Valuing Value-Based Payment

The idea that payment should be linked to the value lies at the heart of most of the transactions we participate in on a daily basis. Yet, value based payment in healthcare has seemingly run into very rocky waters as of late.  It is at this precarious time that stakeholders representing large employers and other purchasers of health care’ took to the Harvard Business Review to write in defense of value based payment reform.  The authors pepper their article with cherry picked ‘successes’ of the value movement and urge the country to forge ahead on the current path.  The picture that comes to my mind hearing this is of the Titanic, forging ahead in dark waters, never mind the warning signs that abound.

One of the authors of the paper – Leah Binder – is President and CEO of the Leapfrog Group – a nonprofit organization founded in 2000 dedicated to triggering ” giant leaps forward in the safety, quality and affordability of U.S. health care by using transparency to support informed health care decisions and promote high-value care”.  This is a laudable goal, but it is very much predicated on the ability to measure value.  A perusal of the Leapfrog group’s  homepage notes a 1000 people will die today of a preventable hospital error.

The warning is explicit – choosing the hospital you go to could be the difference between life or death.  I have spent some time in the past about the remarkably weak data that lead to an estimate of 400,000 patients dying per year in hospitals due to medical errors, but suffice it to say the leapfrog group subscribes to the theory that of the ~700,000 deaths that happen in hospitals per year, half are iatrogenic.  With no exaggeration, I can say firmly that those who believe this are in the same company as those who believe the earth is flat.  If the home page of the Leapfrog group, examination of their claims in their HBR article merits additional concern.

The first example proferred relates to a reduction in venous thromboembolism or blood clots acquired in hospitals after a government agency (AHRQ) began tracking this from 28,000 in 2010 to 16,000 in 2014.  Binder et al., note that this means 12,000 fewer patients had ‘potentially fatal blood clots’.  Ostensibly this reduction in clots was due to reporting of these events and a Bush era rule from 2008 that put hospitals on notice that Medicare would no longer be paying for Hospital acquired Conditions (HAC) like clots after joint surgery.  But how exactly did hospitals achieve these impressive results?  While the hope is that hospitals achieved these reduction by better attention to therapies that prevent blood clots, the reality is somewhat more complicated.

For starters, orthopedic surgeons grew wary of searching for blood clots postoperatively.  The surgeons weren’t necessarily wrong to adopt a newly parsimonious approach.  Easy access to ultrasounds and cat scans meant many patients ended up diagnosed with small clots in the calf or in the small arteries of the lung that were unlikely to cause the patient harm.  It was not lost on surgeons that these clots were unlikely to be fatal to the patient, but were potentially fatal to the hospital and surgeon’s bottom line.

Yet another way of reducing hospital acquired conditions is to improve the diagnosis of blood clots that patients carry with them on admission.  It is clearly unfair to penalize hospitals for patients who present with a blood clot, so improving the diagnosis of these patients is important.  Unfortunately, too much of a good thing is usually too much of a good thing.  Some institutions actually began performing screening whole leg ultrasounds on all inpatients being admitted.  The whole leg is important because asymptomatic blood clots that do develop below the knee are generally not high risk , and indeed, many may resolve spontaneously with no treatment.  Worst of all the diagnostic accuracy of ultrasound falls precipitously as veins get smaller in the lower leg.  In 160 medical inpatients who had an ultrasound and a gold standard venogram, the positive predictive value of an ultrasound for a lower leg/calf/distal vein clot was 50%.  To reiterate – a positive result on a leg ultrasound has a flip of a coin’s chance of being correct, but it does allow the hospital to document a clot in the leg vein (also known as a Deep Vein thrombus (DVT)) as present on admission, and make any actually clinically meaningful DVT that subsequently develops not count towards the all important hospital acquired numbers.  The added benefit of documenting more DVTs in your medical inpatients (as opposed to the post-orthopedic surgical patients) is that it makes patients appear sicker.  This matters because another metric- the all important US News World Report rankings – are based on the difference between hospital expected and observed mortality.  The higher your expected mortality, the better.

It is not even clear that the numbers, if accurate, would tell the whole story regardless.  Consider the feared complication of DVT is a clot that spreads from the leg veins to the heart and causes death – a pulmonary embolism.  As far as I can tell, this information is not being publicly reported, but data for the incidence of pulmonary embolism is available from administrative claims data.  One would think that the reduction of DVTs should have lead to fewer PEs being diagnosed.  Unfortunately, very little in health care is predictable or intuited.   The incidence of PE’s has actually dramatically increased since 1998.  Our ability to find clots in the lung dramatically improved in 1998 with the introduction of MultiDetector Computed Tomography.  This would be ok if finding more PEs results in improved patient outcomes, but it has decidedly not.  Mortality from PE is stubbornly unchanged from prior to 1998 to now, ostensibly because we simply got better at diagnosing PEs that were never going to bother the patient.

The point of this long discussion on the blood clot example Binder et al raised is to demonstrate the absolute utter meaninglessness of the metrics highlighted as an example of success.  I am relatively certain we can ‘fix’ the overdiagnosis of PE problem by publicly reporting PE data.  I am sure the hospital/physician administrator class will respond with some non-granular edict that will strip the physicians ability to order an MDCT for PE.  As history would suggest, fewer unneeded CTs will be done, but fewer needed CTs will be done as well.  Medicine used to advance organically from the bottom up by education and discussion informed by data.  50% fewer coronary stents are placed in the elective setting over the last decade not because of public reporting or leapfrog, but because the data brought the frequent practice by cardiologists into question.

