Health Regulations

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Value-Based Bundles for Total Joint: The Glass Is More Than Half-Full

The bundles are coming! The bundles are coming! While many health systems have been delivering care in value-based bundles for some time, the broad implementation of bundles was made a reality when the Centers for Medicare and Medicaid announced the Comprehensive Care for Total Joint proposal to go into effect in early 2016. Navigating this new world, was the focus of the session “The Business of Total Joint Replacement: Surviving and Thriving” at the American Association of Hip and Knee Surgeons annual meeting. This was one of the best sessions we’ve attended on this topic: both realistic and optimistic about the opportunity to impact patient-centered care and change. This is a long post because the session was jam-packed with information, and I was only able to attend the first part. Heads must have been reeling for those who were fortunate to attend the entire 5-hour session.

The session was kicked off by Mark I. Froimson, MD, MBA EVP and Chief Clinical Officer of Trinity Health who took questions from the audience to start the day to ensure that their needs were addressed. A survey of the room showed that roughly half of the attendees were surgeons or physicians and the rest of the audience was comprised of included administrators, nurses, and physical therapists involved in care. This was apropos as much of the theme of the conference was about how care teams will need to work together across settings in a new patient-centered model to deliver on care.

Questions fielded showed that the audience had done their homework and included concerns about business models and outcome tracking for revisions. The Baby Boomer’s desire to stay active has resulted in earlier joint replacements which means revision surgery in the future. Audience members were concerned that revisions wouldn’t have as strong outcomes and they would be penalized by that. Participants from smaller organizations asked whether there were other metric tracking schemes they could participate in to offset the Meaningful Use incentives if they weren’t able to participate. (We have an idea: how about reimbursement for engagement with digital patient treatment plans?) Complex cases were also of concern: the system needs to ensure that systems will not be penalized for complex case that may also have weaker outcomes. Without risk adjustment for complex cases which are more likely be done at large in-patient facilities rather than ambulatory surgery centers, some organizations could be unfairly penalized.

Risk-sharing

Dr. Fromison handed the session over to the extremely optimistic Kevin J. Bozic, MD, MBA, Chair of Surgery and Perioperative Care, Dell School of Medicine. While value-based the goal of bundled payments is to improve outcomes and lower costs, Dr. Bozic spoke directly to the audience about the value for them: in the current fee-for-service model, the best surgeon gets paid the same as the worst. There is no incentive for efficiency. In the new model, surgeons that can deliver better outcomes at lower costs will be rewarded accordingly.

Interestingly though, the team-based medicine approach and the focus on surgical prep and post-operative care, means that it’s not clear which physician in the team will see the benefits of performance bonus: the primary care or physiatrist, the anesthesiologist, or the surgeon. This will be interesting to watch play out. In the past some surgeons considered their work to be finished after the surgery and others stepped in for post-acute care. As well, there was discussion about how to get hourly workers in the care team on board and aligned with the new models. As we’ve talked to countless organizations and individuals about the move to value-based payments, the common theme is that the patient outcome driven approach is better for patients: perhaps this can be the rallying cry for alignment.

This team-based partnership is not just within an organization or care team. Since 40-50% of costs of a total joint replacement are in post-acute care, surgeons and health systems must partner with post-acute care facilities. We’ve observed this trend directly with both inpatient and outpatient rehabilitation joining health systems and creating new ACOs to share risk.

Dr. Bozic handily turned the negative connotations of risk-sharing on their heads, when he was asked whether these new models were just a measure to shift risk to the providers. His answer was a positive “Yes” and encouraged the audience that providers were really the only ones who could manage performance and appropriateness of care. Note that payers still bear the risk of who gets a disease (although with more health systems focusing on wellness this could change), while providers bear the risk for the outcomes. Because of this, Bozic recommended that a strong physician needed to lead the change and own the bundle implementation within a health system.

Outcomes, Outcomes, Outcomes

Today with the focus on outcomes it’s hard to believe that a surgeon from Massachusetts General, largely seen as the father of outcome tracking, was run out of town and eventually lost his license for suggesting that physicians should track and be accountable for the outcomes of the interventions they performed.

Refreshingly, Dr. Bozic asked the audience to go beyond standardized outcome tracking as it relates to reimbursement, and consider which outcomes matter most to patients. We’re excited about this idea as we track outcomes both based on standardized outcome measures like the HOOS and KOOS (and soon the Hoos Jr & Koos Jr) but also at the task level and soon based on the patient’s own goal.Outcomes-mobile.screen4.jpg Outcomes-mobile.screen5.jpg

Without data transparency and sharing, improvement can’t happen. Finding out where the waste is in the 100-300% variation in inpatient total joint cost is key. Dr. Bozic is suspicious of organizations that boast that they are better than average on all measures: he believes that they are actually are unaware of their flaws and not driving a culture of continuous improvement.

We’ve been at surgeon-focused conferences before, and the booths that were busiest were those promoting joints and surgical instruments. Dr. Bozic told the audience they needed to be evaluating vendors that could help them collect, measure, and act on outcomes, which was music to our ears.

Patients and Prevention

The third speaker was Dr. David Halsey, MD from Vermont, who echoed many of the themes of the previous speakers, especially in the need for outcomes, but also posited a question we haven’t heard before, Dr. Halsey asked who better to do population health for arthritis than orthopedic surgeons? In our travels, we think that both physiatrists and physical therapists might want to join in that population health management, however, if it starts with the surgeons then they would be more incented to try other approaches before surgery, which can be accomplished through preventative care. Preventative care includes patient education and shared decision making and requires new tools to involve and engage patients in their care. It also includes making the patient’s goals front and center to improve care, and understanding and managing their expectations. Today’s patients have higher expectations to have a high level of mobility post surgery, and a low level of pain. Physicians need to engage with patients both to understand and to manage their expectations.

Moving Forward

While we’ve heard some people grousing about the squeeze that is being put on orthopedics through the CCJR, this glass-half-full group sees this as an opportunity for orthopedists to lead the way and actively engage with CMS. Data collection and transparency are the way to do this, and the current tools (aka EMRs) don’t cut it. (While this is our message at Wellpepper, it came directly from the speakers: times are changing!) Expectations are that other specialties will follow the total joint guidelines, spinal surgery is considered to be next, so orthopedists have the opportunity to set the standard for how value-based bundles are implemented in their organizations, while collecting and analyzing real-time data and leading an interdisciplinary team of course. Onwards! We’re ready!

Posted in: Health Regulations, Healthcare Disruption, Healthcare Policy, Healthcare Technology, Healthcare transformation, M-health, Outcomes

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P4 Medicine, How You Can Live To Be 100

I was fortunate enough to be on the guest list for the event, “An Evening Discovering Scientific Wellness” hosted by Arivale at Chihuly Garden and Glass this past week.  The space was packed with over 600 guests, which included: students, scientists, nurses, entrepreneurs, investors, doctors, schoolteachers, software engineers and really anyone with an interest in being part of a new transformation in healthcare.   My fascination with what Arivale plans to do originates from three different perspectives: as a scientist with an undergraduate degree in Neurobiology, a healthcare provider (Registered Nurse) and most currently as a graduate student in Clinical Informatics with a penchant for technology. Arivale plans to bring together all of my interests in science, clinical data and technology to create a personalized plan to optimize wellness.

Be forewarned, P4 Medicine (Predictive, Preventative, Personalized and Participatory), is not for the squeamish.  Maybe you have seen the funny coffee table book “What’s Your Poo Telling You?” Well, now it can tell you more than you ever imagined. Arivale, a new Seattle start-up co-founded by biomedical pioneer Leroy Hood, MD, PhD, actually aims to analyze your microbiome (the polite word for poop and/or the bugs inside you) as one part of their unique approach to transform how we think about our health.

