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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


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

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

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

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What is Return on Investment for the QIO Program?

2016 QIO Program Progress Report

Thoughts from a fiscally conservative taxpayer

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

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

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

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A National Epidemic; Local Experience


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

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

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

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

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

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

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

Where to start?

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HealthInsight: A Top Workplace in New Mexico

Albuquerque Journal Top Work Place

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

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

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

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

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

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Finding New Vistas in Health Care


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

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

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

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Inspiring Leaders in an Environment of Change

Young Adults

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

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

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

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