Healthcare Quality Summit: Promoting Innovation to Achieve High Value

Uploaded by USGOVHHS on 07.10.2010

bjbjLULU HQCS Breakout Session: Promoting Innovation to Achieve High Value, Efficient
Health Care 1042010 Rick Kronick: Well, good afternoon. My name s Rick Kronick and I m
deputy assistant secretary for Health Policy in ASPE in HHS and it s a pleasure to welcome
you to the last session of the day. We ll be hearing in this session from a number of
the nation s innovators and leaders in developing high-quality, high-value health systems. It
s a very exciting panel. The vital support of panelists that are in your packets, so
I m not going to go through them but just very briefly: Patricia Briggs, to my right,
has been the chief executive officer or Northwest Physicians Network since 2000. Thank you for
joining us. Dr. Mike Johns has served as a chancellor for Emory University since 2007.
To Mike s right is Richard Cooper, who is the chief executive officer of the Everett
Clinic, a multi-specialty physician s group practice serving [unintelligible] patients
in North Puget Sound region. Next to Richard, Dr. Doug Eby. He serves as the vice president
of medical services for the Southcentral Foundation, a non-profit, customer-owned health care system
including a 150-bed hospital in [unintelligible] state-wide system in Alaska. Dr. Philip Mehler
is the chief medical officer of Denver Health and professor of medicine at CU Medical School
where he holds the Glassman Endowed Chair of Medicine. And last but not least, Dr. Karl
Ulrich, president and CEO of Marshfield Clinic since 2006. Welcome, and thank you all for
joining us today. d like to start out ending the afternoon with a very similar question
to the one Carolyn Clancy asked at the beginning of the day. And you all are leaders in the
development of high-value systems and I wondered what have been the most salient successes
in your organizations. What have you done to make changes and [unintelligible] can help
us understand how those lessons can be translated to other organizations throughout the country?
Although, having said that, the usual rules are under three minutes, so do what you can.
[laughter] Patricia Briggs: Okay. Thanks for having me here. So, I represent a group of
small and medium practices of about 500 physicians and other providers in the Puget Sound area
in Washington. So, we ve been taking full risk managed care contracts for 15 years from
commercial and government insurers. So, our work really has been about for the last 15
years developing a coordinated health care delivery system. And we ve been involved in
constant quality improvement of our processes over time and we have to use innovation to
bring about a system where we hope that we are providing real value to the patient and
the health care system in general. We ve used the usual things that I guess for some people
are not usual, but for us seem like [unintelligible] doing utilization management, case management,
complex case management, prime care management, among other things. I will tell you that we
have about 30 primary care physicians and that two-thirds are specialists of all kinds
in our system. So, over the last six years, what we re concentrating on is the use of
electronic tools in improving our processes around coordinated care delivery system. So,
an example of this would be we ve gone from using glorified spreadsheets as our registries
for chronic care diseases to putting those registries on a security communications network
that has a patient and provider forum [spelled phonetically] so that nurse case managers,
physicians, and their patients can look at the data regarding their disease and communicate
around that and have better care. Also, in helping these small practices adopt EMR use,
what that has really turned into is not only getting a [unintelligible] if you will, getting
things that aren t intuitive to providers to use so that they will use them, but also
in them install them in the offices, really it s about teaching care and work redesign,
introducing them to how it really can provide team-based care. So, again, it underlines
the importance of using electronic tools and not mistaking them for what is going to make
the real change. So, currently, what we have them working on is improving coordination
at the point of service level using an electronic tool called Clarity [spelled phonetically].
In this, what we re trying to do is concentrate on improving the disjointed, fragmented, and
-- system that has developed over the years in communication among providers around the
patient and subsequently making that fragmented communication -- turns into fragmented communication
to the patient. And in the system, the primary care providers know what information they
need to send with their referrals. And we re used to thinking of referrals as being
some sort of insurance requirement, but really, when you think about it, it s a communication
between the people who are involved in your care. So specialists have helped develop the
template for the kind of information they need to come with the patient and their referral,
and of course, that s all attached electronically now. Also, the specialists then have to say
that they are actually going to communicate back with the primary care and other specialists
who get involved in the patient care. And at any given time, any of those providers
who are involved in the patient care can look into the system and see where the patient
is, see what is going on, see if the patient has made their appointments, et cetera, et
cetera. So, that is one of the things that we ve been working on lately that has really
resonated among the physician community and it hasn t mattered whether they are employed
physicians who get on that system or the independent physicians; they are all actually rejoicing.
The communications they used to have in the doctor s lounge is coming back and coming
back in a way that is meaningful for them and easy for their offices to use. That s
all. Rick Kronick: Thank you, very [unintelligible]. Mike? Mike Johns: Yes, thank you. Thanks for
allowing me to be here with all of you. This being the last panel of the day, everything
s already probably been said. Of course, that won t stop me or any of my colleagues, I m
sure. But I would like to [unintelligible] a point or two. First of all, Emory has a
very large and the largest health care delivery system in the United States. I went to school
for theology, so we [unintelligible] the concession of resurrection [unintelligible] -- [laughter]
We have a -- it s a complex area because we have to maintain the research for [unintelligible]
trying to make a difference in health care, from health policy to site of discovery, at
the same time care for some of the sickest and some of the very poorest in our area.
And all the time while we re doing that, we re trying to lower costs and improve the outcomes
for our patients. s a very challenging atmosphere for us and we ve initiated many, many programs,
many of which we have already heard throughout the day. But I want to say something to [unintelligible]
and this is something [unintelligible]. In 2002, we were revisiting: How do we move ourselves
forward and how do we build better care? And we made a discovery of a secret ingredient,
and the secret ingredient is patients. Patients. Now, I say patients [unintelligible] but we
decided at that time that we would take the providers out of the center and put the patients
in. And we use that for everything we do. So, any care redesign, even when we are going
to build a new space, we bring patients in and we rebuild around what they see is important
to them and what they need. ve got to say, it s been a powerful tool in multiple ways.
