Starting With Curious

In an earlier posting, I discussed evidence regarding how physicians respond to financial and other incentives such as pay for performance.  Many experts propose that increasing financial incentives for patients is an effective way to control health care costs.  The rationale is that spending is driven in large part by artificial demand from physicians who are paid based on volume of services, on the one hand, and from patients who, due to insurance, are insulated from the costs of the services they consume.  Can informed patients, armed with information about quality and cost, and having to pay those costs directly, drive the triple aim of higher quality care, lower cost, and better health outcomes?

It turns out there is some evidence on this topic.  In a classic study, and one of the few randomized trials of payment innovation, the RAND Health Insurance Experiment showed that when patients and families bear a larger share of the costs directly, via co-pays and other forms of cost sharing, they cut back on their utilization of medical services.  However, they reduce both necessary and unnecessary services similarly.  This suggests that having patients have more “skin in the game” can lower costs, but may actually lead to worse outcomes (although the study did not actually find worse health outcomes despite the decreased use of services).  Other studies, largely observational, have mixed but generally similar findings.  It’s not clear why this is.  It may be, as many health professionals argue, that medical care is too complex for even reasonably informed but untrained people to make judgments about quality.  Another possibility is that, given how expensive medical care has become, for most people with average means, there is no choice but to make decisions based almost exclusively on cost.  A co-pay of $175 for an emergency department visit may serve as an effective deterrent to seeking care even when needed if that represents a day’s pay (which it does if you make the median income for a family of four).

The challenge of looking to consumers to drive the push to lower health care spending is underscored by a recent study in Health Affairs.  Researchers at RAND conducted a set of focus groups among individuals with insurance to describe their willingness to discuss and consider costs when making health care decisions, and to identify barriers.  It may not come as a surprise to those of us who deal with patients and families, but there was in fact tremendous resistance to considering costs.  Participants expressed a preference for the “best care” regardless of cost, driven in part by equating “more expensive” with “higher quality.”  Moreover, there was a classic “tragedy of the commons” thinking, in that people felt that since they had paid into the common pool via insurance premiums, they were entitled to all they could get out of it, with no individual responsibility for stewardship of the shared resources.  As one participant said, “I probably should care, because we all pay in the end.  But in the heat of the moment, I’d be like ‘Fix my problem! I don’t care about anyone else.'”

As the saying goes “Everyone wants to go to heaven, but no one wants to die to get there.”

What do we as providers do?  I would argue that the evidence to date demonstrates that we will need to take a leading role.  To start with, we can eliminate waste in the form of unproven treatments, unnecessary testing, and duplication.  We can focus on the efficiency dimension of quality, along with the other dimensions such as effectiveness.  We can embrace rational, evidence-based guidelines to minimize unwarranted variation, such as the Choosing Wisely effort by numerous professional organizations.

I don’t want to minimize the challenges of doing so, highlighted by the recent findings from the Health Affairs study discussed above.  But anecdotally I have found that this approach can work.  One of the five interventions proposed by the American Academy of Pediatrics was to decrease the use of CT and increase the use of observation in children with minor head trauma, based on an evidence-based decision rule.  Since that rule was published, we have seen a decrease in CT scanning in our ED.  I find it far easier to talk with families with that rule in hand, explaining how the quantifiable risk of a bleed is outweighed not only by the economic cost but by the potential harms due to radiation exposure.  I’ve actually been surprised at how many people are receptive to discussing cost, as long as it’s framed in the context of their child’s health first.  If heath care spending is to come under control it will have to be led by us, health professionals who are able to balance our obligation to the individual patient in front of us with all the other potential patients out there.  Health care is a common good, and we need to be its stewards.

“Prediction is very hard, especially about the future.”

–   Yogi Berra (attributed)

It’s not too hard, however, to predict the past, especially the recent past.  And in some cases, the recent past can give us some pretty good indications about what’s coming in the near future.  It’s not exactly going out on a limb to say that health care is changing; less clear is into what is it changing, and how quickly.  Consider a few recent examples that may give us a sense of what we face.