Binder et. al go on to highlight the benefits of transparency in improving outcomes in New York state patients undergoing cardiac surgery.  Apparently, public reporting of outcomes in cardiac surgery patients in New York lead to advances in cardiac care that saved lives.  Its a remarkable statement because there is ample data to suggest that lower mortality with public reporting in this setting related to lower surgical volume driven by a fear of operating on sicker patients.

One is left to contemplate the credentials of these arbiters of value in health care.  How can we possibly evaluate those who have anointed themselves as gods of value?  Data is no longer sufficient to rebut the movement because the data no longer fits the narrative.  It should be somewhat discomforting that this chart depicting the United States as outlier when it comes to dollars spent for life expectancy achieved is essentially unchanged since the Leapfrog group came into being in 2000.

The value based movement as currently envisioned has failed.  Apparently, a maze of third party payers and third party consultants don’t actually make healthcare better or less expensive.

The authors seem to understand the weakness of their arguments by ending their article with a warning about returning to the fee for service that brought us to the abyss.   Fee for service is the culprit that has produced ‘waste, heavy cost, and quality of care issues’, after all.  This is all true, but do the authors really believe that the fee-for-service system that existed brought no good with it?  It is certainly true that the last half century produced a  health care system emerged that was incentivized to treat patients.  Great waste arose as a result.  But this is the same health care system that finances cardiologists on call to open up your blocked artery within 90 minutes of where you currently sit.  It is also the same system that refused to give up on rare, fatal diseases in children when other systems have.  It should be lost on no-one that the value based movement has morphed into a tool to strong arm physicians into giving up on those it is cost inefficient to treat.  Burned by the managed care experience, third party payers have found a way to make physicians the deniers of care – employ the vast majority of physicians, and tie financial reimbursement to value based outcomes that incentivize doing less regardless of patient need.  A generation of physicians now emerges with an allegiance to populations and health systems, so it is no surprise that a good physician today is one who can provide a disney land experience to the consumer, all the while keeping length of stay in hospitals low, while documenting all possible diagnoses in EPIC to maximize patient expected mortality and maximize billing.

The best thing a customer with a sick heart who made the mistake of being admitted to the hospital with heart failure can do in 2017 is die.  Mounting evidence recently lead to leading heart failure physicians to write emphatically that hospital readmission reduction program is associated with fewer readmissions and more deaths.

Waste may abound in our current health care system, but the strategy employed by the value based seers exacts a heavy penalty on our sickest and most vulnerable.  Ideologues should consider that we indeed do have a health care system that resulted in too many heart transplants, but is it really better to live in a world where deserving patients don’t get a heart transplant?

This does not mean to say that massive waste does not exist in our health care system.  As an example: Hospitals have become massively bloated entities that innovate by hiring patient experience officers, giving patients ipads, paying hundreds of million dollars for EHRs that make physicians less productive, and hiring an army of hospitalists to check boxes and reduce length of stay.  I do mean to say that the current plan to give the nations dollars to insurance companies, health care consultants, and non-clinician administrators and expect an intelligent path forward is improbable.

A more honest path appears courtesy of true mavericks like the founders of the Surgical center of Oklahoma that accepts no third party payments but delivers care for elective surgeries at massive discounts relative to regular hospital systems.  Any surgical complications are covered free of charge.  Patients traveling from a distance have their airfare paid for and are put up in a hotel.  Sounds like patient, centric value based care to me.  How could this possibly happen without the Leapfrog group being involved?

I realize that the Surgical center of Oklahoma does not have to keep an ER open 24/7, and doesn’t have to pay for interventional cardiologists to be available constantly, but there is ample evidence to suggest the dollars being spent in hospitals are being spent on a variety of goods that have nothing to do with patient health.

Is it a pipe dream to believe that in the wealthiest country on earth we can have a robust private system that can deliver us CAT scans for $400 and still manage to provide a support system for those financially destitute?  We currently find ourselves hostage to a health care system that has convinced us that health care is unaffordable, and that keeping the lights on in your local hospital requires being paid $50 for an ECG.  The solution has been to create a whole bureaucracy of measurers that have just as much expertise at valuing Big Macs as they do healthcare.  The evidence we didn’t need to generate now tells us we don’t measure value well, and it has not resulted in a net reduction in cost or any significant increase in real value delivered.

I would suggest we refocus on the problem at hand.  We can start by labeling the current value based movement with the cliched yet appropriate moniker: #FakeNews

Anish Koka is a cardiologist based in Pennsylvania 

Wrong answer

This morning I stumbled upon this piece, Wrong Answer (free full text here), by Rachel Aviv in The New Yorker. It’s an old article from 2014, but a wonderfully written, compelling, sad tale. It’s the story of how high stakes testing of middle school students in economically disadvantaged neighborhoods in Atlanta led to cheating by teachers. It focuses on Damany Lewis, a superb teacher totally commited to his students, who tirelessly worked to improve his students’ math knowledge and was successful in doing so, but not successful enough to hit an unreachable goal. Responding to increasing pressure to raise testing scores, he and other teachers began to change the answers on students’ tests. We all know that cheating is unethical, and at first glance I bet most of us would argue to punish those involved, but read this entire piece (warning: it’s long), and you’re likely to soften your stance. The consequences of not meeting unreasonable targets were so severe that the teachers felt compelled to cheat in the best interest of their students.

Now take this article from the education setting into the world of healthcare epidemiology, and if you’re like me, there will be chills going down your spine as you read it. It should be required reading for anyone who works in healthcare quality or the key stakeholders in this space, from those at the front lines, to those who work in professional societies, and to those who create policy at the state or national level. There are also lessons here for patients and patient advocates.