We suddenly have different conversations going on when patients are in the room with doctors
and nurses and health providers. In fact, when I -- the fact that I sometimes am irrational
about this, and we stay focused because we all have raised our hand. It s about the patient
and family being the center. And I can ask that question, What s in the center? Everyone
can raise their hand and tell me. I think this is a very, very important point. While
not technically complicated value that we redesigned our neural ICU around, it [unintelligible]
of course, we ve seen our infection rates drop, all kinds of primers change. And I think
that the most secret ingredient is you ve got to bring patients to the table, you ve
got to have them involve in everything you do and all the planning. I could go on and
tell you about our practice and care management program or our goals that every patient who
comes into our hospital will have [unintelligible]. Every patient, not just specialty. Not just
specialty. I could tell you about our anti-coagulation management program which has radically changed
the success rate of our anti-coagulation programs. I could tell you about how we re approaching
our medical [unintelligible] but I want to go back. The secret ingredient really is to
get the patient involved, put them in the center, and make sure that everything you
are discussing has real patients, real people who actually are not representing anything
but themselves as a patient. Rick Kronick: Thank you Dr. Johns. Next, Richard Cooper
from Everett Clinic. I ve heard about the importance of communication and the importance
of patients. What else? Richard Cooper: ll follow that up with it s important that it
s patient-centered. That was an excellent observation. The Everett Clinic is located
about 25 miles, for those of you who aren t familiar with our group practice, north
of Seattle. We have 400 providers of care; 300 physicians, over 100 advanced clinical
practitioners, and for the comment that was made earlier in the day, we re the first group
practice in Washington state to hire a nurse practitioner in 1972, so we have approximately
25 percent of our providers of care who are non-physician, and over the next five to 10
years, that could reach 40 percent. I thought what I would do was offer up a few case studies
of how we ve attempted to make an impact on improving quality and reducing cost of care
and all of what I m going to share with you is easily replicated elsewhere. If it was
not at the Everett Clinic, it could be implemented elsewhere. Let me start with a project that
Pam French introduced this morning and that was the Boeing Ambulatory [unintelligible]
Program. We were one of the three sites that participated in this project and you might
ask, Well, what motivated you to want to get engaged? Well, other than Boeing being one
of the most important customers of ours, we saw this as an excellent opportunity to learn
and improve. And this project focused on the five to 10 percent of the patients that generated
over 50 percent of the increased in spend. It was also about improving quality, it was
also about reducing the number of days out of work, it was also about improving service,
but it was also about decreasing -- reducing the [unintelligible]. And what we actually
learned was that the three sites, given that the sample size wasn t large enough at any
one site, actually reduced the cost of care 20 percent over a two-year period. And one
of the shortest timeframes -- the results are published in the Health Affairs if you
haven t already read them. So this is a pretty significant intervention and it s all about
focusing on the [unintelligible] prospectively identifying these patients and creating a
multi-disciplinary team to care for these patients. And the team is lead by a primary
care physician, but importantly includes a behavioral health specialist, a nurse case
manager, as well as a pharmacy professional as part of that team. And indeed, most of
the costs that were taken out related to emergency room and hospital utilization. A second brief
story that I d like to share related to our approach to managing prescription costs. And
we ve been engaged in trying to manage these costs for about 10 years. It was actually
in the 1990s that we put in place a program that allowed us to get a full-charge database
from three of the largest health plans in Washington State regarding the number of prescriptions
written by every Everett Clinic clinician. Our clinical pharmacists and data analysts
then translated that raw data into cost of prescription by clinician. In the meantime,
we invited drug reps not to come to the Everett Clinic and visit individual clinicians; we
established business-to-business relationships. If you fast-forward to 2010, about 83 percent
of all of our prescriptions are generic. You compare it to the average cost of prescriptions
in Washington State and the savings is around $88 million. A third case study relates to
advanced imaging. We -- one of our core values is variation at the Everett Clinic. Variation
is alive and well in everything we do in work process and care process, including the ordering
of advanced images. We get actionable -- not information, not data -- actionable information
from one of our health plans that identifies an opportunity to improve. We put together
a multi-disciplinary team; we invented our electronic order entry system. The rules that
there would for ordering prescription, form diagnosis, and two years later, we reduced
advanced images by 39 percent. In our environment, fee for service environment, correction in
excess of $2 million of revenue that also goes to the bottom line and therein is one
of the reasons that we re still interested in financing mononet reports [spelled phonetically],
this kind of behavior. I -- maybe defer to Karl, one of our partners in Medicare for
Practice Demonstration Project, that requires one in 10 organizations around the country
to do this work and again, this was an opportunity for us to learn and improve in how we care
for our 41,000 Medicare patients. The take-away that I probably want to share with you are
two really important services that we offer as -- to our Medicare patients. One is a hospital
coach that actually meets with every patient who s discharged from our hospital that we
admit, and the other was the inclusion -- you ve heard about this earlier -- of palliative
care in our primary care program. Those were two very, very important services that really
moved the dial, and you can go on our website to see our quality of care performance measures.
And we re not -- we re competitive, but we re not performing at quite the level as our
colleagues in Portland, but we re in the low 20 percent of cost of care and utilization
in the country. And in our setting, we see a significant opportunity to improve. So,
with that, I ll close, but those are our four or five programs that could be replicated
elsewhere. Rick Kronick: Thank you, thank you very much, Richard. Moving further North
to Dr. Eby up in Alaska. Doug Eby: Hi. So, the reason we re invited is that [unintelligible]
health care costs and improving health care, you have to understand how it plays out with
people who have these things called health disparities and health equity and health justice
issues and all that sort of thing. I ve been very privileged to work in support of Alaskan
native people and their dreams and wishes for a health care system for quite a number
of years now and our story is one of -- well, first of all, we have about 50,000 local people
in our system and about 10,000 that are spread out over a huge geographic area. If you look
at where our [unintelligible] it s like being centered in St. Louis and providing care to
all of Illinois, all Ohio, all of Kansas, all of Missouri, and big sections of Oklahoma,
Texas, New Mexico, Arizona, and California. That s our target [unintelligible] geographically
relative. The terms disparities and health equity and high socio-economic worth and generational
trauma and that sort of thing have real meaning to people who own and use our system, so it
s all these disparities things and risk factors and so forth. We ve got three to 10 times
the usual risk factors while raised in this country. And the funding for the system, [unintelligible]
health service around data [unintelligible] and data breadth by the corporate [unintelligible]
for the last 12 years. And in our system, we get about two percent more from the government
each year and we raise a little bit more by Medicaid, Medicare, and private insurance,
which is about half of our income. So, about a two to three percent increase in revenue
per year, total revenue, while we see a seven percent increase in population, and of course,
like the rest of you, 10 to 15 percent medical inflation. And in the face of all those realities,
the Alaskan native people say, Hey, let s take this thing over and run it ourselves.
