Value-Based Health Care - Our Solutions for You

The reformation of our healthcare system to one that is value-based, rather than volume-based, is still an ongoing process with quite a way to go. Getting to value is not an easy, or straightforward road.  Healthcare organizations, including providers, payers, and the government have all encountered numerous starts and stops, dead-ends, and flat-out blockades.  Some pioneering organizations have made great progress, but navigating the journey to value-based care is no small feat for any organization and requires a thoughtful plan of action matched to exceptional leadership. 


A well-thought out roadmap to value-based care for a healthcare delivery system includes considerations of organizational structure, integration of facilities, geographic expansion of services, measurement of outcomes and costs of care, reimbursement reforms, and integrated information technology (Porter and Lee, HBR). All components of the roadmap are important and each component presents its own unique challenges.

For instance, take the measurement of outcomes of care and the costs to achieve that care.  To determine either one, you must first determine perspective. Clinicians, patients, and other caregivers can each have their own set of criteria by which they measure a successful outcome of care. The key for an organization is to align those criteria to form a set of metrics which provide sufficient clinical, but patient-focused information about the care being delivered and the process through which it was delivered.  When measuring costs, perspective is again paramount.  Is the organization interested in measuring the costs associated with the delivery and provision of care only? Are they also interested in measuring the cost to the patient of consuming that care? Perhaps, they are interested in the costs to employers of care? Perhaps, to the healthcare system as a whole?   All are valid questions and measurements that determine how organizations will report their unique value proposition.

With unique experience in designing and implementing value-based programs at leading healthcare organizations InterOPERANT provides guidance and leadership to assist our clients in determining their unique roadmap to value-based care.

For more information about our solutions, please contact me:

Heidi Wied Bunyan, MPH, MHA, FHFMA
Don Lyons, FACHE, Managing Partner

1 713.705.3544

The future of Medical School is — almost — here.

The future of Medical School is — almost — here.

Over my career in healthcare I have realized that as much as my clinical work had an evidence basis, how about my management practice? Do we in the healthcare "practice of management" approach our work through a basis in evidence?

Thus began my interest in teaching in both healthcare management and work within the context of learning. Technology is having a dramatic effect on healthcare teaching and service delivery...

More and more, technology is shaping what medical schools teach, how professors teach it and how students learn.  

"There are not a lot of microscopes anymore," laughed Morgan Passiment, director of healthcare affairs for the Association of American Medical Colleges. Cadavers could soon be on their way out too, in favor of virtual anatomy. Instead, schools are beginning to incorporate EHRs, simulation, data analytics and new instructional approaches inspired by mHealth and telemedicine.

Medical school students now need to learn more technology-based skills, which require new settings and strategies that break from the traditional lecture hall environment. The challenge medical schools face is in preparing students for roles that continue to shift as care models and technologies change.

"This is a new era for medical education and it parallels the changes that are happening in our healthcare delivery system," says Marc Triola, MD, associate dean of educational informatics and the director of the Institute for Innovations in Medical Education at NYU School of Medicine.

But curriculum evolves slowly, Ms. Passiment says. Changes are typically reviewed and formalized every eight to 10 years.

"We knew there was a consensus out there for what had to change, but it wasn't happening," says Susan Skochelak, MD, AMA vice president of medical education and director of the AMA Center for Transforming Medical Education.

That's why the AMA decided in 2013 to launch its Accelerating Change in Medical Education Program, which awarded $11 million in grant funding to 11 medical schools. When the AMA put out a request for applications, nearly 85 percent of American medical schools responded, according to Dr. Skochelak.

"People want to teach IT, but they don't have the resources or don't know how to teach it," she says.

The 11 chosen schools were tasked to form a consortium and develop new curricula and learning strategies to share with other institutions around the country. Through 2018, the 11 selected universities, including Indiana University School of Medicine, NYU School of Medicine and Vanderbilt University School of Medicine, will be in the implementation stages of their individual curriculum projects.

The AMA's program isn't the only initiative focused on updating medical school curriculum. The ONC sponsors a Curriculum Development Centers Program, for example, which has awarded schools like Oregon Health and Science University with $2.7 million to overhaul curriculum and include new emphases, like EHRs.

