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					Innovations In Health Care
Tuesday, March 8, 2011
W Hotel Washington
Washington, DC

 Susan Dentzer
 Health Affairs
Health Affairs thanks these organizations for their support
of today’s briefing and the “Innovation Profiles” featured in
the March 2011 issue of the journal:
David Blumenthal, M.D., M.P.P.
National Coordinator for Health IT
U.S. Department of Health and Human Services
Innovations in Health Care
Delivery: From Patchwork to

    Anne-Marie J. Audet, MD, MSc
VP Health System Quality and Efficiency Program
           The Commonwealth Fund
Defining our Terms:
•   From Latin Innovatus, Innovare :“To renew or change," from in-
    "into" + novus "new".

•   Innovation can therefore be seen as the process that renews
    something that exists and not, as is commonly assumed, the
    introduction of something new.
     High Performance Health System
     Attributes and Functionalities*
 •   Patients' clinically relevant information is available to all providers at the
     point of care and to patients through electronic health record systems.
 •   Patient care is coordinated among multiple providers, and transitions
     across care settings are actively managed.
 •   Providers (including nurses and other members of care teams) both
     within and across settings have accountability to each other, review each
     other's work, and collaborate to reliably deliver high-quality, high-value
 •   Patients have easy access to appropriate care and information including
     after hours; there are multiple points of entry to the system; and
     providers are culturally competent and responsive to patients' needs.
 •   There is clear accountability for the total care of patients.
 •   The system is continuously innovating and learning in order to improve
     the quality, value, and patients' experiences of health care delivery.

Source: A. Shih, K. Davis, S. Schoenbaum, A. Gauthier, R. Nuzum, and D. McCarthy, Organizing the U.S. Health Care
Delivery System for High Performance, The Commonwealth Fund, August 2008
    Common Themes
•   Convenience sample
•   Variety of settings (context)

     – Health Systems, Health Plans, Hospitals, Physician Networks,
       FQHCs, Professional Societies, States

•   Assessment according to logic model of change (Prochaska
    Behavioral Model)

     – Knowledge of problem: A+++++
     – Tools (innovations): B
     – Motivation (Incentives, Will): F
 Common Themes
• Identify, know, segment and ongoing close engagement with
  population (McLuhan’s “The medium (cold vs hot) is the
• Prioritize primary and preventive care – health and healthcare
• Multi-disciplinary , accountable team care
• Performance improvement infrastructure
• Maneuver within payment and regulatory environment
• Evolutionary process of change over time (4 or more years)
• Urgent need for data about impact on Three Part Aim
Ears to the Ground: Know Thy
Population and Standardize Person
•   Jo-Ann Lynn’s Bridges to Health Model (young healthy, disabled, stable
    chronic conditions, unstable, end-of-life)
•   Innovations and programs tailored to prevalence of disease, disease burden
•   Segment - high need, low need
•   Standardized tailoring
     – Bellin’s pyramid access cascade model
         • MyChart patient portal
         • Community-based His Health and Her Health programs
         • Employer-based clinics
         • Fast Care Clinics – retail
     – Cambridge Health Alliance – MyChart (parents and kids); high touch-low
       touch segmentation
     – Clinica Family Health Services (CO)- people measure their own BP at time
       of visit
•   Open door philosophy, connect to population – often and variety of methods

   Practice Has Arrangement for Patients’
   After-Hours Care to See Doctor/Nurse
                      89        89
                                          78        77

                                                               54        54
   50                                                                                           43

           NET        NZ        UK        FR        ITA      GER       SWE        AUS       CAN           NOR   US
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

 Online Access at Regular Place of Care
        Percent              AUS          CAN   FR     GER      NETH       NZ     NOR    SWE    SWIZ     UK   US

Has e-mailed
medical question
to regular doctor              2          4     2        7        2        4        4    6          3    9    6
or place of care
in past two years
Can make an
appointment via
e-mail or Web                  7          6     9      60        10        9       23    13         13   25 15
site at regular
place of care

Base: Has regular doctor/place of care.

Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
Accountable Care Teams
• All sites profiled created multidisciplinary teams
• Accountability at core of team supported by IT to allow
  just-in-time sharing of information around an entire care
   – Aurora Acute Care for Elder Tracker on E-Geriatrician
   – Cambridge Health Alliance registry shared by all providers, school
     based clinics, community-based health workers
   – GRACE: web-based care plan shared by NP, SW, geriatrician,
     pharmacist, PT, community resource expert
• Need for more robust data on cost of these models of care
   – VT Community Health Teams – 5 FTEs serve 20K population; $350K
     per year
   – Martin’s Point teams went from 4.3 employee per MD to 6 per MD
   – Healthcare Partners – Comprehensive Care Center Program saves
     $3,500 per hospital day avoided, redirected to support program
     Practices Use Nonphysician Clinical
     Staff for Patient Care
  Percent reporting practice shares responsibility for managing care, including
  nurses, medical assistants
            98        98
 100                             91        88        88

                                                               73        73
                                                                                                54    52


           SWE        UK       NET        AUS        NZ       GER       NOR        US           ITA   CAN   FR
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
 Primary Care is Really Prime
• Primary care as core value and expected outcome is health not
  just health care
• But this entails “system” approach for cross continuum care
   – New business model for acute care settings
   – Successful systems are able to align financial incentives
       •   Mercy Health System working with Keystone Mercy Health Plan
       •   HealthCare Partners Medical Group - partial or full risk capitation
       •   Clinica Family Health Services costs per visit $167, Medicaid pays $155

• Performance improvement infrastructure to support practice
   – Healthcare Partners Medical Group (CA, NE, Fl): “Comprehensive Care Center
     Program – teams concentrate on stabilizing patients and supports MD practices
     in taking care of more patients with more intense needs post discharged (45min
     vs 15 min visits)
   – VT ITE – Blueprint Central Registry; training practices; web of connection (e.g.
     heat assistance->medical home referral)
   – GRACE model – home assessment team
   – Shared services models (TA, workforce): private/public support
Extrinsic Motivation
•   Examples of financial models:
     – FFS + PMPM Medical Home Supplement
     – Risk sharing:
        • Risk-adjusted capitation
        • Global payment
•   Consistent evidence of barriers to innovations: antiquated payment
    methods and regulations
     – Successful systems able to move away from volume and service-
       based payment
     – Balanced payment models that includes rewards based on
       quality and efficiency
     – Allows flexibility in care design
     – FFS environment prohibitive to sustainability and spread of

•   Professionalism, recertification, professional boards (e.g. AAP)

   Financial Incentives and Targeted
Percent can receive
financial incentives* for:
                                          AUS        CAN         FR        GER         ITA       NET         NZ        NOR         SWE         UK         US
High patient satisfaction
                                           29          1          2          4          19         4           2          1          4         49         19
Achieving clinical care
                                           25          21         6          6          51         23         74          1          5         84         28
Managing patients w/
chronic disease or complex                 53         54         42         48          56         61         55          9          2         82         17

Enhanced preventive care
                                           28         26          14        23         28          17         38         12          2         37         10
Adding non-physician
clinicians to practice
                                           38          21         3          17        44          60         19          7          2         26         6

interactions with patients
                                           10          16         3          7         ***         35          5         30          4         17         7
* Including bonuses, special payments, higher fees, or reimbursements. ** Including patient counseling or group visits. *** Question not asked in Italy
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
 From Patchwork to Quilt: Spreading
 Success Local to National One
 Community at a Time?
• Patchwork America Project illustrates subtle, yet significant differences
among communities in the US, that affect numerous cultural, political,
consumer behaviors. Do these also affect behaviors related to health and
health care?

 •   Boom Towns                           •   Minority Central
 •   Evangelical Epicenters               •   Tractor Community
 •   Military Bastions                    •   Mormon Outposts
 •   Service Worker Centers               •   Emptying Nests
 •   Campus and Careers                   •   Industrial Metropolises
 •   Immigration Nation                   •   Monied Burbs

• What is the typology of communities, regions underlying health care system
spread strategies? Geography is not sufficient, market characteristics are
important, what are other determinants that will be key to spread?
    Learning In Order to Spread and
    Get Results
•   Strategy to identify promising innovations
•   Pawson and Tilley’s approach: emphasize the “why” and not only the “what”
    works or does not work
     – “Experimentalists have pursued too single-mindedly the question of
        whether a social program works at the expense of knowing why it works.”
     – CMO vs OXO approach
•   Criteria to determine whether the innovation is worth evaluating with goal of
     – Flexibility of adoption in various settings
     – Requirements for effective adoption
          • How much disruption will be entailed
          • Need for regulatory or other significant changes to allow spread
•   Not every innovation will succeed
     – How much are we willing to spend – ROI (20% in technology)
    From Patchwork to Quilt: What is
    on the Horizon
•   Payment reform (2003 Leatherman et al HA paper Business Case for
    Quality) – now a reality
•   Workforce – National Health Care Workforce Commission; Funding for
    Title VII and Title VIII programs to educate and train primary care
    physicians and other health professionals
•   Innovation and improvement infrastructure (RECs, QIOs, etc)

•   Data needs – more timely, all payers

•   Longer term horizon for impact with short term expected targets

•   CMMI – promising programs
     –   Mission to identify, validate and scale models that have been effective in achieving better
         outcomes, but may be relatively unknown.
     –   Eight States selected to participate in the Multi-Payer Advanced Primary Care
     –   Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration will
         evaluate the impact of this care model on access, quality and cost of care provided to low-
         income beneficiaries served by these facilities
Christopher A. Langston, Ph.D.
Program Director
The John A. Hartford Foundation
Sean Cavanaugh
Director, Provider Contracting and
Reimbursement, Center for Medicare
and Medicaid Innovation, U.S.
Department of Health and Human
Reflections on Innovation

David N. Gans, MSHA, FACMPE
Vice President, Innovation and Research
Medical Group Management Association
Reflections On the Articles
• Patient-centered care reduces the total cost
  of services, while improving quality and
  patient satisfaction.
• Savings come from fewer ED visits, less
  hospital admissions, and shorter lengths of
  stay, but . . .
• With increased expenses to the provider
  due to increased staff, the application of
  new technologies, and having to re-
  engineer workflow.
Key Themes in Innovation and Health
Care Delivery
• Change is not easy.
• Care plans often combine clinical treatment
  with “Lifestyle Medicine” –managing the
  patient’s nutrition, stress, and activity level
  to improve total health status.
• Fee-for-service payment does not
  necessarily consider the costs associated
  with these innovations.
Increased Administrative Complexity
Must Be Addressed
• Quality and performance measures are
  unique to each insurance payer and need to
  be standardized
• Practice management systems do not fully
  support data reporting
• The “Patient Centered Medical Home” has
  three different organizations setting
  requirements: the NCQA, AAAHC, and the
  Joint Commission
A Final Thought on Innovation in
Care Delivery

We are confronted with
insurmountable opportunities.

                         - Walt Kelly
The Financial and Nonfinancial
Costs of Implementing
Electronic Health Records in
Primary Care Practices
Neil S. Fleming, Ph.D., C.Q.E.
Vice President, Health Care Research
Baylor Health Care System
Dallas, Texas, USA

Study Authors: Fleming NS, Becker ER, Culler SD,
McCorkle, R, and Ballard, DJ

Study Description
•Funded by: Agency for Healthcare Research and Quality R-03
•Purpose: To quantify the financial and nonfinancial (time and
    effort) costs of electronic health records (EHRs) in primary
    care practices to inform stakeholders
•Setting: 26 HealthTexas primary care practices as part of the
    Baylor Health Care System, (in North Texas) implementing
    the electronic health record between June 2006 and
    December 2008, tracking 120 days prior to launch and 60
    days after
•Methods: interviews with key personnel, documents, calendars,
    e-mails, and payroll information
•Study groups: HealthTexas network implementation team,
    practice implementation team, and end-users with diverse
    skills and expertise that are carefully coordinated
Time and effort are non-financial costs
   Network implementation team expends 480.5 hours and
   $28k per practice
   Practice implementation team expends 130 hours and
   End-users expend 134.3 hours and $10,325 per physician

