The most commonly heard comment in healthcare these days is that we have to move from paying for volume to paying for value. While it may sound trite, it also turns out to be pretty true. Right now, most healthcare services are paid for on a fee-for-service basis – with little regard for the quality of that service. We clearly need to move towards value-based payments (sometimes referred to as pay-for-performance or P4P).
Although a few folks remain skeptical about whether VBP/P4P can work (as though our pay for volume strategy is working out so well), asking whether we should pay for volume versus pay for quality no longer seems like a particularly interesting question.
The far more compelling and difficult question is how best to pay-for-performance? As I have written before, we need bold experiments with new payment models that employ three key principles: putting real money on the table, focusing on outcomes, and keeping the reward system simple (i.e. the better you do, the more you should get).
One such new payment model is the value-based purchasing (VBP) program from CMS, the largest payer of hospital care in America. It’s a modest program but an immensely important one. It is modeled after the Premier Hospital Quality Incentives Demonstration (HQID), which ran for 6 years and had modest effects on hospital performance on process measures and no effect on patient outcomes.
Despite these disappointing findings, the U.S. Congress, in crafting the Affordable Care Act, modeled VBP closely on HQID. The incentives in the program are small (currently at 1.25% of total Medicare payments) and still more heavily weighted towards process measures than outcomes.
The key question for VBP is whether it will work – whether patients will be better off because of it. We don’t know and realistically, we won’t for another year or so.
But what we do know is that two years into the program, certain hospitals seem to be doing well and others, not so much. Yes, the incentives are small and my guess is that any impact will be very modest as well. But, it’s still worth taking a look at how different types of hospitals are faring under VBP.
So we ran some numbers.
Continue reading “Finding the Value in Value-Based Purchasing”
Filed Under: Hospitals, THCB
Tagged: Ashish Jha, Costs, Hospitals, Pay for Performance, Value-based Purchasing
Nov 20, 2013
In my previous blog, I made the argument that whatever strategy we use to improve care in hospitals will not be implemented and executed well without proper focus by hospital leadership. So, it is in this context, that we recently published some pretty disappointing findings that are worth reflecting on.
We examined the pay of CEOs across U.S. hospitals and found that some CEOs got paid a lot more than others. This was not surprising. CEOs of larger, urban, teaching hospitals get paid a lot more than CEOs of small, rural, non-teaching institutions. But the disappointment was around quality: we found no relationship between a hospital’s quality performance and the pay of the CEO. Holding size, teaching, and other factors constant, what was the pay of CEOs of hospitals with high mortality rates?
About the same as CEOs of hospitals with low mortality rates. What about other quality measures? Most of them didn’t really seem to matter, with the exception of patient experience, which correlated nicely with CEO compensation. It seems that when setting CEO compensation, patient outcomes are not a big part of the discussion. How could this be, and why does it matter?
How you set incentives for senior managers says a lot about your priorities. Boards generally set the salary for their CEOs and they clearly reward patient satisfaction scores. That’s good. They also seem to reward the things that build hospital reputations: having the latest technology such as a PET scanner or academic status. But are boards rewarding CEOs based on mortality rates or adherence to basic quality metrics? Not so much. Why not? I’ve spoken to a lot of board chairpersons over the years and the answer is not that they don’t care. Most boards want to reward quality and believe that they do.
The problem is that most board members lack sufficient expertise on quality metrics and can’t decipher, from the large number of quality metrics, which ones are important (like mortality rates) and which ones are not. Hamstrung, they focus on satisfaction but also end up rewarding things that feel like proxies for quality, such as having the latest technology. And here’s the part that’s frustrating – our national efforts on quality measurement and improvement are not helping. We seem to have done very little to prioritize what’s really important, and shine a light on them.
So what do we do to move forward? Some states have started requiring that boards undergo training in quality. Medicare, as a condition of participation, could certainly require that boards (or at least some members thereof) show a degree of expertise with quality. I like these ideas but worry that training programs would themselves be of variable quality, and for some boards it would become an onerous requirement without achieving real gains in expertise.
Of course, if we really want to help boards be more effective and engage healthcare leaders, the biggest thing that we could do is actually reward hospitals, in a meaningful way, based on quality. Yes, we have the value-based purchasing program, and it is well-intentioned. But, as I’ve written before, it has several big problems. First and foremost: the incentives are very weak and there is little reason to believe it will have a meaningful impact on patient outcomes. Second, the measures are diffuse – we have too many of them, some of which matter (mortality) and many which don’t in the absence of the appropriate clinical context (checking the ejection fraction on a heart failure patient). It’s hard for hospital boards to really get a clear signal on what matters if they aren’t seeing it clearly and consistently from national leaders on quality.