Clayton Lewis, CEO and co-founder of Arivale, introduced co-founder Lee Hood (who probably needs no introduction in Seattle) as a visionary man who “speaks about the future in the present tense.”  Dr. Hood described how Arivale evaluates samples of blood, saliva, microbiome, genetic sequencing and Fitbit data to give participants an entirely personalized set of actionable health data. The fundamental piece is a personal coach who will create a tailored wellness plan.  Not only will the coach call each month to check-in and guide the participant but, they will also integrate any new data and make adjustments to the original plan.

After hearing Arivales pitch, I do question how they plan to deal with the FDA and providing P4 medicine complete with health recommendations to consumers. This is not entirely dissimilar what 23andMe tried to do 2 years ago marketing Personal Genomic Services directly to consumers and shortly thereafter, the FDA required them to stop. Since then, 23andMe has gone through several rounds of R&D and now has the official blessing from the FDA. Along with the FDA approval of 23andMe earlier this year, the FDA also announced two important pieces of regulatory information making the path for other companies like Arivale easier.

  1. FDA is [sic] classifying carrier screening tests as class II. In addition, the FDA intends to exempt these devices from FDA premarket review.
  2. The FDA believes that in many circumstances it is not necessary for consumers to go through a licensed practitioner to have direct access to their personal genetic information.

Why is P4 Medicine so important? The crowd of at least several hundred let out a collective murmur of surprise when Dr. Hood dropped the factoid, ‘living to be 100 is going to be new norm for children being born into the next generation’. He jokingly followed with, “We want to get you to 100 and then you are on your own.” He pointed out that while our genetics may give us the predisposition for certain diseases, they don’t necessarily define our health.  If genetic variants are known, you can do something about them. Arivale wants to provide people with meaningful, personalized diagnostic information so as to optimize as many aspects of their health as possible.  The goal is to make those 100 years of life full of vigor, fitness and optimal health.

Next, two of the original 100 Arivale pioneers took the stage and spoke about their experiences.  The first woman explained her diagnosis of a ‘suspect immune system’ and not having enough T-cells.  This came along with a daily dose of antibiotics and lot of ‘no’s’ to activities she enjoyed such as long distance running.  The microbiome testing revealed that the antibiotic was not wiping out her endogenous gut flora.  Based on genetics, hiking in the woods, not long distance running, was the best exercise for her.  With Arivale, she realized her body was resilient, adaptive and was able to literally ‘start trusting her gut.’  In describing her experience with Arivale, she ended by saying, “Instead of seeing myself as a sickly, non-running person, I now see a person with a diverse life, a diverse gut and an adaptive life.”

The second woman opened by recounted her entertaining experience of giving birth during the 2nd quarter of the Superbowl last year. Her motivation to join the current cohort of 300 Arivale participants, was due in part to optimize her health but she also wants to be around as long as possible for her child. She is part way through the program, has received stellar results on her blood work and just the day before received her genetics phone call. Her genetics revealed a moderate risk for obesity and that her body had difficulties disposing of toxins. Going forward, Arivale will make recommendations on for life style changes based on these revelations.

Patient engagement is one of the newer buzzwords in healthcare and Arivale really gives it a new spin. We are entering a new era where people have access to the data and tools available to truly be active participants and take more control over their health outcomes.  We can no longer lay the blame on genetics because as Arivale is proving, we can now make informed decisions that can alter the expression of our genes and help us to achieve our wellness potential.

After the presentations were over, I went to the Info table to see how I could be part of this second set of 300 beta participants in the Greater Seattle area this fall. Sadly, it is not free this time around, the cost is now $1,999.

Posted in: Health Regulations, Healthcare Disruption, Healthcare motivation, Healthcare transformation, Seattle

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Accountable Care and HealthIT Strategies Summit 2015: Still early days

Patients and providers both need to be empowered to deliver on the promises of the Affordable Care Act. That was the major theme and takeaway of the recent “Accountable Care and Health IT Strategies Summit” that I attended a few weeks ago in Chicago. I would add to this sentiment that IT needs help to implement technologies that empower these end-users. While not underestimating the importance of making sure technology is secure, and scalable, with too much focus on the back-end, IT can miss an opportunity to help deliver real value and change by putting tools in the hands of end-users.

Since value-based payments require health systems to be able to impact patient behavior outside their four walls, technology (and therefore IT departments) have the ability to play a greater role in helping to monitor and manage patients, and scale healthcare providers. Access to real-time data can also help identify issues and impact patient behavior before small problems turn into big ones.

While some of the stories and sessions at the conference were promising, I came away with the impression that we are still in really early days, and the leaders in this care transformation are willing to take leaps without having all the data. Considering that even with data, it still takes 17 years from innovation to transfer from research to clinical best practice, it seems that some amount of faith is required for this healthcare transformation.

In no particular order, here are a few of my notes from the 2-day conference.

Theme: Population Health 2.0: Accountable Care, Big Data and Healthcare Analytics

Population Health seems the furthest along in this transformation both in the way care is delivered and how technology supports care. Participants on this panel from Partners, Geisinger, and Hackensack University Medical Center, along with population health vendor Wellcentive debated the differences between Population Health 1.0 and 2.0. They even tried to see the future with Population Health 3.0.

Population Health 1.0 was seen as identifying risk and gaps in care, and attempting to plug those gaps. Although many organizations are still in this stage, some haven’t even gotten there yet. The panel saw themselves moving to a more evolved state of Population Health where data is used to drive better care, while responsibility for population health moves to the individual primary care physician rather than being managed in aggregate by remote care teams. However, this type of shift requires engagement by both the patients and the physicians which is still a work-in –progress.

The representative from Geisinger stressed for an effective implementation of population health, a multi-disciplinary team needs to be assembled that includes both clinical and IT. Wellcentive agreed and added that analytics need to be in the hands of end-users so they can make informed decisions.

The panel was also asked to speculate on Population Health 3.0: historical data, data driven decisions, and patient empowerment through data from sensors and surveys were all seen as key.

Honestly, my biggest takeaway from this session is that while some organizations may be claiming it’s time for Population Health 2.0, many haven’t gotten to 1.0, and no one seems to be in agreement on the definitions of each stage. Given today we already have the ability to collect survey and sensor data in the context of care, it seems like we are already have the tools for Population Health 3.0. But, we haven’t implemented the technology to address Pop Health 1.0 & 2.0 to achieve value…..so how can we even look to addressing the road to 3.0?

Theme: EMRs and Enabling Technology for ACOs

Another major theme that arose across many sessions at the conference is the limitations of current technology to support the infrastructure of new models of care. While organizations are looking for the EMR to be the Holy Grail, it’s a challenge as most EMRs are built to support older models of care, specifically around billing and reimbursement. Renown Health’s Accountable Care Organization, in Northern Nevada, will look to EPIC to solve some of their technology care needs, but realizes the need for M-health and other care coordination technologies to move up the stack, and exist separately from the EMR will be required.

Many of the participants are either trying to collect and track ACO data in the EMR or build their own systems to engage patients that fed data back into the EMR. Others acknowledged that new systems to directly engage patients need to be built on new technology stacks, although surprisingly one panelist on the Connected Care – How Trends in mHealth, Wearables and Connected Medical Home are Shaping Healthcare keynote boasted about 20-30% engagement rates with paper surveys. Yes, paper.

Theme: Engaging Patients and Providers

For ACOs and the ACA in general to be effective, the consensus at the conference was the need to enable both patients and providers. Adding individual providers into the mix seems to be a bit of a shift in thinking, and one that we’re supportive of at Wellpepper. We know that a key driver of patient adherence is the relationship between patients and providers. With our system, a good provider can influence patients to be over 85% adherent to their treatment plans. Some key ideas at the conference were providers may still need to be convinced of the need to influence patients directly, and that showing them data is the way to do that. However, the method of communication to that patient needs to connect in a way that is of their everyday life routine.