Donald Campbell

What happened in Atlanta shouldn’t surprise us. In 1979, Donald Campbell, a psychologist, published a paper, the crux of which has become known as Campbell’s law. I wasn’t aware of this until I read Aviv’s article. It states: “The more any quantitative social indicator is used for social decision-making, the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor.” Moving this to our world, you can delete the word “social” in Campbell’s law and take a look at Dan Sexton’s commentary, Casablanca Redux, from 2012. Here’s an excerpt:

Our informal discussions with other hospital epidemiologists, our experience in evaluating the source of infection in hundreds of bacteremic intensive care unit (ICU) patients, and common sense have led us to suspect that many hospitals do not accurately report their true rates of CLABSI, using current NHSN definitions. In some cases this may reflect an unwillingness of local staff to accept these definitions as accurate or fair; in other situations it may reflect an unconscious desire to hedge or reduce their rate of CLABSI to avoid criticism and negative consequences from their local supervisors in the press, clinicians, or the general public who review their publicly reported data… If clinicians inappropriately or illogically fear or anticipate negative feedback about the rate of CLABSI in their institutions, they may consciously or subconsciously fail to obtain blood culture results for every patient with a possible or likely BSI. Simply put: no culture equals no infection, using standard definitions of CLABSI. 

At some level, we are all complicit in this. And depending on the action, it may not be the wrong thing to do. In fact, it may benefit the patient. For example, better diagnostic stewardship in the form of appropriately ordering fewer urine cultures, not only lowers CAUTI rates but reduces antibiotic utilization with several resultant benefits. Still it’s important to note that the primary impetus for this was to lower HAI rates. We take into consideration how a new diagnostic test may impact HAI rates and may even allow that to impact the decision to implement (see an excellent paper by Dan on this here). We may allow clinicians to censor infections that infection preventionists have detected even though the cases meet NHSN definitions. And at the extreme, hospitals may engage in practices that may harm patients in order to reduce publicly reported HAI rates. In a recent publication on how physcians in training view quality initiatives, a dirty secret was elicited from a resident during a focus group at an academic medial center: “There’s like the central line infection protocols…. If you suspect that anybody has any type of bacteremia, you don’t do a blood culture, you just do a urine culture and pull the lines … we just don’t even test for it because the quality improvement then like marks you off.” 

While reading Rachel Aviv’s paper, I wondered: Do we ever ignore results (i.e., infection rates) that seem too good to be true like the educational administrators in Atlanta did? Do we critically analyze surprisingly good results to the same degree as we do surprisingly bad results? In Damany Lewis’ case did the end justify the means? Is there ever a situation where I could be pushed to a similar point as Lewis?

The Atlanta school system harmed students and teachers in a thoughtless quest to improve quality. There were no winners. Sadly, the response to the cheating scandal was to raise the stakes for test scores even higher. With pay for performance the same is happening in health care.

Chlorhexidine bathing outside the ICU: Await the ABATE!

Daily chlorhexidine (CHG) bathing has become routine in many ICUs. Given that more healthcare-associated infections (HAIs) (including more central-line associated bloodstream infections (CLABSIs)) occur outside of the ICU, many hospitals have also implemented this practice on general medicine and surgical wards. However, to this point there are few data to support the effectiveness of CHG bathing outside of ICUs. 

So I was very excited to hear Susan Huang present the results of the Active Bathing to Eliminate Infection (ABATE) study at IDWeek last week. Similar to the REDUCE MRSA study, this 53 hospital cluster-randomized trial took place in the Hospital Corporation of America (HCA) system. Units were randomized to routine care or decolonization (this consisted of daily CHG [4% rinse-off shower or 2% leave-on bed bath] with addition of mupirocin nasal ointment for 5 days if + for MRSA by history or culture/screen) for a 21-month intervention period (after collecting baseline data for 12 months). The primary outcome was MRSA or VRE clinical isolates, and the main secondary outcome was any bloodstream isolate attributed to the unit (for common commensals, 2 or more + cultures).

With the requisite reminder that it is always best to wait for the peer-reviewed publication to make firm conclusions, the results presented at IDWeek suggest the likely take-home from this study: No measurable benefit in the entire population, but significant reductions in MRSA/VRE clinical cultures and bloodstream infection in the subgroup with devices (central lines, midlines, and lumbar drains). This subgroup represented 12% of the study population but accounted for 34% of all MRSA/VRE events and 59% of bloodstream infections. The additional reductions in the decolonization arm for this subgroup (compared with routine care) were 32% for MRSA/VRE cultures and 28% for BSI (both highly statistically significant). 

Once published, these findings will leave infection prevention programs with some interesting decisions. A quick take might be, “OK, let’s just use CHG in those non-ICU patients with devices (or just central lines).” However, this isn’t what the ABATE trial evaluated—it showed a substantial reduction in MRSA/VRE/BSI outcomes in patients with devices when everyone else was also receiving CHG (+/- mupirocin). To assume that the decolonization of the non-device population had no beneficial effect on those with devices is to discount any potential role for reduction in pathogen transmission between non-device and device patients. Another tricky question has to do with the role of mupirocin—adding this agent to CHG for known MRSA carriers without knowing how important this component of the intervention was adds some logistical complexity, cost, and antimicrobial resistance concerns (the investigators are also doing the microbiology work to assess for CHG and mupirocin resistance emergence). 

We’ll revisit this study once it is published and all the details are available. For now we should congratulate Susan and the entire ABATE trial team for another tremendous contribution!

Trump Thinks He Just Blew Up Obamacare With a Stroke of the Pen. Did He?

If you had illusions, or hopes, that the “Kill Obamacare” reality show starring Donald Trump would settle down to a dull roar, events of the last few days should blow those illusions out of the water.

You’ve heard the news by now and I won’t repeat it here.   In addition to your favorite media outlets, see this analysis by ACA legal expert Tim Jost.

Trump has been true to his word and his warnings of the last few months—that if Congress didn’t repeal and replace the Affordable Care Act he’d resort to regulatory and executive branch action.

The words of the day (Friday, Oct. 13) are “sabotage” and “spiteful.” And I agree. But I’ll be curious to hear THCB readers’ views on these extraordinary actions by the President. Bear in mind that every independent analysis of the elimination of the CSR (cost-sharing reduction) payments and reviving long-dead association health plans indicates:

  • Both will significantly undermine the stability of the exchanges—by eroding the participation of insurers, the affordability of coverage and enrollment.
  • Association health plans will siphon off the young and health and people at low risk, undermine coverage standards, and serve consumers poorly as they have in the past. (Notably, though, the rebirth of association health plans is not imminent. Trump’s executive order requires the Labor Dept., HHS and others to issue new rules, which could take up to a year).
  • The elimination of the CSR payments will cost taxpayers a projected $194 billion in additional tax credits/premium subsidies over the next decade—because insurers will raise premiums 10% to 20% to make-up for the loss of the CSR payments. That’s according to CBO but the projection assumes, of course, that the exchanges don’t implode.

As Vox’s Sarah Kliff put it: Trump is seeking to enact a policy where the government spends billions more to insure fewer people!

The administration’s argument that it had no choice but to cancel the CSR payments for legal reasons is dubious at best. They’ll be vigorous debate on this point in the coming weeks.   And the issue is indeed complex in the context of an unprecedented lawsuit filed in 2014 by House Republicans against the Obama Administration. The suit claimed that Congress never appropriated funds for the payments. (The CSR expenditure is projected at $8 billion this year rising to $9 to $10 billion in 2018; an estimated 7 million low people benefited.)

Says Jost: “In fact, the ACA requires the federal government to reimburse insurers for these [cost-sharing] reductions. This is not a bailout. It is rather a statutory obligation of the federal government to pay insurers for services they have provided as required by law.”

Moreover, the suit was still pending after:

(a) A D.C. district court judge accepted the House Republican’s argument in the spring of 2016 but stayed her order after the Obama administration appealed, arguing forcefully (with DOJ lawyers in the lead) that there was in fact an appropriation.

(b) The Trump administration never took a position on whether there was an appropriation or not until Thursday, and had agreed to abide by the stay several times and find the payments.

(c) The D.C. Circuit Court of Appeals in August allowed 19 state attorneys general to intervene to retain the CSR payments as an essential protection for their citizens. One health lawyer, Nicholas Bagley argues that the judgment allowing the states to intervene actually technically blocks the Trump administration from unilaterally dismissing the appeal.

However, while Bagley agrees with Jost that there’s a regulation on the books that requires the CSR payments be made, he wrote in August that the Trump administration and Justice Department “could simply announce that, after a thorough review, the Justice Department has concluded that no appropriation exists to continue making the payments.”

That appears to be the avenue the Trump White House has taken.

In quick action—having anticipated Trump’s move—Democratic attorneys general from the 18 states and the District of Columbia filed a lawsuit in federal court in California late Friday. (The states are: California, Connecticut, Delaware, Kentucky, Illinois, Iowa, Maryland, Massachusetts, Minnesota, New Mexico, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, Vermont, Virginia and Washington.)

The states seek to force the Trump administration to make the next round of monthly CSR payments, which are scheduled for Wed. Oct 18.

“His effort to gut these subsidies with no warning or even a plan to contain the fallout is breathtakingly reckless,” New York Attorney General Eric Schneiderman told The Huffington Post on Friday. “This is an effort simply to blow up the system.”

Notably, the new lawsuit is separate from a case pending before the D.C. appeals court in which Democratic attorneys general are defending the legality of the payments.

How the California court will react is unknown. Proving immediate harm to consumers would seem easy.  But the administration could win on the technical legal merits.   The Court could uphold Trump’s action and rule that Congress must now authorize the payments.

What about Congress?

A bipartisan effort is underway in the Senate health committee that has revolved around a deal to fund the CSR payments for two years (what the Democrats want) in exchange for giving states greater flexibility to end-run parts of the ACA and experiment with coverage options (what the Republicans want).

Trump has played a bizarre cat and mouse game over the ACA with both Republicans and Democrats in the past three months—tweet-slamming both. And while he has occasionally has said he wanted to cut a deal with Democrats on health care he has never lent explicit support to the Senate health committee efforts on the CSR payments.

But one interpretation of his action is that it’s intended to gain leverage with Democrats to… what?   That’s the problem. The Dems aren’t going to go along with anything resembling repeal and replace; Schumer flatly told Trump that again after an entreaty earlier this month.   But, even so, Trump tweeted on Friday morning, saying to Dems, “Call me.”

One could make a plausible—and perhaps strong—argument, however, that Trump’s actions enhance the chances Congress will act. All Dems and moderate Republicans support the CSR payments.   Maybe Trump knows that, and he plans to take credit for prodding Congress to act in the public interest even as he claims he’s still trying destroy Obamacare.

Still, the legislation being birthed in the Senate—which was stalled during the debate over Graham-Cassidy—is no slam-dunk. The right-wingers in the House see the CSR payments as “insurer bailouts.”

Schumer said late Friday that he was optimism about the chances for a deal with Republicans to continue the subsidy payments.

All of this is taking place less than three weeks before ACA open enrollment begins. Chaos already reigned, and now this. More chaos. But we all know who thrives on chaos, suspense, brinksmanship and drama. Not to mention self-interest and spite. Mr. Make-it-all-Great-Again.

