Coverage Drives Treatment: The Case of Pain

By |2017-10-09T01:59:34+00:00March 31st, 2017|Uncategorized, What do we pay for and why|

Coverage Drives Treatment: The Case of Pain

Last week Congress decided not to move forward with repealing and replacing the Affordable Care Act with the American Health Care Act of 2017. This doesn’t mean health reform is over in the U.S., though.

Patient access to care and the costs of that care are still hot topics in Washington, D.C. and statehouses across the country. As we move forward in reform, I would propose a close look at the opioid epidemic and ways we can push for payers to cover treatment that is patient-centered and evidence-based. Seems straightforward, but it isn’t.

A USA Today op-ed from last fall had a subtitle on the opioid epidemic that said it all: “There are other ways to manage chronic pain, but insurance companies won’t pay for them.”

In the summer of 2016 the U.S. Surgeon General sent a letter to physicians in the U.S. basically saying they haven’t been properly trained to manage pain and they could do better to manage patients with pain than just handing over a prescription for an opioid. Dr. Vivek Murthy was more eloquent, writing, “We often struggle to balance reducing our patients’ pain with increasing their risk of opioid addiction. But, as clinicians, we have the unique power to help end this epidemic.”

Prescriptions for painkillers vary dramatically by state, further supporting the argument that prescribers may not be following a standard of care for treating pain.

Source: CDC, Policy Impact: Prescription Painkiller Overdoses

It is true that clinicians are uniquely situated to address responsible opioid use and pain management, but that will be difficult to do without support from health insurers. Dr. Robert Bonakdar, the author of the USA Today piece and the Director of Pain Management at the Scripps Center for Integrative Medicine, and immediate past president of the Academy of Integrative Pain Management, succinctly explained the entire U.S. health care system’s approach to pain management:

… many well-established non-pharmacologic treatments like biofeedback and cognitive behavioral therapy (CBT), endorsed [by Murthy], are routinely denied by insurance companies. As an ironic example of the campaign’s shortcomings, on the same day I received the surgeon general’s letter, I received one of the standard insurance denial letters for the biofeedback I had requested for a patient’s headache.

Government agencies and other advisory organizations are coming together to acknowledge that addressing pain is not as simple as writing a script – which is clearly what the system pays for right now.

The National Pain Strategy reminds health care providers and policymakers (and anyone else who will read its 72 pages) that, “Chronic pain is a biopsychosocial condition that often requires integrated, multimodal, and interdisciplinary treatment, all components of which should be evidence-based.”

The Principles of Chronic Pain Treatment prompt health care providers who are treating patients with pain to “use nonopioid therapies to the extent possible,” but also to “identify and address co-existing mental health conditions (e.g., depression, anxiety, PTSD)” in patients in order to best define their treatment needs.

The health care system needs to move in the direction of covering what works. Like other examples we have covered in the Pondering Policy blog, opioids are no exception to the rule.

Service Business Model Innovation, the second case study from our recently published book chapter

By |2017-10-09T02:00:19+00:00March 28th, 2017|Uncategorized|

Service Business Model Innovation, the second case study from our recently published book chapter

As we blogged a couple weeks ago, M2HCC authored a chapter entitled “Essential Characteristics of Service Business Model Innovation in Healthcare: A Case-Study Approach” in Service Business Model Innovation in Healthcare and Hospital Management published by Springer. Today we share highlights from the second case study we feature in the chapter.

The BJC Collaborative
BJC HealthCare is based in St. Louis, Missouri and includes Barnes-Jewish Hospital and St. Louis Children’s Hospital. It is one of the largest nonprofit healthcare organizations in the U.S. and it is the largest provider of charity care in the state of Missouri. In 2012, Saint Luke’s Health System in Kansas City, Missouri, and CoxHealth in Springfield, Missouri, and Memorial Health System in Springfield, Illinois, joined BJC to form The BJC Collaborative. Over the past few years, four more organizations joined the Collaborative and members have combined annual revenues of over $9.3 billion but remain independent, serving residents of Illinois, Kansas, and Missouri.

