Bridging Business & Healthcare

Comfortably Numb

Mark Browne — Wed, 22 Jun 2011 13:24:56 -0500

2,080. 40 times per week. That’s the number of wrong site surgeries still happening annually in hospitals and clinics across the US, according to a recently released study from The Joint Commission. I read the article with great interest yesterday morning as I was making my way through several airports traveling to a client site. As I walked through an airport I stopped to watch several news stations, expecting to see some outrage at such statistics. Maybe even a catchy new headline – “The War on Error”. I watched them all - CNN, Fox News, the political gamut – and saw…nothing. Not one story. Not even a passing interest.

Have medical errors become so much a part of the fabric of our healthcare system that this type of news doesn’t even merit a mention? Has getting the wrong care become not only accepted, but expected?

As healthcare reform continues to press forward, we continue to design fixes that will allow us to slowly evolve into a new delivery system, all while not changing our current system too much or too quickly. We seem to have agreed somewhere along the way that some frequency of errors is acceptable, and that we need to work on this slowly, lest we break the system we have worked so hard to create.

This study proves what we already know – our healthcare system is still broken. How long will we as a nation continue to tolerate slow and steady fixes to the system, and at what cost?

Hold the Mayo?

Mark Browne — Mon, 13 Jun 2011 10:56:22 -0500

In a nine page letter last week to CMS, the Mayo Clinic has definitely outlined its position on ACOs. Under the current proposed rules they, like many others, have publicly chosen not to participate. Mayo goes on to say that the proposed regulations are “in conflict” with the way it currently runs it Medicare operations.

Although the Mayo Clinic is only one voice in a growing chorus of dissent, I can’t help but wonder if their voice is louder than the rest. In a public letter to Senators Ted Kennedy and Max Baucus on June 2, 2010, President Obama stated that "we should ask why places like the Mayo Clinic in Minnesota, the Cleveland Clinic in Ohio, and other institutions can offer the highest quality care at costs well below the national norm. We need to learn from their successes and replicate those best practices across our country. That’s how we can achieve reform that preserves and strengthens what’s best about our health care system, while fixing what is broken." With that type of endorsement, it would hold to reason that if Mayo is a model we can all learn from and even strive to replicate, yet they aren’t going to participate in ACOs, would it be logical for anyone to participate?

I know the Mayo model is certainly not the only way to skin the accountable care cat, but they are certainly held in high esteem by most in the medical community and even more so in the political community. Although there are those who believe that one voice alone will not be enough to derail the ACO train, I do believe that Mayo’s position will significantly drive the outcome of the final rule. As a wise friend of mine once said – “Sometimes you have to count the votes, and sometimes you have to weigh the votes.”

Live Free or Die

Mark Browne — Fri, 10 Jun 2011 05:27:23 -0500

Recently as a colleague of mine and I were debating the latest developments in healthcare reform, he posed a not-so-rhetorical question. “So, when do you think the independent practice of medicine as we know it will cease to be?” Current statistics, if you are believer in statistics, suggest the answer to his question might be “Sooner than you think!” Hospital employment of physicians is up 75% from 2011 to 2012, operating costs in physician practices are up 51% over the last decade, only 25% of practices have successfully implemented a fully functional electronic medical record, all in the face of flat or declining reimbursement. The die does appear to be cast.

However, even in the face of what appear to be overwhelming odds, there still remain a large group of physician practices looking to reinvent themselves in any way needed to assure their continued independence. Although the independent practice as we know it will certainly change, many are unready to write its epitaph quite yet.

So what will it take to remain independent in today’s merger happy, consolidation focused environment? Here are a few thoughts (with many thanks to my colleague Jon-David Deeson for his contributions to the list below):

Define independence – Practices may not have to be employed/aligned/merged/acquired, but every practice will need to learn to work outside of its own four walls if they are to take advantage of new payment systems, particularly bundled payments. Even the most independent of practices will need to become comfortable sharing data, both clinical and financial, with other groups and health systems.
Measure and share your value – Living on the reputation of being the best –ologist in town who the CEO comes to see as his/her personal physician is no longer enough. Those physicians and practices who wish to survive independently must be able to objectively demonstrate their value to patients, physicians, and health systems that they desire to have as partners and customers. Once that value is shown, proactive transparency with the data will be crucial.
Embrace the new quality - There must be an awareness that the traditional ways we as physicians measure ourselves will not be adequate. Successful groups must not only show that they perform better than national benchmarks, they must also demonstrate that they perform better than others in the same specialty. Relative performance will become more important than absolute performance with regard to almost all measures of quality. In a world of reform, if you are not demonstrating quality outcomes, you may not be able to play at all. Those who wish to thrive must also realize that all quality measures will not objective. Patient satisfaction and communication have always mattered, but now your income will depend on mastering them and proving that you have.
Change your ways – Although productivity still matters, maximizing your business model around a fee for service, volume focused model will not allow practices to thrive and control their own destinies. Along with the quality focus mentioned above, physicians must learn to not only provide care, but to direct care. Developing and leading a team of providers (physician extenders, care mangers, home health providers, etc..) will differentiate a physician from the rest of the pack. This model is much different than the traditional “the-doctor-will-see-you-now” model of care most physicians grew up practicing, but mastering it will be critical for any practice wishing to succeed.