Overall, the conference presented some early wins in the shift to ACOs and value-based payments, but showed that we still have a long way to go and a lot of opportunity to improve care based on data. That said, this was the first conference I’ve been to where IT was front-and-center at the table and able to drive change if they wanted to. We have an opportunity to leapfrog old ways of doing things and implement new systems that have focus on the patient and provider, and are based on data to drive better outcomes. I for one am excited about this new opportunity and how it will change the way we deliver care in the future.

Posted in: Behavior Change, Health Regulations, Healthcare Disruption, Healthcare motivation, Healthcare Technology, Outcomes

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HIMSS Federal & Stage Public Policy Update

Speaker:  Jeffrey R. Coughlin, MPP
Senior Director, Federal & State Affairs
HIMSS North America

This luncheon appropriately took place in the relatively new and beautiful Alder Commons Auditorium on the University of Washington Campus. Jeff briefed me (I cannot speak for others in the room) on Meaningful Use current events (what CMS expected upon inception and the reality of now) and the new incentives to push interoperability. I graduated from UW with a degree in Clinical Informatics in 2011 when CMS was just rolling out EHR incentive program, now 4 years later it is an interesting perspective, the positivity outlook I once saw is fading. In 2011 CMS estimated by 2019 that 100% hospitals and 70% professionals would be utilizing EHRs. As of June 2015 537k eligible professionals and 48 hospitals registered for Medicaid/Medicare incentives; a whopping 31 billion incentives were paid out. With all that money paid, it raised question of what was actually bought with those dollars with only 48 hospitals registered. I am sure Congress and the House will try very hard to find this out exactly!

I know that the carrot and stick approach to EHR incentive payments are producing results in regards to getting eligible professionals and hospitals to get on board with Meaningful Use (MU), I am more drawn to the value of care improvement I can see myself in the works; interoperability. Jeff talked about this subject as well with more interest and I sat up in my chair. After the slides he presented on numbers/facts interlaced with disappointment that CMS is no doubt feeling over MU and EP/Hospitals are actually frustrated by, the subject matter of interoperability I was very happy to see. The Office of the National Coordinator for Health IT (ONC) defines interoperability “… as the ability of systems to exchange and use electronic health information from other systems without special effort on the part of the user.” I believe that EHRs are worthless without the ability to follow patients throughout their lives; we are no longer born, live and die in the same town, even less so go to the same doctor, hospital or clinic our entire lives. Therefore it is more important than ever for the 2015 Interoperability Standards Advisory to “…coordinate the identification, assessment, and determination of the best available interoperability standards and implementation specifications for industry use toward specific health care purposes.” Please check out this wonderful graphic that very nicely lays things out.

Jeff’s closing remarks were centered around how important it is for us to advocate the role Health Information Technology has on creating a healthcare system based upon patient centered care and with National Health IT week coming up October 5-9 what better time to knock on your senators door. Also the HIMSS policy summit is October 7-8 and you can sign up for early bird registration until Sept. 10th.

Posted in: Health Regulations, Healthcare Policy, Healthcare Technology, Interoperability, Meaningful Use

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Reducing Readmissions and Costs for Total Joint Replacement

Last week CMS announced a major new initiative for Total Joint Replacement, aimed at both reducing and reconciling costs. Total joint replacements are predicted to increase at a rate of 30% to 2020. Demographics are the major driver: people are getting joint replacements at a younger age, and may have more than one in their lifetime. On the one hand, more active baby boomers have put greater strain on their joints by running marathons, and on the other an overweight population is putting more strain on their joints just by walking around.

Since the demand is increasing, and the costs fluctuate wildly, up to 100% by Medicare’s estimates, the opportunities to look for costs savings and to reward based on outcomes is key. Like other bundled payment recommendations, Medicare is looking at the 90-day readmission rates and also using a carrot and stick reimbursement approach.

“Depending on the hospital’s quality and cost performance during the episode, the hospital may receive an additional payment or be required to repay Medicare for a portion of the episode costs.”

While private payers often follow Medicare, this is one area where Medicare cites that it is following a trend that has already been piloted in private scenarios, most notably with self-insured employers contracting directly with healthcare systems on fixed-price knee and hip replacements, like the deals Walmart and Lowe’s have struck directly with hospitals.

Screen Shot 2015-07-12 at 4.00.51 PMThe American Hospital Association is also ahead of the curve on this trend, and they published some recommendations in a 2013 report entitled “Moving Towards Bundled Payment.” In it, they also noted the wide fluctuations in pricing between health systems for total joint replacement, and also that 33% of the costs of a total-joint replacement come from post-acute care.

Screen Shot 2015-07-12 at 4.01.13 PM
Our research has shown that a large driver of these costs is discharge setting related. While the majority of patients do better when discharged to home, they were being discharged to skilled nursing instead as a “belt and suspenders” type of back up. Discharging to the right setting, can improve patient experience and lower costs. However discharge to home requires the right type of patient tools. Patients need to have great educational materials, the ability to track their progress, and the ability to get remote help if they need it. This is something we’re passionate about at Wellpepper, and we are working with a number of leading health systems that are moving to bundled payments to help them digitize the pre and post surgical instructions and collect patient reported outcomes. We’d like to be part of the solution for both patients and providers as we move to these new models of care and reimbursement.

The Medicare proposal is open for public comment for the next 60 days. It’s over 400 pages long, so you may want to print a copy and take it for a little light beach reading.

 

Posted in: Adherence, Aging, Behavior Change, Health Regulations, Healthcare Policy, Healthcare transformation, Outcomes

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The Case for Patient Video in Doctors Visits: Take a Selfie and Call Me In the Morning

The selfie culture and our desire to photo-document every aspect of our lives has started to influence healthcare as well, and patients want to be able to record their doctors visits. The concept is so prevalent that it’s making headlines in the mainstream media.

Patients Press the Record Button, Making Doctors Squirm” from the Washington Post

Why You Should Record Your Doctor’s Visits” from Forbes.

Having a recording of a visit ensures that you don’t miss any information, and you can review it when you get home and are able to provide more attention to the topic. Much of what is said in a doctors visit is missed by patients, by some accounts between 40 and 80% is missed, and an additional half of that information is remembered incorrectly. As we learned during a course from the Institute for Healthcare Improvement, often healthcare providers are not trained in making sure the message is received.

When we ask patients about their experiences, they tell us that they thought they understood the instructions but realized when they got home they really didn’t retain enough or understand enough to comply with the instructions. Patients are often intimidated by healthcare personnel, worried about wasting valuable visit time with questions, or worrying about how what their being told will impact their lives, for example, who will walk my dog when I have my hip replaced? Is it any wonder that the information isn’t landing?

Patient Record on Parking

Patient record in parking garage of major health system

When handout instructions are available, they are often forgotten by patients, or confusing. One healthcare organization we work with conducted an audit of all their patient handouts and discovered that they were at an 18th grade reading level. The recommended reading level for health information is fifth grade, and yet these instructions required a graduate degree!

Patients have a seemingly simple solution to this: record their doctors. Doctors on the other hand have been warned about PHI and HIPAA, so a common ‘workaround’ is to record patients on their own phones. Legal departments hate this because then the patient has a copy of their prescribed instructions but the health system does not. Liability aside, it doesn’t result in good care if everyone is not working off the same information.

Including patient video as part of a HIPAA compliant digital treatment plan is a great way to solve this problem. Patients have a better experience and the health system is able to keep good records.

Patient video can cueing or instructions that is unique to that patient, and they show the patient’s actual experience whether that’s in wound care, using a medical device, or physical therapy. Patients feel a greater sense of connection and accountability to care plans when they are personalized and customized.

