Planning for Quality

First, a note of sincere thanks to my colleague Dan Dunlop who, in his blog, recently offered far kinder words than I deserve for my sporadic efforts here at hcpropellerheads. To quote Hamlet’s Polonious, “Brevity is the soul of wit,” and Dan’s daily shots of idea-juice show he is a man of concentrated wit (and, possibly, reveal the “witless” nature of my long rambles…) with considerable chops to spark intense, thoughtful discussion. Thank you Dan for introducing your fans to this little project. I hope some of you find it intriguing and helpful.

I spent a lot of last week on airplanes and had the chance to catch up on some reading. One article I found particularly interesting appeared in a supplement to Health Affairs. The entire supplement is dedicated to “Value in Health Care” with some impressive minds providing interesting perspectives on the ubiquitous concept of “value.”

In, “Building Organizational Capacity: A Cornerstone of Health System Reform,” Janet Corrigan and Dwight McNeill from the National Quality Forum posit, “achieving higher levels of performance requires organizational capacity, including information technology and specialized expertise, not present in most settings.” While I could certainly go after this set-up (not today) I’d rather focus on a potentially inflammatory notion they put forth:

“[T]he health sector lacks the ability to bring these innovations [in quality of care systems] to scale; best practices in care delivery may take years, if not decades, to spread throughout an institution, much less the nation. Moreover, what we have not seen is fundamental reform in the delivery system aimed at the development of new organizational models capable of consistently providing effective, safe, and efficient care across each entire patient-focused episode.”

Now, fairly, Corrigan and McNeill can cite studies, like those spotlighted in Modern Healthcare recently, that suggest, despite decades of work, the delivery system struggles to make meaningful gains in quality and efficiency.

Before I proceed, a moment of full disclosure. The Joint Commission is a client of SPM’s and a client with whose work I am intimately involved. And, to quote the old adage, “where you stand depends on where you sit,” I also acknowledge that NQF, the Leapfrog Group, HealthGrades (authors of the two reports cited in the Modern Healthcare article) and The Joint Commission, all have biases and agendas that fuel their respective assertions. I get that. It’s out on the table, admitted. Now, let’s move on.

I have two points to make today. The first is, to say that broad, national progress on key measures of patient safety, quality and efficacy have not been realized and can’t be realized on a broad scale is simply not true. On The Joint Commission’s website you can view the 2008 Report on Quality and Safety. There you’ll see, perhaps self-servingly, that Joint Commission accredited hospitals deliver evidence-based treatment of heart attack 96% of the time – up from 87% in 2002. Further, with many National Patient Safety Goals, such as accurate patient identification, “read-backs” of orders and test results, reducing falls, and implementing the universal protocol, average national performance at Joint Commission accredited hospitals exceeds 95%.

Admittedly, The Joint Commission is an organization that has room for improvement. There is considerable debate about standards and how things like the universal protocol were developed and deployed. True. Fix it. But, to claim that little progress has been made, and that the system is incapable of making leading practice common practice nationwide is pure hyperbole. In my own, biased, opinion I believe The Joint Commission, for all its warts, has been and will continue to be the best catalyst for health system improvements in safety, quality and efficiency.

But, that’s not even my primary point for today. My second concern involves hospital/health system strategic planning and the right role of clinical improvement. Recently I was reviewing a hospital strategic plan for a fairly large (> 500 bed) institution. This particular plan, at first, reinforced a belief of mine that hospital strategic plans typically don’t get much beyond being budget justifications. This plan is much better than most (it included actual decisions on priorities) and, to be fair, acts like a business development plan more than a strategic plan. It outlines programs of excellence, investment, delivery system strategy and criteria for evaluating the future mix of services and programs (all things I love to see in a plan).

However, for all its specificity around target markets, services, programs and capabilities, the discussion around quality was vague. The plan calls for investment in IT and EMR as tools to aiding improvement, the development of new platforms to take a non-siloed approach to quality and patient safety improvement and greater transparency/accountability. Above I said, “at first” because my initial reaction was to be disappointed by the light treatment the issue of clinical practice of medicine received; especially when I read further on that attaining market leadership in patient safety, clinical and service quality are seen as key forces for market differentiation.