It is certainly getting tougher by the day to practice medicine independently, but for those that are willing to innovate and embrace change rather than pining for the “good old days” of medicine, there may yet be hope.

Defining the Core

Mark Browne — Thu, 02 Jun 2011 09:46:42 -0500

In its June 1 letter to CMS, the American Hospital Association outlined a litany of concerns and issues with the ACO proposed rule as it is currently written. One of the key concerns brought out by AHA was the large number of quality metrics to be tracked by participating organizations, currently set at 65 different measures. Their proposal goes on to suggest that CMS consider a “concise set of measures” be included in the startup phases of ACOs to encourage greater participation and a greater likelihood of success in improving those metrics. The AHA did not, however, define what it thought those metrics should be that would adequately define high quality care delivery.

Although there are certainly many quality metrics out there currently defined by CMS and others, most would agree that they have failed to capture the measurement of the delivery of truly high quality care. With that in mind, I am going to attempt, at least in part, to fill in the blank left by AHA. Here are my thoughts on what might constitute a few new core measures for quality.

Physician and nurse communication as a “trigger metric”. Even in the most sophisticated healthcare systems, thorough communication to the patient so about their care is not always the focus for all caregivers. No communication – no quality reward.
Percent of participating physicians using clinical decision support tools – A version of this metric currently exists in the proposed rule, but is limited only to primary care. With the rapidly growing complexity of care, not using decision support tools as they become available will become akin to not using antibiotics to treat infections. We must learn to work in new and innovative ways, using all the tools we have available, if we truly wish to improve care and lower costs.
Time to implementation of evidence based care – The medical field continues to be content with slowly adopting therapies and interventions that are known to work and save lives. As an example, the use of care guidelines around the insertion and care of central lines has been definitively shown to save lives, yet adoption across the country is not yet universal. Adoption of this type of guideline should be expected within one year of release of data deemed as “clinically significant” by a panel led by physician experts in clinical quality.

This list may not be complete and may not represent exactly the type of quality metric that CMS or AHA has in mind. However, if we as a healthcare system, cannot successfully address some of these tough issues at the very core of care delivery, we have little hope of reaching our defined goals of truly providing the highest quality of care that we know can be delivered.

Elevators and Amusement Rides

Mark Browne — Thu, 12 May 2011 15:30:06 -0500

Yesterday was no different than many other days in my life as a consultant. Two clients, three cities, and finally arriving late evening at the hotel. It had been a long day of travel and I was looking forward to getting into my room and off of my feet. As I got onto the elevator, for some reason, the inspection certificate caught my eye and I felt compelled to read it. Capacity 1750 lbs. No more than 5 passengers. Inspection good through January 2012. And then I saw it – Certified by the State Administrator for Elevators and Amusement Rides. Elevators AND Amusement Rides? Did I miss the “You must be THIS tall to ride this ride” sign? Visions of “approved” rusty carnival rides whirling in the air made me very glad to step out of the elevator and onto something a bit more structurally sound.

This week a new study from Mayo Clinic was released, outlining the volume of colonoscopies a physician must perform to demonstrate expertise as rated by an objective test of endoscopic skill. The study showed that the number of procedures needed to show competence in colonoscopy was nearly double the 140 procedures currently recommended. It also raised questions regarding many procedures and the training required to attain true expertise in performing them.

As we continue to plunge into a world of healthcare accountability based on value and not solely on volume, I have to ask the question: are setting the quality bar high enough? It is a difficult discussion for many practices and health systems to have, but the question of clinical competence must be expanded beyond performance that is simply ”greater than the state or national average.” Have we given our nurses and clinical staff the appropriate training to truly excel in caring for our patients? Are we holding all physicians to the same high standards for every procedure, in every setting? Have we allocated our financial resources to truly focus on the highest clinical outcomes attainable, not just performing better than our nearest competitor?

As the concept of measuring value and holding each other accountable for outcomes evolves, we must be cautious not to measure only what we currently can track and assume that it is good enough. We must continue to push to measure that which truly demonstrates a standard of excellence, not just a standard of competence, even if that means that some physicians or health systems won’t be able to provide that service until they can demonstrate a higher level of care. It may be difficult, but until we in healthcare hold ourselves to these new, higher standards, we will never know if we are getting elevator or amusement ride quality.

One Small Step

Mark Browne — Mon, 25 Apr 2011 15:29:07 -0500

Ask anyone who was alive in the 60’s to list the greatest accomplishments of our country and they will most certainly include the successful flight of Apollo 11 and the first moon landing. The US spent nearly $25 billion dollars to get Neil Armstrong and company to the moon and back, but what did we really see when we got there? Buzz Aldrin captured it best when he looked at Neil Armstrong and said: “OK. About ready to go down and get some Moon rock?” $25 billion dollars and over 200,000 miles to get there and we get…moon rock.

In 2008, the US government spent nearly $400 billion dollars on Medicare with another $200 million on Medicaid, and the numbers continue to grow every year. We now find ourselves facing the challenge of nearly 500 pages of new rules governing how this money will be spent and facing a long and arduous journey to find new models of care delivery to somehow make this all work in a new and different way. If and when we finally reach the promised land of Accountable Care Organizations, what will we find when we finally arrive?