The BJC Collaborative has three primary focus areas: 1) Implementing clinical programs and services to improve access to and quality of health care for patients; 2) Lowering health care costs and creating additional efficiencies that will be beneficial to patients and the communities served by the member organizations; and 3) Achieving cost savings. (BJC Collaborative 2016)

We talked with Sandra Van Trease*, group president of BJC HealthCare about how trust, cooperation and leadership have helped the Collaborative increase innovation year after year.

Common values and previous relationships
The importance of trust and relationships is on point, especially in this kind of organization, where entities are coming together as a collaborative, explained Van Trease. For example, the senior leadership of these organizations knew each other before the Collaborative was formed. “We already knew each other, we knew each entity was high performing, we held similar values, we all recognized a need for evolution and change in the healthcare system,” said Van Trease. Common values were a key component to building the Collaborative.

Service priorities should matter to staff and leadership
While it is clear that leadership and strong relationships drove the creation of the Collaborative, the process the Collaborative uses to determine priorities is also driven by a structure built on trust and leadership. It is essential to set service priorities that matter to both staff and leadership, not just one or the other.

Get results to improve results
Notably, Van Trease explained that getting results also helped to build trust, which in turn, drove improved results. High-performing systems are like competitive athletes, always wanting to improve and set higher goals. Getting results makes people more likely to trust each other, and the process, creating momentum that generates further progress, explained Van Trease.

Communicate what works
Finally, and one of the unique components of the four case studies M2 wrote, Van Trease explained that it is essential to celebrate and share successes and best practices that can be replicated is essential. At the BJC Collaborative, there is a dedicated communications roundtable that captures this information, writes it up, and then disseminates it to each local health system.

Talk to your team, then have them talk to each other. Have leaders work in close connection with team members. On paper, it doesn’t seem that difficult, but in practice, the BJC Collaborative worked hard to build trust, increase cooperation and show leadership to create a truly innovative service approach for their area of the United States.

*Blessing Health System in Quincy, Illinois (2013), Southern Illinois Healthcare in Carbondale, Illinois (2013), Sarah Bush Lincoln Health System of Mattoon, Illinois (2015), and Decatur Memorial Hospital in Decatur, Illinois (2016).

*Sandra Van Trease serves as a group president for BJC HealthCare, and provides strategic leadership and direction to the BJC Collaborative. In 2012, Van Trease was appointed president of BJC HealthCare’s Accountable Care Organization and leads BJC’s overall efforts in Population Health.

Evidence is not enough to change health behaviors

By |2017-10-09T02:01:03+00:00March 22nd, 2017|Uncategorized|

Evidence is not enough to change health behaviors

Tobacco use continues to be a major cause of avoidable death, and costs the U.S. health care system billions of dollars per year. However, elderly heart attack survivors rarely filled their prescriptions for smoking cessation drugs upon discharge from the hospital, despite counseling from hospital staff on the need to quit, according to a study presented at the American Heart Association’s most recent annual meeting.

The study evaluated nearly 2,400 heart attack survivors over the age of 65 who were current or recent smokers. Almost all of the patients in the study received prescriptions for smoking cessation medicines before discharge.

However, only about 10 percent of patients actually filled a prescription for the smoking-cessation drugs bupropion (GlaxoSmithKline’s Wellbutrin) or varenicline (Pfizer’s Chantix) within 90 days of discharge from the hospital.

The rate also did not change much over time: At one year post-discharge, only 13 percent filled a prescription for these drugs.

“There remains a great deal of room for improvement in intensifying smoking cessation interventions during and after a patient’s hospital stay for a heart attack,” the researchers, led by Duke University’s Neha Pagidipati, MD, said in a press release.

“These findings come as no surprise for geriatricians and health care professionals who face on a daily basis the challenges of recognizing and managing the complexity of caring for older adults,” Dr. Gisele Wolf-Klein, director of geriatric education, Northwell Health (Great Neck, NY) said in an article in HealthDay News.

Elderly patients face many challenges, such as “multiple medical conditions, which often include depression and forgetfulness,” which can make it more challenging for them to initiate and adhere to a smoking cessation regimen, she said.

Although she agreed with the researchers that more needs to be done during their hospital stay to help patients quit smoking, she said there are reasons patients fail to use smoking-cessation products.

For example, “older adults are particularly concerned with taking too many medications, both because of the increasing and often unsurmountable monthly costs of their prescribed drug regimen, and because of the difficulty of remembering when to take them,” she said.

Too often, patients are simply handed the medications without much explanation; “before buying into” smoking-cessation treatment, “older adults will need strong scientific data to persuade them – and their caregivers – of the longevity and quality of life benefits of giving up one of their last pleasurable habits,” she said.

Dr. Satjit Bhusri, a cardiologist at Lenox Hill Hospital, New York City, agreed that “we clearly have a long way to go in continued long-term counseling” for elderly heart patients who smoke. “We need to enhance our smoking-cessation counseling outside of the hospital by providing additional assistance and education to our patients,” Bhusri said. “The importance of not smoking after a heart attack is crucial to recovery and prevention of future heart attacks.”

This study highlights the challenges inherent in changing behaviors that impact health. The evidence is clear – elderly heart attack patients should stop smoking; however, this will require behavior change on the part of both the physician (in terms of coaching patients) and patients (in terms of adhering to prescribed regimens).

Service Business Model Innovation, the first case study from our recently published book chapter

By |2017-10-24T02:32:10+00:00March 14th, 2017|Uncategorized|

Service Business Model Innovation, the first case study from our recently published book chapter

As we blogged about last week, M2HCC authored a chapter entitled “Essential Characteristics of Service Business Model Innovation in Healthcare: A Case-Study Approach” in Service Business Model Innovation in Healthcare and Hospital Management published by Springer.  Today we share highlights from the first case study we feature in the chapter.

Baylor Scott & White Health’s collaboration with The Cleveland Clinic

In December 2014, three Baylor Scott & White Health hospitals—Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Baylor University Medical Center at Dallas and The Heart Hospital Baylor Plano—were invited to join the Cleveland Clinic’s National Cardiovascular Network, the first hospitals in the Southwest to be invited.

Joel Allison, CEO of Baylor Scott & White Health called it a “collaboration of the future,” in part because Baylor Scott & White Health’s (BSWH) collaboration with Cleveland Clinic spans geographies, but not medical specialties. Instead of cooperating in a geographic area with a broad range of health care provider types, this collaboration is based instead on the quality of a single medical area of focus: heart disease. However, similar to the other case studies M2 researched and wrote, this collaboration clearly demonstrated 1) trust is built over time and 2) leadership takes vision.

Trust is built over time

The importance of trust is multifaceted. Not only are these hospitals some of the most trusted in the world, a reputation they built over years of delivering excellent quality care, the leaders also knew each other for years before the collaboration was executed.

“The folks at Cleveland Clinic were known to us, and us to them,” Dr. Michael Mack* told us. The partnership wasn’t the result of “responding to a request for proposals.” That being said, even such deep-rooted trust was not enough to seal the deal. Only after a year-long intensive due diligence process was an invitation to participate in the network extended.

Leadership takes vision

“The idea behind the model is a vision of how the business of health care is going to change in the upcoming years,” explained Dr. Mack. “This was an opportunity to develop a business model to best adapt to that changing paradigm of health care going forward.” What does that paradigm look like? To BSWH and Cleveland Clinic, it is thinking less about serving a market based on geography, and thinking more about serving the entity who pays for the care, the patient or the employer, for example.

This particular service business model is uniquely innovative in that the network aims not only to provide high quality health care, but also to provide predictability and transparency to the final purchaser—whether a patient, an employer, or a payer. This model “shifts the risk from the insurer to the provider,” said Dr. Mack. “We are providing a high dollar operation, and we guarantee the price and quality.”