What I instinctively wanted to see was a conversation about things like Core Measures, National Patient Safety Goals, demonstrated best practices, evidence based medicine, etc. I later realized that, perhaps, the most important next step for this institution may be organizing better to attack specifics such as this. So, I cut them some slack.

However, that did fuel a question – should we expect/hope to see greater specificity in hospital/health system strategic plans around their pathway to clinical improvement? Just two weeks ago, providers promised the President they could shave $2 trillion over 10 years. “The crux of the plan is to merge more streamlined care and a focus on quality and efficiency with “common sense improvements.” One tenet urges the better coordination of care and adherence to evidence-based best practices. Another calls for better use of health information technology. The groups have wagered that such changes can greatly cut how much is spent each year on healthcare.”

I imagine proceeding down such a pathway – rightly – will require engaging a hospital’s medical and clinical staff in a way they have not before. It’s one thing to pay lip service to quality improvement in a strategic plan and then leave it to task forces and work groups to muddle through sufficiently to meet accreditation and payer standards. But to see actual, planned quality improvement, the kind places like Geisinger [full disclosure part II, also an SPM client] have been recognized for, is for my skeptical mind, a leap. Don’t get me wrong, I believe business development and strategic clinical quality improvement (and marketing communications strategy and brand development) all can and should walk hand in hand.

Are hospital leaders up to the task?

Everybody Pays

I just finished reading the Senate Finance Committee’s “Financing Comprehensive Health Care Reform: Proposed Health System Savings and Revenue Options.” It’s an interesting document (from a Propellerhead perspective) in that it provides a fairly comprehensive-yet-understandable look into the confusing mosaic of America’s health-related financing and regulatory system. It was a sobering illustration of how complicated life in big systems of humans can become.

The key take away for me was the size of the bulls-eye on the back of employer sponsored health insurance. A table on page 5 identifies “Exclusion of employer sponsored health care (income)" as representing $132.7 billion of a possible $194.2 billion in annual “lost revenue” for the Federal coffers. For reference, #2 item on the list is “Exclusion of Medicare benefits from income” that total $40.6 billion. You don’t need an advanced degree in applied mathematical theory or public policy to guess what has the pols’ attention when it comes to paying for expanding coverage (and buoying a soon-to-be-bankrupt Medicare Inpatient Trust Fund).

Yes, your memory serves you correctly. President Obama did take Senator McCain to task during the campaign for basing his health reform program on this very principle. During the last debate, Senator Obama referred to such an approach as a new tax on working Americans.

Now, the Senate Finance Committee paper proposes that a progressive approach be taken, only categorizing this benefit as incremental income for people earning $200,000 or above, phasing in the full incremental tax at some yet-unspoken salary level north of $200,000.

[Sidebar for a second…the Administration’s previous conversations around tax rates have targeted people earning $250,000+. Now the bar seems to have quietly slipped down $50,000. Does this represent an alarming trend?]

The compounding factor here lies in the discussion from earlier on the principles of expanding coverage. In a “pay or play” model such as the one the Committee has thrown around, employers will be “fined” for not offering benefits. So…everyone has to have coverage, and that coverage will likely be taxed one way or another. That’s an interesting double whammy (or triple whammy – if you consider the fine for not providing benefits a de-facto tax on employers).

There is also disturbing language in the report that, in essence, suggests providers might earn too much through programs like IME, GME, DSH and mechanical issues like market basket updates to base payment rates. While certainly these formulas have evolved to level of complexity that makes the IRS tax code seem simple, there are surely legitimate opportunities to refine and tighten the programs. The underlying suggestion that providers might be earning too much – the document singles out home health agencies – is scary.

The AHA has released its most recent batch of comments on the Senate Finance Committee’s policy ideas – with cautionary words regarding how much savings are truly possible through delivery system reform in the short term, identifying possible winners and losers along the way. The AHA is providing thoughtful, sound advice.

Essentially, in two words, “Slow Down.”

But alas, it seems the bull is in the china shop. We’re going to have one heck of an aftermath to figure out.