Healthcare & Technology

Population Health in Crisis: Patient Care Management

Where do nurses and doctors find the time to provide care beyond the office walls? Given the fragmented nature of the U.S. healthcare system, healthcare providers have increasingly implemented Care Management programs aimed at coordinating the care patients receive to improve quality, reduce per capita cost and improve access to care. Traditionally, coordination interventions follow from several perspectives: medical versus social; short-term episodic or acute care versus chronic and long-term care; and various points of access to the patient (e.g., patient targeting to find those in need of high-intensity services, managed care organization, or physician office practice).[i] 

Care Coordinators (a.k.a. Care Managers) provide outreach to at-risk patients to ensure they receive specialized attention related to needed services. They are a key liaison between the patients and their primary care providers. The general intent is to facilitate delivery of the right health care services in the right order, at the right time, and in the right setting.[ii] Recently, care coordination programs have gained a stronghold where managed care organizations, commercial vendors, academic medical centers, and private health insurers sought to implement mechanisms aimed at controlling costs, improving disease outcomes, quality of care, and patient satisfaction.[iii]

At a high level, a 2000 report, entitled, “Best Practices in Coordinated Care,”[iv] made the following five recommendations for Care Management programs:

1. "Programs should follow the three steps: Assess and Plan, Implement and Deliver, and Reassess and Readjust for all enrolled patients;
2. Programs should have express goals of prevention of health problems and crises, and of early problem detection and intervention;
3. Disease-specific programs should incorporate national evidence-based or consensus-based guidelines into their interventions;
4. Care coordinators should be nurses with at least a bachelor's degree in nursing; and
5. Programs should have significant experience in care coordination and should have evidence of having reduced hospital use or total medical costs."[v]

Care Management software comes in various shapes and sizes. Many fill the needs of Clinically Integrated Networks of Hospitals, Clinics, and practices; others come in smaller sizes to meet the needs of small practices. One such package is Stone Health Innovation’s Idea Care. Regardless of the size, certain capabilities should be part of the care management software solution as described below.

Care Coordination Components[vi] should include:

1. The ability to perform a clinical assessment.
2. Develop a Nursing Proactive Plan of Care (POC) separate but approved by the Physician.
3. Identification of participants in the patient’s care and their roles. This also includes those who are not authorized to view or speak to clinicians about the patient’s personal health information (PHI).
4. The ability to communicate to all team members, including patients and their family.
5. Ensure secure information exchange in communications and across care interfaces. Prevention and mitigation of interface issues for transitions and handoffs between settings of care.
6. Provide the ability to monitor and adjust care goals.
7. Evaluate health outcomes – a principle target. Also, identify issues in coordination and care that may impact outcomes.
8. Ensure ability to utilize standard protocols, evidence-based guidelines, self-management programs, and routine reporting and feedback.

Information provided herein serves as development for a working definition that may be a helpful step for others attempting standardization in the area of Care Coordination. Interventions can be demarcated by type that includes not only use of software, but also educational brochures, mailings and member letters, telephonic care management, in-person care management, call centers and self-monitoring devices. Providers may find patient profiling and reports that originate from registries and clinical information systems, electronic medical records, decision support and other electronic communication systems useful. The Agency for Healthcare Quality and Research (AHRQ) published research on care management entitled “Measuring Value in a Care Management Program.“[vii] AHRQ claims that a measurement strategy is critical for determining the value of a Care Management program and to ensure effectiveness in reaching its goals.

 

[i] McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination). Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun. (Technical Reviews, No. 9.7.) 2, Background: Ongoing Efforts in Care Coordination and Gaps in the Evidence. Available from: http://www.ncbi.nlm.nih.gov/books/NBK44011/

[ii] Ibid.

[iii] Ibid.

[iv] Chen A, Brown R, Archibald N, Aliotta S, Fox PD. Best practices in coordinated care. March 22, 2000 [Accessed: January 30, 2006]; Available from: http://www .cms.hhs.gov /DemoProjectsEvalRpts /downloads/CC_Full_Report.pdf. [Reference list]

[v] Ibid.

[vi] McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination). Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun. (Technical Reviews, No. 9.7.) 3, Table 6: Components of Care Coordination. Available from: http://www.ncbi.nlm.nih.gov/books/NBK44012/

[vii] By Using Structure, Process, and Outcome Measures, a State Can Ensure That It Is Receiving a Complete Picture of Its Program's Value., AHRQ. "Section 7: Measuring Value in a Care Management Program." Agency for Healthcare Research & Quality. U.S. HHS: Agency for Healthcare Research and Quality, 2014. Web. 13 Sept. 2016.

