Categories

Tag: Quality

TECH/QUALITY/PHARMA: Active Health used by Mariott

Interesting brief presentation — Mariott uses Active Health Mangement to change its formulary

Integrates pharmacy, medical and labs data from one place—inluding diagnosis and runs it against the medical literature based algoritms. They then communicate information to both providers and consumers (in consumer friendly langauge).

They found that sometimes “care considerations” has been presented to doctors and they’ve reported back that the script was written but the patient counldn’t afford it. So some medications (what they called essential rather than non-essential drugs)they’ve selectively changed the formulary to a lower copay, or none for generics, for those that have the relevant disease. Care engine can both identify those on the drugs and those who are not but should be, and communicates that information back to doctors and patients.

They’re doing a pre & post compare study with another Active Health Client who is not varying copays to see what that does to adherence and cost outcomes. The program is great reminder for docs and patients. Trying to ensure that the essential drugs are acessible.

 

POLICY/QUALITY: Sliding Down the Back Side of the Health Care Quality Curve: Who’s at Greatest Risk?, by Brian Smedley

The recent RAND study that suggested that there were few or no differences in the quality of treament of minorities when they got into the US health system has not been taken lying down by those who believe that there are great differences, and that ignoring them to look at the bigger picture, as the RAND researchers suggested, is not the way to go. Brian Smedley, the research director at The Opportunity Agenda wrote this opinion piece criticizing the RAND study for THCB:

Ask anyone who’s worked in, received treatment in, or studied American hospitals and health care systems, and you’ll find broad agreement:  U.S. health care systems are beset by quality problems.  Information systems don’t "talk" well with one another, medical errors remain all too common, and many patients don’t receive the types of treatments and services that they should.

 

Recently, a new study expands on these problems, finding that treatment is mediocre at best for all patients, regardless of race, ethnicity, gender, or income.  This study, published March 16 by physician Steven Asch and colleagues in the New England Journal of Medicine, finds that, on average, patients receive a little more than half of the care recommended by a set of "gold standard" guidelines.  And even though few patients are well-served, women and minorities were found to fare better than whites and men in receiving recommended care.

 

This finding wouldn’t be so shocking to most Americans, who tend to believe that health care is fair for all groups, even if less-than-stellar.  Many Americans tolerate (and therefore tacitly accept) that fact that minorities are more likely to be uninsured or underinsured, or to live in communities that lack high-quality primary and specialty care, access-related problems which have profound implications for quality of health care. But once patients are in the health care system, we believe, race or ethnicity doesn’t matter.

 

This view, however, squarely contradicts what the vast majority of research studies have found for decades – that some patients, most notably African Americans, Latinos, those who don’t speak English well, and in some cases, women – receive a lower quality of health care than their counterparts, even when they have similar health insurance and are treated for the same health conditions in the same hospitals. This applies across the gamut of health care, ranging from basic services such as screening and immunization, to primary care, to more expensive, high-tech, specialty procedures.

 

These are the conclusions of literally hundreds of studies published in peer-reviewed journals over the last two decades.  And while a few studies, such as the Asch study, find that disparities are diminishing or that all groups receive equal (albeit poor) treatment, their findings must be considered relative to the massive volume of evidence to the contrary.   Even the U.S. Department of Health and Human Services’ National Healthcare Disparities Report, released in January and which represents the most comprehensive survey of its kind, finds that, despite some areas of improvement, racial and ethnic healthcare disparities persist, and are worsening in some areas.   For example, the NHDR found that Latino patients with diabetes are receiving poorer quality care today than they were even a few years ago.   

 

Importantly, the Asch study confirms that quality problems abound.  But the authors’ conclusion – that "quality-improvement programs that focus solely on reducing disparities among sociodemographic subgroups may miss larger opportunities to improve care" – unfortunately presents a false choice.  Policymakers are not confronted with the question of whether to prioritize efforts to reduce inequality, or efforts to improve overall quality. Rather, these problems are inextricably linked.  The persistence of healthcare disparities is a clear warning that systemic problems plague our health systems. Moreover, many of the same interventions that will reduce disparities – such as promoting the broader use of evidence-based guidelines and public reporting of hospital quality scores by patient race, ethnicity, and primary language – will help to improve quality for all patients.

Progressive health care advocates should seize upon health care disparities as a key political issue and an argument for stepped-up quality improvement efforts. Unequal health care is not only wrong, it’s one of many signals that American health care is reeling from systemic problems that hamper the best efforts of hard-working physicians, nurses, administrators, and others to provide the best quality care.  Our concern and focus should be on raising the quality of care for everyone, with particular attention to those who are least well served.

TECH/QUALITY: Are laproscopes really dangerous?

There’s a new crisis every day, and Friday’s was a terrible new affliction as reported in the New York Times caused by poorly used laproscopes which burn holes and cause bacterial infections because don’t have a special new feature that tells the surgeon when they’re leaking electricity. So I asked a rather experienced laproscopic gynecologist that I’ve known all my life (thanks, Dad!) what he thought about how real this problem was? Here are his comments.

It has not happened to me but obviously does. Like all safety precautions it is a question of balancing costs and returns. As well as the cost of the monitoring methods there is the staff time in using them and probably reduced OR activity due to delays when monitoring. As far as I can see from the article there are no definitive figures as to the incidence of leakage burns due to defective insulation. I would guess there are more complications from inadvertant and unrecognised perforation of bowel inserting trochars or unrecognised direct burns from the working tip of the instrument being accidentally activated. There is no completely safe surgery.

Sensible words indeed. But of course, there is a solution!

Of course not coincidentally the stock of the company that makes the solution, called active electrode monitoring technology, went up 35% on twenty times the normal volume on Friday. Pure coincidence of course!

Eci

I’d be prepared to dive in
myself, if the last company the NY Times hyped up that I did dive into
hadn’t had its stock go down 30% since the article came out!
If you bought ECI today I hope that surgeons and hospitals are more
pliant to the NYT’s advice than are the school kids who’ve failed to
buy the Fly Pentop Computer.

POLICY/QUALITY: The intellectual backdrop has been created for P4P

Here’s my FierceHealthcare editorial

Last week a study from Wennberg’s Dartmouth group showed that there were vast variations in the amount of "physician resources" used to produce similar care outcomes, in that case in intensive care settings. This week a RAND study followed up on data released in their much quoted 2003 study which showed that patients receive the correct care from their providers only a little over 50% of the time. This new study showed that there was little to choose between the care meted out to richer, better insured, whiter people and that given to poorer, less well insured minorities. So it appears that unlike in the rest of American life, money can’t buy you better quality. And given the amount of money being spent on health care in America, that’s not a satisfactory outcome.

Putting these two studies together shows that there will be much more concentration in the resources being used and the process and outcomes of care, and most importantly, that the intellectual argument has been created for providers to be paid for quality, performance and by extension cost-efficiency. This will not be an easy change for the system to adopt, and it looks as if it may be the major story of the next decade.

PHARMA/QUALITY: New York Times discovers compliance

Says here, compliance with drug regimens is a big problem. (Adopt Harry Shearer voice with hard “en” sound in “knew”)”

Who knew? Who knew?

And McKesson, plus a boat load of other DM, PBM and pharma-related companies (like Pfizer Health Solutions) are bugging patients to take their pills, and increasing pharma company profits into the bargain. And even after digging up David Sobel, John Abramson & Jerry Avorn, the NYT can’t find too much bad to be said about these programs — even though pharma companies are paying for them. Everyone agrees compliance is good, and getting patients to take their pills is hard work.

But I didn’t notice them referring to any compliance programs for generics. Funny that.

QUALITY/PHYSICIAN/PHARMA: Test of Survival

Those of you who like your reality dressed up as fiction might like this new book, which Greg Pawelski recommends as telling lots of truth about the oncology-industrial complex.  It’s called A Test of Survival and the web site is worth exploring at least.

 

QUALITY: Sam Nussbaum saying the time is now for P4P

Sam Nussbaum is Wellpoint’s chief medical director (before that he was on the provider side). Improvement is too slow and variability is too great. Again it’s all been too slow. Cost and quality bear little relationship to each other. In fact it’s a negative correlation (Dartmouth)

We continually have a lack of excellence in quality but that there is employer and even consumer interest in improving it. He wants to promote the establishment of a national quality coordination board to turbo-charge P4P. He believes that P4P will incent investments in IT. But that we need to add clinical decision support into IT to reduce practice pattern variation (we need more than just EMRs)

So how to start?  Start with a foundation of trust (can this really come from Wellpoint? he doesn’t address that)  He thinks that they need to move from process measures to outcomes measures. He used the example of rich measures of quality process and outcomes in cardiology care, whereby they are rewarding for process and outcome. This is the Quality Insights Hospital Incentive Program (QHIP). In this program complications in PCI were 47% decreased in QHIP hosps vs 20% nationally. So how do they contract with hospitals to do that? They want to earmark a share of (increase in) payment to clinical quality measures. Similar success with OBGYNS in Ohio. They have lots and lots of programs in many states…and they want to move it to more places.

So how to translate that more generally. Within networks (and even within medical groups) there is practice variation, no correlation between cost and quality. Sam is true for hospitals And in the communities, the advertising billboards don’t reflect the real quality issue. But we need to raise the bar for everyone—can’t just send everyone to the top 30%.

And he wants to get consumers involved (so Wellpoint bought Lumenos and is using Subimo) to guide them to the best type of care. Plus roll that into many other programs, such as DM, specialty pharmacy, etc.

All good stuff but he never mentioned the dark side of HDHPs….and the avoidance of people at risk by insurance  firms. Ian Morrison is coming up later, and I’m sure he’ll talk about this.

But how do we pay for those programs via  PPO, or via ASO services? How does risk adjustment become very apparent? He believes that the key driver is CMS brining P4P to market. — but as anyone who reads the comments in THCB knows, that’ll still be a big fight. AND he admits that the unintended consequences of sharing information is that providers want more money, either to support improvement, or because they are already the best and want to be rewarded for it.

So we must close the quality chasm….P4P is one of the strategies. But there needs to be collaboration.

QUALITY: Milstein’s shark

Arnie Milstein from Mercer is probably the smartest “purchaser” in health care on quality. He’s also the only person explicitly linking the inefficiency in health care to the plight of the middle class un- and under insured….as in this story.

What do we know? 1) The low cost regions are 30% cheaper at no worse quality. 2) Within the low spending communities the lowest spending docs with high quality are still 15% below the average cost for the region —  Boeing looked into this in Seattle. And medical errors are still a massive problem (Minnesota health policy adviser was going to have the wrong side of her brain operated on)

But we have the shark (Arnies turn at explaining the increase in spending over incomes) caused by the biomedical miracles. Arnie says that we shouldn’t shut off the shark (i.e. cut off new biomedical miracles). Cutler estimates that every year the shark adds 5 weeks to life expectancy

Answer is to a) rapidly adopt best known delivery methods — b) rapidly incubate cost efficient care delivery innovations so that improvement happens more quickly

So how to do this? a) improve performance measurement, b) increase performance sensitive payments c) faster vetting of cost saving innovations (e.g. no plan had done on ROI on their DM initiatives)

Have to speed up the process knowledge discovery-cycle, by i) expanding role of para-professionals, ii) using engineers to redesign engineer IT-enabled work flows, and then iii) source high end elective care globally. (He’s finding unbelievably cheap prices from JACHO certified hospitals in China)

This has worked elsewhere…on average since mid-90s retail has been gaining efficiency at 2.5% a years, finance at closer to 8%—but they’ve adopted scientific measures. Where this has happened in health care is worked well. Virginia mason is using engineering to reduce unit costs and volume of services, and has just written a letter saying the 50% of dollars are wasted and told its clients that.

He also believes that while not perfect salient public transparency is powerful (Julie Hibbard, Health Aff July 2005), but apparently employers and enrollees support tiering and provider selection preferred 2 to 1 over P4P. He thinks that overall P4P is “medically necessary reset” — but the middle class is not likely to be shielded in time. But it’s not enough to save them unless we really move quickly. I think he’s an optimist.

 

QUALITY/TECH: Brailer on IT in P4P

David “Stalin” Brailer likes being on the west coast, so is happy to come out here and give talks.

He says it’s obvious. Health care IT needs P4P.  And you can’t recoup the benefits of an EMR unless it’s aligned with the direction that the health care market’s going. So the market has to change. But 1.5% of the revenue (a typical P4P bonus) is not enough, although it might be enough on the margins for a few.

Meanwhile, Brailer’s office is now certifying what is a “valid” certified health record (CCIT) and wants P4P programs to help encourage that. And he like everyone else thinks that P4P requires health care IT.

But as there is no agreement on what we’re measuring, none of this works. The industry (public and private) needs to come together to agree what the hell it is we’re measuring. Brailer thinks that  American Health Information community (AHIC) is doing that.

But we also need to commit to changing the way we pay doctors and help them along. No one knows if it’s IT that helps or management or what.

BUT he notices that health IT works better among bigger practices. His mission is not to drive everyone into big groups. This has to be made bite size for smaller practices. As the tools are much further along for the bigger groups, which tracks with the ability to do pay-for-performance. So we have a big investment to make to bring along everyone. We have to bring along the little guys too.

(I’m hearing more about this from Brailer than I was year ago)

Both health IT and P4P favor standalone rather than integrated care. Normal course of health IT can’t be followed which is why interoperability is important, and they will guarantee that certified records will be backwards compatible and be interoperable. So he wants not to reward silos, but instead to reward “interoperability” for P4P — not to create optimal activity in a sub-optimal place.

Finally he wants P4P to be long term, not to die on the vine like capitation because it’s a new name for dumping the risk on someone else!

I asked Brailer about consumerism, HDHPs, and whether that is in conflict with integrated systems. He thinks that those integrated systems will find other solutions and they will integrate with other pieces of the system. Most other industries have moved away from “integration”… He believes IDS are closer to that end point in operation versus where they are psychologically. And closed systems are not totally closed. No one is an island. So they require interoperability, but he hopes those big systems can export their knowledge. So they need interoperability too. (he didn’t really touch on whether the HDHP will destroy the HMO movement before those consumer measures are created.

His final point? This is inevitable as doctors going into practice now will not tolerate paper in their practice. He wants the process of having this happen cleanly and not have it happen as islands.

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