Creating and Implementing Healthcare Innovation – BioPharmaceuticals, Delivery System and Reimbursements

Posted on March 22, 2011 by Michael D. Miller MD

Healthcare innovation is an extremely hot topic right now, ranging from the new Center for Medicare and Medicaid Innovation, FDA’s approach to approving therapies and devices, an entire issue of Health Affairs, and of course patient-centered medical homes and Accountable Care Organizations [Patient-centered medical homes are also known as Advanced Primary Care Model practices, and ACOs are a combination of delivery and reimbursement innovations.]

I’ve been working for many years to create value for patients and society by speeding adoption of these types of innovations by clinicians, other providers, patients, payers, regulators, communities, etc., and have found that healthcare innovations have at least three things in common:

Healthcare innovations occur in steps, with each advance building on the shoulders of what came before
These stepwise advances also produce indirect benefits that can be greater than the innovation’s direct effects
Adoption of innovations doesn’t just “happen.” Strategic planning can improve the speed and breadth of adoption – leading to greater value for patients and society

1. Axes of Innovation – Primary, Secondary and Tertiary Benefits
Every healthcare innovation can have multiple benefits to patients and society – often for different conditions. I call this cascade of different benefits UP, OVER, and OUT Innovations. (The text and diagrams below illustrate this biopharmacueticals.)

UP Innovation: UP Innovations occurs when subsequent medicines in a class, (e.g. Beta Blockers for high blood pressure), have characteristics, (such as once-a-day dosing, and less side-effects or drug-drug interactions), that permits more patients to use the medicine correctly, and thus produce better outcomes.

OVER Innovation: OVER Innovations occur when medicines are discovered that treat the same disease through different mechanisms of action, such as Beta Blockers and ACE Inhibitors to treat high blood pressure.

OVER Innovation also occurs across industries and platforms when devices and other therapies are developed that compete with biopharmaceuticals – and vice versa. This occurred for erectile dysfunction (ED), when devices, (both the vacuum pump made famous by Austin Powers and implanted prosthetics), and an injectable medicine, presented different treatment options. These therapies all had certain characteristics that caused patients to not use them very widely – which provided the clinical opportunity for the oral medicine sildenafil (Viagra®) – and then the other subsequent UP Innovators in the PDE5 Inhibitor class of pills.

OUT Innovation: OUT Innovation involves the use of an existing therapy for completely new diseases or conditions. Sildenafil to treat early-stage pulmonary arterial hypertension is an example of this type of innovation. (You didn’t think I used Viagra® in the previous example just to be salacious did you?). Similarly, many medicines to treat cancer were originally approved for a specific type of tumor and then used for other cancers, or even for non-malignant conditions. (Oncology and immune disorders such as rheumatoid arthritis are also clinical areas where small molecules and biologics compete as UP and OVER Innovations.)

2. Innovations Enable Many Types of Benefits
Another way to view the benefits innovations have for patients and society is to examine how the adoption of an innovation produces indirect changes in care delivery and reimbursements – some of which can be more significant than the innovation’s original change:

New treatments can change how care is delivered, e.g., stents, (originally developed for urology), expanded the treatment options for clogged heart arteries from surgery to include outpatient invasive radiology procedures.
Payment systems for specific illnesses have influenced the development of therapeutic options and care delivery infrastructure, e.g. low reimbursements for chemical dependency present barriers to R&D in that area, while high profit opportunities for cardiac rehab and obstetrics have prompted health systems to build new facilities for those conditions.

Health information technology (HIT) is a great example of a class of innovations with broad enabling effects. At a fundamental level, having clinical information in electronic forms improves the efficiency of storage and transmission, and thus reduces the time (and costs) for copying, billing and looking for records, as well as minimizing the need for repeat tests etc. (This was one of the benefits of HIT that President Obama cited in a State of the Union address.) However, the value of electronic medical records (EMRs) and related HIT applications for patients and society is even greater than these direct benefits because it enables activities such as:

Tracking mechanisms to make sure patients are receiving recommended treatments and preventions
Automatic checking for drug-drug interactions and patient allergies
Easy access to recommended diagnostic and therapeutic protocols based upon the individual patient’s condition
Systems to evaluate the overall progress of physicians and practices in meeting recommended standards of care, such as A1C levels and blood pressure for people with diabetes. (See here for an example of a web-site reporting this type of information.)
Research across a community to identify trends in care patterns and illnesses to better allocate resources for quality improvement and public health initiatives.

Furthermore, advanced HIT applications can enable overall healthcare integration and care coordination via care teams – which leads to better care for individual patients and more rapid adoption of evidence-based practices that improve quality and efficiency. These effects are particularly evident with telemedicine, which can literally force different clinicians and caregivers to work together as a team because they are connected via a sharing technology that clearly demarcates their roles, i.e. monitor/manager and actual deliverers of care. (The draft report Telemedicine’s use in Intensive Care Units describes an example of this in more detail.)

Payment Innovation Enables Quality Improvement
Another example of how one innovation can produce significant secondary benefits is payment innovation’s potential to turbo-charge quality improvement programs: The fee-for-service payment system in the United States often penalizes clinicians and health delivery systems for providing the best quality care. For example, if a hospital/health system provides coordinators (such as social workers) to patients being discharged from the hospital or emergency room to make sure they get proper follow-up care, they are less likely to “bounce back” to the ER or hospital. (This is good quality coordinated care.) However, in many cases the hospital or health system doesn’t get paid for those follow-up outpatient services, and by preventing repeat inpatient and ER visits it also loses potential revenues.

Payment innovations – if properly structured and implemented – can reverse these types of incentives and lead to less overall spending, as well as broader and more rapid adoption of quality improving practices. Such payment innovations could involve bundling reimbursements around an episode of care, (or treatment of a condition for a month or year), or across broader care teams such as the hospital, outpatient physicians, home health and rehabilitation. And, just to come full-circle, by creating the capabilities for monitoring quality and spending, HIT systems enable accountability of health systems, providers and clinicians – as well as payers, patients, and public health officials. That is, such monitoring can ensure that the care delivered in response to the payment innovations are quality and efficiency based, and don’t lead to rationing and budget cuts disconnected from overall costs or quality.

3. Change Adoption – Faster, Sooner, Better
A third important aspect of innovation is that it needs to be adopted in order to produce value. (Duh.) While there has been a lot written about adoption of innovation, it is particularly challenging in the healthcare environment where the “product” is a service delivered very directly (and often intimately) from person-to-person. That is, healthcare is largely a service industry, and thus getting clinicians and patients to adopt an innovation is much more complicated than convincing people to purchase the latest tablet computer, or even to use self-scanners at grocery and drug stores.

