NURSE-FAMILY PARTNERSHIP: A SOCIAL PROGRAM THAT WORKS

I came across an article in the New York Times about the Nurse-Family Partnership and thought it might be interesting for those of you who may have missed it—and those who perhaps are unaware that Rhode Island is one of 42 states that has instituted this remarkably successful program. I found it particularly notable, perhaps, because I’m married to a pediatrician. The article, titled “For Mothers at Risk, Someone to Lean On,” profiles the social program in New York City.

The Nurse-Family Partnership, started in the 1970s, has been adopted in 42 states and has been found to be a social program that works—saving states money and giving tangible benefits to the women and children involved. Rhode Island adopted this program in 2005 after a push by several organizations, including Rhode Island KIDS COUNT, the leading children’s policy and advocacy organization in the state.

The Times story is about a nurse for the New York City Department of Health and Mental Hygiene who is involved in that city’s Nurse-Family Partnership. The program matches specially trained nurses to low-income, first-time mothers. The nurses start meeting with the mothers during pregnancy and continue their visits until the child’s second birthday. Read the NY Times article.

THE ELECTRONIC HEALTH RECORD: SAVIOR OR DESTROYER?

Courtesy www.health.advancestuff.com

The electronic health record (EHR), a digital replacement for patient information that has been stored on paper since the Greeks, has been touted as the technologic advance that will greatly enhance the quality and efficiency of care. But others believe this technology being imposed on doctors will destroy the doctor-patient relationship, increase costs through billing creep, and slow down the busy physician. Is it the answer to many of our problems or the ruination of our healthcare system? We all know the EHR is neither the savior of the system nor its ruination. It’s a new tool, a disruptive technology that, in the short run is a strong dissatisfier for many providers.

Our system has implemented a fairly robust EHR on the inpatient side, and we are in the process of implementing an EHR for the physician practices that are part of the system. The physicians all understand that recording, storing, and retrieving patient health information electronically is here to stay, but, to put it bluntly, most of them hate it. It has changed the fundamental way they work and most would say that they are working harder and really don’t see much benefit to the patient or to them.  Doctors also resent the added cost to their practice of installing and maintaining this technology—as much as $20,000 per doctor per year. So why are we putting millions of dollars into this technology?

First of all, there is clearly a generational divide when it comes to the EHR. Most recently-trained physicians are accustomed to using a computer to record their findings and have learned to relate to the patient at the same time. Those who trained before the advent of this technology are just staying at work longer to enter their notes into the computer. As this new generation of doctors becomes the majority, the noise will subside.

It is clearly too early to evaluate the value of the EHR to patient outcomes. However, we do know that, if implemented correctly, it does facilitate the tracking of progress for groups of patients and the ability to track physician compliance with standards of care, such as routine screenings, for different categories of patients. Prior to the advent of EHRs, we had to rely on claims data for some of this information and it was notoriously inaccurate.  The timely availability of accurate information on the status of the patients served by primary or specialty providers is critical to advance the concept of population health. In addition, as we move away from what many have come to see as the perverse incentives of fee-for -service reimbursement to various forms of global payment, the ability to measure outcomes becomes even more critical to guard against the perception of “cutting corners” to reduce overall medical expense.

EHRs, as we know them today, must undergo extensive development to gain broader acceptance. However, we have crossed the digital divide and can’t turn back. It’s now up to the new crop of providers, who understand the underlying technology, to help evolve the EHR into an effective tool for advancing patient care, much as surgeons have learned to use robots and other technology in the operating room.

I look forward to your comments. --Lou Giancola

HEALTHCARE REFORM ON THE GROUND

One of the most rewarding aspects of being a healthcare administrator is having the opportunity to watch committed doctors and other providers interact around improving the care of patients. Over the years, this has usually been in the context of discussing the care being provided to individual patients during of rounds in the Intensive Care Unit or discussion of patients in the Cancer Tumor Board. In this context, the only focus is the patient, and the different disciplines bring their perspective on how an individual patient should be treated. I feel particular pride on these occasions because I experience the knowledge and dedication of wonderful healthcare providers being brought to bear on determining the best care for an individual patient. During those moments, all the administrative and process issues that occupy much of my time seem to vanish. It’s all about the patient.

