Monday, February 28, 2011

Care Coordination Experiments Deliver Hope, But Doubt Remains

In my daily search for health care news, there's a certain type of story that always draws me in—the tale of a crusading hospital or doctor who's hit upon a fresh way to treat patients with chronic conditions, and wants to replicate it nationally. Last week was no different—on Friday afternoon, I came across a Robert Wood Johnson Foundation report about Project ECHO, or Extension for Community Health Care Outcomes, that links primary and specialty care doctors in rural New Mexico with patients with chronic illnesses who have limited access to care and often must travel hundreds of miles to reach the nearest provider. Using telemedicine and videoconferencing—and leveraging resources in Albuquerque across rural New Mexico—Project ECHO has tackled 19 chronic conditions ranging from diabetes and substance abuse, and has since expanded to Washington State and Illinois.

Rural areas aren't unique in having patients with chronic diseases in need of coordinated primary and specialty care. In today's H&HN Daily podcast series, H&HN Contributing Editor Bob Kehoe sits down with Caroline Blaum, of University of Michigan Health System, to talk about her organization's groundbreaking work in the Medicare Physician Group Practice Demonstration, which included innovations for—you guessed it—ambulatory care coordination for geriatric patients with chronic conditions.

And in a recent New Yorker article, Atul Gawande profiled a Camden, N.J., physician who figured out through rigorous data analysis that 1 percent of that city's patients were accounting for 30 percent of cost and then set out on a door-to-door journey to meet and treat them.

My interest in these stories go beyond the obvious feel-good moments that tales of innovation for acutely ill folks in often underserved communities inspire—because it's precisely these patients whose spiraling costs threaten to devour the U.S. health care system as we know it.

According to the Partnership to Fight Chronic Disease, chronic disease accounts for 75 percent of U.S. health care spending, and roughly $6,032 is spent on each American with a chronic disease each year—roughly five times more than the cost of care for those without chronic conditions.

So it's evident—and has been, for some time—that the road to both improved health and lower costs lies on these patients and the innovations that both hospitals and docs are making to better serve them. I have a healthy degree of skepticism, though, given years of hearing about bending the cost curve and subsequent reality checks each fall, when you, me and everyone else receive notice from our employers that health care premiums are going up—again, because of increased utilization.

ACOs and other experiments around care coordination are designed to battle precisely this discouraging trend—the one where all too many Americans suffer from multiple debilitating conditions and the U.S. health care slice of GDP grows by a few percentage points each year. I'm holding out hope that the innovators driving real change in care coordination—like University of Michigan Health System and Project ECHO—will one day attain that almost-mythical bend in the cost curve, but I until then, I'll continue to dread that fall premium notice.

Thursday, February 24, 2011

Health Care 2.0

Those of you who followed my blogs this week from HIMSS11 know that I've been on a soapbox about making sure that clinical IT is just that, clinical. So many of the conversations I had in Orlando centered not on meaningful use or CPOE or ICD-10, but on making sure that all of those applications are used to provide clinicians with timely and actionable information. For instance, let's assume your hospital has a poor record in a specific DRG, maybe length of stay for that condition is abnormally long. Jonathan Elion, M.D., suggests that a robust computer system should alert nurse managers the minute any patient with that DRG is admitted to the hospital. That nugget of information should provide clinicians with the urgency to develop a proper treatment plan and, hopefully improve performance for that DRG, said Elion, founder of ChartWise, a clinical documentation vendor. Because the fact is, changes in reimbursement are going to hold providers much more accountable for the care they provide. Whether it is value-based purchasing or bundled payments or accountable care organizations, hospital dollars will be more at risk. That sentiment was echoed time and time again this week.

C. Martin Harris, M.D., chief information officer at the Cleveland Clinic and HIMSS board chair, talked to me about the importance of going beyond meeting the letter of law and instead focusing on the broader intent of meaningful use and the Affordable Care Act: to deliver high quality, patient-centered care. In essence, hospital executives need to come to terms with the new value equation.

But if hospitals are going to be successful in deploying health IT, then the technology has to be something clinicians actually want to use, and use appropriately. You’ve certainly heard the complaints before: the technology solution you just installed doesn't work right. Or, more to the point, it doesn't work the way docs and nurses want it to. One of the concerns I kept hearing this week from docs is that they aren't involved in designing the products they are supposed to be using to improve patient care. Some vendors are trying to address this by engaging clinicians in early stages of product development. I spoke about this with Angie Franks, president and CEO of Healthland, which provides solutions to the rural market.