Utah Medicaid.  On January 1, 2013, Utah became the second state after Colorado to implement an accountable care organization (ACO) for its Medicaid enrollees.  (For now, CHIP is excluded.)  The state make global payments to one of four ACOs, which have relatively broad latitude in working with providers to incentivize lower cost and higher quality, including pay for performance and shared savings.  Currently, physicians are paid on a fee-for-service basis, but the plan it to move to other payment methods (e.g., capitation, bundled payments).

What is different between this ACO model and traditional Medicaid managed care?  One is the flexibility in how the capitated payments received by the ACOs are distributed to the various providers.  The other is the requirement that the annual growth rate in Medicaid expenditures is limited to the rate of growth of the state’s general fund.  Those ACOs that are unable to limit the rate of growth may lose share or not be renewed.

Oregon.  Oregon has implemented a version of ACOs for all enrollees in Medicaid, CHIP, and the state employee health plan.  Fifteen geographically-based coordinated care organizations (CCOs) have been created.  Each will have a global budget for all health services (initially medical and mental health, with dental to be added) for the patients they cover.  Again, they have flexibility in how those funds are disbursed, but each CCO will be required to demonstrate a reduction in the rate of healthcare spending growth and meet specified quality metrics.  Shifting care to lower cost settings and preventive care are anticipated to be important elements.

Massachusetts.  Since 2009, Blue Cross Blue Shield of Massachusetts has had the Alternative Quality Contract, a modified global payment model in which annual payments to medical groups are linked to a per member per month budget.  There is both up-side risk (shared savings for coming in under budget) and down-side risk (penalties for exceeding budget), as well as incentives for meeting quality targets.  In 2012, Boston Children’s Hospital and its affiliated provider practices joined the Alternative Quality Contract, making it the first pediatric-only ACO.

What can we learn from this?  First, some form of accountable care, with elements of financial risk for providers and incentives for quality, appear to be the dominant emerging payment model.  Second, although there has been more progress so far in adult care (because the earliest ACO experiments were in Medicare), pediatrics is not immune.  Finally, this is happening very quickly.  There is no reason to think that the public and private payers in Wisconsin are not going to learn from these other states and begin to implement local version of this before long.

For those of you who still find many of these concepts in payment innovation and care delivery redesign confusing, here is a fun video from the Kaiser Family Foundation that puts it in terms even Yogi Berra would understand.

When I assumed my role as CEO of Children’s Specialty Group, someone asked me if I was still going to be a doctor.  Aside from the old dictum “once a doctor, forever a doctor,” the question raises an interesting consideration.  It sometime feels as if being a clinician is antithetical to being a leader, that doctors and nurses care for patients, while administrators look after organizations (and often in an uncaring manner, at that).  According to an article I read recently, “When Clinicians Lead,” leadership by doctors and other providers is critical to the success of health care organizations and the medical system as a whole.  Yet there are important, albeit surmountable, barriers to greater involvement by clinicians in leadership roles.

The article cites a variety of evidence of the importance of clinical leadership.  Several studies have demonstrated an association between higher levels of clinician involvement in management and hospital performance.

So why is there a reluctance for clinicians to assume more leadership roles in hospitals and other health organizations?  The article mentions several.  Clinicians have a certain amount of skepticism about the value of administrative and other leadership activities, in contrast with the obvious value of direct patient-care activities.  Many physicians, accustomed to an evidence-based approach, find the “evidence” for leadership effectiveness to be insufficiently rigorous.  (I confess that I myself have a hard time with the average Harvard Business Review article’s largely anecdotal approach.)  Second, there are weak positive incentives and some disincentives to clinicians’ assuming leadership roles.  Especially in an academic setting, clinical leadership is rarely helpful in promotion or career advancement, and may take time away from more value-added professional activities.  Monetary compensation for administrative time may be less than that for clinical activities.  And a physician leader risks being seen as having “gone over to the dark side.”  All this for the promise of endless meetings, reports, etc.  Finally, leadership development opportunities tend to be sparse for clinicians, leading many to believe (correctly or not) that they are unprepared for such roles.

If we are to do more to encourage clinicians to assume leadership roles – and I would argue that we need to do exactly that – we need to address these barriers.  Within CSG, our Professional Development Committee is working to identify leadership development resources available both internally and externally, and we hope to invest some funding to support such activities for individuals who are willing to take on leadership roles.  But no amount of training is going to do much if people are unwilling to participate, so let me address the skepticism.  I can tell you that personally, I have found administrative leadership to be as rewarding as the clinical work I continue to do.  As a doctor I impact one patient and family at a time; as a leader, my reach can be much broader.  It is also important to recall that leadership comes in many forms.  At one level are the institutional leaders, those with formal titles, and whose leadership is largely in the administrative realm.  Next are service leaders – such as medical directors, or committee chairs – individuals with a more localized focus on a specific area.  Finally, there are the frontline leaders, many without any formal title, but the ones everyone knows to go to when something needs to get done.  The time commitments, required skill sets, and duties obviously vary tremendously.  But all of these roles are crucial, and all are best filled by the doctors and other providers who are at the core of what we do.

It goes by several names: “pay for performance” (a.k.a. “P4P”), “value-based purchasing.”  The concept is that rather than paying for health care based solely on the volume of services performed, payment is based at least in part on some measurable result, with a goal of increasing quality and decreasing cost (i.e., greater value).  In one of the more ambitious P4P initiatives to date, New York City recently announced that 2.5% of the pay for the 3300 physicians employed at the city’s 11 public hospitals will be based on achieving certain quality metrics.  CSG has P4P programs with both our commercial and government payers; we even have one with our own employee health plan.

There are many aspects of P4P that appear to affect its effectiveness and acceptability.  But recently, there has been a debate about whether physicians even respond to financial incentives.  Both skeptics and supporters of P4P can find evidence to support their view, as results of research have been mixed. Yet can it be true that physicians are actually above all that, that our motives are too pure for our practice to be affected by money?  In a New York Times op-ed about the NYC P4P proposal, Bill Keller argues essentially that.  Many of the posted comments about the piece are from physicians, who argue that they are not affected by financial considerations, and would practice high-quality medicine if administrators and payers would simply get out of the way.  One commenter noted that not only do incentives not work, but if P4P leads to lower salaries, there will be fewer individuals choosing to go into the affected specialties.  Hmmm.  If physicians choose a specialty at least in part based on compensation, that seems to me a way of responding to financial incentive!

Indeed, there is evidence that we are just like everyone else in that we do change our practice in response to monetary considerations.  Lowenstein et al. provide several examples, including increased administration of higher cost drugs by oncologists who are reimbursed for them, and changes in rates of procedures depending on whether payment is fee-for-service or capitated.  But it really is complex, in that the decisions of physicians, as for most professionals, are driven not only by financial but by numerous other considerations.  Both Lowenstein and Cassel argue that money, while a factor, is not the most important one.  Fidelity to the patient, professional pride, and competitiveness are also key drivers.

Whether we like it or not, some form of P4P will be an increasing part of our future.  But that doesn’t have to be threatening.  We could fight against the very idea that we can be swayed by financial incentives.  Or we can be part of figuring out how to make it work – defining the right incentives, both monetary and non-monetary, and the outcomes to be achieved – so that our patients will get the best quality at the lowest cost.  That will help us preserve both patient value and our professional values.

Our personal and professional lives are full of things we need to do just to get by, such as doing laundry or completing activity reports.  And then there are the things that are really critical to our success and well-being – building a relationship with a spouse/partner, mastering a professional skill.  While we often spend most of our time on those routine things, there’s a much bigger payoff from focusing on the important stuff.  In our culture enhancement work, we talk about these as our “Blue Chip”.  Granted, we do need to pick up a certain number of lower value white chips, but we need to make sure that with limited time and energy, we pay sufficient attention to the high value blue chips.

The CHW executive team recently spent part of a day sharing our blue chips for 2013.  I used two criteria to define a blue chip.  First, it’s something that is critical to the organization; by providing the foundation for future success, it’s a form of investment of time and effort.  Second, it’s something that requires some type of attention or intervention from me.  We all need to learn how to say no, but the blue chips are those things that we cannot say no to.