The creation of new models of care delivery may be the greatest challenge healthcare has faced in decades, but where we actually end up may not be the most important part of the journey. Even though our Apollo astronauts came back with a bucket of rocks, the trip to get there had great value in and of itself. Without it we may never have had dialysis machines, CT scanners, contemporary physical therapy machines, cook/chill equipment, Mylar, athletic shoes, or even cordless power tools.

What new innovations will come from our journey to a new world of healthcare? A patient portal app that is standard on all smartphones? New medication delivery systems that eliminate the need for IV lines entirely? True real-time quality measures and interventions? - (Mr. Browne, this is your patient care coordinator. I see through your iPhone app that your BP has been above baseline for 5 days. Have you been taking your medications?) And many, many others….

The destination of the new care model as it has been currently defined may end up being no more exciting or memorable than a big pile of moon rock, but the innovations we create along the way may just make it worth the trip.

A new "ist"?

Mark Browne — Mon, 11 Apr 2011 15:01:05 -0500

Since the term hospitalist was coined in 1996, this new specialty has grown faster than any other in the history of medicine. Continued financial pressures on primary care, combined with increased restrictions on resident work hours and the desire of physicians for a more manageable lifestyle, created a perfect environment for the rapid growth of this field. The success of this model has spawned the creation of similar models in obstetrics (the laborist) and, most recently, surgery (the surgicalist). As I read through and began to digest the proposed rule for implementation of ACOs over the last week, I began to wonder if we were once again creating the perfect environment for the creation of a brand new kind of specialist….

The proposed rule has more than 50 pages dedicated to defining specific quality measures, how they will be used, and how physicians will be rewarded (or punished) based on their performance. There are 65 metrics currently outlined, the majority of which are to be measured in the outpatient, primary care setting. Metrics include seven measures on patient satisfaction in the primary care setting, rates of 30-day post discharge visits, surveys for patients on how well they understand their care plans, “ambulatory sensitive conditions” (diabetes, CHF, dehydration, pneumonia, and others) measured both on how well you manage them as well as your ability to keep patients with these diagnoses out of the hospital – and the list goes on. The rule goes on to outline that you must report on and perform well on each and every one of these metrics if you wish to participate in any available shared savings. The potential financial rewards for many organizations are great as are the adverse risks of underperforming.

Primary care has been thrust into the center of medicine once again (can anybody say capitation?), but this time it appears that at least some of this model may actually stick. Although putting the primary physician in the proverbial driver’s seat will have advantages for managing care and outcomes, there is only so much a physician can do in a day. How will primary care physicians find the time to continue to do what they have always done – diagnose, treat, and care for their patients? Ladies and gentlemen, I give you, The Preventionist.

The Preventionist will focus solely on the optimization of care as defined by CMS, BCBS, and any other outside entity or payer. They will only see patients with conditions defined as focus areas for cost and quality, nothing more. Diagnostics or other conditions? Leave that up to your family physician. Acute illness? We have a nurse practitioner that will see you now. Without this focus on the ever-rising bar we are being measured against, how will any organization be able to truly succeed? This may be taking this looming model of primary care to an extreme, but ask any internist who has practiced more than 10 years if they ever thought, when they first began, they wouldn’t be caring for their own patients in the hospital?

The new rules are upon us and I do believe they were well intentioned and designed (at least in theory) to lead to better care for patients and populations at a lower cost by charging primary care, once again, to steer the ship. However, in our haste to create a model to save money and to care for the most challenging patients, I fear we may be creating just what we are trying to avoid – misaligned incentives and a model of care that is even more fragmented than the one we have today.

Draft Day

Mark Browne — Wed, 09 Mar 2011 11:19:49 -0500

As I was getting my daily fix of ESPN this morning, something a bit different than the routine scores and highlights came across my TV. Two very talented men, both potentially bound for NFL stardom, were showcasing their talents for scouts, coaches, recruiters, and reporters – a panel of judges if you will. Although these players have certainly proved their talents in the past, these workouts will likely determine which player an NFL team will choose to build their future around. These workouts are vigorous, competitive, and very, very public. As draft day approaches, there is a running tally of whose stock is up and whose is down. Which player is at the top of Mel Kiper’s big board? Who will be drafted in the top ten? Will they succeed or be a bust?

As I listened to the reporter break down every step of Cam Newton’s latest pro day, I wondered what it might be like if physicians were put through this type of workout and evaluation before we were “chosen to play on a team?” If professional entertainers are subject to this type of scrutiny, shouldn’t we expect at least that from those of us sworn to care for the sick and “do no harm?”

I thought about the standard recruiting process for most physicians. A check of our background and training. A reference check from those with whom we have worked. An interview or two and a nice dinner. All of this is usually followed by an offer and a contract. Not exactly the NFL combine when it comes to assessment of quality.

The world of quality in healthcare is at a pivotal point in its history. Tracking of quality data and performance is certainly central to any health reform effort, but when it comes to individual physician performance, we admittedly have a long way to go. The arguments over which data are good enough and whether or not it “applies to me” continue to be the core of many discussions in many physician lounges and hospital board rooms. We may not ever get to the level of intensity seen on NFL draft day, but if we truly hope to deliver the highest level of quality for our patients, we must be more open to increasingly higher levels of scrutiny and evaluation of our performance.

