Harvard Pilgrim's Patrick Cahill Tries To Make Sense of It All.

The 40-year-old vice president of regional markets for eastern Massachusetts wants enrollees and, especially, employers to know that there will continue to be a lot of public policy change as the ACA evolves. His course? Keep strengthening ties with providers.

A Hospital Is Not Just a Factory, but a Complex Adaptive System-Implications for Perioperative Care.

Many methods used to improve hospital and perioperative services productivity and quality of care have assumed that the hospital is essentially a factory, and therefore, that industrial engineering and manufacturing-derived redesign approaches such as Six Sigma and Lean can be applied to hospitals and perioperative services just as they have been applied in factories. However, a hospital is not merely a factory but also a complex adaptive system (CAS). The hospital CAS has many subsystems, with perioperative care being an important one for which concepts of factory redesign are frequently advocated. In this article, we argue that applying only factory approaches such as lean methodologies or process standardization to complex systems such as perioperative care could account for difficulties and/or failures in improving performance in care delivery. Within perioperative services, only noncomplex/low-variance surgical episodes are amenable to manufacturing-based redesign. On the other hand, complex surgery/high-variance cases and preoperative segmentation (the process of distinguishing between normal and complex cases) can be viewed as CAS-like. These systems tend to self-organize, often resist or react unpredictably to attempts at control, and therefore require application of CAS principles to modify system behavior. We describe 2 examples of perioperative redesign to illustrate the concepts outlined above. These examples present complementary and contrasting cases from 2 leading delivery systems. The Mayo Clinic example illustrates the application of manufacturing-based redesign principles to a factory-like (high-volume, low-risk, and mature practice) clinical program, while the Kaiser Permanente example illustrates the application of both manufacturing-based and self-organization-based approaches to programs and processes that are not factory-like but CAS-like. In this article, we describe how factory-like processes and CAS can coexist within a hospital and how self-organization-based approaches can be used to improve care delivery in many situations where manufacturing-based approaches may not be appropriate.

Do Health Care Delivery System Reforms Improve Value? The Jury Is Still Out.

BACKGROUND: Widespread restructuring of health delivery systems is underway in the United States to reduce costs and improve the quality of health care. OBJECTIVE: To describe studies evaluating the impact of system-level interventions (incentives and delivery structures) on the value of US health care, defined as the balance between quality and cost. RESEARCH DESIGN: We identified articles in PubMed (2003 to July 2014) using keywords identified through an iterative process, with reference and author tracking. We searched tables of contents of relevant journals from August 2014 through 11 August 2015 to update our sample. SUBJECTS: We included prospective or retrospective studies of system-level changes, with a control, reporting both quality and either cost or utilization of resources. MEASURES: Data about study design, study quality, and outcomes was extracted by one reviewer and checked by a second. RESULTS: Thirty reports of 28 interventions were included. Interventions included patient-centered medical home implementations (n=12), pay-for-performance programs (n=10), and mixed interventions (n=6); no other intervention types were identified. Most reports (n=19) described both cost and utilization outcomes. Quality, cost, and utilization outcomes varied widely; many improvements were small and process outcomes predominated. Improved value (improved quality with stable or lower cost/utilization or stable quality with lower cost/utilization) was seen in 23 reports; 1 showed decreased value, and 6 showed unchanged, unclear, or mixed results.Study limitations included variability among specific endpoints reported, inconsistent methodologies, and lack of full adjustment in some observational trials. Lack of standardized MeSH terms was also a challenge in the search. CONCLUSIONS: On balance, the literature suggests that health system reforms can improve value. However, this finding is tempered by the varying outcomes evaluated across studies with little documented improvement in outcome quality measures. Standardized measures of value would facilitate assessment of the impact of interventions across studies and better estimates of the broad impact of system change.

[The integration of telemedicine concepts in the regional care of rural areas: Possibilities, limitations, perspectives]. / Telemedizinische Versorgungskonzepte in der regionalen Versorgung ländlicher Gebiete : Möglichkeiten, Einschränkungen, Perspektiven.