For complex instructions like wound care, using medical devices and durable medical equipment, and physical and occupational therapy, patients feel more confident that they can repeat the exercise or instructions at home when they see video of themselves doing it.

There are so many benefits to including custom video as part of a patient’s care plan. The technology is here today, it can be delivered in a HIPAA compliant manner, and it can be stored and easily retrieved. The challenge is that while patients are ready for this, health systems aren’t and the answer is often ‘no’. The risks to the health system, if video is delivered as part of an overall digital patient treatment plan solution are low, but the potential benefits to care are large.

We’ve tracked the evolution of the ‘consumerization of IT’ through other industries. Some have said it can never happen in healthcare, but this is a great example where patients starting to push the envelope and use technology in their care. Let’s hope they are able to convince their doctors as well.

Posted in: Adherence, Health Regulations, Healthcare Disruption, Healthcare Policy, Healthcare Technology, Healthcare transformation, M-health

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Advancements in Diabetes Research: A Salon Dinner for JDRF

This past week I had the opportunity to attend a salon dinner at Seattle’s lovely Canlis hosted by Derek Rapp, CEO of the Juvenile Diabetes Research Foundation (JDRF).

Derek Rapp

Derek Rapp, source http://www.stltoday.com/

Unlike Type 2 or 3 Diabetes, Juvenile Diabetes, or Type 1 Diabetes is an auto-immune disease so while the symptoms are similar to some of the other two types of diabetes, research into causes and prevention is more closely aligned with other auto-immune diseases like multiple sclerosis. Many autoimmune diseases are thought to be triggered by viruses, and there are some thoughts that this is also true for Type 1 diabetes.

Although this was an informal dinner, Rapp provided some interesting updates to the work the JDRF is doing to find the causes and a cure.

Most of the discussion centered around advancements in care, as Type 1 diabetes care is quite onerous for people who live with it, most of whom have onset of the disease in childhood or early adulthood. Rapp himself has one son who has Type 1 diabetes and another who carries the marker, and many of those in attendance had children with the disease. Type 1 Diabetes requires daily blood tests, hawk-like attention to diet, and insulin injections: quite a burden for anyone let alone children and young adults.

Like all areas of healthcare, diabetes care also has the ability to benefit from big data and from personalized data both for research and to provide better control. An example of a medical device breakthrough that works with both types of data is the artificial pancreas, which will ultimately mimic the function of the pancreas to control blood sugar levels.

Another place information flow can benefit is for relatives, which you can imagine is crucial for helping parents help their children. Providing alerts automatically when blood sugar spikes or drops and enabling parents to see how their children are doing when away from them is another benefit of continuous glucose monitoring.

Other advancements that Rupp shared with the group were glucose responsive insulin that waits in the body until there is excess glucose before being deployed. It works by packaging the insulin within the body and releasing based on reading of a “glucose tag.” Another study in progress is encapsulating a device for insulin within cells so that it can be surgically implanted and not rejected by the body.

The audience was visibly excited by hearing about these developments, but their spirits were dampened slightly when Rapp reminded them that it takes $1B and 14 years for a drug to get to commercialization. One guest also asked whether the same drug companies that made significant revenue from insulin were incented to come up with other solutions. However, between the ability of big data to find connections between information and the current speed of genomic research, Rapp was hopeful. He believes that will be possible to prevent Type 1 diabetes before a cure is found.

Canlis Private Dining Room View

Canlis Private Dining Room View, Source Seattle PI

Posted in: Health Regulations, Healthcare Disruption, Healthcare Research

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Session Picks for 2015 American Telemedicine Meeting

We can’t promise to get to all these sessions and blog about them for you, but here are a few that caught our attention at the American Telemedicine Association Annual meeting coming up in Los Angeles next week.

Monday May 4th

Establishing a Program to Reduce Readmissions and Costs in the Ambulatory Setting: A California Success Story

Telehealth is proven to decrease costs without sacrificing quality for many scenarios.

Learning Opportunities from Large Scale Telemedicine Initiatives

An interesting mix of private and public sector initiatives across disciplines including pediatrics and psychiatry.

Improving Commitment, Quality, and Outcomes

We love outcomes, and this session also feature’s Seattle’s own Carena.

It’s a Small World After All: Approaches in Neonatal ICU Care

Cute title, serious results with examples across pediatric care.

A New Model for Remote Diabetes Care Best Practices

One of the biggest issues facing our healthcare system so new models welcome!

Expanding Telehealth to Improve Hospital-wide Readmission Rates

Readmissions and care transitions, so important.

Mainstream Medicine Moves into Direct to Consumer Health

Mercy, a Catholic Health System from St. Louis, is a quiet leader in telehealth. Find out why they dedicated an entire new building to for their telehealth practice. Plus a case study from Cleveland Clinic. Whew, that’s a lot of great content.

Tuesday May 5th

Utilizing Interactive Voice Response (IVR) and Telemonitoring to Reduce Hospital Admissions and Readmissions for Heart Failure Patients

Heart failure is a patient group where readmissions can be prevented with better communications, which telemedicine and remote monitoring can provide.

A Large Provider Focuses on Consumers: The Experience at Kaiser Permanente

With large deductibles, patients are increasingly making decisions as consumers.

Implementing Successful Clinical Specialty Programs: Burns, Infectious Diseases, and Genetics

Telemedicine helps scale specialists, especially from centers of excellence and to rural areas.

Using Community Health Models to Enhance Patient Performance and Outcomes

Another great benefit of telemedicine is to empower community health workers through remote support from specialists.

Posted in: Behavior Change, Health Regulations, Healthcare Technology, Healthcare transformation, M-health, Telemedicine

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Breaking Bad Healthcare: The Story of Healthcare.gov

It’s generally a good principle to not criticize something if you’re not willing to help fix it. That’s what former Microsoft exec Kurt DelBene learned, when he offered feedback on the Healthcare.gov website after its release in 2013, and instead of just providing feedback, he ended up taking the reins to fix the site. At a recent event sponsored by University of Washington’s Foster School of Business, DelBene provided a mini-business case on what went wrong with the project and how his team fixed it. With clarity, modesty, and wit DelBene both highlighted some major flaws in the process and encouraged attendees to consider a stint themselves helping out the government with major technological and business issues.

One of the first problems stemmed from an issue that is far too common in government and business: saying yes to a project before fully understanding the scope. In this case, and internal Whitehouse IT team, essentially signed up to deliver a website with requirements of something like Amazon.com without ever having built something that big. While most of us think of the consumer interface of Healthcare.gov, and the trouble that happened on that end, the actual site is extremely complex in needing to connect to hundreds of insurance plans among the major payers, and also to the IRS to verify income levels. Any facet of the site’s interface, up-time requirements, and integration needs was a daunting prospect, and the original architects didn’t have the full requirements set, and possibly the experience to know what was missing when they signed up.

Next, they chose two inappropriate technologies. One was a semi-structured database No-SQL database called MarkLogic, which they had always wanted to try out. The database choice itself was not necessarily the problem, but trying a new technology where the team did not have prior expertise for a project of this scale is risky and they chose the database without understanding the project specs. The second, was trying to use a flow-charting application that automatically generated screens to design the website. This type of application might be appropriate for an internal process application used by a small number of technical users, but it is not appropriate for a large scale consumer facing website that is intended to reach the general population, including those whose first language is not English or with a wide range of education. Software has not gotten to the point where it can design user-friendly versions of itself no matter what you read about artificial intelligence.

Another major, and widely publicized failure was delegating different parts of the project to at least 6 different contracting firms. No one took responsibility for the overall integration, and the contractors continued to point fingers about whose technology was failing.

