Monday, July 27, 2009

High Quality / Low Cost Care - 10 Communities who are making it happen

Quite little conference brought 10 communities who consistently deliver high value health care meet in Washington DC to share with policy makers how they did it.

Last week several of the high priests of health care reform convened a little band of 10 top health value performers from accross the country to attempt to explain to each other and to the Washington on lookers how they were able to effectively "bend the trend". They came from all over the country and in as many geographic varities as they did demographic flavors: Asheville, NC, Cedar Rapids, IA, Everett, WA, La Crosse, WI, Portland, ME, Richmond, VA, Sacramento, CA, Sayre, PA, Tallahassee, FL. and Temple, TX. The one thing they all had in common was the fact that they had achieved what only a fraction of health service areas are able to achieve - consistent high quality, relatively low costs, and outstanding outcomes.

I had spoken with Elliot Fisher just prior to the conference and he was excited about how rapidly some of these organizations were able to respond to be in Washington sharing their stories. It seems that all of these folks are interested to share their stories and in some cases try to figure out why they have been so successful relative to others even within their region. For potential X PRIZE teams, I think there are some valuable lessons that can be learned. The highlights include:
  • Physician-hospital collaboration matters. They need to trust each other and have common patient-centered goals.
  • Data matters. All docs think they are doing the right thing for their patients, but they don't have the data to prove it, and when they do get the data, they often find plenty of room for improvement.
  • Teamwork matters; the myth of the "superphysician" who can do it all should be laid to rest.
  • Efficiency matters; philosophies like LEAN work, although you have to stick with them.
  • Leadership matters. Particularly physician-leadership.
In addition, focus areas on clinical and community cultures of health, smoothing of care transitions, and having plentiful data avaiable to measure, monitor, and improve outcomes. We have discussed several of these before and I believe that competing teams will need to master these and other quality / cost challenges to increase value by 50% in a community.

Looking forward to the full report coming out of the meeting.

Monday, July 20, 2009

Incenting the Ideal Health Care Delivery System

Several key themes emerge from 15 Case Studies of high performing health systems.


The Commonwealth Fund recently published a very interesting report on how to reform the health care delivery system by sharing a series of case studies of high performing health systems. I recently highlighted some of the work of Group Health, but wanted to pull out some of the more generic information about the principles of reform that have been learned from these case studies. These principles were first elucidated in the Commonwealth's "Organizing the US Healthcare Delivery System for High Performance" issues in August 2008.


Six Attributes of an Ideal Health Care Delivery System
  1. Information Continuity. Patients’ clinically relevant information is available to all providers at the point of care and to patients through electronic health record (EHR) systems.
  2. Care Coordination and Transitions. Patient care is coordinated among multiple providers, and transitions across care settings are actively managed.
  3. System Accountability. There is clear accountability for the total care of patients. (We have grouped this attribute with care coordination, since one supports the other.)
  4. Peer Review and Teamwork for High-Value Care. Providers (including nurses and other members of care teams) both within and across settings have accountability to each other, review each other’s work, and collaborate to reliably deliver high-quality, high-value care.
  5. Continuous Innovation. The system is continuously innovating and learning in order to improve the quality, value, and patients’ experiences of health care delivery.
  6. Easy Access to Appropriate Care. Patients have easy access to appropriate care and information at all hours, there are multiple points of entry to the system, and providers are culturally competent and responsive to patients’ needs.

You will notice that many of these principles can be found in the incentive and measurement structure of the Healthcare X PRIZE. We are trying to motivate teams to provide the type of care that has been shown over and over to delivery the best care. However, we are not asking people to replicate Kaiser, Intermountain, Mayo, or Geisinger - we are asking them to improve upon those models. While they deliver the best care today, we believe there exists even better, more efficient, and more effective care models out there. We look forward to the many teams, conveners, stakeholders, and other parties coming to the table to surprise us with their novel concepts, ideas, and incentive structures.

Can't wait to see what the innovation approach from a field of what we anticipate will be a global competition.

Thursday, July 16, 2009

Communities on the Move: What gets measured gets improved

Pugent Sound Health Alliance urges doctors, hospitals, patients, insurers, employers and others to use new report to improve local care

The Healthcare X PRIZE Team has been on a brief writing hiatus as we drive toward finishing off the initial Prize Design ahead of some upcoming Board Meetings for both X PRIZE Foudantion as well as the prize sponsor, WellPoint Inc. and WellPoint Foundation. Alot has been happening during the last few weeks, including several new reports and stories coming out regarding some of the high performing systems in our country. The repository for this information seems to be the Commonwealth Fund, which has an impressive listing of all the great case studies from around the country. One of those recently highlighted was Group Health, which is part of the Puget Sound Health Alliance.

Key thing is to note the way they have organized care, the way they use metrics to improve and organize care, and the clear and often dramatic improvements they are making in healthcare. As a respresentative example, please see a recent press release below.

Seattle, WA - July 16, 2009 Recognizing that fixing what's wrong with our health care system is a moral imperative and a fiscal necessity, the Puget Sound Health Alliance has unveiled an expanded and updated the Community Checkup report comparing care in doctors offices and hospitals, highlighting where improvement is needed. For the first time, the Alliance is making the Community Checkup available for use in business decisions such as benefit design, marketing and contract discussions.

The Community Checkup report still shows wide variation in the care that patients receive in this region. "Too many patients still don't get effective health care recommended by national medical guidelines, said David Fleming, M.D., Alliance Board Chair and Director of Public Health - Seattle and King County. "The good news is that by using insights from the Community Checkup report, then making changes to improve the results, we can reduce the personal and financial cost of chronic disease and preventable health conditions."