In rural areas with a low population density and (imminent) gaps in regional health care, telemedicine concepts can be a promising option in supporting the supply of medical care.Telemedicine connections can be established between different health care providers (e.g., hospitals) or directly between health care providers and patients.Different scenarios for the implementation of telemedicine have been developed, from the monitoring of chronically ill patients to the support of acute care. Examples of frequently applied telemedicine concepts are teleradiology, telemedicine stroke networks, and the telemedicine monitoring of patients with heart failure. The development of concepts for other indications and patient groups is apparently difficult in Germany; one reason could be that research institutions are involved in only a small number of projects. However, the participation of research institutes would be of importance in creating more scientific evidence. The development of appropriate evaluation designs for analyzing the effectiveness of telemedicine concepts and economic effects is an important task and challenge for the future. Mandatory evaluation criteria should be developed to provide a basis for the translation of positively evaluated telemedicine concepts into routine care.

[Declared dead? Recommendations regarding integrated care from the perspective of German statutory health insurance]. / Totgesagte leben länger : Empfehlungen zur Integrierten Versorgung aus Sicht der gesetzlichen Krankenkassen.

The traditional separation of health care into sectors in Germany causes communication problems that hinder continuous, patient-oriented care. This is most evident in the transition from inpatient to outpatient care. That said, there are also breaks in the flow of information, a lack of supply, or even incorrect information flowing within same-sector care. The transition from a division of functions into sectors to a patient-oriented process represents a change in the paradigm of health care that can only be successfully completed with considerable effort. Germany's statutory health insurance (SHI) funds play a key role here, as they are the contracting parties as well as the financiers of integrated care, and are strategically located at the center of the development process.The objective of this article is to explore how Germany's SHI funds view integrated care, what they regard as being the drivers of and barriers to transitioning to such a system, and what recommendations they can provide with regard to the further development of integrated care. For this purpose semi-structured interviews with board members and those responsible for implementing integrated care into the operations of ten SHI funds representing more than half of Germany's SHI-insured population were conducted. According to the interviewees, a better framework for integrated care urgently needs to be developed and rendered more receptive to innovation.Only in this way will the widespread stagnation of the past several years be overcome. The deregulation of § 140a-d SGB V and the establishment of a uniform basis for new forms of care in terms of a new innovation clause are among the central recommendations of this article. The German federal government's innovation fund was met with great hope, but also implied risks. Nonetheless, the new law designed to strengthen health care overall generated high expectations.

[Rationale and dissemination of "GP centered health care" ("HzV") in Germany]. / Rationale und Stand der hausarztzentrierten Versorgung in Deutschland.

BACKGROUND: In the face of demographic changes, the aging of the population, and the increase in chronic morbidity and complexity, efficient primary care is needed to ensure comprehensive and high-quality health care. The general practitioner (GP) can only cope with this task, if certain preconditions are met. OBJECTIVES: To strengthen primary health care, the German legislator added § 73b, "GP-centered health care" ("Hausarztzentrierte Versorgung", HzV) to the Social Code Book V. This article seeks to illustrate the rationale and general set-up of the HzV and to report on its dissemination. We discuss whether or not the HzV can promote the preconditions required. MATERIALS AND METHODS: Literature search, querying participants. RESULTS: Several elements of the HzV, such as lump-sum reimbursement, obligatory participation in structured quality circles, continuing education, and the qualification of non-medical health care assistants help to promote an environment that enables GPs to fulfill their new role. Considering all assured people and the Federal Republic as a whole, the distribution of the HzV is poor. However, a growing number of contracts (currently: 79) and participants (currently > 3.6 million) is expected. CONCLUSIONS: The establishment of efficient primary care is heavily promoted by the HzV. In future, ways must be found to overcome the inflexible borders between sectors and to integrate community-based health care, which truly focuses on the patients needs. The HzV can be seen as a starting point.

[Health care networks in Germany: status quo and key success factors]. / Den Kinderschuhen entwachsen - Arztnetze in Deutschland leisten wertvollen Beitrag zur Optimierung der lokalen Versorgungssituation.