I have three blue chips for this year:

                1)  CSG Structure.  As we have discussed at the CSG Board and in various other meetings (and which I will discuss more about in coming posts), the healthcare environment is changing in ways that make it difficult for us to participate effectively given our current structure.  To be able to provide care while taking financial risk, we will need to have better financial integration, data sharing, and alignment of incentives with the hospital.  At the same time, we need to continue doing what we do best – providing outstanding patient care, innovative research, and training the next generation of providers.  It is absolutely essential that we figure out, very soon, how to structure ourselves to best meet these business, clinical, and academic needs if we hope to thrive in the evolving healthcare world.

                2)  Growth.  Our business has been relatively flat for several years, as a result of many factors, but with some areas of growth.  Why grow?  First, with increased competition from both pediatric and other health systems, non-growth is really decline.  Second, the emerging models of healthcare delivery and payment depend not only on better integration (see above), but bigger scale.  If we are to continue to grow, we need to focus on those areas of opportunity – our service lines and regional operations – more aggressively.

                3)  Ambulatory optimization.  Our outpatient clinics are one of the areas that has been growing.  We know our quality is great, but we’re increasingly being questioned about value.  To improve and demonstrate our value, we will need to capitalize on our investment in Epic, honing in on making our ambulatory operation more efficient.

Each of these is critical to positioning us for future success.  Yet all are large, complex tactics requiring attention and sponsorship at the highest levels.  Hence, my blue chips.

What are your blue chips for this year?

We all know the healthcare environment is changing: pressure on reimbursements from both public and commercial payers, need to control runaway costs, emphasis on payment for value vs. volume, etc.  I saw a video recently that steps back and discusses how the changes we are seeing in healthcare are tied in with much broader changes in society – what they refer to as “megatrends.” (I have to admit that the video, from Deloitte Consulting, is way too consultant-y for my taste, but it’s fairly short and raises many interesting points.)

Of the seven megatrends mentioned, five seem especially relevant to the pediatric world.  The most obvious is constrained resources.  In all segments of the economy, people are looking to do the same or more with less.  Quite simply, the money isn’t there.  Another is “big data.”  We are living in the information age, and while not all of that information is terribly useful, we are awash in it.  One the one hand, this gives us tremendous opportunities to learn, and to make data-driven decisions about care and our business; on the other, it means many others also have access to information, including patients, payers, competitors, etc.  Medicine has often had an asymmetric relationship between providers and consumers with regard to information, but the playing field is being leveled.

A third trend is unparalleled connectivity, with which we are all familiar.  Again, this is a two-edged sword.  We have tremendous possibilities for innovative ways of communicating with patients and families.  However, this connectivity has led to an increased expectation of consumer control in all walks of life.  People expect to have the information they want and need when they want it.  It’s another shift in the dynamic of the provider-patient relationship.

Consumer discontent is another general megatrend, manifest in the demand for demonstration of value.  Whether we like it or not, people are increasingly viewing health care as a service not as dissimilar to other services as we have traditionally treated it.  While I believe there will always be an important difference between medicine and say, dining out or financial planning, consumerism in healthcare is an inevitable consequence of consumerism in society as a whole.

The final megatrend is accelerated consolidation.  While politicians love to give paeans to small business as the  engine of growth, the fact is that consolidation is increasing in all sectors.  This is not necessarily a bad thing; there are many gains in both efficiency and quality that come from increased scale.  For example, numerous studies have demonstrated the association between volume and quality in medical procedures.  But how will we operate in an environment where bigger is better?

One of the take home points for me about all this is that, to the extent that what we see in the healthcare environment is a reflection of deeper, broader changes in the wider world, it’s harder to think that we can simply “weather the storm” and wait for these new fads to pass.  Bob Dylan was right, “the times, they are a-changin’.”

While the term evidence-based medicine (EBM) first appeared around 1990, its origins were in the 1960’s.  As recounted by Ariel Zimmerman, in her recent article “Evidence-Based Medicine: A Short History of a Modern Medical Movement,” one of the important driving forces behind the development of what became known as EBM was the institution of the Canadian national health plan (Medicare).  McMaster University, founded in 1968 in Hamilton, Ontario, is arguably the birthplace of EBM.  It was one of four new schools established in the wake of Canadian health reform, in an effort to integrate concepts of epidemiology and public health into the medical curriculum.  It’s not too much of a stretch to assert that a desire to ensure optimal use of finite health care resources – the best outcomes at the lowest cost – led to what eventually became a world-wide effort to promote a more systematic, less variable and idiosyncratic, approach to clinical care.  In other words, if you want value, practice evidence-based medicine.

This was a key revelation to me as I read the series of articles on EBM in the most recent issue of Virtual Mentor, the AMA’s on-line ethics journal.  We talk about value as the ratio of quality to cost; as a result, we often focus on the numerator and the denominator separately, with a natural inclination among clinicians to place far more value on the quality component than the cost.  But the best evidence-based practice automatically maximizes value, for at least a few reasons.

1. EBM leads to less variability; specifically, it eliminates variability that does not add value, while preserving acceptable variability due to either lack of evidence or evidence that multiple approaches might lead to the same value.  Such consistency will necessarily decrease waste.
2. The best evidence (which admittedly is not always available, especially in pediatrics) incorporates some type of cost-benefit analysis.  Synthesizing such evidence into care guidelines helps ensure that both the numerator and denominator of the value equation are considered.
3. One less-emphasized aspect of EBM is the explicit incorporation of patient preferences into the decision making process.  This can be done either in the guideline development stage, by using data about average patients into the analysis, or at the bedside with the use of decision aids.  This is really the ultimate way of ensuring that what we do is of most value to those we serve.

None of this is easy.  First, the evidence base may be lacking or uncertain.  Several of the articles talk about the challenges in communicating issues of risk and benefit, including a delightful essay by the late Stephen Jay Gould.  Another article talks about medico-legal aspects of EBM.  And there are indications that patients are somewhat skeptical about the whole notion of evidence-based medicine, feeling that all medicine must be evidence-based, and that more care always mean better care.  (Both of these assertions, by the way, are demonstrably not true.)

Nevertheless, as we work to improve the value of the care we provide – by decreasing our unnecessary variability – we’ll be best served by following the methods of evidence-based practice.  As difficult as it may be, it’s much better than the alternatives.

We were recently admitting a young child with pneumonia.  She was 2 years old, with a fever of 103 and moderate tachypnea; she had a left lower lobe infiltrate without effusion, and though she appeared ill she was non-toxic.  However, because of an SpO₂ that was 91 percent, we felt she should be admitted for supplemental oxygen and monitoring.  So far so good.  Then the resident suggested sending a CBC and blood culture.

• “Why the CBC?” I asked.
• “To see if it looks like an infection.”
• “What else would cause pneumonia?”
• “I guess I mean a bacterial infection.”
• “How sensitive and specific is the white blood cell count?  If it’s normal, would you not give antibiotics?”
• “No, I guess I’d still give antibiotics.”
• “So why the CBC?”
• “Well, just as a routine, to be on the safe side.”

Now, I’m not picking on the house staff, who do a wonderful job.  But I am wondering who taught her that getting any lab test is “routine,” or that “just to be on the safe side” is an acceptable rationale for ordering a test.  Every diagnostic test should have an anticipated affect on management: the result (either alone or in combination with other results) is going to change the estimate of the probability of disease sufficiently that we would cross a threshold toward a different action.  If not, then it’s not a useful test, and a waste of resources. This is one of the principles of evidence-based decision-making.

The era of “routine testing” needs to end.  We need to be much more thoughtful and selective in how we perform tests, to ensure that there is value to be obtained from the results.  Evidence-based guidelines can help us be more targeted, and (perhaps paradoxically) decrease variation. And as far as “being on the safe side,” it’s pretty clear that there are risks to diagnostic testing, in the form of spurious abnormal results.  A recent NY Times article discusses the economic and emotional impacts of chasing such results.  While this is in some ways a necessary evil (after all, if we define an abnormal result as one that is 2 standard deviations away from the norm, then by definition 5% of all results will be abnormal), risk/safety is one of the factors that ought to be considered when deciding on whether to order a test.

As far as that blood culture.

We’ve heard a lot about how health care spending in the US is not sustainable.  Thus, we are focusing on becoming more efficient, at promoting not just our quality but our value, and of pursuing the so-called “triple aim” of better care, improved patient outcomes, and lower cost.

But health care is unsustainable in another way, too – environmentally.  The health care sector is an important, and in many cases disproportionate, source of solid waste, water consumption, and energy use, all of which contribute to our outsized carbon footprint.   Here is just one statistic:  hospitals have 2.5 times the energy intensity and carbon dioxide emissions of other commercial buildings.

Although the links between the environment and health are clear, we providers and others in the health care industry have not traditionally included environmental considerations as a key element in our decision-making.  It’s not a major part of our culture.  But this is starting to change.  A number of organizations and coalitions have emerged in recent years in an effort to make the health care sector more green.

Some are focused primarily on the environmental impact of health care facilities.  One such organization is the Healthier Hospitals Initiative, comprised of some 475 hospitals from 11 large health systems.  They aim to get hospitals to reduce energy and waste, choose safer and less toxic products, and purchase and serve healthier foods.  One HHI member is Gundersen Lutheran, based in LaCrosse, which aims to be energy independent by the end of 2013, and has a stated goal of being the first hospital to be carbon neutral.  Other organizations are more broadly focused on environmental issues, dealing not only with the impact of health care on the environment, but of the environment on health.  Health Care Without Harm and Alliance of Nurses for Healthy Environments are among those who are also engaging in education and advocacy efforts to improve local and global environments to promote better health for their patients and populations.

Too often we ignore the environmental impact of the care we provide.  But if we are serious about our vision of the children in Wisconsin being the healthiest in the nation, we need to begin to include such considerations into how we think about what we do.  There is growing evidence that not only will it improve the health of our community, but also lead to lower costs in the long run.  After all, all waste is in some way, well, wasteful.  In fact, those who work on sustainability talk about the “triple bottom line”: healthier people, greater environmental sustainability, and improved profitability (a.k.a. people, planet, and profit).  Sounds suspiciously like that “triple aim.”  In future columns we’ll explore some specific things we might do, but in the meantime, I urge you to think how we – as individuals and as an organization – can improve our triple bottom line.

About 10 years ago, a series of stories in the Milwaukee Journal Sentinel, among other places, noted that health care costs in southeastern Wisconsin were up to 55% higher than the average for the Midwest.  Several factors were felt to be responsible: high hospital and physician rates, in part due to less consolidation in the insurance business; and greater utilization (older population, less cost-sharing and more generous plans).  In addition to intense publicity, large local employers banded together to form the Business Health Care Group as a way to increase payers’ bargaining power.

So what’s happened since then?  A recent MJS article notes that the differential between SE Wisconsin and the rest of the region as shrunk to 7%, due in large part to much lower than average increases in hospital costs and utilization rates that are now consistent with, or lower than, average.  That would seem to be good news.

The bad news?  With health care costs continuing to rise faster than overall inflation, the focus is now on payments to providers, which remain substantially above the Midwest average: 191% of Medicare here vs. 158% as the Midwest average.  (As most of you know, MCW is a good bit above the SE Wisconsin average.)

We have justified our higher than average charges in part because of our academic mission, and in part as a way of making up for the fact that approximately half of our patients are on Medicaid, which pays below the cost of providing care in many cases.  A survey showed that the majority (78%) of respondents  were unwilling to pay more for access to an academic medical center; of those who were willing to pay more, the median premium was 10%.  As far as cost-shifting to cover Medicaid, there is some willingness among payers to accept such a need, but not to the extent we have done so in the past.  In short, we are not going to be able to continue to command the very high provider rates we have in the past.  The tea leaves are clear.  The fat lady has sung.

Concerning?  Of course.  But let’s not allow ourselves to be victims.  We may not be able to control our environment, but we can certainly control our response.   Time to move up to the higher rungs of the accountability ladder and determine what we’re going to do about it.