Below is a simple graph illustrating the importance of strategies and steps to promote the adoption of innovation in healthcare. The two diverging lines shows why planning for and investing in change adoption are very important for actually changing clinician and patient behaviors.

The specific strategy illustrated in this figure involves creating and supporting champions for the innovation. These “change agents” are people who can connect to the targeted users and demonstrate the value of the innovation in a real-world way. The two curves in the diagram show the difference between the adoption of innovations when they are just released into the wilds of the healthcare system, (lower line), and when they are actively promoted with an adoption strategy. Specifically, the adoption of an innovation would proceed without these champions for change from point 0 to A1, B1 and C1, etc. But with champions, the path can proceed along the upper line from point 0 to A2, B2, and C2, etc. (The value of investing in the champions and change adoption strategies can be calculated by the vertical distance between the points A1 and A2, B1 and B2, etc.)

Value to Whom
How the value of an innovation is demonstrated to potential adopters depends upon the specific innovation, but generally it requires the champion presenting the information to be a peer-leader, to communicate the relevance of the innovation to the individual, and to demonstrate how the innovation will create a better situation for the individual adopting it.

This last point is crucial for adoption of healthcare innovations – such as the post-discharge care coordinators mentioned above – because many innovations may benefit patients or society, but to the individual adopting the innovation the costs would be greater than the benefits. This is what I call the “Value to Whom?” analysis since it highlights that an ROI calculation about an innovation that aggregates the costs and benefits for all stakeholder may be misleading if the costs are borne mostly by one stakeholder while the benefits are received mostly by another, i.e. their is a value mismatch across stakeholders.

Similarly, many innovations will present differential benefits (and ROIs) for different types of patients based on their clinical states. For example, while the team-based care embodied in patient-centered medical homes is good for all patients, it clearly should be of the greatest benefits to people with the most complicated and chronic conditions.

SUMMARY – The Healthcare System’s Bones are Connected Like a Skeleton (or Gears in a Machine)

Innovations Build on Each Other: Innovations are developed based upon new knowledge, they build upon the existing “standard of care.” But the adoption of innovative treatments, delivery methods, and payment models is not a unwavering process. Rather, the breadth and depth of adoption is greatly influenced by factors intrinsic to the innovation, the clinical/economic environment in which is will be adopted, and how effectively it is presented to those who need to adopt it, i.e. clinicians, patients, payers, regulators, etc…..
Innovations Need to Fit Into the Existing System In Order to Change It: Innovations don’t occur in isolation. Innovations are adopted into highly connected healthcare delivery and financing systems.

Innovations Have Many Connected Benefits: Important innovations not only have direct benefits, but also create changes in the fundamental delivery of care – both by individual clinicians and within the overall structure of the healthcare delivery system. HIT and payment innovations can produce of these types of “game changing” benefits.
Adoption of Innovations are Connected to Reimbursements: The adoption curves for innovations are tied to financial incentives. This is part of the “Value to Whom” reality. Therefore, reimbursement amounts and policies can create incentives or barriers to the development and adoption of innovations – and thus greatly influence the benefits patients and society eventually derive from any innovation.
Innovations are Necessary for Progress: Without innovations – and without the adoption of innovations – healthcare delivery will not improve, and progress towards better quality care and lowered costs, (a.k.a. bending the cost curve), will be very slow and overwhelmed by the wave of Baby Boomers soon to hit our healthcare systems.

Accountable Care Now

Posted on March 7, 2011 by Michael D. Miller MD

If all arrows in Washington pointed to the same spot for solving the healthcare and Federal spending problems could the politicians, pundits and policy people agree? Or would it take some new and powerful force to shine a spotlight and focus the collective vision on this solution, and what would that force be?

These are the two questions I’ve been asking myself as the battle over Federal spending has become near white-hot, and as it has become increasingly clearer that long-term Federal solvency and deficit reduction will require addressing the growth in healthcare spending – particularly Medicare.

[Source: Kaiser Family Foundation "Medicare Spending and Financing," February 2011]

To summarize the highlights of this situation:

Cutting non-defense discretionary Federal spending can’t produce the reductions needed to significantly impact the deficit – contrary to the general misunderstanding about how the Federal budget is spent. (See this recent Washington Post article, and the bullet below from an associated poll.)
- “There are widespread misperceptions about the state of the federal budget. A majority of voters incorrectly believes the federal government spends more on defense/foreign aid than it does on Medicare and Social Security (63%). Also, a similar majority (60%) incorrectly believes problems with the federal budget can be fixed by just eliminating waste, fraud and abuse. Voters do not casually agree with these untruths- at least 40% strongly agree. Further, less than half (44%) believe Medicare and Social Security costs are a major source of problems for the federal budget (49% disagree).”
Medicaid spending is high but counter-cyclical, so improvements in the economy and employment will reduce those costs by cutting the number of people using the program
Social Security is a straight numbers issue – while the Baby Boomers are increasing the program’s numbers, the per person cost growth is close to CPI
Medicare is not counter-cyclical, its growth is a combination of the Baby Boomer influx and the per person growth rate, which is projected to be about 7%. The result is that since Medicare accounts for about 15% of total Federal spending, the Medicare program is the keystone to solving the Federal fiscal puzzle

Solving the Medicare Puzzle
Wouldn’t it be great if there were a way to reduce Medicare long-term spending, and one that most politicians and policy people agreed was the right solution? Fortunately there is. And it’s already in Federal law: It’s a concept that many Democrats and Republicans have repeatedly endorsed because it increases local control and decision-making, while shifting incentives from quantity of services to quality of care. This new model is called Accountable Care Organizations (ACOs), and it was included in the new health reform law, (a.k.a. Patient Protection and Affordable Care Act, or “Obamacare”). This short provision in the law adds ACOs as a fundamental change to Medicare, (i.e., not just a pilot or a demonstration), and it enables Medicare to pay ACOs in any way that both Medicare and the healthcare provider (or delivery system) agree to. Further, it encourages Medicare to work with private payers to enhance the motivations for creating successful ACOs. [See 1899(i)(3) and 1899(j) of Title XVIII of the Social Security Act (42 U.S.C. 1395) as added by Public Laws 111-148 & 111-152.]

So why isn’t there a collective multi-partisan and multi-stakeholder rally of support for ACOs?