Recently I’ve had the opportunity to observe a similarly dedicated group of health professionals, mostly primary care physicians and healthcare policy makers, grappling with the issue of how you improve care and affordability on a macro basis—for the population of a state. The Executive Committee of the Chronic Care Sustainability Initiative (CSI), which is actually the Patient Centered Medical Home project in Rhode Island, is reviewing the available evidence to determine how patient centered medical home (PCMH) practices in other states have affected measureable health outcomes and the cost of care.

We are fortunate to have a group of incredibly smart and dedicated providers and policy makers in our state leading the transformation of primary care.

As with traditional research studies to determine the efficacy of treatment interventions, such as new drugs, there are many variables to deal with in assessing the effectiveness of PCMH practices, and the pilot projects are different in each state. Although almost all the pilot projects require that practices be recognized as Patient Centered Medical Homes by the National Committee on Quality Assurance, we know there is still wide variability in how they function. In addition, it is difficult to control for the differences in patient populations and the relation of the practice to other resources in the community, such as hospitals. Some practices are part of an integrated system with hospitals and other community health providers, while others are stand-alone practices whose patients use various hospitals.

Despite the difficulty in controlling for all these variables, there is mounting evidence that Patient Centered Medical Home practices improve outcomes for patients, particularly those with chronic conditions; these practices reduce costs by reducing expensive emergency visits and hospitalization; and the patient and provider’s experience of care is enhanced. A recent study entitled “Impact of Medical Homes on Quality, Healthcare Utilization, and Costs,” in The American Journal of Managed Care, compared a large cohort of insured patients in PCMH practices and non-PCMH practices and found significant differences in all three categories. Other insurers have reported similar findings and many are investing in pilot programs around the country.

As a friend whose opinion I greatly respect pointed out, the PCMH movement is not the sole answer to obtaining greater value for our healthcare dollar, but I believe it is a very important component. We are fortunate to have a group of incredibly smart and dedicated providers and policy makers in our state leading the transformation of primary care. Their efforts may ultimately transform the entire healthcare system in our state.  In my forty-five years in healthcare, I don’t think I’ve seen the same focus and energy to find solutions, which energizes me to want to be a part of that change.

BALANCING ACT: JOBS VERSUS HEALTHCARE PLANNING

There is a growing body of evidence that the demand for inpatient acute care beds will decline over the next ten years, despite the aging of the population. This, on top of data suggesting that current inpatient bed capacity is underutilized, has led many policy experts to believe that RI has too many hospitals. Overlooked in this conclusion is that hospitals are much more than inpatient beds. They serve as a nexus for healthcare delivery in a community and increasingly are responsible for recruiting and managing traditional physician practices and other outpatient services. There is also the issue of the distribution of hospital beds and what constitutes reasonable access, particularly in an emergency. That said, there is a strong argument to be made for fewer beds and morphing some hospitals into strong ambulatory care delivery systems that are focused on population health management.

Some people, myself included, felt that we had an opportunity to pursue a rational plan for healthcare delivery and population management in Woonsocket and Westerly, as the hospitals in both communities found it impossible to sustain their current profile of services. In both instances, the communities and the staff fought to preserve a full-service hospital. Although there was concern about access to services by the communities, maintenance of employment was the primary goal of hospital staff and the communities. In both instances, the staff were willing to make concessions related to working conditions to preserve the hospital and their jobs. In the case of Landmark Hospital in Woonsocket, the staff are apparently faced with an unknown out-of-state bidder as the only remaining option after Steward Healthcare System withdrew after three years of negotiations.

"Although there was concern about access to services by the communities, maintenance of employment was the primary goal of hospital staff and the communities."

There is clearly a dilemma here as health planning goals appear to conflict with disruption to people’s employment and their lives. One wonders if there isn’t a way to pursue a more balanced approach. The first step in such an approach is to better understand the health needs of a community and, in conjunction with residents of the area served by a hospital, determine what services are necessary to meet those needs. It’s impossible to do this in a crisis, but in the case of Woonsocket we had four years to think this through. The second step is to consider what kind of healthcare roles will be necessary in the new system and where the jobs will exist. Finally, retraining may be necessary to prepare workers for the new roles.

These situations raise the question of whether we will ever be able to plan the healthcare delivery system of the future or whether we will stumble from one crisis to the next? Maybe my approach is oversimplified, but there has to be a better way to approach these situations, particularly if demand for hospital beds is going decline and we’re going to face more situations like Westerly and Woonsocket in the future.

I look forward to your comments. --Lou Giancola

IS THIS PROGRESS?

The Health Insurance Commissioner in Rhode Island has long advocated for increased emphasis and investment in primary care to improve outcomes and decrease costs. I must admit to being a skeptic as to whether investment in primary care was the most efficient way to achieve improved outcomes. I also wasn’t sure how you could shift dollars away from hospitals and specialists. Although the evidence that these investments will turn the tide on outcomes and quality is still mixed, I’ve become a strong believer, a convert if you will, that Christopher F. Koller was right. It makes sense that if primary care is the foundation of the system, and we strengthen the foundation, the whole system will be stronger. The Chronic Care Sustainability Initiative (CSI), which is really the Patient Centered Medical Home (PCMH) Project in RI, has now shown that patient outcomes improve and utilization can be reduced for patients receiving their care from PCMH practices.

It makes sense that if primary care is the foundation of the system, and we strengthen the foundation, the whole system will be stronger.

The Health Insurance Commissioner has, with the cooperation of the insurers, mandated that the insurers increase their spending on primary care by 1% per year from 2010 to 2014. He has further required that this increased spending on primary care not be included in rate increase requests. His Office has reported that the plans have met the spending target through 2011 and in their projected spending for 2012. This is a credit to the Health Insurance Commissioner, the insurers, and the primary care physicians who have embraced the concept. It also shows that change in the healthcare system is possible if you develop a specific intervention with clear targets and create a mechanism for tracking progress. This should give us hope that larger change in the system is possible.

On another note, I want to recommend that you read the statements of the Presidential candidates on healthcare reform published in the June issue of the New England Journal of Medicine and “The Conservative Case for Obamacare” in the Sunday Review Section of the New York Times.

Is Transparency In Healthcare Costs Possible?

One of Webster’s definitions of transparency is “characterized by visibility of information especially concerning business practices.” Therefore, transparency means that the business practices are easily discernible to the public. I have long felt that the business practices of the healthcare industry are lacking in transparency, which means it’s difficult to act as an intelligent consumer of healthcare. As consumers, we’re a lot like car buyers before it was possible to go on-line and get complete information on every make and model of car with every possible accessory. Although more information is now available on-line for consumers to learn about the charges and approximate out-of-pocket costs for selected healthcare procedures, such as hip and knee replacements, the actual cost of care is still nearly impossible to find.

Part of the reason for the difficulty in determining the cost of medical care is that consumers generally associate charges with cost. If you buy a bunch of bananas, you know you’re going to pay $1.10 a pound. That is both the charge and the cost to the shopper. When it comes to healthcare, the charges almost always have no relation to the cost to the patient. Even if the patient has insurance with a high deductible, the cost to that person will be whatever the hospital or doctor has negotiated as the price the insurer will pay the provider for that service, regardless of the charges. For example, the charges associated with a hip replacement may be $30,000, but the insurance company may pay only $15,000. If you have insurance with a $5,000 deductible, you will pay $5,000 and your insurer will pay $10,000. Although the payment, $15,000, is 50% of charges, there is no true relationship. The hospital, in this instance, negotiated a rate of $15,000 with a particular insurer. By the way, the hospital may only receive $14,000 from other insurers and even less from Medicare.  Another reason why it’s difficult for the consumer to get information about the cost of a service is that the provider is almost always prohibited from disclosing what an insurer pays it for a given service.

"The public deserves greater transparency in our healthcare system."

At this point you should be asking yourself two questions. The first is why are the charges so high in relation to the actual cost or payment received? The second is why are providers prohibited from disclosing what they are paid? You may even have a third question, which is what is the hospital’s actual cost to replace that hip? The answer to the first question is that historically some insurers paid hospitals on the basis of charges. As more insurers moved away from paying charges, the hospitals increased the charges to get more dollars from the few who paid charges. The answer to the second question is that insurers were afraid that if every hospital was aware of what every other hospital was paid, it would lead to everyone holding out for what the highest paid hospital was receiving for that procedure. I have long felt that this explanation was a cop out on the part of insurers and regulators. The insurers should have been able to justify any difference in payment and the regulators should have insisted on an explanation, given that insurance costs have been out of control. Many insurers and politicians decried the fact that consumers never consider the cost in making decisions about their care, but they wouldn’t arm them with the information necessary to make intelligent decisions. This underlying lack of transparency persists to the detriment of the consumer and the premium-paying public.

Now for the third question, what does it actually cost the hospital for a patient undergoing a hip replacement? The answer, of course, varies from one patient to another and from one doctor to another. Some patients will require more days in the hospital or more testing than others, so the costs will vary. Different doctors take different amounts of time to perform the procedure and may use different implants, also resulting in variation in cost. However, hospitals have become more sophisticated in using cost accounting techniques to determine their costs for a given procedure and can even break it out by physician. Some components of cost associated with overhead, such as human resources, do require allocation methodologies. Hospitals are required to submit extensive cost information to Medicare, which is available to the public but difficult to interpret.

With the federal government now responsible for more than 50% of healthcare costs, with the increases in health benefits a drag on our economy and with per capita healthcare costs twice the rate of some other European countries, the public deserves greater transparency in our healthcare system. I would start by systematically providing information to the public on what each payer pays each hospital for the top 20 diagnoses and procedures. That should lead to some very interesting questions about variation in payment and to the cost structures that underlie those payments. It should also lead to insurers and hospitals having to explain those differences.

I look forward to your opinions and comments. --Lou Giancola

Rhode Island or Vermont -- Who has the Right Answer for Healthcare Reform?

I had the opportunity to interact with two individuals who have significant roles in leading healthcare reform in Rhode Island (RI) and Vermont (VT)—Christine (Christie) Ferguson and Anya Rader Wallack.

Christie Ferguson

Christie Ferguson has been appointed Director of the RI Health Benefits Exchange. She’s been on the job for five weeks and is struggling with the balance of just getting the Exchange functioning and addressing the larger issues of improving outcomes and controlling costs. She clearly understands that insurance coverage is important, but not sufficient. Improving the effectiveness and efficiency of the system had to be accomplished through the aggregated purchasing power of the Exchange. The purchasing power amassed through the small employer groups and the non-group individuals mandate —those likely to obtain coverage through the Exchange—will not be sufficient to drive the necessary changes. She faces the challenge of somehow marshalling the purchasing power of state employees (19,000) and Medicaid (224,000) to implement payment reform and other tactics designed to improve quality and bend the cost curve.  Other populations that might be coordinated are municipal employees. Coverage is currently purchased for these employees through several buying cooperatives. The question is whether the regulatory and political climate will make it possible to have all of these entities establish similar standards for their plans related to the role of primary care, participation in the provider network, generic drug use and quality. This is a tall order, but Ms. Ferguson has experience in state government and may be able to pull it off.

Anya Rader Wallack

Anya Rader Wallack hasn’t been around healthcare as long as Christie Ferguson, but she finds herself heading up a very ambitious effort in VT to change the state’s healthcare system. Until her recent appointment as Chairwoman of the Green Mountain Care Board, Ms. Rader Wallack served as the Deputy Chief of Staff to Governor Shumlin for Healthcare Reform. The Green Mountain Health Board was created by the VT Legislature in 2011 to:

·         improve the health of Vermonters;

·         oversee a new health system designed to improve quality while reducing the rate of growth in costs;

·         regulate hospital budgets and major capital expenditures as well as health insurance rates;

·         approve plans for health insurance benefits in Vermont’s new “exchange” program as well as plan to recruit and retain health professions; and

·         build and maintain electronic health information systems.

Wow! That’s an impressive set of goals and a tremendous concentration of power in the hands of a five-person board consisting of two doctors, a business owner and the VT Secretary of Human Services, in addition to Radar Wallack. VT has a population of 619,000, one major teaching hospital (Fletcher Allen in Burlington) and 13 community hospitals. Many Vermonters are served by the Dartmouth-Hitchcock Medical Center, another major teaching hospital located just over the border in Hanover, New Hampshire. Radar Wallack says that, although a Healthcare Exchange will be implemented, it will not be the centerpiece of reform in VT. She and her staff are spending more time reviewing hospital budgets and launching projects to test new payment methodologies.

Keep in mind that neither state has the ability to directly affect changes in the Medicare program (18% or 111,420 in VT and 17% or 176,375 in RI) or employer self insured programs, which are regulated under federal laws.

Which state do you think has the greatest chance of successfully extending coverage, improving quality and bending the cost curve?

I look forward to your comments and opinions. —Lou Giancola