Healthcare Quality

Primary Care: Are You Busy Or Effective (or Both)?

May of 2018 we turned on dashboards on the Value of Care for a group of 400 providers. On the dashboard the scale of 0 – 100, a 70 was considered “good value,” below this there were significant opportunity for higher value care. The average score for our providers was 35.

Within hours the phones began to ring – “my care is better than this,” “my dashboard is wrong,” “your data is incomplete” – the general sentiment was “I am making a bigger difference that you are saying I am.”

Let’s look at the facts – they were busy – usually filling their schedule to 80+%, moving through the day giving 100% to each person sitting before them. At the end of the day going home feeling tired but sure of their contribution to their patients. They must be high quality, effective, and their patients are benefiting based on days, months, and years of committed work.

So why the relatively low scores? We set up teams to investigate. The ability to click down to a member level allowed the providers to see what was going on with their patients. Were the patient really theirs or not? An examination revealed YES! Then why weren’t their blood pressure, cholesterol, asthma, blood sugars, immunizations, and screenings not at goal?

Barbara was supposed to come back in but never did, Bob travels all the time, Suzie stopped taking her meds, but never communicated it, John’s son got ill and he missed his appointment and never came back in…. The list of reasons went on and on. But the reality did not change – we were confusing being busy with meeting the needs of our patients. Often, we were not seeing the patients that needed us the most.

This lead to new systems, new ways of proactive (and automated) outreach. Soon the right patients were in the right practice at the right time. Quality took a jump up. Providers knew they were doing the best thing for all of their patients, not just the ones in front of them.

Busy was now productive and we were adding years to the lives and life to the years of those we served!

Is your practice busy, effective, or both?

Avoiding the #3 Cause of Death in the USA: US Hospitals & What You Need To Know About It – Part 1

By DrScott – Posted on March 18, 2014 on www.compassphs.com

Preventable Adverse Events (PAE’s) are the #3 cause of death in the US, leading to between 210,000 and 440,000 American deaths annually.  This must stop.  But how?  The answer involves one of the best stories in US healthcare history.

It started when Dr. Donald Berwick, the co-founder, president and CEO of the Cambridge-based Institute for Healthcare Improvement (IHI), was driving with his son, Dan to the airport.  Dan, a political campaign strategist, explained that he was bringing 350 volunteers to Florida for a weekend to knock on 50,000 doors for his candidate.

Awed by the numbers, Berwick, 57 at the time and a clinical Professor of Pediatrics and Health Care Policy at Harvard, shared IHI’s frustration about the slow pace of change in medicine when it came to adopting practices known to improve care and reduce errors.  As the former head of quality-of-care measurement for a large HMO, Berwick knew the numbers: As many as 98,000 American hospital patients die annually from poor care or medical errors. IHI researchers estimate that approximately 15 million incidents of medical harm occur in U.S. hospitals annually, roughly 40,000 every single day.

So, Berwick asked his son the critical question: “What makes your work so effective?” Dan explained what it takes to run a successful political campaign – coming up with concrete numbers (i.e. how many people you want to reach), establishing field offices to reach more people locally, inviting the widest possible participation, giving specific instructions to workers, and setting a deadline.

The IHI  only had 75 people on staff at the time and no way to mount the national campaign needed to create any significant change, or did they?  On December 14th 2004, Dr. Berwick gave a speech to a room full of hospital administrators.  He said, “Here is what I think we should do.  I think we should save 100,000 lives.  And I think we should do that by June 14, 2006 – 18 months from today.  Some is not a number; soon is not a time.  Here’s the number: 100,000.  Here’s the time: June 14, 2006.”

To accomplish this the IHI proposed six specific interventions for hospitals to adopt that had been proven to reduce unnecessary deaths.  If you have been reading the blogs on the book Switch by Dan and Chip Heath, you will appreciate that the “rider” now has a clearly defined goal to achieve.

