A couple tables in particular caught my attention.

(click on the graphic to view a larger version)

Key findings in this table include:

(more…)

by Jaan Sidorov MD, MHSA, FACP and Vince Kuraitis JD, MBA

Physicians face great uncertainty. According to a survey conducted by The Physicians Foundation, the great majority of physicians (89%) believe the traditional model of independent private practice is either “on shaky ground” or “is a dinosaur soon to go extinct.”

In the face of this uncertainty, many physicians are jumping to a conclusion that “I have to sell my practice to the hospital.” In this post of our series on The 100 Year Shift, we will examine physician practice.  We’ll show that the economic and clinical environment  is changing rapidly and that selling to the hospital is one option. However, it is not the only option. (more…)

In our introductory posting of this series, we noted that economic incentives previously aligning doctor-hospital interests were changing. This creates the potential for The 100 Year Shift – physicians awakening to possibilities for stronger partnerships with payers than with hospitals.

In this post, we will zero in on the changing economic position of hospitals and the effect this is having on physician-hospital relationships. We will examine the trend of hospital employment of physicians and point out challenges and tensions for the future. [This is a long post...so now might be the time to refill your coffee cup.] (more…)

by Jaan Sidorov MD, MHSA, FACP and Vince Kuraitis JD, MBA

In our introductory posting, we suggested that a huge shift is underway in the health care industry.  Decades of hospital-physician cooperation are not only eroding, we suggest this trend could accelerate.  Instead of a natural clinical and economic affinity with hospitals, we foresee the potential for physicians forming a new dyad with insurer-buyers.

In this post, we will examine what we and many other commentators view as inevitable: the demise of volume-based payment systems and how the drive for greater value will cause physicians and insurers re-examine their normally antagonistic relationship. (more…)

Gazing at the horizon, we foresee the potential for a tectonic realignment among physicians, hospitals and payers. Here’s a quick visual representation:

This essay is the first of a seven part series. In this first post we will capsulize our vision of this potential 100 Year Shift, answer initial FAQs, and lay out the structure for the rest of the series.

The Lynchpin — Changing Economic Incentives

In the past, physicians and hospitals have benefited from mutually supportive economic interests. (more…)

1. Administrative Mandates (Compliance HIPAA 5010, ICD-10, etc.).
2. Care Management, Data Analytics, and Informatics.
3. Health Insurance Exchanges and Individual Markets.
4. New Provider Payment & Delivery Systems (ACOs, PCMHs, etc.).
5. Bend the Cost Trend.
6. Medicare and Medicaid.
7. Health Information Exchanges and EMRs.
8. Consumer’s Role in the Modernization of Healthcare.
9. Reform Uncertainties.
10. Payer/Provider Interoperability.

Dear health plan colleagues,

Wake up! The order of this list is totally out of whack.

#2: Care Management, Data Analytics, Informatics. Good…sounds about right.

However,

#2 can’t happen before you address:

#7: HIEs and EMRs

#10: Payer/Provider Interoperability

Health plans can’t analyze the data and assist in care management unless they first have access to it. Payers need access to clinical data, and they are at risk of being cut out of the loop.

P.S.

Please also take a look at priority #1: Administrative Mandates (Compliance HIPAA 5010, ICD-10, etc.). This is completely reactive!

In these times of great change, is this how health plans want to posture themselves in the community?

ACO Fact sheet from HHS

Medicare Fact Sheet: What Providers Need to Know

HHS press release

Don Berwick’s article on ACOs in the NEJM

ACO Quality Performance Standards Summary

FTC/DOJ Joint Antitrust Statement on ACOs

TheHill article “Leaked memo reveals Dem strategy for defending healthcare reg”

The leaked memo

As I’ve written before, the Big Idea behind ACOs (Accountable Care Organizations) is the notion of accountability, not the specifics of organizational structure.

The purpose of the ACP position paper is to address the gaps that exist in care coordination when a physician refers a patient to a specialist. The obvious and logical answer proposed is to develop “Care Coordination Agreements” between primary care physicians and referring specialists, and the position paper takes 35 pages to explain why and how.

A simplified way of thinking about Care Coordination Agreements is that they recognize that coordination of care is a team sport, that specialists are part of the team, and that this paper proposes rules of the game about how primary care physicians and specialists should play together on behalf of their common patients.

However, there’s a great big CAVEAT buried in the position paper.  I don’t doubt the earnestness of the authors, but I do take this caveat as a Freudian slip recognition that not all specialists will be eager to play on the team and to play by the rules:

(more…)

Who has the most comprehensive data about YOUR clinical conditions?

For most people, the answer today is “your health plan”, but it’s not at all clear that health plans will continue to have this role in the future.

As physicians and hospitals adopt EHRs, it’s foreseeable that clinical data about patients will be far more available and accessible.

Will patient data become:

• A jockeying point for control and business advantage between health plans and care providers,
• A collaborative opportunity to optimize clinical care and care coordination, or
• Both? (more…)

(click on the graphic to download the document)

Depending on the nature of the payment changes which are made, physicians may need to enhance their capabilities in some or all of the following sixteen areas:

1. Achieving sufficient patient volume to support a new or improved service.
2. Having sufficient upfront capital to design and implement a new or improved service.
3. Having the skills/experience to efficiently/effectively implement a new/improved service.
4. Having the ability to obtain and analyze data on the quality of services.
5. Having the skills/experience to improve the quality of services.
6. Having adequate resources to support high-quality service delivery.
7. Gaining access to external resources to support patient adherence and health improvement.
8. Obtaining and analyzing data on the variation in services per episode or per patient.

(more…)

Gawande retorts: “Is that a bad thing?”

…and he answers his own question by describing the value of pilot programs contained in both the Senate and House versions of health reform legislation.

Is Gawande correct?  Yes and no….

(more…)

In that post I touched briefly on the potential for MAPCI to create effective networks at multiple levels — contracting networks, health IT networks, social and collaborative care networks.  I’d like to expand a bit today…

So, why is Medicare’s participation in MAPCI  and other regional collaboratives such a big deal? Here’s my hypothesis:

Medicare’s non-participation (to-date) in regional payer/provider collaboratives has been a rate limiting factor in the potential to achieve high levels of network effects that drive adoption.

(more…)

BrightTALK is sponsoring a complimentary Electronic Health Record Summit this Tuesday, October 20, 2009.

David C. Kibbe MD, MBA and I will be presenting “Introduction to Clinical Groupware and the Clinical Groupware Collaborative”

Clinical groupware is a new and evolving model for the development and deployment of health information technology (HIT) platforms and applications having the following characteristics:

• Use of the Internet and the web for EHR technology.
• Explicit design for information sharing and online communication among providers and patients/consumers.
• A modular or component architecture upon which applications can be aggregated to meet specific clinical and workflow tasks.
• Patient/consumer engagement tools that facilitate ongoing health management and care coordination.
• Interface and data exchange standards for information sharing that emerge in a market-driven manner.

The Clinical Groupware Collaborative is in a formative stage organization. To date, representatives from over 50 companies have expressed interest. We are working to be formally incorporated in November 2009.

To register, attend live, or view afterward on-demand, click the following link:  http://www.brighttalk.com/webcasts/6114/attend  

Here’s a full listing of the other Electronic Health Record Summit presentations:   

Kaiser Permanente’s Journey and Ultimate Success with Health IT, Andrew M. Wiesenthal, The Permanente Federation

Prescribing the Best Security for Your EHR System, Andrew Klein, Product Management at SonicWALL

Business Associates Now and Then: HIPAA, EHRs and the HITECH Act, Susan Miller, Security & Privacy Workgroup Chair, WEDI

Fraud & Abuse in the EHR, Jean Bishop, J Bishop Consulting

New HIPAA Rules and EHRs: ARRA & Breach Notification, Raj Goel, Brainlink International; Jim Sheldon-Dean, Lewis Creek Systems

Three Forcing Factors of Electronic Healthcare Records, Kim Singletary, McAfee

How Great EHRs Empower Participatory Medicine, e-Patient Dave deBronkart, Society for Participatory Medicine co-chair

ACOs of various types are being proposed in national health reform legislation. For all you ever wanted to know about ACOs, read How to Create Accountable Care Organizations from the Center for Healthcare Quality and Payment Reform.   I spent an hour and a half poring over the details of this excellent report written by Harold Miller.

My mistaken impression has been to focus on the organizational form of ACOs, rather than their objectives.  Organizational form is relevant in understanding ACOs, but primarily as a means toward creating accountability, not the end in itself.  Thus, expect to see many varying types of ACOs emerging based on local needs and characteristics.

I initially approached reading the report with a number of top-of-mind tactical and programmatic questions about ACOs:

• What kinds of organizations can serve as ACOs?
• What do primary care practices need to do differently to become ACOs?
• What’s the difference between a medical home and an ACO?
• Can small primary care practices become an ACO?
• Should all physicians in a geographic area be included in a single ACO?
• What is the role of specialists in an ACO?
• Should hospitals be part of an ACO?
• Are integrated delivery systems the ideal model?
• How many payers need to support an ACO?
• Accountability for all or some costs?

The answers to these questions are important, but primarily because they go to how an ACO can achieve accountability…

… and the short answer to every one of these questions is “It depends”. 

Depends on what?

To the maximum extent possible, an organization’s ability to serve as an Accountable Care Organization should be determined by its success in improving outcomes – controlling costs, improving quality, and providing a good experience for patients – not on its organizational structure or even the specific care processes it uses. 

Let me try to explain the big idea of accountability from a couple of other angles.

(more…)

I’m writing to extend a warm personal invitation to learn more about the Clinical Groupware Collaborative (CGC).  To-date, purely through word-of-mouth over 40 companies have expressed interest in the CGC, and we expect that you’ll be hearing a lot more about us over the coming months.

Our meeting will take place next Tuesday, September 22, 6 PM in conjunction with The Forum 09, the annual meeting of DMAA: The Care Continuum Alliance.  More details are provided at the bottom of this post.

I’ll address a few questions that might be on your mind.

Q. What is Clinical Groupware? 

(more…)

There’s a double meaning to the title of this new series: Healthcare Crosses the Chasm to the Network Economy

At the level of technology, it’s a reference to Geoffrey Moore’s bestselling business/technology book — “Crossing the Chasm”. The Chasm here is the huge gap between early adopters of technology and mainstream users. The book describes the process of bringing specific technologies into mainstream usage.

At the level of clinical care, its a reference to the landmark 2001 report by the Institute of Medicine — “Crossing the Chasm”.  Here, the Chasm is a reference to the quality/safety gap existing in American healthcare, with major systemic recommendations for how to cross the chasm toward clinical improvement.

In this series, the “Crossing the Chasm” is a reference to both technology and clinical care — and to the interdependence between them. I believe we’re entering a new era in healthcare, marked by passage of the HITECH Act Federal stimulus legislation, but of which HITECH is only the beginning . While to a casual observer HITECH Act might seem focused on electronic health records (EHRs), it goes far beyond that.   

Over the past several years, I’ve had the privilege to work with many leading-edge clients who understand that health IT interoperability, networks, and platform/application technologies and business models will reshape health care over the coming years.  This has given me a chance to do a deep dive into understanding companies, business models and literature from outside health care, and then thinking through implications for health care companies (much blogging and book forthcoming).

This series will pull on concepts, terminology and lessons from two disciplines:

(more…)

…and the title of the eHealth Initiative’s Sixth Annual Survey of Health Information Exchange says it all:

Migrating Toward Meaningful Use

What’s happening here?

(more…)

Interoperability has multiple dimensions — and I’d bet that most of us have never thought of interoperabilty as involving “process” — people working together and collaborating; I know I hadn’t.

The Interoperability Work Group of HL7’s Electronic Health Record (EHR) Technical Committee was formed in April 2005 to attempt to define the concept of interoperability. The group examined 100+ definitions of interoperabilty. Their work is summarized in their report: Coming to Terms: Scoping Interoperability for Health Care, February 2007.

3 Types of Interoperability: Technical, Semantic, Process

Through work group consensus, three principal types of interoperability were identified: technical interoperability, semantic interoperability, and process interoperability. Here’s an overview:

Type 1: Technical Interoperability

The most basic, hardware-based form of interoperability. IEEE-90 defines interoperability as, “The ability of two different systems to exchange data so that it is useful”

The focus of technical interoperability is on the conveyance of data, not on its meaning. Were it not for the fact that computers tend to use written language, this would be similar to the level of interoperability provided by voice communications, e.g., via a telephone.

Type 2: Semantic Interoperability

the ability of information shared by systems to be understood… so that non-numeric data can be processed by the receiving system.

HL7 also defined a quality that is necessary for optimal semantic interoperability to exist. The quality-based rationale of the HL7 semantic interoperability messaging standard asserts that health information systems will communicate information in a form that will be understood in exactly the same way by both sender and recipient.

Type 3: Process Interoperability

Process interoperability is an emerging concept that has been identified as a requirement for successful system implementation into actual work settings. It was identified during the project by its inclusion in academic papers, mainly from Europe, and by its being highlighted by an Institute of Medicine (IOM) report issued in July 2005 which identified this social or workflow engineering as key to improving safety and quality in health care settings, and for improving benefits realization.8 It deals primarily with methods for the optimal integration of computer systems into actual work settings and includes the following:

• Explicit user role specification
• Useful, friendly, and efficient human-machine interface
• Data presentation/flow supports work setting
• Engineered work design
• Explicit user role specification
• Proven effectiveness in actual use

Here’s another helpful angle on the three types of interoperabilty: (more…)

What if the health care payer were re-imagined as a service to the primary care doctor – supplying the tools, information and funding primary care physicians needed to meet the call to reform health delivery?

The structure of physician payment is considered one of the most problematic aspects of our health care system.  Driven by volume instead of coordinated, proactive care and favoring procedures over cognitive work, the payment system has driven primary care into decline and stifled improvements in quality and efficiency.  Indeed, primary care physicians are overstressed and demoralized by demands, coming from every direction, that drive them only to see more patients, as quickly as possible.   In this state, primary care cannot attract new physicians at a time when an expansion of the primary care workforce is desperately needed.  Without new primary care doctors, how will medicine meet the future volume demands of the aging “baby boomers”, much less deliver the kind of comprehensive approach to patient health needed to correct the defects in today’s care?  Despite these growing concerns, little in the way of innovation is arising from payers.

So, what if the payer model was re-imagined?  What would such a payer look like?  At ESSENCE Healthcare, we have developed the Collaborative Payer Model (CPM), which takes the first steps at answering these questions. 

The CPM brings a new approach to address what is missing in much of health care reform, including: (more…)

We have learned that coordinating care of patients — particular care of Medicare patients — is complex and time consuming for physicians.

A breakthrough study quantifies just how complex and challenging care coordination really is.  The study is reported in the February 17 issue of Annals of Internal Medicine and is entitled Primary Care Physicians’ Links to Other Physicians Through Medicare Patients: The Scope of Care Coordination :

We found that in a single year for just fee-for-service Medicare patients, the typical primary care physician needs to coordinate care with 229 other physicians working in 117 different practices…. The number of peers was greater for physicians treating patients with higher chronic illness burden, who may benefit the most from coordination.

My mental visualization of these networks is a series of spider webs.

The authors write that “Coordination involves complex activities that require conscious interactions between providers and between providers and patients, including timely transfer of accurate clinical information, effective communication between the involved parties, and shared decision making.”

The estimate of 229 physicians in 117 different practices is conservative: (more…)

“Why can’t we all just get along?”  Rodney King

The Megatrend: Collaborative Care Management Networks (CCMNs)

It’s been quite a while since I spotted a new Disease Management Megatrend, but here’s one that’s long overdue:

Collaborative Care Management Networks will be necessary to achieve optimal care coordination.

The trend in a nutshell:  payers (and others) are recognizing that optimal care coordination will require collaboration among health care stakeholders. This CANNOT be achieved with yesterday’s proprietary IT and business models.

CCMNs will share many — perhaps all — of the following elements:

(more…)