Hardware costs: one-time infrastructure purchases are $25k
per practice and $7k per physician

Software and maintenance costs: licensing, hosting,
networking, and technical support for first 60 days are
$2,850 and $17,100 per year

Total costs: $32,409 per physician and $162,047 in a 5-
physician group from launch through first 60 days
 Financial Alignment is needed between those stakeholders
  paying for EHRs and those receiving potential benefits

 Some economies of scale can be achieved with larger
  practices due to variable nature of some costs

 Strategies are needed to support and coordinate the diverse
  set of medical and technical skills required to ensure
  successful implementation of EHRs and physician
  More Than Four In Five Office-
  Based Physicians Could Qualify
  For Federal Electronic Health
  Record Incentives

   Brian Bruen,1 Leighton Ku,1
   Matthew Burke,2 and Melinda Buntin2

   1 George  Washington University
   2 Office of the National Coordinator for Health Information Technology

NOTE: Commentary is the authors’ opinion and does not necessarily reflect the views of the Office of the National
Coordinator for Health Information Technology.
HITECH Incentives
• To qualify:
  – Any Medicare patients
  – At least 30% Medicaid patient volume
    • More lenient criteria for pediatricians, also
      clinicians in community health centers and
      rural health clinics
• Must demonstrate “meaningful use”
  of certified EHR technology
• Get Medicare OR Medicaid, not both
   Office-Based Physicians Potentially Eligible For
   HITECH Incentives And Using Electronic Health
             Records (EHRs), 2007–08
                   Not eligible for incentives,
                    does not have basic EHR,
     Not eligible for incentives,
       already has basic EHR,

      Eligible for incentives,
     already has basic EHR,
                                                                     Eligible for incentives, does not
                                                                     have basic EHR, 70.5%

SOURCE Authors’ calculations based on combined 2007–08 National Ambulatory Medical Care Surveys.
NOTE HITECH is Health Information Technology for Economic and Clinical Health.
Highlights from Findings
• Incentives should greatly accelerate
  use of electronic health records
  – 4 out of 5 office-based physicians could
    qualify, if they achieve meaningful use
• Incentives are well-targeted, but
  certain groups of physicians are
  more likely to be excluded
  – pediatricians, psychiatrists,
Policy Responses
• Monitor gaps in eligibility, use
• Pro-rate eligibility for Medicaid
• Assist solo practitioners, smaller
  practices in adopting systems and
  achieving meaningful use
  – Government (e.g., ONC) and private
    roles (e.g., insurers, foundations)
Director, Office of Economic Analysis, Evaluation and Modeling, Office of the National Coordinator, U.S. Department of Health and Human Services

        The Benefits of Health
        Information Technology:
         A Review Of The Recent Literature Shows
         Predominantly Positive Results

         Melinda Beeuwkes Buntin
         Director, Office of Economic Analysis,
         Evaluation and Modeling, Office of the
         National Coordinator, U.S. Department of
         Health and Human Services
• To update policy makers,
  innovators, health IT users, and
  those contemplating adoption about
  health IT’s effects on care delivery
  and provider and patient
• Used framework from two previous
  reviews (Chaudhry et al. 2006 and
  Goldzweig et al. 2009), to identify health
  IT literature from July 2007 up to
  February 2010.

• For inclusion, an article must
  • address a relevant aspect of health IT
  • examine its use in clinical practice
  • include quantitative or qualitative outcomes
Article Flow
Outcomes Addressed and
Conclusions Reached
• Over 92 percent of the studies reached
  conclusions that were generally positive.