While there is still not consistent integration of health IT across medical schools, pockets are diving into technology-based curricula, according to Ms. Passiment.

"The challenge we have right now is helping our learners understand the role technology can play in healthcare, and focusing on care outcomes, not on technology. Technology is a tool," says Ms. Passiment.

The disappearing paper trail

Just as hospitals strive to integrate EHRs as a tool for improved patient care, many medical schools still grapple with how to best integrate EHRs into curriculum, Dr. Skochelak says. Some universities continue to teach old-school paper record-keeping first, while others debate the use of templates. Meanwhile, at the residency level, students are missing the opportunity to use EHRs due to lack of training or HIPAA restrictions, she says.

"The challenge for educators at the beginning level and at the medical school level is we don't know the methods or the pedagogy that work best," says Dr. Skochelak.

IU School of Medicine, based in Indianapolis, is working to develop better methods and pedagogy to incorporate the EHR in a learning environment. It received a $1 million Accelerating Change in Medical Education grant from the AMA for its proposal to develop a virtual health system and teaching EHR, which would let future physicians practice clinical decision making in a realistic environment.

"I want our medical students to understand this. If I just put them in a lecture hall and talk at them, they won't get it," says Sara Jo Grethlein, MD, associate dean for undergraduate medical education and professor of clinical medicine in the division of hematology and oncology at IU School of Medicine.

"It's not just about [the students]; they have a place in a big, complex system, and they need to learn how to function and how they are assessed in that system, so they can thrive in that system," she says.

IU worked with the Indianapolis-based Regenstrief Insitute, an informatics research organization, and with the support of Eskenazi Hospital in Indianapolis it launched a fully functional teaching version of its EHR a year into the implementation stages of the grant. The tEHR uses real, carefully de-identified patient data from roughly 10,000 patient charts, down to the written notes.

The tEHR stands alone, unconnected to the hospital system, so students are free to write in orders and notes in a simulated environment where it can't hurt anybody, Dr. Grethlein says.

Second-year students at IU will soon start using the tEHR. They will receive 12 sessions across the year learning about systems-based practice and big data, according to Dr. Grethlein.

Now officials are developing activity-based assignments for third-year students to incorporate into their rotation schedules. For example, students could be assigned a hypothetical patient in the tEHR with cholecystitis, or a "hot gallbladder", who received gallbladder surgery. The student will then be asked to go into the tEHR, look at the labs and imaging tests performed during the patient stay and justify each of them, Dr. Grethlein says. If they cannot do so, she says, they must find out how much money was wasted on unnecessary tests.

The ideas behind the tEHR are not entirely new — Dr. Grethlein says she used to have students write down tests that weren't justified on index cards — but, "it's just a slicker, higher-tech way of doing the same thing."

The most important part is showing students how to use the EHR as a tool to better understand their role in providing care.

"It's not just how you put in notes or orders, it's how you use it as a tool to answer clinical questions and design intervention," says Dr. Skochelak.

Getting a hold of big data

To use EHRs as a tool, it is increasingly important for physicians to understand how to make data from EHRs and other sources actionable at the point of care.

"The analytics piece, just like the EHR, becomes the tool and mechanism to provide care. Many schools are headed in this direction, however, I don't believe it is consistent across medical education," says Ms. Passiment with the AAMC.

Clinical informatics became a certified subspecialty only a few years ago, in September 2011. It emphasizes data management to help improve how providers, patients and trainees use the information to improve overall health.

"There is a real challenge in getting people to fill the applied analytics positions in healthcare because you have to have some understanding and background in healthcare as well as analytics," says Ms. Passiment. Giving all future physicians some training in the data analytics portion of informatics could help address this challenge.

NYU School of Medicine, which also received Accelerating Change in Medical Education funding, is working to add data analytics into its traditional doctoring course, called "Practice of Medicine."

"NYU is using big data," says Dr. Skochelak with the AMA. "And I mean big data."