Pivoting to the new world of transparency

Providing “transparency of care, transparency of quality, and transparency of price,” said Dr. Mack, is moving the health care market closer to the way other markets function. “You wouldn’t go into a Best Buy without knowledge of the product and price of the product you are considering for purchase,” explained Dr. Mack.

Providing transparency of care, quality, and price to patients and payers shouldn’t feel like a cutting edge innovation. But in fact, it is. Time will tell whether this particular innovation is adopted more widely.

*Michael Mack, M.D., is the Medical Director of Cardiothoracic Surgery for Baylor Scott & White Health and the Chairman of The Heart Hospital Baylor Plano Research Center. Dr. Mack is on the team of physicians on the medical staff that oversees medical care provided in The Heart Valve Center of Texas in the Center for Advanced Cardiovascular Care.

Lung Cancer Screening: Who Gets To Decide?

By |2017-10-09T02:02:29+00:00March 10th, 2017|Evidence-Based Medicine, Uncategorized, What do we pay for and why|

Lung Cancer Screening: Who Gets To Decide?

While the U.S. Preventive Services Task Force (USPSTF) has issued recommendations on annual screening for lung cancer using low-dose computed tomography (CT), and Medicare uses similar criteria for determining coverage of lung cancer screening, a recent article in the Journal of the American Medical Association (Katki, et al.) offers a new enhanced risk-based model for determining who should undergo this type of screening.

Katki, et al., used data from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, the National Cancer Institute’s National Lung Screening Trial, and the 1997-2001 National Health Interview Survey to develop and validate statistical models to estimate lung cancer incidence and death.

In an accompanying editorial, Michael Gould, MD, MS, Kaiser Permanente Southern California, Department of Research and Evaluation, says the findings are “provocative and support the notion that an enhanced risk-based approach to screening is potentially more effective and more efficient than performing a risk assessment based only on age and smoking history.” (There are about nine million adults in the U.S. who meet USPSTF criteria for lung cancer screening.)

However, while this new lung cancer death model constitutes an “important contribution” to the discussion of who should be screened and when, the “overwhelming majority of patients who undergo low-dose CT screening will not benefit, even using enhanced risk assessment,” Gould says.  The enhanced risk-based screening “was projected to only marginally increase the number of lung cancer deaths averted from estimates of approximately 5 per 1,000 screened” to “approximately 6 per 1,000.”

In addition, the limitations of the risk-based model include the fact that the authors “did not consider the increased risk of procedure-related complications or reduced operability that would accompany screening when performed in a population at higher risk,” he says. “For lung cancer screening to be effective, patients need to be fit enough for surgery.” And while less invasive treatments exist, they “have not yet been shown effective in the context of lung cancer screening,” Gould notes. “Thus, a valid counterargument is that the net benefit of screening is highly uncertain in populations (even high-risk populations)” that differ from those that informed the risk-based model.

Other limitations include the social dimensions; for example, given that the risk-based approach “preferentially includes more African-Americans and more individuals with lower educational attainment, compared with screening using the USPSTF criteria,” implementation of enhanced risk-based screening will “require more intensive outreach to communities that have experienced limited access to screening programs,” he says.

Looking more broadly and summarizing the current state of lung cancer screening, he notes there are now “multiple statistical models of lung cancer risk—which ones are most accurate? How does risk evolve dynamically over time?”

At issue is the fundamental question of who gets to decide about lung cancer screening.

This question will be answered differently, depending on whether we examine it from a policy perspective or from an individual patient care perspective. While policymakers are likely to focus on the trade-off in costs – in both dollars and lives – between screening efficiency and avoided deaths, “in clinical practice, the decision to screen is very personal and should be individualized for each patient,” says Gould.

One idea is to let the patient decide whether to undergo testing. Gould recommends offering lung cancer screening to high risk patients who don’t meet the USPSTF or Medicare criteria and letting the patient choose whether to be tested. However, what Gould looks past is the cost to the patient when such a choice is made. Policymakers make recommendations on what insurers should pay for, and cancer screening is a great example. There is a reason for the screening recommendations to have a cut-off value – and that reason is cost.