These were only some of the problems that DelBene inherited with a hard deadline to launch the site. Other issues in site design included no failover system, no beta testing, and no instrumentation or telemetry to understand where the site might be failing. Within the development process there were also failings, for example no tracking of bugs and how much work was left to do.

DelBene started by listening, and this included to all team members not just senior leaders. Although he had to hit the ground running: briefing the President two days into the job, and famously, exiting a meeting into a closet instead of the hallway.

He then had the team prioritize what could be fixed for launch and what couldn’t.

While the site wasn’t conceived as cloud-based (in fact the original team expected the insurers to install servers in their datacenters to connect with the Healhtcare.gov site), DelBene says it was an excellent candidate for the cloud which would have been more secure and more scalable. The team did rebuild many consumer-facing parts of the site on Amazon Web Services and continued to iterate and test capabilities as the site was deployed by sending some groups of users to the new interfaces.

While DelBene was extremely modest, always citing the team, which included recruits from Google and Facebook but strangely not Microsoft, he did have some very specific advice for how to successfully run this type of government project in the first place.

The recommendations can be summed up as “run any consumer-facing government IT project the way you’d run a commercial software project.” Hire the right team, plan, test, and iterate, hold people accountable, and encourage honesty.

Solutions for Government IT Projects

So much of this project’s initial issues were due to a lack of coherent team, and a lack of experience. Developing internal IT infrastructure and commercial software that is used by millions of people is very different, and requires a different skill set. As well, it requires humility as end-users outside your organization will let you know if something doesn’t work as evidenced by the negative press the original roll-out received.

Opportunties

DelBene, who used to run the $11B Office business for Microsoft, described this experience and work as the most important he’s done, and he ended the session by encouraging the audience of MBA candidates and alumni to consider how they could help the country. New programs like the White House Digital Services and 18F Organizations are specifically designed for people from private sector to be able to lend their expertise to government organizations for short periods of time. Considering that the future of all government transactions is digital, this is more important than ever.

Posted in: Health Regulations, Lean Healthcare

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This Month [March] in Telemedicine

March 31, 2015
American Telemedicine Association
Presenters:
Gary Capistrant, Chief Policy Officer, American Telemedicine Association
Latoya Thomas, Director, State Policy Resource Center
Jordana Bernard, Chief Program Officer

I admit this is only my second ATA ‘This Month in Telemedicine’ webcast I have listened to and whereas the federal and state legislative ‘lingo’ isn’t as intimidating anymore, I still have a headache from going into information overload. Luckily it isn’t my full time job to be on top of legislative telemedicine on goings, but ATA’s. To me it was clear with each passing minute that ATA’s mission to achieve “Educating and engaging government, payers and the public about telemedicine” is steadfast, and kudos to their small staff to keep on top of legislative issues and make telehealth materialize for us all.

The biggest Telemedicine conference in the world: The annual ATA Annual Telemedicine Meeting and Trade show is next month, May 2-5 in LA and they are busy in preparation for this event that is over 2500 miles from their headquarters in Washington, D.C. Jordana Bernard, ATA Chief Program Officer, believes the conference highlights will be the pre-meeting courses (continuing education credits offered), State Telemedicine Gaps Analysis awards and the keynote speakers, Emmy-award winning chief medical correspondent for CNN, Sanjay Gupta and Patrick Soon-Shiong, Chairman and CEO, NantHealth. Early bird registration ends tomorrow, so hurry!

Additional up-to-date ATA highlights addressed by Jordana:

  • There will be a survey arriving shortly in your email about how and if your organization is using telehealth in primary and urgent care practices when addressing mental conditions.
  • Accreditation initiative: There are five ATA Accredited Telemedicine training programs with a new online patient consultation accreditation program launched in December 2014. –This newly developed training program could be useful for Therapists utilizing Wellpepper.
  • Practice guideline initiatives: There are fourteen completed online documents under development such as the General Pediatric group, Pediatric mental workgroup, Teledermatology (revised guidelines from 2007), Telestroke guideline and an initial draft of remote burns and assessment treatment is forthcoming.

*Blue enacted, Orange introduced and Grey no status.

State license compacts are still being discussed as I mentioned in my last ‘This month in Telehealth’ blog. Latoya Thomas (a truly remarkable intelligent lady and my hero this week), Director of State Policy Resource center at ATA, summarized the current state of things (no punt intended!). There are 11 states that have introduced bills to legislation on how they would like to tackle this issue and sadly, my state, Washington, hasn’t introduced any bill! Legislation has decided that once physicians enter into a compact they will be issued expedited licenses in order to facilitate interstate licensure practices. Interesting Louisiana, Montana and Tennessee are looking at unique telemedicine licensing. There is a state policy webinar April 23rd that ATA will be hosting that might clarify and will undeniably go into more detail.

Last, but most definitely not least, an important CMS event happened on March 20th when “proposed rulemaking for electronic health record incentive program (meaningful use) stage 3 [1] to begin by 2018. This proposal is open for public comment until May 29.” Also this month CMS announced a new payment model “The Next Generation ACO” (as I referred to in a post) which also contained ATA’s request to Expand Telehealth coverage. Gary Capistrant brushed upon the FCC’s Net Neutrality Rules (brushed because it is a heavily loaded topic). I personally have been avoiding it because it’s 400 pages long… and well I already have a headache.

For full audio/video of this webinar please visit here.

Next “This month in Telemedicine” is 4/26.

 

 

 

Posted in: Health Regulations, Healthcare Technology, Healthcare transformation, Telemedicine, Uncategorized

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Something old, something new, something borrowed, something blue

As someone, (most likely French philosopher Blaise Pascal ) once said, “I would have written a shorter letter but I didn’t have time.” Stanford Professor Dr. Arnold Milstean started his talk for the Health Innovator’s Collaborative on “Providing Better Care With Less.” with a variation of this, saying that if he knew his topic better he would only have 4 slides instead of the 8. Those 8 slides represented so much practical data-driven advice and highly quotable and provocative statements like

“1/3 of healthcare spending could be cut without affecting anything except the quality of life of the providers.”

that it’s hard to imagine how rapid fire the content would have been with only 4 slides. Mistean took us along a path to define goals in healthcare transformation and then apply some simple formulas to affecting that change.

To determine some generally agreed upon principles for healthcare improvement, Milstean and team reviewed policy, research reports, and employer and payer surveys. The team found that getting to a 1% annual increase in quality, with a 30% reduction in costs, and a 2.5 percentage point long term increase in spend (less than GDP) would suit most policy recommendations and were therefore to be considered reasonable goals. To bring about this level of change, Milstean recommended implementing an “Old, New, Borrowed, Blue” strategy, which has nothing to do with marriage: it’s just a catchy and easy way to categorize some common sense thinking.

Old: Take a methodical review of existing evidence. As anyone who’s spent much time in healthcare research will tell you, there are a wealth of studies and best practices out there. Given that it takes 17 years to get from research to clinical practice, rather than starting a new study, reviewing what’s been done and implementing best practices is a better way to go.

New: Use technology to automate assessment, help with decision support, and improve workflow. Being at Stanford and working on multi-disciplinary teams lead Milstean to believe that the area healthcare could benefit most from “new” is in healthcare IT. In other industries the move to electronic records produced 2-6 percentage points in productivity improvement after 10 years. Healthcare, with only recent moves to electronic medical records, is just at the beginning of this and hasn’t seen the rewards yet. As well they have just scratched the surface of the digital opportunities.

Finding Outlier Physicians

Finding Outlier Physicians

Borrowed: Look at examples from other countries best practices and figure out how to implement locally. Milstean gave the example of a city in Finland where the time from stroke identification to tPA injection at an ER was 17 minutes. With each minute of time after the onset of stroke representing the death of 1.9 million braincells, emulating the Finnish model can have real impact on quality of patient life and long-term costs. (The average “door to needle” time in the US today is 60-75 minutes.)