Big as in 5 million de-identified patient records. NYU students are learning to approach big clinical data sets and analyze them to measure providers' performance. They're challenged to think critically about healthcare and ask their own questions of the data, which is compiled from a publically available database called SPARCS, or the Statewide Planning and Research Cooperative System. Launched in 1979, the New York State database houses hospital admission and discharge information, patient diagnoses, treatments and charges, and outpatient services information. NYU combined this with CDC nutrition surveys and NYU Langone Medical Center's own patient data, providing students with access to millions of de-identified records.

The big data then becomes a learning tool. For example, in a pilot class NYU launched last summer, students were asked, "What do you think is the most likely reason a person is hospitalized in the state of New York?"

Most guessed chest pain or pneumonia, Dr. Skochelak says. They were surprised to learn the number one reason for hospitalization in New York is actually childbirth. They were even more surprised when they saw the fluctuation in cost for this service across the state. Delivering a baby costs $2,000 to $3,000 in rural areas, but up to $22,000 in Manhattan, Dr. Skochelak says. Students are challenged to think about why this discrepancy exists and track their own patient and population management activities and queries.

"What our students love most about this is the fact that it's real," says Dr. Triola. "It's not a textbook exercise; it's real clinical data. It's the environment students will be training in and potentially working in."

By October 2014, administrators were so impressed by the pilot they wanted the whole class to have the lesson, Dr. Skochelak says. It is now a core part of the medical curriculum and the entire first year class has taken the course, entitled "Healthcare by the Numbers."

Adding data analytics to the curriculum helps move NYU toward competency-based education, Dr. Triola says. It helps students acquire the tools they need to continue to learn throughout their careers. So, even though medical students are now tackling data analytics and other IT skills in addition to anatomy and biochemistry, Dr. Triola doesn't believe medical school needs to be longer.

"What I do think we need to do is begin using some of these technologies to make medical education more of a continuum," he says.

Applying IT to learning processes

Nashville-based Vanderbilt University School of Medicine did just that, by not only incorporating technology into what professors teach, but also into how students learn.

Vanderbilt calls it Curriculum 2.0.

The new curriculum applies not only to clinical outcomes or patient records, but to students and their learning trajectories. It documents achievements, competencies, faculty ratings and assessments in a portfolio for each student. It is also populated with hospital notes students enter in the EMR during their clerkships, automatically capturing their panel of patients, so they can use it as a teaching space.

Vanderbilt provides each student with a portfolio coach, who they keep throughout their time in school. Students are scheduled to periodically meet with their coaches to talk about their progress and performance.

"It allows us to ask students, 'How can we help you be the very best that you can be?' For high performers, we can ask, 'Given where you are, what else can you do?'" says Kim Lomis, MD, associate dean of undergraduate medical education and associate professor of surgery at Vanderbilt.

The advantage of this system is that it allows students to progress through medical school in a flexible way, Dr. Skochelak notes. Students advance through competencies based on performance, rather than time. This works well for some students who may need more — or less — time in medical school. Physical therapists who decide to go back to medical school, for example, could potentially acquire all the necessary competencies in a time frame shorter than the traditional four-year period, she says.

More importantly, it helps ensure students are building skills like communication, skills that could potentially fall through the cracks in a lecture hall-structured, knowledge-based curriculum, according to Dr. Lomis.  

"It's very much in the spirit of patient safety. It's making sure people are prepared for the roles they're going into," she says.

Vanderbilt's Curriculum 2.0 is more focused on team-based, active learning and puts students into the workplace sooner, Dr. Lomis says. Instead of the traditional two years of basic science, students go into clinics in their second year and the school weaves the remaining science courses through all four years.

"The new curriculum is not only focusing on content, but also on teaching students how they will learn throughout their whole career," she says.

* * *

Technology and technology-based learning strategies are helping medical schools like IU, NYU and Vanderbilt shift into collaborative, interactive learning environments, which may be better suited for a new generation of physicians.

"Students are used to a much more networked, engaged sharing environment and healthcare is not yet like that," says Ms. Passiment. "It's a much more structured tech environment. It's clunky for a lot of learners. It's challenged them to create their own workaround, which allows us to see what the next generation of care will look like."

Written by Emily Rappleye (Twitter | Google+)  | February 10, 2015

Best,

Don 

Healthcare Mergers, Joint Ventures and Governance

"The healthcare industry has experienced increased consolidation in recent years, and there are significant challenges in healthcare mergers that should be addressed both before and after integration. Specifically, there must be common goals, shared values, and one aligned culture within an established governance structure to create efficiencies and best practices with the combined best features of each of the consolidated entities.
As one example of the manifest need for cultural alignment, earlier this year, the HCA Midwest Health System purchased two Catholic hospitals in Kansas City (St. Joseph and St. Mary’s Medical Centers) as part of a transaction that resulted in a total of 12 hospitals, seven surgery centers and over 10,000 employees. In connection with this transaction, the HCA Midwest Health System has agreed to work with the local Catholic Dioceses of Kansas City to preserve the hospitals’ religious heritage. This is one of many examples illustrating the importance of culture and strategy as essential pieces of governance and successful integration.
For healthcare board members contemplating or engaging in mergers or acquisitions, the need for proper governance practices is magnified in the pre- and post-integration environment. If there is not sufficient discussion and alignment on cultural norms and values pre-merger, the consolidated entity will likely encounter costly challenges that could have been proactively addressed and resolved.
To execute their duties effectively, healthcare boards must engage in proper oversight of critical areas. The primary oversight responsibilities for healthcare boards can be grouped into six functional categories:
Culture – Culture is the term that describes the values, attitudes, norms, and behaviors of the entity – who they are and how they interact with one another. When two or more healthcare entities with different backgrounds merge, it is critical for them to (a) reach alignment on culture and (b) have an assured commitment for the going-forward culture before merging. Developing and maintaining the right culture maximizes the benefits of integration, allowing the consolidated healthcare system to achieve synergies and efficiencies that are possible through combined efforts that are greater than the sum of the individual capacities. Boards should devote time and attention to proactively defining, communicating and reinforcing the culture.
Talent – Emerging best practices are to have a more interactive, full-board discussion around robust succession and talent development planning for the CEO and senior management. Boards must demonstrate independence in undertaking executive compensation and evaluation decisions.
Strategy – As the oversight duties for boards increase, trustees are taking a more active role in assuring that their entity has a strategic plan that the trustees fully understand and jointly own with management. Involvement in the strategic process is best achieved through a meeting or retreats after integration devoted to strategy that not only educates on strategic issues, but also permits the trustees to have informal time together to promote collaboration through socialization and trust building. Such meetings allow boards and management to mutually develop their respective macro and micro roles – an invaluable asset for the consolidated system. Effective strategic plans for healthcare entities will take into account compliance and the changes on the horizon for the industry that will result from the Affordable Care Act.
Compliance – Complying with laws and regulations, while simultaneously assuring the highest ethical conduct, is largely dependent on a board’s commitment to best practices in compliance.  The government places additional compliance requirements on healthcare entities and expects healthcare boards to be aware of the applicable complex regulatory structures. The board must continually monitor the entity’s compliance risk assessments, education/prevention, and detection to ensure that all are working well on an integrated basis.
Risk – As board and trustee responsibilities increase, boards are expanding their oversight of risk management. Specific to healthcare entities, the Office of Inspector General requires an ongoing process of risk assessment. Best practice is to establish and maintain an Enterprise Risk Management program with clear allocation of accountability. The board should (a) oversee ERM and assure that it receives sufficient attention at all levels of the entity and (b) ensure that remedying of major risks is discussed by the full board and addressed in the entity’s strategic plan.
Governance – Boards should be large enough to accommodate the need for diverse skill sets, resources and experience and small enough to promote collegiality, flexibility and effective participation. Some healthcare boards are decreasing the size of the board and creating a board of visitors or board of advisors. Thus, the board operates more effectively while still involving well-respected advisors who provide access to experience, resources and networking. To this end, best practices today are for a nominating and governance committee to create a template of needed skills and character attributes for full board input and approval. The approved template is then used to ensure board searches are based on needed skills and required attributes."

Bill Ide is a partner at McKenna Long & Aldridge LLP.

Hire a Chief Integration Officer - not an "Information Officer," and here's why:

CIO.com:

"Peter High, a contributor at Forbes.com, typically focuses his column, “The First 100 Days” on CIOs settled in at corporations. He turned things around recently with an interview with the man he calls the “Greatest CIO for Hire in History.”
That’s quite an accolade, but High argues that Charlie Feld, one of the “first outstanding CIOs in corporate America” deserves the title because he left a lucrative and powerful position at Frito-Lay to form The Feld Group. As High writes, “Along the way, many Feld Group employees went on to become CIOs at the companies that they consulted to, and therefore, Charlie Feld’s influence in the world of IT can be measured not from his own significant contribution, but also from the contribution of the many leaders who he spawned.”
In 1992 Feld founded The Feld Group. According to his official bio at The Feld Group Institute,  in 1997 "CIO magazine named Feld “One of the 12 Most Influential IT Executives of the Past Decade” and in 1998 Computerworld named Feld as one of “25 IT People to Watch in 1998.” In 2001 he was named one of the top 5 CIOs and sold his company in 2004 to EDS. After retiring as a Senior Executive Vice President and member of EDS’s Executive Committee, he founded The Feld Group Institute in 2009.
Feld makes some astute observations in his Forbes interview – chief among them how IT’s relative youth at 50 years old hinders executives who have been talking business for centuries. “Senior executives are reasonably conversant in most of the business disciplines.  They can generally engage in strategy conversations around Finance, HR, Manufacturing, Sales, Distribution, etc.  These professions have been around for centuries and have common languages, frameworks and ‘rules of thumb’ that enable the dialogue.  IT is in its early stages, being less than 50 years old and lacks these essential building blocks,” Feld says.
He also spoke to how the role of Chief Information Officer needs to evolve to become Chief Integration Officer in the interview. “The new robust integration fabrics that are event enabled, in memory-in motion, become great enablers that can embrace the heterogeneity of legacy, cloud, sensors, GPS, functional packages, customers, suppliers and employees.  That’s why I’ve been so bullish about the CIO becoming more that the Chief Information Officer,” Feld says.
That’s an opinion shared by many others, including Mat Ellis, CEO and founder of Cloudability. who writes at TheNextWeb.com, “These challenges of interconnectedness are playing out in parallel inside the enterprise. CIOs have a once in a lifetime opportunity to provide the leadership needed to guide their companies through these challenges. Done right, the I in CIO becomes less about managing information and more about managing integration.”
Feld offers practical advice for those seeking to become CIOs. The secret isn’t being great at technology or business. It’s being pretty good at both. “You don’t have to be the best technician in the company or have the best business mind. You just need to be pretty good at both.  I’m starting to see that happen in companies I’m currently engaged with.  They are the renaissance leaders and they are working hard at developing their next generation,” he opines.
But it also helps to have a defined career path, Feld adds, sharing PepsiCo’s path that he says help develop well rounded CIOs. “A high potential college graduate would see the IT organization from a number of portals during their first 10 years.  Typically, they would spend a couple of years in Data Center operations, followed by 3-4 years in Development.  The next assignment might be in Systems Engineering and finally a 2-year tour in a business function as a major user of IT Systems,” he says."

Analyzing your Continuum to Remain Competitive

Think about those silos - here's an answer...


"Two-thirds of the healthcare ecosystem have analytics strategies in place, yet only one-fifth of these are driving adoption across the entire enterprise, let alone the entire ecosystem. When information is shared across the entire ecosystem organizations can improve patient outcomes.

The healthcare ecosystem is the convergence of otherwise separate entities, such as life sciences organizations, providers and payers, as well as social and government agencies. This convergence, along with enhanced connectivity and mobility, has resulted in a tremendous surge in healthcare-related data that can help create insights and inform actions. 

From managing small details to large processes, analytics can aid the entire ecosystem. Going forward, deriving meaningful insight from the wealth of information available will be a necessity to achieve competitive advantage."

Changing Healthcare: Concepts to Improve Effciency

Rice University - Jones School of Business, Healthcare Management
http://www.youtube.com/watch?v=clP4SHdSfs0

Forward Thinking - Healthcare Financial Management

This article is very relevant to your strategic planning efforts:

"An old rule of thumb is that a hospital needs (requires) 150 percent of depreciation in cash to maintain the physical plant and equipment, replace old technology and acquire new technology. Less than one in five hospitals met this standard in the most recently recorded fiscal year. More concerning, it is estimated that less than one percent of American hospitals broke even on the Medicare program last year.

Despite all of the political bickering in Washington, D.C. there is uncanny bi-partisan consensus to reduce federal support for the Medicaid and Medicare Programs for U.S. hospitals. Why? Two reasons; hospitals have minimal political support and the cost of healthcare has to be moderated. It is breathtaking to take in the political clout of the pharmaceutical industry. Medicare Part D was rammed through the George W. Bush Administration with no offsets and with extraordinary ease. American hospitals have not seen anything on this level since the passage of Medicare itself in 1965. With unlimited political contributions permitted by U.S. corporations to political campaigns and the extraordinary restrictions for political contributions from the hospital sector, we are simply outgunned in the political arena.

Medicare and Medicaid have to be tamed, and they will. The financial cost of Medicare and Medicaid are growing at a rate beyond the rate of growth of the U.S. economy and has been for decades. The natural conclusion of this growth is that our children and grandchildren will not have to worry about the cost of a gallon of gas. They will not own a car, house, clothes, food or anything else. The only thing that will be in the U.S. economy will be healthcare. Obviously, this will not be permitted. The cost of healthcare will be cut with an axe and with surgical precision. It will not be fair - it has to be done.

For those of you feeling warm and comforted by the Affordable Care Act (Obama Care), it is scheduled to remove $550B over the next ten years in federal support for the Medicaid and Medicare Programs. Of course, it is possible the U. S. Supreme Court will invalidate Obama Care in the June deliberations of the high court. Alternatively, if Governor Romney (R) is elected in November, he is committed to repeal Obama Care.

There are or have been other attacks on Medicaid and Medicare funding. Many state houses have already dramatically reduced Medicaid funding and hundreds of hospitals are reeling in an effort to balance their budgets as a consequence. And then there are the speculative proposals to whack away at the Medicare Program. When the congressional Super Committee was debating ways and means to reduce the federal budget late in 2011, the Obama Administration offered an additional $320B in Medicare cuts, over the next ten years, to move the process along. When the committee efforts failed, pre-agreed cuts hit many federal departments. Scheduled for January 1, 2013, under Medicare Sequestration, is a two-percent across the board cut to all Medicare payments to all Medicare providers. While the total is unknown, this is a serious blow to those communities with a heavy Medicare patient care load.

To illustrate that these cuts are by no means partisan, the point person for Republican federal fiscal policy is Wisconsin Representative Ryan (R) who just led the passage of a budget through the U.S. House of Representatives that includes $5.3T in budget cuts over the next ten years. The Ryan Plan provides some definition to the so-called “Medicare Voucher Option.” With respect to Medicare, the program would be privatized. Future beneficiaries will choose from a menu of private options and will not have the choice of the standard Medicare plan. Wealthier beneficiaries will get a small voucher and poorer beneficiaries will get a larger voucher. Vouchers grow at GDP+1%, whether or not Medicare does the same. The implications of this proposal are far reaching.

Under the Voucher Program, hospitals will be obligated to pursue payment from patients after the financial benefits of their “voucher” expire. This will call into question the tax-exempt status of U.S. hospitals. Where is the charity care?

With all of the political volatility in Washington, D.C., it is most likely that none of these cuts, as defined, will ever see the signature of a U.S. President on a piece of federal legislation. The people I trust are the leadership of the Healthcare Financial Management Association and they predict an eight to twelve percent cut in Federal support to the Medicaid and Medicare programs over the next five years. This will close hundreds of marginal U.S. hospitals and cripple essential community providers all over the United States. It is also predicted that 30 percent of U.S. hospitals will close over the next eight years."

Best,

Don Lyons