Great read on narrow networks. Can we afford to live without them? And why can't they deliver equal quality?

http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_160.pdf  

2013 lessons - 2014 plans

The world is speeding up - either truly or as a product of my age!  But Healthcare is spinning at warp speed and the centrifugal force has thrown many off course or out of the game all together.  While at the same time, those at the core, the early adopters are holding close to the strategy and staying in the spin.  (I may also have watched too much Olympics this week for the imagery.)

This is what I have witnessed this past year.
1. Early adopters moved through the alpha stage and either made adjustments or lowered their commitment to risk.  They are still ahead of the curve and making it harder for others to get to that place at the center.
2. The cautious, curious and joiners in the field, put players on the field, also learning some lessons, and reached to the center to affiliate or join.
3. The wait and see crowd or non-believers began to feel the pull of the force to spin them way out of their comfort zone and off course.  Course corrections either followed group 2 for the lucky ones or followed truths from the past that may continue to spin them farther from achieving success.
4. Those who were not in the game at all and hang on normally by their fingernails, either made dramatic changes to position them in a completely new way or they began the final death spiral as the safety net evaporated for most stand alone and safety net hospitals.

I believe this was the year where those that can partner and those that can't matters; it may be the number one success factor for the foreseeable future.
The second critical success factor is recognizing whether there are any differentiating factors or whether your organization is really a commodity in the market that needs to be rationalized and maximized on value basis.
The third notion that may have eluded organizations in group 3 as their stability began to spin away, was that there is no admission based strategy in their future that is sustainable.  They have maximized assets or have costly excess capacity, and their value is in their provider structure.

The interesting thing about these groups is that traditional measures do not predict them.  Their profitability of the last 10 years is not an indicator of their next 10 year success.  What matters is the infrastructure that they have built to reduce the cost of care for the population they serve and the ability to recognize how that moving parts play into that.  Investment strategies for those who are on course are different from those who are not.

And lastly, those that were losers over the last 5 years have little chance to capitalize their future.  There opportunity only exists if they have a capturable market population that is of value to a group one organization.  Its not only about you any more, its about your patients.

The plan for 2014: group 1 moves to refinement of their ability to handle risk and expansion to achieve critical mass.  Group 2 aligns with the best group 1 partner they can focusing on central v local service definitions, access to capital and networks,  reduced overhead and increased content experts; group 3 wakes up yo the realities of their market value and seeks a network or begins the slow and steady decline of days cash on hand.  Group  4 sees a lot of closures, some recovery and partnering, and some restructuring and the re-emerging as ambulatory or other continuum provider.

Let's see what happens.

Another Year of Lessons learned

2012 Closed with drama and 2013 will be filled with more as Obama care provisions roll out- So What did we learn in 2012 to help us go forward?
1. Quality and appropriateness will drive sustainability as much as volume. What seems obvious but it will be tricky are the transition to move volume out that "doesn't benefit the patient and keep some in that just may". For instance, will we see some longer lengths of stay as we assure a decrease in re-admissions. I think it makes sense.  It is a clear paradigm shift.
2. Will we get smart enough by allocating more support in the form of PT/ OT and other paraprofessional support to manage and keep expensive seniors and high cost folks well. It seems to me that we ought to apply the public health philosophy of good prenatal care  from the 1960s and 1970s to an senior model to avoid the trauma expenditures and focus on preventive elder care  - end of life care for the living end of lifers!  It reminds you of the world war posters reminding people to stay strong and resilient.
3."Mind the GAP" - the Brits subway speaker cautions one to Mind the Gap every time you enter or exit a train.  We need to mind the gap to make sure that people are not falling through the cracks in the healthcare system and manage the gap assuring that they have alternative is they are.
4.  Drug costs:  the users of public vs private health care will be drawn by two things: quality and access to providers, especially primary care providers with access to teritary or emergency and discount or paid pharmeceuticals.  The biggest line in the ED are those off their meds - can't afford them or can't understand them. 
5. Change is not going to come to all healthcare but data driven management of the top 20% of healthcare access drivers is going to be important.
6. Managing risk is like nothing else -  it is way more difficult and expense than people think and requires strong IT, clinical analysis, clinical management and structures to support primary care.
7.  IT and staff for primary care that are integrated into hospitals and all levels of care will be essential to creating successful pirmary care proactices.