There were so many other topics that came up during the week: privacy and security, health information exchange, ICD-10, and the list goes on and we'll be covering those topics in the coming weeks and months both here on H&HN Daily and in the print magazine. But before we go, here's a little sample of what things were like on the HIMSS exhibit floor. There were more than 1,000 vendors. Some had mansion-sized booths; others opted for artists, cars, clowns or magicians to draw a crowd.

Tuesday, February 22, 2011

Twitter makes your life easier. Really.

Not long ago, the idea that I would be sitting at my laptop typing merrily away at something called a blog for something called H&HN Daily—well, the idea would never have occurred to me. As a boomer who didn't grow up with the Internet, I could barely get my brain around what a blog was, back then; I didn't read any and I certainly had no interest in writing one. And though H&HN Weekly had been growing in popularity, taking it daily was a thought better left unthunk.

I'm embarrassed to admit it now, but I was one of those people who chuckled every time somebody uttered "Twitter" out loud. It was a fad. It was for teen-agers and 20-somethings. It wouldn't last a year.

Did I mention that in addition to regularly posting blogs, we here at Hospitals & Health Networks now send out a steady stream of tweets every working day?

I know how busy you are and how overwhelming it is to have so much health care information coming at you in so many different formats. I apologize. Far from trying to inundate you with more and more stuff you don't have time to read, our goal is the contrary: to sort out information about health care, organize it in a way that is most accessible to you and then let you decide what you can reasonably invest the time in reading further.

Take Twitter, for an example. As the managing editor of H&HN, one of my jobs is to check dozens of health care Web sites every day. They include organizations like the Kaiser Family Foundation, the Institute for Healthcare Improvement, the Robert Wood Johnson Foundation and many others. Several Web services aggregate news reports about hospitals from around the country. And I keep a steady eye on the Web pages of national and state hospital associations, the Joint Commission, Health and Human Services, CMS and other major players. Other editors and writers here do the same.

From that reading, we try to judge which news reports, which research findings, which policy proposals, which upcoming webinars, conferences, podcasts, etc. H&HN readers might find useful and we post about it on our Twitter page or we spotlight it in H&HN Daily. We always include links for more information. By reading a concise, to-the-point tweet or blog, you can decide if this particular item is relevant to you, and whether to click on the link to find out more or simply zap it into the ether.

Friday, February 18, 2011

Best practices emerge from survey of kids' health care

Recently, the Commonwealth Fund released a scorecard on childrens' health care outcomes that trumpeted major differences in outcomes from state to state. According to the report, "there is a twofold or greater spread between the best and worst states across important indicators of access and affordability, prevention and treatment, and potential to lead healthy lives."

The report also found wide gaps in performance in everything from developmental screening rates to provision of mental health care, hospitalizations because of asthma, prevalence of teen smoking, and mortality rates among infants and children.

It's the sort of report you've read or skimmed through hundreds of times—with the ultimate, unsurprising conclusion that regional differences in U.S. health care are as stark as ever. But tucked beneath the usual headlines were a series of inspiring stories about a diverse collection of states partnering with hospitals and other providers to improve childrens' health care across the spectrum.

Alabama, for instance, got lauded for its 94 percent insurance coverage rate for children, due in part to their status as the first state to adopt an SCHIP program back in 1998—now known as All Kids and to ongoing efforts to keep track of the state's children through information sharing between various state agencies and providers.

And North Carolina earned the highest rates of screening from development and/or behavioral delays, due in part to its decade-old Child Health Assessment and Monitoring Program.

Even in the overall scorecard, which measured performance in several different areas, there was hope for states battling difficult economic environments; the report singled out West Virginia and Tennessee for landing in the top half of overall performance despite high rates of poverty, unemployment and disease.

By the time I was done, I was less interested in the headlines about differences in care than in the case studies of innovations across the country.

In fact, the most valuable insight I got from the report wasn't from a single factoid or policy analysis, but from this simple line, "There is value in learning from best practices around the nation." I couldn't have said it better myself.

Thursday, February 17, 2011

Will the Wellness Generation Bend the Cost Curve?

I’m bending the cost curve.

Please, hold your applause.

I’m part of the Wellness Generation. I eat healthfully. I ride my bike to work every day, year round (OK, I've been known to wimp out if the morning forecast calls for negative anything. And, let's just say that the bike lanes were not the top priority for Chicago’s snowplow brigade following the Blizzard of 2011. Still, I log well over 2,500 miles a year on my commuter bike). I try to get in an extra workout 3-4 times a week. I get my flu vaccine every year. I'm pretty good at managing my asthma and haven't been forced to make any ED visits for that chronic condition in years. Yeah, I’d say I’m putting a little flex into that billion dollar cost curve.

Thankfully, my employer sees the benefit of wellness. For years, the American Hospital Association has enhanced our health benefits with access to such things as a fitness club, Weight Watchers, yoga, acupuncture and more. The AHA also recently started offering the Bicycle Commuter Tax Benefit. Employees share in the cost of some of these benefits, but the expenses are relatively minor when compared to what we'd pay on the open market.

The AHA is not alone. Seven in 10 employers responding to a recent Fidelity Investments and National Business Group on Health survey reported offering 19 or more health improvement programs in 2010 and the number is expected to climb as businesses try to bend their own cost curves. Last year, 50% of employers added one new wellness program to their menus; 63% said they’d do so in 2011.

Estimates vary widely about how much money is at stake. A report issued last summer by the Center for Health Research at Healthways suggested that employers could trim $1 trillion (yes, "trillion" with a "t") over 10 years through risk reduction and prevention programs. But the Center for Studying Health System Change, in a report it pulled together for the National Institute for Health Care Reform, found a mixed bag. Importantly, the report stated that ROI is very hard to measure. The center also noted that financial incentives are the key to engaging employees, which is similar to findings in the Fidelity/NBGH survey.

Hospitals have a double incentive for becoming active on the wellness front. First, as large employers, they can potentially drive down their own health care costs. But secondly, there's a potential new market to capture patients and enhance patient loyalty. Officials at North Shore-LIJ Health System seem to understand this. The New York-based health system is positioning itself as a wellness provider. Late last year, it opened a 15,000-square-foot fitness center and plans to open more. Initially, North Shore is targeting its 42,000 employees and their families, but non-employees are eligible to join and workout as well.

With health reform's emphasis on prevention and improving population health, it only stands to reason that wellness initiatives will continue to become more popular. And who knows, maybe collectively we can put a real arc into that cost curve.

As for me, I won't be cycling next week. Instead, I’ll get my 2,000 miles by walking the halls of the cavernous Orlando Convention Center while attending HIMSS11. Look for my updates on our H&HN Daily blog page.
Wednesday, February 16, 2011

The door to door approach to disparities

Lately, I've been noticing a steady stream of reports on health care disparities, most of which feature alarming factoids within an overall picture of slow progress to reverse those trends. For instance, a recent report from the CDC included the following, troubling findings:
  • Infants born to African-American women are 1.5 to 3 times more likely to die than infants born to all other American mothers.
  • Rates of preventable hospitalizations increase as incomes decrease.
  • Lower-income Americans report fewer healthy days per month.
Overall, the report forecast that the nation is likely to "continue experiencing substantial racial/ethnic and socioeconomic health disparities" even as overall health outcomes improve.

About a week ago, the American Cancer Society came out with a report that found while disparities in cancer mortality for African-Americans are falling, their survival rates still lag other ethnic groups for most cancers.

And even as I was writing this blog entry, I came across a just-published JAMA article that called progress toward reducing disparities "painfully slow."

But even as the disparities headlines continue to filter in, all with the same general theme, there are some signs of improvement. Even the authors of the skeptical JAMA article speculated that the current hubbub about care coordination—including those white-hot ACOs—might drive more health care experimentation in economically depressed areas that would ultimately lead to better care delivery and, theoretically, a reduction in disparities.

Of course, plenty of hospitals are already experimenting with grassroots techniques to identify high-risk patients and provide them with better access to regular care. I recently interviewed Alan Channing, CEO of Sinai Health System, a safety net hospital on Chicago's West Side that has begun literally going door to door to assess everyone in the community for diabetes and asthma. And in a recent New Yorker article, Atul Gawande profiled a New Jersey physician who mapped health care costs in impoverished neighborhoods of Camden, N.J., learned that 1 percent of city patients accounted for thirty percent of costs, and then began—again, knocking on doors—to find those patients and try to provide them with better access to primary care.

Even with slow national progress, plenty of hospitals are addressing disparities at the local level—often by literally knocking on doors. And it's that kind of energy that, one hopes, will eventually reverse the tide of discouraging disparities news.
Tuesday, February 15, 2011

The Boomer Conundrum

That ache in my knee is back. I can't find my glasses even though I must have been wearing them when I got to the office and I haven't left my desk since I sat down. And no matter how long I stood in front of the mirror this morning brushing madly away, I got absolutely no cooperation from my hair. Either of them.

This whole aging thing is not the laugh riot I had been led to expect.

So I was already grumpier than usual when I pressed my nose to the computer screen a little while ago, squinted at my e-mail and found yet another study delineating how many chronic illnesses I—as a certified member of the baby boom generation—can expect to come down with over the next decade or so. Two, if I'm lucky. More, if I'm less so. Ah, the golden years beckon.