Blue: Focus on human-centered design. Too much of healthcare is not working at the most basic human level, which as it turns out is the place where better and cheaper care resides. Here, Mistean showed a chart of “outliers” physicians who delivered a high-level of care at lower costs than their peers. It turns out what these physicians did differently was at the human level. They truly cared for their patients and looked at the whole patient, not the disease or not the specific incident. These primary care physicians acted as quarterbacks when their patients were managing complex issues with specialists. They cared, caught issues, and also motivated patients to participate in their own care.

The Impact of Blood Sugar on Parole Hearings

The Impact of Blood Sugar on Parole Hearings

While the formula is simple, it takes a lot of effort to change the system. Some are organization issues like the number of people involved in making any decision. One hospital, trying to implement a new program, took 3 months to get to the kick-off meeting due to the number of people involved in scheduling. The other issue is the human factor in creating repeatable systems. Here, Milstean used an example from the legal world, where judges were less likely to grant early release when their blood sugar was low. Comparing this to medicine, is remembering that everyone thinks that they are delivering high-quality care, but you often need data to convince them otherwise, and that you need to repeat, repeat, repeat to get to a precision that can cancel out the human factor. As a result, Milstean believes that computer science and behavioral science are two keys to making the big changes we need to improve quality and lower costs in healthcare.

 

 

Posted in: Health Regulations, Healthcare Disruption, Healthcare Policy, Healthcare Technology, Healthcare transformation, M-health

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Reducing Avoidable Readmissions: Transfer to Home

While studies show that discharge to home can be best for patient recovery from surgery, this is an area where communications and continuity of care often break-down, risking readmissions. The idea of a patient-centered medical home where the patient is at the center receiving consistent care from a group that can bring in specialists is intended to solve some of this problem, but better communications between healthcare organization, primary care physician, and patient and the patient’s care team can go a long way to improve discharge to home without requiring an entirely new model.

This post is part of a series recapping a recent training from the Institute for Healthcare Improvement’s course on Reducing Avoidable Readmissions.

Primary care physicians while often the most trusted person in the care team, and besides the patient the person with the best insight into the patient’s overall wellbeing are often out of the loop when it comes to hospitalization. Once a patient is referred to a specialist for surgery the hospital team takes over, and the primary care physician has little insight into what happens, even though when the patient is discharged they are back in the care of the primary care physician. Often the primary care physician has no idea when the patient has been hospitalized or re-hospitalized.

Primary care physicians who were participating in the course expressed both their desire to participate in this post-acute care follow up and frustration at both the lack of insight they had and felt powerless to influence the hospitals.

While the evidence on post-hospitalization follow up visits is mixed, common sense does point to following up with patients as being a good thing to prevent readmissions. However, depending on the model of care, this is either with a primary care physician or a hospitalist. Considering the PCP is responsible for the general health of the patient, moving to reimbursement models where this is possible also seems to make more sense.

 

Source: IHI.org

Source: IHI.org

One example cited was from Capitol District Physicians Health Plan, where physicians were paid to do post acute care follow-ups. The program plus a phone call from a case manager decreased readmissions from 14% to 6%. (Although it would be interesting to know whether the in-person visit or the phone call had the biggest impact.)

As with other sessions in this course, the keys to improving discharge to home were in communication with the patient and patient caregivers around expectations and communication back to the hospitalist or family physician about medication usage at home, and any concerning symptoms. Too often patients understand “You’re discharged” as “You’re better” and miss their responsibilities for doing follow-up care whether that is physical therapy, wound care, or just easing back into activities they participated in prior to surgery. Ensuring patients and their care givers understand that discharge to home still requires follow-up is a key to decreasing readmissions from this setting.

New models of transitional care and intensive care where patients receive personalized follow-up care and regular check-ins with a healthcare professional after hospital discharge were shown to improve overall function in patients, decrease readmissions, and decrease costs. These types of new models become more practical with the carrot of value-based payments coupled the stick of penalties for readmissions. While the overarching goal of decreasing readmissions is about improving patient care, having financial incentives aligned will provide an extra boost.

Continuing with the theme of the course, there is no one silver bullet. There is no one reason that patients readmit. That’s the bad news. The good news is that some basic common sense improvements, like better communication with patients and their care teams can decrease readmissions. We’ll go into more detail on how to improve communications in the next post on this topic.

Posted in: Adherence, Aging, Health Regulations, Healthcare Policy, Healthcare transformation

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Reducing Avoidable Readmissions: Care Transitions

This is the second in our series, recapping the lessons learned from the Institute for Healthcare Improvement’s Reducing Avoidable Readmissions course.

Care transitions are seen as key to improving readmission rates, and understanding that readmissions are not just the hospital’s responsibility but involve a care team that includes the patient, the patient’s caregiver, homecare, and skilled nursing depending on where the patient is discharged.

Both ensuring good care transitions to decrease readmissions, but also discharging to the right facility are crucial for lowering costs and improving care. Post-acute care shows the greatest discrepancy in costs per patient and is growing at 6% annually for Medicare patients. Today, 40% of Medicare patients discharge to a post-acute care facility, and 33% of patients in these facilities experience a care-related adverse event. By 2017, skilled nursing facilities could face penalties of up to 3% of Medicare payments for readmissions, thus there are real incentives to improve transitions, if patient safety isn’t enough to effect change.

The first step in improving care transitions is to ensure that the patient is going to the right setting, and this requires a decision by the care team that includes the patient and the patent’s caregivers. If money is not an object, many hospitals discharge to skilled nursing as a way of insuring that the patient doesn’t readmit. However, if care transitions are not handled properly, this adds costs without improving quality.

One of the biggest challenges in care transitions, is that there are no universally agreed upon assessment tools for determining the best next step for patients on hospital discharge, hence the over prescribing of skilled nursing. Beginning to track readmissions and outcomes should help organizations stratify risk and begin to be able to predict the best setting based on data. In addition to data, interview patients. Often missed care transitions are only identified by the patient him or herself as they are more aware of what was lost in transition.

Possibly because of the make-up of the attendees in the course, the transition from hospital to skilled nursing was a hot topic. Hospital attendees admitted to have little insight into how skilled nursing facilities worked. Skilled nursing attendees expressed frustration with the amount of patient information they received when admitting a patient. One attendee begged “just let me see the patient’s medical record.”

In order to facilitate better transitions, cross-functional teams need to be developed and these need to include members of the receiving facility. One skilled nursing facility reported significantly better transitions by simply placing one of their nurses in the hospital part-time to meet with patients before they were transferred.

These teams must have support at two levels: the executive level must provide resources and be open to changes recommended by the functional team that handles the care transitions. Functional teams must feel empowered to change and improve processes for care. Organizations that are pursing ACO models and bundled payments were seen as great opportunities for these types of cross-organizational and cross-discipline care teams.

The INTERACT tool is a way to ensure that the receiving organization gets the right patient care information during this transition. Unfortunately, given the lack of interoperability of medical systems, this approach requires additional paper work. There is no easy way to share patient records between EMRs or organizations, or sometimes within the same organization.

Other best practices in patient transfer include:

  • “warm handovers” that is, no patient is transferred with out a real-time conversation between physicians
  • Sending the patient with a 3-day supply of medication so there is no interruption and include pharmacy in the transfer team
  • Following up with the skilled nursing facility by phone within 24-48 hours post transfer
  • Sending information about patient preferences. One example was given of a patient who preferred to take her medication with Coke. She was greeted at the skilled nursing facility with a Coke and her medication.
  • Regular meetings between skilled nursing and hospital
  • Relationship building and storytelling for all parties to understand constraints that other side is facing
  • Creating a standard follow up and communication protocol based on patient risk of readmission

Post Acute Care Follow Up Communications

In keeping with the opening statement of the course, there is no silver bullet, just a lot of practical common sense advice, and clear and timely communication.

