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Big cultural barriers to better reliability in healthcare


Craig Clapper is a partner at Press Ganey Strategic Consulting and  a founding partner of Healthcare Performance Improvement and Kerry Johnson is another Press Ganey partner and a founding partner of Healthcare Performance Improvement, acquired by Press Ganey in 2015.

In a recent piece in FierceHealthcare, they looked at eight cultural barriers that slow the healthcare sector’s progress to making sustained reductions in medical errors and, more broadly, achieving better reliability in the sector. Their list:

Acceptance of errors as system complexity grows

“When caregivers feel overwhelmed by the complexity of healthcare or operate outside established processes, a medical error is much more likely to occur.’’

Dysfunctional external accountability

“There are many regulatory agencies in healthcare—The Joint Commission, the Centers for Medicare & Medicaid Services, state agencies and various payers, for instance. While most share the objective of improving the delivery of safe, high-quality care, each has a different mandate and set of metrics that can cause an organization to focus on the near horizon of process and accountability rather than on the ultimate shared goal of zero harm.’’

Lack of comprehensive internal oversight

“In high-reliability industries, risk management is focused on preventing errors and detecting and correcting high-risk situations. In healthcare, risk management tends to be reactionary, with a focus on mitigating loss after an error rather than on preventing error before it can occur. Proactive oversight of processes and guiding principles creates a strong mechanism for internal enforcement on high reliability.’’

Slow introduction of high-reliability principles

“As a complex environment with high-stakes outcomes, it is critical that healthcare providers look outside the industry for operational solutions. To be successful, healthcare organizations should focus on behaviors rather than outcomes.…’’

Fear of retribution

‘’The perceived consequences for identifying serious safety issues can sometimes overshadow the goal to eliminate avoidable patient harm. Internal and external pressures can negatively impact the goal of creating a high-reliability culture. Internally, peer review systems can be punitive and focus on individuals rather than system accountability. No one wants to be responsible for a co-worker losing his or her job.’’

Personal failure is unacceptable

“Perfectionist personalities and professional pride can perpetuate an attitude that ‘only bad doctors or nurses make mistakes.’ We must embrace a culture of full transparency and reporting of errors.’’

Overly developed sense of urgency

“Healthcare providers have a tendency to escalate emerging issues to urgent issues. Factors like impatience, too little time, higher likelihood of proceeding in the face of uncertainty, and patient demands that can be so intense that the ‘end justifies the means’ can provoke caregivers to move ahead too fast when intervention at an earlier stage could prevent a safety event.’’

Standardization is perceived as a burden

“For organizations that embrace a culture of personal authority and individualism, introducing protocols, guidelines and regulations can be seen as bureaucracy. Some clinicians can view process controls as ‘cookbook medicine,’ or feel that dictating care delivery undermines their expertise. ‘’

To read their article, please hit this link.


Comparative-effectiveness studies get boost


The authors of a blog entry   in Health Affairs conclude:

“Coverage with Evidence Development (CED) is a promising solution to a continued problem in healthcare innovation: funding investigations of experimental services. As a result of the Wisdom study (Women Informed to Screen Depending On Measures of risk), Blue Shield has established new standardized policies and evaluation criteria and procedures for the use of CED to support studies that evaluate experimental services that have potential to improve healthcare value. This is a promising development that, through the experience of Wisdom and additional studies, will gain greater use with private payers to address a critical funding gap for comparative effectiveness studies.”

To read the study, please hit this link.

Providers complain about lack of guidance on ‘observation’ status


Modern Healthcare reports that  providers say that the lack of guidance from CMS about a new rule mandating that hospitals notify Medicare patients why they are receiving “observation” care could cause hospitals to lose billing privileges and patients.
Beneficiaries must spend three consecutive nights as admitted patients in a hospital  for Medicare to cover subsequent skilled-nursing facility costs; observation days don’t count.

The publication reported that  as of March 8 hospitals had to begin “giving out the notices, which alert patients that they received observation care rather than being admitted as an inpatient. CMS estimates as many as 1.4 million beneficiaries will receive the notices every year, and they are meant to cut down on the surprise bills observation patients tend to receive.”

“The CMS requires hospitals to give patients a reason for their observation status, but the CMS has declined repeated requests from hospitals to suggest language that providers should use. Providers are concerned that the vague instructions put them at risk of auditor citations.”

“The stakes are huge in that without guidance from CMS, each auditing organization is left only with their personal interpretation if a hospital is in compliance or not,” Ronald Hirsch, M.D., a vice president at R1 Physician Advisory Services, a consulting firm on billing matters for providers, told Modern Healthcare.