One third of all practicing physicians are currently working in one of the 400 German health care networks. These physicians' networks bring together GPs and specialists and cooperate with different partners, for example, nursing homes, hospitals, and self-help groups. To increase the quality and the efficiency of care and patient satisfaction by improving the collaboration and communication between physicians and other health care providers.The example of the accountable care organization "Gesundheitsnetz Qualität und Effizienz" (QuE; Health Quality and Efficiency Network) in Nuremberg is used to show that it is possible to achieve an increase in efficiency while providing above-average quality of care and achieving high patient satisfaction. Additionally, the article deals with the status quo, the core objectives, and the key activities of previous generations of health care networks. Quality indicators, satisfaction surveys, and economic parameters are the basis for measuring and representing the above-average performance of physicians' networks. Regional health care networks offer an entire range of patient care, from outpatients and inpatients to the complementary sector, and thereby have excellent prospects for playing an even more important role in the German health care system. The key success factors are: the consideration of specific regional characteristics, their proximity to the patient, and consistent patient orientation.

[Pursuing the triple aim: evaluation of the integrated care system Gesundes Kinzigtal: population health, patient experience and cost-effectiveness]. / Triple Aim - Evaluation in der Integrierten Versorgung Gesundes Kinzigtal - Gesundheitszustand, Versorgungserleben und Wirtschaftlichkeit.

BACKGROUND: The integrated care system Gesundes Kinzigtal (ICSGK), one of the most comprehensive population-based ICS in Germany, started its work nearly 9 years ago. The ICSGK is pursuing the Triple Aim: improving the health of the population, improving the individual's experience of care, and at the same time reducing the per capita costs of care. OBJECTIVES: To evaluate the impact of the ICSGK on the Triple Aim. MATERIALS AND METHODS: The ICSGK is being evaluated externally and internally via a mix of diverse quantitative and qualitative methods. This paper presents selected results for each Triple Aim dimension. RESULTS AND CONCLUSIONS: Regarding population health, most of the quality indicators examined by the external scientific evaluation show positive development. For example, the prevalence of patients with fractures among all insurants with osteoporosis is presented. In 2011, this prevalence was approximately 26 % in the "Kinzigtal" population (aged ≥ 20 years old) in comparison to 33 % in the control group. As far as patient experience is concerned, to the question "Would you recommend becoming a member of Gesundes Kinzigtal to your friends or relatives?" 92.1 % of those questioned answered "Yes, for sure" or "Yes, probably." Twenty-four percent of those questioned further stated that they would now live "more healthy" than before enrolment in the ICSGK. In the subgroup of questioned insurants who had objective agreements with their doctors 45.4 % answered in this way. On the subject of cost-effectiveness, for both participating socil health insurance schemes, cost savings relative to the costs normally expected for the ICSGK population concerned are observed every year. In the seventh intervention year (2012) the total is 4.56 million Euros for the AOK Baden-Württemberg (BW), which is a contribution margin of 146 Euros per insurant for the 31.156 insurants concerned (LKK BW = 322 Euros per insurant relative to cost savings). The results presented in this paper indicate positive effects in all three Triple Aim dimensions. Further longitudinal studies are recommended to validate those first results together with a detailed analysis to obtain in-depth insights into the specific influence of subcomponents of the total intervention.

[Integrated stroke care]. / Integrierte Versorgung bei Schlaganfall.

The structures and processes of stroke care provision in the acute and chronic phases, during rehabilitation and societal integration, the needs of patients, and the means of meeting those needs are described and analyzed. Deficits mainly involve local multidisciplinary professional aid, focusing on participation under the supervision of a neurologist experienced in rehabilitation. Deficits are mainly caused by a lack of funding from statutory and private health insurance.

Physician organization care management capabilities associated with effective inpatient utilization management: a fuzzy set qualitative comparative analysis.