Six Assertions on Knowing the Unknowable Future of Healthcare

Some things never change. Joe Flower is one of those things. Pay attention. Joe was the keynote speaker at Health 2.0 Silicon Valley earlier this month. We’re excited to feature the text of his remarks as a post on the blog today.  If you have questions for Joe, you can leave them the comment section. You’ll find a link to a complimentary copy of his report Healthcare 2027: at the end of this post. You should absolutely download and read it. And take notes.

The future. The Future of healthcare. 
Here are the seven words at the core. If you take nothing else away from this, take these:

Everything changes.
Everything is connected.
Pay attention.

— Jane Hirshfield 

We are gathered here on holy ground, in Silicon Valley, the home of the startup, the temple of everything new, of the Brave New World.

And healthcare? Healthcare is changing — consolidation, new technologies, political chaos, a vast and growing IT overburden, shifting rules, ever-rising costs, new solutions, business model experiments.

So when I say, “The Future of Healthcare,”
what are the pictures in your head? Catastrophic system failure? The dawn of a bright new day of better, stronger, cheaper healthcare for everyone, led by tech? Do we have all the confidence of a little girl screaming down a slide? Do we just say in denial about the future and end up in a kind of chaotic muddling along?

In this century business sectors crash, transform, and re-emerge constantly.

  • Most malls in America will close in the next 24 months. Yet retail is thriving.
  • Big bookstore chains are history. Yet more books than ever are being published, printed, bought and read, and new physical bookstores are popping up every day.
  • Digital cameras went from a rounding error in the market in 1999 to destroying the film camera and bankrupting Kodak in six years. Ten years later digital cameras are a niche market, yet the world is flooded with images and video because everyone carries a camera in their smart phone.
  • The Encyclopedia Britannica was printed from 1768 to 2010. Now it’s a website.
  • Cassettes replaced LPs and eight-track tapes in the 1970s, CDs replaced cassettes in the 1990s, and now CDs are history — yet music is more widely shared than ever, music distribution is a thriving business, and LPs are making a comeback. My entire music library is on my phone, but most younger people don’t have a library at all — it’s all streaming music all the time.
  • Oil has dominated our geopolitics and economics for over a century. That will end within 10 years. Cars and trucks with internal combustion engines and human drivers will become relics and specialty vehicles in the same 10 years. Tesla already has a higher market capitalization than Ford.
  • This is normal.The people and organizations running each of those businesses and sectors did not anticipate these vast and deep changes until they happened to them. They did not anticipate:
    • that these changes would happen
    • the speed of the change
    • the shape and elements of the change
    • the second- and third-order effects on their business.

    Healthcare is not exempt. We are today where the film business was in 1999, where the retail mall and internal combustion engine is today. Within 10 years healthcare will be unrecognizable. From treatment modalities and workflow, to business models to technologies, it will not be the same industry it is today. Few of those who run healthcare can even picture that future, let alone plan for it. Yet they must not only plan for it, they must plan for it for their particular organization in their market with their constituencies —and they must plan how to get from here to there, how to keep the machine running even as the environment, the funding and the tools change.

    That’s the reason for what I am announcing today here for the first time. The American Hospital Association is increasingly shifting toward recognizing the need to help healthcare executives understand the future better. I will be launching, with them, a curriculum on how to think like a futurist, how to bring futurism into your organization as a normal ongoing part of management and strategy.

    So today I will make six assertions on knowing the future of healthcare:

    1)We need to know the future of healthcare.It is of existential importance to each of our careers, organizations, and products to figure out the future of healthcare.

    2)We can’t.That’s why it’s called the future. It hasn’t happened yet. Making a prediction or a forecast and getting it right is the booby prize. It’s the participation trophy — unless you really understand why you got it right. If you get it right without understanding, you don’t learn nothin’. The real goal of futurism is not getting it right, it’s insight, understanding how the future works.

 must anyway.We have to find ways to say something useful, actionable, practical about the possibilities of the future.
For that, your future casting has to be about

    4) You. It must be localized to your situation, your organization, your product. It has to deal with the fact that healthcare is

    5) Complex. It is a complex adaptive system with many interdependent parts.

    Healthcare is complex. Simple solutions are useless. Any simple picture of the future is a lie. Simple techno-optimism or innovationist neophilia gets us nowhere.

    Thinking about the future is a complex business requiring extraordinary clarity, penetration, the broadest possible view, and the insights of complexity science. Simple futurism is entertainment. Futurism based on the insights of complexity is a tool for thinking, planning, strategizing.

    Simple futurism points at each shiny thing—AI, contractual blockchain, virtual worlds, augmented reality, cell transformation, haptic rebuilds—and says, “Wow! Look at this.” It’s a Jetsons way of looking at the future, as real as using the Flintstones as a guide to the past.

    A futurism based on complexity looks at every element, shiny, dull, or invisible, and asks:

    “What is it for?”
“How does it get its energy?”
“How does it affect other elements?”

    Complex futurism can connect the dots and the 3-D networks of dots building out over time to paint the pictures of future scenarios, of ways the future could really turn out, what will take us there, and what strategies we might employ to meet them.
The sixth assertion is that the future of healthcare can be studied in a table of

    6) Elementsas I lay out in the report Healthcare 2027: Elements. A link to a complimentary version of Joe’s report will be available shortly. Check back later this morning.

IDWeek 2017 is in the books

I’m back from IDWeek 2017 in San Diego — always good to reconnect with old friends, meet new colleagues, and hear the latest in infection prevention and antibiotic stewardship science and practice.  This year I noted an increase in pro-con and clinical controversies sessions, which I think are so valuable for those of us struggling day-to-day with issues where the evidence base is absent or opinion is conflicting.   If you didn’t get a chance to attend, fear not, as I am sure there will be more conference-related news emerging over the coming weeks (all 6 of your favorite bloggers made an appearance). 

Of course, it’s never too early to think about next year — IDWeek 2018 heads back to the left coast, this time it’s San Francisco, October 3-7, 2018 (mark your calendars!).  I’m among the SHEA contingent for the planning committee (along with Hilary), and we’re very interested in program suggestions — please send them our way.

I’ll leave you with one meeting tidbit — Shelley Magill presented the results from the CDC’s 2015 HAI Prevalence study, a follow up to their 2011 survey that was published in the NEJM.  In the 4 years since the first survey (using the same hospitals included previously):

  • The HAI prevalence rate among hospitalized acute care patients fell from 4.1% to 3.2% (a 22% decrease)
  • Central line and urinary catheter use were both significantly lower
  • Healthcare-associated UTIs and SSIs significantly decreased
Nice to see some positive news to reflect the extensive HAI prevention efforts nationwide.  Of note, antimicrobial use stayed stable, reinforcing the need for increased antibiotic stewardship efforts.  Given the enhanced focus in this area, I am hopeful that the next prevalence survey will show improvement on that end as well.

The Three Things Keeping Hospital CEOs Up Late at Night (Hint: Donald Trump Isn’t One of Them)

The Center for Medicare and Medicaid Innovation released a Request for Information (RFI) last week– “New Direction for the CMS Innovation Center.” It’s the latest chapter in the unfolding policy framework that will govern the health system for at least the next 3 years.

The RFI, which doubles down on value-based alternative payment models and consumer directed care, coupled with a proposed rule to cancel mandatory bundles by former HHS Secretary Price, the administration’s actions last week to weaken contraceptive coverage requirements in employer-sponsored health plans and Congress’ FY18 federal budget that include cuts in Medicare and Medicaid funding provide a sobering context for hospital and health system strategic planning. But hospital CEOs have adapted to the new normal from DC: uncertainty about the laws governing our health system is standard fare.

Last month, I interviewed 13 hospital CEO’s in preparation for their upcoming Board-Management strategic planning retreats. They lead organizations in 11 states with substantial differences in the scale, scope and strength of their operations and the dynamics in their markets. Two are academic medical centers, six are independent multi-hospital systems and five operate in multiple markets. When I asked “what’s keeping you awake at night” their answers were the same.

The second wave of cost reduction: All recognize that reducing costs is imperative: there’s recognition that the low-cost position in their market is a huge competitive advantage. They made cuts in their supply chains and modified their contracts with suppliers. They tackled their revenue cycle by leveraging technologies and, in some cases, outsourcing to improve cash flow. They trimmed labor costs, improved productivity and eliminated positions. And they streamlined their clinical portfolio, centralizing programs where possible and applying lean management techniques across service lines. But CEOs see these as defensive strategies—necessary to stay in the game but insufficient to position their organizations for long-term success. They foresee even greater pressure on their cost structure as employers and consumers force price transparency, insurers flex their muscles demanding deeper discounts, the government cuts reimbursement and uncompensated care increases as the ranks of the uninsured and under-insured swell. The academics see cuts in funding for research and education, and all expect labor costs to grow annually. And all are hopeful FDA Director Scott Gottlieb’s efforts to constrain drug costs will be successful, but fearful it won’t. (Gottlieb’s focus is streamlining the approval process so high-priced drugs face more competition. This year, the FDA has approved 34 new drugs vs. 22 at this point last year and 73 applicants for generic approvals vs. 57 last year. He’s won accolades from both parties and is rumored to be the front runner to succeed Dr. Price as HHS Secretary). CEOs are focused on the next wave of costs and recognize it means saying no to projects and investments they’d ordinarily support.

Affordable quality: CEOs see what many overlook: ‘quality of care’ is pass/fail to purchasers and policymakers. You either hit the mark or suffer penalties from payers (including the government) or reputation risk at the hands of competitors. It’s increasingly complicated– more than 500 public measures accessible to competitors, media and the public. It’s report cards that pit clinical programs side by side with competitors alongside costs. It’s not just process measures in their control: it’s outcomes including those many patients themselves control. Exceptional performance on quality means access to cheaper capital from lenders and but only if costs are also low. CEOs see quality of care as highly variable between hospitals, operationally intense and costly. How populations are diagnosed, treated and managed optimizing the interaction of people, process and technologies and evidence-based care ruffles feathers, disrupts routines and causes friction. The public’s keen to know who gets the best results: more than 800 hospitals can lay claim to being among America’s best, based on which clinical program is measured, the metrics used and the list sponsors’ methodology. What keeps CEOs awake is recognition that optimizing quality of care is not a guarantee of financial success or long-term sustainability. It’s a necessary focus that’s getting more complicated and expensive.

Opportunistic growth to achieve optimal scale: CEOs recognize value-based purchasing and alternative payment programs are here to stay. They see lenders and investors making bets in profitable niches once their domain. The bond market is tightening and margins in their core operations—acute and outpatient services—are shrinking. But demand in healthcare is increasing! For CEOs, there is recognition that the scale and scope of their enterprises must expand if they are to remain relevant. But that carries risk: if capital is invested outside the core, will physicians and the board be supportive and will community leaders understand? Is the management team capable and competent to manage business units outside their experiences? How will partners be vetted? How should the current infrastructure change? And what’s the optimal scale and scope of their organization’s long-term? CEOs recognize the economics of ‘going big or getting out’ work in most industries: they sense the same in healthcare.