Continue reading “Hospital Exec Pay: If P4P is Good Enough for Doctors, Why Not the CEO?”
Filed Under: Hospitals, THCB
Tagged: Ashish Jha, Hospitals, Quality
Nov 8, 2013
I was recently chastised by a colleague for being too negative in one of my pieces on hospital care. His is a remarkable story of what happens when things go well, and it has made me think a lot about why, in some places, things seem to work while in others, not so much.
He told me how a few months ago, soon after returning to Boston from a trip to China, he had started feeling short of breath. When his cardiologist convinced him to be evaluated, he found himself at the Beth Israel Deaconess Medical Center (BIDMC), arriving in the ER late one evening. He was triaged within minutes, had an EKG within 15 minutes, at which time comparisons were made to previous EKGs. After ruling out a heart attack, his ER physicians quickly ordered a CT Angiogram.
That test, completed within an hour of his initial arrival to the ER, revealed the reason for his shortness of breath: he had a large saddle pulmonary embolus. He was started immediately on IV heparin and sent quickly to the ICU, experiencing essentially no delay in care. He spent three days there and reports receiving care that was attentive, expert, and consistently of the highest quality. Even after discharge, he received two nursing visits at home to ensure he was doing OK. In discussing his experience, he repeatedly emphasized the fantastic communication and teamwork that he witnessed. Weeks after discharge, he continues to get better and feels the benefits of the excellent care he received.
This is the story we all hope for. And when I heard it, I have to say that I wasn’t surprised. There’s something about the BIDMC that’s unusual. Of the 4,500 hospitals that report their mortality rates to Medicare’s Hospital Compare website, only 22 (less than 0.5%) have better than predicted mortality rates for all three reported conditions: heart attack, congestive heart failure, and pneumonia. And, we know that the combined performance on these three conditions is remarkably good at predicting hospital-wide outcomes, including outcomes for pulmonary embolism.
If you are a patient and care deeply about good outcomes, BIDMC seems to be a good place for you.
So what’s so special about them? What do they do that’s different? I don’t know, specifically, all of their tactics, but I have some guesses about what seems to differentiate high performing institutions from the rest. And in a word, it’s leadership. BIDMC has had two CEOs over the past few years, and both of them have been unusually committed to achieving high quality care. That commitment translates into real activities that make a big difference. Let me divert us with a story of what this might actually mean.
A few years ago, I was working on a strategy for improving the quality and safety of VA healthcare. As part of this effort, I called up senior quality leaders of major healthcare organizations across the nation. One call is particularly memorable. Because I promised anonymity, I will not name names but this clinical leader was very clear about his responsibility: every month, he met with his CEO, who began the meetings with three simple questions: “How many patients did we hurt last month? How many patients did we fail to help? And did we do better than the month before?”
The CEO and the entire hospital took responsibility for every preventable injury and death that occurred and the culture of the place was focused on one thing: getting better. When I looked them up on Hospital Compare, they too had excellent outcomes and they regularly get “A” ratings for patient safety from the Leapfrog Group.
Continue reading “How Many Patients Did We Hurt Last Month? Learning (But Not Too Much) From The Best Hospitals”
Filed Under: Hospitals, Tech, THCB
Tagged: Ashish Jha, BIDMC, Hospital Compare, Quality, VA Health System
Nov 6, 2013
Why readmission penalties are controversial
Penalizing hospitals for high readmission rates has been pretty controversial. Critics of the program have argued that readmissions have little to do with what happens while the patient is in the hospital and are driven primarily by how sick or how poor the patient is. Advocates of the readmissions program increasingly acknowledge that while readmissions may not reflect the quality of care that occurred within the hospital, someone should be accountable for what happens to patients after discharge, and hospitals are the logical choice. While the controversy continues, there is little doubt that the metric is here to stay. This October, the CMS Hospital Readmissions Reduction Program (HRRP) will increase its penalty on excess readmissions from 1% to 2% of total hospital reimbursement.
So far, CMS has focused on readmissions that occur after patients are discharged with one of three medical conditions—acute myocardial infarction, pneumonia, and congestive heart failure. The data on the impact of the program are mixed: while readmission rates appear to be dropping, the penalties seem to be targeted towards hospitals that care for some of the sickest patients (academic medical centers), poorest patients (safety-net hospitals) and for heart failure, some of the best hospitals (those with the lowest mortality rates). No wonder the program has been controversial.