Not enough focus on patient safety and quality outcomes

It really is amazing that a decade after the "To Err is Human"  report that major hospitals are still not adequately focused on safety and quality.  A colleague today pointed out that 5 or 6 quality FTEs is the equivalent of the aerospace industry moving forward with no safety engineers.  The complexity of patient safety issues both (as the old Catholics said about sin) the errors of omission as well as commission - is just as painful and deadly.  They are all costly in terms of human capital and waste - and it is so extremely underreported.

How many hospitals are challenging the types, severity and outcomes of surgery?
How many hospitals are challenging the variation in Internal Medicine orders and outcomes?
 How many hospitals challenge CT or MRI rates, Mammograms, biopsies and their outcomes in terms of longevity, quality of life and mordidity. 

I would say that 1% are focused on the change that we need in healthcare outcomes, followup and choices; a larger percent on creating access to services, and an even larger percent on profitability of the system.  To me that is not a sustainable change model.


How do we really incnetivize the change. 
More importnatly will it come from the upstarts or the old guard....I am guessing like IBM, we will see the Microsoft, Apples and Facebooks lead the change that is needed.  I don't think I like it but it is inevitable!

This is worth a read!

Kaiser Health News' article today

Mass. Aims To Set First-In-Nation Health Care Spending Target 

is well worth the read.  It is interestingly juxtaposed with the article on how little consumers like the idea of expanding Medicaid budgets in their own states.  The absolute notion that leaders have to get their hands around is how quickly the game is changing from how do I squeeze out a margin on what I am now doing to how fast can I handle a global fee and still make a margin.  As the dollars continue to be constrained at the State levels, the message gets louder and louder: the federal constraints are going to come and they will stick...even in the current "leaderless" election cycles.

The perfect storm of aging babyboomers, slowing retirement accounts and slowing government spending really points to more and more risk based and data driven spending.  Massachusett's focus on global payments and data is by necessity going to hit all states and then the feds for those states that can't get their hands around it.

Check it out.

I have participated in my 10th (do I really know how many) on line debates on healthcare because a neighbor of mine loves to rile up his Republican colleagues and his Democratic neighbors and to watch the sparks fly.

It has been one of the few places that I have actually seen intelligent data being quoted with a few barbs thrown in, so I keep returning to the scene of the crime and get baited into participating.    Most discussions of healthcare, or Obamacare or ACA, are mostly barbs so this is kind of enlightening.  I have yet though to see anyone convince the other that they are right....isn't it interesting, no one believes anymore that facts are facts.  They believe that they can toss out an opinion (not their own but someone elses) as a fact, and because they know their facts are often wobbly, they challenge the facts of everyone else.  Its hilarious for adults to be throwing major reference data on a facebook discussion!  Or maybe not so hilarious....I really miss the days when facts were facts and you needed a professionally critiqued replicable study to dispute the facts.  Now all we need is one loony who says it just ain't so.

The only fact that I know is that everyone needs a doctor, or possibly surgeon or midwife or orthopedic specialist or trauma surgeon at some point in their lives.  They need them for immunizations (a nurse can give it I know), ear infections, stomach bugs, terrifying febrile seizures in 4 year olds, and broken hips in your 70s.  These are not life style or choice, these are terrifying or painful moments that affect all humans and the choices are to seek medical and other health attention or to suffer and possibly die.  That makes healthcare no more a commodity than the person who receives it and the person who gives it.  It is not a market but a need.  It is not a want but a necessity.  It is a requirement of most religions to provide it and its a mark of a civilized society to provide it equally to all citizens and visitors.  The good samaritan didn't ask for papers as you might recall.

Today healthcare is about money.  Huge whopping piles of money.  Money coming in and money going out.  Money paying for nurses to valiantly stand by your bedside all night long and hold your hand and money going in boatloads to pay for administrative rules and crazy systems.  Money that lines the retirement account of senior executives to the tune of the whole budget for a town of people and money that keeps some doctors squarely in the 1%.  Money to pay off ridiculously high costs of medical education and money to pay for overmedicating of children and seniors.  Nuns talking about margin. Millionaires talking about mission.  Money, money.  Everyone has a stake.  Do I get less or more.  Do I pay less or more.  Why do I pay for someone else.  Why do they expect to have what I get but don't pay for.  Its all about money and its so broken. 

I am not naive about money and the cost of healthcare.  Its the priority it has and the imbedded vested interest that is so difficult to move.  I have seen organizations put their best interest aside only to be slammed by their constituents.  We really don't understand what is at stake as a country.

So I keep jumping into the debate because it is about the foot that was lost to poor diabetic management or the women who decided living isn't so great when you're poor so she ignores pain. Its about the body, stupid, and that body just might belong to someone you know.

Twenty CCE/MCCN Projects submitted

The State of Illinois is reviewing 20 Care Coordination Entity project bids this summer to care for the most challenging Medicaid clients - the aged and disabled. 

I had the privilege of working with a great team to design and implement a health home network for these patients that is centered on a chronic disease management model as opposed to a family practice model.  This exciting approach to systemic change and patient management - patient partnership and patient engagement - could improve the value of care for thousands of patients.

Implementation that focuses on transition management and structural improvements is underway now.  This model has value for all patients.  Congrats to a great team.

Moving to ACO

The Move to Accountable Care begins with the creation of state of the art medical or health homes.  Based on years of research at major integrated systems like Kaiser and Group Health Cooperative, the medical/health home is very different in structure, fully supported with unique roles and HIT, to create a new model of approaching the management of patient care and outcomes.   The creation of health homes is foundational but is only one  of the process and structure changes that allow an organization to manage both financial risk as well and more importantly, quality outcomes.No longer are leaders asked to tweek a system here or there or cut costs around the edges; this process change requires a wholesale refocusing on the metrics by which all entities are evaluated and compensated. 

Working with Clients to achieve structures to do this work is creative, challenging and culturally wrenching!  Everyone knows that culture trumps strategy. 

Clients need to embed in their cultures the recognition that is not an experiment or an option.  The change that is required is fundamental because the system is fundamentally unsustainable at its current cost and value (outcomes).  Patients will find that its not the options that are available to them that make quality but knowing that the right option for their health and lifestyle is available to them and will have an outcome that they expect.  These value changes are occurring and will be supported by payors whether our cultures accept them or not.  The key to success is to embrace the paradigm shift and begin the build, balancing the "now" with the future in terms of revenue stream.

Moving to Standard Work Elements in a Medical Home

I have found that the most compelling and simple tool in use for the change in moving a practice from medical practice to health home are the elements of standard work from Group Health Cooperative of Puget Sound.  These elements including call management and outreach work cell define core traits of a value based practice.  Clearly a more aggressive model than hospital clinic medicine or private practice offices these elements lead to a trade-off with unnecessary hospital use.  We are using this model with Community Health Centers as they expand their role from a medical and case management outpatient site to one that bridges the transitions with other providers and manages chronic disease.

The Standard Work Elements are available on line at Group Health's website.

If you believed what you hear in the news, you would think that all change in healthcare will cease with a negative supreme court decision.   And if you are leading a healthcare agency and believe that then you are being left behind.  There is radical change occurring from community clinics to hospitals to insurers.  Insurers testified last week before the Senate Finance Committee to the enormous progress their integrated and coordinated models are making in regions throughout country.

As providers attempt to find their niche, those that hoped their niche was in merging or being acquired are rapidly finding out that that is just the beginning. Others are creating unique and experimental partnerships.

I have had a remarkable journey led by a community clinic and partnering with hospitals to rethink the spaces in between them.  The joint responsibility for patient transitions, for navigation, for coaching patients is not only seen in the HIT expansion but in new care coordination roles and RN roles.  Joint venture approaches to afterhours and urgent care are exciting.  Joint efforts to avoid duplication of testing between hospitals based on shared quality standards could produce real savings.

The automation of risk triggers and patient monitoring will drive down unnecessary hospital visits for a significant population of chronically ill patients.  The model embraced by these partners is wholistic and flexible; focused on the strengths of the past and the opportunities to look at care differently and more broadly; less really is more!