BACKGROUND: We studied the relationship between physician organization (PO) care management capabilities and inpatient utilization in order to identify PO characteristics or capabilities associated with low inpatient bed-days per thousand. METHODS: We used fuzzy-set qualitative comparative analysis (fsQCA) to conduct an exploratory comparative case series study. Data about PO capabilities were collected using structured interviews with medical directors at fourteen California POs that are delegated to provide inpatient utilization management (UM) for HMO members of a California health plan. Health plan acute hospital claims from 2011 were extracted from a reporting data warehouse and used to calculate inpatient utilization statistics. Supplementary analyses were conducted using Fisher's Exact Test and Student's T-test. RESULTS: POs with low inpatient bed-days per thousand minimized length of stay and surgical admissions by actively engaging in concurrent review, discharge planning, and surgical prior authorization, and by contracting directly with hospitalists to provide UM-related services. Disease and case management were associated with lower medical admissions and readmissions, respectively, but not lower bed-days per thousand. CONCLUSIONS: Care management methods focused on managing length of stay and elective surgical admissions are associated with low bed-days per thousand in high-risk California POs delegated for inpatient UM. Reducing medical admissions alone is insufficient to achieve low bed-days per thousand. California POs with high bed-days per thousand are not applying care management best practices.

Satisfaction with the level and type of resource use of a health insurance scheme in Nigeria: health management organizations' perspectives.

Some developing countries have incorporated managed care elements into their national health insurance schemes. In practice, hybrid health management organizations (Hmos) are insurers who, bearing some resemblance to managed care in the USA, are vertically integrated in the scheme's revenue collection and pool and purchase healthcare services within a competitive framework. To date, few studies have focused on these organizations and their level of satisfaction with the scheme's optimal-resource-use (ORU) implementation. In Nigeria, the study site, Hmos were categorized on the basis of their satisfaction with ORU activities. One hundred forty-seven Hmo staff were randomly interviewed. The types of ORU domain categories were provider payment mechanism, administrative efficiency, benefit package inclusions and active monitoring mechanism. Bivariate analysis was used to determine differences among the Hmos' satisfaction with the various ORU domains. The Hmos' satisfaction with the health insurance scheme's ORU activities was 59.2% generally, and the associated factors were identified. According to the Hmos' perspectives related to the type of ORU, the fee-for-service payment method and regular inspection performed weakly. Hmos' limited satisfaction with the scheme's ORU raises concerns regarding ineffectiveness that may hinder implementation. To offset high risks in the scheme, it appears necessary for the regulatory agency to adapt and reform strategies of provider payment and active monitoring mechanisms according to stakeholder needs. Our findings further reveal that having Hmos evaluate ORU is useful for providing evidence-based information for policy making and regulatory utilization related to implementation of the health insurance scheme.

A longitudinal model of the dynamics between HMOs' consumer-friendliness and preventive health care utilization.

This study aims at replicating and extending Xiao and Savage's (2008) research to understand the multidimensional aspect of HMOs distinguished by HMOs' consumer-friendliness, and their relationship to consumers' preventive care utilization. This study develops a dynamic model to consider both concurrent and time lagging effects of HMOs' consumer-friendliness. Our data analysis discloses similar relationship patterns as revealed by Xiao and Savage. Additionally, our findings reveal the time-series changes of the influence of HMOs' consumer-friendliness that either the effects of early experienced HMOs' consumer-friendliness wear out totally or HMOs' consumer-friendly characteristics on the concurrent term contain most of the explanatory power.

Service use at the end-of-life in Medicare advantage versus traditional Medicare.

BACKGROUND: Relative to traditional fee-for-service Medicare, managed care plans caring for Medicare beneficiaries may be better positioned to promote recommended services and discourage burdensome procedures with little clinical value at the end of life. OBJECTIVE: To compare end-of-life service use for enrollees in Medicare Advantage health maintenance organizations (MA-HMO) relative to similar individuals enrolled in traditional Medicare (TM). RESEARCH DESIGN, SUBJECTS, MEASURES: For a national cohort of Medicare decedents continuously enrolled in MA-HMOs or TM in their year of death, 2003-2009, we obtained hospice enrollment information and individual-level Healthcare Effectiveness Data and Information Set utilization measures for MA-HMO decedents for up to 1 year before death. We developed comparable claims-based measures for TM decedents matched on age, sex, race, and location. RESULTS: Hospice use in the year preceding death was higher among MA than TM decedents in 2003 (38% vs. 29%), but the gap narrowed over the study period (46% vs. 40% in 2009). Relative to TM, MA decedents had significantly lower rates of inpatient admissions (5%-14% lower), inpatient days (18%-29% lower), and emergency department visits (42%-54% lower). MA decedents initially had lower rates of ambulatory surgery and procedures that converged with TM rates by 2009 and had modestly lower rates of physician visits initially that surpassed TM rates by 2007. CONCLUSIONS: Relative to comparable TM decedents in the same local areas, MA-HMO decedents more frequently enrolled in hospice and used fewer inpatient and emergency department services, demonstrating that MA plans provide less end-of-life care in hospital settings.

