Healthcare Turkey Talk

Posted on November 21, 2011 by Michael D. Miller MD

Thanksgiving is a great occasion for learning what people think about the future of the US healthcare system.* This year, I’m going to find out what people are thinking about some of the coming health delivery system changes – particularly Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMH).

I’ve conducted this two-question informal survey with handfuls of people and found their level of knowledge and positive reactions equivalent to Congress’s approval rating, i.e. 9%. This is worrisome, since if transforming the US healthcare system to increase value and quality will be partially based on ACOs’ and PCMHs’ superior care coordinating abilities, it will be hard to improve cost, quality, and access at the local level if the average person/patient doesn’t know what these organization are, there is inherent aversion to their names, or there is resistant to unexplained “changes.” (For example, several people I’ve talked to have thought Accountable Care Organizations seem like HMOs, and Patient-Centered Medical Homes are home care, nursing homes or hospice.)

So fair readers of this blog, let me know what you hear at your Turkey dinners and associated holiday events – and I’ll post back next week what I heard from my disparate and decidedly unrestrained friends and relatives.

*Unlike most meals and gathering of family and friends, Thanksgiving dinner goes on for a long time, there are no ceremonial interludes, and it is generally a sit-down affair so you can’t move on to someone else – or out the door. This means “Aunt Sally” can pull your ear or kick your leg (either figuratively or literally) for upwards of 2 hours about what’s wrong with the US healthcare system and what how to fix it. My advice is to ask questions to find out root concerns and to gauge people’s understanding of the coming ACA changes in both healthcare delivery and insurance coverage. Also, if you find yourself referring to a recent study from Commonwealth or Kaiser Family Foundation, (or a similar organization or government group), STOP, put food in your mouth and nod encouragement for them to keep talking, because quoting the best studies to someone impassioned about their healthcare will be about as successful as convincing your 7-year-old cousin that 3.14159 is a great dessert.

Patient-Centered Care? Or Not?

Posted on July 11, 2011 by Michael D. Miller MD

The term “patient-centered care” has increasingly been used to describe healthcare structures that deliver better quality care – as well as often doing so with lower costs. And today there was a news story about how some medical schools are assessing applicants’ interpersonal skills, something that is fundamental for being a patient-centric clinician.

While there are have been numerous articles demonstrating the value of patient-centered care and concluding that it is better and should be promoted – including those looking at the ill named “Patient-Centered Medical Homes” – I’ve found myself pondering the following questions:

“What type of care have clinicians been providing if it hasn’t been patient-centered? Has it been clinician/physician centered? Or revenue centered? Or just intentionally confusing and impersonal care designed to stymie the adoption of evidence based standards of care?”

“And along those lines, is the widespread delivery of non-patient-centered care the reason why the IOM concluded that it takes about 17 years for valuable healthcare information to be adopted into clinical practice? Or why Atul Gawande found that hospitals in other countries have widely adopted surgical checklists to reduce medical errors and adverse outcomes, while only 25% of US hospitals are using these checklists?”

I’m just asking….

Health Law Is Reforming System Via Market Forces

Posted on April 3, 2011 by Michael D. Miller MD

All the controversial rhetoric about the new health reform law is missing a huge reality: The law is driving dramatic changes in the real world. Almost every major health delivery system is preparing to reorganize how they provide care to hundreds of millions of Americans by becoming Accountable Care Organizations (ACOs).

Health Systems are Voting With Their Wallets
The magnitude and level of financial interest in ACOs – and proof that it is not just cautious planning – were dramatically illuminated by recent actions and a Washington Post article:

On Thursday, HHS released the long anticipated proposed rule for ACOs and Medicare “Shared Savings.” For the rest of the day the Federal Register’s website was nearly shut down by people trying to download the 429 page document.
Today’s Washington Post article, “Complicated health-care law leads to payday for consultants,” includes figures about the tens of thousands of dollars consultants are charging for strategy sessions about how to think about ACOs, and the millions of dollars in fees they are getting for actually helping health systems to become ACOs. Health systems were signing consultants up for these engagements before the draft regulations were released because of their expectations of how dramatically competition among ACOs will change their financial incentives and structures. And some of the phrases in the article highlight the level of importance being placed on ACOs: “ACO frenzy,” “Oversubscribed,” “Glittering high fees” and, “I have never seen anything quite like this in my 35 years in this business.”

Bottom Line
I could write more about the proposed ACO rule, my interactions with health systems looking to become ACOs (and the organizations helping them), and how ACOs will very likely produce significantly more savings for Medicare than the Congressional Budget Office has projected, but the bottom line looks like this:

ACOs are happening.
The Medicare ACO/Shared Savings rule will shape their form, but not their creation.
ACOs – and their quality/efficiency incentives payments – will fundamentally transform health care in the US.
This transformation will be like an avalanche as health systems compete locally to demonstrate how much more Accountable they are to patients and payers, i.e. how they provide higher quality at lower costs than their competitors down the street or across the river.
While the official title of the new health law is the “Affordable Care Act,” it very easily – and perhaps more accurately – should have been called the “Accountable Care Act” because it is that part of the law which will actually lead to more affordable care for more people.

As always, stay tuned and keep your seat belts tightly fastened for the upcoming wild ride. Like a roller-coaster, the fun is just beginning.

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.

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.]

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.

The Internet Solves Everything in Healthcare – - – NOT

Posted on April 23, 2010 by Michael D. Miller MD

Improving healthcare will require people having better information. That concept is generally agreed upon. The challenge is getting the right information to the right people at the right time. That is the interconnected goal of different facets of health information technology – from EMRs and PHRs, to health information exchanges.

People Are Complex
However, the complexity of medical care and individual variability – both human physiology and patient preferences – makes collecting and analyzing health information so that it is useful for individual clinical decisions much more difficult than presenting information about TVs, computers or cameras on a website such as CNET.

However, that distinction is not apparent to a friend of a friend who I had dinner with recently. This person told me how the internet will solve everything in healthcare by making quality information from patients available to everyone else so that drugs don’t need to be approved by the FDA and doctors don’t need to be licensed. He also believes that this full access to information from other people about the quality of every health care option – from specific medicines to individual surgeons – will make health insurance unnecessary, since people will be able to decide what they want to pay for based upon how high a quality of care they want to obtain.

As a polite dinner guest of a friend I didn’t argue with his Libertarian perspectives. Rather I tried to point out the complexity of analyzing health information because of different patient specific factors, and why risk adjustment is very difficult in assessing the quality of any healthcare option. For example, I mentioned the piece I wrote last winter about a study of different assessments of hospital quality in Massachusetts, and how this showed the difficulty of exactly what this person believed should be easy and currently possible, e.g. if you were a patient in Massachusetts trying to decide which hospital you should go to for a specific condition, how would you decide. As I noted then, the different quality assessments came to conflicting conclusions.

Profit Seeking Isn’t Always A Good Thing
I also noted how the profit motive can lead unscrupulous people to sell fake medicines that can actually do more harm than no treatment at all – such as fake anti-malarial pills containing aspirin, which don’t treat the malaria but do reduce the fever so people think they are getting better. Similarly, the concept of modern snake oil salesmen taking advantage of people’s hope was reinforced by a recent cartoon in the New Yorker showing two people looking at a display of pill bottles adorned with a sign saying “As seen on TV,” and the caption reads, “The active ingredient is marketing.”

However, I found my insights didn’t make much of an impression, and I did make a faux pas by pointing out that there was $1.1 Billion in last year’s stimulus bill for research to get more of this type of information and make it available to people. Unfortunately, this fact only elicited a shaking head in hands response which I took as his disgust at more wasted government/taxpayer money.

“Living is Easy With Eyes Closed, Misunderstanding All You See”
While for those of us not blinded by the limited wonders of computers and the internet, and who understand the complexity of actual healthcare decisions and analyses, the challenge is communicating this reality to people who believe that the internet is rapidly solving all our information problems…… As a society our goal should be to convey this knowledge to people before they or a family member becomes seriously ill – at which point the complexity of making healthcare decisions will be immediate and personal. And just as there are no atheists in foxholes, people facing serious life altering medical decisions want validated and reliable information, not subjective, anonymous opinions from the internet – which may be fine for picking a restaurant, but is certainly problematic for picking a surgeon or a medicine.

Checklists and Physicians’ Behaviors

Posted on January 12, 2010 by Michael D. Miller MD

I recently heard Dr. Atul Gawande talk about his new book “The Checklist Manifesto.” While the evidence demonstrating the value of checklists for improving the quality of healthcare is increasingly abundant, in his presentation Atul talked about how in a study assessing a surgical checklist they ran into resistance from about 20% of physicians.

Another story he told involved his surgical group’s considering how they might manage bundled reimbursements, e.g. accepting a single payment for all the care and testing related to thyroid cancer surgery. Their discussions came to a screeching halt when it became clear that this “might” mean less money for each of the surgeons. This uncertainty in personal income arose because accepting bundled payments would require them to distribute money among the people and organizations involved in the actual surgery, the pre and post surgical testing, and the follow-up, which can be a very complicated process.

His group of surgeons probably found this change too daunting because they didn’t have an overarching group/entity to help them assess how to distribute/divide a bundled payment, and actually manage and monitor the money and their financial performance. While they are part of Partners in Boston – a large integrated health system that includes the Mass General and Brigham and Women’s hospitals – it seems that Partners hasn’t reached the point of providing this type of support for their individual medical groups.

In the broader world of health deliver reform, to manage such bundled payments effectively physician groups might need to become part of – or affiliate with/have relationships with – medical homes and/or accountable care organizations. If every group of physicians – particularly in a single specialty – had to figure out on their own how to accept and manage bundled payments, it is very unlikely to work, leaving us with our current perverse incentives of fee-for-service reimbursements that promote volume over quality.

What these two stories have in common is that they involve the barriers to positive transformations of clinical medicine. Specifically, fee-for-service’s financial incentives give many clinicians few reasons to change to bundled payments or other reimbursement systems that don’t prioritize volume and don’t reward quality outcomes. Similarly, increasing the use of checklists and other care improving protocols faces significant barriers because while they don’t attack clinicians’ incomes, they can be seen as assaulting their professional autonomy.

Change Agents and Care Delivery Transformation
Part of the solution to both these challenges are support mechanisms to assuage clinicians’ concerns about loss of income and autonomy. The simplest way to conceptualize these support mechanisms is as “Change Agents.” For bundled payments, clinicians need some trusted group or organization that can help them understand how they will be compensated, what information they will get and how to use it, and how bundled payments may actually simplify their professional lives and even potentially increase their incomes – assuming they can practice more efficiently and effectively. For example, because medical care has become so complicated – with an ever expanding array of advanced diagnostic and therapeutic options – the use of checklists and protocols can help clinicians standardize the routine parts of care and thus cognitively free them up to focus on patients’ individual needs and goals, including how to optimize adherence to treatment plans. These changes will improve clinical outcomes, which is what patients want, and economic outcomes, which is what society wants because it will help stimulate the economy and make it easier to expand insurance coverage and access to care.

While Change Agents to support the successful adoption of bundled payments may be some combination of administrative groups and other clinicians who’ve successfully used the new reimbursement scheme, Change Agents for care innovations are most often other clinicians. Typically these clinician Change Agents have real world experience showing how the innovation has actually improved the quality of care – particularly by saving an individual life or preventing a specific adverse event. (Dr. Gawande’s research group saw this in their surgical checklist study, and I found this in researching the use of telemedicine in intensive care units.)

Patients as Change Agents
Patients can also be Change Agents. As I’ve previously written, if patients asked their doctors if they use checklists for things like surgery and inserting central IV lines, and then refused care from physicians (or institutions) that don’t use such checklists, there would likely be rapid adoption of these and other innovations as they are validated and their value communicated broadly. Advocacy organizations can also fill this role, as can government agencies as part of their quality improvement activities through programs such as Medicare, Medicaid and the Veterans Health Administration – something I’ve also raised in a previous post.

Conclusions
Improving quality and slowing the grow in healthcare costs will require multipronged strategies. What these strategies will have in common is that they will confront the significant barriers clinicians have in changing how they practice medicine. Achieving this will require Change Agents – clinicians, patients, advocates, and government agencies who can demonstrate and support the value of care innovations. Simple? No. Possible? Yes. But as the pair of old sayings go: If it was easy anyone could do it. And if it was easy, someone would have done it already.

Historical Perspectives on Health Policy: Part 3

Posted on December 4, 2009 by Michael D. Miller MD

I just found my copy of the book “Improving Health Policy and Management” edited by Stephen Shortell and Uwe Reinhardt. The book’s eleven chapters address many of the hot-button issues in today’s health reform debate:

Creating and Executing Health Policy
Minimum Health Insurance Benefits
Caring for the Disabled Elderly
An Overview of Rural Health Care
Effectiveness Research and the Impact of Financial Incentives and Outcomes
Changing Provider Behavior: Applying Research on Outcomes and Effectiveness in Health Care
Health Care Cost Containment
Redesign of Delivery Systems to Enhance Productivity
Medical Malpractice
Prolongation of Life: The Issues and the Questions
Challenges for Health Services Research

The observant ready will notice one critical issue from today’s debate missing from this list… Information technology. That is because this book was published in 1992… and actually the titles of the first and last chapters also included “in the 1990s.”

What this points out is that the fundamental issues of controlling costs, defining benefits, and improving efficiency in care delivery and through financial incentives are not new to the health care debate. Reinforcing this historical reality, I recently ran into Professor Stuart Altman from Brandeis – who is one of the most insightful and clear thinking non-ideological health policy expert I’ve ever had the pleasure of talking to and hearing testify before Congress. And he told me on a rainy NYC sidewalk that he has been talking to people across the country about how the current debate is both similar to and different than the early 1990s, the 1980s, the 1970s….. and back to even the 1930s…and despite the ongoing delays he is hopeful that legislation will be enacted this time.

So while the issues haven’t changed, and likely won’t change no matter what legislation is enacted in the coming months, (and years), the hope is that this time around progress will be made so that health care becomes less of a national obsession, (and drag on the economy), and people and politicians can focus on life, liberty, and the pursuit of happiness, rather than illness, accessing needed treatments, and financial uncertainty.

Health Policy and Communications

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

Category Archives: Innovation