This is not all about me, of course. The number of Americans 55 and older will soar in the next 20 years, hitting 107.6 million by 2030, according to the Census Bureau. And any number of savage beasts are nipping at our heels and other body parts.

According to the American Heart Association, hypertension will climb 9.9 percent by 2030, coronary heart disease 16.6 percent, heart failure 25 percent and stroke 24.9 percent. Some 62 million Americans will suffer from arthritis by 2020, the CDC predicts, and a United HealthGroup study says more than half of Americans will have diabetes or prediabetes by then—though that's largely driven by the obesity epidemic among Xers, Yers and Millennials.

Oh, and there's a cheery little article somewhere around here calling Alzheimer’s "the defining disease of the baby boomer generation." I'll look for it as soon as my glasses turn up, assuming I remember to.

Exactly what this will mean for hospitals is hard to pin down. Everything about health care is changing at such an accelerated pace that just when you think you ought to invest a big chunk of change in some new technology or redesign a wing of rooms to accommodate an influx of a certain patient population, something new in care delivery breaks through and the whole paradigm does a 180.

A case in point: The National Cancer Institute forecasts that as the population ages, the number of Americans with one or another type of that affliction will climb from 13.8 million in 2010 to 18.1 million in 2020. While that might be a clarion call to beef up your oncology services, hospitals should carefully consider where they invest. The consulting firm Sg2 notes that inpatient cancer services will grow by just 9 percent through 2020, compared with 36 percent for outpatient services.

A range of developments will make it possible to provide more cancer services in an ambulatory care setting, Sg2 says:

•Advances in and expanded use of genetic profiling
•Earlier diagnoses
•More regular monitoring following diagnosis
•Targeted therapies to reduce side effects
•Evolving technology such as robotic surgery to simplify procedures
•Improved care coordination among all providers

Many of these big leaps forward will apply to other chronic diseases, as well.

While that's good news for boomers, it raises a lot of questions for hospitals as they position themselves in an ever-more integrated care delivery system.
Tuesday, February 8, 2011

Welcome to H&HN Daily

Welcome to the first edition of H&HN Daily, the new e-publication from Hospitals & Health Networks magazine. I'm Haydn Bush, online editor for H&HN Daily, and along with H&HN editors Bill Santamour and Matthew Weinstock, I'd like to welcome you to our new online home. Every day, we'll be offering up a dynamic mix of multimedia content specifically targeted to the hospital C-suite.

On Tuesdays and Thursdays, we'll be delivering commentary from health care thought leaders like Emily Friedman, Ian Morrison, Dan Beckham, Sita Ananth and Joe Flower—the trusted voices you've come to expect from H&HN Weekly.

The rest of the week, we'll be reporting on delivery system transformation, health information technology, quality, patient safety and other key issues relevant to the hospital C-Suite with a mix of videos, podcasts and blogs. You'll hear about innovations from your peers alongside information about emerging trends and developments you need to know about in a variety of formats.

Today, for instance, you'll see a video featuring Alan Channing, CEO of Sinai Health System in Chicago, who talked to me recently about Sinai's impressive quality scores and innovative public health campaigns to fight diabetes and asthma, all while managing a challenging payer mix in a high-volume urban area.

On Tuesday, regular H&HN Weekly contributor John Glaser writes about the need for accountable care organizations to develop robust information exchanges between providers.

On Wednesday, H&HN publisher Mary Grayson talks about the importance of a powerful mission statement for hospitals in an editorial podcast.

On Thursday, writer Jeffrey Segal explores the need for standards to govern the emerging, often nebulous world of physician rating sites.

And on Friday, I'll be talking to Steve Lieber, CEO of HIMSS, for a preview of HIMSS11 and a frank discussion of key health IT concerns, including vendor readiness to support demand for certified EHRs and the increasingly mobile nature of health IT.

And every day, the H&HN editorial team--managing editor Bill Santamour, senior editor Matthew Weinstock and myself--will be blogging about the financial, clinical and demographic issues facing hospitals, with the same forward-looking perspective you've come to expect from H&HN.

We're excited by the chance to deliver fresh, dynamic health care content to you every day, and we'd love to hear from you. Please send comments and thoughts to

Haydn Bush
Online Editor
H&HN Daily

H&HN Daily

H&HN Daily extends the conversations that readers began in other health care management publications and media. Each daily e-newsletter contains at least two topics with exclusive insights from high-visibility, recognized names in health care. All comments are welcome and may be posted to the blog. Comments may be edited for clarity or length.


Haydn Bush
H&HN Senior Online Editor

Bill Santamour
H&HN Managing Editor

Matthew Weinstock
H&HN Senior Editor

H&HN Daily


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