Next we’ll look at some best practices for discharging to home and the role of the primary care physician.

Posted in: Health Regulations, Healthcare motivation, Healthcare Policy, Healthcare Technology, Healthcare transformation

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There’s No Silver Bullet: Reducing Avoidable Readmissions

Last week I had the opportunity to attend the Institute for Healthcare Improvement’s two-day training on “Reducing Avoidable Readmissions” training here in Seattle.

Reducing Avoidable ReadmissionsI’ve got some good news and some bad news. The bad news first according to this leading organization in healthcare quality improvement, there is no silver bullet. The good news is that there are a number of small practical steps to improve insight, quality, and patient experience.

This blog post provides an overview of the intensive 2-day training, and I’ll follow up with deep dives on a few sessions. Really, there’s enough content for a few weeks of blog posts, so we’ll use this forum to point out some best practices, and capture some of the best insights from the training. As with any training, so much of the value comes from the other participants, so we recommend checking out a training yourself in person. What was amazing about this course is that it brought together healthcare professionals who might not have had the opportunity to meet otherwise, and these different perspectives resulted in actionable takeaways for participants when returning home. Participants ranged from hospital CEOs and other C-level executives, to care coordinators across large and small health systems, primary care, hospitals and health systems, skilled nursing and in rural and urban settings.

Changing Healthcare ParadigmsRegardless of participant, it became clear that information did not flow well between these different healthcare settings, and that each specialty or care location had very little insight into what happened in the other setting. Just bringing these diverse participants together helped them see what could be done to improve patient handoffs and communication across the care continuum. A number of participants expressed how helpful it was to understand the process and constraints that others were seeing. Primary care physicians seemed to be the most handicapped as they had no way of knowing if their patients were admitted to hospital at all.

Sadly, for someone in the digital health field, another key theme that ran across the two days was how many participants felt that their medical records were preventing them from doing a better job on readmissions. The reason for this was two-fold: information did not flow between settings, and it was often too difficult to capture key information about the patient and access it at point of care. Medication reconciliation was cited as the holy grail of patient management but most participants didn’t believe it would ever be possible to get a clear solution to this problem.

Communication with patients was another key theme of the course, both in improving how patient discharge instructions and patient understanding of those instructions were delivered and in asking the patient for feedback. Again, it was a common sense approach rather than a “silver bullet.” Multiple presenters said “The reason your patient readmitted is in the hospital bed” or more simply, “ask the patient why they readmitted.”

Another key focus of the course was on change management within the organization. First understanding and then preventing readmissions requires change within the healthcare organization. Presenters had all led or participated in multi-year change journeys within their organizations and had both battle scars and key strategies for how to motivate and change within a large organization. One most basic tip was “don’t talk about readmissions, fines, or penalties” instead they suggested rallying teams around the benefits to the patients.

Topics that we’ll explore in more detail from the course here on the blog include:

  • Teach back and communicating with patients
  • Care transitions and discharge setting
  • Measuring change

Posted in: Behavior Change, Health Regulations, Healthcare Disruption, Healthcare Policy, Healthcare transformation

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Healthcare Reform and the Affordable Care Act: One Year Later

APTA CSM 2015 Recap: Healthcare Reform and the Affordable Care Act: One Year Later

Speaker(s):

Edward Dobrzykowski, PT, DPT, ATC, MHS

Janice Kuperstein, PhD

Karen Ogle, PT, DPT

Charles Workman, PT, MPT, MBA

CSM StepsThe consensus from the speakers in this session was that the changes are real, they require work on the part of healthcare providers, and that physical therapists have a great opportunity to participate. There was definitely a greater sense of urgency on this topic than in previous years at CSM, and speakers made sure the audience knew that:

“While we’re all worried about G-codes, new players like Walmart, Walgreen’s, and Google are creating entirely new models of care.”

“Patient satisfaction is not enough, we need to look at outcomes”

“Reducing length of stay is not going to be the only way to reduce costs.”

Some of the major themes of the Affordable Care Act that speakers believed impact physical therapy include:

  • Realignment of care models from management of chronic disease to preventative medicine
  • Conservative interventions preferred over surgery due to costs and outcomes
  • New payment models and reduction in visits
  • Direct access to physical therapy
  • Standardization of service
  • Accountability for services delivered
  • Outcomes measurement

All of these were seen to provide both challenges and opportunities to the profession. Similar to other sessions, opportunities in improving outcomes and decreasing costs of post acute care, and in improving discharge, and care transitions to reduce readmissions were seen as key areas where physical therapy could have a big impact, however, physical therapists needed to participate more in the process.

Presenters pointed out that homecare workers and occupational therapists are already working in health coaching positions for population health management, but physical therapists were not really serving in these roles. Given that many studies show that discharge to home is best for the patient, and also lowers costs, this is seen as a missed opportunity for physical therapists.

Full moon over Indianapolis

Full moon over Indianapolis

In order to effect change, moving to more accountability and measurement is important, for example predictor tools to score patient on risk of readmit and standardized outcome tools. By moving to these measures and recording outcomes, physical therapists will be better able to participate as part of new payment models, like bundled payments.

Considering that for the patient, function is usually the most important outcome, and physical therapists are experts in delivering a return to function, the core value equation could be applied directly to physical therapy to deliver better outcomes at lower costs.

Value = Quality x Patient satisfaction

Attendees were encouraged to ask questions during the session and feedback ranged from a hospital-based physical therapist participating in a bundled total joint replacement scenario, where the hospital was receiving 3% back from CMS due to delivering positive outcomes at a lower cost than stipulated to those in smaller or private practice wondering whether there was room for them to participate in these types of payments with hospitals, or whether they would be shut-out. This was a common theme at the conference as private practice owners questioned whether controlling costs and outcomes would mean that hospitals would bring outpatient physical therapy in-house.

Similar to other sessions, suggested that the two keys to delivering on new value-based payment models required better care collaboration among multi-disciplinary teams and standardized outcome reporting.

“Merely aligning financial incentives between providers of acute and post-acute care will not improve quality and reduce costs for episodes of care. True coordination of care is required to ensure the best possible outcomes.” Ackerly DC and Grabowski DC. Post-Acute Reform- Beyond The ACA. NEJM 2014;370(8):689-691

For outcome reporting, the question was asked if patient-reported outcomes were the new gold standard. If patient satisfaction and functional outcomes are key in the value equation, then they are.

To conclude presenters reminded participants what they can do to participate in this new world, which reflects the larger clinical, demographic, and social trends.

  • Develop strategies and tactics around population health management
  • Optimize efficiency in each practice segment
  • Build collaboration “upstream” and “downstream”
  • Position for more integration

The session did a great job of showing that the change is real, the opportunities are there, but also making attendees understand that the time is now. Our overall impression of the conference this year is that physical therapists have a great opportunity to be on the front-lines of some of this change but that they may need to move faster than in the past. Exciting times to be in patient-centered care!

Posted in: Behavior Change, Health Regulations, Healthcare transformation, Outcomes, Physical Therapy, Rehabilitation Business

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The Power of Data: Achieving Consistent Health Outcomes

Recap from APTA CSM 2015: The Power of Data: Achieving Consistent Health Outcomes

Speakers:

Dianne Jewell, DPT, PhD

Heather Smith, PT, MPH

Mary Stilphen, DPT

Outcomes were a hot topic at APTA CSM 2015, and not surprisingly as CMS just announced that by 2018 50% of Medicaid payments would be through new value-based payment outcomes with value defined as the relationship between outcomes and costs.

