Friday, June 26, 2015

The Potential of Community Health Workers (CHWs)

He was among the highest.

Utilizers of healthcare services, that is. 

I had the pleasure of talking to a physician who is leading a group of community health workers (CHWs) assigned to taking care of dozens of patients like this.  Burdened by decades of multiple chronic conditions, patients like him are typically struggling with myriad complications of chronic illness, side effects from numerous medications, mental illness, extreme poverty and homelessness.  The result is an endless cycle of emergency room visits, admissions, discharges and more emergency room visits.

According to the physician I talked to, these highest utilizers don't need more physician care; us docs can only do so much with an office visit. They also don't need health insurance, because they already have it. 

What these patients really need are resources that can help bridge the aspirations of health reform and the reality of the street.

The Population Health Blog agrees. In its professional career, it saw plenty of insured people with access to health care who were still unable to get better.  They didn't need more of the PHB, they needed..... help, in the form of monitoring, education, coaching, encouragement and advice.

Enter this timely article by Dr. Kangovi and colleagues appearing in the June 11 issue of the New England Journal.  It's a good primer on the long history of CHWs and the work that will be necessary to mainsteam them into health reform.  
CHW-based programs in the U.S. have been around since the 1960s. They typically focus on the indigent, are modest in scope, and have been funded "hand-to-mouth" by community organizations.  However, they've also been used to facilitate insurance enrollment, support "Medicaid Health Homes" and provide preventive and screening services on a regional basis. 

The PHB believes, however, that their greatest value proposition may be in supporting interventions for high utilizing patients under Medicaid waiver arrangements or in managed care programs. By coordinating alternatives to the emergency room revolving doors, CHWs can save taxpayers a lot of money.

Dr. Kangovi et al describe five barriers to the widespread adoption of CHWs:

1) Insufficient integration with traditional providers - But the good news is that CHWs can now use the shared data and remote electronic communication of health information technology to extend the reach of the non-physician (e.g. nurses, social workers) members of a medical home.

2) Fragmented health care systems - But the good news is that health care organizations are slowly being forced out into the communities that surround them. CHWs are waiting.

3) Lack of treatment protocols - But the good news is that this is an emerging science. Some on-line resources already exist.

4) High worker turnover - the authors cite one Harlem program that lost a third of their workers over a matter of months.  The good news is that there are ways to identify "keepers" who will find the CHW career to be satisfying.

5) Low quality published evidence - But the good news is that the volume and the quality of published research is going up.  Even better news is that that will help inform accreditation programs.

That high utilizer mentioned above?  The PHB learned that his last encounter with the health care system was in a primary care provider's office, in the company of a CHW.

Image from Wikipedia

Monday, June 22, 2015

Apps Will Astonish

"Now this is meaningful use!"
In case you think the future for healthcare apps will be characterized by health information technology (HIT) "dead zones" of free downloads, fun gadgetry and vacuous consumerism with nothing to show for it, you should take a look at  this article appearing in the peer-reviewed journal Cell Systems

If authors Kenneth Mandl, Joshua Mandel and Isaac Kohane are even half right, "apps" could truly revolutionize HIT.  They argue that a superimposed "apps layer" ecosystem will demolish the "walled gardens" of EHRs and allow for true information sharing across clinics, systems and regions.

And that's just for starters.

As the Population Health Blog understands it, "Application Programming Interfaces" (or "APIs") will enable multiple third party apps to bridge to legacy EHRs.  That, in turn, will catalyze the creation of newer and better user experiences that reconcile doc and patient preferences with the current clunky one-size-fits-all EHRs. 

The result?

1. A "mash up" of "risks, trends and trajectories" with external data sources, telehealth and decision support systems. Why should a patient with cancer and his/her oncologist use the same computer operating environment as a patient and a dermatologist dealing with a rash?  Even better, apps can be easily substituted if a better one comes along.

2. Never mind ICD-9 or ICD-10, apps will be the "afferent limb" that links your unique genetic and phenotypic "diagnosis code" to the efferent limb of tailored treatment protocols.

3. Apps can collect and arrange the data from numerous devices at scale that not only allow for treatment compliance or disease management outside of the clinic, but the early identification of an emerging epidemic or medication side effects.

To achieve this, the authors recommend the EHR manufacturers not only retool, but adopt a uniform and open source approach to API development. Purchasers of EHRs consider should consider the future of APIs in their requests for proposals (RFPs).  They also recommend that research funding be directed toward apps that can operate across multiple information platforms. It would also help if there was a "seal of approval" process for app development that wasn't too closely tied to industry or too tied up in the regulatory miasma of government.

Wednesday, June 10, 2015

Are Some Physicians Stockholm Syndrome Victims?

A hostage sides with her
captors in a bank hold-up
Years ago, when the Population Health Blog was the staff physician supervising an overworked inpatient consult service, its team of residents was asked by a surgeon to evaluate abnormal kidney function tests on one of her patients. After quickly surmising that the cause was a simple case of easily-corrected dehydration, the residents complained that the surgeon should have spotted the diagnosis. As a result, they said, this was a waste of their time.

"Not so!" said the PHB. It pointed out that the resident's medical knowledge was so advanced that they could glance at some lab numbers and spot the diagnosis. It's not that the surgeon was dumb or lazy, but that they were extremely smart.

The PHB also challenged them to snap out of it. Their low self-esteem was allowing them to be held hostage by narrative that not only devalued their expertise, but put their professional well-being at risk.

Fast forward to today when it's not about troubled kidney function, but a troubled healthcare system.

As we look for solutions, physicians are being buffeted by a widespread narrative that they're largely responsible for low quality, high costs and poor patient experience.

For example, there's literature that physicians order too many or (too few) tests, that misdiagnosis is common and that their treatments warrant scrutiny.  Or, thanks to their "power of the pen," misaligned physician incentives have led to the United States' outlier status on life expectancy vs. per capita costs.

How much is truly under the physicians' control is up to debate. What's more, physicians bring tremendous value to the table of health reform.  But, public perception says otherwise, and that's likely playing a role in the declining public trust in physicians and drops in their prestige. That, in turn, is contributing to widespread professional dissatisfaction and burn-out with significant implications for patient care.

Which makes the PHB wonder if it's witnessing the consult service scenario described above, but on a national scale.  It's one thing for its physician colleagues to emotionally struggle with the tectonic challenges of health reform (and there are ways, like this and this, to deal with it), but it's entirely another thing for them to agree that their professional value has been diminished.

Which leads the PHB's to speculate about its biggest fear. In addition to the hassles of physician-owned practice, the intellectual and emotional buy-in of a narrative of incompetence may be leading many docs to willingly outsource national policy as well as local practice decisions about quality and costs to the corporation.

For some docs, this could be a professional version of the Stockholm Syndrome.

As so elegantly described by Paul Levy in his blog, the Stockholm Syndrome occurs when hostages misinterpret the near-term lack of abuse by their captors to the point of emotionally bonding with them. While he was writing about the relationship of healthcare institutions to electronic record vendors, the PHB wonders if the same could be said about the relationship of physicians to their administrators, policy makers, elected representatives, regulators and the other clerisy.

Their reward for any role they've played in marginalizing physicians is greater authority, and some docs may not only going along with it, but embracing it.

The PHB looked for physician surveys or other data to support this, and can't find it. It suspects no one has asked the question.

Until now.

Tuesday, June 2, 2015

The Myriad Ways of Strategy and Population Health for Governance Boards and Health Care Leaders

What's it take to be a "luminary?"
As healthcare organization leaders grapple with health reform's uncertainties, a common refrain is importance of "strategy".

It's no longer enough to maximize revenue, increase patient throughput, lower costs, manage debt, embrace financial risk, optimize FTEs, assure compliance or strengthen the balance sheet.

While those present management and fiduciary functions are still critical, governance boards and c-suite executives in both purchaser and provider organizations also have to make bets about the future.

For example, if healthcare inflation accelerates, how will your current customers react to their future costs-sharing? How and when will today's voters reconcile the burdens from growing public debt and government-sponsorship of the insurance programs you contract with? As "the internet of things" spreads, what is tomorrow's value proposition of your healthcare "things?"  Is reading this blog today going to lead to you being smarter in tomorrow's contentious meeting?

In other words, when leaders grapple with strategy, they're really futurists. They're making bets today on how to adapt current strengths and weaknesses to myriad downstream threats and opportunities.

Uncertainty has become a new watchword. Even if an organization doesn't change and sticks with old fashioned fee-for-service, they're still making a big wager on the future of individual billing versus risk-contracting for populations.

Which is why the Population Health Blog is interested in how leaders outside of healthcare deal with uncertainty. 

Being routinely unable to resist the materialistic allure of the WSJ. Magazine fashion ads, the PHB  happily stumbled into this Soapbox column on the single topic of strategy. Six "luminaries" were asked about it.

The recording industry executive emphasized visualizing the endgame. The professional sailor trusts her gut instincts. The computer gamer is all about capitalizing on lucky breaks. The presidential historian liked ongoing experimentation. The restaurateur is constantly shaping company culture. The matchmaker likes being open to change, even if it means being vulnerable.

Lesson? The PHB has read or heard all of this and more from leaders and in boardrooms. Examples include this (the end-game), this (intuition), this (luck), this (experimentation), this (culture) and this (change management).

"Strategy" remains a highly variable work in progress.  There is no best practice.

And then there's the huge health care opportunities and risks from contracting for the care of populations. Check out this interesting post by George Washington University's Miliken Institute of Public Health that describes a survey of 37 health care luminaries on the topic of population health. As the author points out, consensus on responsibility (and, as a side note, the assets and liabilities that accompany it) is lacking.  In addition, quoting the "Triple Aim" is turning out to be less than its admirers would like.

So it turns out that this is also very much a work in progress.

The PHB's takes?

 There are two:

1) Multiply the many approaches to strategy with the multiple takes on caring for populations and the possibilities are endless. Based on the variations, no one has cracked the code applying strategy to populations and risk-contracting.

For purchaser/provider board members and C-suite leaders, the good news is that your strategic bets on the future are - for now - as good as anyone's. The bad news is that the present day fiduciary work is not lessened and you're going to have to devote more effort (and time) on developing a still unsettled strategy approach to the uncertainties surrounding health reform.

2) Regrettably, despite describing itself as a "luminary" many times to the PHB Spouse, it was not included in the WSJ. column and the Miliken Blog.  This sadly suggests that her skepticism - for now - is warranted.

Image from Wikipedia

Wednesday, May 27, 2015

"Generative" Health Care Leadership, Governance and Boards of Directors

Time to get "generative!"
Thanks to bout of troublesome weather, the Population Health Blog has been stranded somewhere in the U.S. air-travel network. Undaunted by bitter loss of an upgrade and the prospect of a late arrival, it bravely used the down time to dig into the highly interesting book Governance as Leadership: Reframing the Work of Nonprofit Boards by Richard P. Chait, William Ryan, and Barbara Taylor.

While written for "nonprofit board members," the PHB believes the insights are applicable to just about any board of directors or other leadership group of an organization that is grappling with uncertainty. And given the uncertainty in health care, Governance is "must" reading for the leadership as well as the board of any hospital, physician-group, health system or provider organization.

Pointing to years of academic research, consulting experience and common sense, the book describes three "modes" of governance:

1. Type I Fiduciary, which relies on process and uses standing committees to ask (for example) if assets are being effectively deployed.  Think "data."

2. Type II Strategic, which relies on content and uses ad hoc committees to ask (for example) how strengths align with future opportunities.  Think "information."

3. Type III Generative, which relies on "cues," "framing" and "narratives" to ask less about the solution and more about the problem.  Think "insight."  
Boards are naturally inclined toward Type I and II governance. According to the authors, that's a mistake that can foster zero-sum thinking and the triumph of personal influence over group meaning.

Instead, when all three types are used at the right time for the right issues, they become synergistic and can create a tangible competitive advantage for the organization.  The best time to turn to Type III governance is when there is an issue that is ambiguous, salient, high stakes, contentious and irreversible.  The authors compellingly describe how present "cues and clues," can be used to "reframe" facts into new patterns.  As a result, the past can be re-narrated to imagine a new future.

Governance uses the example of the compelling insight that broken windows isn't the result of, but can lead to high crime rates.  That, in turn, led to the creation of "community policing."  The PHB would offer the health industry insight that the "problem" wasn't getting physicians to better care for persons with diabetes, but getting persons with diabetes to be better engaged in self-care.

You get the idea.

 The authors readily admit that Type III Governance is a "wilderness" that is an "outside-the" or "black" box that is non-linear, vague and subjective.

It seeks "sense" or meaning and creates multiple choices, not a single fix.  It generates insight and creativity, not mission setting, strategy development or problem solving.  It gets you to the drawing board.  It frames the problem.  It generates the hypothesis. 

And when reality is recreated, it can ultimately achieve a far richer level of down-stream buy-in.

How can Type III Governance be leveraged?

First of all, governing boards and their management teams must collaborate in this.  Boards have a particular role to play because they have the three "P's" of power, a plurality of multiple perspectives and a position of a more distant ("10,000 foot") vantage point.  Boards can work with their management teams by either acting as 1) sounding boards that foster generative thinking by asking, probing and identifying the cues, framing the data and renarrating the past or by 2) initiating generative thinking by focusing on ambiguous or problematic issues among themselves and their colleagues.

Be prepared to tackle sensitive subjects and dealing with multiple perspectives that is less about fixed unanimity and more about the sense of a "collective mind". Resist succumbing to notions or fostering groupthink.

Use retrospective questioning (to discover unknown strengths, flaws and patterns in the past) and dominant narratives (that create a meaningful bridge from the past to a portray a desired future) to gain greater understanding.

Embrace the generative mode early on the "elephants in the room." A otherwise unaddressed "big issue" will evolve over time and default processes and solutions will recast the situation as a planning or strategic challenge.

Use mindful deliberation without formality or rank that focuses less on creating the solution than on defining the problem.

To increase the chance of success, boards need regular exposure to inside-facing culture of the organization as well its outward-facing environment. That means having unfiltered access to the cues/clues inside (the "factory floor") and outside (with customers or other stakeholders). While there is a risk of board members or senior leaders running amok over established lines of authority, the risk to any organization is ultimately greater if they're confined to the boardroom or the C-suite. 

Generative thinking will feel more like "play" or a "retreat" than a meeting.  That's good.

Use tools like

Counterfactuals: What is it about the budget or the assigned FTEs that explains our goals?
Hypotheticals: If the company ceased to exist, where would its customers go?
Intuition: Is there a hunch about the next five years?
Catalytic questioning: Is there a headline we'd like to see?

Governance makes for interesting as well as fun reading. The authors avoid complex jargon and sprinkle their text with some insightful examples. While readers may struggle with the details of installing "generative" thinking into their leadership "workflows," the idea of using this template to harness the creative juices of a leadership group or a board is exciting stuff.

Thursday, May 21, 2015

Predictions for a 50% Health Care Economy

Health care costs too much.  Having to pay more for doctors, hospitals and pills is threatening national security, undermining our industrial competitiveness, leading to underinvestment in vital infrastructure and exacerbating economic inequality. As we devote more and more of our individual household budgets, business revenues and national treasure to healthcare, it these excess costs will "crowd-out" our ability to pay for other worthy stuff.

Naturally, insightful Population Health Blog readers know the real story is more complicated than that. Inflation-adjusted costs of other "stuff" that comprise much of the U.S. economy have dropped. As the denominator has gotten smaller, the health care numerator appears relatively bigger.  More on that here

What's more, as society has benefitted from lower energy, housing, transportation and food costs, consumers are better able to choose to shift resources toward the health care that they want, which further fuels its growth. 

Plus, there's the observation that government subsidies have a significant impact. Our elected officials are advancing their constituents' wishes, right?

Right now, it appears that health care is costing just under 20% of the U.S. gross domestic product (GDP). Between our

1) appetite for more health care,

2) cheap robots doing everything else for us and

3) the inability of government bureaucrats to resist ever more meddling....

the PHB suspects that the percent of GDP going toward the medical-industrial complex is destined to hit 50%.

The provocative PHB asks if that's such a bad thing.

If 50% of all persons disabled or retired, the other 50% of us can look forward to the happy prospect of being gainfully employed thanks to taking care of them. 

If that's our future, the PHB has some other predictions:

1. 50% of all parking space acreage (for our Google Cars, naturally) will be devoted to the disabled.  The rest of us will benefit from longer walks, with a 50% greater likelihood of achieving our 10,000 per day step quota.

2. 50% of primary care providers won't be physicians.  But 100% of all those non-physicians will have slept in a Holiday Inn last night!

3. For those primary care physicians who remain in practice, 50% of their income will be thanks to the burgeoning science of tattoo removal, botox and dermal fillers.

4. 50% of all wheelchairs and bedside commodes will be of the "jumbo" variety.

5. 50% of all medicines will have dire "black box" warnings.  Likelihood that patients will actually take them will be decreased by 50%.

6. Automated decision support will thwart the ability of lawyers to sue doctors.  Following a path of least resistance, the legal community will respond with a 50% increase in lawsuits in other growth areas of the economy, such as robotic cars and pillow manufacturing.

7. Despite automated decision support, 50% of all providers will still detest their electronic record system.  The other 50% will loathe it.

8. 50% of all mental health counseling will be automated. Not kidding!

9.  When health systems finally grasp the impact of handhelds and apps, there will be a 50% increase in desk-top PC recycling.  Chances that DC's "meaningful use" criteria will recognize this soon enough are 50-50.

10. Growing traffic on the PHB's blog will lead to a 50% increase in its vast web-site related income. There is a 100% chance, however, that the PHB Spouse will not be suitably impressed.

Image from Wikipedia

Monday, May 18, 2015

Vegas' Healthcare Lessons: A Field Trip Report

The Population Health Blog spent the last week in Vegas exploring the actuarial, medical, predictive, economic, social and quality dimensions of an important part of the property and casualty insurance industry.

If memory serves, this was the fourth time it was there.  And a lot has changed over the last few years

Naturally, the PHB's commitment to lifelong learning shielded it from Sin City's too-numerous -to-count temptations.  Being in windowless conference rooms from 7 AM to 6 PM prevented it from the succumbing to The Strip's scintillating jewelry displays, blinka-blinka light pollution and siren call of unfavorable risk-transfer arrangements (a.k.a. "gambling").

Plus, having the spouse for company helped, even though she vetoed perfectly reasonable entertainment options like this and this.  As a consequence, the PHB limited itself to an evening show and a variety of interesting eateries. The good news is that, as a result, the field trips outside the meeting venue gave it some time to compare the "old" and today's "new" Vegas to derive some healthcare lessons:

Old Vegas:

Small hotel lobbies, walls, winding walkways.

New Vegas:

Open hotel atriums, mirrors but still winding walkways

Lesson: You don't have to give away the keys to the business to give the consumer the impression of transparency. While healthcare has a long way to go on truly transparent pricing, the PHB suspects there will be a lot of mirrors and winding walkways between where we are now and where we want to go.

Old Vegas:

Rooms at $250 per night

New Vegas:

While rooms on The Strip can be $300 per night, that's comparatively less in inflation adjusted dollars, plus there are remote controlled curtains for the floor to ceiling windows and one, if not two, flat screen TVs.

Lesson: Consumers are expecting more quality at less cost. Healthcare remains an economic outlier.

Old Vegas:

Computerized slot machines

New Vegas:

Computerized insights on the users of the slot machines

Lesson: Knowing background, revenue/cost determinants and risk preferences of your customers is critical.  In healthcare, we call this "big data."

Old Vegas:

Illusionists, Carrot Top, The Osmonds, Elton John and Cirque

New Vegas:

Illusionists, Carrot Top, The Osmonds, Elton John and Cirque in over the top stages and elaborate auditoriums.

Lesson: If you have a winning formula, stick to it and do it better. Even though health insurers may get in the way, more patients will seek you out.

And finally.....

Old Vegas:

Some homeless people

New Vegas:

More homeless people. 

Lesson: The economy recovery is failing the most vulnerable

Image from Wikipedia

Tuesday, April 28, 2015

For the Commercial Health Insurers, Winter Is Coming

Fans of HBO's hit fantasy TV series Game of Thrones will recognize the adage. 

In the show, the continent of Westeros has had a long hot summer of breasts, butts and beheadings. Now, it's not only getting colder, but there have been sightings in the North of blue-eyed freeze-dried warrior zombies. Crops are failing, the northern tribes are fleeing and the crows are looking more sinister by the minute. The only thing that separates civilization from catastrophe is The Wall.  That's made of a lot of ice and it is guarded by the Night's Watch.  The Watch is made up of mostly unsavory criminal types who have been given the choices of decapitation or taking The Oath.  Think of them as the Fence Frozen Legion.  Cue camera, raise swords... action!

Naturally, the Population Health Blog is enjoying every minute of it, and so is, inexplicably, the PHB Spouse.  We're both gained valuable insights.  While the PHB ponders her observation that men are untrustworthy swine, it has more constructively responded that Game of Thrones has many lessons that speak to the health insurance market.

To wit:

The Night's Watch may be made up of villains, but they're our villains and they're performing a valuable function.  Commercial health insurers likewise have their knaves, but for years they have been pooling risk and paying claims. 

Unfortunately, times are changing. While we've had a lusty summer of low cost inflation and innovation, Accountable Care Organizations are not as successful as hoped, insurer networks have gone skinny, out-of-pocket expenses are climbing and tax bills are coming due.  While we thought the undead "Medicare for All" was just an unpleasant memory, there have been sightings here and here

Will the Night's Watch of commercial insurers hold the wall?  Cue camera, raise swords.... action!

Image from Wikipedia

Thursday, April 23, 2015

The Latest Health Wonk Review Is Up

The Health Wonk Review is a linked summary of the better insights from smart health policy bloggers.  The latest edition is hosted by Joe Paduda of Managed Care Matters.


Wednesday, April 22, 2015

Curing the Healthcare Digital Divide: There's an App for That

Whither meaningful use?
For better or worse, policymakers, politicians and health leaders in the United States are committed to achieving paperless healthcare environment. Even if there is lack of high quality research and reasonable skepticism over the ultimate cost and quality merits of "e"care, there is no going back.

As a result, visitors to ehospitals and eclinics are increasingly surrounded by monitors that, in turn, are surrounded by providers. To gain their attention, patients need to have internet access to make appointments, update medications, obtain education and communicate with their doctor.

And what if they don't have that access? For the last decade, that worry has been characterized as "the healthcare digital divide. " As recently as 2014, it's been documented that the lack of computer hardware and access can have important healthcare implications for persons with low socioeconomic status.

For the doctors and nurses staring at screens all day, the millions of Americans who are living paycheck to paycheck risk being out sight and out of mind.

But it turns out that that it doesn't need to be that way.

The PHB explains.

Check out this telling report from the Federal Deposit Insurance Corporation on the "unbanked" and "underbanked."  Not having a bank account (unbanked) or using any financial services (underbanked) are linked to persons with low income, being of color, disability and being unemployed.

In other words, these are the very persons at risk of being on the losing end of the health care digital divide.

While there's interesting data on how close to 8% of U.S. households are unbanked and just over 20% were underbanked, there were also these stunning observations:

"Relative to fully banked households (86.8%), underbanked households were somewhat more likely to have had access to mobile phones (90.5%) and smartphones (64.5% of underbanked households compared with 59.0 percent of fully banked households)."

"Notably smaller, but still significant, proportions of unbanked households had access to mobile phones (68.1%) and smartphones (33.1%)" (bolding PHB).

In other words, persons of low socioeconomic status are more likely to have smart phones vs. the "banked" population. They may not have a checking account, but, compared to other segments of the population, they are also more able to use these devices to access and manage their "e"care.

The PHB's conclusions?

1. Not  explicitly fostering heandhelds as a part of the healthcare informatics "ecosystem" may be shutting out persons of low socioeconomic status from the health system. While the Washington DC's "meaningful use" (MU) criteria are not explicitly tilted toward desktop/tower computing, they seem to conspicuously silent on advocating for ease of smartphone use, for example, to manage appointments, medications, education and messaging. 

Compare MU that with Google's mobilegeddon and the unwillingness of innovative systems (like this and this) to wait for CMS to catch up.  They're loaning handhelds to patients.

What do you know: if you want to increase access to healthcare for the economically disenfranchised, there truly is an app for that.  It was there all along.

2. Yet, smartphones for the economically vulnerable and access to health information technology are not necessarily a slamdunk.  This report reminds us that smartphone contracts are vulnerable to non-payment and that it's not unusual for service to be turned off. 

Health systems that can navigate that reality that will win.

Image from Wikipedia