Chronic Knee Pain: Internet-Delivered Exercise and Pain-Coping Skills Work Well for Patients, But Will Payers Cover It?

By |2017-10-09T01:54:34+00:00April 27th, 2017|Chronic pain, Evidence-Based Medicine, Reimbursement, Uncategorized, What do we pay for and why|

Chronic Knee Pain: Internet-Delivered Exercise and Pain-Coping Skills Work Well for Patients, But Will Payers Cover It?

Knee pain has increased in the past 20 years, and researchers have connected this increase to aging and obesity. Perhaps more importantly, the increasing prevalence of knee pain has led to a surge in knee replacements. This highlights the growing need for effective, accessible treatments to manage chronic knee pain on a population level. In light of this need, researchers at the University of Melbourne conducted a study of Internet-delivered exercise and pain-coping skills training.

The study, published in the Annals of Internal Medicine, found that for people with chronic knee pain, Internet-delivered, physiotherapist-prescribed exercise and pain-coping skills training (PCST) provide “clinically meaningful improvements in pain and function that are sustained for at least 6 months.”

The Internet-delivered interventions included seven videoconferencing (Skype) sessions with a physiotherapist for home exercise, a PCST program and educational materials, delivered over a period of three months.

At three months, the intervention group reported “significantly more improvement in pain” compared to the control group, Kim Bennell, Centre for Health, Exercise, and Sports Medicine, University of Melbourne, at al., say.

The intervention group also showed improved physical function versus the control group and improvements were sustained at nine months.

The intervention group also reported high levels of satisfaction, and had high rates of completion; 78% accessed the educational materials, with an average of 6.3 of seven Skype physiotherapy sessions completed, and an average of 6.4 of the eight pain­ management modules completed.

This study sheds light on an important challenge for the U.S. health care system; chronic knee pain, is “associated with significant disability and decreased quality of life,” as noted in an accompanying editorial by Lisa Mandl, Hospital for Special Surgery/Weill Cornell Medicine.

“With the aging of the U.S. population, the medical community has braced itself for a tsunami of elderly patients with chronic knee pain – a reasonable response to the projection that almost half of U.S. adults will develop osteoarthritis in at least one knee by age 85 years,” she says. In addition, 50% of people with symptomatic knee osteoarthritis are younger than 65.

“These patients will need effective pain therapy for decades,” Mandl says. “Because osteoarthritis currently has no cure, these demographic characteristics guarantee that a large and diverse cohort of patients will be seeking treatment for chronic knee pain well into the foreseeable future. Therefore, there is a clear and pressing need to identify effective, inexpensive, and low-risk strategies to improve pain and decrease disability in these patients.

The results are also interesting given that “existing therapies have many drawbacks,” as noted in this article on the study. For example, current treatments have adverse effects or may be “cost prohibitive,” and “non-pharmacological therapies, such as physiotherapist-­directed exercise and pain-coping training, may be difficult to access, especially for those in rural areas.”

“These results are encouraging and show that ‘telemedicine’ is clearly ready for prime time,” the study authors say. “An Internet-based intervention circumvents multiple issues related to access to care, making this an inexpensive and easily scalable option for people living in remote areas or any location with an inadequate supply of health care providers.”

This study is an excellent example of evidence-based medicine; the Internet-delivered intervention is a low-risk approach that is clearly preferable to knee surgery, and one that improves access for patients, particularly those in rural areas. However, the key questions are: Will U.S. insurers pay for it? And will physicians be willing to perform this service?

Final thoughts on Service Business Model Innovation, our recently published book chapter

By |2017-10-09T01:55:07+00:00April 24th, 2017|Uncategorized|

Final thoughts on Service Business Model Innovation, our recently published book chapter

As we been blogging for a few weeks, 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 our final thoughts on the lessons we feature in the book chapter.

Now, and increasingly in the future, a health care organization must be concerned about the quality of care a patient receives from other providers as a part of accountable care. Innovation that leads to improved performance requires focusing on the role of cooperation and trust in changing both processes and resources required to deliver value to customers.