Population Health in Crisis: Patient Engagement

In my first post in this series on Population Health, I stated that EFFECTIVE PATIENT ENGAGEMENT IS ALL THAT MATTERS. There is simply nothing more important than the patient if you are trying to deliver higher quality of care at a lower cost for a population of patients. When clinicians are dealing with many patients they generally do not have the time to effectively educate each individual patient in a manner that may help improve their wellness.

For example, patients with Diabetes require education about exercise and the kinds of foods that are suitable for someone with their condition. Likewise,there is a need to teach all patients, but especially those with comorbidities the importance of staying in compliance with their medications. The list can go on and on. 5-10 minutes with your doctor every three months will never suffice vis-à-vis the kind of information needed to support wellness. 

Almost everyone is using the Internet to search for articles on their conditions, however; often they may encounter information that is inaccurate for their specific circumstances. Nurse note here... “It is always best to check with your Doctor or Nurse” – but they may not be available when the patient needs a question answered. Now we have the role of the “care manager” in population health. The healthcare industry recognizes this obvious need but is struggling how to fulfill it.

One thing is certain as we have discussed before, conversations with the patient cannot take place in a multiplicity of places (e.g. patient portals for every specialist). It has to take place in one virtual space or it won’t take place at all. But, how is this possible if every doctor wants to use their own distinct virtual space to communicate? Enter a visionary startup Docola, whose platform allows the conversations to take place in a single virtual space no matter how many clinicians are treating the patient.

Using Docola’s Platform (or something akin to it) the conversation becomes centralized across all care providers. Care coordinators are able to pull the requisite patient information from multiple EHRs and other data sources to effectively educate the patient. In fact, Docola’s Platform is, among other things, a patient education platform. Now clinicians can choose from world-class clinical content publishers the educational courses that have the potential to make an enormous contribution to patient education, while at the same time ensuring that the patient conversation takes place.

The certainty of this approach for patient education is self-evident. The reason that we have not seen this type of system receive widespread success is that the healthcare industry, despite recognizing the need and potential of this type of Platform, is struggling to develop the business model(s) that would make it work. In short, the industry is struggling mightily to remove the shackles placed upon it by Fee-For-Service. However, disruption is coming.

Population Health in Crisis: From Cowboys to Pit Crews

In my last post, using Atul Gawande's TED Talk as an example, I discussed the need for healthcare training to transform itself from educating cowboys and cowgirls (i.e. fiercely independent and self-reliant clinicians) to coaching “pit crew” members.[i] Don’t hold your breath - this transformation will not happen anytime soon; clinicians were trained in a particular way for well over 100 years. Moreover, academia is the last industry in the world from which you should expect innovation. It’s not going to happen. That leads us to the question of knowing what type of professionals and skills are required to deliver on the promises of population health.

Healthcare workforce education has traditionally focused on a siloed approach and rarely offered students of diverse disciplines the opportunity to learn together in the classroom or through experience. This siloed approach has contributed to the constant problems faced in health care. What healthcare needs is a learning organization. A learning organization uses systems thinking to see the surrounding parts as a whole. It is an antidote for complexity and with the scale of complexity at its highest in Population Health initiatives, systems thinking can provide the discipline for “seeing the structures that underlie complex situations.[ii]” Interprofessional education and practice has shown to improve healthcare’s ability to provide high-quality patient-centered care.[iii]

Professional Services

As software and hardware continue their downward spiral toward more and more commoditization, services become the key differentiator. The professional services sector is becoming increasingly critical to the success of population health projects. That is why the main commercial population health vendors have ongoing initiatives to strengthen this part of their value propositions. Even the uninitiated quickly discover the myriad of complex skillsets required for the recipe that delivers on the promise—from HIT professionals to top notch clinicians—spiced of course with professionals who can bridge the gap between the two.

          All growth will come from intellectually based services.

          —James Brian Quinn

My primary complaint against a professional services led model is not that talented consultants do not bring significant value to the table, but that their business models often work to the detriment of providers, especially in the population health space. Here’s why. Maximizing billable hours is their principal mechanism for increasing revenues. They develop sophisticated techniques for achieving this end, including a never-ending obsession with account control. The goal from a provider’s perspective is to minimize the amount of time and risk it takes to develop and implement population health solutions. These two goals are diametrically opposed. In turn, when revenues begin to fall, they cut corners to compensate and as they push harder they begin to realize that the easy way out usually doesn’t work.[iv]

Consider the fact that for professional services, maximizing revenues for a given project requires providing more warm bodies and billable time instead of fewer. The key for providers is to hire a professional services organization that is thoroughly focused on doing more with less and transferring knowledge as fast as providers have the bandwidth to absorb it.

Although professional services continue to increase in importance, not all service providers have the best interest of their customers in mind, caveat emptor! The question you should ask any service provider is “How do you intend to reduce the number of project hours required for closure?” Enough said.

The Environment

During the dot.com craze, companies thought they could instantly manufacture a corporate culture of creativity by having a fully stocked kitchen, game rooms, casual dress code, and mandatory corporate fun activities. All of these culture creation props, for most of these companies, were as empty as their bank accounts. These perks are obviously nice to have, including a physical work environment that is conducive to creativity and personal productivity, but they are no substitute for a sincere corporate culture. The burden of consistently working 60-80 hour weeks for months at a time, and spending precious little time with those you love, will not be lessened by ten free diet cokes a day.

Shared Values

It is clear that a sustainable corporate culture must be built on a foundation of open communications and a shared set of core values, which include: honesty, integrity, respect, diversity, and profitability. Your shared belief system must permeate the entire organization and manifest itself in the day-to-day operations of the business. This common belief system should be self-evident.

Us Versus Them

The business press quickly killed a good-sized forest with all the print space that has been dedicated to the importance of cross-functional teams and communications. Despite this, organizational silos exist everywhere you look. Why do these walls remain when there is universal agreement that they significantly contribute to organizational dysfunction? Apparently, as previously mentioned, the walls remain because individual stakeholders often have a perceived vested interest in maintaining them. Nowhere are silos more insidious than in population health projects given the enormous amount of cross-functional support required for success.

One way to begin tearing down the walls is to eliminate physical barriers that exist between various departments. Have Nurses and Therapists intermixed in adjacent cubes or offices. While you are at it, throw in a Doctor as well. The daily communal contact will enhance cross-functional communications. Without encouragement from anyone, neighbors will begin to break bread, and perhaps have a drink together after work.

Another, perhaps better, way to improve cross-functional communications is to encourage Natural Leaders and individual team members to open dialogs with all business functions required to accomplish the mission. Frequently line executives prevent cross-functional communication because of their prejudices, fears, and insecurities. Learn to maneuver around these obstacles and watch as the communications process improves dramatically.

Talent Connoisseurs

Our people are our greatest asset.  We should all agree to abolish this statement from the business lexicon because at 99.9% of the companies that I have worked or consulted with (unfortunately) this statement is empty rhetoric and corporate propaganda of the worst kind. Most companies do not treat their employees as if they were the business crown jewels, and everybody knows it. Cut the baloney unless you can deliver the goods.

Everything else being equal (and of course they never are), the companies with the best teams will win more often than not. It follows that you will require excellent coaches and talent scouts to sustain an advantage. You better pay these folks well because they will be (and are) in high demand. Recognizing quality talent is a tricky business, and if you rely on Ivy League pedigree nonsense as your principal criteria, one of your competitors is likely to wind up with all the golden needles in the haystack.

The Recruiting Buzz

When I am brought in to help an organization build a team, the first question I ask is “What is your recruiting buzz?” Of course, I always get the expected response, blank stares followed by “What are you talking about?” In a labor market where quality talent is scarce, they are in the driver’s seat and are usually very selective when choosing new assignments—not unlike the best actors and directors in Hollywood.

Why would the best talent want to work for your company, and on this particular population health project? Your recruiting buzz answers this question. It is the story told to candidates to get them excited about your mission. Companies are often engaged in very cool and exciting projects, yet they do not know how to milk it for all it’s worth during the recruitment process. Don’t get me wrong; this is definitely not about selling a story that will vaporize as soon as the newly signed up candidate walks through the door. It is about presenting what your project has to offer in the best possible light. Without a great recruiting buzz you are unlikely to win your fair share of the best candidates. Build it. Practice it. And use it often.

[i] Gawande, Atul, MD. "Transcript of "How Do We Heal Medicine?"" Atul Gawande: How Do We Heal Medicine? TED Talks, Apr. 2012. Web. 28 Aug. 2016.

[ii] Senge, Peter M. The Fifth Discipline: The Art and Practice of the Learning Organization. Revised ed. New York: Crown Business, n.d. Print.

[iii] Knickman, James, Anthony R. Kovner, and Steven Jonas. Jonas and Kovner's Health Care Delivery in the United States. 11th ed. New York: Springer Publishing, n.d. Print.

[iv] Senge, Peter M. The Fifth Discipline: The Art and Practice of the Learning Organization. Revised ed. New York: Crown Business, n.d. Print.

 

Population Health In Crisis: Lack of Communication

It is not the Internet, or the Internet of Things, or Big Data, or analytics, or a host of other technologies that are foundational to population health that will eventually transform healthcare. These technologies may be necessary, but they are certainly not sufficient. No, what will drive transformation is the way in which the medium will improve conversations that take place between human beings (i.e. between providers and patients). The improved human dialog is the change agent.

We need to insert the patient into the equation. Although this may seem obvious, it is one that the FFS model has ignored for well over 100 years. Everything else was a distant secondary consideration. Why has the patient been left out of the equation? Because unlike almost every other market you can imagine, in healthcare the patient historically was not the entity that paid for the services. Hence, from an economic perspective, the healthcare industry was free to ignore the very people they purportedly served.

Atul Gawande spoke about the need for communication and systems thinking in healthcare. In a TED Talk, he summed it up by saying “We’re all specialists now, even the primary care physicians. Everyone just has a piece of the care. But holding onto that structure, we built around the daring, independence, self-sufficiency of each of those people has become a disaster. We have trained, hired and rewarded physicians to be cowboys. But it’s pit crews that we need, pit crews for patients.”[i]

The very reason that population health is in a state of crisis is that the focus formerly has been on a million and one potential distractions with very little attention paid to how we were going to engage with the patient, and moreover exactly where was this engagement going to take place. A premise of the population health “movement” is that healthcare has to transform its view of the patient from a “clinical thing” to be examined and studied, to a natural person with whom we want to engage in a mutually beneficial dialog.

A few thousand years ago there was a marketplace. Never mind where. Traders returned from far seas with spices, silks, and precious, magical stones. Caravans arrived across burning deserts bringing dates and figs, snakes, parrots, monkeys, strange music, stranger tales. The marketplace was the heart of the city, the kernel, the hub, the omphalos. Like past and future, it stood at the crossroads. People woke early and went there for coffee and vegetables, eggs and wine, for pots and carpets, rings and necklaces, for toys and sweets, for love, for rope, for soap, for wagons and carts, for bleating goats and evil-tempered camels. They went there to look and listen and to marvel, to buy and be amused. But mostly they went to meet each other. And to talk.

Yes, markets contain prominent conversations. The Cluetrain Manifesto[ii] propelled this meme on the world’s stage over fifteen years ago. However, very few people intuitively understand the implications, and fewer still are leveraging the idea, as a way of doing business in healthcare. Enormous opportunities await any organization that finds its voice, and through it learns to have an ongoing conversation with its patients.

Further, patients are eager to have this conversation, as long as it is no more demanding of them then their use of Facebook, or WhatsApp, or Snapchat or whatever social media platform they choose to engage with. Moreover, it is clear that the conversation needs to take place in one virtual space, not hundreds. The idea of patient portals is DOA. Why? Because a patient is not going to visit twenty different portals to engage with all the clinicians (i.e. specialists) that our currently fragmented delivery system mandates.

 

[i] Gawande, Atul, MD. "Transcript of "How Do We Heal Medicine?"" Atul Gawande: How Do We Heal Medicine? TED Talks, Apr. 2012. Web. 28 Aug. 2016.

[ii] Rick Levine et al., The Cluetrain Manifesto: the end of business as usual (Cambridge: Perseus Publishing, 2000).

Population Health in Crisis: The Any Good Manager Fallacy

A good manager can manage anything right? Take for example Jack Welch (i.e. former CEO of General Electric), who is universally renowned for his management skills. Can you conceive of a business or government project that Jack would not manage effectively? I can. Jack was a good manager, but he probably would have done a poor job of managing The Manhattan Project (responsible for building the first atomic bomb). Why?  He was a world-class executive but not a world-class theoretical physicist. He would have had a heck of a time trying to discern a great atomic bomb design from a disastrous one. And even if this feat were remotely possible, we certainly would have lost the war by the time Jack made a reasonable determination.

 If you are going to manage, let alone lead, any non-trivial population health initiative (and most trivial ones for that matter), you better be an extremely knowledgeable (i.e. a combination of clinical, healthcare information technology, and managerial expertise) and a respected member of the team. Otherwise, the troops and their respective bosses are going to chew you up and spit you out. Design sessions will turn into popularity contests or position power plays, neither of which is likely to produce great results.

No, Jack Welch, being a world-class chief executive, would have immediately recognized that he was not the right man for the job, and quickly would have gone out and hired the best available talent that money could buy. It seems obvious in this example, but over and over again I have seen individuals put into positions of management or leadership where they have, at best, a rudimentary understanding of the underlying technologies and/or subject matter domain. It is as if charm, good looks, or social graces were enough to get the job done when it comes to leading an inordinately complex population health initiative.

This is not to say that being a technically competent individual with excellent managerial skills is enough either since I have already expounded at length on the importance of leadership. But if you have these skills, at least you are qualified to be in the game!

FOR THE LOVE OF THE GAME

Most people, at the top of their profession, derive some intrinsic value from their work. It is probably one of the reasons they excel in their chosen vocation. Usually, such a calling satisfies significantly more than their financial needs. They derive an extreme sense of satisfaction, and at times, inspiration from the work itself. Ernest Newman noted:

The great composer does not set to work because he is inspired but becomes inspired because he is working. Beethoven, Wagner, Bach and Mozart settled down day after day to the job in hand with as much regularity as an accountant settles down each day to his figures. They didn’t waste time waiting for inspiration.