Making healthcare delivery systems and providers into effective ACOs won’t happen quickly – it will require a stepwise transition. (However, many, many hospitals, health systems, group practices and others are gearing up for the transition – which will likely involve bundled payments and focused bonuses for achieving desired outcomes – but the roads to becoming a full ACO will be varied and lead to many different successful structures.)
The proposed rules for the ACO provisions of the health reform law haven’t been issued yet, so there is still significant uncertainty about how Medicare will implement their new authority.
Political philosophy against government programs – particularly on the national level – is now a very strong force focused on repealing “Obamacare” like college students during spring break fixated on a blinking “Free Beer” sign.
The ACO provisions lack the specific payment formulas or dollar amounts that fiscal forecasters desire for building models and developing multi-year estimates. As a result, the savings projections, (a.k.a. scoring), have estimated only very modest reductions in Medicare spending since there is significant uncertainty about how ACOs will develop and evolve.

Solutions
Here’s why those savings projections are too conservative, and what can be done to swing the political tide the other way:

Hospitals, healthcare systems, other providers, and other organizations are already preparing to become ACOs. That is, rapid movement towards ACOs is happening across the country, and it needs Medicare to be a positive – and maybe even aggressive – supporter. This private sector movement is similar to the reaction health providers and payers had to the potential national health reform legislation in 1993-95 – (see chart below) – but this time the reform is actually in law, and the private sector responses are much broader and intense…. From what I am seeing, this activity is about 10 times greater in terms of resources being committed, and plans being developed and implemented.

[National Health Expenditure Increases: Actual and Adjusted for CPI]

The other “solutions” to reducing Medicare spending are the typical “cuts” in payments to hospitals and doctors, or reducing benefits to seniors…. But for either of those to significantly reduce long-term spending would require politically and socially untenable changes to Medicare. In addition, these changes would involve much greater Federal government intrusion in actual care delivery decisions than would effectively implementing the ACO provisions of the ACA.
For Americans to be receiving UnAccountable Care as the norm is no longer acceptable – just as driving cars without seat belts or dumping raw sewage into rivers is also not acceptable today, even though it was the norm in the past. Just as the standards of care for medical practice change, so should the overall structure of care delivery. For example, high blood pressure in the elderly used to be accepted and not treated because the thinking was that the high pressure was a good thing and needed to push blood through hardened arteries. That idea is no longer accepted, and not treating hypertension today would be UnAcceptable care.
There needs to be a public groundswell for “Accountable Care Now.” This can be true grassroots support, grass-tops advocacy from opinion leaders, and even “astro-turf” campaigns from national advocacy organizations and companies. The end result needs to be getting public opinion and voices to be coherent and loud for change. What matters is that the chorus for “Accountable Care Now” sound something like:

What Do We Want?

Accountable Care!

When Do We Want It?

Now!

Bottom Line
If Medicare beneficiaries, organizations paying for healthcare, (including Medicare and Medicaid programs), and everyone else – including leading healthcare professionals – start a drum-beat for “Accountable Care Now,” it will become UnAcceptable to be delivering or paying for UnAccountable Care. And elected officials across the spectrum, pundits, and policy leaders will have to – and want to – start looking under the Accountable Care spotlight and put their efforts toward making Accountable Care a reality Now – or at least ASAP.

Medical Homes (PCMH) in 2011 – Patient and Consumer Centric

Posted on February 23, 2011 by Michael D. Miller MD

Patient-Centered Medical Homes (PCMH) are continuing to be a bigger and broader part of the real-world discussions about health reform and transformation in the US. According to the the National Committee for Quality Assurance (NCQA) at the end of 2010 there were 7,676 clinicians in 1,506 recognized PCMH practices in the US. This information was released last week by NCQA with their updated 2011 PCMH Standards.

Another marker of medical homes’ increasing pervasiveness is the blurb – “Home sweet medical home” – in the March 2011 issue of Consumer Reports magazine that starts with, “If you haven’t already heard the term ‘patient-centered medical home,’ chances are you will soon.”

Consumer Reports – “Home Sweet Medical Home”
The Consumer Reports blurb is part of an article about what primary care physicians wish their patients knew. Interestingly this longish blurb notes that any practice can be more patient-centric without being officially certified, and it lists the important features patients should look for:

Can you get an urgent appointment within 24 hours?
Can you reach somebody in the practice by phone at night or on weekends?
Can you get test results quickly via e-mail or telephone, or on-line?
If you have a chronic condition, is there a system for tracking how you’re doing?
Does the practice include non-MD staff members such as nutritionists or nurse practitioners to help you manage your medications or chronic conditions?
Does your primary-care doctor keep track of your treatment by specialists?

NCQA’s 2011 PCMH Recognition Standards, Elements, and Factors
The 2011 PCMH Standards NCQA released last week are much more detailed about what a primary care practice should look like to provide high quality primary care – and they are a logical evolution from their 2008 Standards. Specifically they:

Reduce the number of Standards from 9 to 6 – which should make them easier to understand and implement.
- The 6 Standards have multiple Elements. And each Element has various Factors that contribute to the scoring for that Element.
Integrate newer health IT standards and requirements.
- NCQA provides a cross-walk between the Elements and the corresponding Federal Meaningful Use requirements for health IT that enable clinicians to receive higher Medicare and Medicaid reimbursements.
Include a patient survey, which will be available in 2012.
- The optional survey will provide more patient-centric feedback about people’s experiences and enable practices to score extra points towards the recognition Tiers.

NCQA also continues to have three Tiers of possible recognition – with Tier 3 being the highest.The new NCQA standards also continue to have “Must-Pass” Elements (in bold/italics below) for the 6 Standards. And practices must score at at least 50% on all those Elements to receive any recognition Tier.

Standard 1: Enhance Access and Continuity
Access During Office Hours, e.g., same day appointments and telephone or email communications

Standard 2: Identify and Manage Patient Populations
Use Data for Population Management, e.g., using medical record data to remind patients about getting evidence-based care for specific preventive services and treatments for chronic conditions

Standard 3: Plan and Manage Care
Care Management, e.g., individually written care plans and addressing barriers to patients achieving their treatment goals

Standard 4: Provide Self-Care and Community Support
Support Self-Care Process, e.g., providing educational resources and tools to enable patients to improve their self-care and healthy lifestyles/behaviors

Standard 5: Track and Coordinate Care
Referral Tracking and Follow-Up, e.g., coordinating and following-up on referrals to specialists, including testing done by specialists and their recommended treatments

Standard 6: Measure and Improve Performance
Implement Continuous Quality Improvement, e.g., setting goals and acting to improve care for patients with chronic conditions, (such as diabetes, heart disease and depression), and preventive services, (such as immunizations, and cancer and osteoporosis screening)

It is also worth noting that among the various Factors that make up the Elements, NCQA designate some as “Critical Factors,” i.e., they are required for any scoring on that Element. And two of these Critical Factors are for Must-Pass Elements:

“Providing same-day appointments”
“Develops and documents self-management plans and goals in collaboration with at least 50% of patients/families”

Thus, to achieve any level of recognition as a PCMH from NCQA, practices must have these two capabilities.

