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Looking for Quality in the Wrong Place

By CHRIS LANGSTON

Last week I attended the first annual meeting of the Long-Term Quality Alliance and listened to Gregg Pawlson (a geriatrician and executive with NCQA) talk about quality measurement.  Right now, quality measurement does too little to drive practice towards quality care because it is based only on things that are “feasible,” or easy to measure—like what gets coded on medical bills. Pawlson observed that while feasibility must be one of the watchwords of quality measurement for now, in the near future electronic medical records should allow us to move beyond billing codes to gather real clinical data for more important quality measurement, including key care processes and outcomes.

I sure hope so. Because those who have looked beyond the dim illumination of current billing-based “quality measures” and searched in the darkness where real processes of clinical care can found have found that the situation is grave.  The ACOVE (Assessing Care of Vulnerable Elders) process, while laborious, looks at clinical care where it really happens – in offices and charts – rather than in bills and therefore has a better chance of driving meaningful quality improvement. Readers of Health AGEnda know that I am a big fan of this work, begun at RAND by outstanding clinician-researchers including Neil Wenger, David Solomon, David Reuben, and many others.  I believe that ACOVE is an example of what we need in elder care: high quality evidence about essential clinical practices that are sensibly related to real health outcomes and show how we could (often easily) do better for older people.  ACOVE is a blessing.

One of the leaders of the ACOVE program is Neil Wenger, MD, a faculty member in General Internal Medicine at UCLA and a researcher at RAND who I have cited in my posts.  However, in his talk to the Maxwell School of Public Policy at Syracuse University (another treasure I found last fall at GSA), he really outdid himself in delivering one of the most accessible (and provocative) descriptions of this research program I have ever read.  He asks, “Do We Want to Measure the Quality of Care for Vulnerable Older People?” Given the lack of attention to the ACOVE work, I understand his frustration.Continue reading…

Tall Buildings

By KIMBERLY MANNING, MD

Dreading going in there. Know what you will say.  Your pain will be a ten out of ten. When I ask, “How are you?” you will say what you always say: “Terrible.” Your face will be a twisted snarl and you’ll cut your eyes so hard at me that I almost bleed.  I’ll ask you what can I do for you and your answer won’t be reasonable.  Or at least attainable.  That’s why I dread going in there.

Your family is tired. I have decided that they are tired because the only alternative explanation to them not coming to see you or see about you or call you or call about you is that they don’t care. I don’t like that explanation so instead I have decided that they are tired.

Tired of the exhausting marathons that you keep running in circles inside of your own mind. Tired of the short-lived glimmers of normalcy that you sometimes offer only to be smacked back into the reality of your never-quiet mind.  Tired of fighting you and fighting the bureaucracy of how to get you somewhere safe with virtually zero resources.  I know they are tired. Because it’s only been less than two weeks for me. And I’m tired, too.

And so each day I stand before your door on rounds. Secretly wanting to just keep on walking. Shadow boxing in my mind to get over my tired. And over my dread. And over my anger with my hands being tied snugly behind my back and, on some days, your hands being tied snugly down in restraints for your own safety. Your mind a cacophony of voices and poisonous thoughts that win over me and my little bag of internal medicine tricks. I don’t know what to do.

And so on this day, I just start with what my Mama always taught me.

“Good morning.”

“Hello.”

Something is different. Today, no scowl or lancinating eyes. Instead, you reach your hand out towards me. At first I look at it suspiciously, wondering if you intend to grab at me or shoo me away. I see the wrist ties near the rail of your bed from the corner of my eyes. But all you want to do is hold my hand. I am part surprised and part ashamed.

Hold my hand?

Me? I didn’t see that coming. Me? I was all business. There to just listen to your chest leaping with every thump of your dilated and failing heart, to interpret your engorged neck vein pattern, to look into your mouth, to inspect your swollen legs, and to review the orders. And in the midst of it all, to stand there taking your hand slaps and refusal to cooperate while sifting through my brain for a reasonable treatment plan marrying a terrible, end-stage medical problem to a slippery and elusive psychiatric illness.  With no money. And no family.

See? I was shadow boxing to be able to do that. Not hold your hand. You catch me off guard. I stop my busy-ness and let you hold it. I wag my finger at myself and say, tsk-tsk. Your patient is sick, Dr. Manning.

But I knew that before I came. Yet still, I felt tired. I feel your trusting palm, resting in my own. I sit beside you on the mattress and envelope it with my other hand. The room falls quiet as our feet dangle off of the edge of the bed facing the Atlanta skyline. I remember in that moment how beautiful it is. Especially from this room.

“Doctor?”

“Yes?”

“You can see the buildings all the way across town from this window.”

“Yeah.”

“The Marriott Marquis. And behind that is Bank of America.”