All the truly exceptional project managers that I have had the pleasure of working with displayed an intense passion for their craft. They got off on the work. Just like exceptional musicians get off on their music. Passion for your craft is a pre-requisite for greatness. If you want to hire the best of the best, learn to look for a certain fire in their bellies and sparkle in their eyes.

THE ECONOMIC UNIT OF VALUE CREATION

Successful projects drive competitive advantage, and in healthcare, the need for competitive advantage is growing day-by-day. The creativity that impacts activities of the value chain yielding marketplace advantages is almost always unleashed within the context of a project. Therefore, it follows that you want to staff your mission critical projects with the best available talent you can find, wherever you can find it.

Mission critical projects should define and guide your employment practices. Much of the talent you would love to hire would probably want to work on your mission critical project, given that you are willing to pay them what they’re worth, however, they may not be as interested in a stewardship role for the next five years, once the project’s objectives have been met.

In other words, there are people who love to continuously create, and there are those that create and then to nurse their creations. One is not necessarily better than the other, but they are different. To be successful, you must learn to recognize individual differences and then hire world-class players for each category. Mission critical projects will only yield sustainable results if you are astute enough to hire the right combination of both.

PAY FOR PERFORMANCE

By now just about everyone understands that lifetime employment, with the same organization, is a thing of the past. It may still happen in a very small number of cases, but the majority of workers (of whatever color collar), either out of necessity or by choice, will wind up working for many employers over their lifetime. Whether they are employed as permanent employees (whatever that means nowadays) or freelance consultants will make little difference.

One thing is certain; top talent will continue to insist on pay for performance at high market rates. They will also be in a position to negotiate more vacation, flexible hours, and anything else that the current market will bear. If organizations insist on playing thefool’s game of squeezing their best talent financially, the moment things turn a little tight economically; they will be rewarded with mass exodus when the economy improves. You reap what you sow.

“Did anybody think it would be just the people who were downsized who would start thinking like free agents? This is capitalism. If you create a free market for anything, including talent, the people with the most value to sell are going to leverage it for everything it’s worth. And that’s what’s happening. The most valuable people are leveraging their talent in the marketplace for everything it’s worth. Success now is defined by the open market, and that means that the sky is the limit. No single organizational hierarchy puts a cap on your potential. Go wherever opportunity takes you. That is the essence of the free-agent mindset.[i]”

Of course, it is prudent to point out that free agency is not without risks. You may have to accept lower market rates and/or less work whenever economic conditions dictate. It is not all upside by any stretch of the imagination. However, even in a bad employment market, free agents tend to have distinct advantages. Since they often have better skills and are economically motivated to keep them honed, they remain aggressive competitors in good markets as well as bad.

[i] Bruce Tulcan, Winning the Talent Wars (New York: W.W. Norton & Company, 2001) 24

Population Health in Crisis: The Mission

Almost everything non-trivial that happens in the business world, and in many other walks of life, is the result of a project. Projects have a well-defined beginning, middle and end. They always require a project plan. The plan not only defines the stages of the project but also drives its execution. I prefer the word mission because it implies motion and carries a greater sense of urgency. Given the importance of population health initiatives to their respective stakeholders, I can assure you that there better be a sense of urgency, or this initiative will wither and die on the vine.

Signing Up

You usually either sign up for the mission through pressure from your current employer or preferably, you volunteer on your own. However, signing up for a population health initiative is, for me, a much deeper commitment than is apparent on the surface. It means that you will do almost anything within your power to achieve the end game. It may make the difference between your organization thriving and prospering in the rough and tumble world of 21st-century healthcare, or becoming roadkill on the information highway.

For population health initiatives, signing up does not necessarily imply consistently working 60 hours a week for the duration of the mission. However, it does imply that you will go above and beyond the call of duty, which often entails some overtime, and/or other personal sacrifices at critical junctures. Signing up is a binary proposition, you’re either on board or you’re not. There is no acceptable middle ground. It is a contract with the rest of the team members. It is mutually binding and cannot be broken without putting the mission at risk.

Getting all team members signed up is the responsibility of the mission’s Natural Leader. On projects where I have assumed this role, I always look for opportunities to shoot on sight any team members caught sitting on the fence. They usually die a very slow and painful death, often from multiple wounds. I would rather reduce headcount than risk the mission by having to carry wounded combatants iteration through iteration. This is hyperbole of course but you get the drift.

No One Gets Left Behind (the WIIFM)

While Signing Up ensures that everyone on the project commits to everyone else by signing the same mutually binding contract, the Natural Leader also signs a personalized contract with each individual. This contract is a promise that individual, and specific, benefits will accrue to each (and every) team member in return for his or her effort during the mission. It answers the question “What’s in it for me?”  This contract is implicit between the Natural Leader and an individual team member and is not shared with other mission comrades.

Would you persuade, speak of interest not of reason.

—Benjamin Franklin

In Black Hawk Down the movie’s powerful punch was delivered not by outstanding performances from Hollywood’s elite, but by the graphic representation of the brutality of war, and the poignant relationships that are manifested in the middle of life and death situations. The motto of Delta Force is, “No One Gets Left Behind,” and I guarantee you, if the film is to be taken at face value, this is no gung-ho marketing campaign. It is a mutually binding contract that is honored at all costs. Notice that all this contract talk does not involve an organizational abstraction outside of the project team. It is widely known that soldiers in the heat of battle fight harder, and often until no one is left standing, not for God or country, but because of the personal relationships they have with those in nearby fox holes. It is the shared experience of the mission that brings out the best in us.

Natural Leaders

Natural Leaders own the mission. By definition, there is only one Natural Leader for any given mission. They can coexist with a leader that derives authority from position power but are obviously more effective when position power and natural leadership are aligned. Natural Leaders create team magic. Magic is not a by-product of serendipity. It is clear that renowned movie directors do not rely on serendipity to create the cast chemistry required for a great movie. The creation of cast chemistry is premeditated.

Good fellows are a dime a dozen, but an aggressive leader is priceless.

—Red Blaik

How do Natural Leaders do what they do? Does it require charm, superior social skills, above average intelligence, empathy, and love of humanity? Well, the truth is that no one knows for sure. Probably a Natural Leader possesses all the aforementioned qualities and still others that remain unnamed. The nature versus nurture argument is relevant, and like so many other cases where this argument is raised, the only plausible answer is that natural leadership requires some combination of both. That said, it is clear that leadership skills can be improved with practice and grow with experience.

It must be noted that leadership skills are not immutable. Change the mission context in a dramatic fashion and/or within a different domain and you are unlikely to see the same Natural Leaders emerge. Leadership is often fleeting. It is extremely context sensitive and occurs within certain space and time boundaries. That said, within a given context and domain, leadership can certainly be maintained across a relatively large number of missions. As previously mentioned, there are no scientific principles of leadership, and perhaps there never will be; yet there are some rules of thumb that have worked for me and I will share them with you in subsequent posts. These always seem to apply, despite the composition of the current team and the context of the current mission.

 

Population Health in Crisis: The Talent Wars

The guys in the black hats always come out when times are hard, this time, to pontificate on why Obamacare and Population Health initiatives are nothing more than myths invented by an army of pseudo-intellectuals who profit from promulgating this sort of nonsense. The irony is that, despite the near zero growth economy we all now live in, the healthcare industry and the dynamics of its labor markets have both changed permanently and irrevocably and, in my opinion, for the better.

The much-publicized chasm between the old industrial economy and the new knowledge-based economy is not only real, but will continue to grow in importance, and in dramatic fashion, for the foreseeable future. This time, it is healthcare’s FFS model that will be permanently disrupted. Knowledge workers with interdisciplinary skill sets will be in high demand and, for the most part, cannot be outsourced. Bending the cost curve of an industry that consumes 17% of GDP will become a national security initiative. We are a single Black Swan event away from a catalyst of massive disruption.

The Internet and the New Economy, while not one and the same, are certainly part of the same positive feedback loop that, along with globalization in its myriad manifestations, are pushing world economies into increasingly unchartered waters. In the next five years, healthcare’s Talent Wars are likely to increase in ferocity and winners will acquire the assets necessary to dominate their respective markets for the next hundred years.

We are at an inflection point of immense proportions. This is the kind of discontinuous change that occurs once every thousand years or so. Of the three factors of production (land, labor, and capital), labor, in all its incarnations, is about to emerge in a manner that will permanently establish its dominant position in healthcare. Over time you will see smart labor transforming healthcare in ways previously unimagined, all to the upside of both the top and bottom lines.

Just as smart medical devices with embedded software have invaded every nook and cranny of healthcare, from the operating room to the intensive care unit, smart labor will begin to make its presence felt as the key differentiator in emerging pillars of the industry such as business intelligence and patient engagement. The opportunities in healthcare are massive in scope, as the industry struggles with the creative imperative that permeates all aspects of its value chains. As Manuel Castells notes in The Rise of The Network Society:

Toward the end of the second millennium of the Christian Era several events of historical significance have transformed the social landscape of human life. A technological revolution, centered around information technologies, is reshaping, at accelerated pace, the material basis of society. Economies throughout the world have become globally interdependent, introducing a new form of relationship between, state, and society, in a system of variable geometry.[i]

Although Castells certainly does not share my views on the importance of labor, he does an eloquent job of describing, in vivid detail; the general social and economic conditions that place smart labor in a position of prominence in my worldview, especially in healthcare. Why healthcare in particular? Because there is widespread consensus, notwithstanding the political partisanship that surrounds Obamacare, that 17% of GDP is unstainable. Further, there is likely not a single adult over fifty that has not had one or more near financially catastrophic encounters with the perversity of FFS, especially if you have had the misfortune of becoming ill between jobs and without insurance.

The fight for talent will focus on individuals with healthcare experience that also possess strong skillsets in information technology and project management. These resources are scarce today and will become scarcer over time as population health initiatives, out of the “innovate or die” imperative, begin to gather momentum.

 

[i] Manuel Castells, The Rise Of The Network Society (Blackwell Publishers: 1998), 1

Population Health in Crisis - Healthcare’s Business Model Origins

Healthcare’s origins are obviously not as complex or as outrageously expensive as they manifest themselves today. Healthcare has evolved into its current state over the past 150 years with decisions that have altered its sole purpose of caring for the ill to an industry of skyrocketing healthcare costs and lower quality. The latter being the quintessential definition of a dysfunctional marketplace. In 1999, the Institute of Medicine (IOM) reported the annual number of deaths in hospitals from medical errors to be between 44,000 and 98,000[i] – and 12 years later we haven’t seen improvement. In 2004, Healthcare IT News reported that “Preventable medical errors persist as the No. 3 killer in the U.S. – third only to heart disease and cancer – claiming the lives of some 400,000 people each year.”[ii] Healthcare needs dramatic changes to enhance quality and lower costs while expanding patient access – also known as the “Triple Aim.[iii] CMS seeks improvements in quality and financial metrics through its Accountable Care Organizations (ACOs), regulations, Bundled Payments, and other innovations. Despite these efforts by CMS, the question that remains is how do we fix healthcare before it starts consuming even more than 17% of GDP. Before we address the innovation issue in subsequent chapters, let’s first discuss the industry’s business model evolution over time.

In 1909, George Bernard Shaw wrote Preface on Doctors: The Doctor’s Dilemma where he claimed that “the medical service of the community, as at present provided for is a murderous absurdity. That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity. But that is precisely what we have done. And the more appalling the mutilation, the more the mutilator is paid. He who corrects the ingrowing toe-nail receives a few shillings; he who cuts your inside out receives hundreds of guineas, except when he does it to a poor person for practice.”[iv] George Bernard Shaw’s scrutiny on payment for medical services in 1909 stands as it does today – fee-for-service (FFS).

By all accounts FFS is as perverse a business model as one can imagine. In no other industry does one get paid simply for “doing stuff.” Imagine if we were having problems with our car’s brakes and we took our car to the mechanic and he invoiced us because he “did stuff” notwithstanding that our brakes were no better off when we left than when we first arrived.  FFS evolved in healthcare likely because it was the path of least resistance. Without adequate means of tracking quality, and without transparent pricing, there was very little left that a business model could be built upon. As impetuous as this model is, today’s providers are not to blame for a business model they inherited. It was, and remains, the only game in town. If you wanted to make a living as a physician, then FFS is how you were paid. This cobbled together mess that FFS encompasses is not what a civilized nation would design knowing what we know now. The reality is that the answer to this question doesn’t matter, we have to transform from where we are today, all other discussions amount to nothing more than flights of fancy.

Continuing our history, hospitals arose in the pre-1890 era, largely to care for the chronically ill in unsafe environments. Most patients preferred care at home, avoiding hospitals. “In 1908, healthcare was virtually unregulated and health insurance was nonexistent. Physicians practiced and treated patients in their homes. The few hospitals that existed provided minimal therapeutic care. When patients saw a physician, they paid their modest fees out-of-pocket; they were more concerned about the wages they would lose if illness kept them out of work than about the cost of their medical care.”[v] Even so, what doctors got paid was under a nascent FFS model. There was no way to track outcomes effectively. The concept of population health was not even a gleam in anyone’s eye.  It was word-of-mouth personal relationships that physicians used as marketing and they did whatever was within their power (i.e. the reputable ones) to save lives and/or ease suffering.

In the 1900s regulation of the health professions began. We experienced the introduction of health insurance by individual payors and government sponsored healthcare provision. In the 1950s and 1960s government expanded use of hospitals nation-wide and introduced Medicare. Since then, we’ve seen rationing of care through Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). It is hard to use the word innovation to describe HMOs and PPOs because they amounted to nothing more than zero-sum attempts at cost shifting between payers and providers with the patient left completely out of the equation. Medicare and some Medicaid recipients have been introduced to Accountable Care Organizations that seek to improve care and lower costs and out of necessity, put patient engagement at its core. Regulations are now abundant, yet we have not seen significant improvement in quality of care. Nonetheless, we see rising, unsustainable healthcare costs, and FFS still dominates, poised to remain unchallenged for the foreseeable future.