And so they did. And the reason we re up here is because in the last 12 years, we ve reduced
emergency room use by 50 percent. Not five or 10 -- 50. Hospital days, like, 45 percent,
specialty visits by 60 percent, and we have moved the Alaskan native population in our
system into the top 75th or higher percentile [unintelligible] comparables in three-quarters
of the [unintelligible] comparables that we benchmark ourselves in with 98 percent happiness
ratings for people who work in our system and people that get care in our system. So,
way high satisfaction. One-quarter of the staff turnover leads to half with markedly
dramatic improved case outcome measures, putting its marks in the best performance in the country
in the face of disparities and inequities that are some of the highest and most extreme
anywhere in the country. With flat, relatively flat funding, decreasing per capita, the stuff
available to us year after year. So, how do we do this? A couple basic things. It s truly
a long story. We d actually prefer three days to tell our story at minimum, half of the
workshop, because Alaskan native people said they wanted to change absolutely everything
about the entire system of care without running off the doctors, nurses, and pharmacists,
because that was really the best they had to offer. So, two real key points. Probably
the most fundamental thing is the Alaskan native people understand the difference between
a rock and a bird. Here is what I mean by that. If you throw a rock at a target over
and over, eventually you can make the rock hit the target every single time because I
am active and the rock is passive, and I can benchmark, I can Six Sigma, I can read, and
I can understand and learn from best practices. I can standardize the process and eventually
make that rock hit the target every single time. And in health care, there is lot of
things we do that are like throwing rocks at targets, and earlier today, you heard about
central lines, and [unintelligible] and so forth, and that is like throwing a rock at
a target. But unfortunately, mostly in health care with chronic conditions and so forth
it is a whole lot more like throwing a bird at a target, where I can feed it the right
way, I can give it encouragement, I can tell it what to do, and I can push it with some
force, but about 95 percent of the variables that determine whether that bird goes to the
target are in the hands and under the control of the bird. [laughter] And in health care,
we have a lot of rock throwing and we have a lot of bird throwing. And if you do this
for the OR, the ICU, the NICU, the PICU, and to some degree, ER and trauma situations,
it is really like the rock. There is a whole lot of complicated things that happen in sequence
where someone is passive and someone is active, and you should apply manufacturing, rock based
technology to those environments. But most health care costs these days are driven by
bird environments where really the customer or the patient or whatever have the control.
That echoes what you say about pushing the -- the secret ingredient is the patient.
Well, we don t even use the word patient anymore; there is a whole lot of terminology that we
don t use any more. What I really want to do is talk about compliant and non compliant,
because really it is about whether the system is compliant or non-compliant, and that is
another story. But the point here is that we just didn t go to the patient-centered
[unintelligible] actually patient customer control, so our board, our CEOs, three-quarters
of our leadership, three-quarters of our staff, and they are being counted and reconfigured
and reencountered so that the customer is in control. We designed everything: the facilities,
the environment, the care packets, the cumulative care plans -- every single piece. The work
force, hiring; all kinds of things we did to change the whole system. And the last thing
people the understood is that this difference of throwing the bird is truly fundamental.
So we didn t go after the hospitals, we didn t go after specialists; we went after the
longitudinal platform where we re in constant, continual, personal, trusting, accountable
relationships with the individual at the time. We brought the whole body together so the
mind and body are back together, bring all the services where the person is and figure
out how to insert our services into people s lives. And we did all kind of really stupid
things, like we would write [unintelligible] make as much money as we can off of doing
the right thing, so we encouraged female installment, labor workers, all kinds of ways that aren
t rigid based and don t really get us paid. And then you take the Medicare and saved a
ton of money off of us in the last 12 years, so [unintelligible] one additional penny.
Rick Kronik: The last [unintelligible] -- [laughter] Rick Kronick: Next, Dr. Mehler
from Denver Health. Philip Mehler: Thank you for inviting me today. Denver Health is a
vertically integrated health and safety net system in Denver and it has a 500 bed Level
I trauma center, nine federally-qualified health centers, and a number of other components
that make up our [unintelligible] system. We just this year celebrated our 150th year
of existence. We have 300 employed full time physicians and a staff of about 700 physicians,
200 mental health providers. We do about 30,000 admissions a year into the hospital and about
750,000 outpatient visits per year, so we re a large system. Our successes are remarkable,
given the fact that 50 percent of our patients have no payer source, so we take care similarly
of a very vulnerable population with a health diversity level of about the fourth grade
overall. So, our studied successes over the last number of years, number one, is really
that despite being a safety net hospital, we put a lot of energy into becoming a force
with regard to the delivery of high-quality health care to our patients. Just last week
at the University Health Consortium, the UHC annual meeting, it was announced that Denver
Health had the lowest mortality of any hospital in all of UHC for the last year. We ve done
that by investing in IT. We put about $500 million into IT over the last decade. We have
a fully-functional CPOE system, MAC [spelled phonetically], PAX [spelled phonetically],
EMR, and we believe strongly that part of our success has to do with the investment
in IT. A second success that we re very proud of is the fact that despite the fact that
our funding streams have become more and more challenging and less predictable year after
year, we have been financially solvent over the last 17 years, and have been in the black
during that time, and that s a culmination of becoming more efficient and having less
waste. Specifically, we plunged full ahead into making lean our process improvement for
the hospital, and so we have trained over 400 of our staff to become black belts, and
to date, we ve saved in real, hard dollars that were blessed by the CFO about $60 million
due to Lean. In order to do a process improvement like Lean or Six Sigma, you really have to
have the direction of the leadership. They have to be engaged in it. You have to promote
it and avail training to those that are going to do it, and then you have to really embrace
it fully. So, we have about 10 rapid improvements per week, events going on. We have 15 different
value streams and this is really pushed by our CEO, Dr. Patty Gabow. That s a big reason
as to why we have been able to achieve the success we have in the last number of years.
In addition to that, given the sort of fragmentation of care because of the work hour restrictions
of the residents that has been a real challenge for us to maintain clinical excellence. And
we can debate whether those who founded on science or not, but the reality is we have
to live with them. And so as a result of that, we rededicated our efforts to making sure
that attendings are much more involved in the care than they were perhaps when you and
I trained 20 or 30 years ago. Because the residents are completely providing 90 percent
of the care at Denver Health, we believe that given the fragmentation of care and the more
hand-offs going on, that if you are going to achieve success in an academic center,
you have to have increasing resident supervision, increasing attending involvement compared
to the way it was years ago. In addition, we believe strongly that you have to have
data that are concurrent and timely and provider-specific going back to the providers, that if you want
to achieve success in medicine, these data have to be available and be given back to
the providers on a regular basis. And so we have a very robust data warehouse that houses
both clinical and financial data, and every month, we give to the clinicians, the full
time clinicians in the outpatient departments, a whole litany of indicators that we follow
that are compared to their peers and that are timely based on their progress through
the 30 days before the report is sent out. This data warehouse and the investment that
we have made in IT allow us that when I go to clinic and I get an internal medicine physician,
it auto-populates on every counter that I fill out the patient s last Pap smear, their
last hypertension, their average BMI over the last year, what medications they are on,
and having these data available to us in real-time has certainly helped us promote better quality
of care. The last things that I would say are that we believe strongly in the development
of registries for chronic conditions. Because we take care of a vulnerable population, most
of our patients are on more than 10 different medications. Most of our patients have more
than four co morbid, chronic illnesses, and to do a job, a good job taking care of them,
you really need to have data available on them over time. And so we ve developed very
robust registries for all of our chronic care conditions: asthma, diabetes, hypertension,
hyperlipidemia, cancer prevention, and by doing so and giving this information to the
providers in a concurrent manner at the time we re seeing the patient has helped us achieve
-- 70 percent of our patients have their blood pressure controlled compared to perhaps
50 percent nationally; 50 percent of our diabetics have their lipids controlled compared to perhaps
25 percent nationally. So having these data available at the point of service and working
in a vertically integrated system has helped Denver Health achieve the success it has despite
taking care of very vulnerable populations. Rick Kronik: Thank you, Dr. Mehler. And then
Dr. Karl Ulrich from Marshfield Clinic, you have the last word on this. Karl Ulrich: Thank
you. I guess [unintelligible] the saying you are saving the best for last. [laughter] m
Karl Ulrich from Marshfield Clinic, and I m really pleased to represent our clinic and
our patients here today. We ve been a member of the Physician Group Practice Demonstration
Project at CMS, and CMS has given us the blessing to go ahead and release our results from the
fourth year now of the demonstration project. And through the first four years of the project,
Marshfield Clinic has saved $83 million for CMS. We have been the recipient then of $30
million in that shared savings and another $10 million in kind of an escrow account that
if we do okay on quality measures [unintelligible] participate in that [unintelligible] too.