I look.  “You’re right.”

“How did they make such tall buildings?”

I pause for a moment, pondering the answer to that question. I’m not exactly sure. “I think they do it with cranes and big equipment. And people who aren’t afraid of heights.” I smile and for the first time in two weeks, you smile, too.

“I’m afraid of heights.”

“You are?”

Your smile dissipates and your expression grows distant.

“I am afraid. What will become of me? I am so afraid.”

You look at me with eyes so sane that I forget all of the diagnoses that compete with believing them. Your fingers tighten around my own. I feel more ashamed for shadow-boxing and dreading seeing you.

“Doctor?”

“Yes?”

“I’m tired.”

“I know.”

I sit in silence, rubbing your veiny and weathered hand. I’m tired, too.  We both breath in synchrony, yours more laborious from fluid, mine affected by growing emotion. I stare out of the window at The Equifax Building, the shiny cylindrical Westin Hotel, and the skycraping Georgia Pacific building.  Suddenly my eyes sting and my face feels warm. Because you are trusting me to help. I want to leap from one of those tall buildings with a single bound to save you.  But I can’t. Sometimes even when I want to, I can’t.

I’m not sure how they build those buildings. I also don’t know how to save you. My wings are tied and clipped. So are yours.

On this day, I will start by simply holding your hand. And shadow boxing to keep myself from giving up on you.

Kimberly Manning, MD, is an assistant professor in the Department of Medicine at Grady Memorial Hospital in Atlanta. As both a clinician and educator, she teaches pre-clinical medical students and residents and serves as residency program director for the Transitional Year Residency Program. She blogs regularly at Reflections of a Grady Doctor.

Think Medical Billing, Not “EMR First”

By JONATHAN BUSH

I have heard from our sales force (and at more than one cocktail party) that most hospitals and practices around the country are focused on Electronic Medical Records (EMR) these days and not so much on medical billing or Revenue Cycle Management (RCM) now because they want to “Do EMR first.”

But what if you are doing EMR first for revenue cycle reasons?

Isn’t the bonus money offered for “Meaningful Use” of an EMR the main driver behind the rush to implement them?  And isn’t the rush intensified by the threat of reduced Medicare rates for those who don’t “meaningfully use” health information???

Okay, so how will you get the incentive money?  My guess is that you will claim to the Feds—through the attestation process—that you are a meaningful user, right?  Claim it?  Like as in file a claim?

I don’t care if it’s MU, PQRI, BTE, or LFG for Do-Re-Mi, if you are going to be glad you moved to EMR, it’s going to be because you’re able to include clinical information in your medical billing system! If you don’t have this in mind from the get-go, you will lose LOTS and LOTS of money on your choice to do “EMR First.”Continue reading…

Medicare Is Lousy Insurance

By GREG SCANDLEN

The House budget proposal is serving as the latest piñata for Democrats who always use the exact same cudgel — “Extremist Republicans are threatening to throw America’s elderly into the streets!”

This, after these exact same Democrats cut half-a-trillion from Medicare to subsidize ObamaCare.

How do they get away with it?

Partly because Republicans have failed to tell the truth about Medicare for decades. They have enabled the Democrats to create this sacred cow because they either: (1) don’t know enough about it to articulate a different view, (2) don’t care enough about health care in general to become better informed, or (3) are so timid that they are afraid the speaking the truth will get them in trouble with the electorate.

Now their ignorance and/or timidity has come back to haunt them. Most of the elderly hold on to Medicare for dear life because there is nothing else available and they have no basis for comparison.

But the fact is that Medicare is a lousy insurance program. It would be impossible to sell a benefit structure like this on the private market.Continue reading…

Is Your Lack of “MQ” Costing You Money ?

By MICHAEL TURPIN

As health reform continues to play out across state legislatures and within Washington, employers continue to wrestle with rising costs and the corrosive effects of skyrocketing medical trends. It’s clear that there is enormous variability among employers in their confidence and abilities to identify, mitigate and manage the complexities of the employer sponsored healthcare delivery system.

Many industry pricing and billing practices are opaque. Employers are not always getting good advice and often have to entrust the management and control of employee benefit plans to generalists who do not have the time, resources or ability to engage in managing a corporate expense that has eclipsed a composite average of $11,000 per covered employee.

If employer sponsored healthcare is going to survive to drive market based changes that cut fraud, waste and insist on personal health improvement, corporate decision makers must improve their Medical Quotient (MQ). While larger employers such as Safeway have begun to reap the dividends of lower costs by driving employee health improvement and employee engagement through prevention and chronic illness management, small and mid-sized businesses are increasingly getting failing scores for understanding and managing their own cost drivers.

Success in managing medical costs begins with understanding one’s own MQ and committing to improve it against a rapidly changing market that is exceeding the rate of change of many HR and financial professionals. Jack Welch once commented, “When the rate of change outside an organization exceeds the rate of change within, the end is near.” While ignorance can be bliss, it is an expensive consequence in employer sponsored healthcare. Can HR generalists and less engaged CFOs and CEOs finally grab the horns of their own population health costs and drive toward a healthier tomorrow?Continue reading…

Technologic Decline in Health Care

By JAAN SIDOROV

The Disease Management Care Blog has been delighting in the geopolitical lessons of George Friedman’s book The Next Decade: Where We’ve Been . . . and Where We’re Going. While most of Dr. Friedman’s work deals with foreign policy (for example, a better relationship with Argentina can serve as an important counterweight to the emerging power of Brazil and its threats to sea lanes in the south Atlantic), there were two unexpected healthcare insights toward the end of the book.

They are 1) U.S. technology innovation is in decline and will stay that way for years, and 2) the next area of innovation will be “robotics.”

First, the technology.

The United States’ twin health care challenges are demography and technology. Most DMCB readers understand the demography: there is an aging baby-boomer population that is well on its way to living long enough to develop degenerative diseases that will sap the available labor pool and cause consumption of expensive services to soar. Yet, the problem with the parallel issue of technology, according to Dr. Friedman isn’t cost. It’s that technology occurs in waves of innovation that have crested and is now in decline just when we need it.

Technological “waves,” you ask? Looking back, Dr. Friedman argues that the first great wave in the 80’s and 90’s was characterized by the advent of increasingly powerful computers, microprocessors and robust data storage. Think Microsoft. The second was this decade’s massive data transmission and communication. Think the Internet. Unfortunately, both technology waves ended with an emphasis on expanding capacity and finding new applications for the existing technology. In the 90’s, personal computers plateaued and Microsoft’s business model focused on protecting its business models. While today’s Internet is still being rocked by Facebook and Twitter, the fundamentals of “many to many” communication haven’t really changed for years. Productivity gains from technology have peaked and the rest is, in the author’s words, a matter of rearranging the deck chairs.

Despite our investment in medical research, that pales compared to the benefits from military research spending. Ironically, that, not the Institutes of Health, has been the most powerful impetus to new waves of health care innovation, from penicillin to MASH units to remote robotic surgery. All that is now in decline, thanks to the U.S. focus on applying current technologies (the exception being remotely piloted drones) to a limited style of infantry-based land warfare. Another impediment is America’s budget woes combined with the unwillingness of the private financial markets to commit capital to anything other than safe bets. Add it all up and Dr. Friedman argues that it is unlikely that another technological innovation wave is going to occur before 2020.

Now…. robotics.

Dr. Friedman points out that there aren’t enough people to care for all the aging boomers. He says that the answer will be devices that he says “change reality,” but could be better termed as capable of manipulating the environment. When the DMCB thinks about this, aren’t all those blue toothed glucose meters, remote blood pressure monitors, telephonic heart devices and other “input” devices merely “half” of what is ultimately needed? The other half will be “output” devices that administer medicine, generate a treatment, give advice or trigger other responses from the health care system. They may not “look” like “robots” with a pair of flashing eyes or waving arms, but they will definitely “speak” to their masters and will probably be mobile.

They will need even higher levels of computing power as well as more powerful batteries. We don’t have that yet.

It’s no accident that the military seems to be leading the way on the robotics. Ironically, the DMCB has a new appreciation for that technology and is now cheering it on. That’s because until they come on line, the only answers we have are 1) drugs that may delay the onset of the diseases plaguing the boomers along with 2) providing palliative services. Neither options seem to be very attractive.

2020 is about when the DMCB and the spouse are going to be in their 60s.

Jaan Sidorov, MD, is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination. He shares his knowledge and insights at Disease Management Care Blog, where this post first appeared.

Ryan’s Attack on IPAB

By MERRILL GOOZNER

In defending his controversial proposal to turn Medicare into premium support for buying private insurance, Rep. Paul Ryan, R-Wis., on Meet the Press last Sunday took a potshot at the Independent Payment Advisory Board, which is the key cost control component of President  Obama’s health care reform law.

Premium support would give seniors the power to choose the level of care in their plans, Ryan asserted. “The alternative to that is a rationing scheme with 15 bureaucrats the president is going to appoint next year on his panel to ration Medicare spending. We don’t think we should give the government the power to ration care to seniors.”

The House Budget Committee chairman didn’t explain why faceless bureaucrats working for insurance companies would be any different or better than their counterparts in government in choosing what should or should not be covered.  But a group of more than 100 academic and think tank health care experts  has rallied to the defense of the board,  which won’t swing into action until 2015.

Their ranks include liberal economists like Brookings scholar Henry Aaron and Harvard’s David Cutler, who was one of the architect’s of the health care reform law. But they also include former Congressional Budget Office chief Alice Rivlin, who has her own version of a premium support plan, and Harvard’s Joseph Newhouse, who has been a big booster of private insurance plans over the years.Continue reading…

Essential Health Benefits: The Secretary’s Joystick

By ROBERT F. GRAYBOYES

Beginning in 2014, the Patient Protection and Affordable Care Act  (PPACA) hands the Secretary of the U.S. Department of Health and Human Services a joystick – the Essential Health Benefits package – with the potential to rocket small-business health insurance premiums skyward. EHB is the menu of goods and services that must be covered under all exchange-purchased insurance plans and non-grandfathered small-group and individual insurance plans. By vesting one set of hands with control over EHB, small business faces permanent administrative uncertainty. At the same time, the brunt of EHB appears largely to bypass big business, unions, and governments.

EHB, Ban on Limits, Actuarial Value
Beginning in 2014, PPACA (§1302) makes EHB a mandatory feature of most insurance plans purchased by America’s 6 million small businesses and 21 million self-employed individuals. Exceptions initially include businesses with more than 100 employees and those with grandfathered policies. The EHB requirements apply to policies purchased both in exchanges and in non-exchange small-group or individual markets.

In the small-group and individual markets, annual or lifetime coverage limits on all EHB items are forbidden. And plans must have an actuarial value (AV) of at least 60 percent, meaning the plan’s total reimbursements must be at least 60 percent of the total qualifying health care costs incurred.

Section 1302 empowers the Secretary of HHS to define EHB, but gives little specificity beyond requiring that EHB include 10 general categories (e.g., ambulatory patient services) and “the items and services covered within the categories;” the Secretary is to also assure that EHB includes “benefits typically covered” by a “typical employer plan.” The meaning of these words in quotation marks is left to the Secretary (and future Secretaries) to define and redefine. The fluid definitions and concentrated discretion mean uncertainty, which carries a financial cost for small business.Continue reading…

Horses, Camels & Signals

By MARGALIT GUR-ARIE

On June 8, the HIT Policy Committee at ONC has approved the Workgroup recommendations for Meaningful Use Stage 2. Before diving into the details, it is worth noting that the time crunch for moving from Stage 1 to Stage 2, for those seeking incentives in 2011, was proposed to be resolved by postponing Stage 2 for these early adopters for one year. As I noted before, if you are able to attest and obtain incentives in 2011, go ahead and do that. You will be rewarded by having the opportunity to stay at Stage 1 for 3 consecutive years. The final Stage 2 ruling is not expected to occur until June 2012 and judging by previous experience with Stage 1, the recommendations approved today will be significantly relaxed by the CMS process of proposed rulemaking and public comments. So although analyzing (rejoicing or bemoaning) the various measures on this long list is a bit premature, it may be helpful to look at the general principles embedded in this new stage of Meaningful Use.

Horses

Many of the Meaningful Use more pedestrian measures have remained unchanged, have increased in intensity, or have been moved from menu to core (more on this later). These measures include such items as recording patient demographics, maintaining medications, allergies and problem lists, recording of vitals, running reports, electronic prescribing, incorporating structured lab results, medications reconciliation, using formularies, enabling clinical decision support, reporting to state and federal agencies and ensuring privacy and security of medical records.

Continue reading…

ICD-10: Rough Seas Ahead

By JAAN SIDOROV, MD

Have you heard of “ICD-10?”  In addition to the many requirements of the Affordable Care Act, this may turn out to be another big headache for insurers and providers.  According to CMS’ web site, under the authority granted to it under the 2003 Health Insurance Portability and Accountability Act (HIPAA), if you want to do business with Medicare or any other health insurer…

“ICD-10 codes must be used on all HIPAA transactions, including outpatient claims with dates of service, and inpatient claims with dates of discharge on and after October 1, 2013. Otherwise, your claims and other transactions may be rejected, and you will need to resubmit them with the ICD-10 codes. This could result in delays and may impact your reimbursements, so it is important to start now to prepare for the changeover to ICD-10 codes.”

Which is why the DMCB paid attention to this “Report from the Field” Health Affairs article “Coding Complexity: US Health Care Gets Ready For The Coming Of ICD-10.”

The Disease Management Care Blog was reminded that “International Classification of Disease” or “ICD” is an alphanumeric billing system used to specify and describe diseases and treatments.  Originally developed in 1763, it was adopted by the World Health Organization in 1948 for use in public health reporting.  It was later used by physicians, hospitals and health insurers to specify diagnosis coding and payment levels.  For example, persons with “diabetes” may think they saw a doctor for that particular disease, but as far as their insurer goes, they were really seen for “250.”Continue reading…

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