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A Response to Steven Brill

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By ROBERT PEARL, MD

Robert PearlAs CEO and Executive Director of The Permanente Medical Group at Kaiser Permanente, I have been following with interest the exchange between Malcolm Gladwell and Steven Brill, prompted by Gladwell’s critique of Brill’s book (America’s Bitter Pill).  Gladwell accurately points out that the solution to the problems of the American health care system that Brill puts forth in the book are very close to the structure of Kaiser Permanente.  We provide world class hospital and ambulatory care to millions of Americans through our dedicated, physician-led Permanente medical groups, and pay for it through the not-for-profit Kaiser Foundation Health Plan.

Brill dismisses Gladwell’s criticism explaining that “Kaiser Permanente is not the same because it doesn’t have a monopoly, or oligopoly power, in any of its communities. It’s not a teaching hospital. It doesn’t have the network of high-quality doctors, or isn’t perceived to, like New York Presbyterian has in New York or the Cleveland Clinic has in Cleveland.”Continue reading…

The Promise of Informatics-Enabled Research: The California Mastectomy Study

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By KATHLEEN ALLER

IntersystemsLike far too many women, I know what it means to confront the prospect of breast cancer. I spent the better part of a year in watchful waiting for what eventually proved to be a benign lump. Some of my friends participate in randomized clinical trials in hopes of being among the first to benefit from a promising new therapy. Some have passed away.

All have faced agonizing challenges sorting through options and confusing medical jargon, poring over statistical data they may or may not understand, and trying to reach a treatment decision in the midst of their fear.

A recent observational study reported in The Journal of the American Medical Association (JAMA) compared survival rates for several different treatment approaches to breast cancer. The primary finding picked up in the press was that the long-term survival rate for women undergoing bilateral mastectomy was not statistically different than that for women who chose lumpectomy and radiation.

I’m not going to outline the entire study – there are a number of good summaries available elsewhere. What particularly caught my interest was the way the study was conducted.

What excited me about the new study is that it is a terrific example of the secondary use of data for informatics-based clinical research. That is, information captured as part of the normal care process for a single patient is combined with information from an entire population segment in order to compare clinical alternatives.Continue reading…

The Kaiser Permanente Model and Health Reform’s Unfinished Business

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By JEFF GOLDSMITH

Halvorson WEF

For decades, health policymakers considered Kaiser Permanente the lode star of delivery system reform.  Yet by the end of 1999, the nation’s oldest and largest group model HMO had experienced almost three years of significant operating losses, the first in the plan’s history. It was struggling to implement a functional electronic health record, and had a reputation for inconsistent customer service.  But most seriously, it faced deep divisions between management and the leadership of its powerful Permanente Federation, which represents Kaiser’s more than 17,000 physicians, over both strategic direction and operations of the plan.

Against this backdrop, Kaiser surprised the health plan community by announcing in March 2002 the selection of a non-physician, George Halvorson, as its new CEO.  Halvorson had spent most of his career in the Twin Cities, most recently as CEO of HealthPartners, a successful mixed model health plan.  Halvorson’s reputation was as a product innovator; he not only developed a prototype of the consumer-directed health plan in the mid-1990’s, but also population health improvement objectives for its membership, both firsts in the industry.

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Waiting For Payment Reform?

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By CHARLES KENNEY and JACK COCHRAN,  MD

Jack CochranThe Health Care Blog recently featured our Open Letter to Primary Care Physicians,generating quite a bit of reaction. A commenter made the point that “we cannot expect” primary care physicians “to act differently until and unless they get paid differently.” [Emphasis added]

The comment refers to a doctor in solo practice and notes that “the first step is changing how you are paid, in one way or another. And there are many ways that work better than the current code-driven fee-for-service model.”

Does waiting for payment reform make sense? Or should primary care practices act now to change the way they practice in anticipation of payment shifts?

Moving Toward Value-based Care

Some physicians groups seem somewhat frozen – unsure exactly where health care payment is headed and thus waiting until there is a clearer signal.

But it seems to us that the payment reform signal grows louder and clearer and support for that contention comes in a recent research report* from McKesson, the international consultancy:

We can now say with certainty that healthcare delivery is moving in one direction: towards value-based care.

This is care that is paid for based on results – on measurable quality – as opposed to the traditional fee-for-service approach that pays for volume. McKesson notes that

The affordability crisis is causing unprecedented changes in the healthcare landscape, the most significant of which is the transition from the current volume-based model [fee-for-service] to myriad models based on measures of value.