We also achieved 100 percent quality measures for the fourth year as well for the second
time in four years. In four years, we ve done that. We figure we missed one quality measure
each year. The good news for us and the good news for the whole part of the all 10 demo
sites is that everybody has improved quality year over year, so this can be done. We have
the shared savings concept, shared fee for service, and shared savings, I mean, can work
and you can get things done on quality measures as well, too. Now, the question is how did
you actually bend the cost curve? Well, we concurrently undertook several things and
it s the same theme over and over again. It s the utilization of data. We have our own
electronic medical record that we developed at Marshfield. We have portable computers
that our providers use. We ve got about 3,500 of them in use in our system. And what that
does is we had our electronic medical records ready to go probably somewhere around 15,
20 years ago. We decided to wait until they made that information portable. So, we didn
t want the information sitting in the doctor s office. We wanted the information where
the doctor or providers were. So, we got a convertible [unintelligible] are mobile; they
go home with the doctors and the providers at night. When they take call, they have over
a million patients electronic -- or their health records available to them when they
need them. If the doctors at the hospital get a call about an outpatient, the information
is there, vice versa [unintelligible]. What we have been able to do, our software engineers
have to have an iterative process with the physicians, so when the physicians leave the
practice well and typically what would happen is just the doctors would say, We like to
have this done, we think it would improve our practice and make us more salient. And
we would take it to the software engineers, who were probably going to come back several
months later and demonstrate to the doctors how [unintelligible] this was. The doctor
would say, That s one click too many, send it back to the software engineers, and then
they would come back. And so over the course of many years, these processes evolved, and
they were very iterative, very friendly in the practice of medicine, and what we have
been able to do is now take point of service for physicians relative to allergies, stroke,
drug interactions, relative to the quality measures that the CMS asked us to do as part
of the PGP project. So for example, if a diabetic patient had not had their hemoglobin A1c checked
within the appropriate time, that just shows up automatically in red on that physician
s chart. We didn t want the physicians to have to even think about whether or not they
needed to go back somewhere in the chart or in the electronic medical record and find
-- it just automatically pops up. Same thing for drug interactions. A little box comes
up and it says, Doctor, did you really need to order this particular medication because
it interacts with another medicine the patient is on. So, we found that not only the utilization
of electronic medical records, but asked to have a data warehouse and withdraw that data,
feed it back to physicians is absolutely critical for us to move forward. We also at the same
time developed a nurse triage line that s available 24 hours a day, seven days a week,
365 days a year. They have been instrumental in decreasing the number of ER and urgent
care visits in our patients. So about 50 percent of our callers now, I think it is around 75,000
calls per year, are handled strictly over the telephone and so the beneficiaries of
this are not only the patients and the families, but a few health insurance companies, and
[unintelligible] some of the work that the ERs and urgent cares centers handled in the
past. ve also undertaken, as Mike had mentioned, cholesterol control clinics and other dyslipidemia
clinics, congestive heart failure clinics where we interact with people and a coumadin
clinic that [unintelligible] referred to as well. I will tell you, Mike, that our number
of hospitalizations for maleffects is two percent of the population of those now in
our coumadin clinic which is about 6,500 people. And that compares with hospital admissions
of 17 percent in [unintelligible] part of the system, so that reduces the burden of
care in the hospital setting and obviously improves the lifestyle of our patients, as
well, too. [unintelligible] we have been particularly proud of is when a patient is seen in our
system now, at the end of the visit, we then now hand out to them a summary of that particular
visit and it gives them their weight, gives them their blood pressure, gives them a complete
list of the medications that they are on, including any changes that have been made
during that visit, and we have found that -- we also give them lab results as well,
too. We have found that that has done two things. One, it allows the patient now to
engage in meaningful questions with their providers. It allows also the provider to
teach the patients about, Gee, I see your weight is down and your cholesterol is down,
and there is a correlation there. That is something we were not able to do before. Lastly
is we find that people from my generation are caring for elderly parents at the same
time that you are raising the kids, that having that handy list and medications, because mom
and dad could not remember what that was, what they were told to do, or how many times
a day to take their medication, it has clarified the role of medications in a particular person
s life and clarified communication within families, so we feel very good about involving
now a lot of that information for patients moving forward. Lastly, I would tell you,
as you engender some of these changes to kind of provide new methodologies, taking care
of patients, it is a little bit like a chain is not oiled in your car when it is going
down the road at 65 miles an hour, because you are still providing services. Physicians
and medical providers have set ways in which they want to do things. They hear the harbinger
of people having to make changes and you have to do a lot of explaining. There is a lot
of hard work administratively to get these things taken care of. Let me give you just
one example of something, one change, that as we [unintelligible] another change, and
I ll finish. As you begin the process of talking to clinicians about paper performance, quality
and other things, et cetera, one of the [unintelligible] That s not my patient, or, I did everything
right, but the patient didn t get the medication prescription filled, or what have you. It
is the patient s fault. Why are you penalizing me for this? We get a fair amount of that
early on. What we did in a particular case of the comment that -- especially in the more
rural areas of Wisconsin where we serve, up north, where physicians are complaining that
the patients were not getting their prescriptions filled, we went to the state of Wisconsin
and we asked for a new law that would allow us to have a telepharmacy so that the patient
education process, where the pharmacist has to interact with the patient, tell him about
the side effects, et cetera, we can now do that by televideo. That was something that
we had not thought of before, but it eradicated that particular problem. So, we stock the
pharmacies [unintelligible] small [unintelligible] top 25 medications that physicians in small
communities provide and then the pharmacist comes on from Marshfield or Eau Claire or
Wausau and does direct interaction with the telepharmacy. So, it is a pretty innovative
way of addressing a problem that we weren t prepared to handle initially. So, one change
begat another one, so to speak. So, we look forward to the rest of the discussion, and
thank you. Rick Kronick: Thank you very much, Karl. A very interesting set of presentations
and a number of common themes; certainly, the importance of patients at the center.