This session presented a basic primer on outcomes, how to evaluate them, and the differences between functional and patient-reported outcomes before jumping into the meat of the topic, presented as a case study of some interesting new work done at The Cleveland Clinic to drive better decision making in post-acute care.

Embarking on a new model is not for the faint of heart and the case study outlined in this session is still under-development and refinement even though the journey was started in 2010 with a definition of which outcomes they wanted to collect.

To explain this, presenters quoted Eleanor Roosevelt:

“Each time you learn something new you have to adjust the whole framework of your knowledge”

For The Cleveland Clinic, Step 1 back in 2010 was to implement an EMR so that consistent data could be tracked for every patient visit, and then start to use this data to effect care, with the main goal to make better decisions about appropriate discharge from acute care.

In order to collect data consistently however, they had to define a tool, and wanted to ensure that it was not cumbersome. They modified Boston University’s 24 question “Activity Measure for Post Acute Care” or “AMPAC” to a shorter survey they named“6 Clicks” to represent the number of mouse clicks to complete the survey. While acronyms are often all the rage in research studies, a catchy and evocative name is better if you want someone to actually use something, and “6 Clicks” definitely fit the bill.

The goal of completing the “6 Clicks” survey was to measure longitudinally across patient care and eventually be able to predict the best discharge setting based on this information. The ultimate goal was to improve outcomes without increasing costs and the flip-side decrease costs without impacting outcomes.

The 6-Clicks consists of 12 questions, 6 each for PT and OT accessment. For PT the questions are related to Mobility and for OT to Self-Care. The ultimate use of the data is to ensure the best care for the patient and the optimal use of resources within the hospital.

The 6-Clicks tool raised the visibility of the physical therapists within the hospital as they were able to make the best recommendations for patient discharge setting based on analyzing the data, and the data-driven approach gave all staff a way to talk about these decisions. Prior to using the tool, it wasn’t clear whether in-patient physical therapists were spending time with the right patients or whether the patient would thrive in the discharge setting.

6-Clicks Results. Source: The Cleveland Clinic

6-Clicks Results. Source: The Cleveland Clinic

Based on the patient’s 6-Clicks score they could determine whether to discharge to home with no services, with services, to skilled nursing facility, or to long-term care facility. 6-Clicks could also be used to determine the appropriate in-hospital care based on eventual discharge. For example, if a patient was predicted to be best discharged to home with no services, the in-patient physical therapists would focus on mobility and self-care to make sure the patient was self-sufficient on discharge.

As The Cleveland Clinic continues on this outcome journey, which has been rolled out across all of their hospital locations, the next step is to provide outcome analysis for the continuum of care: that is what happens when patients are discharged to these different settings. To do this they will repeat 6-Clicks on each care transition and continue to amass and analyze data. Other extensions will be adding additional outcome measures based on patient issues, and potentially beginning to communicate this data back to patients.

For those daunted by this impressive but long journey, presenter Mary Stilphen offered a few tips to get started on an outcomes journey:

  1. Rally stakeholders
  2. Determine what you want to measure
  3. Understand what change you want to effect
  4. Choose your instruments
  5. Collect data
  6. Share and socialize data

And we would add, keep it simple as evidenced by the thinking behind the 6-Clicks tool.

If you’d like to read more about the 6-Clicks Tool, there’s a great description in this publication.

Posted in: Health Regulations, Healthcare Technology, Healthcare transformation, Outcomes, Physical Therapy

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Stroke Rehabilitation is the Poster Child for the Need for Collaborative Care

APTA CSM 2015 Recap: Anne Shumway-Cook Lecture: Transforming Physical Therapy Practice for Healthcare Reform

Speaker: Pamela Duncan, PhD

Interdisciplinary teams and patient-centered care are key to the future of healthcare, and physical therapists attending this keynote of the Neurology track at APTA CSM 2015 in Indianapolis were encouraged to embrace this change. Bemoaning the lag time from research to clinical practice, Pam Duncan suggested that researchers find ways to work with interdisciplinary teams of biomechantical engineers and even private companies to bring innovation to patients faster. She started with the inspiring example of Carol Richards who received the Order of Canada for her work with the interdisciplinary team on the Stroke Network Canada, aimed at decreasing the impact of stroke across Canada.

Source @mdaware on Twitter

Source @mdaware on Twitter

Duncan then told a story to explain her passion for changing post-acute stroke care, involving a personal experience that changed the course of her career. Duncan’s mother suffered a stroke and while Duncan was trying to provide comfort in her mother’s last days, a traveling physical therapist arrived in the hospital room with a goal of getting her mother to get her mother to stand, which was apparently the clinical protocol she was assigned to do. Duncan protested and later spoke to the owner of the physical therapy company that had contracted to the hospital. He shrugged and asked her why she cared since Medicare would pay for the visit. Incensed at the waste of time and money but more furious at the way this care completely disregarded the patient’s best interests, Duncan put aside her plans for opening a private practice and focused research to improve post-acute care for stroke patients.

Translating Research to Evidence and the Humble Researcher

With the same vehemence, Duncan described how she believed that over 180 publications she’d made on the topic had done little to advance stroke care, largely due to the difficulty of translating clinical research into practice, and asked the researchers in the audience to change this by developing interdisciplinary teams, questioning all their assumptions, and thinking about the patient holistically, not just from their own discipline.

She asked researchers to be “humble researchers” referencing a column by the New York Times columnist David Brooks and not just set out to prove what they want to be true. Duncan used an example in her own research which disputed a popular belief on stroke recovery and showed that home-based exercise was more effective than treadmill-based. Duncan described herself as still having arrows in her back from that publication.

Best Practices for Stroke Recovery

After lighting a fire for the audience to think about things differently  by saying

“Take off your neuro-plasticity hat and think about patients holistically.”

Duncan continued with specific examples on how to change care. First was to understand the overall situation. 10-30% of stroke patients face permanent disability, something that is not always clear when they are released from hospital within 3-5 days of the incident. She gave an example of a patient who was discharged with care instructions and prescriptions yet when she got home she couldn’t follow them: she discovered the stroke had affected her ability to do basic calculations.

“If you asked if I had discharge instructions I would have said yes, I heard what the nurse said and I showed her I could inject my drugs, and my math deficit wasn’t diagnosed until I got home. I did the things I needed do to get discharged but wasn’t really able to cope.”

This is a clear example of how our current system fails us. It does not support the patient outside the clinic, and yet it’s so much less expensive and more comfortable for the patient to be released to home. Looking at the costs it’s clear that we need to improve home health options.

Post stroke care costs:

  • Acute inpatient care: $8,000
  • Skilled Nursing Facility: $41,000
  • Inpatient Rehab: $14,000
  • Home health: $6,000
  • Long-term care: $62,000

As Duncan put it, “Home health is a dirty word in Washington” yet this where the patient should be. She called stroke the poster child for the discontinuity of care in healthcare as 73% of post stroke readmissions are for other issues not related specifically to the heart. Duncan sees hope though, and called bundled payments the best thing to happen to stroke recovery as providers will have to collaborate across the care continuum.

She sees the benefits as:

  • Coordinated high quality care with seamless transitions
  • One primary metric for integrated care
  • Excellence based on outcomes

The message to physical therapists is that they are uniquely suited to these multi-disciplinary teams focused on patient outcomes. For patients, outcomes are measured by function. For CMS, value is measured by those functional outcomes divided by the cost and physical therapists can deliver on both.

This session was a great kick-off to the conference, which had an overall tone of embracing the changes coming in healthcare and the role of physical therapists in it. As a company providing continuity of care through digital treatment plans and connections with healthcare providers outside the clinic we were inspired to see so many people embracing this change.

Posted in: Aging, Health Regulations, Healthcare Disruption, Healthcare transformation, Physical Therapy

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