Healthcare’s Business Model, FFS, has not changed in 150 years. Therefore, healthcare executives have zero experience reinventing business models nor any practice introducing new and innovative ideas for improvement, the latter often involving a deep understanding of information technology. Healthcare needs a blood transfusion if it has any hope of eliminating the status quo that leads nowhere. We will discuss what that blood transfusion will look like at more length in the “Talent Wars” chapter; however, it is safe to assume that project teams will look radically different than they do today and that some sort of Agile methodology will be in place.

 

[i] Kohn, Linda T., Janet Corrigan, and Molla S. Donaldson. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academy, 2007. Print.

[ii] McCann, Erin. "Deaths by Medical Mistakes Hit Records." Healthcare IT News. Healthcare IT News, 18 June 2014. Web. 14 Aug. 2016.

[iii] "The IHI Triple Aim." The IHI Triple Aim. The Institute for Healthcare Improvement, n.d. Web. 14 Aug. 2016.

[iv] Shaw, George Bernard, ed. The Doctor's Dilemma: Preface on Doctors. N.p.: n.p., 1909. Print.

[v] Moseley, George B., III, JD, MBA. "The U.S. Health Care Non-System, 1908-2008." AMA Journal of Ethics®., 2008. Web. 15 Aug. 2016.

Accountable Care Organizations and use of Telehealth/Telemedicine?

Link: Early Savings from Banner Telehealth Pilot

 Health Data Management (in the above link) reported savings from use of Telehealth that resulted in reductions in readmissions and healthcare costs. The ONC's Federal Health Information Technology Strategic Plan 2011-2015 described the use of technology to improve care, improve population health and reduce per capita costs of health care.  Goal II defined opportunities to Improve Care, Improve Population Health, and Reduce Health Care Costs through the Use of Health IT.

This same technology could be used in an Accountable Care Organization (ACO) to improve care and reduce costs. Systems, like telehealth, have been implemented in certain ACOs. Remote monitoring, mobile health (mHealth), and the medical home have the potential to positively affect patient lives.

The light bulb has been turned ON. Healthcare is migrating from a disease management system to a “National Prevention and Health Promotion Strategy” that prevents adverse health conditions where possible, anticipates and responds to threats and emergencies and identifies at-risk populations. To me, this strategy represents the goals for ACOs.

Reducing spend for ACO populations is key to health transformation and overall cost reductions in Medicare spending. According to the Banner Health Telehealth pilot, results were dramatic. By having a strong support system for patients, clinicians were able to "collect and analyze objective and subjective health information to identify early stages of deterioration" and to prevent worsening health conditions. Banner health reported enrolling its 500th patient into their program.

An Accountable Care Organization has a minimum of 5,000 patients with care coordinators responsible for monitoring patient status. Their beneficiaries are located throughout a geographic area and the ACO could gain significant cost reductions with positive patient care opportunities using Telehealth.

Several years ago, I was asked to be a panelist on a Bloomberg webinar on Telehealth. The question at the time was simple, "Is telehealth a viable alternative to face-to-face patient care?" I believed it then, and I believe it now, when used in appropriate situations. For more information on Telemedicine and its Telehealth subpart, read this post about the World Health Organization and Telemedicine Opportunities.

 

Pioneer Accountable Care Organizations exhibited smaller Medicare expense

Link: JAMA

In 2012, CMS launched the Pioneer Accountable Care Organization model and the Medicare Shared Savings Program. The Pioneer ACO model is a more ambitious test of population health management that targets experienced organizations. This model is an attempt to test viability of Accountable Care organizations and their ability to reduce spending and improve the quality of care provided to beneficiaries.

A study reported in the May 4, 2015 edition of JAMA reviewed Medicare spending, utilization and CAHPS domain scores for Pioneer ACOs in 2012 or 2013. The objective of the study was to evaluate spending and utilization between beneficiaries aligned with Pioneer ACOs and other FFS beneficiaries.

The study was "based on the work of evaluation contractors for the Evaluation of CMMI Accountable Care Organization Initiative performed under Contract HHSM-500-2011-00019i/HHSM-500-T0002 with the Centers for Medicare & Medicaid Services (CMS). CMS provided access to the data to the evaluation contractors to perform analyses under the guidance of Drs Nyweide, Lee, and Cuerdon. In conjunction with the contractors, Drs Nyweide, Lee, and Cuerdon designed the study and helped with interpretation of the data."

Data was obtained from CMS' Chronic Conditions Data Warehouse. The CMS Chronic Conditions Data Warehouse (CCW) provides researchers with Medicare and Medicaid beneficiary, claims, and assessment data linked by beneficiary across the continuum of care. The following graph is an example of Medicare Chronic Conditions by Medicare Status Code for 2013.

 For more information about Accountable Care Organizations and the regulations that support them visit the ACO Survival Guide store. ACO Quality Checklist coming soon!