Lessons in building trust, cooperation and leadership
The case studies clearly show trust, leadership, and cooperation are the pillars of innovation. In talking with leaders at Baylor Scott & White Health, BJC HealthCare, Massachusetts General Physician Organization, and Sutter Health and the Sutter Medical Network several common lessons emerged for successful health care service innovation.

Practical advice for health care service innovation
1. Attain commitment from leaders. A commitment from top leadership on the vision for change was a suggestion from Sutter Health. Commitment from top leadership to ensure proper resourcing was also a key component at BJC.

2. Find a way to collaborate. BJC, MGPO and Sutter all discussed collaborating on the creation of common clinical goals and provided specific examples on processes they used.

3. Build better quality measures. BJC and Sutter both discussed processes for designing meaningful projects that were clinically driven in order to improve quality.

4. Change the mentality. While changing the mentality of clinicians and staff was a common theme from all four of the case studies presented, two cases, BSWH and MGPO, specifically addressed changing the mentality in a way that focused on the external marketplace.

5. Get results. While results certainly matter to all of the organizations that served as case studies, BJC specifically explained the usefulness of getting results in helping to build trust and cooperation. BSWH used results as a way to offer transparency of price and quality to health care purchasers.

One final lesson: Innovation in health care must be “clinician-forward”
In addition to the key skills of trust, cooperation and leadership, the four case studies M2 wrote identified another condition necessary for service business model innovation in health care, that is, the need to be “clinician-forward,” which we define as reflecting or elevating the mindset and experience of health care clinicians without being exclusive of other inputs or opinions from those not specifically trained in medicine or other health care professions that diagnose and treat patients. In every case, the innovation in their health care service business model was not just about changing processes and resources, but also about achieving meaningful improvements for patients, their families and the clinicians and staff that serve them and their communities. Trust, cooperation and leadership were not just tools the organizations used, but were in fact, the very foundation of the innovative health care service business models they created.

Breast Cancer: Less is More Says Surgical Chief

By |2017-10-09T01:55:31+00:00April 18th, 2017|Uncategorized|

Breast Cancer: Less is More Says Surgical Chief

When it comes to breast cancer surgery, sometimes “less is more,” Memorial Sloan Kettering (MSK) Breast Surgical Service Chief Dr. Monica Morrow says.

As simple as it sounds, it proves be quite difficult for health care providers, as well as patients, to accept that evidence-based medicine recommends less surgery, not more, for women with breast cancer, Dr. Morrow said in a video for Breast Cancer Awareness Month released by MSK via Twitter.
Memorial Sloan Kettering Cancer Center has “the largest experience in the world with [an] approach in over 700 women,” she said. “We have now shown that if a woman is having a lumpectomy and radiation and has cancer in only one or two sentinel nodes, we don’t need to take out the rest of the lymph nodes.”

“We have found that we’ve saved 84% of them from having their lymph nodes removed, which is something that has really eased the burden of their treatment.” This kind of clinical innovation, however, is not readily adopted in practice. Why not?

“The idea that less is more is one that has been very difficult for both physicians and patients to accept, because somehow it seems like if you have something bad like cancer, a bigger operation must be a better operation that cures more cancer,” she said. However, “clinical trials over the years have shown us that that is really not the case.”

This is partly because of “multidisciplinary treatment, meaning we now treat breast cancer not just with surgery the way we did a hundred years ago, but with surgery, and radiation, and drug therapy.”

“So the benefits of the radiation and the drug therapy allow us to do a smaller surgery, like a lumpectomy, and still get the same survival as a mastectomy,” she noted.

This raises an obvious question: if breast cancer treatment relies more on drug therapy than surgery, how should we value the drug used for that treatment? Most of us are not surprised to hear surgery costs $100,000 or $200,000, or more. But what of a cancer treatment in the form of a drug administered by a physician? How much should that treatment cost? How much of that treatment should be covered by insurance?

The move toward a “less is more” approach to breast cancer surgery may also have positive implications for drug costs for breast cancer patients in that the value of those medications will be more apparent.

When real-world evidence tells a story, will we listen? Informing patients, providers, and insurers as to the best use of their health care dollars, for example, ensuring drug therapy is covered as robustly as surgery, would be a good start.

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

By |2017-10-09T01:56:26+00:00April 13th, 2017|Uncategorized|

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

As we blogged a few 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 fourth case study we feature in the chapter.

Sutter Health and the Sutter Medical Network
Sutter Health is a community-owned, not-for-profit health care system operating in northern California. The system has over 50,000 employees and 5000 affiliated physicians. Facilities include 24 hospitals, 34 outpatient surgery centers, 9 cancer centers, 9 neonatal intensive care units, 6 behavioral health centers, 5 acute rehabilitation centers, 5 trauma centers, and more than 4,000 licensed acute care beds. Sutter was recently named as one of the Healthgrades Top Hospitals in the U.S. for 2017.

We talked with Sarah Krevans, President and CEO of Sutter Health, and Don Wreden, M.D., Senior Vice President for Patient Experience, about how Sutter has been able to build the trust necessary to move from a diverse health care delivery system with inconsistent patient experience to a more integrated approach over the past several years. Their advice to build trust, cooperation and leadership? 1) Find a way to collaborate; 2) Embrace strong leadership; 3) Change takes time; 4) Acknowledge innovative ideas can come from anywhere.

Find a way to collaborate
Sutter was able to build trust that lead to service innovation, first, by finding ways to collaborate. Sutter’s collaboration efforts initially focused on selecting common clinical performance standards, goals and measurement mechanisms seeking to develop new and more efficient ways of delivering coordinated, consistent, high quality health care. It was essential to unite around common clinical goals so the medical group partners were motivated to work together in attaining clinical goals focused on patients. The common clinical goals were driven in part by looking at the varying practice styles of health care practitioners across the organization in a non-threatening way. For example, by aiming to reduce clinical variation, Sutter helped clinicians focus on the goal, instead of demanding practice style change.

As our Sutter case study interviewees described it, “we got our training wheels” by doing small, focused clinical initiatives where providers could agree on the goal and “could all understand how to work together.”

Embrace strong leadership
“We remember the health care market of the 1990s,” said Dr. Wreden, “where hospitals were buying medical groups without a clear strategy for clinical integration. We know now that didn’t work out in California.”

What Sutter did instead was nurture engagement of physicians in leadership roles and commit to educate and train physician leaders—which was part of a cultural evolution in the industry. Developing leaders, perhaps not surprisingly, requires a vision that embraces the importance of physician leaders.

One way to encourage leadership, Krevans explained, is not to be afraid of bringing in strong leaders through growth or mergers. If a strong leader exists outside the organization, it is okay to keep that leader engaged and interested in serving the Sutter mission when they come into the organization. As part of its commitment to developing leaders, one particularly innovative approach Sutter uses is to evaluate for leadership potential as part of the recruitment process. “We invest in team development,” Krevans said. Sutter seeks to ensure that it is growing and recruiting the right leaders; for Sutter, a leader needs to be thinking about how to better integrate the health care services the organization provides in service to the needs of the patient.

Trust takes time
Dr. Wreden further explained saying, “We facilitated this evolution by giving true responsibility to physician leaders. We ensured they were focused on partnership, collaboration, shared accountability” and they were serving patients the culture that supports a trusting, cooperative organization. However, both leaders acknowledged such an approach “is fragile, and takes time—it can’t be done in a year.”

These Sutter executives recognized that in today’s turbulent health care market, organizations needing to innovate will probably have to move faster than Sutter had to when they embarked upon this journey several years ago.

Acknowledge innovative ideas can come from anywhere
Finally, and uniquely in the case studies M2 wrote, the Sutter leaders advised health care organizations seeking to innovate their service model would do well to recognize innovation can come from people from a variety of backgrounds, including those with non-clinical training or experience.

For example, in 2015, Sutter hired Chris Waugh to be its first Chief Innovation Officer. Waugh had previously held leadership roles at IDEO, a global design firm that creates human-centered design. Sutter also relies on ethnographers, technologists, and other types of experts, to name a few, to ensure the organization is always improving at serving patients.

One of the key lessons from Sutter Health’s innovation experience is: “Don’t just value a particular kind of leader. Respect every member of the team,” according to Krevans. It is important to appreciate the skills and background of all different kinds of staff within the organization.

“Innovation in the service model and true breakthroughs will come from this range of expertise,” said Krevans.

Opioid Abuse: State Prescription Drug Monitoring Programs Help Reduce Overdose Death Rates

By |2017-10-09T01:57:06+00:00April 10th, 2017|Uncategorized|

Opioid Abuse: State Prescription Drug Monitoring Programs Help Reduce Overdose Death Rates

In 2015, the director of the National Institute on Drug Abuse, Dr. Nora Volkow, “told a group of Kentucky journalists and others at the Foundation for a Healthy Kentucky Health Journalism Workshop” that it is “possible to decrease the over-prescription of opioids, but” she said, “the solutions aren’t ‘sexy.’”

For example, to address the opioid epidemic in the U.S., some states have implemented policies to curb inappropriate opioid prescribing. These policies include, for example: mandatory provider use of prescription drug monitoring programs (PDMPs), and pain clinic laws that feature requirements such as registration of pain clinics with the state, physician ownership of the clinics, prescribing restrictions, and record-keeping requirements.

A recent study published in Health Affairs found that “combined implementation of mandated provider review of state-run prescription drug monitoring program data and pain clinic laws reduced opioid amounts prescribed by 8 percent and prescription opioid overdose death rates by 12 percent.”

The study results “suggest that some opioid prescribing policies had intended effects on opioid prescribing and overdose death rates.”
“We found that mandated review of prescription drug monitoring program data combined with pain clinic laws was significantly associated with both decreased amounts of opioids prescribed and with decreased prescription opioid overdose deaths,” the authors state.

As for potential effects of these policies on heroin overdose death rates, the study notes that “publications in mainstream media and in the scientific literature have advanced the idea that opioid prescribing policies have unintentionally driven demand for heroin (a drug with similar effects) as people search for ‘a cheaper, more accessible high.’” However, the study “did not find any evidence to support the concern that these opioid prescribing policies result in increased heroin-related overdose deaths. However, additional factors, including increased heroin supply, a population already widely exposed to prescription opioids, and increased mixing of highly potent illicitly manufactured fentanyl with heroin, are likely to continue to pose daunting challenges to the prevention of heroin overdose deaths.”

“This combination of policies was effective, but broader approaches to address these coincident epidemics are needed,” said Deborah Dowell, senior medical advisor at the Centers for Disease Control & Prevention’s (CDC) National Center for Injury Prevention and Control.

One step forward is better than none, boring and unsexy as those solutions might be.

The third case study from our recently published book chapter in Service Business Model Innovation

By |2017-10-09T01:58:36+00:00April 4th, 2017|Uncategorized|

The third case study from our recently published book chapter in Service Business Model Innovation

Service Business Model Innovation in Healthcare and Hospital ManagementAs 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 third case study we feature in the chapter.

 

The Massachusetts General Physicians Organization

The Massachusetts General Physicians Organization (MGPO) is a multi-specialty medical group that provides patient care, teaching, and research in partnership with the Massachusetts General Hospital and in cooperation with Partners HealthCare. Several of the hospitals in the Partners HealthCare system, including the Massachusetts General Hospital, are teaching affiliates of Harvard Medical School.

We talked with Dr. Daniel M. Horn, Assistant Medical Director for Ambulatory Quality at the MGPO whose work is focused on the next steps in quality in his role leading efforts to improve the quality of care for 160,000 patients across 21 primary care practices.

Quality measures and the binary fail

Measuring quality is a building block for payment and delivery system reforms, such as accountable care, integrated delivery, shared-savings or value-based approaches. However, there is a difference between true quality of care and quality measures. Improving patient outcomes is likely to represent high quality of care, but how would that be measured?

At MGPO, the organization is using the current “binary fail” method of measuring quality as an opportunity to build trust. For example, most healthcare providers are in some way subject to quality measures designed for health plans called the Healthcare Effectiveness Data and Information Set (HEDIS). Dr. Horn used the example of the HEDIS measure for controlling blood pressure to explain the problem of the “binary fail.” Heart disease and stroke is the leading cause of death in the U.S., and because high blood pressure (hypertension) increases the risk for heart disease and stroke, there is no question that controlling high blood pressure is important. What is at issue is the way providers are measured on the concept of “controlling.”

Controlling high blood pressure, according to HEDIS, is the measurement of the percentage of patients 18–85 years of age who had a diagnosis of hypertension and whose blood pressure (BP) was adequately controlled during the measurement year, for example, by showing the patient’s blood pressure was less than 140/90 mm Hg. In a clinical practice, this means the denominator is the number of patients who come into the practice in the first 6 months of the year where the clinician submitted a bill with the appropriate ICD-10 code related to an abnormal blood pressure reading without a hypertension diagnosis, and the numerator is the number of patients who come into the practice in the second 6 months of the year and have a blood pressure reading below 140/90 mm Hg.

Even a non-clinical reader can quickly see various patient scenarios that would fall outside of this narrow consideration of the quality measure called controlling high blood pressure; hence, Dr. Horn’s pronouncement that the HEDIS measure creates a binary fail for measuring the control of a patient’s blood pressure.

Building trust, then, is accomplished by rewriting the measures with an algorithm for all of your patients. MGPO developed a measure that is clinically valid and acknowledges what the clinician knows, which is that it might have taken 18 months to control a patient’s blood pressure, for example.

Dr. Horn explained that building trust and cooperation in order to achieve service business model innovation requires: 1) Building better quality measures; 2) Changing the mentality; and 3) Providing usable data.

Build better quality measures

Dr. Horn explained that in response to the changing healthcare environment, and in an effort to build trust with clinicians to show that their work and interest in patient care is paramount to the organization’s success, MGPO addressed the gap between payer-defined measures, such as HEDIS, and clinically valid and meaningful quality measures. His team, in close cooperation with other clinicians, has helped the organization rewrite measures used internally so they would be clinically valid in the healthcare provider’s point-of-view. “We have electronic health record (EHR)-based data sets to manage clinical care, so let’s build better measures, then maybe build that into contracts,” said Dr. Horn.

Change the mentality

Thinking first about how clinicians work and why they choose to serve patients, meant changing the rhetoric and mentality around payer-driven measures. Dr. Horn explained, “We want to empower you to do this work and we want to define it in clinically meaningful terms.” By doing this over the past 3 years, the system is, in a way, divorcing itself from the market-driven quality measures when it comes to thinking about true quality and patient outcomes

Provide usable data

Trust is also bolstered when data being used to measure quality and performance is actually usable. Clinicians are more likely to trust data with three characteristics, according to Dr. Horn. First, it must be reliable. Second, the measurement criteria being used “must represent something they believe in as a physician.” Third, the data must be timely. To incentivize behavior change, showing a clinician or clinical practice information from 6 to 12 months ago is simply too old. The data should be real-time, valid and represent clinician values. In Dr. Horn’s experience, showing data that has even a single mistake or two is enough to create some distrust with clinicians.

As we grapple with ways to improve health care quality and lower costs, the MGPO approach to quality measures is certainly an innovation. To create truly accountable care, quality measures that are valid, valued and usable by clinicians are needed to improve the provision of primary care.

*Daniel M. Horn, M.D., is the Assistant Medical Director for Ambulatory Quality at the Massachusetts General Physicians Organization (MGPO). Dr. Horn is also a primary care physician and Unit Chief at Internal Medicine Associates, where he provides comprehensive primary care and helps with day-to-day leadership of the largest primary care practices at Massachusetts General Hospital (MGH).

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