Conclusions:
While it may be coincidental that Consumer Reports lists 6 criteria for patients to consider in evaluating primary care practices for their “medical homeness,” and NCQA has 6 Must-Pass Elements, the two lists do parallel each other.

NCQA and Consumer Reports are targeting different groups of stakeholders – which is appropriate. NCQA’s requirements enable practices and providers to become recognized, while also informing payers and regulators so they can determine how to utilize a practice’s recognition in their policies and practices – including reimbursement levels.

Similarly, Consumer Reports is seeking to educate consumers, (a.k.a. patients and families). What is reassuring is that Consumers Reports doesn’t try to compare medical homes or clinics using its normal format of tables of numbers and those great red and black circle symbols. That type of evaluation works well for commodities like TVs, but medical care is a process not a product, and it needs to be individualized for the patient – so what is a good medical home for one person may not be as appropriate for another. (Atul Gawande’s recent New Yorker article “Hot Spotter” includes some examples of how cultural appropriateness can be a determining factor for the success of care for severely ill people.)

NCQA’s standards focus on structures and processes, and thus are not the beginning and end of what is needed for a successful patient-centered medical home. But certainly rigorous structural and process standards, combined with consumer education – along with other contributing drivers like cultural change motivators and incentives for achieving better outcomes – should lead to better quality, value, and efficiency in our health care system.

Let me know what you think about Medical Homes.

[Full Disclosure: I was given the Consumer Reports magazine by a friend who bought it because it has an article about TVs - and now I have to help her go buy a TV.]

Fundamentals of Health Reform and Transformation

Posted on February 5, 2011 by Michael D. Miller MD

Trying to follow what’s being written about implementing health reform has been like trying to drink a waterfall. Having followed these issues for many years I’ve gleaned some fundamental aspects about many of the ideas and recommendations that simplifies how to approach this flood – including how to evaluate ideas and proposals like Patient-Centered Medical Homes (PCMH), Accountable Care Organizations (ACO), Shared Savings, Health Information Exchanges (HIE), Pay-4-Performance (P4P), etc…

Structure v. Reimbursement Systems/Arrangements
First, discussions and descriptions that don’t affirmatively recognize the distinction between Structures and Reimbursement Systems can create significant confusion. For example, the requirements for a PCMH to be recognized by the National Commission for Quality Assurance are structural, but how they are reimbursed will strongly influence how successful such practices are for improving quality of care and controlling costs.

Similarly, at one level ACOs are structures for organizing care – albeit to assume some level of financial risk. But their reimbursement systems and arrangements (both external and internal) will be tremendously important for their clinical and financial success. For example, the health reform law has a “Shared Saving Program” for Medicare and ACOs, but it specifically state that Medicare can reimburse ACOs under three different options:

A shared savings arrangement (essentially a one-sided risk situation where the ACO can get savings but isn’t at risk if costs are higher than projected)
Partial capitation (i.e., some two-sided risk)
And, any other type of arrangement that the Secretary of HHS thinks makes sense.

Until the proposed recommendations for this part of the health reform law come out, (and they are expected very soon), it is mostly speculation as to what each of those three options might look like – as well as what related options might be created as demonstrations by the new Center for Medicare and Medicaid Innovation.

Process v. Outcome Measures
Another confusing aspect of discussions about reformed or transformed healthcare is a blurring between measuring processes and outcomes – both clinical and economic. Part of this blurring occurs because process measures are often used as proxies for outcomes. While these type of proxy measurements are common in clinical medicine, (e.g., blood cholesterol levels are a proxy for risk of heart attacks and stokes), using them for broad transformations in healthcare is more challenging because there is generally a very strong desire to see the savings (or improved clinical outcomes) before investing time or money to expand the reforms.

Conclusion: Focus on the Fundamental Big Questions
So, to simplify thinking about how to create a better healthcare system in the US, I recommend coming back to these two sets of questions:

What is the structure? And what are the reimbursement systems/arrangements?
What process and outcome measures will be used to evaluate the new structures and reimbursement systems? And how do those process and outcome measure relate to each other, i.e. how do we think the process measures lead to better outcomes?

US Healthcare Spending – 2009

Posted on February 5, 2011 by Michael D. Miller MD

With all the focus on US health spending I thought it would be useful to update the pie chart I’d posted previously that showed 2007 and 2006 National Health Expenditures. So below is the chart showing US health spending for 2009.

What can be seen by comparing this chart with the previous ones is that the percentages haven’t changed very much. Which means that the foci for cost containment still needs to be on hospitals and physician services and how they influence other types of spending. For example, avoiding hospital admissions, and utilizing clinical services provided by non-physician professionals, etc…. More on this to come in future posts.

Smoking, Exercise and Obesity – The Big Three

Posted on February 2, 2011 by Michael D. Miller MD

I’ve been working with a Midwestern community for the past 7 months to improve the quality, efficiency, and value of their healthcare – as measured by public health population status, and the cost and quality of medical services. This experience has reinforced what I’ve been hearing repeatedly for the 28+ years I’ve been working with healthcare challenges: The three most significant areas for improving quality and controlling costs related to illness and healthcare are reducing smoking, increasing exercise, and reducing obesity. (The latter two are connected, but they also have separate and important benefits.)

While I will be writing more about each of these health problems in the coming weeks, (along with many other health policy issues involving innovation, system transformations, and the ongoing debate about health reform legislation), I first wanted to lay out some top line perspectives on smoking, exercise, and obesity.

Smoking
While many people think that smoking is no longer common in the United States, the data says otherwise. The chart below from a recent CDC report shows that while smoking rates have declined significantly since the 1960s, about 20% of the US population still smokes.

This report also states, “Tobacco use is the leading cause of preventable illness and death in the United States.” It doesn’t get much simpler than that.

A deeper look into the data also shows that smoking rates vary dramatically by education level achieved:

This makes another great case for the value of education.

