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Uncertainty in Health Care: A Snapshot as of January 2017

Nurse with questions

With as much focus on effort and resources that have been spent in working to transform health care over the past decade, there has never been as much uncertainty about the direction that health care should go as there is right now: January 2017!

Tremendous strides have been made over the past decade with improved technology – adoption of electronic health records, creation of health information exchanges, implementation of all payer claims databases, widespread use of video visits, expansion of telehealth use, and development of new drugs that provide definitive relief for some diseases if not cures. In addition, health care coverage is more accessible than ever for those who have been uninsured – particularly those with pre-existing conditions.

Yet, we find that many health care professionals are very anxious right now. Hospitals are restructuring to provide less inpatient care while remaining a viable part of the delivery system. Ambulatory care providers are dealing with staffing shortages while working to provide care to more people, developing team-centered care, and adapting to new payment systems. Public health is struggling to find its path in the midst of all the change and contending with, in most states, reduced funding. These are only a few examples of the complexity of transforming the health care system. The implementation of electronic health records across delivery systems has supported and encouraged more comprehensive and coordinated care; however, this hasn't been the panacea that everyone thought it would be. Even with the implementation of the technology, we have not seen widespread improvements in the quality of health outcomes, although this is moving in the right direction. We have spoken about transparency regarding quality and cost, yet we are only just beginning that journey in most markets to achieve the Triple Aim of improved care in a more efficient manner, with better outcomes and lower costs.

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Positively Impacting the Health of a Community

Mother with Sons

As a community physician and a staff member at HealthInsight, I believe I am uniquely positioned to positively impact the health of my community. On a daily basis I am working with improvement teams to advance data transparency, community and consumer engagement, and quality processes that lead to best outcomes for patients.

Over the last 18 months, I have been honored to participate in the Institute for Healthcare improvement (IHI) 100 Million Lives initiative. This initiative is an unprecedented collaboration of change agents across sectors who are pursuing an unrivaled result toward better health. In my role, I represent the Network for Regional Healthcare Improvement (NRHI), and the Collaborative Health Network in coaching a vanguard of teams bringing the 100 Million Lives initiative to their communities.

Our mission is to see 100 million people living healthier lives by 2020 and to measure health through what matters to people. The 100 Million Lives initiative asks "Whose life is getting better because we are here?" and looks at physical health, mental health, social well-being, spiritual well-being, life expectancy, and health equity. The initiative promotes sustainable change by asking us to develop financing and workforces that allow for long-term impact. As part of this effort, the initiative has intentionally crafted a survey of health and well-being that is being considered by organizations as large as the Veterans Healthcare System, as a metric for success in improving the entirety of a person's health. The survey's seven questions can provide real-time data about a program's impact. For details about the survey, contact IHI at 100MLives@ihi.org.

What have I seen in my participation to date? Here are two examples: Henry Ford Allegiance Health in Jackson, Michigan is developing a sustainable financing model that will integrate the resources needed to care for at-risk youth such as health care services, behavioral health care and educational investment. This pool of resources can serve the youth and their families in the most appropriate and efficient ways possible. Henry Ford Allegiance Health is developing a system to coordinate a network of care around families of youth and will reinvest any savings into wellness and prevention services and maintain those resources in the community for families right in Jackson.

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Opportunity – In the Eye of the Beholder?

TEST LINK FIRST

On Nov. 3, 2016, the Centers for Medicare & Medicaid Services (CMS) published the final rule updating the Medicare Physician Fee Schedule (PFS) for calendar year 2017. With all of the attention that the Quality Payment Program (QPP) established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), there is some risk that meaningful changes may have escaped notice.

There is also a risk that the implications of these payment policy changes, and the opportunities they may create, will not be fully realized or that they will only slowly create positive change in care delivery.

The 2017 PFS update is nearly 400 pages – too much to summarize in this forum. But I'll highlight a couple of changes:

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Understanding Burnout

Doctor charting

In your work, have you come across people with symptoms and signs of burnout? They just don't seem to be themselves, are cynical and negative toward others, seem totally exhausted, and they seem to feel like they do nothing good. They are stressed out.

A recent study of 2,000 physicians found that over 45 percent of physicians nationally have at least one symptom of burnout. The incidence has been increasing the past two decades. People usually get happier as they age. But health care professionals seem to be going the other way, and physicians have the highest incidence of burnout compared to other highly educated professionals. Physicians often start healthier than other professionals but they tend to take less care of themselves and deteriorate faster. Harried training schedules early in their careers may limit exercise, normal sleep patterns and good eating habits, and may contribute to excessive alcohol use. Life change units like isolation, divorce, moving, work overload, excessive interruptions, job changes, births of children, and changes in living and working conditions increase their stress scores. In recent decades, increasing time devoted to billing and documentation requirements displacing patient care time, increasing demands of payers and customers while compensation changes intensify, and less time for conversations and socialization with professional colleagues has reduced joy in work.

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2016 Quality Conference Focuses on Patient and Family Engagement

CMS Gallery Walk

Each year the Centers for Medicare & Medicaid Services (CMS) holds a quality conference in Baltimore, Maryland, to explore how key stakeholders – specifically patients, advocates and health care leaders – can develop and spread solutions to health system challenges. As a first time attendee, my expectation was influenced by my experiences at other large conferences. I was expecting thousands of people, some good presentations and a lot of information to absorb, and my expectations were met. In addition, this conference maintained a consistent focus on the patient, their family and how we, inside the health care system, can collaborate with them to improve their health and their lives.

CMS describes how the health care system could include the patient and family perspective in their quality strategy:

  • If an individual feels their beliefs, desires, and culture are considered in their care, they are more likely to follow that plan of care.
  • If an individual is able to communicate effectively with their providers and have a role in making health care decisions, they will receive better care and can more effectively manage their health. This can lead to a reduction in expensive health care services, such as emergency department utilization.

Effort was clearly made to involve the patient and encourage family engagement as evidenced by the number of activities provided throughout the conference. For instance, patients from various advocacy groups were asked to hand out the quality awards from CMS to the Quality Improvement Networks-Quality Improvement Organizations (QIN-QIOs). Others were invited to listening sessions scheduled with CMS. Patients were filmed while talking about their personal health care journeys and these videos were shown in the gallery throughout the three-day conference. In addition, their photos and personal stories were displayed in an informal gallery for viewing by passersby.

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What’s Next for Transparency in Health Care?

Stethescope

Regardless of whether you celebrated or grieved the results of our recent presidential election, the reality is a new administration will soon be upon us. And as with any change, there is fear, there are rumors and there is uncertainty.

On a website that details the President-Elect's views on health policy reform, Transparency—an issue near and dear to our HealthInsight hearts—appears to be a priority:

"Require price transparency from all health care providers, especially doctors and health care organizations like clinics and hospitals. Individuals should be able to shop to find the best prices for procedures, exams or any other medical-related procedure."

This policy principle is consistent with a business-like approach to health care, an industry that has historically lacked some of the fundamental elements of successful, competitive business markets, such as a consumer orientation and access to comparative performance information.

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Checking the Pulse of Health Care Reform

Stethoscope and money

The recent national election has clouded the outlook for the health care industry that accounts for one-sixth of the U.S. economy. The fate of the Affordable Care Act (ACA or "Obamacare") hangs in the balance, and the stakes are enormous-not only for the more than 20 million Americans who gained insurance through the ACA, but for the health professionals who provide services for them, the insurers that cover those lives and the elected officials who have pledged to "repeal and replace" the law.

Beneath this high-profile political drama, though, beats the quiet, steady pulse of a reform movement that seeks to improve health care for all Americans.

For the past 12 years, I've been privileged to work with people who have devoted their careers to improving the quality of health care for those with Medicare and Medicaid benefits, and by extension, for all citizens. Much of our work with community partners—providers, health plans, public health agencies, consumers and others—has been guided by an activist federal program that has devoted significant resources to the reform of health care delivery, and more recently to payment reform.

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A Tale of Two Patients

TEST LINK FIRST

In the last two weeks, my mother and my husband had surgery. I'm happy to say that both had relatively positive experiences and outcomes. However, what was striking to me was the difference in the course of their stays.