I have [unintelligible] of ownership and making this work, but also the importance of information
technology, the importance of the systems chain we heard quite a lot. And I just following
up, Karl, on one of your comments about the difficulty of [unintelligible] is really hard
making the change as you are moving, hurtling forward. I would like to ask each of you to
comment very briefly -- and I emphasize the very briefly -- what you have been able to
do, if anything, around the issues of having the primary care physician and their patients
closer to the center. I, before I came to the administration of [unintelligible] medical
school and like Mike Johns at Emory and probably Denver Health. You know, specialists are what
we value; it s what medical students learn. It s a value both in terms of -- you know,
it s intellectually exciting but also where the money is. And I think that in many of
these delivery systems, in order to have the patients at the center that is a change. And
I wonder what would we be able to do to change, what some of the obstacles are, and how you
ve been able to accomplish the sort of culture of financial changes that might be needed.
Patricia, you ve been very patient [unintelligible] very brief comments. Patricia Briggs: Well,
I think that what s happening now is that we re seeing with a change perhaps in how
reinforcement is going to be made, that the primary care and specialists in our community
are coming together and actually demanding our organization to help them with more direct
communication around patient-centered care. And the specialists in our community have
always been very good about sharing best practices with the primary care; the primary care have
been appreciative of that kind of education. And so the promise of change has just kind
of upped that in our whole system. Because we re small practices, our patients really
are very passionate -- the primary care practices -- and we ve been able to help that with
our nurse case managers working directly with the primary care physician and the patients
and the families around very complex episodes of care. Rick Kronick: The mic handed back
to the university system [unintelligible]. Mike Johns: s interesting. First of all, Karl
Ulrich questioned -- we are trying to rewire our house while the power is still on. Probably
is the second thing; that s what it feels like, and in many of these areas, it s pretty
tough. One of the things that [unintelligible] I m going to try to be brief. First of all,
we find that many of these initiatives that we have been care redesigned end up doing
[unintelligible] to make that happen. And what we find is that best practices are really
effective, at least in our situation, communicating across all streams. So the connection between
primary care and special care is [unintelligible]. They may be seeing the guy in the heart failure
[unintelligible] we re totally wired electronically with the patient and all that, but this brings
actually more of a direct communication and [unintelligible]. I think that has been very
helpful and very useful to us. I do want to say something about trying to promote primary
care overall. And I have to say that this is important as a team. This is not just about
doctors. It s about how do we get the teamwork here. Well we re going to implement [unintelligible]
from the beginning, how do we get people working together creating sort of a medical home model
using it as a demonstration for our education. But I think part of it s this: We have to
start [unintelligible] properly. I find that all the kids that are coming out of biomedical
engineering have very low interest in primary care [unintelligible]. But what s in it for
students who are sociology majors, who major in the humanities, who take a file, and they
have another perspective of what they re looking for. And so some of these students -- or all
of them -- they all get great everything else in school so that s not an issue. So, hard
to select the right kind of kid if you want to hit the [unintelligible]. One of the pieces
I ve been looking at of role models: the faculty, the people doing the primary care. I try to
find those people who are [unintelligible] to be exposed, who are passionate about what
they do, who love going to work every day, and who think what they do is critically important
to health care. Are we trying to [unintelligible] for the students. I just want to say one thing:
geriatricians are really primary care as well. And they are one of the least paid people
in the hospitals. They get paid less than primary care. [unintelligible] if you re taking
your father or mother to see a geriatrician, look how long they stand [unintelligible]
the table. Look how many stories they want to know. Look how many drugs they want. Those
folks are not being paid properly, or at least appropriately for the time they spend. And
I think that if that can change in the payment system, that really rewards the time spent
when it s needed. And I think that could also help. But that s another thing. Rick Kronick:
Richard, about 25 percent of your practitioners are non-physicians to begin with, and kind
of a different situation than Mike s or [unintelligible]. How do we manage that? Richard Cooper: Well,
being patient-centered is the responsibility of all of our staff. But that work on culture
and focus on the patient is led by our government body as well as the leadership team. And so
we have embraced the goals referenced by Dr. Berwick earlier in the morning, and I guess
we are quite persuaded if you really listen to your patients and customers that can guide
you in making important value decisions for your enterprise. And in our community, we
increasingly hear about cost of care. And we don t hear candidly as much about quality;
it s assumed by our patients and our business partners. And so we recognize the importance
of getting a handle on this national challenge we have related to cost of care. Last spring,
sent out an enterprise goal to reduce cost of care by 25 percent over the next three
to five years. And we have [unintelligible] information against which we can measure this
kind of an ambitious goal. But we re quite persuaded that we can take that kind of cost
out of the system in a part of the country that ranks in the lowest 20 percent cost of
care for our Medicare patients. That s if I do share responsibility that it s associated
I think [unintelligible] these organized systems of care. That, again, in response to the question,
What could be replicated elsewhere? That s the kind of goal all of us ought to be setting.
Rick Kronick: Thank you. Doctor [unintelligible] environment. Doug Eby: [unintelligible] has
a story he likes to tell about a car. And he talks about this car. He takes it out in
the back road and puts the accelerator down. And it has a top speed of 105 miles an hour.
And if he yells at the car, it won t go faster. If he encourages the car, it won t go faster.
If he offers paid-per-performance, it won t go faster. And you have to reengineer the
car: You have to change the breaks and the motor and the transmission and whatever to
work for the car and go faster. And Juan uses this to show that you re not going to get
different health care unless you reengineer health care. We sort of like this story, but
we like it for really different reasons. What if their conversation went with the purpose
of that car is, the purpose of the car is not the car. The purpose of the car is to
transport from location A to location B. The same thing in health care. The purpose of
health care is not about doctors and nurses about making doctors and nurses happy and
meeting their professional needs. It s about meeting the needs of the people who come for
services: reducing anxiety, reducing their pain, reducing their discomfort while we answer
their questions. So if instead the purpose of the car is transportation from point A
to point B, we back up and we start to think about that. And might come up with a train
and an airplane and a bicycle. We might decide that one size doesn t fit all, and you need
to understand the purpose and need of the situation that people are after in order to
get the right match of transportation to the thing that you want. The health care conversation
is almost entirely about how to use doctors better, how to use nurses better, and that
s just dumb. If you understand it s about health and health for a population then you
start to understand what is it they need and want and need and listen to them, they ll
start to tell you what they want and need. And so I m a private care doc; I m a family
practice physician moved to administration management. And I would tell you that that
profession is the most broken and to blame part of the health care system. And private
care s response says, s their fault. It s their fault. We re just victims. Don t blame
us. If they d only give us money and respect and so forth, everything would be fine. Baloney.