The Best of All Worlds

Mark Browne — Mon, 28 Feb 2011 16:05:18 -0500

As a consultant, I spend a lot of time on airplanes and subsequently get to meet a new “person in the next seat” almost every week. Once the small talk is over, the conversation is nearly the same every time. “Oh, you work in healthcare! What do you think about all of this reform stuff anyway? Is there an answer?” I’m always very cautious how I frame my answer. As those of us who work in this world know, there is not AN answer so I am very careful not to endorse one model or the other, keeping the conversation turned toward the general nature of reform and the complexities it entails.

Well today I am breaking my own rule. I want to talk about a model that just might work. I’m not sure if my inspiration was generated by the storms this weekend, making me feel a bit like the good Dr. Frankenstein, but I began to consider what a new model of care might look like if we took the best parts of some good models and built an entirely new “beast.” My thoughts are not entirely complete and your feedback is welcomed, but here goes….

The model is based on the following premises:

Some of the best and brightest physicians have become frustrated with the complexities of billing, the noise of paperwork, and the inability to care for an unmanageable number of patients to make ends meet. As these complexities worsen, more and more physicians will either leave practice, seek out a partner (read “hospital”) to accept the growing economic risk, or move to a model of “cash for care”.
A small number of the sickest patients consume a large share of available medical resources. In many of the new models proposed, safeguards are built in so that physicians don’t select these patients out of the care model as the risk for caring for them poses too great of a financial penalty.
Carrots work better than sticks.

So here is the plan. Why not pay the best and brightest physicians to care for the sickest patients as simply and effectively as humanly possible? Let’s take the best parts of a concierge model of care, throw in a bit of primary care medical home and a touch of Dr. Gawande’s hotspotting model and see what we get.

The model would work like this. Take a population of no more than 300-400 patients with at least one chronic disease as their primary diagnosis and assign them to one physician. This physician would be responsible for the care of those patients and those patients only. But rather than pay the physician through any type of complex, CPT driven payment mechanism, pay them cash. No billing, no coding, simply cash up front. Sound too much like capitation? Here would be the key difference. In a capitated model, it is assumed that too much care is given and the payments are designed to reflect the risk of managing care down to a certain level of payment and reimbursement. Physicians are motivated by avoidance of an undesired negative financial outcome. In this model, the assumption up front would be one of excellent care. Remember, only those physicians who have demonstrated that they are already the best of the best in caring for complex patients would be invited. Physicians would receive payments based on their continued provision of the highest quality care to patients - not just to avoid negative outcomes, but assure positive ones. Payments would be based on the assumption that at least one hospital admission for at least half of the patients would be avoided on an annual basis. Although current payment structures for hospital care are based primarily on the volume of admissions, this model will set the stage for a value based model of reimbursement that is likely represents the next iteration of hospital payments. If you assume that a hospital admission for a chronically ill patient can quickly add up to $10,000 or more, you would very easily have enough cash flow to run a practice. In order to assure that excellent care was given, outcome based quality and cost metrics would be measured on all patients. There would be no “quality bonuses”. Quality care is assumed and paid for on the front end. As long as the highest quality is continually demonstrated, physicians would be allowed to continue practicing in this model.

So in the end here is what we get:

Patients who need the most care get focused attention from the best physicians leading to better outcomes of care than they can achieve in our current fragmented system.
Unnecessary care, in particular expensive hospital based care, is reduced, thus decreasing total costs to the system.
Physicians are rewarded (instead of penalized) for caring for complex patients with financial recognition, and by minimizing the administrative burdens inherent in practices currently.

As always, the devil on any idea like this is in the details, but if we are to come up with meaningful solutions we may need to develop a tolerance for living out here closer to the edge of creativity, avoiding the gravitational pull of current thought and the status quo.

The Elephant in the Room

Mark Browne — Tue, 22 Feb 2011 15:24:13 -0500

“Primum non nocere” – First, do no harm. This is one of the first things we are taught as physicians going through training. If Hippocrates were alive today, I think he would make it even simpler – “Do the right thing. Every time.” It seems simple. It seems so straight forward. But as we all learn, practicing medicine is neither of those things. To many physicians, medicine seems to have become a maze of complex clinical algorithms laced with a myriad of regulatory and legal hurdles and barriers to overcome. And at the center of it all is the dirty little issue no one seems to want to discuss – defensive medicine and tort reform.

On Jan 25^th, to very little fanfare, the HEALTH act was reintroduced into the House and passed by the Judiciary Committee several days later. The bill has been introduced to congress annually for the last 6 years with little or no traction at all. The bill, which focuses on medical malpractice reform, is a mere 28 pages in length - 1900 pages less than PPACA. The bill’s basic tenets are pretty straight forward: cap punitive damages; replace joint and several liability (in other words, not every physician can be held liable for the actions of other physicians); set statute of limitations on filing claims; and limit the amount attorneys can make on malpractice claims.

The arguments on both sides of tort reform are certainly passionate, both for and against, but one thing is certain – sweeping the discussion under the proverbial rug and doing nothing (again) is no longer an option. Whether defensive medicine costs $7 billion, as the CBO claims, or $70 billion, as the AMA claims, it is a very real practice leading to the waste of very real dollars.