To remain relevant and competitive, payers, hospitals, health systems, and clinicians must respond now to integrate value-based models into their existing systems.

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An Open Letter to Primary Care Physicians

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By JACK COCHRAN, MD and CHARLES KENNEY

Screen Shot 2014-08-19 at 9.52.07 AM
Dear Doctor,

The future is in your hands.

You have the opportunity to make primary care better.

More efficient.
More accessible.
And more affordable.

We know you and other primary care doctors have more responsibilities than ever. But you also have great influence, along with the ability and opportunity to change this country’s health care system for the better.

Primary care is essential to the quality of health care, and we need you now more than ever.

Maneuvering the Minefield

According to research firm Harris Interactive, “the practice of medicine is … a minefield. … Physicians today are very defensive – they feel under assault on all fronts.’’* Harris questions, “how much fight the docs have left in them. Some are still fired up … while others have already been beaten down.’’

Those who feel frustration, anger and burnout say they are squeezed by administrators, regulators, insurance companies and more. They worry about the possibility of a lawsuit that could destroy your career.

The question is: What can be done about it? Some of you may choose to remain in the status quo. Some of you have chosen to retire early or otherwise leave the field of medicine entirely. Yet some of you have said enough is enough and found specific solutions that mark a pathway forward. You sought – and found – specific solutions that mark a pathway forward.

If you’ve rejected the status quo and joined your fellows in search of innovations from other practices that you have applied at home, congratulations. You’re a physician leader who’s doing great things for your patients, your colleagues and yourself. You are undoubtedly more satisfied in your work than before, and you are quite likely providing better care.

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Crowdsourcing the Kaiser Permanente Center For Total Health

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By THCBist

Our friends at Kaiser Permanente asked us reach out THCB readers for help with a cool crowdsourcing project. The Kaiser innovation team is working on developing new content for The Kaiser Permanente Center For Total Health , KP’s shiny new 16,000 square foot exhibition and meeting space in downtown Washington D.C.

If you’re close enough to make the trip, we highly recommend that you stop by and take an hour or so to poke around a bit before submitting your suggestions.  Failing that, you can take the online interactive tour here.

If you’re a doctor, a med student, a designer, an entrepreneur, a patient – or if you just have a good idea –  we’d like to hear from you.  KP’s innovation team asked us to ask you four questions. You can answer one or you can answer them all.

1.  What is Total Health? In other words, what is health? What’s important to you?

2. What should total health look like when implemented? What innovations can be used to drive change in the healthcare system? What will healthcare look like in the future?

3.How should total health be supported? What can be done to make healthcare better? Smarter?  Both within the healthcare system? And in our own lives?

4. If you were designing an interactive wall to demonstrate total health to visitors what would you focus on. In other words, if you were designing an exhibition what would it look like? What would your message be? What would help educate the public? How would you get that message across? Yes, you can send us an picture.

Answers can be left in the comment thread below. If you prefer to submit a video response via YouTube send the link to editor@thehealthcareblog.com. or paste in the comments below.  Blog posts should be submitted to THCB editors at editor@thehealthcareblog.com

For the interactive design question, we asked THCB’s editors what they’d like to see. Here’s what we came up with on the back of our paper napkin:

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What Kind of Ancestor Will You Be?

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By Jack Cochran, MD

Is excellent good enough?

As physicians, we are trained to diagnose and treat disease. We dedicate ourselves to searching for cures and perfecting procedures that will restore the health of our patients. Over the last 50 years, we’ve made some remarkable progress. We’ve reduced the death rate from heart disease by 32.5% with a better understanding of primary and secondary prevention and advances in treatment. We’ve made similar progress in cancer care with better treatment options through radiation, surgery, chemotherapy, and genomics. We’ve changed an HIV diagnosis from a hopeless death sentence with limited treatment options to a manageable, chronic condition.

These truly excellent accomplishments in medicine have been life-changing for millions of people. But is excellent good enough?

While we have made great strides in clinical care, the American dream is faltering. Americans are more obese, more medicated and more in debt than at any other time in the history of our nation. One-third of our nation’s total health-care spending, about $750 billion per year, is wasted on unnecessary treatments, redundant tests, and uncoordinated care [1]. Health Care Reform will have limited impact on this waste. While the rate of increase of health care spending has slowed in recent years, the United States still spends 2.5 times more than most developed nations on health care [2]. U.S. health care spending is on track to reach $4.8 trillion in 2021, almost 20% of our gross domestic product [3].

