistics. There are areas in health care we don't quantify but are extremely important, such as time spent with a patient discussing end of life care, treating co-workers respectfully and timely follow up with results. Although hard to quantify, few argue against the direct health benefits of the health care professional who spends extra time listening to a patient who has just had a difficult life event.

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25 Years of Advancements: Change at HealthInsight and in Health Care

Open Road

Twenty five years ago I stepped into the HealthInsight office, then called Nevada Peer Review, in Las Vegas and began my career in health care improvement. I was thrilled to have an advanced piece of equipment—an IBM Selectric self-correcting typewriter. Staff used dumb terminals to verify patient information for our Medicaid and Medicare review work, and our health care analysts had very large computers taking up a good bit of space in their office. Within a couple of years, we all upgraded to PCs and before long, cables and cords were draped everywhere as we established our first company-wide network.

We’ve come a long way at HealthInsight, and as I reflect upon my 25 years here, I think about the advancements made in health care over that same time period, and which of those, in my opinion, have had the biggest impact. There are many, and I’m sure each advancement may resonate differently, depending on your own personal perspective. These are just a few that made my list—focused on either public policy impacting an individual’s ability to manage their own care or technology advances.

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Embracing the Cloud

People using laptop and iPad

We've all heard the words nimble, adaptive and security when it comes to information systems. We want those systems to be more nimble and adaptive to users, while ensuring that data and infrastructure remain secure. These needs are a key priority for HealthInsight as we strive to remain a trusted partner and leader in our field. We are constantly looking for ways technology can help us achieve these needs.

This is where cloud services can come in. Cloud services, as defined in Webopedia.com, are "services made available to users on demand via the Internet from a cloud computing provider's servers." These services can allow businesses to offload tasks such as server maintenance, storage needs and software licensing to cloud providers, at what is becoming a very compelling and competitive cost structure. Use of cloud services can allow the IT department to focus their work on strategic projects instead of the day-to-day tasks that infrastructure requires.

But IT isn't the only one that can benefit from this potential approach; the business can too. Moving key services like file storage to the cloud can create a centralized repository where data can be collected and accessed from a wide variety of devices. Cloud providers have a high degree of availability, so it's unlikely that users would ever be without their information. Imagine accessing a report on a laptop while another user is able to make changes to the same document from their iPad, while yet another user is able to pull up the latest version on their cell phone. The collaborative and productive possibilities are plentiful.

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Putting the “Health” Back in Health Care

Doctor with patient

You're not feeling well. You have a fever, a sore throat, an unusual pain. What do you do? You seek medical attention, of course. Why? Because when you are sick, you go to the doctor. But are there reasons to go to the doctor when you're not sick?

When my husband was 55, he went to his primary care doctor and suggested that it was probably time he got a colonoscopy (an initial one is recommended at age 50 and his mother had colon cancer), maybe an EKG or treadmill test (his dad had a massive heart attack at age 52), and maybe a shingles or pneumonia vaccination. His doctor said, "Why are you asking for all of this? I don't get paid for ordering or providing these services." In other words, "I provide sick care, not wellness/preventive care." Not only was his statement true, but in most cases, commercial insurance does not pay for services that are intended to prevent, not treat, a certain condition; so if patients want these tests, they have to pay for them themselves.

Fast forward to 2012. Medicare expanded benefits to their fee-for-service beneficiaries to include an annual wellness visit. This is a visit focused on maintaining and improving health, making a plan for preventive and screening care, and keeping the clinic up to date on all the care a patient is receiving. An annual wellness visit includes a review of all the medications a patient is taking, the names of all other doctors they are seeing and the patient's medical/family history. Among other things, the doctor conducts a screening for depression, assesses the patient's ability to perform activities of daily living, his or her risk of falling and any hearing impairment.

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Recycling: Forethought, Not Afterthought

Bag of recycling material

Recycling and forethought go hand in hand – deliberation, consideration and planning for our future.

One of the Albuquerque programs I am most impressed with is how our city has fostered a robust and visible recycling program. The City provides blue recycling bins and these blue bins, like soldiers in uniform, line our curbside every weekday morning.

HealthInsight has whole-heartedly embraced this program. Recycling is ubiquitous in our HealthInsight New Mexico office. We have set places for mixed and glass recycling and have incorporated taking these items for recycling as part of our kitchen duty rotation. Blue bins for material to be shredded are in every office suite. During the recent renovation of our offices, we recycled many hundreds of paper hanging file folders, manila file folders, and even the metal file cabinets that held those items.

A few months ago however, I noticed not everyone plans for the recycling of their plastic, paper and glass. My sisters and I went to an annual festival at a local park where we had a great time sampling all the wonderful food, listening to music and watching the kids play games and run around on the grass. It was when it was time to leave and we looked around for a place to recycle our bottles and plastic cups that we discovered there were no recycling bins. Instead, we saw clean-up crews throwing bulging plastic bags into a dumpster.

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Inspiring Ourselves

Hiker celebrating

Imagine you are in a position where you are expected to help people change unhealthy habits or otherwise maladaptive behavior. You're not expected to be a miracle worker, but you want to make a difference. Finding effective ways to help these people is important to you. Now, let's make the problem a little harder: the people you're expected to help know that it's in their best interest to change; they've known for some time. Many have made prior attempts to change and have been discouraged by their results.

You are not in an enviable position. It may be even worse than it seems. The very people you are expected to help might see you or what you have to say as being threatening to their sense of self-worth and become defensive. What can you do to help them change?

A recent study points to a simple and inexpensive technique that you might consider. In the field of positive psychology it is called self-affirmation. It works like this:

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