We are all trying to make progress on changing the healthcare system to one that is focused on decreasing costs, improving outcomes, and holding one another accountable. If we do not address this barrier to providing high quality, appropriate clinical care, our ability to focus on the real issues will continue to be clouded and our chances of developing a truly improved care delivery system are greatly diminished.

A Rose by Any Other Name

Mark Browne — Wed, 16 Feb 2011 12:13:01 -0500

As a healthcare consultant, I live in a world of TLAs – three letter acronyms. Accountable Care Organizations are ACOs, and are kind of like PHOs (Physician Hospital Organizations), which sort of remind us of clinically integrated IPAs (Independent Practice Associations). Once we have made that shift from actual words to brief alphabetical snippets, the meaning of the original words seems to get confused or even lost entirely. This may be the case with one of our latest acronyms – PCMH.

Many would say that PCMH stands for Primary Care Medical Home but recently I have seen the definition shift. PCMH now can also mean the Patient Centered Medical Home – which, when you look at most published definitions, still looks more physician centered than patient centered. Much of our society is already light years ahead of medicine when it comes to being consumer centric. As I considered this, I wondered what a truly Patient Centered Medical Home might look like. Not one that just talks about the patient, but one that is all about the patient.

Whose network is it anyway? Primary care medical homes are all about coordination of care by a single physician, one who can make sure all of my medical needs are met with high quality and efficiency. In a Patient Centered Medical Home, the physician is part of the patient’s network, not the other way around. Why would I want only one doctor to care for all of my needs? If I have diabetes, CHF and osteoporosis, I want to choose the best endocrinologist, dietician, cardiologist, rheumatologist, nurse practitioner, and maybe even an acupuncturist if I happen to believe it might help my pain. In a patient centered model, the physician is no longer the coordinator of care; the patient has assumed the majority of that role.

Care when I want it– In a primary care medical home, access is important. Things like weekend hours, evening hours, and even telemedicine are key components. In a patient centered medical home, the physician’s schedule is not the issue at all; the patient’s schedule is the key. Access to care would simply be on demand, 24/7. Sound extreme? Think ATMs and TiVo. When is the last time you heard a 25-year-old ask when the bank was open or when a TV show was on?

No secrets - Physician led medical homes focus on transparency. Sharing information with patients and patient education is an important element of their success. However, in the world of instant access to information, including medical information, a patient centered model would move fromtransparency about information to listening to information that I, as the patient, bring regarding me and my care. Current models of care are still designed for the medical information and treatment plans to flow from the physician to the patient, not the other way around. Patients may not have the level of education that we as physicians have, but they do have access to the same information and, at times, new and different information, that we may not always consider. The information playing field may never be leveled, but in the new healthcare world it is certainly tilting more toward the patient than ever before.

Making sure we understand the meaning of the new care models we are developing is critically important as reform marches on. Words are important, and how we interpret them is even more so. MD – Medical Doctor – still has great meaning, and I believe it always will in any new care model. But to many people, MD is also beginning to mean Modern Doctor - and that definition is still in the works.

A Glass Half Full

Mark Browne — Fri, 11 Feb 2011 08:02:57 -0500

My last several posts have been, shall we say, a bit on the frustrated side, so I’ve decided today to change my approach and embrace my inner optimist. Rather than lament the challenges surrounding us as we all swim our way through the muck and mire of healthcare reform, I have resolved to focus on the positive and share some of the new care models that are being tried by some very innovative folks. To be sure, these ideas are not what has been in the mainstream press and not one of them has the momentum of ACO’s, but I believe there are some real pearls in each of them. This list is not complete by any stretch and I would love to hear about others that I might have missed.

The Prometheus Payment system – The theory of getting a group of physicians together to decide what it costs to care for a particular disease, paying them upfront, and then holding them accountable for the care is a very interesting physician-led twist on the ACO. Several large health systems are trialing this system as we speak. It has significant backing through the Robert Wood Johnson Foundation.
FaircareMD – By striving for transparency in pricing, this model targets those with large out-of-pocket expenses and lets patients choose their doctors based on price. Wouldn’t this get interesting if it also included good solid quality measures and let patients choose on value? Maybe we could call it ValueCareMD….?
Practice Fusion – Practice Fusion provides a completely functional EMR free of charge (yes, that’s right – free). The EMR is web-based and ad-supported with non-intrusive ads throughout the product, shifting the cost away from the provider to the vendors.
Care Practice – By providing 24/7 urgent care and house call service this group has embraced the concept of “radical access” leading to “the practice of least resistance.”
Qliance and One Medical Group – These models are bringing concierge care to the masses. For a fee similar to your monthly gym membership, you can get a greater level of service and attention than your traditional primary care practice as well as online records access and same day appointments. This may appeal to those with a high deductible HSA plan and who are becoming more and more cost conscious.
Hello Health – By putting patients in charge of their own healthcare through creative use of the Internet and social media, this model is truly on the leading edge of the healthcare curve, and it may be just what the doctor ordered for the new iPad generation.
ZocDoc – Think OpenTable.com but for medical appointments. The website says it all: Find a doctor. Choose a time. See a doctor. You are in control.

Even though CMS has created a Center for Innovation, true innovation is much more likely to occur on the fringes in models like the ones mentioned above. I, for one, will be watching these new and exciting innovations closely as they continue to evolve. PPACA is certainly not the only game in town and others are providing us with lots of great ideas and information along the way. Maybe the healthcare reform glass is half full after all.

For a Few Dollars More

Mark Browne — Tue, 08 Feb 2011 15:17:45 -0500

Over the last several days I have been pouring myself into the latest information from CMS on what lies ahead in the world of quality – that being the proposed rule on Value Based Purchasing as published in the Federal Register. As with most things that the government produces, I prefer to read the original text, not only the summaries, as many of the finer details tend to get overlooked.

As I dug into the first page, I was actually a bit encouraged. We all know that quality will be included in whatever form of reimbursement is on the horizon and CMS’s approach sounded reasonable.

Scoring methodologies should be reliable, as straightforward as possible, and stable over time and enable consumers, providers and payers to make meaningful distinctions among provider performance.

Makes sense to me. Then I read on….

After a 7 page description on why the metrics chosen were the most appropriate metrics, CMS goes on to dedicate a full 20 pages of the 39 page rule to describing the proposed scoring system, including a discussion of the use of "cube versus linear models" of the exchange function to determine ultimate distribution of payments among hospitals. It reminded me a bit of my vector physics classes from undergrad, but a little less understandable.

As those of you who know who know me well, I am in full support of integrating the measurement of quality into any reimbursement model. However, by trying to so fully objectify this measurement, it appears as if CMS has created (or at least proposed) a system that is begging to be gamed by those that participate in it. How long will it take for vendors to begin promoting “key indicators” that, if focused on and improved, will lead to greater reimbursement? And even if these “key indicators” are met, will we really see any appreciable improvement in quality of care? By focusing on payment reform first and care delivery reform second, we are once again creating another model of measurement rather than a model of improvement.

I don’t have all the answers, but I do believe as do many of my colleagues, that for any new delivery system to succeed, there will need to be a greater degree of collaboration between physicians and hospitals. If a measurement system of this complexity is ultimately implemented, it may very well lead us to the law of unintended consequences. By focusing on the details of the payment system and not the improvement of the delivery system, we make it more difficult, if not impossible, to achieve the integration, alignment, and redesign necessary to build the new delivery system that we can all agree is sorely needed.

One Size Fits Most

Mark Browne — Fri, 04 Feb 2011 14:19:02 -0500

This may be a surprise to some of you, but I do not look good in a mu’u mu’u. For those of you who may not know, a mu’u mu’u is a very comfortable, very loose fitting Hawaiian dress that just sort of hangs off the shoulders of the wearer. It is designed to fit almost anyone and to be worn for any situation. And although it may fit over my frame, I certainly do not look good in one.

As I read and follow what’s happening in the healthcare landscape, it seems to me that many people are searching for the mu’u mu’u model for healthcare. What can we design that fits (most) everyone in every situation? And by doing so we have lost sight of the fact that there are very likely multiple solutions to this very complex problem.

Last week Atul Gawande wrote an excellent article in The New Yorker entitled “The Hot Spotters” that asked the question Can we lower healthcare costs by giving the neediest patients better care? His arguments were both persuasive and thought provoking. I do believe, this model may indeed work for certain patient populations – the sickest among us, but will almost certainly not work for the remainder of us. Models such as Qliance in Seattle or Hello Health in New York City provide new and innovative ways of seeing patients and will be great for some, but will not work as well for the patients Dr. Gawande describes.

Much of the discussion and debate on Capitol Hill and around the country is focused on which model will improve quality the most and save the most cost. This equation too frequently circles back around to a model which is driven by the most efficient payer structure or by what will fit into the already existing mammoth infrastructure that exists in healthcare today. As long as we continue to ask the question of which model is best, I fear we will continue to get the same answers. The question we should be asking is how can we best care for very different patients with very different healthcare needs. Before we all get herded blindly into the ACO corral, let’s be certain we are focusing on caring for the needs of patients, not just the need to have a solution.

O Brother, Where Art Thou?

Mark Browne — Fri, 22 Oct 2010 13:56:46 -0500

In yesterday’s Wall Street Journal, Tennessee Governor Phil Bredesen presented a well-written argument to show how many employers may benefit financially under the new healthcare law by no longer providing insurance coverage to their employees as a direct benefit of employment. Today, Louisiana Governor Bobby Jindal announced that his state would delay changes to the Medicaid system that would have made care available to thousands of the poorest citizens of his state due to opposition from many hospitals there.

As I read both of these pieces, I couldn’t help but notice something, or should I say someone, continues to be conspicuously absent from these discussions. Throughout Governor Bredesen’s piece he refers to “coverage,”“plans,” and “employers” caring for patients. Governor Jindal’s plan refers to “coordinated care networks” caring for patients. Networks, plans, and employers do not care for patients – physicians do.

As politicians and businesses scramble to try to define and implement the new normal, physicians continue to be seen at only at the end of every story, simply reacting to each new twist in interpretation of the law as it is imposed. With few exceptions, physicians seem to be content to follow the actions of others.

I am not calling for a massive rebellion on the physician front, but simply for individual physicians to begin to take a leadership role in the process. Ask most physicians and they will agree that the current delivery system is unsustainable and that changes must be made. If we as physicians want to be more than a footnote in this process, then we must begin to take a more active role in shaping it as it unfolds.