The report shines the light on specific areas of care where there is real opportunity to improve local health care value, improving effectiveness of care, patient health and saving money:

  • Insight #1: Depression - On average in this region, 30 to 50 % of patients diagnosed with depression and put on antidepressants go off the medication too soon. Some medical groups have earned better results; however, even the best result in the region still shows as much as 25 - 40% of patients who don't stay on their medication for the recommended time. ROI: Depression is the top driver of health-related costs in the workplace. Getting better results will improve patient health and the bottom line for employers.
  • Insight #2: Medicaid - The report now shows results for care to people on Medicaid, a low-income population often challenged with language, transportation and other barriers. Yet some local clinics are still able to provide recommended care to Medicaid clients at better rates than national benchmarks for the commercially-insured population. Every medical group can learn from these clinics about ways to ensure that all patients get recommended care. ROI: Nationally, 83% of Medicaid spending is associated with chronic conditions. Improved care for people on Medicaid improves personal health, saves tax dollars, and can reduce the cost shift from public to private sector payers.
  • Insight #3: Generic Drugs - The report shows that too many patients fill prescriptions with expensive, advertised brand-name drugs rather than an equally effective generic. For antacids, for example, some local clinics do very well in getting as much as 85% of patients to take a generic, yet other clinics have only 5% of patients on a generic version. The spread of variation for Medicaid is smaller, likely due to strong financial incentives for doctors to recommend cost- effective generics to patients. ROI: An Alliance estimate, using local health plan data for four types of drugs, shows that for every 1% increase in the use of a generic in lieu of a brand-name drug, more than $2.5 million can be saved in this region.

"Real health care reform isn't just about legislation, it's about improving how health care is delivered, covered and received by patients," said Mary McWilliams, executive director of the Alliance. "Now that we're shining a light on areas for improvement, it's time for each of us to roll up our sleeves and make specific changes to improve health care value in this region."

In April, the Alliance Board lifted restrictions on how the report may be used, starting with the July Community Checkup, to encourage decisions that change behavior and improve results. "The Alliance is the one place where everyone has come together to improve health care," said Lloyd David, CEO of the Polyclinic and Vice-Chair of the Alliance Board. "The Community Checkup is an essential part of ensuring that we all head in the right direction together."

The report can be used by doctors and other health professionals to see how they compare with peers then learn and apply best practices to improve quality. Patients can use the report to see the importance of certain health services, then talk with their doctor about how to be as healthy as possible. Health plans, employers and union trusts can use the report to improve benefit design, remove barriers to effective care, and engage individuals to make better decisions. All organizations can also use the report results during contract discussions. Several organizations are making changes based on what they've learned, such as:

  • The Birth and Family Clinic has implemented a plan to ensure that patients are aware of equally effective yet affordable generic drugs.
  • Providence Physician Group built templates into their electronic medical record system to reflect the elements of care measured in the Community Checkup report.
  • Valley Medical launched a breast cancer screening awareness campaign to ensure that their patients receive needed care.
  • Northwest Kidney Centers use the Community Checkup as they work with clinics to help reach the goal of 100% of people with diabetes being screened for kidney disease.
To highlight even more stories of health care changes in this region, the Alliance now collects examples from organizations and individuals through the Community Checkup website.

"The Community Checkup has established the Puget Sound Health Alliance as a leader in the growing national movement to improve the quality of care," said Michael Painter, J.D., M.D., senior program officer at the Robert Wood Johnson Foundation, which helped fund this report through its Aligning Forces for Quality program. "It is important reading for anyone who gets, gives or pays for care in the Puget Sound region to make informed choices and improve local health care."

The Community Checkup is the largest medical care comparison report produced for the Puget Sound area. The updated report shows results for clinics with four or more clinicians, based on care provided to about 2 million residents by 76 medical groups, about 240 clinics and 30 hospitals. The clinics account for about 80% of the primary care doctors in pediatrics, family or general medicine, obstetrics and gynecology, and general internal medicine in the region.

Online, the Community Checkup shows medical group results based on all data, commercial insurance data only, and Medicaid data only. Medical groups have access via a secure portal to all of their results at a detailed level. The data used for the report was provided by 18 health plans, union trusts and self- insured employers. That data does not include patients' personally identifiable information, such as name or birth date. Nor does it include cost, charge or payment amounts.

For care provided in medical groups or clinics, the Community Checkup measures care in the following areas: use of antibiotics and imaging, asthma, depression, diabetes, heart disease, prevention, and generic drugs. Three new measures being added are Avoidance of Antibiotics for Adults with Bronchitis, Adult Use of Preventive Care, and Use of Primary Care for Children.

For hospital care, the report shows performance in care for patients who have surgery or are treated for heart attack, heart failure or pneumonia, plus topics such as communication with patients, actions to reduce medication errors, and more. Hospital results are drawn from several sources of publicly-available data, including Health and Human Services Hospital Compare, the Washington State Department of Health, and the Leapfrog Group.

Later in 2009, the online Community Checkup report will compare health plans in this market based on national standards and compared to national best practices. Also to be added are measures of the variation of intensity of services or relative use of resources, comparing: (1) the amount and types of care during hospital visits, and (2) 'episodes' of care tracked across time, provider type and locations. High- value care uses fewer resources to get similar results.

The next print version of the Community Checkup is expected to be published in 2010. "Our goal is to continue to have the Community Checkup report be the single best resource for patients, doctors, hospitals, employers, unions, health plans and others to find information about local health care performance in this region," said Dr. Fleming.

Current funding to produce the Community Checkup comes from organizations and individuals who participate in the Alliance, and special grants from the Robert Wood Johnson Foundation.