Exercise
Exercise has gotten lots of attention lately – particularly in the context of obesity. However, exercise has significant benefits aside from weight reduction and control – where is certainly can play a very important role. For example, a January 1, 2010 article “Physical Activity Guidelines for Older Adults” indicates that there is strong evidence that physical activity in adults results in:

Decreased Risk of:
- Early Death
- Heart Disease
- Stroke
- Diabetes (Type 2)
- High Blood Pressure
- Adverse Blood Lipid Levels
- Metabolic Syndrome
- Colon Cancer
- Breast Cancer
Reduced Depression
Improved Cognitive Function (in older adults)

In addition, the article also lists improving sleep quality and decreasing the risk of lung and endometrial cancers as benefits where there is moderate evidence.

Another point often missed about exercise is that the type of exercise doesn’t matter too much – just as long as it involves moving in some significant way. For example, pushing a lawnmower and raking up the clippings may be just as beneficial as lifting weights and going for a walk. (Conversely, thumb scrolling on a Blackberry, texting on a cell phone, or pushing buttons on the TV remote don’t count.)

If the benefits of exercise for cancer risk, mental health status, (and even controlling the symptoms of arthritis), were more commonly appreciated, maybe there would be greater emphasis on recommending exercise as part of integrated courses of therapy for a wide range of health problems – particularly since there is evidence that such recommendations are effective: An editorial accompanying the Physical Activity Guidelines article referenced above cites a New Zealand study that found prescribing physical activity and referring people to community resources resulted in an average of 35 more minutes of exercise per patient per week.

This editorial also concludes: “By implementing an evidence-based approach to promoting physical activity, we have an opportunity to improve the health of the public – particularly the older population. As a society, we need to increase our commitment to promoting physical activity. To be successful, we need continued leadership and involvement from primary care physicians.”

Obesity
With all the focus in recent years on obesity, it is still shocking to see the data. Below are the US state obesity maps from the CDC for the years 1985 and 2009.

While comparing these maps is interesting, you can also see an automated slide-show on the CDC’s website that shows the year-to-year changes – click here.

Obesity is clearly a huge problem involving not only medical and nutritional issues, but also broad sociological, cultural, and economic challenges.

Bottom Line
There is clearly overlap in the benefits people (and society) can get from stopping smoking, increasing exercise, and weight reduction, so calculating clinical or economic value from any single initiative can be difficult. While the synergistic effects among initiatives creates analytical challenges, it also present opportunities for better real world results. For example, besides helping with weight reduction, increasing exercise (as noted above) improves many other measures of health status and quality of life.

Similarly, smoking, exercise and obesity are all related to diabetes – a disease that is more than just “a little sugar,” and a condition of great concern because of how it decreases quality of life and produces tremendous costs to society. Specifically, diabetes is the leading cause of kidney failure, blindness, and lower leg amputation. And someone with diabetes has the same risk of having a heart attack as someone who has already had a first heart attack.

To close with one example of the bottom line of the bottom line, an estimate in the year 2000 put the US costs of obesity and overweight, (which included how it contributed to diabetes, heart diseases, etc.), at $117 billion/year.

—–

That’s all for now. In the coming weeks I’ll explore how clinical, technological, community-social and “other” advances and interventions can address the issues of smoking, exercise and obesity within the US healthcare system as we move toward transformed financing and delivery systems. As the same time, I’ll also bring some more quantitative perspectives to these issues, since in the current fiscal environment the economic implications of health proposals are of great interest and concern.

Rise of the Tea Party Machine (and I Am Back)

Posted on November 14, 2010 by Michael D. Miller MD

Interpreters of the recent election results have been pointing fingers in many directions about alleged successes and failures of policies and messaging. Having run a consulting business for more than 10 years I see a parallel between how people vote and how people and organizations making hiring decisions. That is, people voting for their elected officials are essentially making decisions about who they want to hire to run their government.

Politicians certainly want the people who voted for them last time to vote for them the next time. This is a fundamental tenant of business success, i.e., getting your current clients to become repeat customers. In business, a sure fire way to make a customer happy and come back is to over-deliver. This is easier if you can also under-promise, but that’s not always possible if you’re competing with others for the same customer. Which is why politicians almost always go the opposite way, i.e. WAY over-promising in an attempt to outdo their opponents, while also using negative messages to undermine the credibility of their opponent’s promises.

The result is that elected officials, (and by extension “government”), WAY under-deliver on their promises. This has been true for almost every elected official, with a few exceptions whose over-delivering was generally not due to their own actions. (For example, the budget surpluses at the end of the Clinton Administration were largely due to a booming economy, which may or may not have had that much to do with the Administration’s actions.) And in situations where governments do deliver on promises, actions often takes longer than people think they should. (In fairness to government agencies and officials, this is because rules for transparency and accountability require lengthy processes for implementing new programs or changing existing ones.)

Under Delivering = Political Upheavals
Over the past 10 years, perceived under-delivering has driven dramatic swings in elections. At the most fundamental level, economic and employment downturns and sluggish improvement drove Obama into office and the Republicans into control of Congress. And because it became apparent that neither party seemed able to deliver on their promises for actual economic recovery, the Tea Party has risen as a “plague on both your houses” solution.

Whether the Tea Party will survive and flourish in our political system, be assimilated, or wither and die remains to be seen. The actual outcome will likely depend upon the state of the economy, job growth, and the military situations in Iraq and Afghanistan over the next 2-6 years – as well as how the Democratic and Republican parties shift their own actions and communications about their promises. (Although I highly doubt any politicians will start under-promising as a strategy for then being able to show how they over-delivered.)

Whether the Tea Party Machine comes to resemble Terminators, Cylons, or Borg will be determined by their own actions and the economic and political environments in which they will be competing. But what does seem clear is that if the economy and employment don’t improve then voters will continue to look for new alternatives to those who have a track record of over-promising and under-delivering. Businesses that do this don’t last long and get pushed aside by innovators who can deliver. Will that happen in the political marketplace? Only time will tell.

What This Means for Health Reform
The resurgent Republican party – in part fueled by the Tea Party movement – has promised to dismantle, defund or repeal the health reform law as it’s being implemented. But some of the specific components – particularly the basic insurance reforms – are generally liked by people on an individual basis… once they understand what they are. In this instance the Republicans have put themselves in a tough position, because if they actually deliver on their promises, they may find that people aren’t very happy with the results, i.e. no increased assurance about their ability to get or maintain health insurance. So if philosophy and a commitment to fulfilling their promises trumps political wisdom, whatever they can undo they will. But if they seek to maintain their political momentum, they will be best served by undoing or stopping only those provisions that don’t have popular appeal and/or are not fundamental to improving the security people have about their health insurance, such as the 1099 reporting requirements.

——————–

p.s. Sorry to have not posted in so long. I’ve been busy helping a community in the Midwest launch a community-wide multi-stakeholder initiative to transform health delivery and financing in their region. Very interesting work and a great real-world implementation of what I and others have been writing about for many years. More on that later – and I promise to write more soon on specific health issues. Best Wishes, M

ACOs – Accountable Care Organizations: Now and in the Future

Posted on June 28, 2010 by Michael D. Miller MD

Because Accountable Care Organizations (ACOs) promise to reduce costs and improve quality it seems like everyone is talking about them as the solution for what ails the US healthcare system.

What is an ACO?
ACOs are a generally described as entities consisting of care delivery providers and clinicians, (e.g. doctors, hospitals, clinics, labs, etc.), organized so that they can more effectively coordinate care and the ACO can accept and mange some type of global, bundled, capitated, or case-base payments for this care in a way that makes the ACO financially accountable for all – or nearly all – the care individuals receive. In addition, ACOs would be held accountable for their clinical outcomes by requiring them to report various clinical outcomes and performance measures, with the clear expectation that these clinical outcomes are tied to reductions in cost growth.

However, exactly what ACOs are is still very cloudy even though in recent years they have been described in many articles and presentations, and the concept was incorporated into the health reform law as a Medicare “shared savings pilot.”

The reason for all the interest in ACOs is partly due to the Medicare pilot scheduled to start in January 2012, and other initiatives for moving away from fee-for-service payments to more comprehensive payments for value – which is the kernel at the center of the ACO nut. The hard part – and the source of the uncertainty – is putting substance and specificity around that seed. In other words, some of the “devil of the details” for ACOs are in delineating what the ACO would be responsible for, and how they would be held accountable:

Would the ACO be responsible for all a person’s care or only that provided within the ACO, or possibly not including some catastrophic illnesses, etc.?
What type of information about what clinical and economic factors would the ACO have to provide to payers and the public, and would they need to have all the information collection, analysis and distribution capabilities, or would that be shared with other ACOs or the community at large?

In addition, there are a variety of practical implementation issues that need to be specified in creating an ACO, including:

How individual providers would be paid within an ACO?
How would individual patients be assigned or connected to an ACO, and what would be the requirements or incentives for individuals to receive their healthcare within an ACO?
What are the antitrust issues involving providers coming together to form an ACO?

How to Think About an ACO
With all this uncertainty about the specifics of ACOs many people are trying to paint pictures about what ACOs would look like in comparison to existing structures or arrangements in healthcare, i.e. managed care organizations, IPAs, Medical Homes, etc.

Part of the problem people are having in describing or visualizing ACOs is that they will certainly vary across the country – and very possibly even within the same cities. This variety means that what works for building an ACO in one community won’t be exactly replicable in another.

ACOs are the House inside which Medical Homes can be Formed
One way to think about ACOs are that they are like a house. The house is an overall structure that contains many different rooms with different functions – from bedrooms to bathrooms to a single kitchen, etc., while distributed service functions are inside the walls, (like electricity, phone, cable, plumbing), the roof and outside walls provide structure with windows to let in light and enable the inhabitants to see outside, and the yard and front walk provide buffers and a path to the outside world. In this analogy, primary care practices (or Medical Homes) would be the multiple bedrooms, other outpatient clinical settings might be the bathrooms, the kitchen might be a clinical lab, the laundry room a hospital, the living room an imaging center, the windows and wires the information technology systems, etc…..

And consistent with this analogy, in different locations, houses are constructed very differently, i.e. multi-story colonials in New England, apartment buildings in cities, single-story stucco in Florida, etc…. and some are free standing while others share walls, utilities and other functions like laundry rooms.

Follow the Money Into and Within ACOs
While the house analogy may describe the organizational structure of ACOs, the flow of money into and within an ACO can be complicated to understand, and may be even more important for the long-term success of the ACO: The flow of money into an ACO will typically be from a payer to the ACO as an umbrella organization for the care of specified individuals connected to that payer, i.e. an employer, or an insurance company. The flow of money within the ACO is where things get more granular since an ACO needs to distribute funds to providers and clinicians in ways that are both fair and create incentives for them to delivery quality and cost effective care.

These internal financial payment systems and incentives are essential since the success of the ACO depends upon it being able to achieve savings, and sharing them not only with payers, but also internally and potentially with patients as well. In addition, the ACO will need to have information systems capable of keeping providers updated about their progress toward clinical and economic goals – possibly in conjunction with various payers or the community overall. It is also important that whatever information is provided to clinicians within the ACOS – and their associated patients – is delivered in a way that is usable and within a time frame that relates to their actual healthcare decisions, ideally within a month.

ACOs v. MCOs
Some have questioned how ACOs are really different than managed care organizations. This is a fair point since at a very macro level, like a staff model HMO, an ACO is accepting a fixed amount of money, (a.k.a. capitation), for providing comprehensive care to individuals. However, there are many differences below that broad description. For example, ACOs will most likely be formed as business relationships among a variety of different care providers rather than as a fully integrated single business entity. Therefore, in a very general way, ACOs could be seen as virtual managed care organizations, with their structures varying based upon the existing relationships within a community. But ACOs may not be fully responsible for the cost of care for a defined population, and at least initially they will likely enter into shared savings and shared risk relationships with payers – who will also continue to play a role in managing the enrollment/assignment of individuals to the ACOs and the flow of dollars from the individual (and their employer as a contributing payer) to the ACO.

Medicare’s Shared Savings (a.k.a. ACO) Pilot
Last week, the Centers for Medicare and Medicaid Services (CMS) held an Open Door Forum conference call about the Medicare shared savings pilot created in the Accountable Care Act, and scheduled to begin January 1, 2012. This conference call was designed to provide individuals and groups the opportunity to comment upon the legislation and make recommendations about how various issues should be addressed by CMS in their regulations for the pilot – a draft of which are scheduled to be released this fall. As expected, on the conference call CMS repeatedly stated that no decisions have been made, and most of the organizations made comments that seemed to be from prepared statements outlining their major concerns about how the pilot is implemented.

Not raised in the conference call was what may be one of the most important sentences in this section of the new law, “The Secretary may give preference to ACOs who are participating in similar arrangements with other payers.”

This is a key concept for two reasons. First, for a group of care providers to organize themselves and establish new ways of providing healthcare and managing payments based upon quality and efficiency will require them to have a significant percentage (e.g., >60%), of their patients coming to them with some type of shared savings/risk payments. Otherwise they may find they are losing money for their efforts because delivering care in more efficient ways while still receiving mostly fee-for-service payments will reduce their income rather than potentially raise it. Therefore, while Medicare is a major payer in many areas, for most potential ACOs it will not represent anything close to 50% of their patients or revenues. Thus for the pilot to be successful, CMS should seek to leverage their efforts with other payers who are also looking to change their payment mechanisms to promote the creation of ACOs – which is the reason that sentence was added to the legislation. Second, the word “similar” is key in the sentences since while Medicare may “assign” patients (and hence payments) to ACOs based upon where individual beneficiaries have historically received care, but as a government program they will likely find it difficult to require beneficiaries to choose a specific ACO or create significant financial incentives for beneficiaries to receive their care within the ACO. Conversely, large private payers – insurers and large self-insured employers – can more easily create incentives or situations for individuals to enroll into or preferentially use a single ACO.

Good News about ACOs
The good news about ACOs, their formation, and the ability of Medicare to work in conjunction or parallel with private payers, is that in many communities across the country multi-stakeholder conversations are taking place about how to form ACOs. And from what I have heard several things are clear: First, these conversations recognize that ACOs need to reflect existing relationships among local providers. Second, managed care organizations and provider groups, (e.g., multi-specialty physician groups and IPAs), seem to be ahead of the curve in these discussions since they see a clear path for establishing the care delivery and information processing capabilities required to be an ACO. And third, multiple stakeholders are part of these conversations, i.e. employers, insurers, hospitals, patient groups, etc.

The importance of these discussions should not be trivialized because they will lead to negotiations and legal documents for the formation of ACOs, and thus need to be conducted in good faith and with diligent examinations of the financial, clinical and information processes required to be “accountable.”

The bottom line is that while the regulations from CMS about the Medicare shared saving pilot will be important guidance for those looking to create ACOs, they will only be part of the equation since private payers’ goals and payments will also be significant for planning the creation of ACOs. The success of nascent ACOs will not be apparent on January 1, 2012 when the Medicare pilot starts, but rather over the following years as their clinical and IT operations are improved, and the financial mechanisms and incentives (both internally and externally) get refined.

As I’ve said before about the health reform legislation, keep your seat belts fastened since this will be a rough and twisting ride. However, what is different now is that all stakeholders need to be at the table for these discussions and negotiations, and it will be an ongoing process of analysis and improvement for making ACOs a successful part of the US healthcare system over the next decade and beyond.

Health Reform’s Effects on Star Trek Medicine – Diabetes and Otherwise

Posted on May 11, 2010 by Michael D. Miller MD

A long-time colleague recently asked me what effect the new health reform law would have on the use of the famous Star Trek Medical Tricorder.* I told him that provisions of the new health law will try to reduce the number of unnecessary imaging tests, and since the tricorder is a hand-held imaging scanner the new law might reduce its use – if it really existed.

Thinking about it later, I realized that if/when such hand-held scanners are developed they would replace much larger and more expensive devices. The impact of innovations like this on healthcare spending depends upon how health insurance pays for these tests. For example, if these hand-held tests are paid the same amount as the big machine tests, then spending would likely increase because more of these tests would be done since they would be easier and faster to do. However, if the amount paid for each scan were reduced, then the total effect on spending would depend on that old economics formula: Spending = Price x Volume. But a third scenario is also possible. If the tricorder were inexpensive enough that it was just another tool in the clinician’s hand – like a stethoscope is today – then there wouldn’t be any separate reimbursement and spending would dramatically decrease.

But back to the new health reform law: The new health reform law could directly alter incentives for discovering and developing new imaging and diagnostic tests, (as well and new therapies), since R&D incentives are closely tied to future expectations for payment amounts and methodologies. The new health reform law has several provisions that could either positively or negatively change these incentives. For example, increasing the number of people with insurance creates a larger paying population, which would increase incentives for investing in R&D.

Conversely, the provisions for comparative effectiveness research, the Independent Payment Advisory Board, and movement towards bundling payments to larger groups of healthcare providers could put negative financial pressure on the incentives for some types of R&D……. depending upon how those provisions are implemented – particularly how robust the quality monitoring efforts are in conjunction with any initiatives to control spending. That is, quality monitoring needs to make sure that spending cuts are not broad-sword like hacks at the biggest costs categories, but rather surgical in nature so that they truly reduce ineffective spending while appropriately valuing clinically and cost effective diagnostic and therapeutic interventions.

How the new health reform law’s implementation, (and other initiatives such as the President’s new National Commission on Fiscal Responsibility and Reform which could dramatically effect Medicare payments), will impact biomedical R&D remains to be seen. But how it changes government and private sector payment amounts and methodologies, (as well as any changes to the policies and practices within regulatory agencies such as the FDA), will be closely watched by biomedical research companies, investors, and patient groups looking for better therapies, diagnostics, and disease monitoring devices.

Advancements in Diabetes
One clinical area where therapeutic and diagnostic advancement has occurred in recent decades is diabetes. Not only are first generation glucose monitoring watches now available, but insulin pumps – which were in clinical trials when I was in medical school – are now being used by such proto-celebrities as Crystal Bowersox, one of the four finalists on this season’s American Idol TV show. (Note – Ms. Bowersox was shown on the TV show telling Harry Connick Jr. to hang on during their rehearsal session since her insulin pump was “talking at her.”)

While diabetes monitoring and treatment are certainly not inconsequential, it is now possible to avoid the devastating effects of poorly controlled blood sugar levels so that a 24 year old Mom can compete on a tremendously popular live TV show. And similarly, the disease wasn’t an issue in the nomination or confirmation of Sonia Sotomayor to sit on the US Supreme Court.

*According to Wikipedia, “The medical tricorder is used by doctors to help diagnose diseases and collect bodily information about a patient; the key difference between this and a standard tricorder is a detachable hand-held high-resolution scanner stored in a compartment of the tricorder when not in use.”

Making Health Reform Work

Posted on May 6, 2010 by Michael D. Miller MD

The May issue of Health Affairs focuses on Reinventing Primary Care – a topic that has been part of health policy discussions for at least 20 years. A few things have changed in that time: now there is better evidence about the importance of primary care providers in coordinating care to improve quality and reduce costs; the structural concept of this care coordination has been codified under the new term the “Patient Centered Medical Home,” (which has also been given precise parameters by NCQA); the complexity of medical care has increased so that the need for care coordination is greater; and electronic information storage, analysis, and communications technologies have been developed which – in theory – should make care coordination and the resultant quality improvement and cost control easier and more practical.