Why surgery may be different
In 2015, CMS extends the program to focus on surgical conditions, which provides an opportunity to think again about what readmissions measure, and what it might take to reduce preventable ones. And if you think about it, surgery may be different. Most patients who are admitted for Acute MI, CHF, and pneumonia are chronically ill and bounce in and out of the hospital, with any one hospitalization likely just an exacerbation of underlying chronic illness (especially true for pneumonia and heart failure). Not so for surgery—at least not for the major surgeries.
Continue reading “Finally Some Good News on Readmission Rates”
Filed Under: OP-ED, THCB
Tagged: Ashish Jha, CMS, Hospitals, Quality, Readmissions, Thomas Tsai
Sep 19, 2013
The Bike Path:
On a warm and sunny August Sunday, I was rollerblading with my kids on the Shining Sea Bikeway. On mile nine on the trip, I hit a tree root, went flying, and landed on my shoulder. I could tell immediately that something was wrong — I couldn’t move my arm and was in the worst pain of my life. Feeling for my left shoulder, it was obvious that I had dislocated it. What happened next was that I received some of the best care of my life – unfortunately it was not from our healthcare system.
As I was lying on the bike path, nearly everyone stopped and asked how they could help. A pediatric nephrologist offered to pop my shoulder back into place. I declined. This wonderful couple on a two-person reclining bike stopped and insisted on pedaling me to the hospital. We were far from the road and knew that calling an ambulance was not straightforward. So I sat with my left arm dangling, in excruciating pain, while David rode the bike to Falmouth Hospital. It was a 20 minute ride finishing with a very steep hill. David apologized after each bump on the road as he heard me swear and wince.
The Emergency Room:
We finally made it to the ER, and, ironically, it was then that my care stopped being so wonderful.
It started off well enough – a triage nurse saw me walking in holding my arm, in distress. She got me a wheelchair and brought me into triage. I explained what happened, gave my name, date of birth and described the pain as the worst of my life. I was then shuttled to registration, where I was asked to repeat all the same information. It felt surreal: I had moved all of 10 feet and yet somehow my information hadn’t followed me. The registration person asked me question after question. Initially, the same ones: name, address, phone #, etc. Then, my Social Security number (presumably so they could go after me if I didn’t pay my bill), my primary care physician’s name, his address, his phone #, my insurance status, my insurance #, my insurance card, my emergency contact, their address and phone #, etc. etc. etc.
I told her I was in excruciating pain and needed help. A few more questions, she said. She needed the complete registration.
I was wheeled to radiology and sat in a hallway for what felt like forever, groaning in pain. I couldn’t find a comfortable position. Six or seven people walked by – and as they heard me groan, they would look down and walk faster. The x-ray technologist avoided eye contact. It was hard — I was right outside her room. Finally, I asked a passerby if she could help. Caught by surprise (I must have sounded human), she stopped. She looked at me. She then went into the x-ray suite. A few minutes later, a second technologist came out, saw my arm, and was the first to acknowledge that my arm looked painful. He told me the ER was pretty quiet and he would get me in right away.
Continue reading “Average Care at a Typical Hospital on an Ordinary Sunday in August”
Filed Under: Hospitals, OP-ED, THCB, The Insider's Guide To Health Care
Tagged: Ashish Jha, emergency care, Hospitals, Patients, Quality, Quality measurement, Wait times
Aug 14, 2013
Right now there’s a fierce debate going on for the hearts and minds of health IT. Finally American health care (well, half of it anyway) is using electronic medical records. But it’s not the panacea we were lead to believe. Costs haven’t gone down, health hasn’t markedly improved and the taxpayer/Chinese government is poorer. So too are many doctors and hospitals, and the main beneficiaries appear to be construction companies in Madison, Wisconsin.
Worse, those who promote the impact and importance of EMRs (Farzad Mostashari, Ashish Jha) are being attacked by Ross Koppel, Steve Soumerai, Scott SIlverstein and others who essentially say that EMRs are more dangerous and inefficient than paper.
This reminds me of the World War One British Army preparing to fight in the mud of Flanders with cavalry charges suited to the Boer War, the French Army in 1939 retreating to their WWI style trenches while the Germans flew over them, and (dare I say it) today’s TSA strip searching grandmothers looking for boxcutters.
Yes, we’re having the wrong fight by focusing on old problems. The EMRs that are producing the studies we’re fighting about are the current equivalent of 1990s EPR implementations. In general they’re hard to use and require lots of money and training to produce halfway decent results. The real improvements from IT came when user-centered tools came to consumers and then to business with Web 2.0 and new devices like the iPhone.
It may take months of training on Epic or Cerner to get a doctor or nurse to be three-quarters as productive as they used to be, but my two-year-old daughter can fire up an iPad and play games and watch videos with no training.What we’re seeing every day at Health 2.0 is a whole new generation of data-driven applications and devices that are going to make the health care user experience much more like the one my daughter has.
When we get there, the real improvements in both productivity and safety, as well as in quality and even cost, will emerge and we’ll wonder why we ever were having this fight.
Filed Under: Tech, THCB
Tagged: Ashish Jha, EHR
Jul 18, 2013
If one were writing about the improvement of gastronomy in America, one would probably not celebrate “over 300 billion hamburgers served.” But that’s very much the type of success Dr. Ashish Jha is celebrating in last week’s piece on recent US healthcare IT sales. Unfortunately, the proliferation of Big Macs does not reflect superior cuisine, and healthcare IT (HIT) sales do not equate with better healthcare or with better health. Quantity does not equal quality of care.
To be sure, Dr. Jha acknowledges the challenges of rolling out HIT throughout US hospitals. And he should be strongly commended for his admission that HIT doesn’t capture care by many specialists and doesn’t save money. In addition, Dr. Jha points to the general inability of hospitals, outpatient physicians and laboratories to transfer data among themselves as a reason for HIT’s meager results.
But this is a circular argument and not an excuse. It is the vendors’ insistence on isolated proprietary systems (and the government’s acquiescence to the vendors) that created this lack of communication (non-interoperability) which so limits one of HIT’s most valuable benefits.
In our opinion, the major concern is that the blog post fails to answer the question we ask our PhD students:
So what? What is the outcome?
This entire effort is fueled by $29 billion in government subsidies and incentives, and by trillions of dollars spent and to be spent by hospitals, doctors and others .
So where is the evidence to back up the government’s and industry’s promises of lower mortality, improved health and lower health care costs?
Single studies tell us little. Sadly, as many as 90% of health IT studies fail the minimal criteria of the respected international literature syntheses conducted by the Cochrane Collaboration.
In other words, studies with weak methodology or sweetheart evaluation arrangements just don’t count as evidence.
Continue reading “More Work Is Needed on the Safety and Efficacy of Healthcare Information Technology”
Filed Under: OP-ED, THCB
Tagged: Ashish Jha, Cochrane Collaboration, Costs, EHR, HIT, Hospitals, Interoperability, Kaiser, Patient Safety, Physicians, Quality, Rand, Ross Koppel, RWJF, Stephen Soumerai, Vendors
Jul 17, 2013
Just a little over four years ago, President Obama, in his inaugural address, challenged us as a nation to “wield technology’s wonders to raise health care’s quality and lower its costs.” This was an awe-inspiring, “we will go to the moon” moment for the healthcare delivery system. But the next thought that ran through the minds of so many of us who work on health IT issues was this: how were we going to get there?
We were essentially starting from scratch. Less than 1 in 10 hospitals had an electronic health record, and for ambulatory care physicians, the numbers weren’t much better – about 1 in 6 had an EHR. Hospitals and physicians reported an array of challenges that were holding them back. No nation our size with a healthcare system as complex as ours had even come close to universal EHR use. Yet, the President was calling for this by just 2014.
And it was clear why. The promise of EHRs was enormous and we knew that paper-based records were a disaster. They lead to lots of errors and a lot of waste. I have cared for patients using paper-based records and using electronic records – and I’m a much better clinician when I’m using an EHR. In the weeks that followed Obama’s inaugural address, the U.S. Congress passed, and the President signed the Health Information Technology for Economic and Clinical Health Act, which contained a series of incentives and tools to drive adoption and “meaningful use” of EHRs. None of us knew whether the policy tools just handed to the Obama administration were going to be enough to climb the mountain to universal EHR use. We were starting at sea level and had a long climb ahead.
