Lola Butcher

I interviewed George C. Halvorson, chairman and CEO of Kaiser Foundation Health Plan, Inc. and Kaiser Foundation Hospitals, last week. Kaiser Permanente is the nation’s largest integrated health plan, serving more than 8.4 million members in nine states and the District of Columbia, so I am interested in what he considers the perfect health care system.

Are you ready?

“A perfect system basically says that we should have all of the information about all of the patients, all of the time, and that information should be available in real time. It should be available to the caregivers and to the patients; and the information should include information about each patient and about their conditions, and about optimal treatments for the conditions. And all of that connectivity is possible. It’s all doable. Pieces exist, but we have chosen not to put those pieces in place in a way that we should put them in place.

What I’m going to be arguing and suggesting is that we need to e-connectivity, e-visits, e-scheduling, e-linkages, that the patient should be able to get e-consults, and that the computer and connectivity should become possibly the single most important tool available to healthcare. That the computer should go from being something that just stores data and is rarely used to improve care, to being maybe the single most important tool in care–a  little bit like Bones in Star Trek, when he pulled out that little device and scanned the patient, and quickly get a sense of all of the information about the patient, and all of the information about the disease. I think that’s actually a model for where healthcare ought to go, is they ought to be creating that kind of functionality. Probably not hand-held at this point, but actually, hand-held not that far down the road.

We need computer models of the human body, we need computer models of the patient, but we also need information about each patient, and that information needs to be real time, and it needs to be focused on best care. So, I’m (advocating) about the need to move this country and our healthcare infrastructure toward the perfect system and the perfect set of connectivity, and basically say that doing anything less than that would be a huge mistake, and almost criminal relative to our patient care.”

I had the chance to interview Dr. Paul Ginsburg, president of the Center for Studying Health System Change, as a preview to his presentation at the World Congress on Consumer Healthcare and Wellness in mid-September.

Dr. Ginsburg is an economist, nationally recognized for his work in health economics and health policy, especially healthcare market changes and cost trends. He will participate in a panel that addresses something everyone in health care is wondering about:  Will Consumers Be Effective Catalysts to Reform the U.S. Health System?

Butcher: You just released a study that says 56 percent of American adults - that’s more than 122 million people - sought information about a personal health concern from a source other than their doctor during 2007. Does this suggest that Americans are becoming more active participants in their healthcare decision making?

Ginsburg: Oh, yes, they certainly are. American’s interest in their health has increased a great deal, say, over the past decade. We just know how much more space newspapers and television is devoting to personal healthcare issues, and of course we have a lot of development on the internet as far as sites that people can go to seek this information.

Butcher:  Many health plans have developed consumer support tools - speaking of the internet - such as online information about hospital and physician quality, and calculators that help plan members estimate the cost of care. Are consumers using these tools, and if so, how are they using them?

Ginsburg: Well, I’ve spoken to the plans, and the plans are all eagerly developing these tools. So when you ask them, Are consumers using them? They don’t know.

My sense is that this is clearly the direction long-term where plans will play an increasingly valuable role as an information intermediary. But I think we’re at the very early stages of it, and I doubt that there’s a lot of use. I doubt that consumers are depending on it.

One of the chicken-and-the-egg problems is that I don’t think consumers are going to be very receptive to using price information until they have more confidence in understanding the quality of different providers… Consumers can actually act perversely in the sense of not having confidence in the quality information, and equating higher price with higher quality, and thus shifting to higher priced providers, even if they actually reduce their quality of care in the process.

Butcher:  Is America’s healthcare system organized in a way that allows consumers to be effective shoppers for healthcare services? And does the healthcare marketplace respond to consumer behavior in the same way that the retail marketplace works?

Ginsburg: No, the healthcare system is very far from accommodating consumer desires, to the degree they have them, of being effective shoppers. For most cases,  medical care isn’t standardized enough that you can just call up places and, knowing what you need,  find out what the price is and the indicators of quality. Because so much of health care involves diagnosis, checking into what something is going to cost (and learning about) a provider (requires the patient) to invest a lot of time and money to make that call.

If you go to the dentist, if you need an inlay put in, a dentist won’t give you that over the phone because they’re going to say it all depends on the details of your condition. So, you’re going to have to invest the time and money of visiting a dentist to get an estimate.

So, I don’t think the healthcare consumer will ever be able to be as good a shopper as in other areas.

I enjoyed interviewing Jack Needleman, PhD, an associate professor in the Department of Health Services at UCLA’s School of Public Health. His research focuses on the impact of changing markets and public policy on quality and access to care.

Dr. Needleman is currently leading the team evaluating the Robert Wood Johnson Foundation initiative, Transforming Care at the Bedside, which is intended to improve the quality, safety, patient-centeredness and efficiency of hospital medical surgical units by engaging front line staff and unit managers in process improvement. 
 

Butcher: There are so many quality measurement initiatives in health care currently underway. Where is this movement headed?

Needleman: That’s a big question. If you look at the types of measures that are used, they fall into four categories: outcome measures like deaths or falls, process measures like beta blockers on discharge, structural measures like staffing levels, and perception measures from surveys such as the adequacy of pain management or communication with physicians and nurses. There are several directions that I think we’re moving in with regard to all of these kinds of measures. One of them is to simply expand the number of measures which raises issues of burden.  A second issue that’s emerged is what balance should there be among the four categories? Related to that, whether to give prominence to outcome measures, which require adequate risk adjustment and all the problems involved in that, or process measures which require that you have competence that the process is in fact closely associated with outcomes that we care about. So that’s a second ongoing debate that is nowhere near resolved.  A third direction is to increasingly link payment to adequate performance on specific measures.  There’s a substantial debate going on over which measures to pay on and how strongly payment should be affected by the measures.

Butcher: You mentioned burden there. I know many hospitals complain already about the burden associated with supporting the various quality measurement initiatives they participate in.  Do you see any relief for providers on the horizon?

Needleman: I think there are two different kinds of burdens we need to think about. One is due to different organizations requiring different measures of the same or similar outcomes of processes.  That, I think, is an easier issue to address, and I do see conscious efforts among the different parties, the payers, the creditors and regulators, groups that endorse measures like the national quality forum, to move to some conversion over which version of the measure is required. So that burden, I think, is going to get easier.
 
The second kind of burden is over the number of measures and whether those that are required for external reporting are actually useful for internal management in quality improvement.  I think one of the reasons why providers perceive a burden there is they don’t perceive the measures they are being asked to deliver to the outside world particularly useful in their internal work.  That’s a more difficult issue to address. Relief may emerge to the extent that providers can make the case that they are using measurements internally to improve, and the measures most useful for this work should be those that are required for external reporting.

I was lucky to interview Stuart Guterman, senior program director of the Medicare’s Future program at the Commonwealth Fund. A couple of things that caught my attention:

Lola: How should value in health care be measured, and do we need more measures or fewer?

Guterman:  That’s really the crucial issue. There has been a lot of discussion about paying for outcomes, and certainly one can make a strong case that how the patients survives the health care, what the health status of the patient is in the long run is really the bottom line. But I think we are where we are on being able to pay for quality because we’ve developed a set of more reliable process measures, that is measures of how services are provided that are expected to lead to better outcomes. So we now can put together a list of things that are pretty much accepted as ways health care should be provided that will lead to better outcomes.

In terms of more measures or fewer, there are arguments for fewer measures because a long list of measures is thought to present the prospect of confusion. I think that actually if you have a longer list of measures and if you really are comprehensive in the list of measures for what you pay for, then you’re really transmitting a broader message that the objective is to improve quality and improve the value that you get for the health care dollar.  I think that’s really the message that needs to be sent in value-based purchasing, not doctors should do this or doctors should do that. Doctors should really do a broad range of things that lead to better health for their patients.

Lola: How should providers be rewarded for value?

Guterman:  There are different ways to approach rewarding for value. Certainly you want to reward providers that provide the best care.  There have been studies that found, however, that if you rely only those kinds of measures, then you end up basically making most of your bonus payments to providers who already are at the level that you’re looking for.  If you’re really trying to improve the system, then you need to provide incentives for providers that aren’t where you’d like them to be to get where you’d like them to be.

So I think at some point you need to be able to reward improvement over time, and I think you also, when we have more information and we’re able to be more confident about setting levels of acceptable care, that we might want to pay on that as well. I think a good pay for performance system will basically incorporate measures of all three types of good performance so that we can have rewards for the folks who do it right, incentives for the folks who aren’t quite there yet but are improving, and then some more explicit recognition of the fact that you really need to be at a certain level in order to be considered a top-notch provider.

Physicians who do not like pay-for-performance programs may rue the day they started complaining about them.

P4P programs, which generally keep patients out of the mix, are easy to accept in comparison to public rating systems that reward patients, via lower copayments, for learning which physicians offer the highest quality care at the lowest cost and taking their symptoms to those doctors.

Physicians are understandly nervous about ratings, which can be misleading or downright wrong. But payers–frustrated that the P4P movement is going nowhere fast–are looking for new ways to reward physicians who will get in line with payers’ cost-effectiveness goals, and physician ratings is one of them.

In Massachusetts, the state medical society sued Group Insurance Commission, which buys insurance for more than 300,000 current and retired state employers, claiming that its physician rating system “fraudulently misleads patients and unfairly affects the reputation of physicians.”

No quaking in Massachusetts. Other payers are undaunted. As reported in the Boston Globe, two of that state’s biggest health plans are moving ahead with physician rating systems instead of waiting for the lawsuit to play out.

The New York state Medicaid program is the latest to announce it’s going to stop paying for some of the so-called health care that hospitals provide that, in fact, hurts more than it helps. Wrong-site surgery, anyone? Foreign object left in during surgery?

FierceHealthcare reports on the latest payer to make the seemingly common-sense move to stop paying for preventable medical errors:

New York’s Medicaid program has decided to stop reimbursing for avoidable hospital complications and medical errors it considers to be “never events.” Starting in October, it won’t pay for care related to 14 conditions, including wrong-site surgery; foreign objects left in the body; medication errors; blood incompatibility; contaminated drugs and patient disability from electric shock. Hospitals that want to receive Medicaid payments will have to prove that such conditions were present on admission to get paid for treating them. Meanwhile, the state expects to keep expanding this list.

This trend, which now includes Centers for Medicare &  Medicaid Services, CIGNA, WellPoint, and lots of others, makes so much sense…and yet why does this feel like a raft of unintended consequences getting ready to be revealed?

It is regrettable that hospital administrators do not recognize, let alone deal with, the unacceptability of preventable medical errors until payers start refusing to send the checks. There’s no doubt that the financial consequences of poor practices that result in infections and other serious medical harm will get hospitals to change their ways. But at what cost? The bureaucracy that is being built up to make the “no pay” trend work will be substantial, adding to the high cost of care. And the high cost of care translates into reduced access for some patients.

Term limits for legislators seemed like a good idea until they were passed–and now they look like big problems. I wonder if we’ll say the same thing about the ‘never event’ trend some day.