Category: Uncategorized

Why ACOs Are not HMOs and Other Important Questions

Jan 16, 2013• 21

By Mohammad Al-Ubaydli, MD

Mohammad Al-Ubaydli: Let’s just start from the beginning. Tom, can you please give us an introduction about yourself and your background?

Thomas Tsang: I’m a general internist by training. I practiced internal medicine in New York City, first at a small community hospital where I predominantly worked with residents and medical students and mostly taught principles of outpatient medicine, ambulatory care and interviewing techniques.

Then I was recruited by the Charles B. Wang Community Health Center. That’s when I got to use some of the public health knowledge that I had acquired: I worked on various public health initiatives for the community in New York City. The health center itself served a predominantly Asian population. It had four sites and one of the things that I did in the beginning was implement an electronic health record. That work led to my involvement with the Board of Health of New York City, which, in turn led to my work in Congress.

I was then selected for the Robert Wood Johnson Foundation/IOM Health Policy Fellowship on the Committee on Ways and Means-Subcommittee on Health and worked on some of the policies that led to the creation of ACO’s, i.e., Value-Based Purchasing, Pay for Performance and so on. I was fortunate enough to actually help implement some of the policies that I worked on! It’s a long answer to your question, but that’s the route I took.

Mohammad: It’s perfect. It’s really interesting to learn. Among the many things under your belt, it sounds like you have a successful electronic health record deployment, which is good–so well done! Tell me and our readers a bit about Accountable Care Organizations. What is an ACO and what is the point of it?

Thomas: The ACO is not a very new concept. It was a term that was coined by Elliott Fisher from Dartmouth Medical School, who is the director of Center for Health Policy and Clinical Practice. I hate to use the word HMO, but in a way, it’s almost like an HMO. It’s not really an HMO because it is actually a provider-led organization, not an insurance-led one.

Inside Three ACOs: Why California Providers Are Opting for the Model

Jan 16, 2013• 5

By Dan Diamond

Visit SDIndyACO.com, and you’re greeted by a Hawaiian shirt hanging in an otherwise empty closet. “Future home of something quite cool,” the page’s headline reads.

Forget unicorns, camels and all the other metaphors used to describe accountable care organizations these past few years.

The website — the homepage of the newly formed San Diego Independent ACO, which was one of 106 organizations named last week to Medicare’s Shared Savings Program — could sum up where we stand now on ACOs.

While we’re close enough to see their outline, some ACOs are still just teasing their promise. Many organizations have yet to launch a Web presence (or in San Diego Independent ACO’s case, are waiting to get CMS approval). And more health care providers are rushing to build the ACO structure in hopes of winning federal contracts — and filling out the details later.

Understanding the Medicare ACO Model

The ACO model is loosely defined as having integrated teams of providers share responsibility for caring for a select population of patients. (That isn’t a new idea — and based on that definition, California’s had dozens of physician-led groups and integrated networks essentially operating as ACOs for years.)

Unleashing the Innovation Monster

Jan 16, 2013• 14

By David Dranove

I have been absent from the blogosphere for about two months. The fact is, there just isn’t all that much new to write about. Healthcare spending growth continues to moderate, but not by enough to stave off forecasts of doom for Medicare and Medicaid. Nor can employers begin to shift money from health benefits back into wages. But wheels are turning. Health networks are expanding as providers prepare to offer ACOs and/or increase their bargaining clout. A handful of states are poised to start up exchanges with the feds ready to take the reins in the laggard states. Aon/Hewitt is about ready to launch a private sector exchange. We will start to learn whether exchanges save or destroy private health insurance.

The Affordable Care Act has had many detractors but at least it has disrupted the status quo. We needed to see fundamental changes in how we pay for and deliver healthcare services and the ACA has delivered. But ACA has brought us a very particular set of changes. Time will tell if we have chosen the right path.

Even as the industry changes the way it does business, one critical aspect of change is missing. The faces are all the same. The same large systems that dominated the fee for service world seem poised to dominate the shared savings world, and the same insurers that dominated the traditional employer-based insurance market stand ready to dominate exchanges. Value might be created when old businesses play by new rules, but even more value is created when new players are free to enter and perhaps even break the rules.

Entry is the engine that drives economic progress. Entrants bring new technologies to manufacturing and new service models to sales. Threatened by entry, incumbents strive to innovate and improve customer service. This is as true in high tech industries as it is in the service economy. Research confirms that entry is ubiquitous – in a typical manufacturing industry, fully one third of established firms are replaced by entrants within five years. Though the data is not as readily available, turnover in the service sector is likely even higher.

The Nursing Shortage Myth

Jan 15, 2013• 171

By David Williams

For years we’ve read that the US faces a looming shortage of nurses. Shortfalls in the hundreds of thousands of nurses are routinely predicted. These predictions have been good for nursing schools, which have used the promise of ample employment opportunities to more than double the number of nursing students over the last 10 years, according to CNN.

Yet somehow 43 percent of newly-licensed RNs can’t find jobs within 18 months. Some hospitals and other employers openly discourage new RNs from applying for jobs. That doesn’t sound like a huge shortage, then does it?

But the purveyors of the nursing shortage message have an answer for that. Actually two answers: one for the short term and another for the long term. The near term explanation is that nurses come back into the workforce when the economy is down. Nurses are female and tend to be married to blue collar men who lose their jobs or see their hours reduced when the economy sours, we’re told. Nurses bolster the family finances by going back to work –or they stay working when they were planning on quitting. There’s something to that argument even if it’s a bit simplistic.

The longer term argument is that many nurses are old and will retire soon, just when the wave of baby boomers hits retirement age themselves and needs more nursing care. Don’t worry, the story goes, there will be tons of jobs for nurses in the not-too-distant future. This logic comes through again in CNN’s story:

Demand for health care services is expected to climb as more baby boomers retire and health care reform makes medical care accessible to more people. As older nurses start retiring, economists predict a massive nursing shortage [emphasis mine] will reemerge in the United States.

Mobilizing Data for Pressure Ulcer Prevention

Jan 15, 2013• 2

By Hemali Thakkar and Mel Meder

Developers, you have a chance to improve the care that over 2.5 million people receive annually for pressure ulcers. Join the ‘Mobilizing Data for Pressure Ulcer Prevention Challenge’ by creating a mobile application to innovate how healthcare teams use patient data. The winner will receive $60,000 plus a conference exhibition opportunity.

Currently, patients may receive care for pressure ulcers from several providers, but their data does not travel with them, creating a barrier to effective coordination of care. Nurses, working with clinical and technical specialists, have developed a foundational model to capture and communicate information about pressure ulcers in a standardized way. By applying this model, evidence-based documentation can be compared and shared between different health care systems to improve quality outcomes in pressure ulcer care.

The Office of the National Coordinator for Health IT (ONC), in collaboration with the Department of Veterans Affairs, Kaiser Permanente, and the American Nurses Association, is sponsoring a challenge to implement this model in a mobile health app. Development of an app that implements standards for documenting health information about pressure ulcers will facilitate meaningful information exchange, simplify continuity of care, and improve the patient experience while reducing health care costs.

NYeC Launches Patient Portal for New Yorkers Design Challenge

Jan 15, 2013• 1

By Matthew Holt and Paul Wilder, NYeC

Imagine New Yorkers: you have access to your healthcare records when and where you need them. As easy as logging onto your banking website. You can print out a list of your current medications, see when the last time you had a test or immunization was, see recent test and lab results, and manage your consent for which doctors and specialists you want to be able to see your records too. Safely. Securely. YOUR health information when YOU need it.

This is what the New York eHealth Collaborative (NYeC) is planning for the future of New York and why today, in partnership with Health 2.0, we’ve launched the Patient Portal for New Yorkers Design Challenge.

The deadline for challenge submissions is April 11th.

This is the first step in beginning to design what this portal— essentially a website for patients to access their medical records online—will look like. The Patient Portal for New Yorkers Design Challenge has $25,000 in prizes. We are calling all designers and developers to submit prototypes for the portal. The top portal interface designs will be chosen, publicized, and voted upon by New Yorkers after the April 11th deadline. The winner will be announced early this summer.

Designers and Developers: we want you to innovate and put on your most creative caps for this exciting challenge. New Yorkers need to be able to see their information in a way that’s easy to use and meaningful to them. This is a chance to make a big difference in the healthcare of 20 million New York residents.

Doctor Code: Learning EMR Language

Jan 15, 2013• 20

By Rob Lamberts, MD

OK, I’ll admit it: I had no idea. I thought that the whining and griping by other doctors about EMR was just petulance by a group of people who like to be in charge and who resist change. I thought that they were struggling because of their lack of insight into the real benefits of digital records, instead focusing on their insignificant immediate needs. I thought they were a bunch of dopes.