Continue reading “As the Debate Over Obamacare Implementation Rages, a Success on the IT Front”
Filed Under: Tech, THCB
Tagged: Ashish Jha, EHR, HIT, HITECH Act, Hospitals, Michael Painter, Obamacare, RWJF, The Affordable Care Act
Jul 12, 2013
There is an old saying that every unsustainable trend, by definition, comes to an end. The U.S. healthcare system has been on an unsustainable trajectory, consuming more and more of our national income while failing to deliver the kind of care that Americans need and deserve. But although every unsustainable trend eventually ends, how it ends is up to us.
The healthcare system has the potential to collapse under its own weight, requiring Americans to pay even more for healthcare, forcing draconian and blunt cuts in the kinds of services available, and putting high quality healthcare out of reach for the poor and the sick.
An alternative future is one in which payers pay for value, providers become more efficient and patient centered, and consumers become increasingly engaged in caring for themselves. In this future, healthcare becomes an important force for improving the health of the American public.
What will determine which path our healthcare system will take? While the fate of our healthcare system will be influenced by policymakers in Washington DC and the state capitals, it will ultimately be decided by each of us – providers and patients who are involved in the daily work of delivering and engaging in healthcare.
The journal Healthcare: The Journal of Delivery Science and Innovation is an effort to nudge us toward a better, sustainable path for our healthcare system. The mission of the journal is simple: to play a meaningful role in fostering real change in the healthcare delivery system. The journal wants to be a venue for sharing the best ideas for delivery science, payment innovation and smart use of health information technologies. The journal was conceived by Amol Navathe and Sachin Jain, who have been thinking long and hard about compelling new approaches to bring about change in the healthcare system. It took years of persistence to line up a terrific publisher, put together a top notch editorial board and recruit some of the nation’s best minds to lead individual theme areas. And it paid off handsomely. Today, June 26th, Healthcare officially launches with its premier issue, and what an issue it is.
The two introductions are short, pithy and worth reading over and over again. The first is by Don Berwick, the former Administrator of the Centers for Medicare and Medicaid Services but even more importantly (at least to me), the man who has done more to promote quality and safety than anyone in recent memory. Don frames the issues in ways that only he can, reminding us that we can have the best healthcare system in the world – we have all the pieces – but we have to learn how to put it together.
Continue reading “Healthcare Lands: Announcing the Journal of Delivery Science and Innovation”
Filed Under: Hospitals, THCB
Tagged: Ashish Jha, health care delivery, Innovation, Quality, The Journal of Delivery Science and Innovation
Jun 26, 2013
It has been a couple of weeks since the landmark Oregon Experiment paper came out, and the buzz around it has subsided. So what now? First, with passage of time, I think it is worth reflecting on what worked in Oregon. Second, we should take a step back, and recognize that what Oregon really exposed is that health insurance is a small part of a much bigger story about health in general. This bigger story is one we can’t continue to ignore.
So let’s talk quickly about what worked in Oregon. Health insurance, when properly framed as insurance (i.e. protection against high, unpredictable costs) works because it protects people from financial catastrophe. The notion that Americans go bankrupt because they get cancer is awful and inexcusable, and it should not happen. We are a better, more generous country than that. We should ensure that everyone has access to insurance that protects against financial catastrophe. Whether we want the government (i.e. Medicaid, Medicare) or private companies to administer that insurance is a debate worth having. Insurance works for cars and homes, and the Oregon experiment makes it clear that insurance works in healthcare. No surprise.
The far more interesting lesson from Oregon is that we should not oversell the value of health insurance to improving people’s health. While health insurance improves access to healthcare services (modestly), its impact on health is surprisingly and disappointingly small. There are two reasons why this is the case. The first is that not having insurance doesn’t actually mean not having any access to healthcare. We care for the uninsured and provide people life-saving treatments when they need it, irrespective of their ability to pay. Sure – we then stick them with crazy bills and bankrupt them – but we generally do enough to help them stay alive. Yes, there’s plenty of evidence that the uninsured forego needed healthcare services and the consequences of being uninsured are not just financial. They have health consequences as well. But, claims like 50,000 Americans die each year because of a lack of health insurance? The data from Oregon should make us a little more skeptical about claims like that.
So what really matters? Right now, we are pouring $2.8 trillion into healthcare services while failing to deliver the basics. To borrow a well-known phrase, our healthcare system is perfectly designed to produce the outcomes we get – and here’s what we get: mediocre care and lousy outcomes at high prices. Great.
Continue reading “The Oregon Experiment Revisited”
Filed Under: OP-ED, THCB
Tagged: Ashish Jha, Costs, Insurance, Oregon Medicaid Experiment, Outcomes, Quality
May 23, 2013