The publication added that a CMS spokesman declined to comment on the issue, but pointed to an FAQ document on the agency’s Web site “that encourages providers to use their clinical judgment when writing the notices and make them ‘reasonably understandable’ to the beneficiary.”

To read more, please hit this link.



Higher physician spending doesn’t help hospital patients’ outcomes


A study published in JAMA Internal Medicine found that higher spending on physicians doesn’t lead to better  outcomes for patients who have been hospitalized.

The study included data from a little more than 72,000 physicians over 1,324,000 hospitalizations of Medicare beneficiaries.

The authors found that, perhaps unsurprisingly, spending variation is greater among than physicians than among hospitals.

They said the data “suggest that not only does physician spending vary substantially even within the same hospital, but also that higher-spending physicians do not reliably achieve better patient outcomes.”

The authors point out that many payment-reform and value-based care efforts are targeted to hospitals that, it is assumed, can help influence physician behavior.  They  suggest that this targeting should also directly include physicians,  to help cut  costs.

“Our findings suggest that higher-spending physicians may be able to reduce resource use without compromising patient outcomes. Policy interventions that target physicians within hospitals (e.g., physician-level pay-for-performance programs and reporting of how resource use of each physician compares with other physicians within the same hospital) should be developed and evaluated.”

“Among both hospitalists and general internists, physicians with higher spending per hospitalization had no detectable differences in 30-day mortality or readmissions compared with lower-spending physicians within the same hospital. Given larger variation in spending across physicians than across hospitals, policies that target physicians within hospitals may be more effective in reducing wasteful spending than policies focusing solely on hospitals.”

To read the JAMA piece, please hit this link.

For a ‘Cascade of Care’ model for treating opioid addiction

Authors of a Health Affairs article are touting the  “Cascade of Care” framework  used for HIV treatment as a model for treating opioid addiction.  They write:

“Like HIV, opioid use disorder is a chronic, relapsing, often fatal disorder that typically requires long-term medication treatment to be effective. Similar to the goal of achieving HIV viral suppression, combating opioid overdose requires success along sequential stages, from screening and detection of opioid use disorder, to linkage to care, to medication initiation, and long-term retention.

‘The HIV Cascade of Care has served as an organizing framework by codifying quality outcome measures at each stage along the cascade, targeting interventions to overcome barriers, and comparing effectiveness of interventions across populations and settings.”

They propose these fundamental approaches:

  1. Linkage to care among those diagnosed.
  2. Medication initiation among those entering care.
  3. Retention for at least six months among those initiating medication.
  4. Continuous abstinence among those retained.

To read the article, please hit this link.

Fact-checking news about GOP healthcare bill


For Kaiser Heath News

Republicans are in a hurry to get their “repeal and replace” healthcare bill to the House floor.

In just the week since it was introduced, two committees have approved the “American Health Care Act,” and a floor vote is planned before month’s end.

But in the rush to legislate, some facts surrounding the bill have gotten, if not lost, a little buried. Here are five things that are commonly confused about the h effort.

1. The GOP bill would replace the health law’s subsidies with tax credits.

Not really. The GOP bill would replace the Affordable Care Act’s tax credits with different tax credits.

Under the ACA, people with income above the poverty line (about $12,000 for an individual in 2017) and under four times the poverty line (about $47,000) who buy their own insurance are eligible for advanceable, refundable tax credits. “Advanceable” means they don’t have to wait to file their taxes, so the money is available each month to pay premiums; “refundable” means credits are available even to those with incomes too low to owe federal income tax. The ACA’s tax credits are based on income and the actual price of health insurance available to each individual.

The GOP bill also has advanceable, refundable tax credits. They are based on different criteria, though. The Republican tax credits would increase with age (from $2,000 for youngest adults to $4,000 for older adults not yet eligible for Medicare), and would gradually phase out with income (starting at $75,000 for individuals and $150,000 for families). They would not vary by geographic region or the cost of coverage. And while older adults would get credits twice as large as younger adults, another change in the bill would let insurers charge those older customers’ premiums that are five times as high. In the current law, the difference is 3-to-1.

There are actual subsidies in the ACA — they help people with incomes between 100 and 250 percent of poverty ($12,060 to $30,150 for an individual) pay their deductibles and coinsurance or copays. These subsidies are the subject of an ongoing lawsuit filed by the House against the Obama administration. Those subsidies would be repealed under the GOP bill.

2. Republicans have left popular provisions of the ACA in their bill because they are popular.

Not necessarily. True, the public supports the provisions of the law that allow adult children to stay on their parents’ health plans until they turn 26 and that prohibit insurers from rejecting or charging more to people with preexisting health conditions. Those things remain in the GOP bill.

But even if Republicans had wanted to get rid of those provisions, they likely could not. That’s because the budget rules Congress is using to avert a filibuster in the Senate forbid them from repealing much of the ACA that does not affect government spending.