The problem is that primary care is meeting people where they are, meeting their needs,
and supporting them on their journey over the top. And doctors frankly are not trained
very well to do that. We re good at diagnosis. We re good at really complex medical care.
And frankly, nurse practitioners are not a whole lot better than we doctors for the most
part. What we need are ways to meet people where they are. So we use a whole range of
lay workers and home health people and community-based people. And in our primary care clinic, we
have [unintelligible] and nutritionists and pharmacists and medical assistants and case
managers supporting -- case managers: They do 95 percent of the primary care. The doctor
puts in the violin players in place to kind of orchestrate back there. And sort of the
captain, if you will, of the team, because medical payments are required to sign off
on things and prescribe things. The doctor s not trained to do primary care very well.
They are important parts of the puzzle, but the real point is when it s a customer need,
what do they need? What does the customer need? What do they need? And let s quit trying
to fix the damn car and start to think about what are the different ways in which we get
health provided rather than makes doctors happy and nurses happy and pharmacists happy
and money in their pocket. In order to do this, we do all things these people say. We
have a ton of people training [unintelligible], we have a ton of people train -- we have 85
people trained in Fallridge [spelled phonetically]. We have 30 people whose full-time work is
improvement advising in specialist work. We have five times the investment in workforce
training and development in improvement advising and so forth. So we do all the other things
that people talk about. [unintelligible] we post 75 different indicators publicly for
people to benchmark and prepare and all those sorts of things. We know how to take a car
and make it a much, much better car. But we first understand that we re in the transportation
business and that we ought to build all of this rebound framework on a different platform
to begin with. Rick Kronick: [unintelligible] Philip. Philip Mehler: Denver Health, because
we have 100 percent employed physicians, there are no incentives for the specialists to order
more tests or do more procedures. Perhaps in contrast to the fee-for-service paradigm
that is out there in non [unintelligible] employed hospital physician lines. And so
we don t deal with that problem specifically, but we certainly do deal with a problem that
there is inadequate communication between the specialists and the captain of the ship,
the primary care doctor. And so we put in a number of rules that we hope will shape
and improve that relationship. Specifically, we do not allow any specialist-to-specialist
referrals. If somebody goes to the rheumatologist and they feel they need pulmonary next, they
have to go back through the primary care physician because perhaps some of that work has been
done already. We know people don t always look in the medical record. We heard this
morning about duplication of tests. So by not allowing specialist-to-specialist referral
without involving the PCP, that helps in that regard. In addition to that, we have our stickers
with one of the patient identifier that lists the PCP s name, and therefore, that hopefully
exhorts the specialist to communicate back to the PCP. We have a number of automated
points in the system where a paid patient of Denver Health who has a PCP is admitted
to the hospital, there s an automatic e-mail to the PCP that that patient was admitted
within the last 12 hours. Similarly, anybody that has anything more than a plain radiate
wrap done -- maybe a CT, MRI, ultrasound -- that patient information is conveyed back
to the PCP in an automatic fashion through e-mail. In addition to that, we ve developed
guidelines for the PCPs as we heard early in order to educate them about what to refer,
since we know that there isn t an endless capacity for specialty referrals. We have
found that if you truncate the referrals by defining what needs to be done prior to going
to the specialist that will help in making a better communication pattern between them.
In addition, because as a safety net hospital we oftentimes with the high-paid specialties
can t recruit as many specialists as we may want, we have allowed the specialists to refuse
to see a referral that s sent to them by e-mail but the proviso is that you can t just refuse
to see a patient but rather you have to send the PCP an intelligible note saying why you
don t think this patient needs to be referred at this time. In addition, as I mentioned,
we employ about 200 full-time mid-level providers. And certainly they are a very valuable part
of our institution but their training is a bit different than a physician. And therefore,
we have found that a lot of them were referring patients to the specialists at a lower threshold.
And so therefore what we ve tried to do is make these guidelines, allow the specialists
to communicate back with them that they may not need that, but also we ve engendered an
ambience in the clinic that the mid-level providers should feel empowered to speak to
the attending physicians. Because again, if you sort of demean a person when they come
to you about a patient, you don t give them the proper time, they re going to go ahead
and just send the person on to the specialist. But by creating an environment that empowers
the mid-level providers to seek primary care consultation, we ve found that we ve been
able to keep control of and better manage referrals of specialty clinics. Rick Kronick:
Thank you, Philip. Really interested to hear that after Doug s discussion of two very different
approaches to deal with this problem. [unintelligible] I don t believe that but that s very gracious
of you. Questions now, kind of time to be very patient. Any questions for our panelists?
And I told our panelists also here you are with a chance to say what you want to change.
And I m sure that [unintelligible] as far as the Q and A, I invite you all to give us
your suggestions here. Female Speaker: [unintelligible] I think it was Richard who talked about working
with Boeing. So I kind of want to ask the panelists if you ve had experience working
at all with purchasers or if you have considered that or would consider that? You talked about
how to engage the federal government. Well, what about the private sector? And I really
specifically am very interested, Doug, in your model. You said that you saved a ton
of money from Medicaid and Medicare. Would the purchasers save money or is there a way
that we can look at forging more public-private partnerships around some of these innovative
models? Doug Eby: We don t have a large employer like Boeing and we have many, many scattered
private employers. And private insurance for us is only about 15, 16 percent of our payer
mix. So the [unintelligible] employers not so much. But we and our sister health corporation
together employ 3,500 people. And so like many employers, we have been trying to wrestle
with how to do this differently. And [unintelligible] a single place we try to have most of our
conversations about redesigning payment have been Medicaid because Medicaid is liable to
do certain waivers and that kind of stuff. Although we ve discovered as the federal clamp-down
on fraud becomes way more aggressive, the state is way less willing to be creative with
us about different ways of paying, so forth around Medicaid. But we ve certainly talked
to Medicaid and, you know, one of my big resentments against Medicare and Medicaid policy is that
our friend here to the right gets to keep half the money he saves from Medicare whereas
I don t get to keep any of the money I save from Medicare cause he got into a special
club by applying for a demonstration project. But they don t allow us to because our population
isn t big enough to meet the minimum criteria for a Medicare population. So, I mean, this
goes back to Don Berwick talked a whole lot about innovation and variation and being curious
and learning from people who do it differently and so forth. And our payment methodology
ought to -- whether it s from an employer or from Medicaid or Medicare --ought to [unintelligible]
incentivize us to be creative and innovative and ought to reward us when we are. So, if
I can show Medicare, Here s what it cost you from 1990 to 2000 per person, and then I can
do something dramatic in 2000 to 2010, I ought to get half that money back whether or not
I m in some special demonstration club or not. Philip Mehler: Just as a safety net provider,
we ve been doing some unique things with the payers. We believe in centers of excellence.