Board readiness: CEOs worry about their boards. Many think their trustees are not fully prepared for the expanded challenges ahead. Owning the issue of affordability in their market, operating in a model in which revenues are at risk based on value, and expanding their enterprises regionally in social services, retail, digital, financial domains are not fully grasped. Applying evidence to care aggressively, immersing the organization in data-driven decision-making, moving services into homes, schools and workplaces, and building population health capabilities are daunting imperatives. And informed vigilance about expanding regulations and encroachment by non-traditional competitors require more time invested in board education and deliberation. CEOs see functions like physician leadership, advocacy, regulatory compliance, philanthropy, analytics, capital planning, reputation management and planning taking on added significance as they equip their boards for the new normal.

I believe hospitals are at a crossroad. The sector cannot content itself that its clinical innovation and local economic impact guarantee a sustainable future void of major change. The public thinks them unwieldy and expensive. Employers think they’re costly and inefficient. Physicians believe they’re dabbling in areas they should otherwise avoid. And policymakers expect them to do more with less while also handling the public’s health.

For hospital CEOs, it’s hard to get a good night’s sleep.

Sorry. Health Care Reform Can’t Wait for Quality Measures to Be Perfect

There’s a debate in the United States about whether the current measures of health care quality are adequate to support the movement away from fee-for-service toward value-based payment. Some providers advocate slowing or even halting payment reform efforts because they don’t believe that quality can be adequately measured to determine fair payment. Employers and other purchasers, however, strongly support the currently available quality measures used in payment reform efforts to reward higher-performing providers. So far, the Trump administration has not weighed in.

The four of us, leaders of organizations that represent large employers and other purchasers of health care, reject any delay in payment reform efforts for the following three reasons:

Even imperfect measurement and transparency accelerate quality improvement. One set of measures often questioned is the Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Indicators (PSIs) used by the Centers for Medicare and Medicaid Services (CMS) and others in value-based payment programs. These indicators measure surgical complications and errors in hospitals, which is critical given that one in four hospital admissions is estimated to result in an adverse event.

PSIs remain among the most evidence-based, well-tested, and validated quality measures available. CMS uses many in its value-based purchasing programs. Use and reporting of PSIs through AHRQ’s Medicare Patient Safety Monitoring System has measurably improved quality. For instance, CMS reported a reduction in inpatient venous thromboembolisms (VTEs) from 28,000 in 2010 to 16,000 in 2014, meaning that 12,000 fewer patients had potentially fatal blood clots in 2014.

In addition to using quality measures in payment programs and for quality improvement, making measures public is key to accelerating change. “If transparency were a medication, it would be a blockbuster,” concluded a multi-stakeholder roundtable convened by the National Patient Safety Foundation’s Lucian Leape Institute in 2015. The foundation’s report cited the Leapfrog Group’s first-ever reporting of early elective delivery rates by hospitals in 2010, which galvanized a cascade of efforts to curtail the problem and thus reduce maternal harms and neonatal intensive care unit (NICU) admissions. This was effective: The national mean of early elective deliveries declined from a rate of 17% to 2.8% in only five years.

Using measures improves measurement. Providers and health care executives sometimes point to flaws in their medical-record and billing systems as a main reason certain measures shouldn’t be used. As they see it, their performance on the measures isn’t the issue; it’s their medical records or billing coding that’s the problem. They believe these internal systems should be fixed before measures that use this information are applied in payment formulas or public reporting.

But use of these measures is often necessary to break logjams in correcting the health care industry’s long-neglected weaknesses in data-quality control. Indeed, many of the nuanced imperfections providers criticize were only uncovered by public reporting, which revealed unexpectedly poor performance for some providers, prompting them to research the medical records to find out the reasons.

Even rough measures make a big difference when they are publicly reported. For instance, New York State’s release of surgical mortality data for coronary artery bypass grafting (CABG) procedures jump-started the movement to define and more carefully collect much stronger measures of CABG outcomes, and today we have many advances in cardiac care and its measurement.

In the New York example, the success in generating ever better measures — and more importantly, achieving ever better outcomes for patients — came about because providers made the changes that saved lives, and they deserve all the credit for that. A thorough, respectful process for building scientific and stakeholder consensus around measures has been orchestrated by leaders like the National Quality Forum (NQF) and the National Committee for Quality Assurance (NCQA). Purchasers are committed to partnering in the development and refinement of excellent measures while we advance transparency and payment reform alongside that work.

Returning to fee-for-service is not an optionGiven the widely acknowledged waste, heavy costs, and quality-of-care issues produced by the fee-for-service system, the fact that there are rough spots on the road to value-based payment is hardly a justification for slowing down reform. If converting to a more sensible payment system were easy, it would have been done a long time ago.

The change to performance-based payment and market share requires tenacity and patience. Current quality measures may have rough edges, but stakeholders have worked hard to steadily improve their validity and reliability. Employers and other purchasers, such as those involved in our organizations, must work with forward-thinking colleagues in the health care system to continually improve the measures that publicly signal value. It will be a learning process for providers and purchasers as long as we’re guided by a spirit of transparency.

Whatever the risks of imperfect measurement, America’s first priority must be to eliminate avoidable suffering, mortality, and waste in its uniquely costly health care system. We hope that the Trump administration and lawmakers on both sides of the aisle will continue to recognize what our members see clearly: delaying payment reform is not an option.

This post first appeared in the Harvard Business Review

Leah Binder is is the president and CEO of the Leapfrog Group.

Brian Marcotte is the president and CEO of the National Business Group on Health.  

Annette Guarisco Faldes is president and CEO of the ERISA Industry Committee (ERIC), a national association that advocates solely for large U.S.employers.