Some background: I've been a nurse and have lived in Las Vegas for a long time. I know and work with lots of people in Nevada who:

  • Are senior executives in health care organizations
  • Are senior executives in insurance companies
  • Are skilled health care providers

Mom was having a hernia repair, a common and relatively uncomplicated procedure. And, as with most procedures, it requires coordination and communication among different disciplines and hospital departments. Despite my background and experience, I found myself:

  • Unable to get my mother answers to her questions (e.g., "Why am I getting antibiotics?")
  • Unable to get her providers the information they needed about her past medical history in a timely manner (e.g., "What were the results of the outpatient CT scan ordered by another physician?")
  • Unable to coordinate her care among providers

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Dreaming of What Can Be

Woman looking up

Each year at this time, I begin humming a tune in my head by song writer Bob Franke: "Thanksgiving Eve." The simple and inspiring lyrics begin with:

It's so easy to dream of the days gone by
So hard to think of the times to come

Nostalgia for "days gone by" is part of the human condition. It helps us appreciate and commemorate the past and, hopefully, to learn and to grow. The trick is to not become stuck in this place. As my horoscope recently reminded me, fear of the unknown is part of a journey, but it shouldn't become a parking lot. This is true of our work in the health care environment. Things are changing-fast-and we can be part of crafting the journey if we can use our uncertainty to propel us forward and dream of what can be.

The song's chorus continues:

What can you do with your days
But work and hope
Let your dreams bind your work to your play

What a glorious notion: that the work you do helps fulfill your dreams. At HealthInsight we have hope for a health care system that delivers on its intrinsic promise of care. Care for those in need, who are frightened and troubled, who worry if they can continue to work and be who they have always been as they face illness and treatment in a complicated system. I see the dedication in those I work with who advocate every day for a system that puts the patient first, that delivers the safest and best quality care at a fair cost, and that contributes to individual and community well-being.

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Fall Chili and Physical Activity

Couple walking in forest

Recently, my family and I attended a chili cook-off in our neighborhood. Although we did not win the cook-off, I'm still confident our beef-cubed chili, with just the right amount of spices, is a winner. Nevertheless, between the aromatic spells of chili, fall, pumpkins and cider, I enjoyed talking to and getting to know folks in my neighbor's backyard, many of whom I had never met.

While visiting with our neighbors, I had a conversation with a man who is a researcher at the University of Utah. He told me about a clinical trial he is working on where he is tracking the effects increased physical activity on aging. If I understood my neighbor, his main hypothesis is that increasing physical activity at any age or in any circumstance has positive health outcomes and can contribute to living longer. He mentioned various studies which are showing a link between lower hospital readmission rates and physical activity.

After my conversation, and after having indulged in several varieties of chili, I left the evening thinking of my personal need to increase physical activity and the simplicity of this health care intervention. I wondered what other information was available correlating with my neighbor's hypothesis.

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Total Cost of Care: A vital step toward payment reform

stethoscope and money

Constant change is the "new normal" in health care, and for me, some of the most exciting changes involve redesigning the way we pay for care. Recent federal legislation and Medicare program directives have aligned the monetary stars in favor of fundamental change in provider reimbursement, emphasizing health outcomes and value over volume of services.

Public and private payers, purchasers, providers and consumers all recognize that payment reform is essential to achieve better care at lower cost. First, though, we need more comprehensive quality and cost information to make the business case for change, enhance delivery systems and measure outcomes. At the core, we need reliable, transparent data about costs and their drivers.

That's why the Network for Regional Healthcare Improvement (NRHI) was so excited to receive funding from the Robert Wood Johnson Foundation (RWJF) for a multiregional pilot initiative focused on producing, sharing and using data on the Total Cost of Care (TCoC). This initiative, launched in November 2013, has developed a standardized approach to measuring and reporting the total cost of care and resource use across regions, and has created and tested a process for benchmarking multi-payer commercial health care costs.

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New Initiative Supporting Transition to Alternative Payment Kicks Off At HealthInsight

Doctor with clipboard

I am really excited to announce that HealthInsight was recently awarded a special innovation project as an add-on to our Quality Innovation Network - Quality Improvement Organization contract from the Centers for Medicare & Medicaid Services (CMS). The project is titled Catalyzing Complex Systems Change by Optimizing Patient Flow with the ECHO Model™. Our goal is to make it simpler for primary care practices to undergo the change needed to be successful in emerging payment models that focus on quality markers and smart spending. The project focuses on optimizing patients process (or flows), with an initial focus on annual wellness visits and follow-up sessions on chronic care management, or community referrals and end-of-life. The project will include 50 practices across Nevada, New Mexico, Oregon and Utah.

We are inviting a diverse group of primary care practices to learn together using the Extension for community Healthcare Outcomes (ECHO) model, which brings providers together using video conferencing and allows participants to learn from experts in other fields. Presenters will provide short lectures on key topics, and then participants will spend much of the ECHO session sharing the changes they made to their patient flows, including what went well and what barriers they experienced. The outcomes will initially be seen through increased claims for the target services with downstream positive impacts on health and spending. For example, claims for the Annual Wellness and Welcome to Medicare Visits should increase by at least 20 percent, along with tasks that might occur at those visits, or be triggered by them, like advanced directive use, immunizations, behavioral health screenings, cancer screenings, referral for diabetes education, etc. We also hope the patient experience is improved and the practices learn skills needed for success in the new Quality Payment Program (formerly known as MACRA) and a variety of alternative payment models. If the pilot is successful, we hope CMS will extend funding, beyond the initial two years, so we can add in other patient flows such as care across the continuum, acute and urgent care, and complex patient care.

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Try a Little Mindfulness

Brain

I like to think I have an analytical mind. I've built a career in accounting and finance, with side interests in technology and programming, and I've worked with health-related organizations for a number of years. Given that context, what I'm about to share may come as a surprise.

Daily meditation has had a greater impact on my wellbeing than any pharmaceutical drug or diagnostic test. It has also been a valuable resource in my professional life. Best of all, it costs nothing but my own time and dedication.

In our quest for the "quick fix," we may overlook the power of mindfulness. As often as we talk about engaging patients in their own care, we may not recognize the potential for healing within ourselves.

Migraines and epilepsy have run in my family. I was young when my migraines began, and I was given opioids to treat them from age 12 on. Sometimes I had to visit the emergency room for higher doses of morphine to find pain relief. My epilepsy required me to undergo semiannual electroencephalograms (EEGs) to maintain my driver's license, and to take medications that had negative effects on my personality. Yet all of this seemed normal and sustainable until I found a better solution.

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Board Retreat - Value and the Voice of the Patient

Three Generation Family In Park

On Oct. 6-8, HealthInsight held our annual Board of Directors Retreat in beautiful Deer Valley, Utah. The meetings brought together board members and leadership from our four state-based affiliates in Nevada, New Mexico, Oregon and Utah, along with our two End-Stage Renal Disease Network affiliates in Southern California and the Northwest. Two main threads wove together the variety of presentations, panels and discussions: value in health care and the voice of the patient.

Jean Moody-Williams, the Deputy Director of the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS), encouraged our board and leadership when she said that as part of the push that CMS is making towards quality and value in the health care system, Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) will be helping to lead and support patients and families, along with the providers we serve. She shared a very personal and touching story of her mother's battle near the end of life and her desire to see her experience used to motivate providers and stakeholders. "Patients at the center of care is better care," shared Jean Moody-Williams. "As part of the move to value, all stakeholders in the health care system need to be concerned with moving beyond patient attribution and reaching for true patient engagement and patient motivation."

Karen Feinstein, founder and president of the Jewish Health Foundation addressed how HealthInsight, in our role as a regional health improvement collaborative, along with other members of the Network for Regional Health Improvement, are working to convene stakeholders to take on issues to increase the value of health care in our communities. Our greatest value is in partnering together with others that share our vision to drive improvements at the community level.

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Blockchains and Health Care

Computers and People Connected

As the CIO for HealthInsight, I'm often researching new tools and technology to help keep our organization secure. The further immersed in health care data research I become the more I hear the following words repeated over and over: data management, interoperability and security. Nobody wants to become the next news story about a security breach or data exposure, and with ever increasing public scrutiny, neither do the businesses housing the data. Patients, on the other hand, also want their data protected and available to their physicians when needed most.

What is one way health care can go about protecting all of this data? Enter the blockchain.

A blockchain, in its most basic definition, is a distributed database that provides a semi-public record of digital interactions - like pages in a book, sequentially ordered with information about itself and links to previous pages. Perhaps another way to visualize it would be to think about how some people balance their bank accounts with written ledgers. In this case, all of the expenses would be tracked by the owner and then copied instantaneously to a small number of identical copies across the internet. Having multiple copies makes it more difficult for hackers and thieves to gain access to the data or corrupt it through encryption.

So how do blockchains apply to your health care?

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Sustaining Medicare into the Future

Group of Seniors

Fifty years ago this summer (1966), the federal Medicare program was born. For the very first time, guaranteed health insurance coverage and benefits were in place for seniors 65 and older. To date, nearly 140 million Americans–retired or disabled–have relied on the retirement security and benefits of Medicare. Few would disagree that this program has blessed the lives of our parents/grandparents and markedly reduced the poverty rate among seniors. If you are a baby boomer like I am, you also recognize the fact that Medicare will need to play a vital part in our strategies to not only survive, but to enjoy our retirement years.

Fast forward to 2016: Medicare's sustainability and future success in providing health care coverage and access will be challenged by some serious, growing fiscal concerns. One might call the drivers of these concerns "inconvenient trends". They include:

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Desperately Seeking Support: Motivating Myself and the Link to Active Involvement in Health

Couple on bikes

I like "to do" lists. I was reminded of that last weekend as I was planning a remodel of my bathroom. This is a change I have been thinking about for a while – nearly two years, actually – ever since I purchased the vanity. I know it needs to happen. I know what's involved, as I've done it before. I'm in charge. So, why have I waited so long?

That process got me thinking about motivation and a term we have been talking about at HealthInsight: patient activation. There is actually a way to measure patient activation and it is the basis of many self-management programs for diabetes and other chronic diseases that we are involved in.

Designed for persons with chronic conditions, the Patient Activation Measure (PAM) is a 13-item scale that asks people about their beliefs, knowledge and confidence for engaging in health behaviors and then assigns them to one of four levels:

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Civilizing Medicine

Nurse and patient holding hands

When I first started working in nursing homes, I was struck by the sheer volume of rules and regulations governing the care of residents. Unfortunately, those rules often inhibited patient-centered care rather than offering protection. The result was an institutional approach to care with strict rules based on the diagnoses of the resident. For some residents, food was one of life's simple pleasures they could still enjoy. Despite this reality, most residents were placed on a special diet, based on their medical condition, instead of one based on their individual goals. Many residents would awaken to the smell of bacon cooking in the morning only to be told that they were not allowed to have it because of their low sodium diet. Of course, medical conditions must be taken into account, but the goals of each person must be considered—first and foremost.

This is also true outside of nursing home walls. All too often, care is overwhelmingly curative and narrowly disease-specific instead of goal-focused. My father, who had heart failure and Type 2 diabetes, had his diabetes strictly managed until the end of his life, despite the fact his life expectancy was far less than likely to benefit from strict blood sugar control. If his diabetes would have been managed according to his goals of care, instead of by the results of his hemoglobin A1c, his quality of life would have significantly increased. In fact, the results of strict management interfered with the goals of care as it caused several hospitalizations from hypoglycemia. According to an editorial in British Medical Journal (BMJ), "People with disabling, progressive illnesses expect active care, but they also seek comfort, control, and dignity."

Palliative care offers a potential patient-centered solution for the aging population facing the burden of chronic illnesses. Palliative care is specialized medical care for people with serious illness that focuses on improving the quality of life for both the patient and the family. It employs a multi-disciplinary approach consisting of specially trained doctors, nurses, social workers and other specialists who work alongside patients' doctors to provide an extra layer of support. Unlike hospice care, palliative care does not require a terminal diagnosis and includes curative/life-prolonging treatment. It is also associated with higher quality outcomes at lower costs.

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Growing HealthInsight in Oregon

Portland Waterfront

Today more than ever, success in the quality improvement (QI) business depends on collaboration as well as community-focused teamwork. HealthInsight has a long history of working with health care providers, community partners and patients in Nevada, New Mexico and Utah to improve health and health care.

The past two years have brought us the opportunity to expand our services and expertise, build new partnerships and collaborate with health care leaders in another key western state: Oregon.

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Compassion Fatigue

Nurse holding patient hand

The end stage renal disease (ESRD) Networks of HealthInsight play an important role in helping dialysis patients who have concerns about the quality of care they are receiving. The patient services staff, including three Masters level social workers, is required to be available, per the Social Security Act and the Conditions for Coverage, to mediate, coach, listen, instruct and empathize with our dialysis population that exceeds 60,000 patients. What does this all really mean?

If you walk for a minute in the shoes of a dialysis patient, you might understand that their lives have tremendous potential for "issues". Think about it. Dialysis patients receiving their treatments in center must get to the center, check in, wait to be called in, wash their access, interact with the dialysis staff who provide life-saving treatment to them for three to four hours while they are tethered to a chair, socialize with their fellow patients, return home, watch their diet and fluid intake meticulously. Add to that not feeling well and having to return for dialysis two more times each week just to survive.

While most of our patients are heroes - bringing joy and resilience every time they come to dialysis, many struggle through the challenges that living with a chronic illness can bring. Even the most resilient dialysis patients – hit bumps in the road.

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