Health Affairs held a briefing on Tuesday about their May issue at the National Press Club. Keynoting the meeting was HHS Secretary Sebelius. She rightly pointed out that healthcare delivery in the US is a “truly broken system.” Her remarks touched on the various parts of the new health reform law that would help fix what’s broken, but the reality is that the Patient Protection and Affordable Care Act (PPACA) is very heavily weighted toward health insurance/financing reform, with comparatively little addressing delivery system reform. Similarly, the Health Affairs articles are very heavy on the situation with primary care, the problems with our delivery system, and what a reformed (or transformed) delivery system should look like, but aside from reimbursement reforms, the articles have very little about how to achieve this transformation.

No “How” to go along with the “Who,” “What,” “When,” and “Why”
Like a good news story, a successful reform initiative needs to address the basic concepts of Who, What, Why, When, and How. Unfortunately, the “How” part is frequently missing or minimal in most health policy discussions and proposals – aside from financial rearrangements. This heavy emphasis on financial incentives is because government programs like Medicare and Medicaid are significantly limited in what they can change outside their payment amounts and methodologies. And in the private sector, changing financial incentives is also the easiest thing to do. In other words, changing reimbursements and other financial incentives, (such as pay-for-performance or bonus payments), is the lever most often used because it is the one that policy leaders are most familiar with, and it is the easiest for them to pull or push.

Challenges of Reorganizing the Unmotivated
Even though transforming healthcare delivery is based upon reorganizing the structure of healthcare delivery there has been very little focus on how to actually get physicians to participate in this reorganization. While economists and others keep pointing to the economic incentives lever, it is pretty clear that physicians are not interested in reorganizing for the sake of improving their incomes. David Rotherman’s review of Timothy Hoff’s book about primary care physicians’ practices at the back of the Health Affairs May issue discusses how physicians like the current situation and their incomes. In this review he notes that it doesn’t appear that “primary care physicians have substantial dissatisfaction with the current system or levels of pay,” and that, “They seem comfortable as pieceworkers, not professionals.”

Thus, while policy researchers and payers correctly describe the great need for and value in delivery system reform, those actually delivering care seem to like many parts of the system – particularly their steady income stream and ability to run their own operations. And while delivery system integration could solve many things clinicians don’t like – such as insurance and paperwork hassles – convincing them that working in a larger organization will significantly improve their lives is a difficult concept to sell. The challenge here is to overcome the inertia of change and getting them to consider the value of shifting from the “devil that they know.”

Private Medical Practices are Small Businesses
Another way to look at this is to see primary care physicians as small businesspeople. As Boedneheim and Pham illustrate in their Health Affairs article, “Primary Care: Current Problems and Proposed Solutions,” 88% of primary care physicians are in practices with 5 or fewer physicians: 32% in solo practice, 14% in two person practices, and 32% in groups with 3-5 physicians.

What distinguishes these small businesses from non-medical enterprises is that because reimbursement systems using fee schedules create fee-for-service volume incentives, these physicians have very few business incentives to change. Since their businesses are generally making a profit, and most physicians’ training and skills are not in running an efficient business, they few reasons to change their businesses operations. While classic economic theory would disagree with that statement, and posit that their incentive should be to improve efficiency to increase profits, the reality is that people don’t like change – and they generally need to believe there there will be a 2:1 return for their financial or psychological investment before they are willing to undertake changes. And small business practicing physicians don’t want to make those changes because they are concerned that no matter what the policy rhetoric states, they believe that any changes will decrease their income.

In addition, physicians generally believe that proposed health delivery transformation changes will reduce their autonomy – something they may value as high, or higher, than their income since it may be one of the reasons they became physicians, it may be why they are practicing in a small group or solo practice, and autonomy of clinical decisions is part of how physicians are trained.

Conclusions – How to Go About Achieving Health Transformation
Transforming healthcare delivery in the US will not be as simple as paying more for primary care services, and/or training more primary care clinicians, and/or training all physicians to work in team-based environments rather than as autonomous clinicians. While all those are good things that certainly should be done, reforming how clinicians are trained will take 20-30 years to produce significant changes in the makeup of the US clinician workforce – and maybe even longer to change the ratio of primary care to specialty practitioners.

Therefore, what is needed is more emphasis on non-financial levers that can be used to alter physicians’ attitudes and actions around improving healthcare delivery – including their immediate practice situations, and how they relate to other providers and their patients. Changing financial incentives can certainly support this, but it is very unlikely to successfully produce these changes in isolation.

Rather, some of the general principles involving the adoption of innovations should be applied to bring physicians – and other community care leaders – to be more receptive and participatory in making delivery transformation both a reality and a success. These principles, (as described by researchers in the 70s and 80s), have been applied to improving the quality of hospital care by organizations like the Institute for Healthcare Improvement, and include providing information about how simple the proposed changes are and how comparable they are to the clinicians existing day-to-day actions, and making it possible for clinicians to observe and/or try out these changes before they have to adopt them.

One of the major catalysts for using these principles to successfully implement reforms is to use change agents to communicate the value and reality of the proposed practice changes, and to simultaneously diffuse misconceptions and fears about them. Since the old adage about physicians is that you can tell them, but you can’t tell them much, the best change agents for leading physicians through this transformation are other physicians who have participated in and/or observed, and/or analyzed other practices that have gone through similar changes. There are also two caveats about these change agent leaders. First, they need to be seen as independent and not biased or conflicted for financial or other reasons. And second, they must be able to culturally and geographically connect to the clinicians they are trying to educate and lead. For example, information about practice transformations in Vermont aren’t going to have much traction with physicians in Texas, nor are the experiences of Philadelphia practices going to carry much weight with physicians in rural Illinois.

Afterward: “Making Health Reform Work” Book Project
These concepts and messages about care delivery transformation using the principles of innovation adoption and stakeholder engagement are at the core of what I’ve been trying to construct into a book containing logical and understandable prose and graphics. The working title for the book is “Making Health Reform Work.” However, the passage of health reform and its impending implementation have overtaken my ability to finish it. Therefore, I wanted to put forward some of these ideas here to stimulate more discussion about these issues and concepts because I strongly believe that without a broad based and balanced approach to health delivery transformation, significant efforts and money will produce suboptimal results and leave a bad precedent for future transformation and quality improvement efforts.

Health Policy and Communications

Health Policy Consulting and Writing to Improve Quality, Reduce Costs, and Increase Value in US Healthcare

Category Archives: Health System Reform