Letting the patient decide, also means, letting the patient pay. A more nuanced view would be to pay for lung cancer screening in some instances, but not in others. If lung cancer screening to high-risk patients is cost-effective, shouldn’t insurers cover this intervention?

Service Business Model Innovation, an overview of our recently published book chapter

By |2017-10-09T02:03:42+00:00March 7th, 2017|Health Care Trends, Uncategorized|

Service Business Model Innovation, an overview of our recently published book chapter

We are proud to announce the publication of Service Business Model Innovation in Healthcare and Hospital Management by Springer. The book includes process innovations and toolkits that can be used to improve value generation and build competitive business architectures in the health care sector.

M2 authors contributed a chapter entitled “Essential Characteristics of Service Business Model Innovation in Healthcare: A Case-Study Approach.” The chapter highlights examples of successful service business model innovation at four different U.S. health systems, based on interviews with leaders from each institution. The next few blog posts will highlight key learnings from the case studies we wrote about Baylor Scott & White Health’s collaboration with The Cleveland Clinic, BJC HealthCare and the BJC Collaborative, the Massachusetts General Physician Organization, and Sutter Health and the Sutter Medical Network.*

Why did we write these cases?
In my work with clients, and as a lecturer for graduate students in public health, I have been given access to two unique viewpoints into the U.S. health care system, and in my opinion, each set of observers need to know more about the other. My clients are often grappling with creating health care system change, but don’t have a roadmap – they often have to create models from scratch. Graduate students, who are often academic learners and professionals in their field, are taught theoretical models or frameworks, but don’t have a good sense of how theory translates into practice.

In addition, the system of delivering and paying for health care in the U.S. is undergoing seismic changes. Some of this change is driven by federal, state and local governments, who pay for about half of all U.S. care, and some of the change is driven by innovation created by the marketplace. Health care organizations that have succeeded in creating service business model innovation in the new world of accountable care, integrated delivery, shared-savings, and value-based approaches have certain characteristics in common.

Based on the case studies we wrote, which represent a range of U.S. geographies, provider types, and collaborative arrangements, we found service business model innovation rests on the pillars of trust, leadership, and cooperation.

Why is innovation needed now?
The health care system is undergoing massive change, no doubt. But why is innovation needed now?

Thomas Robertson, the Executive Vice President of Member Relations and Insights for the University HealthSystem Consortium, an alliance of nonprofit academic medical centers and their affiliated hospitals, wrote in an opinion piece for Academic Medicine in 2015:

“Seemingly lost in the race to manage everything everywhere is the recognition that a very small subset of very sick patients account for the vast majority of health care spending. Any programs, prospective payment systems, or policies designed to curb health care spending must focus on improving the efficiency of complex episodes of care delivered to the sickest subset of the population. Whether a population is defined as a company, a county, or a country, the overwhelming majority of its health care spending comes from a small minority of the individuals, and the bulk of that spending is associated with either largely unavoidable and unpredictable single events or complex episodes of care. Achieving an economically sustainable health care system will require more efficient and effective delivery of those complex episodes of care.”

More efficient and effective delivery of complex care, however, requires a diverse set of providers to work together – which is not how the current system was built, nor is it how most payers reimburse health care practitioners for providing care. In these contexts, a health organization must trust its partners more than ever before.

Our chapter, “Essential Characteristics of Service Business Model Innovation in Healthcare: A Case-Study Approach”, provides a roadmap of the various ways organizations are meeting the challenge to efficiently and effectively deliver complex care by using the key skills of trust, leadership, and cooperation to create service business model innovation in the U.S. health care system. We hope this roadmap serves health care leaders, health care system students, and anyone else interested in creating health care change.

*A special thanks to Dr. Horn (MGPO), Sarah Krevans (Sutter), Dr. Mack (BSW), Sandra Van Trease (BJC) and Dr. Wreden (Sutter) for participating in interviews on behalf of their organizations.

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