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It’s the System, Stupid: Reversing the Law of Unintended Consequences

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By Edmund Billings, MD

We should have seen it coming, really. It was entirely predictable, and the most recent RAND report proves it.

We incentivized comprehensive IT adoption, making it easier to bill for every procedure, examination, aspirin, tongue depressor, kind word and gentle (or not) touch without first flipping the American healthcare paradigm on its head, if such a thing is even possible.

According to analysis by the New York Times, hospitals received $1 billion more in Medicare reimbursements in 2010 than they did five years earlier. Overall, the Times says, “hospitals that received government incentives to adopt electronic records showed a 47 percent rise in Medicare payments at higher levels from 2006 to 2010 … compared with a 32 percent rise in hospitals that have not received any government incentives …”

To paraphrase the mantra of Bill Clinton’s successful 1992 presidential campaign: It’s the system, stupid. More specifically, it’s the business model, stupid, the fee-for-service system in which electronic health records are enabling tools.

It’s also the law of unintended consequences. You know … you take action, planning on this but instead you get that.

Like the introduction of cane toads in Australia to kill beetles (they couldn’t jump high enough). Like letting mongooses loose in Hawaii to manage the rat population (they preferred native bird eggs). Like Kudzu, the insatiable vine that’s devouring the South.

According to the authors of the RAND report, the problem is with the incentive structure that encourages more tests and procedures. Well, of course it is. Doctors and administrators have a clinic or hospital to run. They have expensive invoices from Epic and Cerner to pay. They can now track and bill for all this stuff they used to not get paid for. Are we surprised?

And meanwhile, fee-for-service leads us down a contradictory rat hole of massive healthcare costs and lousy public health.Continue reading…

Building a Better Health Care System: Electronic Health Records Could Help Identify Which Patients Most Need ICU Resources

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By Brian Ahier

It wasn’t until I had read this.

A national shortage of critical care physicians and beds means difficult decisions for healthcare professionals: how to determine which of the sickest patients are most in need of access to the intensive care unit. What if patients’ electronic health records could help a physician determine ICU admission by reliably calculating which patient had the highest risk of death?

Emerging health technologies – including reliable methods to rate the severity of a patient’s condition – may provide powerful tools to efficiently use scarce and costly health resources, says a team of University of Michigan Health System researchers in the New England Journal of Medicine.

“The lack of critical care beds can be frustrating and scary when you have a patient who you think would benefit from critical care, but who can’t be accommodated quickly. Electronic health records – which provide us with rich, reliable clinical data – are untapped tools that may help us efficiently use valuable critical care resources,” says hospitalist and lead author Lena M. Chen, M.D., M.S., assistant professor in internal medicine at the University of Michigan and an investigator at the Center for Clinical Management Research(CCMR), VA Ann Arbor Healthcare System.

The UMHS and VA study referenced in the article finds that patients’ severity of illness is not always strongly associated with their likelihood of being admitted to the ICU, challenging the notion that limited and expensive critical care is reserved for the sickest patients. ICU admissions for non-cardiac patients closely reflected severity of illness (i.e., sicker patients were more likely to go to the ICU), but ICU admissions for cardiac patients did not, the study found. While the reasons for this are unclear, authors note that the ICU’s explicit role is to provide care for the sickest patients, not to respond to temporary staffing issues or unavailable recovery rooms. Continue reading…

Embracing Change: Leading Through Transformation

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By Bernard Tyson

It is often said that the one and only constant in life is change. This is certainly the case in business where every change in the external market or new initiative or idea brings some type of change to the organization. As leaders, our success or failure can hinge upon how well we are able to facilitate change and how well we help our members of our team adapt to and appreciate change.

As president of a large, national health care organization, like many other business leaders, I am involved in important decisions related not only to performance today, but also preparing the organization for what will be required in the future. This means I spend a lot of time thinking about change. What can we expect with change? How will people react to change? How can I help my team work through the change? How will change affect the way we operate or service our members? What will it cost us?

The reality is most people don’t like change because it can be stressful, especially when change happens unexpectedly. Change can be scary, and understandably so. It represents the unknown, taking us out of our comfort zones. Any time an organization embarks on a new initiative there is the risk of failure, which could have significant financial consequences. Yet, if we don’t change, failure is certain. As society evolves, we must too. Organizations that not only understand the importance of change, but embrace change, are the ones that will ultimately be most successful.

Continue reading…

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