But this was a challenge for hospitals to embrace and get behind.  If they did embrace it, it implied that unnecessary deaths were occurring in their hospitals.  So, Dr. Berwick made it personal.  At his speech he asked the mother of a girl who had been killed by a medical error to join him.  She said, “I’m a little speechless, and I’m a little sad, because I know that if this campaign had been in place four or five years ago, that Josie would be fine….  But, I’m happy, and thrilled to be a part of this, because I know you can do it, because you have to do it.”  Another guest on the stage, the North Carolina State Hospital Association Chair, then spoke up: “An awful lot of people for a long time have had their heads in the sand on this issue, and it’s time to do the right thing.  It’s as simple as that.”  (Switch: the elephant was motivated).

The IHI made joining the campaign easy; hospital CEO’s only had to sign a one page form.  Once a hospital enrolled, the IHI team helped them embrace the new interventions.  Research, step by step instructions guide and training were provided, and regular teleconferences with the hospital leaders to share their victories and struggles were arranged.  Hospitals with early successes were encouraged to become mentors of hospitals who joined the campaign later. (Switch: the path had been made easy).

But would they achieve the goal? Eliminating errors and documenting the results had never been done this way in the US Healthcare system. As a patient, the challenge of finding an excellent facility and doctor to use can be daunting.

Bending the Health Care Cost Curve. Making Sure Your Plan Can Succeed

 

By DrScott – Posted on February 13, 2014 on www.compassphs.com

Final Blog in the How to Switch On Your Employees Series

Engaging and activating employees to become more proactive in screening for and managing medical conditions when an employee “Feels Fine” is a challenge confronting every employer. Many companies are figuring out how, resulting in lower costs and healthier employees.

The authors Dan and Chip Heath, in the book Switch – How to Change Things When Change is Hard, point to key variables in any change management effort. Using the simile of a rider guiding an elephant down a path to your destination, they share three areas vital to success. Here are the key variables:

1. Directing the Rider. The culture and beliefs of a company are vital in identifying what will lead to successful change management. Start by:

  • Identifying successful efforts in the past and understanding why they worked;
  • Scripting the critical, necessary moves – like moving to outcomes based benefit design; and,
  • Pointing to the destination – moving from providing insurance to providing a culture that supports proactive early intervention and saves lives to insure every employee is there for their co-workers, family, and friends.

Mistakes often made by employers in directing the rider include: Failing to get C-suite support; not appreciating the politics and informal power structure within a culture; not making the key moves clear; not communicating clearly and repetitively; and failing to articulate the goal in a way that employees can appreciate and will understand the relevance to their whole life, not just their time at work.

2. Motivating the Elephant. Rational understanding of what to do and why is only one aspect of successful change. Elephants are large, have momentum, and don’t like to change from the well-known, understood, and worn path. Turning an elephant requires:

  • Appealing to the “heart” to touch, move and inspire action. “I have a dream” and “We choose to go to the moon,” united and solidified a change far more than, “here are the three things to be done and why we are going to do them.” Share inspirational moments along the journey so employees appreciate the difference being made by this change.
  • Create baby steps. Trying to bite off too much too quickly will choke the process. We all know the joke, “How do you eat an elephant? One bite at a time.”
  • The importance of a learner’s mindset, being open to growth and change, is so obvious it goes without saying. However, making this as a theme of the change effort is often overlooked. To embrace a new way of thinking about proactive health requires a shift in mindset from, “providing insurance” to “insuring that we are doing what we know to do to empower employees to be healthy and productive at work and at home.”

This is an area of health benefit change that will need significant attention in most companies. As opposed to directing the employees (telling them what to do), motivating the employees requires the HR team to lean heavily on their EQ (emotional), SQ (social), CQ (cultural) quotients as opposed to only the IQ.

3. Shaping the Path. Employees are busy. Having to stop and figure out aspects of their life, like health benefits, which are not central to everyday success at work and home slows the development of “muscle memory”.  Answering the question, “How do I get employees to ‘do the right thing’ to utilize their benefits to the fullest”, without them having to “figure it out” every time is the challenge being addressed.

  • The environment must support the change, making it easier to do what you want them to rather than going back to their old ways. Healthy on-site cafés; on site, near site, or mobile clinics; starting every shift with injury preventing stretching or activity; and on site activity centers will all change the environment and have been implemented (in the right situation) with success.
  • Building new habits such as “contact your Health Pro” for any benefit related question simplifies and allows employees to confront new challenges in a “just in time” fashion with the development of one simple new habit.
  • Elephants (and employees) travel in packs. Behavior is contagious and reaching the “tipping point” where embracing the change you are advocating in the company goes from, “you did what?” to “of course, that is what we all do” does not happen overnight, but will occur.