And although there s a debate in the literature whether volume equals improved quality, we
believe that in certain areas that s true, specifically in trauma care. We think there
needs to be perhaps more legislation with regard to not having over-designation of Level
I, Level II trauma centers. I think there s good evidence that if you don t do a lot
of trauma that cost of care is going to go up and perhaps the outcomes aren t going to
be as good. And so we ve tried to aggressively --because we re in Colorado with the sea industry
[spelled phonetically] -- we ve tried to aggressively market this about being a safety net hospital
to have a very sophisticated, complex trauma program. In addition, I actually have a unique
specialty that I take care of the most severe patients with anorexia nervosa from across
the world. I ve been doing that for about 25 years on the medical stabilization side.
So we see patients who have gone in and out of acute care hospitals sort of floundering,
trying to get better. They come to our program with BMIs eight, nine, and 10, weighing 40
to 50 pounds. We believe that there s an expertise in dealing with this very rare population.
So, I would say at Denver Health it s tried to -- successfully, actually -- work with
payers to promote centers of excellence. And we think more of that will actually ultimately
save costs and improve outcomes. Karl Ulrich: I just want to respond to the special club
comments. [laughter] We actually found -- I mean, you re trying to make the point that
somehow we were specially blessed. The reality is that CMS is looking for innovation primarily
in our delivery of care. And what s happened is that if you put the policy writers in the
same room with the deliverers of care, that s where real change can occur. And it needs
to be a starting point. I think [unintelligible] starting point so that [unintelligible] state
has evolved so we understand [unintelligible] that we go from a policy standpoint to [unintelligible]
standpoint [unintelligible] down the road. Male Speaker: Just to respond to that real
quickly, I think that there s two points to be made there. One is we need to create payment
systems that encourage innovation and creativity, reward [unintelligible]. And we ve been very
connected to [unintelligible] since 1990, whom in IHI one time did a closed club sort
of thing where they stop swiping people for the so-called pursuing perfection and one
of the major things they learned from doing that was that that was terrible. And so from
then on, IHI s clubs, if you will, of people who do improvement and all of that kind of
stuff [unintelligible] open and anyone who wants to aspire to the goals and aspirations
and meet the requirements is allowed to play. And they found that that s much better because
you don t know for sure where innovation and creativity is going to spring up and succeed
and so you often have a process by which you encourage, recognize, incentivize, and reward
wherever that pops up [inaudible]. Patricia Briggs: I would agree with that last point.
Coming from an organization that represents small to medium-sized practices, we have created
a virtual system of care we re always trying to improve, and all the improvements that
we ve made and have been made by taking waste out of the system, which has resulted in lower
costs in our area. We ve also done this through a TPA [unintelligible] find work directly
with the employers and we have been able to help them safely self-insure, given them great
reports and great personalized case management, and helped to save them money. And I think
one of the things the federal government has to do is recognize that there are different
ways of approaching a problem and to pick one particular model and fund endless pilot
programs around it while the rest of us are out there floundering around, not getting
any kind of financial support doesn t make a whole lot of sense. Mike Johns: m going
to try to answer the question that was asked and say that the [unintelligible] ourselves.
Emory University [unintelligible] is the -- if you take away the state and federal
[unintelligible] to employers and [unintelligible] we re the largest [unintelligible] self-insured
for. We tried to put in programs that promote wellness and [unintelligible] control our
costs. Putting in now nurse-run clinics or urgent care, like a retail clinic would do,
and a number of wellness programs, new incentives [unintelligible]. The interesting thing is
because we as a university are [unintelligible] and also health care delivery systems, there
s a -- of course, a university which has got faculty who, as you know, report directly
to [unintelligible]. They have some reticence about in fact tossing their own employer s
health care. It s really quite [unintelligible] could as we re learning begin to offer, I
think, more [unintelligible] with the employers. We ve learned a lot experimenting ourselves
here. Michael Dolan: Dr. Michael Dolan, Gundersen Lutheran. As Dr. Clancy noted earlier, I m
a practicing primary care interns, and last week, one of my partners announced that she
was leaving the practice of medicine. She s 42 years old and burnt out. And so it was
a startling reminder for me that there are primary care providers out there that are
burning out and are feeling the pressures. I agree with Dr. Eby that if we re going to
accommodate this influx of patients that are now covered by some type of health care insurance,
we will need a different model in order to survive. I think Massachusetts demonstrated
that. In Wisconsin -- and I d like Dr. Ulrich to comment on this -- University of Wisconsin
Medical School added 25 slots to their incoming class a couple of years ago [unintelligible]
and then they are rotating the students out into places like Marshfield and Gundersen
where they ll spend their third and fourth years working alongside primary care providers,
hopefully generating more interesting in primary care but at the same time, we also run a transitional
residency that is littered people who are taking the ERO [spelled phonetically] --
and I ll leave your imagination to figure out what that stands for -- but specialties
that their quality of life will be higher. Mike Johns: If I can just explain the WARM
program, WARM standing for the Wisconsin Academy for Rural Medicine, that is very strong [unintelligible]
in state that had partnered with the University of Wisconsin School of Medicine [unintelligible].
The first class actually was five students, came from small, rural communities in Wisconsin
who went through a different set of criteria to be accepted to the medical school over
in Madison. They indicated that they were from small towns, wished to spend their career
working in small towns. So, this was a response to the perceived problem of rural-based primary
care physicians to try to select right then at the end of training -- or rather at the
front of training. But I think there were four students that will be graduating out
that spent most of the last of their third and fourth year [unintelligible] Wisconsin
and the plan is to expand that program to about 25 students over the course of the next
couple years. And there will be a similar cohort, then, for inner-city physicians as
well, too, which are [unintelligible]. So this is a innovative process to get young
students engaged with some goals in mind right from the get-go. Steve Weicheck [spelled phonetically]:
[unintelligible] I m Steve Weicheck [unintelligible] Massachusetts practicing pathologist [unintelligible]
but I will second the earlier commenter. My wife is presently a physiatrist, a physical
medicine rehab specialist, who was previously a Massachusetts internist. So this phenomenon
is alive and well and should really be addressed. My question had to do with the issue of sort
of clubs and, in fact, whether a shared savings is a long-term strategy. Pathologists operate
in laboratories, which are [unintelligible] and incredibly intensely measured. I mean,
in that regard, we are way [unintelligible] in medicine in terms of our surveys and our
assessments. We realized this when we were trying to procure our metrics and discovered
we had already been doing it for ourselves for so many decades [unintelligible]. To what
extent is shared savings really a long-term strategy or to what extent does it factor
[unintelligible] the system up until the moment they have an opportunity to turn it the other
way versus those who have been really striving to try and improve and absolutely diligence,
maybe foregoing a few perks along the way and now might find themselves paying for it
because there are fewer savings to be shared? Rick Kronick: [unintelligible] [laughter]
Doug Eby: I think this is a huge issue for what we finally discover and how do you deal
with risks? I mean, several people today have mentioned the fact that five percent of the
people drive 50 percent of the cost and 10 percent of the people drive 70 percent of
the cost, and we ve heard variations on that. So how do you -- I mean, I can tell you that
in the population I work in, 50 percent of our population is like five percent of most
other people s five percent. And so how do I [unintelligible] payment be adjusted for
that risk? You know, social risk, medical risk, and disintegration of social fabric,
and in my case, generational trauma and complete -- all kinds of different things have happened
to Alaskan native people over time to put them where they are today, which makes the
idea of giving them comprehensive health a big challenge. [unintelligible] system for
entering into that population is extremely difficult and it s got to be addressed with
them because, you know, [unintelligible] system, so we ve driven out a massive amount of waste
in the last 10 years. So my baseline now as it gets reset for ACL for example is going
to be where I am now where it was 10 years ago. Because I already saved all that money
for somebody and I [unintelligible] penalized [unintelligible] -- [laughter] s extremely
important to wrestle with. Now [unintelligible] paid for. I want to get paid for population
health comes, I want to get paid for processes, but I want to be paid not based on my licensure
and accreditation of my workforce. So if I want to use a whole church and a whole bunch
of pastors and lay workers in the church as a primary platform by which to deliver health
care, as long as that can produce the safety, the quality, the outcomes, and the performance,
I should be able to get paid no matter what my workforce looks like. I want to be paid
for partnering people in the last few years of their life and living really well in their
home. I want to be paid for conception and pre-conception pregnancy, birth, and the first
five years of life, because we all know that 90 percent of the determinants of life-long
health and cost are in place by the time you re five years old, and I m paid crap for doing
that kind of work right now. I want to be paid for [unintelligible] -- [speaking simultaneously]
[laughter] -- [unintelligible] innovation, and right now they don t have codes for any
of those things to get paid. [applause] Male Speaker: [unintelligible] to the shared savings
process, because ultimately, it burns out quickly if it doesn t work for you very well.
And so I think, as best I understand, [unintelligible] systems as they look at transitioning to [unintelligible]
that you may start with the fee-for-service insurance [unintelligible]. Philip Mehler:
I think a similar issue to what you brought up is the issue of, A, for performance, I
think as a safety net provider really has to also reward improvement and not just achievement
of certain thresholds. If we don t do that, I think we really run the risk of further
dividing and putting at risk the vulnerable populations because people are going to figure
out a way to selectively not take care of those vulnerable populations. Mike Johns:
I couldn t agree with that more. I think that s an important issue that you re raising.
Now, if you re at an academic medical center with the kind of [unintelligible] that we
have, we accept urban [unintelligible] that comes our way. We re more than happy to do
it. We like taking on the tough case, the hard case, the people with multiple co-morbid
diseases. And in fact, already [unintelligible] track them. We take transfers from other specialists
who ve said it s a most interesting case, which means they don t want to take care of
it because it s sort of complicated and probably doesn t have any health care coverage. We
accept them willingly. Our [unintelligible] don t have the option whether to take call
at night [unintelligible] and holding out for the fee to take the call. Our doctors
take the call and end up accepting patients from all over Atlanta when those hospitals
who actually have the specialists who won t take the call [unintelligible]. And we have
a situation here that needs a lot of work, quite frankly, [unintelligible] policy. So
that and then do we get penalized? Sure. But then you look at our [unintelligible] oh right,
those are really expensive. Well, we re more expensive [unintelligible] say, We won t do
that anymore. We won t take [unintelligible]. The good news is [unintelligible] highest
case index in the cities, in the country, and we are [unintelligible] like, 13th, when
it comes to efficiency. So we do pretty well, but it s probably because we re trying to
manage those costs and [unintelligible]. Rick Kronick: We have time for one last question.
Jerry Jacobs [spelled phonetically]: I hate to interrupt this very lively debate. I m
Jerry Jacobs, AFL-CIO. We in the union world see a tremendous opportunity and also responsibility
geared to engage in this whole quality improvement [unintelligible] by entertaining and recruiting
unions and our employers two-way concerted effort to support through their purchasing
factors to support major and serious quality initiatives. And I would be just interested
in any comment you might have, either about success stories or about problem stories.
I have a lot of problem stories that I could tell you. But I m more interested in sort
of what examples could you give me, if any, where employers have become really engaged,
not on benefit design changes, but on the kind of quality, basic clinical quality improvement
programs that you ve been talking about in the subject of this day? Richard Cooper: Well,
we -- a case study that I referenced earlier involving Boeing and the advanced medical
home was really driven by an opportunity to improve the worker and dependent s health,
and hopefully, as a secondary benefit, reduce the cost curve. This was an initiative that
was a partnership between organized labor, Boeing, the patient, as well as these three
systems of care, and I think it offers the best illustration of the opportunity for all
parties to benefit when they re having true collaboration, incentives are designed properly
and you can get information to most importantly the patient, the provider, and the plan sponsor
who is paying for the premium. While I have the mic, I must -- I d be remiss if I didn
t observe that in spite of all of our challenges with reimbursement and whether we re having
[unintelligible] environment or [unintelligible] sharing, I would like to think about this
through the eyes of our patients and those who are paying us when we have these kinds
of conversations. You know, if it s tough for us on the delivery side, it s even more
difficult for patients trying to access this system that is the most expensive in the world
when they think about where is the value proposition. So I need to be reminded -- I need to remind
myself that our patients deserve better for the money invested in our system and our pledge
is to sort out [unintelligible] a very complex subject with lots of points of view that we
have the ability through partnerships, which I think is a significant opportunity that
is offered to us by Secretary Sebelius and Administrator Berwick to create something
different that s more value-based that will get us to a better place that s more sustainable.
Doug Eby: Very good. Question; thank you. Claud Rapids [spelled phonetically], SISCO,
Cerner, and Boeing are the four examples I know of. They ve all reduced by 20 to 35 percent
per member per month costs by an employer and their staff designing their own health
system without being cluttered up by [unintelligible] people. Rick Kronick: Thank you, Doug. Thank
you, Richard, for a wonderful kind of benediction in ending this panel. I d like to thank you
all very much for your efforts today. It s [inaudible] [unintelligible] and wonderful
work and that we have a very, very long way to go. But thank you for sharing your insights.
Thank you for being here today and please join me in thanking our panelists. [end of
transcript] HHS: Promoting Innovation to Achieve High Value PAGE DATE \@ "M/d/yy" 10/14/10
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