3. This bill is one part of a three-part effort to remake the  law.

This is true; Republicans continually refer to their healthcare effort as having three “buckets.” One is the budget bill currently under consideration. A second is the power of Health and Human Services Secretary Tom Price, M.D., to make administrative changes that would undermine the ACA.

The third is follow-up legislation that would allow things like selling insurance across state lines and limiting damages in medical malpractice lawsuits. House Speaker Paul Ryan (R.-Wis.) referred to that in a Thursday press conference as “additional legislation that we feel is important and necessary to give us a truly competitive healthcare marketplace.”

What Republicans usually don’t say, though, is that the second and third parts are complicated. Changing federal regulations generally requires a cumbersome process of advertising the changes, soliciting comments and revising the rules. Controversial changes also can bring lawsuits and lengthy legal proceedings. In addition, any subsequent bills on the law would require 60 votes to pass the Senate because they would not be covered by the budget rules Republican are using for this first legislation. Republicans currently have a 52-48 vote majority in that chamber, and Democrats have so far been united in opposing the GOP’s health changes.

4. The bill’s Medicaid provisions just scale back the program’s expansion.

In truth, the Medicaid portions of the GOP bill would fundamentally restructure the Medicaid program.

The Affordable Care Act allowed states to expand Medicaid, whose cost is shared between the states and federal government, to everyone with incomes under 138 percent of poverty. Previously, eligibility was restricted to those in specific categories (primarily low-income pregnant women, children, seniors and those with disabilities). Because Medicaid was already a significant financial burden for states, the federal government offered to pay the entire cost for the expansion population for the first three years, eventually dropping back to 90 percent, which is still more than states get for traditionally eligible populations.

The GOP bill would end new enrollment in that expanded program in 2020. It would continue to cover people who had already qualified — but since many people in Medicaid churn in and out of the program, the number of enrollees is likely to gradually decline.

But that’s just the beginning of the Medicaid changes. The Republican bill would, for the first time ever, limit the amount the federal government provides to states for Medicaid spending. It would make payments based on the number of enrollees in each state and that “per-capita” cap is expected over time to shift more financial responsibility for the program to the states. The left-leaning Center on Budget and Policy Priorities estimates that states could be on the hook for an additional $370 billion over 10 years if the bill becomes law.

5. The GOP bill is a huge tax break for the wealthy.

This is technically true — the bill would provide nearly $600 billion in tax breaksover the next decade, almost all of it going to the wealthy, according to the nonpartisan Committee for a Responsible Federal Budget.

But that’s not because Republicans set out to lower taxes on wealthy people. It’s because they are repealing nearly all the taxes that helped pay for the health law’s benefits, and the Democrats had targeted many of those to higher-income people.

Cutting hospitals’ vast supplies waste could make big dent in overall health costs


A huge source of potential savings in America’s astronomically expensive healthcare system are the vast quantities of medical supplies and equipment that hospitals and other providers waste.

Read about  Elizabeth McLellan,  R.N., a former resident nurse who now runs Partners for World Health, a nonprofit that collects such waste, much of which is still safe for use, and distributes it to providers in such poor countries as Syria and Uganda.

A ProPublica piece about her notes:

“Ten years ago, McLellan, a registered nurse, shocked to see what hospitals were tossing out, began asking them to give her their castoffs instead. In 2009 she launched Partners for World Health, a nonprofit that now has four warehouses throughout Maine. Today, she and hundreds of volunteers collect medical equipment and supplies from a network of hospitals and medical clinics, sort them and eventually ship containers full of them to such countries as Greece, Syria and Uganda.

“‘This is money. This is one of the reasons why your health insurance is so expensive,” she says.

The article continues:

“Talk to experts and many agree that waste would be a good place to start. In 2012 the National Academy of Medicine estimated the U.S. healthcare system squandered $765 billion a year, more than the entire budget of the Defense Department. . ..The annual waste, the report estimated, could have paid for the insurance coverage of 150 million American workers — both the employer and employee contributions.”

To read the ProPublica article, please hit this link.


Moody’s, S&P warn GOP plan would hurt hospitals


Moody’s Investors Service and S&P Global Ratings say that Republican legislation to dismantle the Affordable Care Act would hurt hospitals financially, including downgrades on their debt. Central culprits are that the legislation  relies on per-capita Medicaid caps and tax credits instead of mandates for individual insurance.

Also, taking issue with GOP assertions, S&P said that the legislation would probably be more likely to leave leave older and sicker Americans unable to afford insurance than to coax younger and healthier people to buy coverage.

“The overall payor mix for providers would weaken as the number of people without insurance would most likely rise, as would the hospital sector’s level of bad debt and charity care expenses,” S&P said.

Moody’s, for its part, predicted that the legislation would reduce the number of people with health insurance and “increase bad debt and uncompensated care costs,” by freezing Medicaid expansion as of 2020.

To read more, please hit this link.


Timothy J. Babineau, M.D.: Look at what works well in U.S. healthcare and build on that


American healthcare is expensive. Too expensive. On this, there is little debate. In 2001 the median U.S. household spent 6.4 percent of its income on healthcare; by 2016, the same household spent 15.6 percent of its income on healthcare. That bigger share of the pie leaves less for other essential purchases such as food, education and housing.

The same phenomenon exists at the national level, with spending on education, the environment and social programs getting squeezed. Recent estimates from the Centers for Medicare and Medicaid Services (CMS) have the American healthcare tab coming in at $3.6 trillion for 2016 and projected to continue to soar through 2025. Despite broad agreement that rising healthcare costs are unsustainable, the root causes of the rates of increase and the best ways to combat them remain the subject of some debate and confusion.

Numbers matter. The 80/20 rule—known to healthcare actuaries as the Pareto principle, posits that 80 percent of all medical spending is incurred by only 20 percent of the population. Whether a population is defined as a company, a county, or a country, most healthcare spending is for care of a small minority of individuals. Moreover, the bulk of that spending arises from either largely unavoidable or unpredictable single events (such as trauma or sudden-onset acute illnesses); such chronic conditions such as diabetes; complex episodes of care for such illnesss as cancer, and care delivered at the end of life.

A critical (but often overlooked) point is the fact that as much as 40 percent of spending during chronic and complex episodes is avoidable if providers and systems adhere to established standards of care. Reining in runaway healthcare spending must involve better management of high-cost episodes of chronic and complex care.

A key buzzword in today’s debate is “population health”. Confusion occurs when the term is interpreted as a strategy for controlling healthcare costs when it is applied across our entire population as opposed to the sickest 10 percent or 20 Percent. Wellness initiatives, early detection, the avoidance of emergency room visits, and disease prevention have undeniable value, and should all be pursued, but they will not (by themselves) sufficiently reduce healthcare spending by enough to make the system “affordable”.

As the Baby Boomers swell the ranks of Medicare beneficiaries, the inevitability of illness is the only certainty in an otherwise uncertain world. To be successful, programs, payment systemsand policies to curb healthcare spending must focus on improving the efficiency and effectiveness of care delivered to the sickest subset of the population. This is best accomplished within a completely integrated healthcare-delivery system.

American hospitals and healthcare systems are among the best in the world. Rather than asserting that “American healthcare is broken” and in need of rebuilding from scratch, a better strategy may be to look at what works well within our system and ask how we can build on those strengths while facing the escalating costs head on. Hospital systems are in the health care business, and we should not be reluctant to say so. No matter what wellness and prevention programs we collectively offer, inevitably a small subset of the population will still get very sick, and it is a core mission of health systems—working in close partnership with our primary and specialty providers—to take the very best and most efficient care of them when that happens.

Irrespective of what happens with the Affordable Care Act (ACA), as leaders in health care, we must redouble our efforts to eliminate unnecessary variations and wasteful spending in the clinical care we deliver to patients.

Rather than debate the actual percentage that is “wasteful spending” (now commonly referenced at around 30 percent) we would be better served by continuing the hard work of identifying and eliminating areas within our own systems where needless variations in care add cost without improving outcomes. As Lifespan, the system I lead, continues to evolve into a comprehensive, high-value, integrated healthcare system, we are doing just that.

Timothy J. Babineau, M.D., is president and chief executive of Providence-based Lifespan, a large hospital system, and a professor of surgery at the Warren Alpert Medical School of Brown University.


Taking providers beyond the ‘Controllability Principle’


Robert Simons and Robert S. Kaplan of the Harvard Business School write in in NEJM Catalyst about “the entrepreneurial gap applied to health care”

Among their observations:

Value-based health care increases providers’ accountability for patient outcomes. Many physicians have resisted taking on such increased accountability, claiming that patient outcomes are influenced by many forces outside their control, such as care provided by other clinicians, patient compliance with post-acute and rehabilitation care, and the quality of external rehab personnel and facilities. These skeptics are, in effect, invoking the well-known ‘Controllability Principle,’ in which managers are held responsible only for resources and outcomes that they directly control.

“Yet contemporary management practice advocates the benefits of holding individuals accountable for results well beyond what they can immediately control. The difference between accountability and control is called an ‘entrepreneurial gap,’ evoking the Harvard Business School definition of entrepreneurs as those who pursue opportunities — internally and externally — without regard to the resources they currently control.”

To read their article, please hit this link.


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