The Slippery Slope of Value

Mark Browne — Wed, 20 Oct 2010 15:07:47 -0500

This morning United Health Care announced its new Cancer Care Payment Pilot. According to UHC, this pilot is designed to “advance a new cancer payment model that focuses on best treatment practices and better health outcomes.” As a matter of fact, most agree that the cost of treating cancer under the current model is unsustainable. As evidence for this position, Dr. Michael Neuss, an oncologist from Cincinnati, described existing payment plans that reward physicians for using expensive chemotherapy medications as “our dirty secret” in today’s New York times. In this world of the “new normal” of healthcare reform, I am “all for” exploring new models of care that attempt to provide the best care at the best price, but that does not appear to be the true goal of this model.

In reviewing the details of the model as outlined by UHC, this new pilot will reimburse providers utilizing a bundled payment plan based on the “expected cost” of treating a patient. The physician will choose the care plan, but all reimbursement will be independent of the drugs that are chosen to treat the patient. Basically, the physician will get a flat fee for what it should cost for him/her to see the patient in the office, plus a bit of a bump for case management and drug administration. The drugs will be reimbursed at cost, removing any profit incentive for the physician.

So far so good right? Not so fast. Although the disincentive for profiting on medications may lead to lower costs, what incentive will there be for truly improved quality and better care? Reading on in UHC’s press release, they do mention that they will be measuring the number of emergency room visits (a cost measure), the incidence of complications (a cost/quality measure), and “health outcomes.” Exactly how they will be measuring outcomes is not said.

Even if you give UHC the benefit of the doubt that they are going to create robust, meaningful, outcomes-based quality metrics (which I am admittedly skeptical of), they have missed the boat on one very important piece of this equation. None of these quality metrics appear to be tied in any way to the physician’s income. How much the physician is paid is tied solely to the time likely to be spent caring for the patient – a bundling of expected fee for service payments, nothing more.

Creating appropriate incentives for any behavior is complicated, but B.F. Skinner showed long ago that negative reinforcement is short-lived. If you desire to have long-term change, you must reinforce a desired behavior. We must create new models that help us reign in cost. However, without including positive financial incentives that reward the best care, we will simply end up with another band-aid approach that rewards the payer, frustrates the physician, and fails to provide incentives to improve the outcomes of those at the center of care, the patients.

.....And Now for Something Completely Different

Mark Browne — Mon, 11 Oct 2010 14:30:43 -0500

Last week the healthcare world was all abuzz. The federal government was set to begin the journey that every player in the marketplace has been waiting for, the road to the accountable care organization. Over 300 industry leaders gathered in Baltimore to hear just how this was going to occur, to hear the “new normal.” Well… that’s not exactly what was heard. Although there were some mentions of changes to safe harbors and inclusion of all players, not a lot of new and different ideas were shared. While following those who were live tweeting the event, comments like “..is an ACO a PHO without the H?” and “Without antitrust legislation, we’ll have only large hospital networks remaining..” and even “..capitation is on the horizon” were the norm of the conversation.

The closer we get to implementation of this “new” model, the more similar it appears to ideas that have been tried (and failed) before. It seems we have not yet developed the appetite for a model that is new and truly different.

Apple’s iPad has been out for less than a year. It is anticipated that within the year it will have its own category of electronics, and will outsell netbooks by a large margin within the next two years. The iPad was expected to do well, but not this well. The iPad, like healthcare reform, was promoted as something new and truly different. But the iPad was not only new and different, it was also better for the customer…at least at some things. It made doing things that customers truly wanted to do (get information fast) better and easier, even at the cost of not being as good at others (word processing, gaming, etc.).

In an article in Kaiser Health News this morning, the author outlines how many industry players are lining up to make ACO’s work – not for the patient, our customers, but for them, the providers of services. These industry insiders all seem to be afraid of what they might have to give up under this new model of care, and are looking to make sure they maximize their own gains. There may be a lesson for us to learn from our friends at Apple. If we truly want to improve our model of care, we are going to need to give some things up. Everything cannot stay the same with different titles. Different for the sake of different is not going to cut it either. If healthcare is truly going to be reformed, we need to come up with both “different” and “better” – for the providers AND for the patients. So the question remains, does the highly publicized and government-endorsed accountable care organization meet these standards? Based on those attending the listening sessions this past week, I’m afraid the jury is still out.

Certifying Quality

Mark Browne — Mon, 20 Sep 2010 15:47:22 -0500

As we continue to move further down the path of healthcare reform, finding ways to focus on and measure the quality of clinicians is generating more and more discussion. An article published this week in the Columbus Dispatch highlighted the value of board certification as a proxy for quality. The article even went so far as to reference the possibility of a higher rate of pay for physicians who maintain their certification. Opponents to board certification argue that performing well on a multiple choice exam does not truly represent good clinical quality, and that the cost to the physician as well as the time lost caring for patients in this era of physician shortage is not warranted.

In a related article from NPR, the dying art of physical examination of the patient was highlighted. In a 2002 study of family physicians, less than 40% could correctly identify 12 common heart sounds.

It would seem to me that these two studies cry out for the same solution – include hands on testing as a component of demonstrated competence for physicians. Now, before I cause a revolt at the ABMS, let’s think about this for a minute. Nurses are required to continually demonstrate hands on competencies in most hospitals to continue working in individual units such as the ICU. To be certified as an open water lifeguard you must demonstrate at least 4000 hours of open water experience to even be considered. If you want to fly a multiengine commercial jet you need at least 280 hours of experience, 10 of which are under the eye of an inflight instructor while demonstrating all the requisite skills needed to fly in a myriad of different circumstances. Why then would it seem so far fetched to require the same demonstration of skill for physicians? Combine a written course to assure mastery of knowledge with a live demonstration of clinical skills relevant to each physician specialty. Putting something of this nature into practice would of course be very challenging, but if we are truly going to demonstrate quality, this may be a good place to start the conversation.

Things Unsaid

Mark Browne — Tue, 14 Sep 2010 13:15:02 -0500

This week the newly appointed head of CMS, Dr. Donald Berwick, gave his first public speech since his appointment in July. As the speech opened, he mentioned a lot of the “what’s” of healthcare reform; costs must decrease, new ideas are needed, we must work together, change is imperative, etc He did not, however, mention much regarding “how” he intends to lead us there. Further into the speech however, Dr. Berwick may have given us a glimpse into his plan. He referred to a “three part strategy" to:

Improve the experience of patient care;
Attack population-wide causes of disease; and,
Reduce per-capita costs of health care.

This strategy is an apparent reference to the “Triple Aim”, a concept first promoted by Dr. Berwick following its introduction in an article published in the journal Health Affairs in 2008.

Since his appointment, Dr. Berwick has been criticized for not outlining a solid plan to implement healthcare reform. When asked how he would do just that in his original article, Dr. Berwick did have a plan. That plan included some very difficult and not very politically popular suggestions: global budget caps on total healthcare spending, measurement and fixed accountability for the health status of populations of patients, standardized measures of care and quality, sharing of financial gains with those that help reduce cost and improve quality, and training clinicians to improve their ability to change processes of care. Curiously, Dr. Berwick chose not to include any of those suggestions in his speech this week.

Over the last few months, the healthcare reform debate has been peppered with cries of things that various groups will NOT do, but no one has yet emerged as the leader who has the ideas of what we CAN do to achieve meaningful reform. Among other attributes, leadership involves establishing a clear vision, sharing that vision clearly so that others can follow, and then providing the information, knowledge and methods needed to accomplish that vision. I may not agree with every tenant of Dr. Berwick’s plan, but he at least he (at one time) had a plan. By choosing not to continue casting his vision for that plan, the opportunity to become the leader healthcare reform desperately needs may just have passed him by.

Things I Think . . . I Think

Mark Browne — Tue, 31 Aug 2010 18:44:27 -0500

We all have our guilty pleasures. One of mine is reading my weekly issue of Sports Illustrated cover to cover. During this time of year, every issue ends with the same column titled “Things I Think I Think” – a column dedicated to “all the latest news, buzz, and inside information”. Like all of you, I have been bombarded with buzz daily about the latest developments in healthcare reform. In an attempt to keep up, I have immersed myself in the law for the last several months, trying to make as much sense of it as I can. After taking in all of this information, and adding in a few of my own thoughts, here (so far) is what I think…I think.

Even though I get email every day on how to be one, and the law allows for the formation of them, I don’t believe that ACOs are ready for primetime just yet. There is a lot of good that may come from them in theory, but the operational challenges of actually designing, implementing, and successfully managing an ACO are daunting at best. The complexities of actually pulling all of the moving parts together may prove too much for the majority of healthcare organizations, leaving much of what the law has set out to do a distant goal for many.
The pilot project that CMS has underway for orthopedics, interventional cardiology, and cardiovascular surgery is already approaching the halfway mark, with preliminary performance data expected in November of 2010. These bundled payment models are likely here to stay, at least in high dollar specialties. There are several facts that lead me to this conclusion. First, these models are designed to jointly incentivize physicians and hospitals in their efforts to deliver high quality care by removing the primary reimbursement barrier facing them today; disparate payment systems that are misaligned. Secondly, the outcomes metrics in these specialties are well developed, and some of them have already been rolled out by CMS for public comment outside of the demonstration project to be used in other portions of the healthcare law. And last, but certainly not least, the enormous amount of financial savings that is likely to be gained by implementing these models will simply be too great for CMS and other payers to ignore.
Physician payment reform may not come in the form of repealing the SGR, but will be greatly shaped by the Value Based Payment Modifier section of the new law. This section (section 3007) is designed to reward physicians who deliver high quality, low cost care with respect to their peers by changing the amount paid per work RVU. The metrics to be used are due out by January 2012, rule making is set for 2013, with full implementation scheduled for January 1, 2015. This may seem a long way out, but the advantage this modifier may have over other methodologies is that it avoids the need to overhaul the payment infrastructure currently in place. Once quality metrics are defined, you will simply be paid more (or less) per work RVU using the same systems that CMS currently has in place.

At the end of the day, I guess what I think I think is that even though we have a long way to go before all of the pieces of the puzzle fall into place for truly meaningful reform, we are soon to see the effects of several of these pieces, signaling the beginning of truly significant change to our system.