Michael Thompson is the president and CEO of the National Alliance of Healthcare Purchaser Coalitions. 


AARP Caregiver Quality of Life Challenge Winners Announced!

Roughly one out of every three people in the United States serves as a caregiver for a chronically ill, disabled, or aging loved one at some point in their life*. Not only do most caregivers dedicate a significant amount of time to these duties, 

but they often also work full or part-time jobs to make ends meet. These stresses result in 40-70% of caregivers exhibiting clinically significant signs of depression*. Fortunately, there is an increasing focus on caregiver well being, and now, more than ever, innovation in caregiving has the opportunity to make real change and improve tens of thousands of lives.

The AARP Caregiver Quality of Life Challenge, supported by AARP, and administered by Catalyst @ Health 2.0 in partnership with Mad*Pow, aimed to find tech-enabled solutions designed to help caregivers identify as caregivers, find available resources to ease their burden, and connect with others who can build and strengthen their support systems.

The Challenge, launched at HxRefactored in June 2017, received over fifty applications, with solutions ranging from AI solutions to podcasts and mobile apps. Submitted solutions were judged by our panel of experts, and scored based on how innovative they were, their potential for scalability, the strength of their design, and the potential for impact in the caregiver community. Winners were announced live this morning at Health 2.0’s 11th Annual Fall Conference.

Taking home the grand prize of $10,000 is Tickit (@TickitHealth). Founder and CEO, Daniel Penn wowed the judges with the platform’s emphasis on the importance of physicians in caregivers’ lives. Too often, caregivers feel isolated, lonely, and burnt out. With an application that can be used at point-of-care or email, combined with AI, Tickit provides a breadth of resources to caregivers, and is delivered in a way that works in conjunction with physicians. And, this is all done without adding clinical time for physicians! Take a look at how Tickit works in this video.

The second place prize of $7,000 goes to Carrie, created by the Salesforce Experience Design Team. Although many caregivers feel alone, Carrie recognizes that there are over 40 million other people going through the same thing. The idea is simple–match caregivers with other caregivers who can provide emotional support, firsthand advice, and personalized recommendations and resources. But more importantly, the app sends reminders to help caregivers set aside time for themselves. Learn more about the platform here.

And finally, Team Aspen came in third place for a prize of $3,000. Aspen assigns each caregiver an advocate who consolidates all the support the caregivers receive into one place. Caregivers can then access support from each the people in their lives. To learn more, check out the video explaining the product here.

So, whether you yourself are caring for a loved one, you know a caregiver, or you’re simply interested in helping the caregiving population, be sure to check out these solutions that may just make a difficult job a little less difficult.

To learn more about Catalyst @ Health 2.0 and other programs or opportunities, subscribe to the Catalyst/Development Newsletter, and follow @catalyst_h20 on Twitter.

Chelsea Polaniecki is a Program Manager at Catalyst @ Health 2.0.

Homeopathy for Women Related Health Woes

Yes, the new age superwoman definitely exists! No, she does not fly around the city saving lives and definitely does not wear a cloak.

Today’s superwoman is a doting mother, an unbelievably kind daughter-in-law, a devoted wife, a loving daughter and the quintessential career woman – all blended into one! She does it all, has it all and handles it all with suave, efficiency and focus.

Women today manage to achieve almost everything they wish to by multitasking – they juggle between kids, career and work hard at the home as well as the work front. Be it their children’s PTA; be it their fitness or yoga classes; or running around doing odd jobs such as grocery shopping to banking! A whole lot depends on the lady of the house and they try to manage it all – almost single-handedly.

But all these endless responsibilities along with the constant pressure can definitely take a toll on their health if they are not careful. The body could succumb to the combined pressures of sleepless nights, gruelling office hours, exhausting kitchen chores and trotting around kids. While they definitely try their best to maintain a work-life balance, it’s the hormonal balance that goes for a toss!

Be it those monthly headaches before periods, or the pre-menstrual stomach-bloating. Be it their joint pains, backaches or pigmented skin! Be it those menopausal woes or the post-natal hair loss; be it the angry outbursts or the crying spells, health conditions such as Hypothyroidism, hair fall, PCOD, endometriosis, fibroids to acne – all of these can be attributed to hormonal imbalances as a result of stress and over work.

And what do we do? Pop pills to regulate our thyroid gland, start OCPs uninhibitedly to “normalize the cycle” and stack up on pain killers for aches and pains! It is such a harsh way to treat your delicate body!

Homeopathy on the other hand, offers a holistic approach to all the health issues that are related to women in general. Homeopathy not only treats hormonal imbalances but also sets the system right – from inside out – naturally and effectively.

Homeopathy is the answer to most gynaecological problems like irregular periods, painful periods, PCOD, endometriosis, infertility, PIDs and many more. Homeopathy works really well in pregnant mothers who may suffer from morning sickness, constipation, piles, varicose veins and many other pregnancy related problems. Homeopathy is a saviour for menopausal ladies suffering from hot flushes, arthritis, obesity etc.

Homeopathy is absolutely safe, natural, chemical and side-effect free. The Homeopathic medicines act deeply and treat illnesses right from the roots. Homeopathy is incontestably the best alternative for women’s health issues.

Homeopathy along with healthy lifestyle and food habits and of course a little bit of de-stressing is undoubtedly the best solution for women related health issues.

Its time you ladies give yourself a much needed break, take care of your own health and indubitably choose homeopathy for your health problems!

To consult our expert Homeopathic physician Dr. Daxa Vaishnav who specializes in women’s issues and  many other such Homeopaths of international repute, log on to or call us on 98335 98553