• Studies emerging from traditional health IT
  leaders (e.g. Kaiser, the VA) are no more robust
  in their study design or positive in their

• Studies examining provider satisfaction are
  more likely to have negative findings.
How the Affordable Care Act Can
Help Move States Toward A High-
Performing System of Long-Term
      Services and Supports

By Susan C. Reinhard, Enid Kassner and Ari Houser

                 March 8, 2011
Characteristics of a High-
Performing LTSS System

• Support for Family Caregivers
• Ease of Access and Affordability
• Choice of Settings and Providers
• Quality of Care and Life
• Effective Transitions and Organization of Care

State LTSS Scorecard

• States will be ranked on five dimensions that
  approximate the five characteristics of a high-
  performing LTSS System.
• Scorecard will call attention to state variation and put
  each state’s performance into context.
• Scorecard will provide a mechanism to track progress
  in years to come.

Creating a State LTSS
Scorecard            High
                                    LTSS system

                                      is composed of

                    characteristics of a high performing LTSS system

                        that are approximated in the Scorecard by

                          dimensions based on available data

                            each of which is constructed from

        Individual indicators that are interpretable and show variation across states

The Affordable Care Act’s Role

• Offer States “Carrots” to Support
  Improvements in their LTSS Systems
• Balance Types of Services
• Establish a Singe Point of Entry
• Improve Coordination and Transitions

ACA Opportunities to Promote
Scorecard Measures

• Ease of Access:
  – Expanding Aging and Disability Resource Centers
  – Balancing Incentives Payment Program
• Choice of Settings:
  – Community First Choice
  – Money Follows the Person

Palliative Care Consultation Teams
Cut Hospital Costs For Medicaid
R. Sean Morrison, Jessica Dietrich,
Susan Ladwig, Timothy Quill, Joseph Sacco,
John Tangeman, Diane E. Meier
 Mount Sinai School of Medicine (New York)
 Center to Advance Palliative Care (New York)
 National Palliative Care Research Center (New York),
 University of Rochester Medical Center (Rochester),
 Bronx-Lebanon Hospital (New York)
 Center for Hospice and Palliative Care (Cheektowaga)
• Patients with serious or life-threatening illness account for
  a disproportionately large amount of Medicaid spending

• Palliative care, when provided alongside disease directed
  care, has been shown to reduce symptoms, improve
  quality of life, reduce family burden, and prolong survival

• This study was performed to examine the effect of
  palliative care teams on hospital costs for Medicaid
 Palliative Care: A Definition
Interdisciplinary specialty that aims to relieve
  suffering and improve quality of life for patients
  with advanced illness and their families.

Palliative care is provided simultaneously with all
 other appropriate medical treatment.

Distinct from hospice care which is medical care
  toward the end of life devoted exclusively to
As Illness Progresses…
An Increasing Emphasis on Palliation
• Retrospective analysis of hospital administrative
  and cost-accounting data
• Sites: Four structurally diverse urban New York
  State hospitals in one large and two mid-size
• All sites had mature palliative care consultation
• Adult Medicaid beneficiaries with advanced
  illness receiving palliative care were matched by
  propensity score to usual care patients
• Calendar years 2004-2007
• GLM and multivariable logistic regression
  models used to analyse results
Palliative Care and Cost Outcomes

                  *P<.05, † P<.01 ‡P<.001. N/A = not applicable
Cost/Day For Patients Discharged Alive
• Hospital costs among Medicaid beneficiaries were
  significantly lower when they had consultations with
  the palliative care team

• Palliative care team consultations may reduce
  expenditures, while helping to ensure quality care
  consistent with patient wishes, for hospitalized
  Medicaid beneficiaries.

• New payment mechanisms aimed at improving quality
  and efficiency would benefit from inclusion of
  palliative care teams.
Health Affairs thanks these organizations for their support
of today’s briefing and the “Innovation Profiles” featured in
the March 2011 issue of the journal: