I was recently in New Orleans and coincidently listened to an interview with Robert Wachter of the University of California, San Francsico talking about health IT and his new book on where the nation stands regarding electronic health records (EHRs).
Somehow, the temptations of the French Quarter and the problem of EHRs combined in my mind to produce the image of the nation’s health system out on the town, binging on HITECH Act ARRA money, blackout drunk, and waking up married to some very inappropriate electronic health record system.
This isn’t exactly how it happened, but most of the bloom does seem to be off the rose of the electronic medical record and we are in a phase of regret and disillusionment. Physicians have been complaining for years about the hours added to their days by the workflow disruption of digital data entry and the breach in the relationship with patients created by interacting with the computer, rather than the person. At the same time most of the anticipated fabulous features of EHRs are still in the anticipated stage.
Yesterday, the New York Times had an interesting piece looking at the star rating system that Medicare has been using to evaluate long-term care facilities.
Coincidentally, I was moved to learn that a family friend, my “Aunt Betsy,” has been in an institution for going on 10 years, exceeding almost every expectation for longevity in advanced dementia.
The Times writer, Katie Thomas, observes that much of the data that drives this public reporting system, Nursing Home Compare, of “hotel-like,” 1- to 5-star ratings comes from institutional self-report and seems susceptible to gaming—including staffing up for the critical two weeks that are the basis of reporting for the year’s rating, and then letting the staff go immediately afterward. Sort of the way that television shows pump up their ratings with guest stars during sweeps week and then fall back to meh afterwards.
Like a lot of new concepts, population health seems to be on everyone’s lips and there seems to be a lot of excitement to “do” population health. It sure sounds good and yet I am entirely unclear about the specifics and I’m pretty sure that everyone is feeling a different part of the elephant.
Unfortunately, a recent paper published on BMJ Open suggests that these divergent views are common.
We can all understand the goals of the triple aim: better care—higher quality health care with fewer defects; better health—a related but independent goal that the population at large is actually healthier; and lower cost, at least on a per capita basis—reducing total costs of care.
Last week on Health AGEnda, I stuck up for the Center for Medicare and Medicaid Innovation (CMMI) in the face of what seemed to me fairly unrealistic criticism from a Wall Street Journal op-ed.
I approached the issue from my perspective as a funder and as a very, very, much smaller player in the reform of the health care delivery system than CMMI. It got me thinking that, while I have offered advice directly to the Centers for Medicare and Medicaid Services (CMS) and CMMI staff and mentioned various concerns here on the blog in passing, I haven’t really tried to think through what our experience at Hartford suggests might help CMMI be as effective as possible.
CMMI is the big player in health care delivery reform—the changes to culture, training, regulation, payment, and organization in health care that we all hope will lead to higher quality care, a healthier public, and lower costs of care per capita.
When I first saw the Wall Street Journal op-ed attacking the Center for Medicare and Medicaid Innovation (CMMI) for many purported sins, my first thought was that I should just congratulate CMMI for having arrived. After all, in our hyper-partisan environment, you aren’t anybody unless you are considered worth bashing by someone.
CMMI was set up and funded as part of the Affordable Care Act under section 3021of Title III, the hitherto relatively noncontroversial part of the law aimed at “IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE.” The agency’s goal is one that the John A. Hartford Foundation has pursued on behalf of older Americans for 30 years and one that we feel passionate about:
The purpose of the CMI is to test innovative payment and service delivery models to reduce program expenditures under the applicable titles while preserving or enhancing the quality of care furnished to individuals under such titles. In selecting such models, the Secretary shall give preference to models that also improve the coordination, quality, and efficiency of health care services furnished to applicable individuals defined in paragraph (4)(A).
Over the weekend, Gina Kolata, a New York Times health reporter, wrote a piece on the work of the new Center for Medicare and Medicaid Innovation (CMMI) that was created as part of health reform to test potential improvements in health care organization and delivery.
Interestingly, the slant on the story was on the lack of rigor in the work of CMMI in its failure to use true experimental research designs, those in which participants are randomized to experimental conditions. Using these designs, often referred to as randomized control trials in bio-medicine, yields results that can be interpreted most authoritatively as something about the treatment causing something about the outcome. (Causal inferences.)
Now, I have been critical of the work of CMMI ( See Groundhog Day and Good Judgment Comes from Experience) and of the Centers for Medicare and Medicaid Services (CMS ) more generally in its efforts to answer critical questions about improving health care in America and particularly for the older adult Medicare beneficiaries for whom they are uniquely responsible.
As we enter 2014, the topic of health care costs continues to be a major topic of conversation in the media and among policy makers. The topic is complex and can be spun in different ways.
You may have seen the recent news about how growth in health care spending in the United States has remained low for four consecutive years, for which the White House would like to take some credit. Or you may have seen news reports about how Medicaid expansion in Oregon led to higher emergency department use (and therefore higher costs), which is used by some to argue against the Affordable Care Act. The bottom line is that understanding health care costs is a complex task.
Clearly, the issue of out-of-control U.S. health care costs is of crucial importance and has been a serious challenge to increasing funding for other needs, such as improving infrastructure and education. It is also one in which the general public, pundits, and politicians look for simple, single reasons and matching solutions, e.g., obesity/calorie designations on menus; malpractice insurance/tort reform, too much government involvement/more private sector competition, etc.
Change is hard. It takes leadership to drive change. Robert Jarvik—a former John A. Hartford Foundation grantee and inventor of the artificial heart—once said, “Leaders are visionaries with a poorly developed sense of fear and no concept of the odds against them.”
Today’s successful leaders need that same vision, but they also require a set of skills that go far beyond their clinical training and experience. They need strategies to address policy and payment methodology. They need to engage stakeholders. And they need to measure what matters in terms of cost and quality.
In order to develop this new kind of leadership, people capable of driving health care redesign for vulnerable elders, the Hartford Foundation funds—in partnership with The Atlantic Philanthropies—the Practice Change Leaders Program.
Last Friday I was at a session of the National Health Policy Forum (NHPF) in Washington D.C. focused on Medicare’s readmission reduction program The program, authorized under section 3025 of the Patient Protection and Affordable Care Act (PPACA), is the “stick” to section 3026’s “carrot.”
Section 3026 authorizes the $500 million Community-based Care Transitions Program that will pay partnerships of community-based organizations and hospitals to offer evidence-based, post-discharge services to reduce readmissions. Section 3025, in effect since October 2012, dropped the other shoe and requires the Centers for Medicare and Medicaid Services (CMS) to reduce payment for Medicare services to hospitals whose patients have higher than expected rates of rehospitalization within 30 days of discharge. (For more background, watch this Modern Health interview with longtime John A. Hartford Foundation grantee Eric Coleman, MD, read this recent Reuters article featuring Coleman, and this post I wrote on Health AGEna in December 2010.
Clearly the audience at the session was very concerned about the program and seemed sure that it should changed, if not abandoned (See my response to a Wall Street Journal op-ed last month.). I see the matter very differently and I’d like to explain why. NHPF Sessions are off the record, so I won’t use any quotes or attribution.