Measuring up: musings of a family doctor on the employee time clock.

Recently, at the health maintenance organization (HMO) where I work, they introduced an employee time clock. As in many other workplaces, doctors across the country are now obligated to punch the clock at the beginning and end of their workday. This is the final act in an ongoing attempt to enhance management of doctors' schedules: limit nonurgent appointments to 10 minutes, define planned or urgent home visits, and control a physician's time, as well as managerial and clinical decisions. In this story I describe a day in the life of a family doctor, a salaried employee at a large HMO where there is now a time clock. I provide details on how the introduction of the clock influences small everyday clinical decisions that potentially affect the quality and depth of treatment while sharing the internal dialogue that accompanies me as I reaffirm my professional integrity again and again with each hastened visit. I also bring the internal dialogue of 2 of my patients, to illustrate the emotional world on the other side of these 10-minute interventions.

Characteristics of practitioners in a private managed behavioral health plan.

BACKGROUND: Little is known about the practitioners in managed behavioral healthcare organization (MBHO) networks who are treating mental and substance use disorders among privately insured patients in the United States. It is likely that the role of the private sector in treating behavioral health will increase due to the recent implementation of federal parity legislation and the inclusion of behavioral health as a required service in the insurance exchange plans created under healthcare reform. Further, the healthcare reform legislation has highlighted the need to ensure a qualified workforce in order to improve access to quality healthcare, and provides an additional focus on the behavioral health workforce. To expand understanding of treatment of mental and substance use disorders among privately insured patients, this study examines practitioner types, experience, specialized expertise, and demographics of in-network practitioners providing outpatient care in one large national MBHO. METHODS: Descriptive analyses used 2004 practitioner credentialing and other administrative data for one MBHO. The sample included 28,897 practitioners who submitted at least one outpatient claim in 2004. Chi-square and t-tests were used to compare findings across types of practitioners. RESULTS: About half of practitioners were female, 12% were bilingual, and mean age was 53, with significant variation by practitioner type. On average, practitioners report 15.3 years of experience (SD = 9.4), also with significant variation by practitioner type. Many practitioners reported specialized expertise, with about 40% reporting expertise for treating children and about 60% for treating adolescents. CONCLUSIONS: Overall, these results based on self-report indicate that the practitioner network in this large MBHO is experienced and has specialized training, but echo concerns about the aging of this workforce. These data should provide us with a baseline of practitioner characteristics as we enter an era that anticipates great change in the behavioral health workforce.

Paying for quality not quantity: a wisconsin health maintenance organization proposes an incentive model for reimbursement of chiropractic services.

OBJECTIVE: The purpose of this study is to describe a reimbursement model that was developed by one Health Maintenance Organization (HMO) to transition from fee-for-service to add a combination of pay for performance and reporting model of reimbursement for chiropractic care. METHODS: The previous incentive program used by the HMO provided best-practice education and additional reimbursement incentives for achieving the National Committee for Quality Assurance Back Pain Recognition Program (NCQA-BPRP) recognition status. However, this model had not leveled costs between doctors of chiropractic (DCs). Therefore, the HMO management aimed to develop a reimbursement model to incentivize providers to embrace existing best-practice models and report existing quality metrics. The development goals included the following: it should (1) be as financially predictable as the previous system, (2) cost no more on a per-member basis, (3) meet the coverage needs of its members, and (4) be able to be operationalized. The model should also reward DCs who embraced best practices with compensation, not simply tied to providing more procedures, the new program needed to (1) cause little or no disruption in current billing, (2) be grounded achievable and defined expectations for improvement in quality, and (3) be voluntary, without being unduly punitive, should the DC choose not to participate in the program. RESULTS: The generated model was named the Comprehensive Chiropractic Quality Reimbursement Methodology (CCQRM; pronounced "Quorum"). In this hybrid model, additional reimbursement, beyond pay-for-procedures will be based on unique payment interpretations reporting selected, existing Physician Quality Reporting System (PQRS) codes, meaningful use of electronic health records, and achieving NCQA-BPRP recognition. This model aims to compensate providers using pay-for-performance, pay-for-quality reporting, pay-for-procedure methods. CONCLUSION: The CCQRM reimbursement model was developed to address the current needs of one HMO that aims to transition from fee-for-service to a pay-for-performance and quality reporting for reimbursement for chiropractic care. This model is theoretically based on the combination of a fee-for-service payment, pay for participation (NCQA Back Pain Recognition Program payment), meaningful use of electronic health record payment, and pay for reporting (PQRS-BPMG payment). Evaluation of this model needs to be implemented to determine if it will achieve its intended goals.

Program for uninsured cuts ED visits, admissions.

MetroHealth Medical Center in Cleveland has saved about $18 per member a month by enrolling uninsured patients in an HMO-like system developed by the health system. Patients pay on a sliding scale based on their income. Uninsured patients are signed up for the program when they come to the emergency department and cannot have a clinic visit unless they enroll. The hospital embeds case managers in the health system's clinic to work with uninsured patients to help them avoid emergency department visits and hospitalizations.

Organized colorectal cancer screening in integrated health care systems.

Colorectal cancer (CRC) is an ideal target for early detection and prevention through screening. Noninvasive screening options are the guaiac fecal occult blood test and the fecal immunochemical test. Organized screening offers the promise of uniformly delivering screening to all members of a population who are eligible and due. Organized screening is defined as an explicit policy with defined age categories, method, and interval for screening in a defined target population with a defined implementation and quality assurance structure, and tracking of cancer in the population. The UK National Health Service; the Ontario, Canada Ministry of Health and Long-Term Care; and the US Veteran's Health Administration have used varied organized approaches to deliver guaiac fecal occult blood test screening to their populations. Kaiser Permanente Northern California began CRC screening in the 1960s, initially using flexible sigmoidoscopy. Implementation of organized fecal immunochemical test outreach was associated with improved Healthcare Effectiveness Data and Information Set CRC screening rates between 2005 and 2010 from 37% to 69% and from 41% to 78% in the commercial and Medicare populations, respectively. Organized fecal immunochemical test screening has been associated with an increase in annually detected CRCs, almost entirely because of increased detection of localized-stage cancers.

Modifying prescribing behaviour of angiotensin receptor blockers by selectively rescinding managerial prior authorization requirements for losartan.

AIMS: To evaluate whether rescinding the prior authorization (PA) requirement (managerial pre-approval) for losartan in an health maintenance organization (HMO) could reduce prescribing of the more expensive angiotensin receptor blockers (ARBs). METHODS: HMO physicians were notified that losartan would no longer require PA, and appropriate changes were made to the electronic prescribing computer program. The monthly distribution by drug of the number of prescriptions for ARBs dispensed for new patients was calculated before and after the policy change from data captured from electronic records. The proportion of patients (percentage and 95% confidence interval) treated with losartan who met the criteria for treatment with ARBs (hypertension or cardiac insufficiency in patients who have developed adverse effects in response to angiotensin-converting enzyme inhibitors or macroproteinuria) during the first month after the PA requirement was rescinded was calculated. RESULTS: The total number of PA requests for ARBs declined by 48.6% from 961 in December 2008, the month before the policy change, to 494 the following January, rising again to 651 during January 2010. Prescription incidence changed from 121 to 255 patients treated per month (114% increase) for losartan, from 15 to 16 (6.7% increase) for candesartan, and from 89 to 71 (20.2% decrease) for valsartan. The duration of effect for decrease in ARB requests for the more expensive drugs was approximately 1 year. Only 23.3% (95% confidence interval 18.1-28.4) of patients receiving losartan met the criteria for receiving ARBs. CONCLUSIONS: Rescinding the PA requirement for this drug alone was an effective limited-duration strategy for reduction of prescription of relatively expensive drugs.