As I wrote this blog, I received an email from a human resources director at a rural production facility:

“Hi all. I just wanted to let you know that one of our employees had one of his age and gender screenings due to the new benefit plan. An issue was found at an early stage and he will be having surgery to correct it and is expected to be 100%. He told me that if it hadn’t been for our new health plan he never would have gotten the screening and in about a year would have been in a much worse state. So, thank you for the new health plans.”

This is a recurrent theme. Plans that encourage and support effective change make a difference. If you enjoyed this blog series, I encourage you to read Switch – How to Change Things When Change is Hard. This blog only begins to scratch the surface of this revealing, well done book. The research and stories shared from Vietnam to radishes (and many others), in Switch provide more examples of how to navigate change successfully and will both entertain and motivate your team.

Increasing Employee Engagement: Switching Your Focus

By DrScott – Posted on January 23, 2014 on www.compassphs.com

Second in the How to Switch On Your Employees Series

Have you ever been overwhelmed by all the TBU (true but useless) data provided in your Health Insurance Annual Report? It reminds me of looking at a photograph of a car accident – lots to see that went wrong, vehicles damaged, people hurt; but it is already done. To add insult to injury, the Annual Report is often received months after the end of the year and a whole new set of wrecks have occurred. There has got to be a better way!

In this series, we are going to examine how to get your employees to follow you as you plan and execute a new path to lower healthcare costs, higher quality care, with fewer hassles.

In previous blogs we discussed the three keys to success in changing behavior for yourself or your employees. The paradigm is laid out in the book Switch by Dan and Chip Heath, and they use the example of trying to change the direction of an elephant walking down a path.

  1. First the rider (representing our reason) must know the destination, the steps to get there, the reason to go there, and have a sense that the journey is possible.
  2. Second, the elephant (our emotions or the inertia of our life based upon habits, beliefs and experience) needs to be inspired and has to have the journey broken down into achievable, small steps, and, where necessary, the employees will need to cultivate an “I can do this” mindset.
  3. Third, understanding the path of least resistance based on the terrain, well-formed habits, and following the pack.

Let’s go back to the somewhat depressing and very sobering annual report on health benefit spends we spoke of earlier. What do we see?

  1. We see Sarah, a 50 year old diagnosed with stage 3 breast cancer,
  2. John, a 48 year old who had a heart attack at work,
  3. Kristen, a 23 year old diagnosed with advanced cervical cancer,
  4. Bill, a 37 year old having low back surgery,
  5. Randy, who had a serious car accident when he fell asleep driving one evening, and
  6. Twins born at 26 weeks who spent six weeks in the hospital,
  7. And the many employees with neck, back, hip, knee, chest, pelvic, and other pain going to emergency rooms and doctors trying to figure out what is causing their pain, while spending millions of dollars.

With the exception of the twins, these medical problems built up over time – five to fifteen years – and didn’t have to happen. What could have been done to avoid these tragedies? Basic prevention, wellness, and treatment recommendations – in today’s vernacular the evidence based “Gaps in Care” would have to be closed. Sarah and Kristen would have their screening for cancer done earlier, John would have his blood pressure and cholesterol treated, Randy would have treated his sleep apnea, and Bill would have maintained his weight and focus more on fitness. All reasonable and very possible goals.

How do we motivate the rider, change the path, and turn the elephant to a new direction? Every trip starts with a clear destination. Focusing on what we can do to stop the tragedies and reduce the cost by closing Gaps in Care is one example. In the next blog we will show how a company focused on this and how it saved employee lives and hundreds of thousands of dollars.

What Does Your Employee Health Balance Sheet Look Like?

By DrScott – Posted on January 21, 2014 on www.compassphs.com

What is the most expensive item on your statement of revenue and expenses every month? Employee payroll tops the list for almost every company, with health benefits landing in the second or third position depending on whether you are in manufacturing (raw materials often in second place), or a service industry.

Now, how carefully do you manage employee costs? Cost of raw materials? What about health costs? When I ask this question of most CEOs and CFOs the answer is consistent – on employees and raw materials they are meticulous, but they don’t feel like there is much they can do when it comes to health benefits.

Really? As we have examined in these blogs, there is A LOT that they can do. In fact, given the high cost of health benefits it would not surprise me if soon companies will not have to add “Employee Health & Wellbeing” to their Balance Sheet. How? Well, disease doesn’t appear in a person overnight – it takes years, and if detected early it can be cured or slowed dramatically. Why don’t we slow or prevent disease progression?

The “I Feel Fine” Syndrome lulls us into a false sense of security (as we discussed in the last 4 blogs). But this is not inevitable – identified and handled properly, costs stay down, employees stay at work, and families keep their mothers and fathers.

Smart venture capital firms like Blackstone have already figured this out and established companies like Equity Health to get control of this issue. Imagine buying a company, putting in place proactive solutions, and dropping the cost of your number 2 or 3 spend by 10 – 30% in the first 36 months consistently. Regardless of how much the rest of the company performs, you already have created significant shareholder value.

So what will the Balance Sheet say? No one knows exactly, but an educated guess includes:

Assets:

Employee Health (Assets = lower costs relative to average employee of $X)

  • % of Employees

Healthy Employees : $3,000/employee

  • 15%

Employees with Chronic Conditions well managed : $1,400/employee

  • 8%

Liabilities:

Employee health (Liabilities = higher costs relative to average employee)

  • % of Employees

Employees with poor physical fitness <$500/employee>

  • Unknown

Employee with unknown health status <$1,400/employee>

  • 57%

Employees with uncontrolled Chronic Conditions <$3,200/employee>

  • 14%

Employees with Serious Illness <$19,000/employee>

  • 6%

So let’s take a company with 1000 employees paying on average $5000 per year for health benefits. This calculation would be a net negative of <$798,000> on the balance sheet. Getting biometrics, age and gender screenings along with active primary care involvement would shift this from a net negative on the balance sheet to a break even on the balance sheet. It would also reduce health care costs by over $60,000 per month. This approach is logical and attractive both from a financial and employee well-being standpoint. However, it takes experience and competent systems to achieve.

Tremendous opportunity to make very significant differences for your employee’s health and well-being exists. Designing systems that help your employees keep their Seven Numbers at goal will add years to their life and life to their years. Thank you for following this series. Please let us know if you have thoughts or stories of how you are accomplishing this in your companies.

Why You Care About Your Employees Numbers

By DrScott – Posted on December 18, 2013 on www.compassphs.com

In the first two installments of the Seven Number Series, we examined how heart disease, diabetes, and cancer, gradually appear in our bodies. Every one of us is born with a higher likelihood of developing one disease over the other (a genetic predisposition). We then take in more calories than we burn, and we begin to gain weight and can become overweight or obese. Next, we continue to force calories into our body and our organs – the blood vessel, pancreas and other tissues of our body, are forced to put in overtime, often to the point of exhaustion or destruction, until finally the control (homeostatic) mechanisms become overwhelmed and fail, allowing the disease to manifest and gain a firm foothold in our body.

Why do you and your company care about this process? They significantly determine the health and future of your career and company; the loss of good employees, loss of productivity at work, and the cost of managing absenteeism. Here is where you find this on your health benefit reports:

  • Heart disease and type 2 diabetes (which is over 90% of diabetes) are directly driven through this process.
  • Many cancers – endometrial, pancreatic, breast (after menopause only), rectal, and colorectal cancers
  • Many emergency room visit are related to these processes, but are reported as “Injury and Poisoning” on cost reports,
  • “Pain and Suffering” on health cost reports include headaches, chest, abdominal, and pelvic pain not uncommonly related to these issues, and finally
  • Musculoskeletal costs are driven through the same pathway of decreased fitness, overweight and obesity with neck, back, hip, knee, and ankle destruction and the resulting treatment.

Altogether, these account for over 70% of many companies’ health spend. What would it mean to your company to reduce or eliminate a significant portion of these conditions?