Yep. I am a jerk.

My transition to a new practice gave me the opportunity to dump my old EMR (with all the deficiencies I’ve come to hate) and get a new, more current system.* I figured that someone like me would be able to learn and master a new EMR with ease. After all, I do understand about data schema, structured and unstructured data, I know about MEDCIN, SNOMED, and HL-7 interfaces. Gosh darn it, I am a card-carrying member of the EMR elite! A new product should be a piece of cake! I’ll put my credentials at the bottom of this post, in case you are interested.**

So, imagine my shock when I was confused and befuddled as I attempted to learn this new product. How could someone who could claim a bunch of product enhancements as my personal suggestions have any problem with a different system? The insight into the answer to this sheds light onto one of the basic problems with EMR systems.

Problem 1: Different Languages

As I struggled to figure out my new system, it occurred to me that I felt a lot like a person learning a new language. Here I was: an expert in German linguistics and I was now having to learn Japanese. Both are systems of written and spoken code that accomplish the same task: communication of data from one person to another. Both do so using many of the same basic elements: subjects, objects, nouns, verbs. Both are learned by children and spoken by millions of people. But both are very, very different in many ways.

New on Bookshelves: Innovation with Information Technologies in Healthcare

Jan 15, 2013• 3

By Matthew Holt

Lyle Berkowitz, MD, associate chief medical officer of innovation for Northwestern Memorial Hospital, and Chris McCarthy, MBA, an innovation specialist with Kaiser Permanente’s Innovation Consultancy, have just released a compilation of stories about various organizations’ HIT projects. The two coeditors of Innovation with Information Technologies in Healthcare talk about what they learned after gathering these examples from across the U.S.

Accidental Tourist: Visiting the Bumrungrad Hospital in Bangkok

Jan 14, 2013• 77

By Jeff Goldsmith

There’s been a lot of recent speculation that more Americans will be taking their elective medical problems overseas. In 2008, Deloitte’s Center for Health Solutions estimated that 750 thousand Americans travelled overseas for medical care in 2007, and forecast a eight-fold increase by 2010 In a 2009 update, Deloitte found that the 2008 financial crisis devastated overseas medical travel, but still forecast 1.6 million US citizens going abroad for medical care in 2012.

Among overseas medical destinations, no facility is mentioned more than Bumrungrad (last syllable rhymes with “hot”) Hospital. Bumrungrad is a privately owned but publicly traded 550 bed acute care hospital in central Bangkok. On a recent trip to Thailand, I stopped at Bumrungrad to find out what all the shouting was about and was really impressed with what I saw.

Bumrungrad’s CEO is a courtly, silver-haired Virginian named Mack Banner, who spent most of his career in the US investor-owned sector. Though the hospital was founded in 1980, it moved into its new facility in 1997, just in time for the Asian financial crisis. The facility was Joint Commission (International) certified in 2002, and one fifth of its physicians are US Board certified in their respective specialties.

In 2008, the hospital opened a beautiful 21 story Clinic building next door, housing 30 specialty clinics and most of its medical staff. Bumrungrad’s Clinic Facility is Mayo-esque, enabling patients with particular specialty problems to be worked up, evaluated and cared for on a single floor. The hospital subsequently renovated its inpatient rooms, which resemble those of the Asian-themed Washington DC Park Hyatt in elegance. The hospital is a sunny, happy place, with apparent high morale and very high service standards. English is spoken widely throughout the hospital.

A Tale of Two Studies: What Are the Actual Costs of an EHR?

Jan 13, 2013• 30

By Edmund Billings, MD

Does anyone in their right mind believe that these are the best of times in healthcare or health IT?

Scratch that.

Does anyone besides Judy Faulkner and Neal Patterson believe these are the best of times? (I mean, everyone knows that Dramatic Transition + Industry-wide Upheaval + Piles of Cash = Satisfaction / Contentment, proving the point mathematically.)

The question: At what cost to overall healthcare improvement do Epic and Cerner (and others, to be fair … except you, Allscripts) reap massive profits?

The short answer: We don’t really know.

While it is generally acknowledged by most (certainly not all, which you know if you’ve spent any time on HIStalk) that the ready availability and automated cross-checking of electronic health records improves care, there is no definitive study showing dramatic clinical improvement, demonstrable return on investment, etc.

Indeed, we now have a number of studies suggesting exactly the opposite: