Innovations In Health Care
Delivery
Tuesday, March 8, 2011
W Hotel Washington
Washington, DC
Susan Dentzer
Editor-in-Chief
Health Affairs
Health Affairs thanks these organizations for their support
of today’s briefing and the “Innovation Profiles” featured in
the March 2011 issue of the journal:
David Blumenthal, M.D., M.P.P.
National Coordinator for Health IT
U.S. Department of Health and Human Services
Innovations in Health Care
Delivery: From Patchwork to
Quilt
Anne-Marie J. Audet, MD, MSc
VP Health System Quality and Efficiency Program
The Commonwealth Fund
Defining our Terms:
Innovation
•
From Latin Innovatus, Innovare :“To renew or change," from in"into" + novus "new".
•
Innovation can therefore be seen as the process that renews
something that exists and not, as is commonly assumed, the
introduction of something new.
High Performance Health System
Attributes and Functionalities*
•
•
•
•
•
•
Patients' clinically relevant information is available to all providers at the
point of care and to patients through electronic health record systems.
Patient care is coordinated among multiple providers, and transitions
across care settings are actively managed.
Providers (including nurses and other members of care teams) both
within and across settings have accountability to each other, review each
other's work, and collaborate to reliably deliver high-quality, high-value
care.
Patients have easy access to appropriate care and information including
after hours; there are multiple points of entry to the system; and
providers are culturally competent and responsive to patients' needs.
There is clear accountability for the total care of patients.
The system is continuously innovating and learning in order to improve
the quality, value, and patients' experiences of health care delivery.
Source: A. Shih, K. Davis, S. Schoenbaum, A. Gauthier, R. Nuzum, and D. McCarthy, Organizing the U.S. Health Care
Delivery System for High Performance, The Commonwealth Fund, August 2008
Common Themes
•
•
Convenience sample
Variety of settings (context)
– Health Systems, Health Plans, Hospitals, Physician Networks,
FQHCs, Professional Societies, States
•
Assessment according to logic model of change (Prochaska
Behavioral Model)
– Knowledge of problem: A+++++
– Tools (innovations): B
– Motivation (Incentives, Will): F
Common Themes
• Identify, know, segment and ongoing close engagement with
population (McLuhan’s “The medium (cold vs hot) is the
message”)
• Prioritize primary and preventive care – health and healthcare
• Multi-disciplinary , accountable team care
• Performance improvement infrastructure
• Maneuver within payment and regulatory environment
• Evolutionary process of change over time (4 or more years)
• Urgent need for data about impact on Three Part Aim
Ears to the Ground: Know Thy
Population and Standardize Person
Tailoring
•
•
•
•
•
Jo-Ann Lynn’s Bridges to Health Model (young healthy, disabled, stable
chronic conditions, unstable, end-of-life)
Innovations and programs tailored to prevalence of disease, disease burden
Segment - high need, low need
Standardized tailoring
– Bellin’s pyramid access cascade model
• MyChart patient portal
• Community-based His Health and Her Health programs
• Employer-based clinics
• Fast Care Clinics – retail
– Cambridge Health Alliance – MyChart (parents and kids); high touch-low
touch segmentation
– Clinica Family Health Services (CO)- people measure their own BP at time
of visit
Open door philosophy, connect to population – often and variety of methods
10
Practice Has Arrangement for Patients’
After-Hours Care to See Doctor/Nurse
Percent
100
97
89
89
78
77
75
54
54
50
43
50
38
29
25
0
NET
NZ
UK
FR
ITA
GER
SWE
AUS
CAN
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
NOR
US
11
Online Access at Regular Place of Care
Percent
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
UK
US
Has e-mailed
medical question
to regular doctor
or place of care
in past two years
2
4
2
7
2
4
4
6
3
9
6
Can make an
appointment via
e-mail or Web
site at regular
place of care
7
6
9
60
10
9
23
13
13
25 15
Base: Has regular doctor/place of care.
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
Accountable Care Teams
• All sites profiled created multidisciplinary teams
• Accountability at core of team supported by IT to allow
just-in-time sharing of information around an entire care
plan
– Aurora Acute Care for Elder Tracker on E-Geriatrician
– Cambridge Health Alliance registry shared by all providers, school
based clinics, community-based health workers
– GRACE: web-based care plan shared by NP, SW, geriatrician,
pharmacist, PT, community resource expert
• Need for more robust data on cost of these models of care
– VT Community Health Teams – 5 FTEs serve 20K population; $350K
per year
– Martin’s Point teams went from 4.3 employee per MD to 6 per MD
– Healthcare Partners – Comprehensive Care Center Program saves
$3,500 per hospital day avoided, redirected to support program
Practices Use Nonphysician Clinical
Staff for Patient Care
Percent reporting practice shares responsibility for managing care, including
nurses, medical assistants
100
98
98
91
88
88
73
75
73
59
54
52
50
25
11
0
SWE
UK
NET
AUS
NZ
GER
NOR
US
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
ITA
CAN
FR
Primary Care is Really Prime
• Primary care as core value and expected outcome is health not
just health care
• But this entails “system” approach for cross continuum care
services
– New business model for acute care settings
– Successful systems are able to align financial incentives
•
•
Mercy Health System working with Keystone Mercy Health Plan
HealthCare Partners Medical Group - partial or full risk capitation
•
Clinica Family Health Services costs per visit $167, Medicaid pays $155
• Performance improvement infrastructure to support practice
– Healthcare Partners Medical Group (CA, NE, Fl): “Comprehensive Care Center
Program – teams concentrate on stabilizing patients and supports MD practices
in taking care of more patients with more intense needs post discharged (45min
vs 15 min visits)
– VT ITE – Blueprint Central Registry; training practices; web of connection (e.g.
heat assistance->medical home referral)
– GRACE model – home assessment team
– Shared services models (TA, workforce): private/public support
Extrinsic Motivation
•
Examples of financial models:
– FFS + PMPM Medical Home Supplement
– Risk sharing:
• Risk-adjusted capitation
• Global payment
•
Consistent evidence of barriers to innovations: antiquated payment
methods and regulations
– Successful systems able to move away from volume and servicebased payment
– Balanced payment models that includes rewards based on
quality and efficiency
– Allows flexibility in care design
– FFS environment prohibitive to sustainability and spread of
innovations
•
Professionalism, recertification, professional boards (e.g. AAP)
16
Financial Incentives and Targeted
Support
Percent can receive
financial incentives* for:
AUS
CAN
FR
GER
ITA
NET
NZ
NOR
SWE
UK
US
High patient satisfaction
ratings
29
1
2
4
19
4
2
1
4
49
19
Achieving clinical care
targets
25
21
6
6
51
23
74
1
5
84
28
Managing patients w/
chronic disease or complex
needs
53
54
42
48
56
61
55
9
2
82
17
Enhanced preventive care
activities**
28
26
14
23
28
17
38
12
2
37
10
Adding non-physician
clinicians to practice
38
21
3
17
44
60
19
7
2
26
6
Non-face-to-face
interactions with patients
10
16
3
7
***
35
5
30
4
17
7
* Including bonuses, special payments, higher fees, or reimbursements. ** Including patient counseling or group visits. *** Question not asked in Italy
survey.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
From Patchwork to Quilt: Spreading
Success Local to National One
Community at a Time?
• Patchwork America Project illustrates subtle, yet significant differences
among communities in the US, that affect numerous cultural, political,
consumer behaviors. Do these also affect behaviors related to health and
health care?
•
•
•
•
•
•
Boom Towns
Evangelical Epicenters
Military Bastions
Service Worker Centers
Campus and Careers
Immigration Nation
•
•
•
•
•
•
Minority Central
Tractor Community
Mormon Outposts
Emptying Nests
Industrial Metropolises
Monied Burbs
• What is the typology of communities, regions underlying health care system
spread strategies? Geography is not sufficient, market characteristics are
important, what are other determinants that will be key to spread?
Learning In Order to Spread and
Get Results
•
•
•
•
Strategy to identify promising innovations
Pawson and Tilley’s approach: emphasize the “why” and not only the “what”
works or does not work
– “Experimentalists have pursued too single-mindedly the question of
whether a social program works at the expense of knowing why it works.”
– CMO vs OXO approach
Criteria to determine whether the innovation is worth evaluating with goal of
spread
– Flexibility of adoption in various settings
– Requirements for effective adoption
• How much disruption will be entailed
• Need for regulatory or other significant changes to allow spread
Not every innovation will succeed
– How much are we willing to spend – ROI (20% in technology)
From Patchwork to Quilt: What is
on the Horizon
•
Payment reform (2003 Leatherman et al HA paper Business Case for
Quality) – now a reality
Workforce – National Health Care Workforce Commission; Funding for
Title VII and Title VIII programs to educate and train primary care
physicians and other health professionals
•
Innovation and improvement infrastructure (RECs, QIOs, etc)
•
Data needs – more timely, all payers
•
Longer term horizon for impact with short term expected targets
•
CMMI – promising programs
•
–
–
–
Mission to identify, validate and scale models that have been effective in achieving better
outcomes, but may be relatively unknown.
Eight States selected to participate in the Multi-Payer Advanced Primary Care
Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration will
evaluate the impact of this care model on access, quality and cost of care provided to lowincome beneficiaries served by these facilities
Christopher A. Langston, Ph.D.
Program Director
The John A. Hartford Foundation
Sean Cavanaugh
Director, Provider Contracting and
Reimbursement, Center for Medicare
and Medicaid Innovation, U.S.
Department of Health and Human
Services
Reflections on Innovation
David N. Gans, MSHA, FACMPE
Vice President, Innovation and Research
Medical Group Management Association
Reflections On the Articles
• Patient-centered care reduces the total cost
of services, while improving quality and
patient satisfaction.
• Savings come from fewer ED visits, less
hospital admissions, and shorter lengths of
stay, but . . .
• With increased expenses to the provider
due to increased staff, the application of
new technologies, and having to reengineer workflow.
Key Themes in Innovation and Health
Care Delivery
• Change is not easy.
• Care plans often combine clinical treatment
with “Lifestyle Medicine” –managing the
patient’s nutrition, stress, and activity level
to improve total health status.
• Fee-for-service payment does not
necessarily consider the costs associated
with these innovations.
Increased Administrative Complexity
Must Be Addressed
• Quality and performance measures are
unique to each insurance payer and need to
be standardized
• Practice management systems do not fully
support data reporting
• The “Patient Centered Medical Home” has
three different organizations setting
requirements: the NCQA, AAAHC, and the
Joint Commission
A Final Thought on Innovation in
Care Delivery
We are confronted with
insurmountable opportunities.
- Walt Kelly
The Financial and Nonfinancial
Costs of Implementing
Electronic Health Records in
Primary Care Practices
Neil S. Fleming, Ph.D., C.Q.E.
Vice President, Health Care Research
Baylor Health Care System
Dallas, Texas, USA
Study Authors: Fleming NS, Becker ER, Culler SD,
McCorkle, R, and Ballard, DJ
Contact: Neil.Fleming@Baylorhealth.edu
Study Description
•Funded by: Agency for Healthcare Research and Quality R-03
grant
•Purpose: To quantify the financial and nonfinancial (time and
effort) costs of electronic health records (EHRs) in primary
care practices to inform stakeholders
•Setting: 26 HealthTexas primary care practices as part of the
Baylor Health Care System, (in North Texas) implementing
the electronic health record between June 2006 and
December 2008, tracking 120 days prior to launch and 60
days after
•Methods: interviews with key personnel, documents, calendars,
e-mails, and payroll information
•Study groups: HealthTexas network implementation team,
practice implementation team, and end-users with diverse
skills and expertise that are carefully coordinated
Results
Time and effort are non-financial costs
Network implementation team expends 480.5 hours and
$28k per practice
Practice implementation team expends 130 hours and
$7,857
End-users expend 134.3 hours and $10,325 per physician
Hardware costs: one-time infrastructure purchases are $25k
per practice and $7k per physician
Software and maintenance costs: licensing, hosting,
networking, and technical support for first 60 days are
$2,850 and $17,100 per year
Total costs: $32,409 per physician and $162,047 in a 5physician group from launch through first 60 days
Conclusions
 Financial Alignment is needed between those stakeholders
paying for EHRs and those receiving potential benefits
 Some economies of scale can be achieved with larger
practices due to variable nature of some costs
 Strategies are needed to support and coordinate the diverse
set of medical and technical skills required to ensure
successful implementation of EHRs and physician
satisfaction
More Than Four In Five OfficeBased Physicians Could Qualify
For Federal Electronic Health
Record Incentives
Brian Bruen,1 Leighton Ku,1
Matthew Burke,2 and Melinda Buntin2
1 George
Washington University
2 Office of the National Coordinator for Health Information Technology
NOTE: Commentary is the authors’ opinion and does not necessarily reflect the views of the Office of the National
Coordinator for Health Information Technology.
HITECH Incentives
• To qualify:
– Any Medicare patients
– At least 30% Medicaid patient volume
• More lenient criteria for pediatricians, also
clinicians in community health centers and
rural health clinics
• Must demonstrate “meaningful use”
of certified EHR technology
• Get Medicare OR Medicaid, not both
Office-Based Physicians Potentially Eligible For
HITECH Incentives And Using Electronic Health
Records (EHRs), 2007–08
Not eligible for incentives,
does not have basic EHR,
14.6%
Not eligible for incentives,
already has basic EHR,
2.8%
Eligible for incentives,
already has basic EHR,
12.1%
Eligible for incentives, does not
have basic EHR, 70.5%
SOURCE Authors’ calculations based on combined 2007–08 National Ambulatory Medical Care Surveys.
NOTE HITECH is Health Information Technology for Economic and Clinical Health.
Highlights from Findings
• Incentives should greatly accelerate
use of electronic health records
– 4 out of 5 office-based physicians could
qualify, if they achieve meaningful use
• Incentives are well-targeted, but
certain groups of physicians are
more likely to be excluded
– pediatricians, psychiatrists,
obstetrician-gynecologists
Policy Responses
• Monitor gaps in eligibility, use
• Pro-rate eligibility for Medicaid
incentives
• Assist solo practitioners, smaller
practices in adopting systems and
achieving meaningful use
– Government (e.g., ONC) and private
roles (e.g., insurers, foundations)
Director, Office of Economic Analysis, Evaluation and Modeling, Office of the National Coordinator, U.S. Department of Health and Human Services
The Benefits of Health
Information Technology:
A Review Of The Recent Literature Shows
Predominantly Positive Results
Melinda Beeuwkes Buntin
Director, Office of Economic Analysis,
Evaluation and Modeling, Office of the
National Coordinator, U.S. Department of
Health and Human Services
Purpose
• To update policy makers,
innovators, health IT users, and
those contemplating adoption about
health IT’s effects on care delivery
and provider and patient
satisfaction
Methodology
• Used framework from two previous
reviews (Chaudhry et al. 2006 and
Goldzweig et al. 2009), to identify health
IT literature from July 2007 up to
February 2010.
• For inclusion, an article must
• address a relevant aspect of health IT
• examine its use in clinical practice
• include quantitative or qualitative outcomes
Article Flow
Outcomes Addressed and
Conclusions Reached
Findings
• Over 92 percent of the studies reached
conclusions that were generally positive.
• Studies emerging from traditional health IT
leaders (e.g. Kaiser, the VA) are no more robust
in their study design or positive in their
conclusions
• Studies examining provider satisfaction are
more likely to have negative findings.
How the Affordable Care Act Can
Help Move States Toward A HighPerforming System of Long-Term
Services and Supports
By Susan C. Reinhard, Enid Kassner and Ari Houser
March 8, 2011
Characteristics of a HighPerforming LTSS System
• Support for Family Caregivers
• Ease of Access and Affordability
• Choice of Settings and Providers
• Quality of Care and Life
• Effective Transitions and Organization of Care
43
State LTSS Scorecard
• States will be ranked on five dimensions that
approximate the five characteristics of a highperforming LTSS System.
• Scorecard will call attention to state variation and put
each state’s performance into context.
• Scorecard will provide a mechanism to track progress
in years to come.
44
Creating a State LTSS
High
Scorecard
Performing
LTSS system
is composed of
characteristics of a high performing LTSS system
that are approximated in the Scorecard by
dimensions based on available data
each of which is constructed from
Individual indicators that are interpretable and show variation across states
45
The Affordable Care Act’s Role
• Offer States “Carrots” to Support
Improvements in their LTSS Systems
• Balance Types of Services
• Establish a Singe Point of Entry
• Improve Coordination and Transitions
46
ACA Opportunities to Promote
Scorecard Measures
• Ease of Access:
– Expanding Aging and Disability Resource Centers
– Balancing Incentives Payment Program
• Choice of Settings:
– Community First Choice
– Money Follows the Person
47
Palliative Care Consultation Teams
Cut Hospital Costs For Medicaid
Beneficiaries
R. Sean Morrison, Jessica Dietrich,
Susan Ladwig, Timothy Quill, Joseph Sacco,
John Tangeman, Diane E. Meier
Mount Sinai School of Medicine (New York)
Center to Advance Palliative Care (New York)
National Palliative Care Research Center (New York),
University of Rochester Medical Center (Rochester),
Bronx-Lebanon Hospital (New York)
Center for Hospice and Palliative Care (Cheektowaga)
Background
• Patients with serious or life-threatening illness account for
a disproportionately large amount of Medicaid spending
• Palliative care, when provided alongside disease directed
care, has been shown to reduce symptoms, improve
quality of life, reduce family burden, and prolong survival
• This study was performed to examine the effect of
palliative care teams on hospital costs for Medicaid
beneficiaries
Palliative Care: A Definition
Interdisciplinary specialty that aims to relieve
suffering and improve quality of life for patients
with advanced illness and their families.
Palliative care is provided simultaneously with all
other appropriate medical treatment.
Distinct from hospice care which is medical care
toward the end of life devoted exclusively to
palliation
As Illness Progresses…
An Increasing Emphasis on Palliation
Methods
• Retrospective analysis of hospital administrative
and cost-accounting data
• Sites: Four structurally diverse urban New York
State hospitals in one large and two mid-size
cities
• All sites had mature palliative care consultation
teams
• Adult Medicaid beneficiaries with advanced
illness receiving palliative care were matched by
propensity score to usual care patients
• Calendar years 2004-2007
• GLM and multivariable logistic regression
models used to analyse results
Palliative Care and Cost Outcomes
*P<.05, † P<.01 ‡P<.001. N/A = not applicable
Cost/Day For Patients Discharged Alive
Implications
• Hospital costs among Medicaid beneficiaries were
significantly lower when they had consultations with
the palliative care team
• Palliative care team consultations may reduce
expenditures, while helping to ensure quality care
consistent with patient wishes, for hospitalized
Medicaid beneficiaries.
• New payment mechanisms aimed at improving quality
and efficiency would benefit from inclusion of
palliative care teams.
Health Affairs thanks these organizations for their support
of today’s briefing and the “Innovation Profiles” featured in
the March 2011 issue of the journal: