Next Things First

Getting It Right the First Time, Warranty Included by charlottegee
April 1, 2009, 6:40 am
Filed under: hospitals, innovation | Tags: , ,

Yesterday the Washington Post ran a piece on Geisinger Health System’s ProvenCare program, which the health system began three years ago:

Mimicking the [Maytag] appliance company that advertised its products’ reliability, the health system devised a 90-day warranty on elective heart surgery, promising to get it right the first time, for a flat fee. If complications arise or the patient returns to the hospital, Geisinger bears the additional cost. The venture has paid off. Heart patients have fared measurably better, and the health system has cut its bypass surgery costs by 15 percent. Today, Geisinger has extended the program to half a dozen other procedures, and initiatives such as the counterintuitive experiment in Pennsylvania coal country are now at the heart of efforts in Washington to refashion how care is delivered across the United States.

How’d they do it?

Geisinger … achieves those goals through standardization. Science-based protocols are “hard-wired” into the process, in much the same way that high-end manufacturing works, said Alfred S. Casale, Geisinger’s associate chief medical officer and a driving force behind the program. For heart bypass surgery, Geisinger guarantees that every patient will receive 40 action items it has identified as best practices. The list includes, for example, properly administering antibiotics within 30 minutes of the operation. The wrong dose increases the likelihood of infection, and infection can lead to a second surgery, prolonged hospitalization and greater risk of death. Surgeons can opt out of doing any element if they give a reason, and an operation is canceled if a single step is missed in the preparations. Electronic medical records contain built-in reminders for the surgical team and track the results.

Of course, not all is well (and many of the reader comments point out that the writer focused only on the good things, leaving out some of the negative effects, and didn’t cover the systematic problems with replicating this program):

But its success has been limited. Geisinger also treats patients who are insured by other companies, and those insurers are not convinced that the savings would be large enough to make it worthwhile for them to renegotiate contracts with the health system. Many still feel more comfortable with the traditional pay-per-procedure approach, even though they run the risk of having to pay thousands of dollars to fix surgeries that go wrong.

Most hospitals are also skeptical of Geisinger’s innovation, saying they would lose money by being unable to bill for treatment of patients who must return. “If they do the right thing and keep patients out of the hospital, it costs them,” said Glenn Steele Jr., Geisinger’s president and chief executive. … Geisinger doctors initially recoiled at the idea of “cookbook medicine,” believing they already followed best practices, Casale said.

PBS’ “NewsHour with Jim Lehrer” also reported on the ProvenCare system:

DR. ALFRED CASALE: We’re saying that we’re so sure that by doing these things right, we’re going to lower complication rates that we’re willing to share the risk of that with the payers, rather than, in the past, there was this perverse mechanism where, if I forgot to give an antibiotic and the patient developed a wound infection after that, and if that patient had to come back in and have another operation to fix the wound, I’d send you another bill, and your insurance company would happily pay it. We think this ProvenCare process has shifted from paying for individual items to paying for value delivered by a high-quality, high-performing system.

MedInnovationBlog had something to say about systems in health care:

Geisinger’s 90 day warranty is an example of “systems engineering” in health care. A number of large integrated multipspecialty groups – Kaiser, Virginia Mason, Intermountain Healthcare, Partners Health, and various academic centers – are following this approach. Systems engineering advocates say, in essence, if you get enough health care people within a health system working together in an organized and systematic way to achieve specific goals, you will reduce errors and improve performance. This requires data, commitment, infrastructure, computer monitoring, electronic records, and physicians in intergrated large multispecialty groups. In American medicine , systems engineering is not common since only 4% of doctors belong to groups of 50 or more.

Posted by CharlotteGee


More on the Value of Care (Hint: It Varies Widely) by charlottegee

“Value is the watchword in today’s economy, and health care cannot be the exception.” – Hal Andrews, CEO of Data Advantage

Back in December, we featured a guest post by Hal, where he wrote:

VBP [value-based purchasing], in some form, is headed to a hospital near you. Hospitals have always ultimately adapted to changes in the financing of healthcare, but usually reluctantly and slowly. Value can, and will, be defined for healthcare, and CMS is leading the charge. History suggests that private payers will not be far behind. If you don’t know your value proposition today in comparison to your peers, time is not on your side. If you don’t join the discussion of how value should be defined, others will fill that void.

That post continues to see quite a bit of traffic. … Google searches for “value-based purchasing” remain high. And the information available on value of care also continues to build: According to the latest edition of the Hospital Value Index™, a study that looks at quality, affordability and efficiency, and patient satisfaction at more than 3,000 hospitals, the value of care offered to hospital patients can vary by as much as 40 percent across the United States. (Data Advantage developed the Hospital Value Index™.)

Just a couple of the study findings:

  • The median Hospital Value Index™ score declined more than 8.5 percent since June 2008.
  • Hospitals in the Northeast (also known as CMS Region I) have hospital value scores some 40 percent better than those in the Southwest (CMS Region IX). The sharp contrast between Regions highlights the complexity of measuring value. For example, some hospitals provide similar quality at a lower cost, while others provide higher quality at a similar cost.

More here (PDF).

In the announcement, Hal noted: “We found that the delivery of high value care is widely divergent across the country, among regions, and even among markets. Measuring value in healthcare is more complex than measuring solely quality or cost and represents a significant challenge for every stakeholder who wants to improve healthcare.” We talked with Hal to get a little more perspective on what all this means. hcvalue

1) Explain to someone who doesn’t know anything about how health care works (say, someone who just goes to the doctor when he gets sick) why your findings are important?

In some ways, consumers and employers have operated under the assumption that “priceless quality” in health care was OK. As consumers increasingly become responsible for shouldering more of the cost of healthcare, we believe that value will become as important in health care as it is in other buying decisions.

Obviously, for matters of life and death, a value analysis will place more emphasis on quality than price; at the same time, for basic health care, like blood tests or X-rays, we believe that understanding the relationship between quality, price (what is charged), cost (what is paid) and patient satisfaction will become more important.

2) I’m a little confused. The data shows that quality scores “significantly” declined since June 2008, but “patient safety, patient satisfaction, and affordability and efficiency scores showed improvement across virtually all hospitals.” How does that work?

The Index is a composite number that moves depending on the number and weight of variables. The most recent Index included information about mortality that was not available in the first Index, and including mortality in our calculation of quality offset gains in other elements of quality.

3) How can hospitals, and health care in general, take this data and use it to spur innovation in care? Given the news that came out recently about 50 percent of hospitals being unprofitable in 3Q 2008, there’s little cash on hand to pay for staff or facility improvements or IT or anything. Give one example of what a hospital CEO might do to improve her hospital’s value rating, now that she’s seen this variation in value.

Any unprofitable business should perform an internal and external analysis of its performance. Benchmarking is the starting point in this analysis – a hospital should analyze what service lines are unprofitable (internal) and then compare that to its peer group (external) to understand where the opportunities for improvement are. In anticipation of CMS’s proposed Value-Based Purchasing, every hospital should have a clear understanding of how it compares to the benchmarks that CMS will use.

4) How does all this fit in with the current political landscape, with the idea of larger health care reform in general?

CMS first proposed Value-Based Purchasing in the fall of 2007, at the peak of the stock market. Even then, it was clear that “priceless quality” was not sustainable. In the current economic environment in which value is the watchword, healthcare can no longer be the exception.

5) Will having this kind of information at their fingertips drive people to, well, drive to other areas of the country to get care?

We have found wide variance in value across the country, within regions, and within individual markets. Value is different to everyone, and we would hope that people would use the information to make decisions that fit their own personal needs.

Posted by CharlotteGee

“And the Hits Just Keep Coming” by charlottegee
January 23, 2009, 8:48 am
Filed under: economy, hospitals | Tags: ,

One of my old bosses used to say that, whenever some unpleasant email hit his inbox or a complaint was left in his voice mail. (He also would whistle loudly, high pitch to low pitch, sounding like a bomb flying to the ground, if something especially bad had transpired. I do this now, like when I open my gas bill.)

These days, well, the hits just keep coming. Every day I hope to see some good (miraculous?) news about the economy, about unemployment rates, about start-ups being formed and funded, but it is slow to come. Yesterday (waiting two days for Inauguration fever to pass), the AHA released an announcement dramatically titled “HOSPITALS REPORT ‘CAPITAL CRUNCH’ IS FORCING DELAYS IN FACILITY AND TECHNOLOGICAL UPGRADES THAT WOULD BENEFIT COMMUNITIES’ HEALTH AND WELL-BEING,” along with the (very nicely designed) report. From the press release:

From cancer centers to expanded emergency departments to electronic health records systems, hospitals are postponing or delaying projects that could greatly benefit health care in communities across the country,” said AHA President and CEO Rich Umbdenstock. “Stopping these projects also means new jobs are not created within the health care field or for construction workers, contractors, IT specialists and others. The ripple effects of the capital crunch on employment are cause for great concern.” Stopping or postponing facility upgrades and technology investments has significant ramifications for communities served by these hospitals and for the health care system as a whole.

And a few highlights:

  • More than 8 out of 10 hospitals said they have delayed projects to update or replace aging clinical equipment or use IT to automate clinical processes.
  • More than six out of 10 hospitals reported that facility upgrades, and clinical and information technology projects would have increased patient care efficiency and improved quality of care.
  • Nearly 60 percent of hospitals said the IT projects that are put on hold would have improved care coordination.

I have a feeling a few of those companies providing services to hospitals may need to update a few things–like their PowerPoints and “Market Opportunity” sections of the business plan–at least for now.

Don't Know What You Got (Till It's Gone) -- Via Hal

Don't Know What You Got (Till It's Gone) -- Via Hal

Related: Health Reform Passes! (In China)

Posted by CharlotteGee